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SuperiorLabrumAnteriorPosterior(SLAP)Repair(TypeI&III)ReturntoSportProtocol

GeneralRehabilitationGuidelines:- AspecificRehabilitationprogramisdependentontheseverityofthepathology/injuryandshould

specificallymanagethehealingandrequirementoftheprocedurethepatientunderwent(Debridementvs.Repair),inadditiontootherconcomitantinjuries/proceduresperformed

- TheemphasisoftheSLAPprotocolshouldbeonrestorationandenhancementofthedynamicstabilityoftheglenohumeralandscapulo-thoracicjointswhileprotectingthehealingtissuesfromadversestress

- Hypersensitivityintheaxillarynervedistributionisacommonoccurrence- ForpatientswhosustainedaSLAPlesionsecondarytoafall/compression(MVA,Fallonout-

stretchedarm),weight-bearingexercisesshouldbeavoidedtominimizecompressionandsheeronthesuperiorlabrum

- Patientswhosustainedatraction-typeinjuryshouldavoidheavyresistanceorexcessiveeccentricbicepscontractions

- Patientswithpeel-backlesions(typicallyoverheadathletes),shouldavoidexcessiveamountsofshoulderERwhiletheSLAPlesionishealing

- SLAPClassifications:(basic4,recentlyadditionalclassificationsadded):o TypeI:IsolatedFrayingofthesuperiorlabrum,withafirmattachmentofthesuperiorlabrumto

theglenoid(typicallydegenerativeinnature).o TypeII:(Mostcommon,especiallywithoverheadathletes):Adetachmentofthesuperior

labrumandtheoriginofthelongheadofthebicepsbrachiitendonfromtheglenoidcreatinginstabilityofthebiceps-labralanchor.

o TypeIII:Abucket-handletearofthesuperiorlabrumwithanintactbicepsinsertion.o TypeIV:(Theleastcommonofthe4maintypes):Abucket-handletearofthesuperiorlabrum

thatextendsintothebicepstendon.Thistypewillalsohaveinstabilityatthebicep-labrumanchor.

o TypeV:SLAPlesionswiththepresenceofaBankartlesionoftheanteriorcapsuleextendingintotheanteriorsuperiorlabrum.

o TypeVI:Adisruptionorseparationofthebicepsanchorwithananteriorposteriorsuperiorlabralunstableflaptear.

o TypeVII:Lesionsthatextendedanteriorlytoinvolvetheareainferiortothemiddleglenoidligament.

o TypeVIII:AtypeIISLAPtearwithaposteriorlabralextensiontothe6o’clockposition.o TypeIX:Isacircumferentiallesioninvolvingthefull360°oflabralattachmenttotheglenoid

rim.o TypeX:Ininvolvesasuperiorlabraltearcombinedwithaposteroinferiorlabraltear(areverse

Bankartlesion).o *ItiscommontohaveconcomitantinjurieswithSLAPlesions,sotheseclassificationscanbe

beneficialforcreatingthemotappropriatetreatmentplan*

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TypeIandTypeIIIRepair(Debridement):- Thisprotocolcanbeaggressiveatrestoringmotionsecondarytothebiceps-labralanchorbeing

intactandstable.PhaseIRestorationofMotionPhase(approximately1-10days):- Goals:o Achievenormalnon-painfulshoulderROMo Preventmuscleatrophyo Decreasepainandinflammationo HavepatientfilloutabaselineKerlan-JobeOrthopaedicClinicOverheadAthleteShoulderand

Elbow(KJOC)questionnaire-*moreaccurateassessmenttooldesignedspecificallyforoverheadathletes,ortheAmericanShoulderandElbowScore(ASES)

- PatientEducation:o Theslingisworn3-4daysfollowingsurgeryo CardiovascularFitness:WalkingorStationaryBike,WearingtheSling.- Treatment:o Modalities:Cryotherapy,Moistheat,ESTIM,DryNeedlingo Assessanybreathingdysfunctionsandteachappropriatebreathingexercisesfordiaphragmatic

breathingo Desensitizationtechniquesforaxillarynervedistribution,ifpresento PROMandAAROMmaybebegunimmediately,withfullPROMexpectedtoberestoredwithin

10-14dayspost-op§ Manualstretching,jointmobilization,andevaluationandtreatmentofcervical,thoracic,

andribimmobilityanddysfunctionalpatterns§ Pendulumexercises§ Ropepulleyexercises§ Bar/Caneforflexion/extension,abduction/adduction,ER/IR(beginat0°ofabduction,

thenprogressto45°inthescapularplaneandthento90°)-bypost-opday4-5§ Patientdrivenmanualstretches(jointandcapsularstretches,aswellasanyothertissue

extensibilityissueofotherjoints/muscles)o Strengthening:

§ Isometricstrengthening(allplanes)-Sub-maximallyandpain-freeduringthefirst7dayspost-optominimizeatrophy.NoBicepsisometricsfor5-7dayspost-op

§ LighttubingmaybeinitiatedforER/IRat0°abductionlatenthisphase(approximately7-10dayspost-op)

o CriteriatoProgresstoPhaseII:§ FullPROM§ Minimalpainandtenderness§ 4/5MMTofIR,ER,andFlexion

PhaseII:IntermediatePhase:(approximately10days-4weekspost-op):-Goals:

§ Toregainandimprovemuscularstrength§ NormalJointarthrokinematics-Cervical,Thoracic,Shoulder,Hips,andAnkles(ifneeded)§ ImproveneuromuscularcontroloftheShoulder,Scapula,Trunk,andHips

- PatientEducation:o Instructpatientonprecautionsandlimitationswhileinthisphaseofrehabilitation

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- Treatment:o Assescorestabilityanddysfunction-determinewhetherdysfunctionsaretruestrengthissues

oriftheyarearesultofmuscularinhibitionfromajoint/movementrestrictiono Initiateneuromuscularcontrolexercisesfortrunk/core,hips,andscapulothoracicareaso Initiateproprioceptivetrainingexerciseso TeachbasicDynamicStretchingProgram(totalbody)o Lightisotonicstrengtheningforshoulderandscapulothoracicmusculature,(withtheexception

ofthebiceps),withresistancetubinganddumbbells§ *SeeShoulderMuscleFunctionandhighmuscleactivitywithshoulderexercisessheet

andprogressappropriately§ ER/IRtubinganddumbbellsat0°abduction:side-lyingER,ProneRowing,Prone

horizontalAbduction,ProneER,PNFmanualresistanceanddynamicstabilizationtechniqueswithinallplanesofscapularmotion

§ Activeelevationexercises:Scapularplaneelevation(fullcan)andlateralraises§ Beginusing1lbweightsandprogressweeklyin1lbincrements(gradual,controlled,

progressiveresistance)§ Lightbicepsresistanceisnotinitiateduntil2weekspost-optopreventdebridementsite

irritation.*Cautionwithearlyover-aggressiveelbowflexionandforearmsupinationexercises,particularlyeccentric

o Normalizingjointarthrokinematics:§ Jointmobilizationintheglenohumeral,cervical,thoracic,lumbarandribjoints§ Continuedstretchingoftissueextensibilitydysfunctionalmuscles/jointsalongtheentire

kineticchain§ Asthestrengtheningprogramprogresses,emphasisonobtainingmuscularbalanceand

promotingdynamicshoulderstability§ Themanualresistanceandtheend-rangerhythmicstabilizationdrillscombinedwith

isotonicstrengtheningandcorestabilizationexercises,willhelpmeettheultimategoalofre-establishingdynamichumeralheadandscapularcontrol/stability

o Thrower’sTenprogrammaybebegunapproximatelyweek3-4(SeeAttachedSheets)o Towardtheendofthisphasehighemphasisisplacedonrotatorcuffandscapularstrengtheningo Patientshouldberidingastionarybikeorellipticalforcontinuedendurancetraining

- CriteriatoProgresstoPhaseIIIo Fullnon-painfulPROMandAROMo NoPainorTendernesswithExercisesandADL’so Comparativestrengthof70%ofthecontralateraluninjuredUE

PhaseIII-TheDynamicStrengtheningPhase-(approximately4-6weekspost-op)- Goals:o ImproveStrength,Power,andEnduranceo Improveneuromuscularcontrolo Beginpreparationtoinitiatethrowingactivities/exerciseswiththepatiento PatientisevaluatedwiththeFunctionalMovementScreen(FMS)andY-Balance/StarExcursion

assessmentsforbaselinevaluestowardtheendofPhaseIII- PatientEducation:o Instructpatientonprecautionsandlimitationswhileinthishaseofrehabilitation- Treatment:

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o ContinueThrowsTenProgram-ProgressingtotheAdvancedThrower’sTenprogram(SeeAttachedSheets),whentolerated

o ContinueStrengthtrainingwithweights,withtheadditionofthesupraspinatusanddeltoid-*SeeShoulderMuscleFunctionandHighMuscleActivitywithShoulderExercisesSheets-progressappropriately

§ Advancedcontrolledweighttrainingexercises/activities,withemphasisonpropertechnique

§ Patientshouldavoidexcessshoulderextensionwithexercisessuchasbenchpressandseatedrowstominimizestressontheshoulder

o Progresstubingexercisesto90°offlexionorabductionforIRandERexercises-Setsshouldbeperformedatslowandfastpaces

§ Begintubingexercisesforbicepsstrengtheningo Continuestrength/endurance/stabilizationexercisesforscapulothoracicmusculature-including

closed-chainexerciseso InitiateUEPlyometricPhaseI(Two-Handed)protocolatapproximately4-5weekspost-op(*if

criteriaforphaseIIIwasmet),thenprogresstoUEPlyometricPhaseII1-2weekslater(SeeAttachedSheets)

o InitiatePNFDiagonalpatternswithtubingandDumbbellsinvariouspositions(standing:DL->Staggeredstance->SL->unevensurface,DLandHalfkneeling:evenorunevensurface,seatedonanexerciseball,etc)

o InitiateWalk-to-RunProtocol(SeeAttachedSheets)tokeeppatientsenduranceandprepareforreturntoactivityphase

- CriteriaforProgressiontoPhaseIVo FullPROMo Nopainortendernesswithexercises,ADL’s,oradvancedstrengtheningandplyometric

activitieso Strengthcomparisonof³80%tothecontralateraluninjuredUEo ScoreontheFMSof³14,DemonstrateimprovementintheY-Balance/StarExcursionBalance

Testo SubjectiveEvaluationFormscoreorminimaldetectablechangeimprovement

PhaseIV-ReturntoActivityPhase(*approximately7+weekspost-op)*Dependentonconcomitantinjuries/procedures- Goals:o Toprogressivelyincreaseactivities/exercisestoassessandpreparepatientforreturntosport

specificactivities- PatientEducation:o Instructpatientonprecautionsandlimitationswhileinthisphaseofrehabilitation- Treatment:o ContinueallexercisesfromPhaseIIIthatarestillneededo Continue/ProgressCore,Hip,AndScapularStabilizationExercises

§ Makesuretoinclude:Deadliftvariations,Chop-n-Liftvariations,Bridgingvariations,PlankVariations,PNFSquattingvariations,Push-UpProgressions,Balance/Proprioceptionexercises,andReactionTraining

o BeginPhaseIIIUEplyometricprotocol(SeeAttachedSheets)o InitiateandevaluatewithLEPlyometricProtocol(SeeAttachedSheets)

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o TeachSportSpecificDynamicStretchingProgram-(SeeSpecificSportDynamicStretchingSheet)

o ContinueAdvancedThrower’sTenprogramo InitiatetheIntervalRunningProtocol-SeeIntervalRunningProtocolo Patientmaybeginspecificsportskillactivities/Initiateintervalsportprograms,betweenweeks

8-12,dependingonconcomitantinjuries§ </=20%-30%RotatorCuffTearcanprogressatthistimeframe,§ Moreextensivepathologymaybedelayedforupto4months-determinedbyROM,

Strength,functionalassessment,andMDclearanceCriteriaforenteringReturntoSpecificSportandContinuedIntervalSportProtocols:1- ClearancefromthesurgeontobegintheReturntoSportSpecificProtocol.2- Nosignsofanylingeringshoulderinstabilitywithactivities.3- RestorationofallROMneededtoparticipateindesiredsport.4- Strengthtestingof≥90%comparedtocontralateral/uninvolvedside.5- Adequatestrengthandmuscleenduranceoftheshoulder,rotatorcuff,trunk,hips,andscapular

musculatureneededtoperformsportspecificdrills/activitieswithminimaltonopainordifficulty.

6- IfAvailable:PerformIsokinetictesting:WiththegoalsofthepatientbeingabletoachieveaERpeaktorque/bodyweightratioof18%-23%,anER/IRratioof66%-76%,andanER/ABDratioof67%-75%,at180°/sectesting.

7- PatientscoresanappropriatescoreontheKerlan-JobeOrthopaedicClinicOverheadAthleteShoulderandElbow(KJOC)Questionnaire,orASESsubjectiveevaluationforms,thatwouldshowabilitytoreturntosportingactivity.

8- >14ontheFMSandscoreequaltotheirpeersforsportandagethroughtheY-Balance(Move2Performdatabase),orCKCUTESTequaltonormativevalues.

9- NoPainwithanyofthepreviousexercises/activities/evaluationsperformed.10- CompletingtheThrowersTenProgram,andAdvancedthrowersTenProgram,aswellasthe

UpperExtremityPlyometricProtocols.11- PassingoftheFunctionalTestslistedbelow:(Testingcanbeovermultiplesessions):a. TrunkTesting:Re-Test(Seeattachedsheets)

i. DeepNeckFlexorTestii. SegmentalMultifidusTestiii. TrunkCurl-UpTestiv. Double-LegLoweringTestv. ProneBridgeTestvi. EnduranceofLateralFlexors(SideBridge)Testvii. ExtensorDynamicEnduranceTest

b. UpperExtremityTesting:(Seeattachedsheets)i. Alternative/ModifiedPull-upTestii. Push-upTestiii. BackwardOverheadMedicineBallThrowTestiv. SidearmMedicineBallThrowTestv. One-HandandTwo-HandSeatedShot-PutThrowTest-6-poundmedicineball(Dominant

andNon-DominantUE)vi. *IfpatientisabaseballorSoft-ballpitcher/player:

1. FunctionalThrowingPerformanceIndex(FTPI)Test-bestassessedwithvideoanalysis

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2. Baseballpitchersonly-PT/ATCfillsoutUpperExtremityThrowingAnalysisForm-todetermineareasofthethrowingmotionthatneedtobeaddressedintheSportSpecific/ReturntoBaseballPitchingProtocol

*SeeReturntoSpecificSportandIntervalSportProtocol

References

Blackburn,TA,Guido,JA.RehabilitationAfterLigamentousandLabralSurgeryoftheShoulder:Guiding

Concepts.JAthleticTraining.2000;35(3):373-381.Cooketal.DiagnosticAccuracyofFiveOrthopedicClinicalTestsforDiagnosisofSuperiorLabrum

AnteriorPosterior(SLAP)Lesions.JShoulderElbowSurg.2012;21:13-22.Davies,GA,Wilk,KE,Irrgang,JJ,Ellenbecker,TS.TheUseofaFunctionalTestingAlgorithm(FTA)to

makeQualitativeDecisionstoReturnAthletesBacktoSportsFollowingShoulderInjuries.(APTASportsPhysicalTherapySectionHomeStudyCourse,Chapter6)2013.

Dessaur,WA,Magarey,ME.DiagnosticAcuracyofClinicalTestsforSuperiorLabralAnteriorPosterior

Lesions:ASystematicReview.JOrthoSportsPhysTher.2008;38(6):341-352.Dodson,CC,Altchek,DA.SLAPLesions:AnUpdateonRecognitionandTreatment.JOrthoSportsPhys

Ther.2009;39(2):71-80.Escamillaetal.ShoulderMuscleActivityandFunctioninCommonShoulderRehabilitationExercises.

SportsMed.2009;39(8):663-685.Micheneretal.DiagnosticAccuracyofHistoryandPhysicalExaminationofSuperiorLabrumAnterior

PosteriorLesions.JAthleticTraining.2011;46(4):343-348.VanKleunenetal.ReturntoHigh-LevelThrowingAfterCombinationInfraspinatusRepair,SLAPRepair,

andReleaseofGlenohumeralInternalRotationDeficit.AmJSportsMed.2012;40(11):2536-2541.Wilketal.CurrentConceptsintheRecongnitionandTreatmentofSuperiorLabral(SLAP)Lesions.J

OrthoSportsPhysTher.2005;35(5):273-291.

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ShouldermusclefunctionandhighmuscleactivitywithshoulderexercisesRotatorCuff:

Supraspinatus:- Thesupraspinatuscompresses,abductsandprovidesasmallERtorquetotheglenohumeraljoint- Atlowerscaptionangles,supraspinatusactivityincreasetoprovideadditionalhumeralhead

compressionwithintheglenoidfossatocounterthehumeralheadsuperiortranslationfromthedeltoids

- ‘Fullcan’maybepreferredoverthe‘emptycan’forrehabilitationandsupraspinatustesting:o 1.IRofthehumeruswiththe‘emptycan’doesnotallowthegreatertuberositytoclearfrom

undertheacromionduringhumeralelevation,whichincreasessubacromialimpingementriskfromdecreasedspacewidth.

o 2.AbductingwhileinextremeIRprogressivelydecreasestheabductionmomentarmofthesupraspinatusfrom0°to90°abduction,whichcreatesadiminishedmechanicaladvantage,increasingtensileforcesonthehealingtendon.

o 3.Scapularkinematicsaredifferentbetween’emptycan’and‘fullcan’exercises.ScapularIR(transverseplanemovementwiththemedialbordermovingposterior,resultingin‘winging’),andanteriortilt(sagittalplanemovementwiththeinferioranglemovingposterior),bothofwhichdecreasesubacromialspacewidth,aregreaterinthe‘emptycan’versusthe‘fullcan’.The‘emptycan’tensionsboththeposteroinferiorcapsuleandrotatorcuff(infraspinatusprimarily).Tensioninthesestructurescontributestoananteriortiltedandinternallyrotatedscapula,whichprotractsthescapula.ScapularprotractionsignificantlyreducesglenohumeralIRandERstrengthby13%-24%and20%respectively.Scapularprotractionhasbeenshowntodecreasesubacromialspacewidth,whereasscapularretractionhasbeenshowntoincreasesubacromialspacewidth,aswellas,enhancesupraspintusforceproductionduringhumeralelevation,makingstrengtheningscapularretractorsandgoodpostureveryimportant

o 4.Theuseofthe‘fullcan’testpositionmaybedesirableintheclinicalsettingbecausethereislesspainprovocation,andithasbeenshowntobeamoreoptimalpositionforsupraspinatusisolation.

- HighmuscleactivityoftheSupraspinatuswithexercises:o Pronehorizontalabductionat100°abductionwithERo ProneERat90°ofabductiono StandingERat90°ofabductiono Flexionabove120°withERo MilitaryPress(trunkvertical)o Side-lyingabductiono PNFscapularclock,D2diagonalpatternflexionandextensiono Standingforwardscapularpuncho Rowingexerciseso Push-upexerciseso Two-Handmedicineballoverheadthrows

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InfraspinatusandTeresMinor- TheinfraspinatusandTeresMinorcomprisetheposteriorcuff,whichprovidesglenohumeral

compression,ERandabduction,andresistssuperiorandanteriorhumeralheadtranslationbyexertingaposteroinferiorforcetothehumeralhead.TheERprovidedfromtheposteriorcuffhelpsclearthegreatertuberosityfromunderthecoracoacromialarchduringoverheadmovements,minimizingsubacromialimpingement

- Infraspinatus:o It’ssuperior,middle,andinferiorheadsallgenerateitslargestERtorqueat0°abduction.This

impliesthattheinfraspinatusisamoreeffectiveexternalrotatoratlowerabductionanglescomparedtohigherabductionangles

o Asresistanceincreases,infraspinatusactivityincreasestoresistsuperiorhumeralheadtranslationduetotheincreasedactivityfromthedeltoids

o HighmuscleactivityoftheInfraspinatuswithexercises:§ Pronehorizontalabductionat100°abductionwithER§ Flexion§ Side-Lyingabduction§ StandingExtensionfrom90°to0°§ D1andD2diagonalpatternflexion§ VarietyofPush-upexercises§ Bipodposition(alternatingarmandleg)

- TeresMinor:o TheTeresMinorgeneratesarelativelyconstantERtorquethroughoutarmabduction

movement,whichimpliesthattheabductionangledoesnotaffecttheeffectivenessoftheTeresMinortogenerateERtorque

o TheTeresMinorisaweakadductorofthehumerusregardlessoftherotationalpositionofthehumerus,andbecauseofitsposteriorpositionattheshoulder,italsohelpsgenerateaweakhorizontalabductiontorque

o HighmuscleactivityoftheTeresMinorwithexercises:§ Pronehorizontalabductionat100°ofabductionwithER§ Standinghigh,mid,andlowrows§ Standingforwardscapularpunch§ IRexercises(stabilizingtheglenohumeraljoint)

Subscapularis:- Thesubscapularisprovidesglenohumeralcompression,stability,IRandabduction- ThemovementmostoptimalforisolationandactivationofthesubscapularismuscleistheGerber

Lift-off,againstresistance,whichisperformedbyliftingthedorsumofthehandoffthemid-lumbarspine,againstresistance,bysimultaneouslyextendingandinternallyrotatingtheshoulder.*Thiswasoriginallydevelopedasanassessment,however,canalsobeusedasatreatmentexercisesince:o Ittendstoisolatethesubscapularismusclebyminimizingpectoralismajor,teresmajor,

latissimusdorsi,supraspinatusandinfraspinatusactivitywhenperformedwithnoresistanceo ItgeneratesasmuchormoresubscapularisactivityascomparedwithresistedIRat0°or90°of

abductiono ItavoidsthesubacromialimpingementpositionassociatedwithIRat90°ofabduction

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o *Itisimportanttohavethepatient’shandatthemid-lumbarleveltoperformtheexercise,becausetheloweranduppersubscapularisactivitydecreasesapproximatelyby30%whentheexerciseisperformedatthebuttockslevel.

- Highmuscleactivityofthesubscapulariswithexercises:o The‘FullCan’–itmaybemoreeffectiveingeneratingthesubscapularisthanthe‘EmptyCan’o Flexionandabductionabove120°withERo Scaptioninneutralrotationo Side-lyingabductiono Militarypresso D2diagonalpatternFlexionandExtensiono PNF-scapularclocks,depression,elevation,protractionandretractionmovementso Push-upso Standingscapulardynamichugo Standingforwardscapularpuncho Standinghigh,mid,andlowscapularrowso 2-Handedoverheadmedicineballthrows

DeltoidBiomechanicsandFunctioninRehabilitationExercises- Theanteriorandmiddledeltoidarenoteffectiveabductorsatlowangles(especiallyanterior

deltoids),whilethesupraspinatus,infraspinatusandsubscapularisaremoreeffectiveabductorsatlowabductionsangles

- Theanteriorandmiddledeltoidsactivitygenerallypeaksbetween60°and90°ofscaption,whilethesupraspinatus,infraspinatusandsubscapularisactivitygenerallypeaksbetween30°and60°ofscaption

- At60°ERand0°abduction(fullcanposition),theanteriordeltoidiseffectiveasanabductor,evenatsmallabductionangles,notsowiththeemptycanposition,inIR

- HighmuscleactivityoftheAnteriorandMiddleDeltoidwithexercise:o D1andD2diagonalpatternflexiono Flexiono Push-upexerciseso Benchpresso Dumbbellflyo Militarypresso 2-Handedoverheadmedicineballthrowso Press-upso Dynamichugexerciseo Standingforwardscapularpuncho *Anteriordeltoidincreasesasthetrunkbecomesmorevertical(inclineandmilitarypress),and

leswithbenchpressanddeclinepress(leastactivity)o *HandGripalsoaffectsshoulderbiomechanicsanddeltoidactivityduringthebenchpress

§ Widehandgripresultsinslightlyhigheranteriordeltoidactivityduringinclineandmilitarypress

§ Narrowhandgripresultsingreateranteriordeltoidandpectoralisactivityduringdeclineandbenchpress

o Push-uptechniquevariationsalsoaffectdeltoidactivity:§ Anteriordeltoidshowedtheleastactivityinastandardpush-up,greaterwithapush-up

withelevatedfeet,andgreatestwiththe1-armpush-up

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§ Anteriordeltoidshowed60%-70%MVICwiththeplyopush-up(clapping)andthe1-armpush-up,versus40%-50%withthestandardpush-up,push-upwithstaggeredhands,andpush-upswith1orbothhandsonaball

o *ThehighestMiddleDeltoidactivityisduringshoulderabduction- PosteriorDeltoido Itmoreeffectivelyfunctionsasascapularplaneadductor,andhaslowactivitywithscaption,

flexionandabductiono Highmuscleactivitywiththeposteriordeltoidwithexercises:

§ The‘EmptyCan’–whichmeanstheIRwithscaptionwillfiretheposteriordeltoid§ Rowingexercises§ Pronehorizontalabductionat100°abductionwithERandIR(posteriorandmiddle

deltoid)§ D1diagonalpatternextension,D2diagonalpatternflexion§ Push-upexercises§ Shoulderextension§ Side-lyingERat0°abduction

ScapularMuscleFunctioninRehabilitationExercises

ScapulohumeralRhythm:- Near30°-40°ofhumeralelevationthescapulabeginstoupwardlyrotatesinthefrontalplane,

rotatingapproximately1°forevery2°ofhumeralelevationuntil120°ofhumeralelevation,andthereafterrotating1°forevery1°ofhumeralelevation(totalof45°-55°ofupwardscapularrotation)

- *Thescapulohumeralrhythmisaffectedbyhumeralrotationo ScapularIR(winging)andanteriortiltaregreaterwithhumeralIR(‘EmptyCan’)vs.(‘FullCan’)o ScapularIRandanteriortiltarealsoassociatedwithasmallersubacromialspacewidth,

increasingimpingementrisko Duringhumeralelevation,inadditiontoscapularupwardrotation,thescapulanormally

posteriortilts(theinferioranglemovinganteriorinthesagittalplane)approximately20°-40°andexternallyrotates(lateralbordermovesposteriorinthetransverseplane)approximately15°-35°

o Ifnormalscapularmovementsaredisruptedbyabnormalscapularmusclefiringpatterns,weakness,inhibition,fatigueorinjury,theshouldercomplexfunctionslesseffectivelyandinjuryriskisincreased

o ThePrimarymusclethatcreatesandcontrolsmovementsofthescapulaaretheSerratusAnterior,Trapezius,LevatorScapulae,RhombiodsandPectoralisMinor

- SerratusAnterioro Theserratusanteriorworkswiththepectoralisminortoabduct(protract)thescapula,andwith

theupperandlowertrapeziustoupwardlyrotatethescapula.o Itcontributestoallcomponentsofnormalscapularmovementsduringhumeralelevation,

whichincludesupwardrotation,posteriortiltandexternalrotation.o Italsohelpsstabilizethemedialborderandinferiorangleofthescapula,preventingscapularIR

(winging)andanteriortiltingo HighmuscleactivityoftheSerratusAnteriorwithexercises:

§ D1andD2diagonalpatternflexionandD2diagonalpatternextension

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§ Supinescapularprotraction§ Supineupwardscapularpunch§ Militarypress§ IRandERat90°abduction-whichisinterestingsinceitwastraditionallythoughttobe

rotatorcuffmusclesonly§ Flexion§ Abduction§ Standingscapulardynamichug§ PNFscapulardepression,andprotraction§ ‘EmptyCan’§ WallSlides-Withforearmsonthewallwithprotractionastheyleaninandelevatetheir

arms-patientreportslesspainwhenperformedthisway§ Push-upplus• Muscleactivityislowerwithwallpush-upplus,moderatewithpush-upplusonknees,

andhighwithpush-upplusinstandardpush-uppositionorwiththeirfeetelevated• *Thisisthesuggestedsequencetoprogressapatient

- Trapeziuso Thegeneralfunctionofthetrapeziusincludesscapularupwardrotationandelevationforthe

uppertrapezius,retractionforthemiddletrapezius,andupwardrotationanddepressionforthelowertrapezius.

o TheinferomedialfibersofthelowertrapeziusmayalsocontributetoposteriortiltandERofthescapuladuringhumeralelevation,whichcandecreasesubacromialimpingementrisk

o HighmuscleactivityoftheUpperTrapeziuswithexercises:§ Shouldershrugs§ Pronerows§ Pronehorizontalabductionat90°an135°ofabductionwithERandIR§ D1diagonalpatternflexion§ Standingscapulardynamichug§ PNFscapularclocks§ Militarypress§ 2-handedoverheadmedicineballthrows§ Scaptionandabductionbelow80°,at90°,andabove120°withER• Duringscaptiontheuppertrapeziusactivityincreasesfrom0°-60°,remainsconstant

from60°-120°,andprogressivelyincreasesfrom120°-180°o HighmuscleactivityintheMiddleTrapeziuswithexercises:

§ Shouldershrug§ Pronerowing§ Pronehorizontalabductionat90°and135°ofabductionwithERandIR

o HighmuscleactivityoftheLowerTrapeziuswithexercises:§ Pronerowing§ Pronehorizontalabductionat90°and135°§ Abduction§ D2diagonalpatternflexionandextension§ PNFscapularclocks§ Standinghighscapularrows§ Scaption,flexion,andabductionabove120°withER

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§ *SignificantlyhigheractivityofthelowertrapwithproneERat90°thanwiththe‘EmptyCan’

- RhomboidsandLevatorScapulaeo Boththerhomboidsandlevatorscapulaefunctionasscapularadductors(retractors),downward

rotators,andelevatorso Highmuscleactivityoftherhomboidswithexercises:

§ D2diagonalpatternflexionandextension§ StandingERat0°and90°ofabduction§ StandingIRat90°ofabduction§ Pronehorizontalabductionat90°ofabductionwithIR§ Scaption§ Abductionandflexionabove120°withER§ Pronerowing§ Standinghigh,mid,andlowscapularrows

o Highmuscleactivitywiththelevatorscapulaewithexercises:§ Scaptionabove120°withER§ Pronehorizontalabductorsat90°abductionwithERandIR§ Pronerowing§ Proneextensionfrom90°offlexion