Rehabilitation of the athlete’s shoulder

The orthopedic surgeon’s roles in rehabilitation

The orthopedic surgeon plays several roles in shoulder rehabilitation. The first is to understand the basic principles of the kinetic chain. The biomechanical model for striking and throwing sports is an open-ended kinetic chain of segments that work in a proximal-to-distal sequence. The proximal segment contributions are key components of the sequential activation of body segments that is necessary to accomplish any athletic activity. The kinetic chain harmonizes the interdependent segments to produce a desired result at the distal segment. The goal of the kinetic chain activation sequence is to impart maximum velocity or force through the distal segment (the hand) to the ball, racquet, or other implements. The shoulder does not function in isolation but functions as a link in the kinetic chain activity that optimizes shoulder function. Alterations in any of the kinetic chain links can affect the shoulder, and alterations in the shoulder can affect the other kinetic chain links. The ultimate velocity of the distal segment is highly dependent on the velocity of the proximal segments. The proximal segments accelerate the entire chain and sequentially transfer force and energy to the next distal segment. ^, Because of their large relative mass, the proximal segments are responsible for most of the force and kinetic energy that is generated in the kinetic chain. As a result, lower extremity force production is more highly correlated with ball velocity than is upper extremity force production.

This interaction creates two implications for shoulder rehabilitation: first, the evaluation and identification process preceding shoulder treatment and rehabilitation should include more than just local shoulder structures. The evaluation process should result in a complete and accurate diagnosis of all of the altered structures throughout the kinetic chain. It can be divided into three sections—leg/hip/core, scapula, and shoulder. Second, optimum restoration of shoulder function requires that all of the kinetic chain segment interactions are reestablished to meet the individual’s needs that existed before injury.

The second role is to place an emphasis on establishing the comprehensive diagnosis of the causative factors of the clinical symptoms that will need to be addressed in treatment and rehabilitation. Most patients come to the clinician’s office with an experience of an alteration of function or dysfunction ^, that they wished to be restored. The dysfunction frequently has multiple causative factors which may include altered anatomy (rotator cuff tear, labral injury, biceps tendinopathy, arthritis), physiology (strength weakness or imbalance, muscle tightness, loss of endurance), and/or mechanics (altered joint motions, altered bony alignment), both locally and distantly from the site of symptoms. This may seem obvious but is sometimes difficult to implement unless the entire kinetic chain is screened for alterations. The actual shoulder injury is thought by most orthopedic surgeons to be the primary factor that determines treatment and rehabilitation. However, both nonovert local alterations and distant alterations are frequently associated with shoulder clinical symptoms and dysfunction and must also be evaluated. By this type of evaluation, the altered anatomy can be evaluated in relation to how it affects and is affected by the altered physiology and mechanics to produce the clinical dysfunction.

The most common local alterations are decreased shoulder internal or external rotation, which creates altered glenohumeral translations, ^, altered rotator cuff strength or strength balance, ^{, ,} muscle tightness in the pectoralis minor and upper trapezius, and alterations in scapular motion and position (scapular dyskinesis). These alterations can disrupt the normal smooth coupling of scapulohumeral motions in voluntary activation and are present in most patients with shoulder impingement. Distant alterations include lumbar muscle inflexibility and muscle weakness, and hip and knee inflexibility. Because these alterations are common findings in shoulder injury, they need to be assessed through a screening process in the clinical evaluation. This requires a clinical evaluation approach known as “victims and culprits” in which the site of symptoms is the “victim” but the “culprits” may include alterations at other sites.

The clinical evaluation of the legs/hip/core should include screening tests for hip/trunk posture and functional strength. Our screening examination includes standing posture evaluation of legs, lumbar, thoracic, and cervical spine, bilateral hip range of motion assessment, trunk flexibility assessment, and a one-leg stability series ( Fig. 2.1 ), which assesses control of the trunk over the leg. Any observed abnormalities should be further evaluated in more detail.

Evaluation of the scapula should be performed to establish the relation of the resting position and dynamic motion to the clinical symptoms, to determine the need for scapular rehabilitation. An algorithm for the evaluation sequence has been established. ^, The first step is the evaluation for the presence or absence of scapular dyskinesis (includes alteration of scapular resting position and alteration during dynamic motion).

Scapular evaluation is performed from behind the patient. It should assess resting position and note any asymmetries with respect to bony landmarks of the inferior angle, medial and superior border of the scapula. Dynamic motion screening involves evaluation of the same asymmetries of scapular control with weighted arm abduction and forward flexion, in both ascent and descent. ^, Observation of any of the types of scapular asymmetry correlates highly with actual biomechanical alteration and can be reliably used as a marker of scapular dyskinesis.

The second step is to determine the relationship of the dyskinesis to the clinical symptoms. Manual mobilization by the scapular assistance test or stabilization by the scapular retraction test can demonstrate improvement in range of motion, demonstrated strength, clinical symptoms of impingement, biceps tendinopathy, glenohumeral instability, and labral injury, as well as provide subjective improvement in awareness of scapular position and stability. These positive findings provide indications for inclusion of scapular rehabilitation as part of the comprehensive treatment. If this step is positive, then the evaluation can be directed at the known causative factors for dyskinesis ( Fig. 2.2 ). Appropriate clinical examination tests for muscle strength, balance, and flexibility, testing for glenohumeral internal derangement, neurologic testing, and imaging may be used. Assessment should be done for loss of conscious control, an alteration of normal coordinated muscle activation which decreases the effectiveness of standard rehabilitation exercises to optimize scapular control. The treatment and rehabilitation prescription will include protocols to address each of these factors.

The third role is to determine the timing of entry into and exit from the rehabilitation program. If surgery is required, entry into rehabilitation should be started before surgery to address deficits of flexibility and strength both locally and at distant portions of the kinetic chain. In many cases rehabilitation interventions focused on addressing the correct “culprits” may prevent the need for surgical intervention. Postoperative entry into rehabilitation can begin quite early, while the shoulder is still protected. Kinetic chain rehabilitation of the legs, trunk, and scapula may be started early, and closed chain range of motion may be started in safe ranges determined at the time of surgery. Exit from rehabilitation should be based not only on healing of the anatomic lesion but also on normalization of physiology and biomechanics to allow functional return to the demands of the desirable sport or activity. This requires frequent functional assessment as rehabilitation proceeds. Key functional components include range of motion, balanced strength, intact kinetic chain, and functional activities.

The fourth role is to be familiar with the phases of the rehabilitation program, the content and goals of each stage, and the criteria for progression between each stage. Rehabilitation may be divided into three phases (acute, recovery, and functional) based on anatomic injury, anatomic healing, functional capabilities, and functional tasks ( Fig 2.3 ).

The fifth role is to guide the “pace” of the rehabilitation protocol. In the early stages, this will be determined by the anatomic diagnosis and integrity of the anatomic repair. In later stages, it will be determined by the progressive acquisition of components of normal kinetic chain function, normal flexibility, normal strength, and sport or activity specific functions. This requires periodic reassessment of the patient and frequent precise communication with the physical therapist or athletic trainer. Rehabilitation should be viewed as a “flow” of exercises that will vary according to stages of healing and reestablishment of key points of muscle and joint function. This flow is indicated in the rehabilitation flow sheet based on categories of rehabilitation exercises ( Table 2.1 ). In most cases, it is not appropriate to abdicate the responsibility or involvement in rehabilitation by marking “evaluate and treat” on a physical therapy prescription. Even though the orthopedic surgeon does not actually provide the details of the exercises, the surgeon must be an integral part of the team that provides the rehabilitation protocol. Several guidelines can be followed to guide the flow and make sure kinetic chain principles are followed.

The sixth and most important role is communication, because the physician is ultimately responsible for the care of the patient. Establishing an open line of communication with the other members of the rehabilitation team is critical. This may be done in several ways, including written notes, prearranged protocols, sheets with specific guidelines, or direct electronic or phone communications. Ideally, the physician would have an established working relationship with the physical therapist or athletic trainer. However, practically this is not the case; therefore the physician must make it clear to the patient that any questions from the rehabilitating clinician should be directed back to the referring physician. During subsequent follow-up visits, the physician should share primary concerns and precautions in the referring prescription. The notation “continue therapy” does not provide adequate communication or direction to yield optimal outcome for the patient.