Flexibility and Rehab Tips

The Flexibility and Rehab Tips Column provides practical

information on the role of rehabilitation and flexibility on
both performance and the modification of injury risk.

COLUMN EDITOR:
Ben Reuter, PhD, CSCS*D, ATC

External Rotation
Strengthening With Manual
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Distraction for Individuals

With Glenohumeral
Osteoarthritis
Nicole D. Nicholas, PT, DPT1 and Steven B. Ambler, PT, DPT, OCS2
1
Tallahassee Orthopedics and Sports Physical Therapy, Tallahassee, Florida; and 2Center Coordinator of Clinical
Education, School of Physical Therapy and Rehabilitation Sciences, USF Health Morsani College of Medicine,
University of South Florida, Tampa, Florida

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in the HTML and PDF versions of this article on the journal’s Web site (http://journals.lww.com/nsca-scj).

ABSTRACT DESCRIPTION OF THE EXERCISE IS movements that create an imbalance

OSTEOARTHRITIS CAN LEAD TO
MOVEMENT LIMITATIONS, WHICH
ARE A BARRIER FOR STRENGTH
TRAINING. IN SOME INSTANCES
WHERE IMPROVED STRENGTH IS
KNOWN TO DECREASE SYMP-
TOMS AND IMPROVE PATIENT RE-
PORTED FUNCTION, THERE EXISTS
A DIFFICULTY IN DEVELOPING
TRAINING ROUTINES THAT
ADDRESS THE WEAKNESS WITH-
OUT SYMPTOM AGGRAVATION.
THIS ARTICLE AIMS TO DESCRIBE
A TECHNIQUE TO DECREASE PAIN
AND IMPROVE JOINT MOTION
WHILE STRENGTHENING THE
ROTATOR CUFF IN INDIVIDUALS
WITH OSTEOARTHRITIS OF THE
GLENOHUMERAL JOINT. A
PROVIDED USING MANUAL DIS-
TRACTION TO REDUCE COM-
PRESSIVE AND SHEAR FORCES
WHILE ALLOWING FOR PAIN-FREE
PERFORMANCE AND STRENGTH-
ENING OF THE ROTATOR CUFF.
INTRODUCTION
steoarthritis is a degenerative
O disease that affects the integrity
of the entire joint, including
articular cartilage, tendons, ligaments,
capsule, and bone (5,7,14,15). While
the direct causes of the disease are still
debated, a relationship between high,
repetitive, or abnormal mechanical
stress and cartilage degeneration exists
(5,8,15). Joint forces can be affected by
sustained postures or repetitive
of the supporting structures of the joint
(5,8,15). While research has favored
muscle strengthening and exercise to
improve movement patterns and
reduce mechanical stress in osteoar-
thritic joints of the lower extremity,
evidence for the glenohumeral joint
is lacking, especially in the areas of
pain and function (1,5,13). While it is
unclear whether muscle weakness,
most notably the rotator cuff, is a cause
or consequence of osteoarthritis, there
is a notable correlation (5,13,14). The
rotator cuff, consisting of the supraspi-
natus, infraspinatus, teres minor, and
subscapularis, functions as a force cou-
ple among the larger musculature, such
as the deltoid, surrounding the shoul-
der girdle. This force couple allows for
uniform compression and a reduction

80 VOLUME 37 | NUMBER 4 | AUGUST 2015 Copyright Ó National Strength and Conditioning Association

Figure 1. (A and B) Starting and ending position. Position the arm in the plane of the
scapula using a towel roll, 308 of abduction and 308 of flexion with the
elbow flexed to 908 to allow easy access for distraction while maximizing
posterior muscle activity. The forearm may be placed 308 below the hor-
izontal plane for comfort.
of sheer forces during physiologic
shoulder motion (3,6,12). Excess of
these sheer forces lead to microtrauma
of the cartilage and eventually macro-
trauma characterized by visible
arthritic changes, pain, and functional
limitation (10,14). Specifically, the
external rotators (infraspinatus and
teres minor) have been shown to assist
in maintaining normal glenohumeral
kinematics (4). Furthermore, impair-
ments in the glenohumeral external
rotators have been found in conditions
thought to produce the repetitive
microtrauma, such as impingement,
which are a likely precursor to osteo-
arthritis in the shoulder (4,5,9). Pain
itself has been suggested to alter the
sensorimotor system causing impair-
ments in muscle strength and motor
control (11). Pain has been suggested,
along with weakness and stiffness, to
cause further alterations in mechanics
and deterioration of the joint (5,11,13).
This creates a paradox for the client
with osteoarthritis, with a condition
that worsens with weakness, but an
inability to strengthen the muscles or
Strength and Conditioning Journal | www.nsca-scj.com
be active secondary to pain. The pur-
pose of this article is to describe a tech-
nique using a distraction mobilization
that could allow for reduced or pain-
free strengthening of the rotator cuff of
an osteoarthritic joint.
There are many exercises that
strengthen the rotator cuff muscles.
Careful considerations for exercises
that minimize sheer forces and maxi-
mize rotator cuff recruitment are
important for the osteoarthritic shoul-
der (5,13,14). For the purposes of this
article and describing a specific exer-
cise most likely to reduce the sheer
stress producing microtrauma at the
glenohumeral joint, strengthening of
the infraspinatus and teres minor will
be discussed. These muscles are pri-
mary movers for external rotation
and decrease anterior and superior
translation of the humeral head
(3,6,12,13). The exercise (see Video,
Supplemental Digital Content 1,
http://links.lww.com/SCJ/A156) per-
forming external rotation at approxi-
mately 308 of abduction was chosen
for multiple reasons. First, the infraspi-
natus and teres major demonstrate
their greatest moment arm with slight
humeral abduction using a towel roll
(3,12). Biomechanical analysis and
electromyographic studies have also
demonstrated maximal muscle recruit-
ment in this position from these
muscles compared with higher degrees
of abduction (3,12). Second, this posi-
tion reduces the need for dynamic con-
trol of the scapulothoracic joint (12).
Many studies have shown poor scap-
ulohumeral control in those presenting
with pain and range of motion restric-
tions (11). By reducing the potential for
scapulohumeral impairments, there
can be added focus on the correct rota-
tion of the humeral head within the
glenoid until the client can progress
to more functional exercises that may
mimic the client’s daily or desired rec-
reational activities. An example of
impingement syndromes helps to
explain the importance of positioning
for this exercise, as well as in describing
the important function of the muscles
that are addressed during this
81
Flexibility and Rehab Tips
Figure 2. (A) Scapulothoracic joint positioned in neutral and should not deviate during the exercise: A1, with shirt; A2, without shirt.
(B) Glenohumeral joint positioned in the plane of the scapula and should not deviate during the exercise.
technique. Subacromial impingement
can be characterized by weakness of
the rotator cuff musculature and move-
ment impairments of excessive supe-
rior glide of the humerus during
shoulder flexion or abduction (2,12).
The importance of strengthening the
rotator cuff is highlighted in the treat-
ment of the movement impairments
seen with impingement. In addition,
the joint positions chosen for this exer-
cise have been shown to reduce move-
ments associated with impingement,
while maximizing muscle recruitment
(3,12). While evidence demonstrating
a direct association between impinge-
ment syndromes and osteoarthritis is
lacking, one can see the link between
rotator cuff weakness, impingement,
and the potential cartilage destruction
associated with osteoarthritis through
an understanding of abnormal move-
ment patterns and its effect on the joint
(5). It is, therefore, important to not
only address the osteoarthritic joint
with an exercise that maximizes muscle
recruitment but that also maximizes
82 VOLUME 37 | NUMBER 4 | AUGUST 2015
correct joint mechanics and reduces
mechanical stress.
Performing the exercise (right glenohum-
eral external rotation with distraction):
 Secure the resistance (elastic resis-
tance band or cable weight stack)
to the left of the client at the height
of the umbilicus.
 Position the arm in the plane of the
scapula using a towel roll, 308 of
abduction and 308 of flexion with
the elbow flexed to 908 to allow easy
access for distraction while maxi-
mizing posterior muscle activity.
The forearm may be placed 308
below the horizontal plane for com-
fort (Figure 1A).
 The client should externally rotate
the glenohumeral joint as far as
they can without substitution and
then return to the starting position
(Figure 1B).
 Do not allow substitutions such as
glenohumeral elevation or horizontal
abduction and trunk rotation during
the motion (Figure 2B).
 The resistance should be present at
the starting position and remain
throughout the entire motion.
 Both concentric movement into
external rotation and the eccentric
return to slight internal rotation
should be at a speed that allows for
correct performance without substi-
tution or compensatory movement
at the glenohumeral and scapulo-
thoracic joints.
 The glenohumeral joint should
remain in the plane of the scapula
with care taken to prevent scapula
dyskinesia during the motion
(Figure 2A).
 The optimal resistance will be
dependent on the phase of participa-
tion and individual characteristics of
the client. The resistance level
should be one that can be performed
without participant discomfort or
substitution.
Adding distraction:
 The rehabilitation provider will
place the web space of one hand
under the arm as close to the axillary

Figure 3. (A and B) Lateral distraction is applied manually throughout the motion of
glenohumeral external rotation. Care is taken not to place excessive
compression on the neurovascular structures of the medial arm.
fold as possible while taking care to
prevent compression of the neuro-
vascular structures, such as the bra-
chial plexus and the brachial artery.
The opposite hand should be placed
on the lateral side of the elbow
(Figure 3A).
 The client will start in slight internal
rotation, with their hand in front of
their umbilicus and the forearm in
pronation. Apply a distractive lateral
force with the hand in the axilla and
instruct the client to slowly rotate
the arm clockwise, into external
rotation, while maintaining an
adduction force into the towel. An
adduction force can be added with
the opposite hand at the elbow to
create an increased fulcrum for dis-
traction (Figure 3B). See Supplemen-
tal Digital Content 1 (see Video,
http://links.lww.com/SCJ/A156)
for a video demonstration of this
exercise.
Optional modification (Figure 4)
 Clients with balance impairment may
benefit from performance of this tech-
nique while sitting (Figure 4A and 4B).
 The client should have adequate
trunk stability since the hip muscu-
lature is limited in their ability to
stabilize in this position.
Strength and Conditioning Journal | www.nsca-scj.com
 Care should be taken to prevent
rotation of the trunk and a chair
may be used to prevent compensa-
tory trunk movement.
The success of this technique depends
on the severity of osteoarthritis includ-
ing the anatomical positioning of
degeneration, the available range of
motion of the joint, and the profi-
ciency of the provider in performing
the technique. The distraction compo-
nent of the exercise is a joint mobiliza-
tion technique and thus should only be
performed when it falls within the pro-
fessional purview of the provider, and
when applicable, within their jurisdic-
tional scope. There are many other
considerations for the success of this
technique, including but not limited
to scapular humeral rhythm, postural
alignment, and other rotator cuff and
periscapular muscle performance. The
distraction with strengthening tech-
nique can be modified to address these
impairments as well.
In conclusion, osteoarthritis is a de-
generative disease, which causes re-
strictions in motion and pain.
Conservative management can be dif-
ficult and is understudied in this pop-
ulation. For client’s wishing to avoid
surgery or those interested in maxi-
mizing strength and motion before
surgery, distraction with strengthen-
ing is an alternative. Distraction not
only decreases compressive forces
but is also beneficial to the surround-
ing synovia, which is important for
joint nutrition and the inflammatory
process (7,8,10). While exercise has
not been shown to reverse existing
degeneration of cartilage, stress within
normal mechanics and under accept-
able tissue loads can promote remod-
eling of injured tissue and perhaps
prevent progression of the disease
process (7,8). Perhaps most impor-
tantly, by strengthening the appro-
priate muscles and controlling for
repetitive abnormal and excessive
mechanical stress on the tissues, one
could theoretically break the cycle of
degeneration and subsequent pain
and functional limitation in these in-
dividuals (15).
83
Flexibility and Rehab Tips
Figure 4. (A and B) Modification of the exercise and mobilization technique to sitting.
Conflicts of Interest and Source of Funding:
The authors report no conflicts of interest
and no source of funding.
Nicole D. Nicholas is a staff physical
therapist at Tallahassee Orthopedics and
Sports Physical Therapy.
Steven B. Ambler is an Assistant
Clinical Professor in the School of Phys-
ical Therapy and Rehabilitation Sciences
at the University of South Florida.
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