Exercise
• Short but frequent exercise sessions (four or five times per day).
• Low number of repetitions per exercise.
• Only passive or assisted shoulder ROM exercises and only within the “safe” limits of ranges noted during surgery. Absolutely no end-range stretching.
• Passive external rotation to neutral or to less than 30° to avoid […]

Supine
• Arm immobilized in sling, which is worn continuously
• Elbow flexed to 90°
• Forearm and hand resting on abdomen
• Arm supported at the elbow on a folded blanket or pillow slightly away from the side and anterior to the midline of the trunk
• Forward flexion (10° to 20°), slight abduction, and internal rotation of the […]

Intraoperative
• Insufficient lengthening of a tight subscapularis muscle-tendon unit
• Intraoperative damage to the axillary or suprascapular nerves, affecting the deltoid and supraspinatus/infraspinatus muscles, respectively
• Fracture of the humerus
Soft Tissue-Related Postoperative Complications
• Re-tearing a repaired rotator cuff mechanism
• Postoperative disruption of the repaired subscapularis (detached from the lesser tuberosity for the surgical approach and reattached medially […]

Arthroplasty of the GH joint falls into several categories, the most common of which are total shoulder replacement arthroplasty, in which the glenoid and humeral surfaces are replaced and hemireplacement arthroplasty (hemiarthroplasty), in which one surface, the humeral head, is replaced. Other categories of shoulder arthroplasty include interpositional and resurfacing arthroplasties, which involve less extensive […]

Severe deterioration of one or both surfaces of the GH joint, causing significant pain and loss of upper extremity function, or an acute or nonunion fracture of the proximal humerus often must be addressed with surgical intervention. Underlying pathologies, causing advanced joint destruction, include late-stage osteoarthritis (OA), rheumatoid arthritis (RA), traumatic arthritis, cuff tear arthropathy, […]

Related Pathologies and Etiology of Symptoms
Overuse Syndromes. Overuse syndromes of the AC joint are frequently arthritic or post-traumatic conditions. The causes may be from repeated stressful movement of the joint with the arm at waist level, such as with grinding, packing assembly, and construction work, or repeated diagonal extension, adduction, and internal rotation motions, as […]

Progressively Increase Flexibility and Strength
• Stretching and strengthening exercises are progressed as the joint tissue tolerates. The patient should be actively involved in self-stretching and strengthening by this time, so emphasis during treatment is on correct mechanics, safe progressions, and exercise strategies for return to function.
• If capsular tissue is still restricting ROM, vigorous manual […]

When symptoms are subacute, follow the guidelines emphasizing joint mobility, neuromuscular control, and instructions to the patient for self-care.
NOTE: For normal shoulder joint mechanics, there must be good scapular posture and control, and the humerus must be able to externally rotate. To avoid suprahumeral impingement, passive stretching above 90° should be avoided until there is […]

Control Pain, Edema, and Muscle Guarding
• The joint may be immobilized in a sling to provide rest and minimize pain.
• Intermittent periods of passive or assisted motion within the pain free/protected ROM and gentle joint oscillation techniques are initiated as soon as the patient tolerates movement in order to minimize adhesion formation.
Maintain Soft Tissue and […]

To make sound clinical decisions when managing patients with shoulder disorders, it is necessary to understand the various pathologies, surgical procedures, and associated precautions and to identify presenting impairments, functional limitations, and possible disabilities.
JOINT HYPOMOBILITY: NONOPERATIVE MANAGEMENT
Glenohumeral Joint
Restricted mobility of the glenohumeral joint may occur as a result of pathology such as rheumatoid arthritis or […]

Common Sources of Referred Pain in the Shoulder Region
Cervical Spine
• Vertebral joints between C3 and C4 or between C4 and C5
• Nerve roots C4 or C5
Referred Pain from Related Tissues
• Dermatome C4 is over the trapezius to the tip of the shoulder.
• Dermatome C5 is over the deltoid region and lateral arm.
• Diaphragm: pain perceived […]

Scapulohumeral Rhythm
Motion of the scapula, synchronous with motions of the humerus, allows for 150° to 180° of shoulder ROM into flexion or abduction with elevation. The ratio has considerable variation among individuals but is commonly accepted to be 2:1 (2° of glenohumeral motion to 1° of scapular rotation) overall motion. During the setting phase (0° […]

Scapulothoracic Articulation
Normally there is considerable soft tissue flexibility, allowing the scapula to slide along the thorax and participate in all upper extremity motions.
Motions of the Scapula
Motions of the scapula are:
• Elevation, depression, protraction (abduction), and retraction (adduction), with clavicular motions at the SC joint are also component motions when the humerus moves.
• Upward and downward […]

The shoulder girdle has only one bony attachment to the axial skeleton. The clavicle articulates with the sternum via the small sternoclavicular joint. As a result, considerable mobility is allowed in the upper extremity. Stability is provided by an intricate balance between the scapular and glenohumeral muscles and the structures of the joints in the […]

The design of the shoulder girdle allows for mobility of the upper extremity. As a result, the hand can be placed almost anywhere within a sphere of movement, being limited primarily by the length of the arm and the space taken up by the body. The combined mechanics of its joints and muscles provide for […]

The function of the temporomandibular joint (TMJ) is closely related to the function of the upper cervical spine and posture. Because of this close relationship, a brief description of impairments and interventions related to the TMJ are included.
Signs and Symptoms
Pain from a variety of sources is often cited as part of the temporomandibular joint (TMJ) […]

As described, symptoms in soft tissues, including muscles, can occur as a result of direct trauma (tears/contusions), strain from sustained or repetitive activities, or as a protective mechanism (guarding/spasm) from injury to joints or other tissues.
Management During the Acute Stage: Protection Phase
Pain and Inflammation Control
Use appropriate modalities and massage to control pain and inflammation. Passive […]

Some patients benefit from spinal manipulation during the early stages of intervention. A clinical prediction validation study determined that those most likely to benefit from spinal manipulation presented with: (1) symptom duration of less than 16 days, with no symptoms distal to the knee; (2) at least one hypomobile lumbar segment; (3) at least one […]

Patients with segmental instability—including hypermobility; ligamentous laxity; diagnoses such as spondylolysis, spondylolisthesis, or poor neuromuscular control of the core and stabilizing musculature—require interventions that improve stability. Some of the patients may have a history of trauma, repeated manipulations, or early signs of spondylosis. Mobility testing of the spinal segments reveals increased mobility at one or […]

Patients may present with a flexed posture and be unable to extend because of increased neurological symptoms and decreased mobility; these patients would benefit from early interventions that emphasize flexion of the involved segments to relieve symptoms. The patients may have a medical diagnosis of spondylosis or spinal stenosis, may have sustained an extension load […]

Disk lesions in the cervical spine are less common than in the lumbar spine. Often disk extrusions are an indication for surgery because of potential compromise of the spinal canal and pressure on the spinal cord. Patients may present with peripheral neuropathy and forward-head posture without a diagnosis of disk pathology. Symptoms increase with activities […]

These techniques are used only if the test movements have shown that the postures and movements used decrease the symptoms. If no test movements decrease the symptoms, this mechanical approach to treatment should not be used.
Management of Acute Symptoms
If symptoms are severe, bed rest is indicated with short periods of walking at regular intervals. Walking […]

Patients with an extension bias often assume a flexed posture or a flexed posture with lateral deviation of the trunk or neck, but during the examination sustained or repetitive extension maneuvers reduce or relieve their symptoms. These patients would benefit from early interventions that emphasize extension of the involved segments. The impairments may be due […]

Indications. Extension is used if pain and/or neurological symptoms centralize (decrease of move more proximally) during extension testing maneuvers and peripheralize (worsen) during flexion. Extension is also indicated for flexed postural dysfunctions with limited range into extension.
Contraindications to Specific Spinal Movements
Extension of the spine is contraindicated
• When no position or movement decreases or centralizes the […]

During examination, some patients do not respond to extension, flexion, or even mid-range spinal positions or motions due to the acuity of or mechanical stimuli from their condition. The person is often more comfortable lying down and may have partial or full relief with a traction test maneuver to the painful region of the spine.
For […]

When the signs and symptoms of the inflammatory process are under control and pain is no longer constant, the patient is progressed through a program of safe muscle endurance and strengthening exercises to prepare the tissue for functional activities and rehabilitation training. Functional activities that can be performed safely are resumed. Pain may still interfere […]

Patients who have been treated through the acute and subacute phases of healing with appropriately graded exercises should have minimal impairments that prevent or restrict daily activities. Individuals who must do heavy material handling (e.g., a manual laborer, firefighter, caregiver of small children or patients) or who participate in high-demand sports activities may require additional […]

• Supine:
Hook-lying flexes the lumbar spine; legs extended extends the spine. A pillow under the head flexes the neck; a small roll under the neck stabilizes a mild lordosis with the head neutral.
• Prone:
Use of a pillow under the abdomen flexes the lumbar spine; no pillow extends the spine. To maintain the cervical spine in […]

Use of modalities and massage to decrease pain and swelling from acute symptoms is appropriate during the acute stage. It is also important that the patient becomes an active participant in his or her program. Kinesthetic training of neutral or functional spinal posture, nondestructive movements in the pain-free range, awareness and activation of core musculature, […]

General—Stage of Recovery

• Acute with inflammation (0-4 weeks).
• Acute without inflammation (0-4 weeks): intermittent symptoms with acute nerve root symptoms.
• Subacute (4-12 weeks).
• Chronic (> 12 weeks).
• Chronic pain syndrome (> 6 months).
Non-Weight-Bearing Bias (Traction Syndrome)
• Patient does not tolerate being upright for basic ADLs and IADLs.
• Movement testing makes symptoms worse.
• Traction (or other […]