Rotator Cuff Surgery: What to Expect in Physical Therapy

Rotator cuff tears occur in nearly 30% of people over the age of 60.  Some rotator cuff tears can be treated conservatively with physical therapy.  However, many will require arthroscopic surgery to repair the torn tendons.  Nearly 500,000 rotator cuff repair surgeries are performed each year in the United States.  Postoperative physical therapy is crucial if you want to achieve a successful long-term outcome following surgery.

Early Physical Therapy After Rotator Cuff Repair

Re-tearing of the surgically repaired rotator cuff tendon is common following surgery.  Most re-tears occur within the first 3 to 6 months following surgery.  Another potential complication is stiffness or loss of motion in the shoulder.  Appropriate exercise prescribed by your physical therapist will minimize your risk of re-tearing the repair and help reduce stiffness.

rotator cuff tear exercises

Some surgeons recommend a 6-week period of strict immobilization in a sling without any physical therapy.  Other surgeons allow protected motion and passive exercise within 2 weeks following surgery.  Research suggests most patients can safely begin physical therapy early after surgery. This minimizes stiffness of the shoulder and loss of muscle in the rotator cuff.  However, patients with larger tears may benefit from delaying physical therapy for 4 to 6 weeks to protect the healing repair.

Protection and Early Motion

After surgery, your shoulder will be immobilized in a sling for the first 4 to 6 weeks.  During this period, you may perform very low-load exercises initiated by your physical therapist.   These exercises require low activation of the rotator cuff muscles.  This approach protects your healing repair, reduces stiffness, reduces pain, and minimizes muscle loss.  Some of the following 7 exercises may be prescribed based on the size of your tear, surgeon preference, and other individual factors.

Forward Bow

Begin standing with your hands resting on a tabletop or counter.  Relax your shoulder and neck muscles.  Slowly step backward while keeping your hand on the table or counter.   When a mild stretch is felt, pause and hold the position for 5 to 10 seconds.  Avoid exercising through pain.

Table Slides

Stand holding a towel with your hand of the involved arm resting on a tabletop or counter.  Relax your shoulder and neck muscles.  Slowly lean forwards and slightly out to the side (a 45 degree angle) while sliding your hand on the table or counter.   When a mild stretch is felt, pause and hold the position for 5 to 10 seconds.  Avoid exercising through pain.

Ball-Assisted Scapular Protraction

Begin standing with your hand resting on an exercise ball on a table top or counter.  Relax your shoulder and neck muscles.  Slowly roll the ball forward and slightly to the side (a 45 degree angle).   When a mild stretch is felt, pause and hold the position for 5 to 10 seconds.  Avoid exercising through pain.

Wall-Assisted External Rotation

Stand facing the corner of a wall.  Place a small towel roll under your arm.  Bend your elbow and rest your hand on the corner of the wall.  Slowly step and turn your body away from the wall.  Maintain your elbow tucked to the side and hand on the wall.  Pause and hold the position for 5 to 10 seconds.  Avoid exercising through pain and avoid overstretching the shoulder into external rotation.

Cane-Assisted External Rotation

Begin lying on your back with a small pillow or towel roll under your upper arm.  Hold a cane, golf club, or similar object with both hands.  Use your other arm to passively rotate your involved arm out to the side.  Maintain the elbow of your involved arm at a 90-degree angle throughout the exercise.  Pause and hold the position for 5 to 10 seconds.  Avoid exercising through pain and avoid overstretching the shoulder into external rotation.

Washcloth Press-Up

Lie on your back with your knees bent.  Hold a small towel with your hands close together.  Your other arm assists in lifting your involved arm straight up to the ceiling.  When your elbow reaches full extension, pause and hold the position for 5 to 10 seconds.  Avoid exercising through pain.   Progress this exercise by performing it in a slightly reclined position.

Supine Self-Assisted Flexion

Begin lying on your back with your hips and knees bent.  With your other hand grasp the wrist of your involved side.  Next, passively lift your involved arm overhead.  Maintain a straight elbow.  Pause and hold the position for 5 to 10 seconds.  As pain begins to diminish, progress the exercise by increasing the duration of the stretch up to 30 seconds.

Rotator Cuff Rehabilitation: Closing Thoughts

Rehabilitation following rotator cuff surgery begins with an introduction to protected range of motion exercises.  During the first few weeks of rehab, you will perform exercises similar to those in this article.  At approximately 6 weeks after surgery, the focus shifts to restoring active range of motion exercises without resistance or weights.  Progressive strengthening exercise begins at postoperative week 12.  Future articles will address these phases of rehabilitation.

If you want to learn more about rehabilitation and recovery from rotator cuff surgery, contact your physical therapist today.

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Shoulder Impingement: Stretching and Strengthening Exercises

Shoulder impingement involves compression of the rotator cuff tendons between the top of the shoulder blade (acromion process) and upper aspect of the arm bone (humerus).  Other structures involved include the biceps tendon and bursa (a fluid-filled sac between 2 bones).  Shoulder impingement accounts for approximately 1/3 of all shoulder pain.  Pain is usually worst when reaching with an outstretched arm or lifting overhead.

Impingement Syndrome

During normal activities of daily living, your rotator cuff becomes compressed and stretched.  This typically does not result in any pain.  However, several factors can contribute to excessive compression of your rotator cuff and pain.  Thankfully, the majority of these factors are modifiable through exercise.  In fact, research shows exercise is at least equally effective or better than medications, injections, and surgery for most painful shoulder problems.

Exercise addresses many of the modifiable risk factors that contribute to shoulder impingement.  Stretching exercises increase the available space between the shoulder blade and humerus. This can alleviate compression of the rotator cuff, bursa, and biceps tendon.  Strengthening exercises  that target the rotator cuff and shoulder blade muscles also increase the available space.  Exercising with an appropriate load strengthens the tendons which further reduces pain.  There is no one-size-fits-all exercise approach for shoulder impingement.  The following exercises are only examples which may be included in an individualized rehabilitation program.

Stretching Exercises for Shoulder Impingement

Stretching the shoulder is an important part of any shoulder rehabilitation program.  In particular, exercises targeting mobility of your pectoralis minor muscle, thoracic spine, and posterior shoulder are important.  Increasing the length of your pectoralis minor pulls the shoulder blade back, improves posture, and increases the available space for your rotator cuff.  Improving extension of your thoracic spine improves posture and overhead shoulder mobility. Stretching the back of your shoulder helps reposition your upper arm bone allowing greater space for any compressed soft tissues.  For the best results perform stretching exercises daily.

Rotator Cuff Exercises for Shoulder Impingement

The primary job of your rotator cuff is to center the ball of your arm bone (humerus) in the socket of your shoulder blade.  Any weakness of your rotator cuff causes the ball to migrate upwards into the bone above it leading to impingement.  Once your  shoulder becomes painful, your rotator cuff muscles shut down leading to a vicious cycle of pain and weakness. It is imperative that your rotator cuff is strengthened in order to restore proper shoulder function. There are 4 muscles of the rotator cuff.  They are the supraspinatus, infraspinatus, teres minor, and subscapularis.  These muscles function together and are all strengthened during rehabilitation.

Performing the following 3 exercises will improve the strength of your entire rotator cuff.  Strengthening exercises are performed 3-4 times per week.  Start with a weight that allows you to perform 12 to 15 repetitions for 3 sets.  Over the course of several weeks, progress the weight so you are performing closer to 8 to 10 repetitions for each set.  A sense of fatigue and some pain is acceptable and in most cases beneficial for recovery.  On a 0 to 10 scale, keep the pain levels at a 5/10 or less.

Shoulder Blade Exercises for Impingement

Your trapezius and serratus anterior muscles function together to rotate your shoulder blade upwards.  They also tilt your shoulder blade backward as your arm is raised.  This is essential for overhead function.  If your shoulder blade does not appropriately tilt backwards or rotate upwards,  aryourm bone will jam into your acromion.  This results in impingement of your rotator cuff.   Follow the same guidelines described above for rotator cuff strengthening exercises (i.e., sets, repetitions, etc).

Closing Thoughts

Shoulder impingement is a common disorder in athletes, weekend warriors, and sedentary adults.   Exercise is the first line of treatment and in most cases, very successful.  Your shoulder complex is composed of several joints and many small but intricate muscles.  Therefore, recovery is often slow at first.  However, if you stick to your exercise program expect a full recovery in 3 to 4 months.

For faster results, it is best to work with your physical therapist so your exercise program is targeted to your individual needs.  Give us a call if you would like some help.

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Lat Stretches to Improve Overhead Mobility

The length of your lats, or latissimus dorsi muscle, affects your ability to raise your arms overhead.  Shortened lats restrict overhead mobility.  Short or overactive lats also pull your shoulders inward and can increase compressive forces on your low back.  This commonly occurs with aging and those with rounded shoulders.  Performing lat stretches reverses this problem.

The latissimus dorsi is the largest muscle of your upper body.  It is a long broad muscle that originates in your low back.  It spans your upper back and passes under your armpit to attach onto your upper arm.  The lats function to pull your arm down and across your body.  It also rotates your arm inward toward the middle of your body.   Common exercises which include these movements and strengthen your lats are pull-ups, pull downs, and rows.   It is also highly active during other common exercises such as presses, squats, deadlifts, and planks.

Lat Stretches

Many exercises performed in the gym require full overhead mobility.  Also, many of us perform daily activities which require overhead reaching.  When lats are short or overactive, the brain will take the path of least resistance and figure out a way to compensate.  This often manifests by excessively arching the low back when reaching overhead.  The following four exercises are examples of stretches for the lats.  Performing these regularly can improve overhead shoulder mobility and spare your low back from unnecessary stress.

Foam Rolling the Lats

Brief periods of foam rolling can reduce overactivity or tension in your lats.  This is a nice way to prepare your lats for the next two stretches.  Performing about 30 seconds of foam rolling is usually adequate.  Longer periods are rarely needed.   Lie on your side with the foam roll positioned in the area of your armpit.  Bend your bottom leg and straighten the top leg.  The palm should be positioned facing up to rotate the upper arm.  Engage the abdominals slightly to maintain a posterior tilt of your pelvis.  Slowly roll up and down covering an area of about 6 to 12 inches.  Gentle pressure is all that is needed.  Aggressive pressure or foam rolling often increases tension in your lats.

Active Lat Stretch in Quadruped

Assume a kneeling position with both elbows resting on the floor.  Reach up and across the body with the side to be stretched.  Also, rotate your palm upwards.  Slightly sit back on your heels to increase the stretch felt in your upper back or armpit.  Engage your abdominals slightly to maintain a tilt of your pelvis.  Hold this position for 10 to 30 seconds.  Deep breathing can be incorporated to relax and further stretch the muscle.  Gentle stretching is all that is needed.

Supine Flexion

By lying on your back and flexing your arms overhead, shoulder flexion is assisted by gravity.  To increase the stretch to your lats, position your palms up.  As you gain mobility, move the hands closer together.  You can also perform the exercise lying on a bench to allow for greater range of motion overhead.  Be sure to keep your abs engaged and low back flat to avoid compensations.

Bench T-Spine Mobilization

This is my favorite exercise for restoring thoracic spine extension and stretching the lats.  The exercise begins by assuming a kneeling position facing a bench.  Place your elbows on the bench in front of you holding a PVC pipe or dowel with the palms facing up.  Sit back, pushing your buttocks towards your heels.  Engage your abdominal muscles to maintain a slight tilt of your pelvis.  You should feel a nice stretch in your upper back or arm pit.  For an added stretch you can bend your elbows further past your head.  Hold this position for a few seconds, and exhale fully.  Reverse the motion to return to the start and repeat for 10 to 20 repetitions.

Final Thoughts on Stretching Your Lats

Improving the length of your lats takes patience and persistence.  This is a big strong muscle that is prone to overactivity and tightness.  Stretching 3 to 4 times per week for several weeks is needed to see any meaningful improvements.   Increase your chance of success by also performing abdominal and thoracic spine mobility exercises.  With consistency, you will see a payoff in your ability to perform overhead movements.   If you are unsure about how to get started, meet with your physical therapist.

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Frozen Shoulder Exercises to Restore Mobility

Stiffness from frozen shoulder can last 1 to 3 years.  Performing regular home exercises can expedite your recovery.  As mentioned in a previous article, the exercise program must be individually tailored and match the stage of the disorder.  We recommend gentle exercises with minimal pain early during the freezing stage.  Increase the intensity and volume of stretching during the frozen stage.  However, you must always respect pain.  During the thawing stage, expect pain during exercise as long as it dissipates soon afterward.  The frozen shoulder exercises that follow in this article are examples of those commonly prescribed by our physical therapists.  The effectiveness of frozen shoulder exercises is enhanced by combining them with manual physical therapy.

Supine Shoulder Flexion

Performing stretching exercises in the lying position will minimize the effects of gravity.  This results in less pain and improved range of motion.  Begin lying on your back with your hips and knees bent.  With your uninvolved hand grasp your wrist of the involved side.  Use the uninvolved arm to passively lift your involved arm overhead.  Maintain your elbow straight.  At the onset of mild discomfort or a stretch, pause for 5 to 10 seconds.  Perform 10 repetitions.  We prescribe this exercise during the early freezing stage of frozen shoulder.  As your pain begins to diminish progress by increasing the duration of the stretch up to 30 seconds.

Supine Shoulder External Rotation

Begin lying on your back with a small pillow or towel roll under your upper arm.  Hold a cane, golf club, or similar object with both hands.  Use your uninvolved arm to passively rotate your involved arm out to the side.  Maintain your elbow at a 90-degree angle throughout the exercise.  At the onset of mild discomfort or a stretch, pause for 5 to 10 seconds.  Perform 10 repetitions.  We prescribe this exercise during the freezing stage of frozen shoulder.  As pain diminishes the exercise is progressed by increasing the duration of the stretch up to 30 seconds.

Standing Shoulder Extension

Restoring the ability to reach behind your body is important for everyday living.  This takes repetition and time.  Be patient.  Standing shoulder extension with a cane or golf club is a great starting point.  Stand tall holding a cane behind your body with your arms straight.  Maintain both elbows straight and lift the cane backward until mild discomfort or a stretch is felt.  Pause in this position for 5 to 10 seconds.  Perform 10 repetitions.  We prescribe this exercise during the freezing stage of frozen shoulder.  As pain diminishes the exercise is progressed to the cross body or sleeper stretch described below.

Cross Body Stretch

This stretch addresses tightness in the back of your shoulder.   It is most appropriate if you are in the frozen and thawing stages of frozen shoulder.  Perform this stretch lying on your involved side with your hips and knees bent.  Position your involved shoulder and elbow in 90 degrees of flexion.  Gently pull your elbow across your body.  Hold this position once you feel a mild stretch on the outside or back part of your shoulder.  Perform this stretch 2-3 times each session.

Sleeper Stretch

The sleeper stretch is effective for improving your ability to reach behind your back.  Difficulty with dressing behind your back is a common complaint for people with frozen shoulder.  For this stretch, assume the same starting position as the cross body stretch.   Next, gently move your wrist and forearm down towards the table.  Hold this position once you feel a mild stretch on the outside or back part of your shoulder.  Perform this stretch 2-3 times each session.   This stretch is most appropriate if you are in the thawing stage of frozen shoulder.

Closing Comments: Frozen Shoulder Exercises

Patience and persistence are the keys to success with frozen shoulder exercises.  The rate of recovery from frozen shoulder can only be increased to a certain point.  Overly aggressive stretching early when pain levels are high will prolong your recovery.  Conversely, infrequent or painless stretching, later on, will result in incomplete recovery.  Dealing with frozen shoulder is a marathon, not a sprint.

Team up with your physical therapist so you can plan the exercise strategy which is best for you.  Give us a call if you would like help getting started.

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Frozen Shoulder: What is it and What Can Be Done?

Frozen shoulder, also known as adhesive capsulitis, is characterized by tightening and contracture of the shoulder joint capsule and surrounding ligaments.  The inner lining of the shoulder joint is called the synovium, and the surrounding muscles are also affected.  In the majority of cases, pain and loss of motion occur without any specific injury.  Sometimes only a minor trivial incident, such as bumping the shoulder against a wall, can be recalled by the patient.

The true underlying pathology of frozen shoulder is not well-understood.   Some reports show the lining of the shoulder joint becomes inflamed while other studies show a lack of inflammation.  Changes in blood flow and nerve sensitivity have also been found.  However, it is well known that the outer capsule of the joint shrinks and thickens leading to significant pain and loss of motion.

adhesive capsulitis

Who is most commonly affected?

Frozen shoulder affects between 2% to 5% of the population.  The disorder most commonly affects women between the ages of 40 and 65 years old.  It often occurs in both arms several years apart.  It is also more common in those with certain diseases such as diabetes and thyroid disorders.

Signs and Symptoms

Patients with a frozen shoulder often have pain at rest which is worsened at night and with movement.  As the disorder progresses, the range of motion becomes more and more restricted.  Pain typically begins to subside during this time but function can remain extremely limited due to stiffness.  The inability to reach overhead and behind the back are hallmark signs.

The Course of Frozen Shoulder

Frozen shoulder progresses through stages over the course of 1 to 3 years.  The first stage, called the “Freezing Stage” is characterized primarily by increasing pain with some loss of motion.  As the disorder progresses into the “Frozen Stage”, pain begins to subside but significant stiffness is present.  During the “Thawing Stage”, pain continues to diminish and range of motion slowly improves.

adhesive Capsulitis

Previously, it was believed that frozen shoulder would resolve on its own by waiting 12 to 18 months.  However, several studies show persistent loss of motion and limited function for up to 3 years.  Therefore, it is important to take an active approach in order to avoid a delayed recovery.  Three of the most common treatment options include physical therapy, corticosteroid injection, and manipulation under anesthesia.

Physical Therapy for Frozen Shoulder

Range of motion and stretching exercises can be an effective treatment option for people with frozen shoulder.  However, it is important that the exercise program matches the stage of the disorder.  Overly aggressive stretching performed in the “freezing stage” can result in increased pain and delayed recovery.   Exercise is carefully prescribed by the physical therapist in order to meet the individual’s goals.

Frozen shoulder

Manual physical therapy can also be an effective treatment for people with frozen shoulders.  In particular, joint mobilization and passive stretching techniques are useful in the later stages when pain is minimal.  The effects of manual therapy are always enhanced when patients perform regular home exercises.

Corticosteroid Injection

Injections can be particularly helpful during the early “freezing stages” of frozen shoulder.  They can help reduce some of the acute pain which occurs at night and while at rest.  Research shows combining injections with 4 to 6 weeks of daily home stretching can significantly improve pain and function.  Caution should be used for those with diabetes, as steroid injections can acutely influence blood sugar levels.  You can discuss this with your doctor to determine the best course of action.

adhesive capsulitis

Manipulation under Anesthesia

Manipulation of the shoulder joint by a physician while under anesthesia may be considered in cases where stiffness is not resolving.  This is often used during the later stages of frozen shoulder.  There may be some short-term increase in pain for several days.  However, when combined with regular home exercise and supervised physical therapy, manipulation under anesthesia can be very effective for improving function.

Frozen shoulder

Conclusion

Frozen shoulder can be very frustrating for people because of the prolonged recovery.  However, there are effective treatments that can reduce pain, disability, and in some cases speed up recovery.  If you are suffering from a frozen shoulder, discuss these treatment options with your physician.  In upcoming articles, we will go into more detail about physical therapy’s role in your recovery.

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Bodyblade Shoulder Rehabilitation Exercises

Proper coordination between different parts of the body is required to maintain normal shoulder function.  As mentioned in previous articles, the lower body, trunk, shoulder and arm muscles function together.  These body segments are links in a chain.  If one link is not functioning properly, the entire kinetic chain suffers.  The kinetic chain approach to shoulder rehabilitation is based on control of the shoulder blade and coordinated stabilization of the trunk.  The Bodyblade is a rehabilitation tool that can be used to train these links of the kinetic chain to function in a coordinated fashion.

Strong shoulder muscles, such as the trapezius, serratus anterior, and rotator cuff provide a base of support to stabilize the scapula and optimize arm function.  Also, normal movement patterns of the upper body require lower body and trunk muscle activation before upper extremity movement occurs.  The Bodyblade is an oscillatory device which requires co-activation of these body segments.  The Bodyblade trains muscular strength, endurance, and coordination through the co-contraction of several important muscle groups.

Bodyblade Exercises

Shoulder rehabilitation programs using the Bodyblade can take on different forms.  Different exercises can target different links in the chain such as the glutes, core, scapular muscles, or rotator cuff.  The three exercises included in this article are a few examples which can be used for patients recovering from a shoulder injury.   These exercises are typically performed for a period of time (i.e., 30 seconds) or repetitions (6-10 repetitions) using multiple sets (i.e., 2-4 sets).  Your physical therapist can help you design a program which is best for you.

Closing Thoughts

Shoulder rehabilitation has become more of a total body rehabilitation approach versus focusing solely on the shoulder.   The Bodyblade is a device that facilitates the co-contraction of muscles in the shoulder and throughout the body.  This is characteristic of how the body functions in everyday life and sports.  For people experiencing shoulder pain, the Bodyblade can be an effective adjunct to other foundational shoulder strengthening exercises.

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Kinetic Chain Exercises Linking the Shoulder and Hip

Overhead activities such as throwing require proper sequencing of different body parts.   The lower body, trunk, shoulder, arm, and hands are considered links in a chain.  If any of these links are not functioning properly, the chain is broken.  Effectively using the body as a kinetic chain maximizes overhead athletic performance and reduces injury risk.  Shoulder rehabilitation programs now integrate the kinetic chain theory for a broader approach versus focusing only on isolated muscles.

Why Involve the Kinetic Chain?

Exercises targeting the shoulder muscles receive a great deal of attention in overhead athletes and rightfully so.  The rotator cuff and scapular muscles are important for dissipating high forces created during throwing.  However, most of the energy created during throwing occurs from the lower body and trunk.  Weak links in the lower body leads to additional stress to the shoulder and elbow during throwing.  Therefore, including exercises that incorporate all links of the kinetic chain are beneficial.

lower body strength throwing

 

Lower body exercises such as the squat and lunge can be integrated with common shoulder rehabilitation exercises.  Total body exercises which incorporate resistance bands or tubing are ideal for integrating links of the kinetic chain.  This article described only 3 exercise examples.  However, there are many other variations which can be developed based on the athlete’s profile and goals.

Overhead Squat with “Y”

Stand holding a resistance band in both hands with your shoulders flexed and elbows straight.  Perform an overhead “Y” by raising both hands with your elbows straight. Maintain this overhead “Y” position as you perform an overhead squat.  Try to reach a maximum depth of the squat without compromising your upper-body position.  Maintain the overhead “Y” until completing your set.  Perform 8 to 10 repetitions  eachset.  This exercise integrates the gluteus maximus, rotator cuff, low back muscles, and trapezius.

Lunge with “T”

Stand holding a resistance band in both hands with your shoulders flexed and elbows straight.  Perform a “T” with both arms by pulling your hands and shoulder blades back with your elbow straight.   Once in the “T” position, perform a reverse lunge with one leg.  The “T” position is maintained until one alternating repetition is performed on each leg.  Reset the “T” before completing your next repetition.  Perform 6 to 8 slow and controlled repetitions on each side.  This exercise activates the gluteus medius, gluteus maximus, lats, and trapezius.

Lateral Band Walk with “W”

Perform an exaggerated sideways walk with a resistance band just above your knees. Remain in an athletic position keeping your toes pointed straight ahead.  It is important to push the knees apart against the resistance band in order to activate your hip muscles.  Your shoulder blade and rotator cuff muscles are activated by using a second resistance band in your hands.  Make a “W” with the elbows in order to achieve scapular retraction.  Take 3 steps to the right followed by 3 steps back to the starting position.  Also, think about pulling the elbows to your opposite back pocket.  Perform 6 to 8 slow and controlled repetitions to each side.  This exercise activates your gluteus medius, gluteus maximus, rotator cuff, and lower trapezius.

Closing Thoughts on Kinetic Chain Exercises

Combining lower body exercises with traditional shoulder rehabilitation exercises is beneficial for overhead athletes.  Muscles throughout the entire body function in a coordinated sequence during baseball and softball throwing.  Resistance bands have gained popularity in the baseball and softball communities as part of pre-throwing routines and strength and conditioning programs. These shoulder-focused exercises train only a limited number of links in the kinetic chain.  A wise approach is to integrate upper body resistance band exercises with dynamic, full-body exercises.  Talk to your physical therapist or give us a call if you are unsure about which exercises are best for you.

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Closed Kinetic Chain Shoulder Rehabilitation Exercises

In order for the arm and shoulder to optimally function, muscles of the entire body must contribute.   During most dynamic activities in everyday life and sport, the lower body creates most of the needed energy.  Energy is transferred from the lower half of the body up through the trunk and finally to the arm.  The important links in this sequence are the core and shoulder blade muscles.

Shoulder strengthening exercises which focus on the rotator cuff are usually only partially effective for patients with shoulder pain.  Muscles do not function in isolation.  The brain programs movement as patterns, not individual muscles.  Therefore, shoulder rehabilitation programs should include exercises that integrate the entire kinetic chain including the core and shoulder blade.

These same rehabilitation exercises can also be utilized in a dynamic warm-up for athletes.  Ideally, muscles throughout the body are involved in the pre-game warm-up for baseball and other overhead sports such as tennis and swimming.   These exercises have the potential to improve strength, performance and reduce the risk of injury.  The 5 closed kinetic chain exercises included in this article activate the core muscles along with the trapezius and serratus anterior.   Closed kinetic chain exercises involve bearing weight through the arms and hands.

Quadruped Band Series

Begin in the quadruped position with the hands positioned under the shoulders and knees under the hips.  Maintain a neutral spine and pelvis.  Loop a resistance band around the wrists.  Next, reach 6-8 inches to the side with one arm.  The hand is placed down on the floor for 2 seconds before returning to the start position.   Typically, 8 repetitions are performed on one side then repeated on the opposite side.  This exercise activates the serratus anterior muscle.   To keep these muscles highly activated, push the upper back up toward the ceiling throughout the exercise.

High Plank on Balance Board

This exercise is performed in a push-up position with your hands on a balance board or BOSU.  The hands are positioned below the shoulders with the pelvis in a neutral position.  From this position, move the board in a circular fashion by touching the edges of the board to the floor.   Perform 30 seconds in one direction.  After a brief rest period, repeat the same sequence moving the board in the opposite direction.   This exercise activates the serratus anterior muscle.

Shoulder Taps

Begin in a push-up position with the hands under the shoulders.  Maintain a neutral spine and pelvis.  Perform the exercise by alternately touching the opposite shoulder with the opposing hands while maintaining a pelvic neutral plank position.   Perform 8 to 10 slow touches to each shoulder.  This exercise highly activates the serratus anterior muscle and to a lesser degree the lower trapezius.  To keep the serratus anterior highly activated, push the upper back up toward the ceiling throughout the exercise.

Ball Walkouts

Begin by lying over an exercise ball with both hands on the floor.  Walk your hands and body out from the ball.  Maintain a neutral spine and pelvis as you walk out from the ball.  Pause and hold the end position for 10 seconds.  Then walk back to the starting position.  Perform 8 repetitions in a slow and controlled fashion.

Bear Crawls

Assume an all-4’s position with the hands shoulder-width apart and the knees under the hips.  Elevate the knees from the floor so you are stabilized by 4 points of contact.  Begin by pushing the back up towards the sky to protract the scapula and activate the serratus anterior.  Crawl forward starting with your right hand and your left foot following with the left hand and the right foot.  After each step, pause briefly to exhale. Take four steps or more depending on space, then turn around and bear crawl back.  To increase the challenge, crawl in both a forward and backward direction.

Final Thoughts About Closed-Chain Exercises

The 5 exercises shown in this article integrate the lower body, core, and upper body.  More specifically, these exercises challenge the rotator cuff and scapular muscles while simultaneously activating the core.  This is similar to how we function in sport and everyday life.   Closed-chain exercises are excellent for improving the coordination between muscles and adjacent body regions.  Integrate these exercises into a warm-up or as part of a stand-alone exercise program.  If you have questions, contact your physical therapist for help.

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5 of the Best Exercises for Overhead Shoulder Mobility

Loss of overhead shoulder mobility occurs slowly over time from your daily routines and habits.  A subtle loss of mobility will make a big impact on how your shoulder functions.  Sitting at a desk for most of your day results in a slow loss of shoulder range of motion.  Over time, the small changes in your shoulder mobility begin to accumulate.  Before you know it, your shoulder begins to feel a little tight.   Next, reaching overhead is painful.   Things snowball from there.

You may not realize you have lost shoulder mobility until you begin or resume an exercise program.  Exercises that require overhead shoulder mobility include the shoulder press, push press, snatch, and pull-up.  These types of exercises are performed at or near end ranges of motion.  Without your full range of motion, your shoulder begins to break down.  With more weight, repetitions, and speed the problem is magnified.

Why is Overhead Shoulder Mobility Important?

shoulder mobility exercise
Full shoulder flexion range of motion is crucial for overall shoulder health

Your ability to function overhead requires mobility of your shoulder joint, scapula, and thoracic spine.  Your scapula must freely rotate and tilt in order to reach fully overhead.  Exercises that target your serratus anterior and lower trapezius are helpful.  Also, your thoracic spine must be able to fully extend in order to achieve end-range overhead positions.   Thoracic mobility drills are essential to maintain or restore overhead mobility.

Manual Therapy & Shoulder Mobility Exercise

Full range of motion in your shoulder joint is needed to function overhead.  Restrictions can be due to your joint capsule (frozen shoulder) or your soft tissue (muscles and tendons) structures surrounding your shoulder.   Joint restrictions are treated best with manual therapy performed by your PT.  Soft tissue restrictions are treated by combining soft tissue manual therapy techniques with mobility exercises.  The remainder of this article describes 5 shoulder mobility exercises to get your overhead mobility back.

Supine Shoulder Flexion

There are many variations to this exercise.  When you lie on your back and flex your arms overhead, shoulder flexion is assisted by gravity.  To increase the stretch to your lats, position your palms up.  As you gain mobility move your hands closer together.  You can also perform the exercise lying on a bench to allow a greater range of motion overhead.  Be sure to keep youe abs engaged and low back flat to avoid compensations.

Bench T-Spine Extension

This exercise improves thoracic spine (your upper back) extension.  It also provides a stretch to your lats and triceps.  Both of these muscles restrict your overhead mobility.  By moving your hips back to your heels, your lumbar spine flexes.  This adds to the stretch in your upper back and lats.

Floor Slides

Perform the floor slide with your hips and knees bent.  This position facilitates a neutral low back position.  This is a great way to stretch tight pectoral muscles that contribute to rounded shoulders and limited overhead mobility.  Be sure to keep your abs engaged and back flat against the floor.

Shoulder Flexion over Foam Roll

Lying over a foam roller helps maintain a proper spine position when flexing your shoulder overhead.   It also facilitates stretching of your pectoralis major and minor muscles.  Adding a resistance band to your wrists engages your rotator cuff muscles.  Be sure to keep your abs engaged and low back flat to avoid compensations.

Prone Lifts

This is a challenging exercise but it can be very effective for restoring the last bit of your shoulder mobility.  The prone position also facilitates the tilting of your scapula.  Backward tilting of your scapula is an important part of functioning overhead.  Be sure to keep your abs engaged to avoid compensations in your low back.   As you gain mobility move your hands closer together.

Let Us Know if You Need Help Restoring Your Shoulder Mobility

The shoulder is the most mobile joint in your body.  However, mobility problems are very common and lead to pain and a lot of frustration.  Performing any of these 5 mobility drills will combat and reverse the loss of overhead shoulder mobility.  Don’t expect huge improvements after a few sessions of stretching.

Your results can be expedited by combining these exercises with manual therapy performed by your physical therapist.   It takes consistent and disciplined performance to achieve the best long-term results.  If you need more help, contact your physical therapist.  The physical therapists at BSR have been helping people move without pain since 2007.

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Reverse Shoulder Arthroplasty (Replacement)

A reverse shoulder arthroplasty (RSA) or replacement is characterized by changing, or “reversing”, the position of the ball and socket so that the ball is on the socket side of the joint and the socket is on the ball side. In the normal shoulder, the rotator cuff muscles help the large deltoid muscle to raise the arm. When the rotator cuff is torn and non-functional, the humeral head (arm bone) “escapes” upwards within the joint, and the deltoid is then unable to lift the arm by itself. By reversing the position of the ball and socket the loss of the normal rotator cuff is compensated for and the deltoid muscle can once again raise the arm.

Who Benefits from Shoulder Replacement Surgery?

RSA has been performed for over 25 years in Europe but has only been FDA-approved in the United States since 2003. In 2011 approximately 1/3 of shoulder replacement procedures were RSA. Approximately 80% of patients who undergo RSA do so because of arthritis and rotator cuff deficiency.   Another common and increasing indication is complex fractures of the upper part of the arm bone (humerus), accounting for about 10% of reverse shoulder arthroplasty. Other indications include rheumatoid arthritis and revision arthroplasty.

The Role of Physical Therapy

Physical therapy following reverse shoulder arthroplasty is based on three important considerations: protecting the healing joint, maximizing deltoid muscle function, and establishing appropriate functional and range of motion expectations. Rehabilitation during the first 4 weeks following surgery focuses on joint protection strategies (including sling use), pain control, and gradual restoration of range of motion. Joint protection is important to minimize the risk of complications following surgery. Shoulder dislocation is one such complication that requires care during the early phases of recovery. Movements such as reaching behind the back should be avoided or minimized due to the vulnerability of the shoulder to dislocate in this position following RSA.

By the sixth postoperative week, gentle deltoid and shoulder blade muscle strengthening exercises are initiated. These exercises are important in order to regain functional use of the arm for activities of daily living (dressing, bathing, etc) and light athletic activities (tennis, swimming, etc). Normal full active range of motion following RSA is not expected in most cases. However, we have witnessed some very impressive results where individuals have recovered to the same extent, or better, than their uninvolved shoulder.

Closing Thoughts

From our experience and the latest research, recovery of functional ROM is dependent on the patient’s pre-surgery status, the extent of rotator cuff damage, and the patient’s adherence with their home exercise program.  If you are considering undergoing a reverse shoulder replacement, or have recently undergone this procedure, please call one of our physical therapists to learn more about your recovery and return to function.

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