L9: Management Exercise of the Shoulder

Question 1

What are 4 reasons for using exercise for shoulder conditions?

Answer 1

Neuromuscular system is a key stabiliser of the shoulder (esp. GHJ)

1. To relieve pain
2. To address or prevent strength deficits
3. To address movement impairments

Question 2

What are 7 things to consider when prescribing exercises?

Answer 2

1. Impairments (from assessment findings)
2. Pathology
3. What are you trying to achieve?
   
   • patient’s activities and goals – task specificity
4. Patient’s preferences – home, clinic, gym
5. Type of exercise
   
   • resistance, motor control, proprioception, functional
6. Dosage appropriate to goals – not just 3x10!
   
   • Need to have a rationale for the dosage
7. Recovery (especially if high load)
   
   • Adequate time to recover, does not allow for adaption

Question 3

What are the parameters for resistance training for strength, power, hypertrophy and endurance?

Answer 3

Question 4

What are 5 features to consider in motor control?

Answer 4

1. Coordinated and efficient use of muscles of the shoulder complex
   
   1. Rotator cuff and scapular muscles
2. Cognitive phase- Learning how to do the task well
3. Start where the patient is not failing at the task, but it requires effort
   
   • Not too hard; not too easy – needs to be some cognitive effort involved
4. Slow, controlled; high repetition (motor learning)
   
   • Need to build up strength and control before progressing exercise
5. Feedback +++
   
   • Variety of sources – you, self-regulation, others
6. Consider:
   
   • Tactile – touch, tape
   • Verbal
   • Visual – mirror, video

Question 5

What are the 2 characteristics of proprioception for shoulder?

Answer 5

1. Awareness of position of upper limb in space
2. Can start training early post-injury

Question 6

What are 5 examples of exercise progression?

Answer 6

1. Unstable or painful positions
   
   • Eg. for anterior dislocation start ER in neutral –> abduction 90˚ –> overhead
2. Increase speed
3. Increase load
4. Incorporate functional tasks
5. Return to function (sport/work)
   
   • graded return to sport-specific tasks (built on exercise progressions)
   • build up chronic workload
     
     • Might have disuse or weakness (low workload) –> can be a risk of re-injury
   • gradual introduction to full activity
   • Return to work/sport criteria

Question 7

What are 3 things to consider before starting management?

Answer 7

1. Scapula:
   
   • Dyskinesis, aberrant movement patterns
   • Does correction of the scapula help or assist the movement strategy (TDT)?
2. Humeral head:
   
   • Increase or decrease in translational motion
   • Altered humeral head centering
   • Does correction improve the movement strategy (TDT)?
   • Length tension relationship
3. 3. Pathological restrictions or implications:
      * Likely or known pathology
      * How will this affect rehabilitation & exercise selection
      * Is this exercise safe?

Question 8

What is the primary action of the subscapularis (rotator cuff) for dynamic stability (GHJ)?

Answer 8

IR

Question 9

What are the 3 functions of the subscapularis (rotator cuff) for dynamic stability (GHJ)?

Answer 9

1. transverse force couple with infraspinatus and teres minor (to control anterior translation)
2. GH compression, anterior & posterior stability
3. upper and lower portions function differently:
   
   • upper: higher EMG activity during IR MVIC
   • lower: higher EMG activity during ER MVIC & abd

Question 10

What is the primary action of the infraspinatus and teres minor (rotator cuff) for dynamic stability (GHJ)?

Answer 10

ER

Question 11

What are 6 functions of the infraspinatus and teres minor (rotator cuff) for dynamic stability (GHJ)?

Answer 11

1. transverse force couple with subscapularis (control anterior translation)
2. humeral head depression (with lat dorsi)
3. deceleration
4. extension (especially at 90o abduction)
5. infraspinatus generates greatest torque in 0˚ abduction (e.g. shoulder ER in side lying)
6. adding a rolled towel increases infraspinatus and teres minor EMG activity

Question 12

What is the primary action of the supraspinatus (rotator cuff) for dynamic stability (GHJ)?

Answer 12

abduction

Question 13

What are 3 functions of the supraspinatus (rotator cuff) for dynamic stability (GHJ)?

Answer 13

1. generates small ER torque
2. compresses GHJ (especially during initiation of abduction)
3. greatest torque when shoulder is in neutral rotation

Question 14

What are 5 motor control rotator cuff exercises?

Answer 14

1. Start with neutral positions (as appropriate)
2. Make sure ideal scapular position – can affect RC activation
3. Relaxed pec major, lat dorsi
4. Slow, small controlled movement
5. Theraband around proximal humeral head (proprioception) or taping to facilitate – can increase RC activity and provide feedback
   
   • Pushing into the resistance for feedback (pull anteriorly/ PA)

Question 15

What are 5 progressions for motor control rotator cuff exercises?

Answer 15

1. Increasing degrees of abduction, ER
2. Positions of instability or impingement
3. Functional positions
4. Add dynamic movement
5. Incorporate into function

Question 16

What are 3 muscles that do elevation in the scapular plane (30˚ into frontal plane)?

Answer 16

1. Supraspinatus
2. Infraspinatus
3. Subscapularis

Question 17

What are 3 muscles that do external rotatation?

Answer 17

1. Supraspinatus
2. Infraspinatus
3. Teres minor

Question 18

What is a muscle that do internal rotatation?

Answer 18

Subscapularis

Question 19

What is a muscle that do horizontal adduction with ER (eg. prone)?

Answer 19

Infraspinatus

Question 20

What are resistance training for rotator cuff exercises?

Answer 20

Question 21

What are the parameeres for resistance for rotator cuff exercises?

Answer 21

Question 22

What are 4 combined and functional movements for resistance training in rotator cuff exercises?

Answer 22

1. Internal rotation in HBB position
2. Abduction and ER (concentric & eccentric phases)
   
   • Add horizontal abduction e.g. in throwers (ensure scapular retraction)
3. Flexion/abduction/ER – extension/adduction/IR
4. Flexion/adduction - extension/abduction

Question 23

What is the Ball on the Wall rotator cuff exercise for proprioception?

Answer 23

Position of humeral head and resting position of scapula

• Circles/ up and down movements
• Bigger
• Other sizes
• Increase weight of ball (eg. not has heavy as medicine ball but weighted ball)

Question 24

What is the Bodyblade rotator cuff exercise for proprioception?

Answer 24

Across all ranges and no hitching of the shoulder

Question 25

What is a progression of the rotator cuff exercises?

Answer 25

Integrate kinetic chain

Question 26

How can upper trapezius be tight and lengthened?

Answer 26

Upper trapezius can tighten but lengthen (scapula downward rotation)

• Try to rotate (scapula rotate to ear) rather than shoulder elevation

Question 27

What are 3 features of early shoulder rehabilitation?

Answer 27

1. Focus on motor control, recruitment, correct patterning/technique
2. High repetitions, multiple times a day
   
   • e.g. 20 reps, 1-2 sets, 3 x day
   • e.g. 60 reps, 1 set
3. Cortical imprint & carryover –motor learning (Learning the skill)

Question 28

What are 3 features of late shoulder rehabilitation?

Answer 28

1. Higher level exercise demand
2. More hypertrophy & strength drills
3. Once a day or every 2nd day
4. Progress to functionally specific drills
5. Dynamic loading drills – eccentric activity, plyometrics, ballistic movements – better carryover to function
   
   • Wont be compliant unless they see the relevance

Question 29

_____ is a key component of management of all shoulder conditions

Answer 29

Exercise