Posterior Capsule Tightness Common problem of throwers and racket sport players Especially seen in pitchers Prevented with posterior capsule stretches Results in reduced medial rotation range of motion Can increase anterior capsule stress

Progression of Strength Exercises Isometrics Concentrics, eccentrics in single plane Diagonal, multiplane motions Begin at less than 60° Advance to midrange and then to higher elevations with  strength and control (continued)

Progression of Strength Exercises (continued) Isometrics –Performed when use of arm motion or activity is restricted –Performed in pain-free positions –Contraction: gradually built to maximum, held at max, decreased gradually –Held for 5-10 s, repeated 10 times Isolated-plane isotonic exercises

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Stabilization Exercises Important in aiding strength development and facilitating neuromuscular reeducation Some are open kinetic chain; most are closed kinetic chain Closed kinetic chain: facilitates cocontraction, permits stabilization with less shear, facilitates proprioception for stabilization What is important to improve early in the rehabilitation program? (based on your understanding, provide an answer)

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Advanced Exercises Plyometrics –Push-up –Resisted movement in weight bearing –Medicine-ball exercises Functional activities –Progress in time, resistance, distance –If overhead, from lower to higher Activity-specific activities: progression depends on sport, position, or work requirements

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GH Instability Injury to either static or dynamic restraints   instability Anterior instability most common TUBS: Traumatic, Unilateral, Bankart lesion, Surgery required AMBRI: Atraumatic, Multidirectional, Bilateral, Rehabilitation ineffective, Inferior capsule shift required What are the concerns for rehabilitation?

Subacromial Impingement Primary impingement: result of structures present in narrow subacromial space Secondary impingement –Subacromial space narrowed by alterations in shoulder function –May be caused by or result in instability

Increased Rotation With Flexion Glenoid Positioning Function Glenoid moves to give rotator cuff a mechanical advantage + maintain relative spacing Deficiency Anterior scapular tilt + reduced rotation upward  impingement

Scapula on Thoracic Wall Serratus Anterior Function Serratus anterior holds scapula on wall Deficiency Winging  reduced subacromial space

Scapular Retraction Retractor Importance Function Rhomboids and middle trapezius prevent round shoulders Deficiency Protracted scapula narrows subacromial space

Rotator Cuff GH Stabilization Function Depresses humeral head into lower glenoid fossa Deficiency Elevation of humeral head into upper glenoid fossa

Treating Subacromial Impingement What is the rehabilitation emphasis? What areas should be assessed? What methods would you use to relieve each problem?

Rotator Cuff Pathologies Pathologies include: –Acute rotator cuff strain –Partial tear –Complete tear –Postsurgical conditions Most tears occur after some degeneration of the rotator cuff tendon has occurred. Fewer tears occur from sudden traumatic events.

Rx of Rotator Cuff Conditions Conservative management versus post-op rehabilitation: Time is 1° difference between them. Rehab procedure is the same but time of progression is slower for surgical management. Rehabilitation considerations?? (identify what these are)

Arthroscopic Decompression Rehabilitation can begin immediately post-op. Rehabilitation takes 3-5 months. What are the rehabilitation considerations?

Glenoid Labrum Tears SLAP lesion: Superior Labrum tear Anterior and Posterior in location 2  to throwing deceleration forces Difficult to diagnose Either arthroscopic debridement and repair or open repair What are the rehabilitation considerations?

Adhesive Capsulitis Capsular motion loss most apparent with ER, followed by abduction, then flexion What are the rehabilitation considerations? What are precautions must you take?

Electrothermally Assisted Capsular Shift Long-term effects unknown Immobilization followed by active motion What are the rehabilitation considerations? What should you be aware of with these patients?

Acromioclavicular Sprains Most such sprains are not surgically repaired or immobilized for more than symptomatic relief. Deformity may be present but does not impede performance unless heavy forces or exertion are required of shoulder. What are the rehabilitation considerations for the nonsurgical program? What are precautions should be taken? What is the healing time? What motions should the patient avoid?

Biceps Tendon Injuries Tendinopathy is more common than ruptures. Ruptures are often associated with rotator cuff pathology or impingement. Ruptures are more often seen in middle-aged adults  nonsurgical. Surgery may be necessary for younger patients with long head (LH) ruptures, especially if very active What are the rehabilitation considerations?