1. Jesse Totoro

2.  Anatomical Mechanisms  Biomechanical Mechanisms

3.  Short Term: -Rest -Reduce Pain -Reduce Inflammation -Begin ROM exercises -Begin resistance exercises  Long Term -Full ROM -Full Strength -Pain free -Psychologically prepared for safe return

4.  A progressive rehabilitation protocol based on the healing phase should be implemented: -Inflammatory Phase (0-2 weeks) -Sub-Acute Phase (2-4 weeks) -Tissue Remodeling Phase (4-6 weeks)

5.  Goals: -Rest -Reduce pain -Reduce any inflammation -Begin ROM exercises (within pain tolerance)  Modality for pain modulation (Ice and E-Stim)  Flexibility  Criteria for progression -Pain starts to decrease -Inflammation becomes reduced -Exercises become too easy for the athlete

6.  Important factor in the rehabilitation process  Can help decrease the onset of re-injury  Helps to increase performance  Should not be performed with acute pain

7.  Sleeper Stretch -Can be performed at 70, 90, and 110 degrees of motion.  Biceps -Make sure palm is facing up when performing this stretch.

8.  Goals: -Continue with stretching protocol -Introduce CV endurance (elliptical for upper extremity) -Continue to reduce pain/inflammation -Continue to increase strength and ROM  Joint Mobilizations  Resistance Training can begin  Continue with modalities to modulate pain  Criteria for Progression: -Athlete feels significant reduction in pain -Significant improvements in ROM -Very little to no swelling -Athlete is not challenged by resistance exercises

9.  Swelling reduced  Provides a precise stretch  Tensile forces applied over time  2-3 oscillations per second  Allowing capsular tissue to remodel in an elongated position.  Remember the convex/concave rule!!!

10.  Inferior Glide  Posterior Glide  Anterior Glide  Long Axis Traction

11.  Progress from light to heavy resistance  Easy to complex exercises  Stable to unstable surfaces  Do not perform resistance training with acute pain!!

12.  Theraband/Theratubing Exercises  Scapular Stabilizer Strength

13.  D1 and D2 patterns

14.  Goals: -Begin more sport specific exercises -Throwing program -Overhead activities -Acquire full ROM -Pain free -Full strength  Athlete should be preparing for functional testing and RTP

15.  Functional test should include sport specific maneuvers (throwing, blocking, tackling, etc.)  Athlete should meet the following criteria before RTP: -Ability to have full ROM -Perform all overhead tasks the sport demands -NO PAIN!! -Full strength (specifically rotator cuff musculature) -Should be able to perform all tasks at full speed

16.  Don’t do too much too soon!!  Stretching, Stretching, and more Stretching!!  Be creative with rehab!!

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18.  Michener L, McClure P, Karduna A. Anatomical and biomechanical mechanisms of subacromial impingement syndrome. Clinical Biomechanics. 2003;18:369-379.  Conroy D, Hayes K. The effect of Joint Mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome. J Orthop Sports Phys Ther. 1998;28:3-14.  Bang M, Deyle G. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;30:126-137.