The document discusses shoulder rehabilitation and focuses on regaining appropriate range of motion through stretching tight muscles like the latissimus dorsi and pectoralis minor. It also emphasizes strengthening the scapulothoracic muscles like the serratus anterior and lower fibers of the trapezius to maintain dynamic scapular control and proper mechanics when returning to high-risk overhead sports. The goal of rehabilitation is to restore harmonious shoulder rotation and good alignment while maintaining dynamic control during athletic activities.

1. Shoulder Rehab
Martin A. Scott MSc MCSP
Nottingham Shoulder & Elbow Unit
martin.scott@nuh.nhs.uk
Meister, 2000a
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2. © Bodies
Factors affecting glenohumeral
The “hypermobile” shoulder
hypermobile”
joint stability
Labrum X
Joint capsule X
Stability is lost to increase the
range of motion (Tennent,
(Tennent,
Ligaments X
Beach & Meyers (2003)) Internal pressure ?
gradient
Dynamic control is a major Bony cam ?
issue
Dynamic muscle √
contraction
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3. Dislocation Dislocation
Traumatic Atraumatic Traumatic Atraumatic
End of range Mid range End of range Mid range
Ligament/labral damage Not constrained by Ligament/labral damage Not constrained by
ligaments ligaments
Controlled by
muscles
Lippitt S & Matsen F (1993) CORR 291 Lippitt S & Matsen F (1993) CORR 291
Lee SB et al (2000) JBJS 82A(6) Lee SB et al (2000) JBJS 82A(6)
Instability Instability
High risk sports TUBS
Contact +/- throwing (Boileau et al., 2006 )
+/- (Boileau Can be hyper lax (eg
(eg At 4 year mean follow up,
26/91, Boileau et al., subscapularis function
Return to sport (mean 36 months post-op)
post- 2006) correlates with outcome
14/91 failures (further instability) Conservative treatment from surgery (Sachs et al.,
gives 17-96% recurrence
17- 2005)
2005 )
58/91 at same level in patients <30 (Bottoni
(Bottoni
13/91 at a lower level et al., 2002)
6/91 stopped participation (Boileau et al., 2006)
(Boileau
Instability Impingement
Harryman et al., 1990
Sachs et al., 2005
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4. Impingement Impingement
Primary
Secondary
Internal (Budoff et al.,
(Budoff
2003; Belling Sorensen
and Jorgensen, 2000; van
der Hoeven and Kibler,
Kibler,
2006)
Observed in arthroscopy
(Yoneda et al., 2006 )
Harryman et al., 1990
Impingement Impingement
Primary Primary
Secondary Secondary
Internal (Budoff et al.,
(Budoff Internal (Budoff et al.,
(Budoff
2003; Belling Sorensen 2003; Belling Sorensen
and Jorgensen, 2000; van and Jorgensen, 2000; van
der Hoeven and Kibler,
Kibler, der Hoeven and Kibler,
Kibler,
2006) 2006)
Observed in arthroscopy
(Yoneda et al., 2006 )
Impingement Impingement
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5. Impingement Impingement
Primary
Secondary
Internal (Budoff et al.,
(Budoff
2003; Belling Sorensen
and Jorgensen, 2000; van
der Hoeven and Kibler,
Kibler,
2006)
Neer, 1972; Yanai and Hay, 2000; Wilk et al., 2002
Impingement Impingement
Labriola et al., 2005 Elliott, 2006
Instability Assessment
Muscle patterning Observation
Under/over recruitment Relative alignment of
Low/high tone bony landmarks
Movement patterns Relative timing of
movements of body
segments
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6. Range of motion Gain appropriate ROM
Tight posterior inferior
glenohumeral joint capsule
Tightness/stiffness Allow free movement of can pull the scapula away
• Latissimus Dorsi the scapula around the from the chest wall (Burkhart
thorax, and external et al 2003)
• Pectoralis Minor Stiff latissimus dorsi impedes
rotation of the humerus full scapulothoracic motion
• Posterior structures throughout range Stiff pectoralis minor is
associated with Type I
dyskinesia (Borstad &
(Borstad
Ludewig 2005)
Silliman JF & Hawkins RJ (1993) CORR 291
Borstad JD & Ludewig PM (2005) JOSPT 35(4)
Strengthen scapulothoracic
Strengthen
musculature
Rotator cuff
Allows control of the Scapulothoracic Serratus anterior
humeral head in the muscles Lower fibres of trapezius
glenoid Allows the glenoid to
be positioned relative to External rotators
the humeral head
Hawkins RJ & Saddemi SR (1990) Cur Orth 4
Kibler, W. B. (1998). Medicine & Science in Sports &
Exercise 30(4 Suppl): S40-50.
Strengthen scapulothoracic Strengthen scapulothoracic
musculature musculature
Serratus anterior Serratus anterior
Lower fibres of trapezius Lower fibres of trapezius
(Ekstrom et al 2003, Decker
Closed chain exercises
et al 2003, Michener et al
(Kibler 1998)
2005)
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7. Maintain scapular dynamic
Gain scapular dynamic control
control
Scapulothoracic
movement
Glenohumeral rhythm
Multiplanar exercises
Visual feedback
Maintain scapular dynamic Maintain scapular dynamic
control control
Scapulothoracic
Scapulothoracic movement
movement Glenohumeral rhythm
Glenohumeral rhythm Multiplanar exercises
Multiplanar exercises Visual feedback
Maintain scapular dynamic
From the feet up!
control
Scapulothoracic
movement
Glenohumeral rhythm
Multiplanar exercises
Visual feedback
Function!
Limpisvasti et al., 2007
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8. Harmonious rotation(s)
rotation(s) Good alignment
Limpisvasti et al., 2007
Good alignment
Exactly what are effective throwing
mechanics?
by Paul Nyman
May 02, 2008
Maintain scapular dynamic Maintain dynamic control – and
control – and take it into sport! take it into sport!
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9. Maintain dynamic control – and Maintain dynamic control – and
take it into sport! take it into sport!
Thank you
Martin A. Scott MSc MCSP
Nottingham Shoulder & Elbow Unit
martin.scott@nuh.nhs.uk
Stretch before Strengthen Rugby
● Establish tissue mobility to allow normal
kinematics ● Scrum
● Allows greater muscle volume to contract and ● Rook
release ● Lineout
● Reduces risk of secondary compensation ● Tackle(pile on,collision,shirt pull,ankle tap)
● Pass
● Handoff
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10. Football Basketball/handball/volleyball
● Collision(with other player or ground) ● Blockshot/
Blockshot/
● Throw in ● Hookpass/shot
Hookpass/shot
● Goalkeeping dives ● Ball dribbling
Boxing
Cricket
● Outfield throws ● Impact
● Bowling ● Missed punch
● Wicketkeeping/slip
Wicketkeeping/slip dives ● Fatigue
● Crease slides ● Poor defensive posture
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