21
Importance of the History in the
Diagnosis of Shoulder Pathology
Richard Romeyn, MD  |  Robert C. Manske, PT, DPT, MEd, SCS, ATC, CSCS
The patient history is the first step in the evaluation of shoulder
symptoms. The possible diagnoses will be confirmed or refuted
during the physical examination and radiographic evaluation.
Because different pathologies may manifest themselves with
similar presenting complaints, with the underlying problem
producing only secondary symptoms (although these will be
the ones apparent to the patient), assessment of the shoulder
is uniquely challenging, and an illuminating history requires
the examiner to be well organized and ask specific and focused
questions because patients generally do not readily volunteer all
necessary information. These questions should be asked consis-
tently in a structured and organized format so that they can be
replicated easily with each evaluation. If done in this manner,
rarely will an important question be missed or forgotten.
When taking a history, the crucial elements about which one
must inquire are as follows:
1. Patient age: Most shoulder pathologies occur characteristi-
cally within a specific age range.
2. Presenting complaint: Subjective complaints most frequently
include pain, instability, weakness, crepitus, and stiffness, the
character and location of which offer clues to the underlying
diagnosis.
3. Details of the onset of symptoms (Mechanism of injury): Did
the symptoms have a traumatic or insidious origin; did they
arise subsequent to a new recreational activity or occupa-
tional demand?
4. Duration of symptoms: Are they acute, subacute, or chronic?
5. Response to previous treatment: Has the patient taken medi-
cation for the symptoms; rested or protected the shoulder; or
had injections, physical therapy, or surgery? Never assume
previously rendered diagnoses are correct or that previous
treatment was appropriately prescribed or successfully com-
pleted. Obtain and review all treatment reports and proto-
cols.
6. General health: Diabetes and hypothyroidism are associated
with adhesive capsulitis; rheumatoid disease can present
with shoulder pain; depression, workers’ compensation and
other insurance claims, and other life stresses can magnify
shoulder symptoms.
7. Hand dominance: In some of the general population and
certainly with unilaterally dominant sport athletes the domi-
nant shoulder may sit slightly lower due to increased muscle
mass or shoulder laxity. Range of motion may be different
from that of the nondominant side.
Following are the most commonly encountered primary
shoulder pathologies to keep in mind when evaluating a symp-
tomatic shoulder, along with the most likely elements in the his-
tory that will suggest them. Always keep in mind the fact that
more than one pathology may be present concurrently.
100
• Structural injury to the rotator cuff
• Glenohumeral instability
• Detachment of the superior glenoid labrum (i.e., SLAP le-
sion)
• Scapulothoracic dyskinesia, core stability deficits, and other
fitness or technique-related provocations
• Adhesive capsulitis (“frozen shoulder”)
• Calcific tendinitis
• Biceps tendon pathology
• Acromioclavicular degenerative joint disease
• Glenohumeral degenerative joint disease
• Cervical spine pathology
• Fractures
STRUCTURAL INJURY TO THE
ROTATOR CUFF
Although traumatic tears of the rotator cuff have been reported
even in children, structural injury to the cuff is most character-
istic in those older than age 40 years. Rotator cuff tears are so
characteristic of the elderly population that anyone older than
age 60 with shoulder pain can be presumed to have a rotator cuff
tear until proved otherwise. Younger patients with cuff symp-
toms tend to have only irritation of the rotator cuff (tendinosis)
rather than structural injury, with their pathology and symp-
toms frequently being the secondary manifestation of occult
primary pathology such as glenohumeral instability, SLAP
tears, scapulothoracic dyskinesia, core stability deficits, or poor
biomechanics.
Rotator cuff pathology may be of insidious onset, but it is
most often produced by a traumatic event or acute overuse,
particularly with an abduction/external rotation mechanism. In
the elderly, rotator cuff tears frequently occur during falls. Night
pain is characteristic of primary rotator cuff pathology and may
be severe enough to prevent sleep or awaken the patient from
sleep if she or he rolls onto the affected shoulder. Patients with
cuff disease find relief by placing the affected arm overhead with
the hand behind the head (the so-called Saha position). Pain is
minimal with use of the arm below breast level and is maximal
between 90 and 120 degrees of active elevation/abduction. Low-
ering the arm from the overhead position is often more painful
than raising it. Patients may describe crepitus, which is associ-
ated with chronic full-thickness cuff tears or thickening of the
cuff during chronic tendinosis and scarring of the subacromial
space.
Pain is localized to the subacromial area or the anterior/lat-
eral corner of the acromion, with radiation down the lateral arm
to the deltoid insertion. The pain is characteristically of a dull
aching quality, with the superimposition of a sharper stabbing
 21  Importance of the History in the Diagnosis of Shoulder Pathology
Biceps tendon
Supraspinatus
Infraspinatus
Posterior
glenohumeral
ligament
(Posterior bundle)
Teres minor
"Sling" of inferior
glenohumeral ligament
Posterior
Fig. 21.1  Superior Labrum Anterior to Posterior (SLAP) tear.
pain with use of the arm in the overhead position or with inter-
nal rotation. Rotator cuff pain does not radiate distal to the
elbow.
The use of medications may help relieve shoulder symptoms.
Rotator cuff pain is characteristically mitigated by anti-inflam-
matory medications, especially subacromial corticosteroid
injections, but with diminishing returns over time.  may be scapular and at the posterior joint line or anterior sub-
GLENOHUMERAL INSTABILITY
Glenohumeral instability is the most common underlying
pathology producing shoulder symptoms in patients younger
than 30 years of age. In children and teenagers, it is virtually
the only likely pathology. In the elderly population, instability is
associated with massive rotator cuff tears. In many instances, the
symptoms reflective of glenohumeral instability had a traumatic
origin of which the patient is aware. Apprehension with use of
the arm in a specific position is a subjective sign of instability,
but it is important to keep in mind that many patients with gle-
nohumeral instability have no subjective awareness of that fact.
When the diagnosis of instability is suspected, an important
goal when taking the history is to ascertain: (1) the degree of
instability (subluxation versus dislocation), (2) the onset (trau-
matic versus atraumatic or overuse), (3) the direction or direc-
tions of instability (anterior, posterior, or multidirectional), and
(4) whether there is a voluntary component.
The most common direction of instability, whether traumatic
or occult, is anterior/inferior. The direction of instability can be
determined during the history with specific questions related
to the arm position that produces symptoms: external rotation,
with or without abduction reflects an anterior/inferior laxity
pattern (e.g., pain with the cocking position during throwing).
Pain during the follow-through when throwing or during activ-
ities that position the arm in forward flexion/adduction/inter-
nal rotation suggests posterior instability. Pain that is associated
with activities that apply primarily inferior distraction force to
101
Superior glenohumeral
ligament
Subscapularis
Middle glenohumeral
ligament
Inferior glenohumeral
ligament (anterior bundle)
Pectoralis major
Latissimus dorsi
Teres major
Anterior
the shoulder, such as carrying a heavy object like a suitcase or
a pail of water, suggests inferior capsular laxity and multidirec-
tional instability.
Subtle glenohumeral instability is associated with a nonde-
script level of discomfort and diffuse pain about the shoulder
girdle. The discomfort is characteristically poorly localized and
acromial mimicking rotator cuff discomfort. Often patients will
relate that use of the arm overhead produces numbness and
tingling radiating distally without a specific dermatomal distri-
bution. This is known as the “dead arm syndrome.” A history
of repetitive microtrauma, such as participation in swimming
or throwing sports, without proper preparticipation condition-
ing is characteristically present when atraumatic glenohumeral
instability produces symptoms in teenage athletes. Although
labral pathology is often associated with glenohumeral instabil-
ity, its presence cannot generally be predicted by specific ques-
tions during the history.
If occult glenohumeral instability was not recognized, there
are associated deficits in scapulothoracic function and core sta-
bility, or poor technique was not adequately addressed during
treatment, there may be a history of failed medication use, reha-
bilitation, or surgery. 
DETACHMENT OF THE SUPERIOR
GLENOID LABRUM
Tears of the superior glenoid labrum (i.e., SLAP lesion) (Fig. 21.1)
do not generally produce unique primary symptoms that distin-
guish the pathology. Patients may describe pain generally located
in the posterior shoulder or “deep inside” the joint. Large labral
tears may produce “clicking” or “catching” sensations. Charac-
teristically, they produce secondary rotator cuff symptoms or are
associated with a history suggestive of glenohumeral instability.
Patients often relate a history of trauma, such as a fall onto an
outstretched hand, or a history of longstanding participation in
102 SECTION 3  Shoulder Injuries
an overhead throwing sport (the “peel-off ” lesion associated with
a tight posterior capsule).  over a lifetime of use or from prior trauma, and an inflammatory
SCAPULOTHORACIC DYSKINESIA,
CORE STABILITY DEFICITS, AND
OTHER FITNESS OR TECHNIQUE-
RELATED PROVOCATIONS
Scapulothoracic dyskinesia, core stability deficits, and other
fitness issues commonly contribute to shoulder symptoms
as a result of secondary irritation of the rotator cuff or other
muscle–tendon units resulting from biomechanical overload.
There is frequently a history of the atraumatic insidious onset
of shoulder pain associated with participation in a new recre-
ational or occupational activity.  (cuff tear arthropathy), particularly in elderly women. Symp-
ADHESIVE CAPSULITIS ("FROZEN
SHOULDER")
The typical “frozen shoulder” is not caused by trauma, although
patients will often retrospectively recall some history of minor
injury to which they ascribe the symptoms. Characteristically,
patients first recognize the problem when they find it difficult to
reach behind their back (secondary to an evolving internal rota-
tion deficit). Symptoms are progressive, with “freezing,” “frozen,”
and “thawing” stages having been defined to describe the natural
history of the problem. Frequently, secondary rotator cuff pain
will account for a substantial portion of the subjective symptoms.
Patients may also describe posterior shoulder discomfort with a
trapezius or periscapular location because those muscles become
fatigued when compensating for poor glenohumeral motion.
There is a significant association with diabetes and hypothyroid-
ism, and patients should be questioned about those general health
conditions. Adhesive capsulitis occurs bilaterally in this group.  FRACTURES
CALCIFIC TENDINITIS
Calcific tendinitis is characterized by the insidious, but rapid,
development of extremely severe subacromial or lateral-sided
shoulder pain, characteristically in patients of middle age. Nar-
cotics are often necessary to control the discomfort.  stretched arm). Characteristically, pain is immediate after
BICEPS TENDINOSIS
With advancing age, pathology in the long head of the biceps
becomes a frequent source of shoulder pain. Biceps tendinosis is
often associated with rotator cuff disease. However, pain origi-
nating in the biceps is referred to the anterior arm, as opposed
to cuff disease, which is characteristically lateral. It may radiate
to the elbow but not typically beyond. Because the biceps is a
supinator of the forearm, patients with biceps pathology may
complain of symptoms related to forearm rotation (i.e., when
turning a doorknob).  therapeutic regimen. One of the main keys to recovery is to
ACROMIOCLAVICULAR
DEGENERATIVE JOINT DISEASE
The symptom originating from the AC joint most typically is pain
over the superior shoulder that increases with horizontal adduc-
tion of the arm (because that compresses the AC joint) or use of the
affected arm overhead. Injury to the AC joint can occur with a fall
onto the lateral shoulder, AC joint arthritis can develop insidiously
condition known as “osteolysis of the distal clavicle” is associated
with weight lifting in young adults. AC joint disease may produce
scapulothoracic dyskinesia and secondary rotator cuff discomfort. 
GLENOHUMERAL DEGENERATIVE
JOINT DISEASE
Glenohumeral arthritis is an uncommon condition pro-
ducing generalized aching shoulder pain and progressive
loss of motion. GH arthritis may be associated with a his-
tory of previous surgical procedures (open ligament stabili-
zation, arthroscopic repair of large labral tears, and the use
of implantable “pain pumps”) and massive rotator cuff tears
toms are often maximal at night and more tolerable during
daily activities. Systemic rheumatoid arthritis may affect the
glenohumeral joint, but particularly in younger individuals, it
involves the AC or SC joints. 
CERVICAL SPINE PATHOLOGY
Cervical spine disease typically produces pain radiating from
the neck toward the posterior or superior shoulder. The pain is
usually worse at the end of the day and relieved by support of
the head at night. Generally, patients will experience pain and
stiffness with neck motion. Especially in the elderly, a coincident
association with rotator cuff disease is common. When cervi-
cal nerve root compression is present, most commonly C5 and
C6 are affected, and radicular symptoms (“sharp,” “stabbing,” or
“burning pain”) involving the forearm and hand radiate distal to
the elbow in a typical dermatomal distribution. 
Fractures about the shoulder are not uncommon in all age
groups. Typically, there is a specific history of trauma, but in
the osteoporotic elderly or other special situations, the injury
may seem to be of minimal force. The mechanism may be direct
(a fall or blow to the shoulder) or indirect (a fall on an out-
trauma, localized to the specific point of injury, and severe
enough to leave little doubt as to the nature of the problem.
Diagnosis is confirmed by radiographs. 
GENERAL SHOULDER
REHABILITATION GOALS
Range of Motion
Once the intake evaluation is completed, the therapist should
be more comfortable anticipating the patient’s response to the
normalize ROM. Early professions relied on visual estimations
or “quick” tests to assess shoulder motion. These tests include
combined shoulder movements such as the Apley’s scratch test
(Fig. 21.2), reaching across the body to the other shoulder (Fig.
21.3), or reaching behind the back to palpate the highest spi-
nous process (Fig. 21.4). These quick tests are great to observe
for overall asymmetry, but they cannot give an idea of isolated
losses objectively.
 21  Importance of the History in the Diagnosis of Shoulder Pathology
Fig. 21.2  Apley's scratch test.
Fig. 21.3  Reaching across the body to the other shoulder to deter-
mine range of motion.
Fig. 21.4  Reaching behind the back to palpate the highest spinous
process to determine range of motion.
Even more important is regaining normal arthrokinematic
motions at the shoulder. Active shoulder ROM is always gath-
ered before passive motions (Manske and Stovak 2006). Active
shoulder ROM measurements are seen in Table 21.1 (Man-
ske and Stovak 2006) and Fig. 21.5. Many times, gross overall
shoulder motion may appear to be only slightly limited, whereas
arthrokinematic motion is drastically dysfunctional. For
103
example, it is not uncommon for a patient to have full glenohu-
meral motion yet impinge as a result of altered scapulohumeral
motion from a restricted inferior or posterior shoulder capsule
creating obligate humeral translations.
Therefore, it is imperative to also ensure evaluation of isolated
glenohumeral motions is performed. One of the more common
problematic limited motions with a variety of shoulder con-
ditions is that of the posterior or inferior shoulder structures.
Debate continues as to whether this is a result of capsular or other
soft tissues. Regardless, it becomes an issue whenever elevation
of the glenohumeral joint is required because it may increase the
risk of impingement. Assessment of the posterior shoulder can
be done by measuring isolated glenohumeral internal rotation.
To perform this test the humerus is taken into passive internal
rotation while the scapula is stabilized by grasping the coracoid
process and the spine and monitoring for movement (Fig. 21.6).
When passive slack from the posterior shoulder is taken up,
the humerus will no longer internally rotate and resistance to
movement will allow the scapula to tilt forward. When motion
is detected or internal rotation has ceased, the examiner mea-
sures isolated glenohumeral internal rotation. Wilk et al. (2009)
have shown this to be moderately reliable, whereas Manske et al.
using the same technique have proved excellent test–retest reli-
ability (Manske et al. 2015). This motion should be compared
bilaterally to assess for a glenohumeral internal rotation deficit
(GIRD) between involved and uninvolved shoulders. A differ-
ence of greater than 20 degrees of internal rotation is thought to
be a precursor to shoulder pathology. Loss of shoulder internal
rotation is not always pathologic because some of this motion
may be lost as a result of bony changes in the humerus. The
concept of total shoulder rotation ROM should also be men-
tioned. By adding the two numbers of GH internal rotation and
external rotation together, a composite of total shoulder motion
can be obtained (Fig. 21.7). Ellenbecker et al. (2002), measur-
ing bilateral total rotation ROM in professional baseball and
elite junior tennis players, found that although a dominant arm
may show increased external rotation and less internal rotation,
the total ROM was not significantly different when comparing
the two shoulders. However, when Wilk and colleagues (2009)
examined professional baseball pitchers, they found that those
whose total ROM limitation exceeded more than a 5-degree
difference were more prone to injury resulting in loss of play-
ing time. Therefore, one needs to not only address the GIRD
but also should ensure that the total ROM is not limited. Using
normative data from population specific research can assist the
therapist in interpreting normal ROM patterns and identifying
when sport-specific adaptations or clinically significant adap-
tations are present (Ellenbecker 2004). Because there seems to
be a threshold to determine what can be considered a clinically
significant loss of internal rotation, Manske et  al. (2015) have
suggested two descriptions of naming GIRD—one which is
pathologic and one which is a normal, nonpathologic alterna-
tion of shoulder motion in overhead athletes.
Early in rehabilitation following soft tissue shoulder
repairs passive motion may predominate. These passive
ROMs can be performed using Codman circumduction
exercises or by therapist assistance. Passive motions can be
gained in all classical directions as long as there are no soft
tissue limitations. Other methods of gaining motion are
through joint mobilizations.
Passive and active assistive exercises initially should begin
with the patient in a supine position with the arm comfortably
104 SECTION 3  Shoulder Injuries

TABLE
21.1 Active Shoulder Range of Motion
American Academy of Kendall, McCreary, American Medical
Orthopedic Surgeons* and Provance† Hoppenfeld‡ Association§
Flexion 0–180 0–180 0–90 0–150
Extension 0–60 0–45 0–45 0–50
Abduction 0–180 0–180 0–180 0–180
Medial Rotation 0–70 0–70 0–55 0–90
Lateral Rotation 0–90 0–90 0–45 0–90

*American Academy of Orthopedic Surgeons: Joint motions: method of measuring and recording. Chicago, 1965, American Academy of Orthope-
dic Surgeons.
†Kendall FP, McCreary EK, Provance PG: Muscle testing and function with posture and pain, ed 4, Baltimore, 1993, Williams & Wilkins.
‡Hoppenfeld S: Physical examination of the spine and extremities, New York, 1976, Appleton-Century-Crofts.
§American Medical Association: Guide to the evaluation of permanent impairment, ed 3, Chicago, 1988, American Medical Association.

Adapted from Norkin CC, White DJ: Measurement of joint motion: a guide to goniometry, ed 2, Philadelphia, 1995, FA Davis.

180o

180o

Abduction
Forward
flexion

Adduction

Horizontal
0o flexion

60o
Extension Neutral-plane
of the scapula
("Scaption")
Internal External
rotation rotation
90o 90o
30–45o

A
Horizontal
extension
B
Fig. 21.5  Active shoulder range of motion measurements.

IR

ER
Fig. 21.7  Total rotation range of motion concept. (Redrawn from El-
lenbecker TS: Clinical Examination of the Shoulder. St. Louis, Saunders,
2004, p. 54.)

Fig. 21.6  Assessment of the posterior shoulder performed by measur-

ing isolated glenohumeral internal rotation.
 21  Importance of the History in the Diagnosis of Shoulder Pathology 105

at the side with a small towel roll or cushion under the elbow
and the elbow flexed. This position reduces the forces crossing
the shoulder joint by decreasing the effect of gravity and short-
ening the lever arm of the upper extremity. As the patient begins
to recover pain-free motion, the exercises can be progressed to
sitting or standing.
Once active motion can be initiated, the patient is encour-
aged to work early on pain-free ROM below 90 degrees of eleva-
tion. For most patients an early goal is 90 degrees of forward
flexion and approximately 45 degrees of external rotation with
the arm at the side. For surgical patients, it is the responsibility
of the surgeon to obtain at least 90 degrees of stable elevation
in the operating room for the therapist to be able to gain this
same motion after surgery. At this point in rehabilitation, meth-
ods to gain motion include active-assisted ROM with wands or
pulleys, passive joint mobilization, and passive stretching exer-
cises (Figs. 21.8 and 21.9). 
Pain Relief
Both shoulder motion and strength can be inhibited by pain
and swelling, with pain being the major deterrent. Pain can
be the result of the initial injury or from surgical procedures
attempting to repair/replace injured tissue. Pain relief can be
achieved by a variety of modalities including rest, avoidance of
painful motions (e.g., immobilization; Fig. 21.10), cryotherapy,
ultrasound, galvanic stimulation, and oral or injectable medi-
cations (Fig. 21.11). Previous literature substantiates effective-
ness of continuous cryotherapy following surgical procedures
such as open rotator cuff repairs, shoulder stabilization,

A B
Fig. 21.8  Exercises to regain motion. Active-assisted range of motion exercises using a pulley system (A) and a dowel stick (B).

A B

C D
Fig. 21.9  Passive joint mobilization. A, Forward flexion. B, External rotation with the arm at the side. C, External rotation with the arm in 90 degrees
of abduction. D, Cross-body adduction.
106 SECTION 3  Shoulder Injuries
biceps tenodesis, total shoulder arthroplasty, and arthroscopic
subacromial decompression (Singh et  al. 2001, Speer et  al.
1996) when compared to a placebo treatment. Postopera-
tive cryotherapy results in immediate and continued cooling
of both subacromial space and glenohumeral joint tempera-
tures (Osbahr et al. 2002) and decreases the severity and fre-
quency of pain, which allows more normal sleep patterns and
increases overall postoperative shoulder surgery comfort and
satisfaction (Singh et al. 2001, Speer et al. 1996). Recent evi-
dence has shown that compressed cold therapy around the
shoulder following surgery does not have any increased bene-
fit over a standard ice wrap when outcomes were average pain,
worst pain, or morphine equivalent doses of pain medication
(Kraeutler et al. 2015). The theoretical mechanism behind the
physiologic benefits of cryotherapy include local modulation
of blood flow and oxygen utilization (White and Wells 2013)
to spinal cord–mediated reflex arcs (Boyraz et  al. 2009, Lee
et al. 2002).  exercise used in an elevated, more functional position is the
Muscle Strengthening
Appropriate timing for initiation of muscle strengthen-
ing exercises during shoulder rehabilitation is completely
dependent on the diagnosis. A simple uncomplicated
impingement syndrome may allow strengthening exercises
Fig. 21.10  Immobilization of the shoulder for pain relief.
A B
Fig. 21.11  Modalities for pain relief. A, Ultrasound. B, Galvanic stimulation. C, Cryotherapy.
to begin on day 1, whereas a postoperative rotator cuff repair
may require up to 10 weeks before initiation of strengthen-
ing of the cuff, allowing the repaired tendon time to heal
securely to the greater tuberosity. Strengthening of the
muscles around the shoulder can be accomplished through
different exercises. Early safe exercises include isometrics
(Fig. 21.12) and closed kinetic chain exercises (Figs. 21.12
and 21.13). The advantage of closed chain exercises is a co-
contraction of both the agonist and the antagonist muscle
groups that help enhance glenohumeral stability. This co-
contraction closely replicates normal physiologic motor pat-
terns and function to help stabilize the shoulder, limiting
abnormal and potentially destructive shear forces crossing
the glenohumeral joint. A closed chain exercise for the upper
extremity is one in which the distal segment is stabilized
against a fixed object. This fixed stable object may be a wall,
door, table, or floor. One example of a closed kinetic chain
“clock” exercise in which the hand is stabilized against a wall
or table (depending on the amount of elevation allowed) and
the hand is rotated to different positions of the clock face
(Fig. 21.13). This is done by creating an isometric contrac-
tion in the direction of the numbers around the clock face.
Alternatively, the therapist can also give manual resistance in
the same directions to the patient’s arm as he or she is stabi-
lizing it by holding on to the wall (Fig. 21.14). These motions
are thought to effectively stimulate rotator cuff activity. Ini-
tially, the maneuvers are done with the shoulder in less than
90 degrees of glenohumeral abduction or flexion. As healing
tissues improve and motion is recovered, strengthening pro-
gresses to greater amounts of shoulder abduction and for-
ward flexion.
Isometric exercises can also be performed in various
ranges of shoulder elevation. It is easiest to do this with the
patient in supine. The “balance position” is that of 90 to 100
degrees of forward flexion of the shoulder while supine (Fig.
21.15). This position requires little activation of the deltoid
so that the rotator cuff can be worked without provoking
a painful shoulder response. In this position a contraction
from the deltoid will result in joint compression, helping to
enhance joint stability. Rhythmic stabilization or alternating
isometric exercises can be performed very comfortably in the
supine position and can be done for both rotator cuff and
shoulder muscles.
C
 21  Importance of the History in the Diagnosis of Shoulder Pathology 107

Strengthening of scapular stabilizers is important early on in
the rehabilitation program. Scapular strengthening can begin in
side lying with isometric muscle contractions or isotonic con-
tractions or even closed chain (Fig. 21.16) and progress to open
kinetic chain exercises (Fig. 21.17).
Recovery can be enhanced by utilizing proprioceptive
neuromuscular facilitation (PNF) exercises. The thera-
pist can apply specific sensory inputs to facilitate a specific
activity or movement pattern. One example of this is the D2
flexion–extension pattern for the upper extremity. During
this maneuver, the therapist applies resistance as the patient
moves the arm through predetermined patterns. These exer-
cises can be done in various levels of shoulder elevation
including 30, 60, 90, and 120 degrees of elevation. These
exercises are to enhance the stability of the glenohumeral
joint through a given active ROM.
As the patient progresses, more progressive strengthening
can be instituted by moving from isometric and closed chain
exercises to those that are more isotonic and open chain in
nature (Fig. 21.18). Open chain exercises are done with the
distal end of the extremity no longer stabilized against a fixed
object. This results in the potential for increased shear forces
across the glenohumeral joint. Shoulder internal and external
rotation exercises are done initially standing or seated with the
shoulder in the scapular plane. The scapular plane position is
recreated with the shoulder between 30 degrees and 60 degrees

A B
Fig. 21.12  Closed chain shoulder exercises. A, Isometric strengthening of the rotator cuff in abduction (pushing out against the wall). B, Isometric
strengthening of the rotator cuff in external rotation.

Fig. 21.13  Wall clock exercise. Fig. 21.14  Wall clock exercise with manual resistance.
108 SECTION 3  Shoulder Injuries
anterior to the frontal plane of the thorax or halfway between
directly in front (sagittal plane) and directly to the side (fron-
tal plane). The scapular plane is a much more comfortable
plane to exercise in because it puts less stress on the joint cap-
sule and orients the shoulder in a position that more closely
represents functional movement patterns. Rotational exercises
should begin with the arm comfortably at the patient’s side
and advance to 90 degrees of elevation based on the patient’s
injury, level of discomfort, and stage of soft tissue healing. The
variation in position positively stresses the dynamic stabilizers
by altering the stability of the GH joint from maximum stabil-
ity with the arm at the side to minimum stability with the arm
in 90 degrees of abduction.
For those who participate in either competitive or recre-
ational overhead sporting activities, the most functional of all
open chain exercises are plyometric exercises. Plyometric activ-
ities are defined by a stretch-shortening cycle of the muscle ten-
don unit (Davies et al. 2015). This is a component of almost all
athletic activities. Initially the muscle is eccentrically stretched
and loaded. Following the stretched position the shoulder/arm
quickly performs a concentric contraction. These forms of exer-
cises are higher-level exercises that should only be included
Fig. 21.15  The "balance position" is that of 90 to 100 degrees of for-
ward flexion of the shoulder while supine.
B C
Fig. 21.16  Closed chain strengthening exercises of the scapula stabilizers. A, Scapular protraction. B and C, Scapular retraction.
once the patient has developed an adequate strength base and
achieved full ROM (Davies et al. 2015). Not all patients require
plyometric training, and this should be discussed before their
incorporation. Plyometric exercises are successful in develop-
ment of strength and power. Tubing, medicine ball training, or
free weights are all acceptable plyometric devices for the shoul-
der (Fig. 21.19).
Nothing is more important when rehabilitating the shoul-
der than remembering the musculature of the upper extremity
and core. Total arm strengthening is a must when rehabilitating
the shoulder because injuries to the shoulder that limit normal
functional movement patterns and use will result in strength
deficits of other upper extremity muscles. Overall conditioning
including stretching, strengthening, and endurance training of
the other components of the kinematic chain should be per-
formed simultaneously with shoulder rehabilitation.
Patient motivation is a critical component of the rehabilita-
tion program. Without self-motivation, any treatment plan is
destined to fail. For complete recovery, most rehabilitation pro-
tocols will require the patient to perform some of the exercises
on his or her own at home. This requires not only an under-
standing of the maneuvers but also the discipline for the patient
to execute them on a regular basis. Patient self-motivation is
even more crucial in the present medical environment with
increased attention and scrutiny directed at cost containment.
Many insurance carriers limit coverage for rehabilitation at the
patient’s expense. As a result, a comprehensive home exercise
program should be outlined for the patient early in the rehabili-
tation process. This allows patients to augment their rehabilita-
tion exercises at home and gives them a feeling of responsibility
for their own recovery.
REFERENCES
A complete reference list is available at https://expertconsult
.inkling.com/.
 A B

C D

E F

G H
Fig. 21.17  Open chain strengthening exercises of the scapula stabilizers without (A–D) and with (E–H) lightweight dumbbells.

A B C
Fig. 21.18  Open chain isotonic strengthening of the rotator cuff (internal rotation) using Theraband tubing (A), lightweight dumbbells (B), and
external rotation strengthening (C).

A B
Fig. 21.19  Plyometric shoulder strengthening exercises using Theraband tubing (A) and an exercise ball (B).
REFERENCES
Boyraz I, Oktay F, Celik C, Akyuz M, Uysal H. Effect of cold application and ti-
zanidine on clonus: clinical and electrophysioligical assessment. J Spinal Cord
Med. 2009;32:132–139.
Davies GJ, Reimann BL, Manske RC. Current concepts of plyometric exercise.
Int J Sports Phys Ther. 2015;10(6):760–786.
Ellenbecker TS. Clinical Examination of the Shoulder. St. Louis: Saunders;
2004.
Ellenbecker TS, Roetert EP, Bailie DS, et al. Glenohumeral joint total rotation
range of motion in elite tennis players and baseball pitchers. Med Sci Sports
Exer. 2002;34(12):2052–2056.
Kraeutler MH, Reynolds KA, Long C, McCarty EC. Compressive cryotherapy
versus ice-a prospective, randomized study on postoperative pain in patients
undergoing arthroscopic rotator cuff repair or subacromial decompression. J
Shoulder Elbow Surg. 2015 Jun;24(6):854–859. http://dx.doi.org/10.1016/j.jse
.2015.02.004. Epub 2015 Mar 29.
Lee SU, Bang MS, Han TR. Effect of cold air therapy in relieving spasticity: ap-
plied to spinalized rabbits. Spinal Cord. 2002;40:167–173.
Manske RC, Stovak M. Preoperative and postsurgical musculoskeletal examina-
tion of the shoulder. In: Manske RC, ed. Postsurgical Orthopedic Sports Reha-
bilitation. Knee and Shoulder. St. Louis: Mosby; 2006.
Manske RC, Wilk KE, Davies TE, Ellenbecker TS, Reinold M. Glenohumeral
motion deficits: friend or foe? Int J Sports Phys Ther. 2015;8(5):537–553.
Osbahr DC, Cawley PW, Speer KP. The effect of continuous cryotherapy on
glenohumeral joint and subacromial space temperatures in the postoperative
shoulder. Arthroscopy. 2002;18(7):748–754.
Singh H, Osbahr DC, Holovacs TF, et al. The efficacy of continuous cryotherapy
on the postoperative shoulder: a prospective, randomized investigation. J
Shoulder Elbow Surg. 2001;10(6):522–525.
Speer KP, Warren RF, Horowitz L. The efficacy of cryotherapy in the postopera-
tive shoulder. J Shoulder Elbow Surg. 1996;5(1):62–68.
White GE, Wells GD. Cold-water immersion and other forms of cryotherapy: phys-
iological changes potentially affecting recovery from high-intensity exercise.
Extrem Physiol Med. 2013;2(1):26. http://dx.doi.org/10.1186/2046-7648-2-26.
Wilk KE, Reinold MM, Macrina LC, et  al. Glenohumeral internal rotation
measurements differ depending on stabilization techniques. Sports Health.
2009;1(2):131–136. 23015864.
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