Shoulder: Therapeutic Exercises Flashcards
Common Sources of Referred Pain in the Shoulder Region
- Cervical Spine:
-vertebral joints between C3 and C4 or between C4 and C5
-nerve roots C4 or C5
- Referred Pain from Related Tissues:
-dermatome C4 is over the trapezius to the tip of the shoulder
-dermatome C5 is over the deltoid region and lateral arm
-diaphragm: pain perceived in the upper trapezius region
-heart: pain perceived in the left axilla and pectoral region
-gallbladder: pain perceived at the tip of shoulder and scapular region
Nerve Disorders in the Shoulder Girdle Region
- Brachial plexus in the thoracic outlet: common sites for compression are the scalene triangle and the costoclavicular space and under the coracoid process and pectoralis minor muscle
- Suprascapular nerve in the supra scapular notch: this injury occurs from either direct compression or from nerve stretch, such as when carrying a heavy book bag over the shoulder
- Radial nerve in the axilla: compression occurs from continual pressure, such as when leaning on axillary crutches
Exercise Techniques During Acute and Early Subacute Stages of Tissue Healing
-inflammation is present or beginning to resolve
-healing tissues should not be stressed
-motion can be utilized to inhibit pain, minimize muscle guarding and help prevent adverse effects of immobilization
-valuable to treat associated regions (cervical and thoracic spine, scapulae, rest of upper extremity) to relieve stress to the shoulder girdle and prevent fluid stasis
- Early Motion of the Glenohumeral Joint:
-PROM within pain-free ranges
-when tolerated, active-assisted ROM can be initiated
• Broom handle exercise: supine on table, initiate A-AROM using a broom handle, cane, etc. held with both hands, move through all available ranges
• Ball rolling or table top dusting: sitting with arm resting on table and hand on ball or towel, initiate gentle circular motions of shoulder by moving thorax forward, backward and to side; as pain subsides, use shoulder muscles to actively move ball or towel
• Pendulum exercise: standing with thorax flexed at hips to 90°
Hexed thaps to 909, am angs bosely downward moue
thorax in a rhythmic rocking motion; increase arc of motion as tolerated
• Gear-shift exercise: seated holding a broom handle, cane, etc. with affected hand, end on the floor, move through all available ranges
Self-Stretching Techniques to Increase Shoulder ROM
Exercise Techniques to Increase Flexibility and Range of Motion: -increase flexibility in restricted muscles and fascia so proper shoulder girdle alignment and functional ranges are possible
Self-Stretching Techniques to Increase Shoulder ROM:
• To increase flexion and horizontal adduction:
-seated or standing: horizontally adduct shoulder by placing arm across chest and applying over-pressure
• To increase flexion and elevation of the arm:
-seated beside table with forearm resting along table edge, elbow slightly flexed; slide forearm forward while bending from the waist
• To increase external rotation:
-standing facing door frame, palm against frame, elbow flexed to 90°, elbow against side or slightly abducted, turn away from hand
• To increase internal rotation:
-standing facing door frame, back of hand against frame, elbow flexed to 90°, elbow against side, turn toward hand
• To increase abduction and elevation:
-seated with side next to table, forearm resting with palm supinated and pointed to opposite side of table; slide arm across table as head is brought down toward the arm and thorax moves away from table
• To increase extension:
-standing with back to table, both hands grasping edge with fingers facing forward, begin to squat while allowing elbows to flex
• To increase internal rotation, extension and scapular tilting:
-seated or standing, hold towel or broom handle with one arm overhead and arm to be stretched behind lower back, pull up on towel with overhead hand (caution with recent GH joint dislocation or anterior stabilization surgery)
Self-Stretching Exercises for Specific Muscles
Exercise Techniques to Increase Flexibility and Range of Motion
Self-Stretching Exercises for Specific Muscles:
• Latissimus Dorsi: standing with back to wall and feet forward enough to allow hips and knees to partially flex and flatten low back against wall, with arms abducted to 90° and laterally rotated 90°
slide back of hands up wall as far as possible without arching back
• Pectorals Major: standing, facing corner or doorway, arms in reverse T or V, lean body forward
• Pectoralis Minor: standing with shoulder abducted to 90° and elbow flexed to 90°, forearm stabilized on door frame, rotate trunk away from shoulder
• Levator Scapulae: seated with head side bent and rotated away from tight side, hold seat of chair to stabilize scapula, other hand placed on head to gently pull forward and to side
• Upper Trapezius: seated or standing with ipsilateral hand behind back to stabilize scapula, rotate head to gently apply stretch
neck toward tight side, side bend away from tight side and add neck flexion, other hand placed on
Exercises to Develop and Improve Muscle Performance and Functional Control
- begin at the simplest or least stressful level and progress to more complex and difficult levels
- progress from uniplanar or isolated muscle activation to use of combined, functional patterns
- choose exercises that hop patient focus on activating correct muscles with appropriate timing and sequencing to counteract impairments
- then increase the challenge by emphasizing patterns of exercises that prepare the musculature to respond to functional demands
Isometric Exercises
Exercises to Develop and Improve Muscle Performance and Functional Control
-applied along a continuum of very gentle to maximum contraction
-applied at varying muscle lengths by changing joint angles
• Self-applied multiple-angle isometrics: teach patient how to apply resistance using positions and intensities consistent with therapeutic goals, can use opposite hand or a stationary object
Stabilization Exercises
Exercises to Develop and Improve Muscle Performance and Functional Control
-begin training scapular muscles so that when muscles of the GH joint contract, they have a stable base on which to produce force
-apply alternating resistance slowly and instruct patient to ‘hold’ against resistance
-may be necessary to tell patient which way you will push to help focus on contracting muscles and alternating forces
-as patient learns to respond by contracting the proper muscles and stabilizing the joints, increase the speed of the shifting resistance and decrease the verbal cues to enhance automatic responses
• patient supine holding a rod or ball with elbows extended and shoulders flexed to 90°, stand at patients head and grasp rod, instruct patient to hold against or match resistance you provide, move rod in various directions
• standing with shoulder at 90° and one or both hands leaning against a wall or on a ball, apply alternating resistance against the shoulders or thorax and ask patient to ‘hold’ against the force; progress to patient on all fours on the floor, then on a wobble board.
Dynamic Strengthening Exercises: Scapular Muscles
Exercises to Develop and Improve Muscle Performance and Functional Control
• Scapular Retraction (Rhomboids and Middle Trapezius)
-prone with arm over edge of table, weight in hand, squeeze scapulae together
-progress to seated/standing with shoulders flexed to 90° and elbows extended; grasp elastic band or pulley and squeeze scapulae together
• Scapular Retraction combined with Shoulder Horizontal Abduction/Extension (Rhomboids, Middle Trapezius, Posterior Deltoid)
-corner press: standing with back toward a corner, shoulders abducted to 90°, elbows flexed, press elbows into walls and push body weight away from corner
• Scapular Retraction and Shoulder Horizontal Abduction combined with external Rotation (Rhomboids, Trapezius, Posterior deltoid, Infraspinatus, Teres Minor)
-prone with shoulders abducted to 90° and externally rotated to 90°, elbows flexed to 90°, instruct patient to lift arm a few degrees off table
-progress to seated with arms in same position; grasp elastic band or pulley and pull hands and elbows back while squeezes scapulae together
• Scapular Protraction (Serratus Anterior)
-seated or standing with shoulder flexed to 90° and elbow extended, secure elastic behind patient at shoulder level and have patient push forward against the resistance without rotating body
-push-up plus: standing and leaning on forearms or hands against wall, push trunk away from wall, then give extra push to protract the scapulae
-progress to hand on floor
• Scapular Depression (Lower Trapezius, Lower Serratus Anterior)
-upright press: sitting or standing with both hands on blocks, armrests of a chair or parallel bars, push down on hands and lift body, after elbows are fully extended, emphasize scapular depression
• Scapular Upward Rotation with Depression (Lower Trapezius, Serratus Anterior)
-superman: prone with humerus elevated overhead, barely lift arm off table
Dynamic Strengthening Exercises: Glenohumeral Muscles
Exercises to Develop and Improve Muscle Performance and Functional Control
• Shoulder External Rotation (Infraspinatus, Teres Minor)
-seated/standing, using elastic band or pulley in front of body at elbow level, rotate arm outward
-prone on table, upper arm resting on table with shoulder at 90°, elbow flexed with forearm over edge of table, lift weight as far as possible by rotating shoulder, not extending elbow
• Shoulder Adduction (Pectoralis Major, Teres Major, Latissimus Dorsi)
-seated/standing with arm abducted, pull down against elastic or pulley tied overhead; greatest resistance when line of resistive force is at right angles to patient’s arm
• Shoulder Horizontal Adduction (Anterior Deltoid, Coracobrachialis, Pectoralis Major)
-supine, arms out to side in horizontal abduction, bring arms forward into horizontal adduction until arms are vertical
• Shoulder Extension (Posterior Deltoid, Latissimus Dorsi, Rhomboids)
-seated/standing with arm flexed, elastic or pulley overhead, pull down against resistance into extension
• Elbow Flexion (Biceps Brachii)
-Biceps curl: seated/standing, flex elbow while holding weight, forearm supinated and arm at side
Functional Progression for the Shoulder Complex
Exercises to Develop and Improve Muscle Performance and Functional Control
• Rowing
• Lawnmower pull
• Pushing a weighted cart
