EXERCISES FOR RANGE
OF MOTION AND STRENGTHENING OF SHOULDER
The rehabilitation exercises shown in
this section are applicable to both nonoperative and postoperative treatment
for all of the shoulder conditions discussed in this book. The specific
exercises used, their progression, and their coordination with other treatment
modalities are specific to the diagnosis, the severity of the pathologic
process, and many other patient and surgical factors. A detailed discussion for
each of these conditions is beyond the scope of this book.
In general principles, the exercise
program should start with the easiest exercises to perform and can be
progressed when the early phase exercises can be done easily and with comfort.
The first priority in rehabilitation of the shoulder is pain management and to
avoid injury during the exercises. Pain management may include one or more of
the following: application of ice or heat; use of nonsteroidal anti-inflammatory
agents, narcotic medication, corticosteroid injections, or bracing; nerve
blocks; or surgery. The first priority is to regain most of the passive range
of motion before concentrating on strengthening. Strengthening should include
both the shoulder and scapula as well as the trunk musculature. Strengthening
of the scapula should begin at the time to start phase I strengthening of the
glenohumeral musculature. Scapula-strengthening exercises include shoulder
shrugs and rowing-type exercises (shoulder protraction and retraction).
Coordination of scapula strengthening with glenohumeral strengthening is
necessary for successful progression to the overhead exercises of phase II. In
general, the progression of strengthening of the glenohumeral muscles should be
first strengthening the rotator cuff in nonimpingement arcs of motion (phase I)
to obtain good strength in rotation by the side as well as good scapula
strength before beginning active elevation strengthening. Before starting
resisted elevation with weights the patient should have full active elevation
without a weight. If this is not achieved, continue phase I strengthening and
scapula strengthening and add gatching and closed-chain active elevation
strengthening. When full active elevation is achieved without resistance, then
the patient can start phase II strengthening.
Most effective rehabilitation programs
require a daily home-based effort by
the patient. In most circumstances
the exercises should spread out over the day and not be concentrated into an
intense once-a-day regimen.
This basic principle of early shoulder
rehabilitation is particularly important in the early or acute stages of
rehabilitation when the shoulder is at its worst with respect to pain, motion,
or strength. The worse the problems, the more frequent the exercises should be
performed, but with short periods of exercise done well within the patient’s
abilities. The initial program should focus on the most key and deficient
problems for that diagnosis.
For example, the primary problem with early severe frozen shoulder is pain and
loss of passive range of motion. This should result in the need to achieve
effective pharmacologic pain management and to focus on passive range-of-motion
exercises to achieve improvements in passive range of motion and improvement in
pain before considering adding strengthening exercises to the program. The more
painful the shoulder, the more gentle the exercises, which are done for a
shorter duration but frequently during the day. As the shoulder improves, the
exercise periods can be more consolidated for longer duration and then
progressed with respect to intensity.
Patient education and participation is
critical to success for either nonoperative rehabilitation or post-operative
rehabilitation. Clear and precise communication between the physician and
patient and therapist is as important to a successful outcome as is the
precision and expertise by which all of the other treatment is performed,
including surgery.
Pendulum exercises are performed with
the patient leaning forward with the arm supported on a stable structure such
as a table and the waist bent at approximately 90 degrees. The affected
extremity is allowed to dangle in front of the patient’s body, and small
circular motions are made either clockwise or counterclockwise, allowing for
general passive range of motion of the glenohumeral joint.
Supine passive forward elevation is
done in the supine position using the unaffected extremity as a means to move
the affected arm passively or with active-assisted elevation (some muscle
activity of the affected shoulder). This is generally done in the plane of the
scapula. The plane of the scapula is midway between the true coronal plane
(parallel to the plane of the body [pure abduction] and the sagittal plane,
which is perpendicular to the plane of the body [pure forward flexion]). The
plane of the scapula lies 30 to 40 degrees anterior to the coronal plane. The
plane of the scapula for motion exercises places the rotator cuff and other
muscles of the shoulder in the most physiologic and natural position with
respect to the scapula body. For all passive exercises, when the arm reaches
its maximum level of gentle passive arc, there is a gentle stretch given to
increase the arc of motion. Repetitive movements are done during one session a
few times each day.
Active-assisted forward flexion can
also be done using an assistive device such as an exercise wand in the standing
position. Passive external rotation is done using a device such as a cane or
exercise wand. Cross-body adduction stretches the posterior capsule, and normal
posterior capsule length is important to achieve full forward elevation or full
internal rotation.
Basic Shoulder-Strengthening
Exercises
Progressive resistant strengthening exercises
can be performed in phases. Phase I involves the use of an elastic band for
external rotation with the arm by its side to avoid impingement or
overstressing of the rotator cuff tendons. The concept of progression of
strengthening from phase I to phase II is to first strengthen the rotator cuff
by doing rotational exercises in the least difficult or pain-provocative arm
and body position. After achievement of better rotator cuff strength and
shoulder function with the phase I exercises performed with the arm by the
side, then the shoulder should be better able to tolerate the more difficult
exercises for phase II strengthening.
Phase I strengthening can be done
either using both hands with the elastic band or with the elastic band to a
stationary object such as a doorknob with a pillow under the arm to provide
slight abduction and then external rotation away from the body. It is best to
use a stationary object so that the better or stronger shoulder does not
overpower the weaker shoulder. Internal rotation can likewise be performed with
the arm in slight abduction and internal rotation toward the abdomen. Extension
is performed in a similar matter with the elbow by the side pulling the band.
Forward flexion is shown with the elastic band with the arm moving in the
forward position generally below shoulder level. Many of these same exercises
can be performed with alternative techniques using a handheld 1- to 5-lb
weight.
For patients with severe weakness of
forward elevation, graduated exercises are performed starting initially in the
supine position without a weighted extremity. The arm is actively elevated with
the patient in the supine position.
When this can be easily achieved with
multiple repetitions, a small 1-to 2-lb handheld weight is utilized again until
this can be done easily and repetitively. When this is accomplished, the
patient is then elevated with the torso at 30 to 40 degrees without a weighted
extremity. This is again tested repetitively until this can be done with ease,
after which a small 1-to 2-lb hand-held weight is added. This is repetitively
accomplished until the patient is able to g adually bring the arm up actively
in a seated position.
An alternative way to graduate to the
full active elevation without assistance is the use of closed-chain
activeassistance strengthening in forward flexion. This can be done with an
exercise wand or preferably by a lightweight exercise ball. The patient places
both arms on the ball and with assistance squeezes the ball and raises the arm
above the head. The weak side is on the upper portion of the ball and is
assisted by the strong arm, which is on the lower part of the ball. As the weak
shoulder becomes stronger, the patient moves his or her hands to an equal and
opposite side of the ball and when very strong can use the affected arm on the
underside of the ball as an assistant to the normal side. These exercises are
useful as an intermediate step to achieve full active elevation and progressive
resistive exercises and forward flexion above shoulder level.
