Secondary Logo

Postrehabilitation Strength and Conditioning of the Shoulder: An Interdisciplinary Approach

Pabian, Patrick S DPT, CSCS1; Kolber, Morey J PT, PhD, CSCS2; McCarthy, John P PT, PhD, FNSCA, CSCS*D3

Strength and Conditioning Journal: June 2011 - Volume 33 - Issue 3 - p 42-55
doi: 10.1519/SSC.0b013e318213af6e
Article
Free

AN INDIVIDUAL WHO HAS SUSTAINED A SHOULDER INJURY WILL ENCOUNTER NUMEROUS PROFESSIONALS THROUGHOUT THE RECOVERY PROCESS. TO OPTIMIZE OUTCOMES, THESE PROFESSIONALS NEED TO HAVE A FUNDAMENTAL UNDERSTANDING OF THE COMPLETE RECOVERY PROCESS OF COMMON SHOULDER PATHOLOGIES, RANGING FROM INITIAL INJURY MECHANISMS, SURGICAL CONSIDERATIONS, AND POSTOPERATIVE/REHABILITATION MANAGEMENT TO CONSIDERATIONS OF POSTREHABILITATION DESIGN. ALL PROFESSIONALS INVOLVED WILL GREATLY BENEFIT FROM BEING AWARE OF EACH OTHER'S PRIMARY ROLES AND LIMITATIONS. THIS ARTICLE AIMS TO LINK THE ENTIRE SPECTRUM OF RECOVERY FROM COMMON SHOULDER PATHOLOGIES, FROM INJURY, TO POSTREHABILITATION DESIGN.

1Department of Health Professions, University of Central Florida, Orlando, Florida; 2Department of Physical Therapy, Nova Southeastern University, Fort Lauderdale, Florida; and 3Department of Physical Therapy, The University of Alabama at Birmingham, Birmingham, Alabama

FIGURE. Ca

FIGURE. Ca

Patrick S. Pabianis an instructor/academic coordinator of clinical education in the Department of Health Professions at the University of Central Florida and a physical therapist at the Orlando Sports Medicine Group.

FIGURE. Ca

FIGURE. Ca

Morey J. Kolberis an associate professor in the Department of Physical Therapy at the Nova Southeastern University.

FIGURE. Ca

FIGURE. Ca

John P. McCarthyis an associate professor in the Department of Physical Therapy at University of Alabama at Birmingham.

Back to Top | Article Outline

INTRODUCTION

The management of strength and conditioning programs for individuals who have had a history of shoulder injury or pathology can be challenging. Although there are common overarching principles of strength and mobility that will optimize outcomes, a requisite understanding of specific injuries including mechanics, recovery, and rehabilitation principles is necessary when prescribing postrehabilitation strength and conditioning programs. The primary objective of this article is to educate readers on the more common shoulder injuries and provide a framework to link rehabilitation principles to postrehabilitation strength and conditioning program design. The specific aims designed to complete this objective are as follows:

  1. Educate strength and conditioning professionals on the foundational concepts of rehabilitation of common shoulder pathologies
  2. Educate rehabilitation and strength and conditioning professionals on the progression and advancement opportunities of postrehabilitation
  3. Integrate concepts of rehabilitation into the postrehabilitation design.
Back to Top | Article Outline

LIMITATIONS OF REHABILITATION AND STRENGTH AND CONDITIONING PROFESSIONALS

After injury, a variety of professionals with backgrounds ranging from healthcare to fitness will play a role in returning the injured population to prior level of activity. However, nearly all these professionals are limited in their abilities to guide an injured individual from acute injury to full recovery. Strength and conditioning professionals may lack awareness of common injuries and the risks specific to common operative and rehabilitative procedures, while sport-specific performance and training tasks may be beyond what the great majority of medical professionals are prepared to provide. Athletic trainers (ATCs) are usually the first to encounter injuries among the athletic population, and according to the National Athletic Trainers' Association, their training encompasses the “prevention, diagnosis, and intervention of emergency, acute, and chronic medical conditions involving impairment, functional limitations, and disabilities” (79). However, role strain due to the various duties of an athletic trainer (such as budget, teaching, supervision, and rehab) and the sheer volume of whom ATCs are responsible for provides challenges.

Most nonathletes and some athletes will be referred to a physical therapist for rehabilitation from injury. Physical therapists “provide services to patients/clients who have impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes” (3). Physical therapists will continue to care for individuals as long as they continue to have limitations; however, these professionals are often limited in the ability to guide a patient to complete recovery because of patient insurance coverage and, in most states, the referral by a physician. Physical therapists often discharge patients who have not reached full return of strength and mobility and in many cases transition care to the strength and conditioning specialist. Certified strength and conditioning specialists “are professionals who practically apply foundational knowledge to assess, motivate, educate, and train athletes for the primary goal of improving sport performance” (80). It is the experience of the authors that strength and conditioning specialists are often limited by the information provided by their clients in regard to the injuries that they have had or are recovering from and the activity modifications or restrictions given to them by healthcare providers.

Therefore, communication between medical professionals and strength and conditioning professionals is a critical factor for efficient and safe progression of the individual to achieve prior levels of high performance. A lack of communication between medical providers and strength and conditioning specialists can slow the return to peak function and increase the risk of reinjury. Unfortunately, communication between clinicians and strength and conditioning professionals is often lacking or suboptimal. In the transition from medical care, information regarding the status of injury, previous exercise prescription, and specific precautions will better enable the strength and conditioning professionals to safely progress the program. Constant feedback from the athlete or client is also needed to assess and adjust exercise prescriptions. For the strength and conditioning professionals, some working knowledge of common injuries and awareness of resources may be beneficial to the management of their clients. Limitations in knowledge and training across professions make it clearly evident that all professionals, from ATCs, to physical therapists, to strength and conditioning specialists, need to have a clear understanding of each other's backgrounds to better use a team approach. Additionally, increased knowledge and awareness of the management of the common injuries that each will encounter will assist in the evidence-based decision-making process to optimally care for our athletes/patients/clients.

Back to Top | Article Outline

SHOULDER INJURIES: CONSIDERATIONS OF REHABILITATION PROFESSIONALS

OVERARCHING PRINCIPLES OF SHOULDER REHABILITATION

The shoulder is a complex region because of the numerous interdependent joints of this region; these include the glenohumeral (GH), sternoclavicular, acromioclavicular, and scapulothoracic joints. Movement of any one of the joints of the shoulder complex is accompanied by motion at one or several of the others, with injury to 1 joint often resulting in altered kinematics of the others and muscular compensatory strategies during functional movements. That being noted, there does appear to be some common considerations in the rehabilitation of the shoulder.

Back to Top | Article Outline

Rotator cuff strength

The rotator cuff functions as a dynamic stabilizer of the GH joint. Collectively, it provides axial compression of the humeral head into the glenoid, with mild depression during active elevation and abduction. This primarily acts to counterbalance the muscle forces of the deltoid and center the humeral head in the glenoid during movements. Muscular weakness of the rotator cuff and imbalances of the internal and external rotators have been consistently shown in individuals with impingement, rotator cuff pathology, and instability (30). Imbalances of the rotator cuff have also been found in both throwing athletes (83) and the recreational weight-training population (55). Most injuries result in collective rotator cuff weakness, with recovery being dependent on strengthening of the superior (supraspinatus) and posterior (infraspinatus and teres minor) rotator cuff musculature and restoration of dynamic muscular balance. These principles of strength and balance of the rotator cuff have historically been linked to successful rehabilitation in various shoulder injuries or surgeries, ranging from GH instability (28,41) to impingement and rotator cuff pathologies (27,73).

Back to Top | Article Outline

Scapular stability and rhythm

Another anatomical region in the shoulder complex that is of emphasis to rehabilitation professionals is the scapulothoracic joint. Because the scapulothoracic joint allows a great deal of motion of the scapula on the thorax and lacks ligamentous or capsular support, it greatly relies on muscular stability and control to optimize function of the shoulder. Scapular positioning during activity is complex and requires a delicate balance of strength and coordinated mobility. Normal scapulohumeral rhythm is defined as a 2:1 ratio of GH to scapulothoracic motion during elevation (25).

Alterations in the scapulohumeral rhythm, along with a protracted scapular resting position, contribute to numerous shoulder pathologies. These deficits result in decreased joint congruency, with migration of the humeral head away from the center of the joint, causing capsular stress and contributing to GH instability (84,93). Additionally, this position is associated with superior labral pathologies in throwing athletes (15). However, one of the most common shoulder pathologies associated with scapular positioning is impingement syndrome (51). Impingement syndrome (compression of the soft tissue between the acromion and greater tuberosity of the humerus) is often the result of reduced subacromial space, which occurs through excessive protracted scapular position, or muscular imbalances, which do not maintain scapulohumeral rhythm during elevation (51). Impingement syndrome will be further discussed in the Rotator Cuff Pathology section of this article.

Because of the association of the scapulothoracic region with numerous GH pathologies, scapular positioning and scapulohumeral rhythm are often a focus of rehabilitation programs in addressing shoulder pathologies. Training musculature in the scapulothoracic joint improves functional strength and balance of the entire shoulder complex. The primary area of emphasis in the literature and rehabilitation programs is scapular retraction with avoidance of protracted positions (51). It has been found that positioning and dynamic stabilization of the scapula in a retracted position during use of the upper extremity improves the muscular activation of the muscles that attach to it (52,87).

Rehabilitation programs for shoulder pathologies often focus on the muscles that stabilize the scapula into a position of adduction, external rotation, and posterior tilt and those muscles that guide upward rotation (27,51). Some studies have identified weakness and altered timing of the serratus anterior, middle trapezius, and lower trapezius, with increased activity of the upper trapezius during overhead motions (22,76). Rehabilitation guidelines focus on improving the activation of the serratus anterior, middle trapezius, and lower trapezius, with avoidance of positions, exercises, or postures that will facilitate the upper trapezius (50,51,53).

Back to Top | Article Outline

Joint mobility and flexibility

GH mobility has been linked to improved shoulder function and recovery from injury. It is expected that range of motion (ROM) limitations will be encountered from nearly any shoulder injury. The restoration of normal (preinjury) ROM after shoulder injuries is usually a goal of rehabilitation professionals, although the achievement of this is not always guaranteed. Return of preinjury ROM has been correlated with decreased pain levels and improved functional outcomes after shoulder surgery (12,78). ROM deficits can occur because of surgical procedure, muscular compensation, ligamentous contracture or disruption, or pain. ROM deficits have been observed in the postsurgical population (12,78), recreational weight trainers (55), and current or former throwing athletes (29). Surgical patients often have limitations because of the specific procedure performed, and anyone working with these patients or clients needs to have some understanding of the stresses placed on the repair site with ROM of the shoulder.

A common focal point of shoulder mobility is internal rotation ROM. This is a common direction of motion loss after shoulder injuries and a resultant focal point of rehabilitation. Internal rotation loss has been linked to increased incidence of impingement syndrome (27) and superior labral pathologies (15). The loss of internal rotation ROM is often termed “glenohumeral internal rotation deficit” (GIRD) and usually occurs because of muscular tightness of the posterior rotator cuff and tightness of the posterior inferior GH ligament (1). Another potential source of internal rotation ROM loss is humeral retroversion. This alignment adaptation is skeletal in nature and common in throwing athletes. It results in increased external rotation ROM and decreased internal rotation ROM (70). The resultant misalignment of the humeral head because of either soft tissue tightness or osseous adaptation results in increased compressive forces to the subacromial and coracoacromial regions, especially in overhead athletes (77).

Back to Top | Article Outline

ROTATOR CUFF PATHOLOGY

The primary culprit for rotator cuff pathology is the supraspinatus. The role of the supraspinatus is to compress and abduct the humerus, with slight torque generated into external rotation. Therefore, individuals with rotator cuff pathology will likely have pain or weakness with shoulder abduction. Rotator cuff pathology includes tendinopathy, impingement syndrome, and varying degrees of muscle/tendon tear.

Tendinopathy is correlated with overuse of the upper extremity, especially in positions that stress the rotator cuff musculature. When acute, tendinopathy should subside with rest and ice. Impingement syndrome has several types. Primary impingement syndrome is directly related to compression of the supraspinatus tendon under the acromion (81). Sources of this reduced subacromial space can be because of the development of osteoarthritis or protracted scapular postures. Secondary impingement can develop because of shoulder instability, resulting in compression of the biceps tendon or the anterior supraspinatus (44). Finally, internal impingement can develop because of extreme external rotation of the GH joint with scapular protraction, resulting in compression of the infraspinatus and supraspinatus in the posterior-superior GH joint (92). Internal impingement is prevalent in overhead athletes because of the approximation of these tissues in the overhead throwing position along with humeral retroversion, posterior shoulder tightness, and/or protracted scapula (27).

Any of these impingement syndromes can lead to eventual tearing of the supraspinatus or infraspinatus. The degree of tearing should correlate with the amount of weakness or pain associated with movements that stress the rotator cuff musculature, although patient symptom presentation may be quite variable. Notable compensations will be visualized, with the individual elevating the scapula, especially as load is applied. Tears of the supraspinatus will often result in profound weakness in abduction, with inability to complete abduction of the humerus (69). Individuals, however, may still be able to complete forward flexion and have a fair amount of external rotation strength because these positions do not engage the supraspinatus to the same degree as frontal plane abduction (31).

Another site of tearing is the infraspinatus, which serves primarily to externally rotate the humerus. The infraspinatus provides most of the external rotation torque at the shoulder. The infraspinatus, along with the teres minor, serves to further depress the humeral head with abduction (39) and counterbalance the strong internal rotators (subscapularis and pectoralis major) during dynamic activities. Because of these functions, tears involving the posterior rotator cuff will often result in significant weakness of external rotation, although the lack of ability to depress the humeral head during abduction will also result in weakness in the frontal plane as well.

Back to Top | Article Outline

Surgical intervention

Surgical repair of the rotator cuff usually involves the supraspinatus and, at a lesser incidence, the infraspinatus. The primary goal of surgery is to restore the normal anatomy, which is achieved through arthroscopic, mini-open, or open surgical techniques. Complications exist with all types of procedures. Although a recent systematic review found slightly increased complications in individuals who have undergone an open procedure (82), another study found that the complication rates were similar when comparing arthroscopic versus open procedures (12). Surgical success is typically measured through subjective functional outcome scales, ROM, and healing of the repair site. Comprehensive strength measures are not typically reported in many outcome studies.

A wide range of failure rates have been published in recent studies. The failure rates have varied from 12 to 36% (20) in one study to 94% (33) in another study depending on the size of the tear. These rates varied greatly depending on patient age and size of the tear. These variables result in an increased chance of surgical failure and more profound weakness and functional deficits (20,33). In another recent study, it was found that 54% of patients with massive rotator cuff tears had associated injury to the suprascapular nerve, further reducing the strength of the supraspinatus and infraspinatus (23). Outcomes are further reduced in individuals who have had a revision or repeat cuff repair (46,47).

Considering these findings, caution is warranted when working with individuals who have had rotator cuff repair. Healthcare and strength and conditioning professionals need to be cognizant of individuals who have had a rotator cuff repair. Surgical repair does not always result in a successful outcome. It is not to be assumed that all individuals who have had rotator cuff repairs will have good strength and stability of the rotator cuff musculature, specifically in frontal and horizontal planes and overhead motions. Assessment of active movement, strength, and performance of exercise is warranted in this population by all healthcare and fitness professionals.

Back to Top | Article Outline

Rehabilitation

Rehabilitation programs are individualized and dependent on the size of rotator cuff tear, age of the patient, prior level of function of the patient, rehabilitation goals, and other comorbidities. Although variations in the protocols exist depending on the sources and size of the tear (61,94), rotator cuff rehabilitation (postsurgical) follows the guidelines of protection of the repair, progressive mobility, and strength/balance of the scapula and rotator cuff musculature. Common rotator cuff repair rehabilitation protocols are provided in references (26,35,72,91,95).

As rehabilitation progresses, the focus turns to establishing normal GH mobility and strength and balance of the rotator cuff and scapular musculature. An emphasis of mobility is on establishing full GH internal rotation ROM, which is accomplished through the sleeper stretch (Figure 1) and the cross-arm stretch with internal rotation overpressure (Figure 2). Muscle strengthening primarily targets the supraspinatus and external rotators (infraspinatus and teres minor) at the GH joint and the middle trapezius, lower trapezius, and serratus anterior at the scapulothoracic joint.

Figure 1

Figure 1

Figure 2

Figure 2

Facilitation and strengthening of the supraspinatus and infraspinatus is a common focus of rehabilitation programs. The following exercises have been shown to best facilitate the supraspinatus: prone horizontal abduction with external rotation, isolated external rotation sidelying or prone at 90/90 position, and empty and full can elevations. However, because of decreased subacromial space with the “empty can” exercise and based on the findings that the recruitment differential of the supraspinatus is insignificant when compared with the “full can” exercise (10), the empty can exercise is not advised (10,27). Although all the aforementioned exercises facilitate the supraspinatus and infraspinatus at high levels, the empty and full can elevations and prone horizontal abduction also have significant deltoid recruitment (10), resulting in the potential for compensatory strategies during these specific exercises.

Isolated external rotation either in sidelying with a dumbbell or standing with tubing resistance produces significant supraspinatus and infraspinatus muscle forces. While performing this exercise, it is beneficial to place a towel roll under the axilla because this position elevates activity of the infraspinatus by 10% (71), prevents decreased blood flow to the supraspinatus (85), and increases the subacromial space (37). Another consideration is exercise load or intensity. A cadaveric study has found that the rotator cuff musculature has a type I to type II muscle fiber distribution of nearly a 50:50 ratio (68). Thus, exercise prescription should be structured in accordance with this consideration. In addition, when performing external rotation exercise, a load of 40% maximum voluntary isometric contraction has been found to have superior selective recruitment of the infraspinatus versus higher levels, which increased deltoid recruitment (9).

Strengthening is progressed in rehabilitation, with the emphasis on dynamic activities while maintaining scapular position and stability. Maintaining the scapula in a position of retraction improves rotator cuff function (52,87). Dynamic challenges to rotator cuff stability and strength include oscillations, impulses through throwing with the upper extremity, overhead pressing, and closed kinetic chain activities. However, considering the length of recovery from rotator cuff repair, and the previously identified limitations of physical therapists in mind, it is likely that strength and conditioning specialists will encounter individuals who have not yet reached advanced stages of rehabilitation.

Back to Top | Article Outline

GLENOHUMERAL JOINT INSTABILITY

Because of the lack of joint congruency of the GH joint, significant ranges of motion allowed, and the forces placed on the joint during athletic activities, the GH joint is susceptible for developing instability. Classification of instability through dislocation or subluxation of the GH joint is often distinguished through traumatic or atraumatic events, with traumatic events often resulting in unidirectional instability and atraumatic events resulting in multidirectional instability. Both traumatic events and microtraumatic stresses leading to instability have been reported in the strength training population (40). Regardless of this nature, instability occurs through disturbance in any one or more of the following (41): (a) rotator cuff, (b) GH joint capsule or labrum, (c) area of contact between the glenoid and the humeral head, (d) proprioception loss, and/or (e) neural mechanisms. These causes can be either structural or nonstructural (proprioception loss and neural mechanisms) (66), with the structural causes being because of either the static (labrum, capsule, and GH ligaments) or the dynamic (rotator cuff) restraints. These structures are often the focus of the orthopedic surgeon and rehabilitation professionals.

Back to Top | Article Outline

Surgical intervention and rehabilitation

Surgical intervention of both traumatic and atraumatic GH instability, coupled with rehabilitation, has proven to be successful. Traumatic instability usually involves anterior shoulder dislocation, with resultant disruption of the anterior glenoid labrum, capsule, and capsular ligaments. This injury is commonly referred to as a “Bankart” lesion. Because the labrum is a fibrocartilaginous ring that serves as a static stabilizer of the GH joint, disruption of this structure has been associated with high rates of redislocation (75%) (11). Therefore, patients with this injury are often surgical candidates (Bankart repair). Surgical repair of these structures is performed through either an arthroscopic approach or open incision. Both methods are found to have good results (19,74), with normal symmetrical ROM in all planes of motion, satisfactory outcome scores, and return to activity with a 2-year follow-up.

Atraumatic instability, although possibly congenital, is commonly the result of microtraumatic stresses to the shoulder and laxity of the GH ligaments, resulting in multidirectional instability. Multidirectional instability is often treated conservatively, with physical therapy emphasizing the restoration of the dynamic stabilizers of the GH joint, the rotator cuff musculature. Rehabilitation also focuses on retraining motor control and proprioceptive input to the GH joint and scapular stabilization. Stabilization is enhanced through interventions designed to improve neuromuscular stabilization, often through oscillatory techniques or closed kinetic chain exercise (41,67). Surgical intervention consists of multiple options, which include arthroscopic or open procedures. Most procedures have been found to have good results (8,18). However, most outcome studies do not present return to weight training after surgical stabilization procedures.

Rehabilitation programs for surgical intervention for GH instability often include a brief period of immobilization, followed by conservative progressive ROM and submaximal rotator cuff facilitation and strengthening for several weeks. Rehabilitation protocols for common GH instability procedures are provided in references (24,45,65,86,88). Focus of strengthening of the scapula stabilizers and scapular positioning is emphasized early and progressed throughout rehabilitation. Rotator cuff strengthening is progressed throughout the phases of rehabilitation, and emphasis is placed on neuromuscular control and proprioceptive training through closed kinetic chain exercises, oscillatory and impulse training, and dynamic activities in multiple planes of motion. Sport-specific activities are often withheld for at least 6 months (21).

Back to Top | Article Outline

LABRAL PATHOLOGY

As previously noted, the glenoid labrum is a fibrocartilaginous ring that serves as a static stabilizer of the GH joint. Of specific concern to rehabilitation and strength and conditioning professionals is the superior labrum. The superior labrum is connected to the long head of the biceps tendon and is placed under great tension with extremes of external rotation because of pull from the biceps tendon. This is common in overhead athletes and facilitated by protracted scapular positions and GIRD, resulting in injury through the “peel-back mechanism.” The peel-back mechanism is the separation or peeling off of the superior labrum from the glenoid because of excessive tension through the proximal biceps tendon when the humerus is excessively externally rotated and the scapula is in excessive protraction (14,15). Because of their abnormalities in ROM, scapula position, and repetitive external and internal rotations, much literature has focused on the prevalence of superior labral tears in overhead athletes. However, with similar muscular, postural, and ROM asymmetries noted in recreational weight trainers (55), it is conceivable that these tears are prevalent in this population as well.

Tears to the superior labrum are referred to as SLAP (Superior Labrum, Anterior, Posterior) tears because of their resultant increase joint play in anterior and posterior directions. The long head of the biceps tendon is directly related to SLAP tears because of the peel-back mechanism and eccentric pulling of the tendon during throwing activities (4). However, the biceps tendon is now becoming more appreciated for its role as a humeral head depressor and as an anterior stabilizer to the GH joint (62). Dysfunction in the stability of the humeral head because of SLAP tears, ligamentous laxity because of scapular posture, or excessive external rotation ROM leading to anterior superior migration of the humeral head (43) will likely lead to increased tension on the long head of the biceps tendon, leading to irritation or tendonitis. In addition, weight-training exercises that place the shoulder in an extreme of horizontal abduction, extension, or external rotation increase tension on the biceps tendon and superior labrum.

Back to Top | Article Outline

Surgical intervention and rehabilitation

SLAP tears are surgically repaired through arthroscopic approaches, involving suture anchors to fixate the torn labrum. This procedure has been found to be successful in prospective studies, with return to previous levels of function ranging from 74 to 91% (13,54). Rehabilitation from surgical repair involves a period of immobilization, with protection of extremes of external and internal rotations to minimize tension on the superior labrum once ROM is initiated and progressed. Rehabilitation protocols for SLAP repair procedures are provided in references (42,64,89,90). Because the superior labrum is a static noncontractile tissue, isometric exercise is allowed early in rehabilitation, except for contractions that stress the proximal biceps tendon, which attaches to the superior labrum. As patients progress, the extremes of rotation, horizontal abduction, and extension are protected during intermediate phases and eventually allowed in late phases. Progression to return to prior athletic activities is allowed 6-9 months after surgery (21). Strengthening exercises commonly focus on strengthening of the rotator cuff (dynamic stabilizers). Additionally, strength, rhythm, and balance of the scapular musculature are also a focus throughout rehabilitation because of the association with GIRD and subsequent stress on the superior labrum. Consistent with other shoulder pathologies, outcome studies involving surgical intervention or rehabilitation rarely examine return to weight-training activities.

Back to Top | Article Outline

PRINCIPLES OF POSTREHABILITATION DESIGN

OVERARCHING PRINCIPLES

Regardless of the shoulder pathology, there are some common themes to postrehabilitation management. The common links appear to be rotator cuff strength, scapular strength, stability, and rhythm, and GH joint mobility. All these areas need to be addressed in the design of postrehabilitation programs.

Back to Top | Article Outline

CONSIDERATIONS OF PROGRAM DESIGN

Rehabilitation programs often involve periods of protection or avoidance of specific motions or strengthening exercises. These restrictions can vary considerably and are based on several variables, such as procedure, surgeon preference, and extent of the injury. Over the course of the rehabilitation, these restrictions are gradually lifted. As the individual enters into postrehabilitation, the strength and conditioning specialist needs to identify these precautions and appropriately train the individual. These precautions should not be avoided rather trained. A similar flaw would be to progress with aggressive weight training without regard to the healing tissues. In many cases, although repair may have been successful, physical and physiologic adaptation of the GH joint to sustain all loads of weight training may not have been reached during the formal rehabilitation process. Modifications to typical lifts will likely be necessary to properly train an individual.

Back to Top | Article Outline

UPPER EXTREMITY WEIGHT-TRAINING MODIFICATIONS

In regard to the shoulder complex, weight training has been advocated as a means to enhance muscle performance and for its utility in the rehabilitation of injuries (2,3,7,17,30,32). Although the benefits ascribed to upper extremity weight training are well known, participation is not without risk (36,49,59,60). The likelihood of injury increases with improper attention to exercise technique, biased exercise selection, and unfavorable shoulder positioning required of the more common exercises (38,57,96). Given the association between upper extremity weight training (38,57,63) and shoulder pain, it is essential that postrehabilitation training programs consider documented injury trends and risk factors. Of the various risk factors, exercise selection with regard to technique and shoulder positioning is most amenable to program design and should be considered (58). Professionals designing postrehabilitation weight-training programs must be cognizant of exercises that place the shoulder in the abducted and externally rotated “high-five” position (Figure 3), in the impingement position (Figure 4), and in the end-range amortization position (lowest position of the bar) assumed during flat bench press.

Figure 3

Figure 3

Figure 4

Figure 4

The high-five position places stress on the anterior capsule, potentially leading to anterior shoulder laxity and eventually anterior shoulder instability (34,38,63,75). Moreover, this position is likely to aggravate and/or injure the shoulder of individuals with labral tears, anterior instability, or impingement syndrome. Common exercises such as behind the neck military press, dumbbell press, pectoral flies using certain seated machines, and behind the neck pull-downs require assumption of the high-five position and have been associated with shoulder pain and/or injury (38,56,59,63). Individuals participating in such exercises should be advised to modify positioning by pulling or lowering the weights to the front of the chest, which would minimize unfavorable end-range positioning (56).

In regard to impingement positioning, exercises that require the arm to abduct beyond 90° without external rotation (Figure 4) may perpetuate injury. During shoulder abduction, the arm is required to externally rotate, thus preventing the rotator cuff and long head bicep from being impinged between the acromion process and greater tuberosity. More common exercises such as lateral deltoid raises may be associated with shoulder pain and/or injury. Individuals desiring to perform lateral deltoid raises are often advised to substitute the full can exercise (Figure 5), which involves elevating the shoulder in the scapular plane, by externally rotating their arm (thumb up).

Figure 5

Figure 5

The flat bench press has been cited as a primary contributor to numerous shoulder and upper extremity pathologies (6,16,96). The amortization phase of the exercise where the arms are in end-range horizontal extension in particular has been postulated to place the most stress on the involved structures. Individuals performing the flat bench press may minimize stress through the use of a 3-in towel roll on their chest (Figure 6). The towel roll prevents end-range positioning and thus should decrease risk of injury and mitigate stress (58).

Figure 6

Figure 6

Back to Top | Article Outline

DESIGN OF POSTREHABILITATION STRENGTH AND CONDITIONING PROGRAMS

Exercise prescription in regard to volume and load should be based on individual considerations (i.e., sports versus power, strength, hypertrophy, and endurance). For specific programming guidelines, readers are encouraged to review the text Essentials of Strength Training and Conditioning (3rd ed) (5).

Back to Top | Article Outline

ROTATOR CUFF PATHOLOGY

Strength and conditioning specialists encountering individuals who have had rotator cuff repairs need to be aware of the very slow process of recovery and the rather high rates of failure of the repair. These individuals may need some focus on gradual progression of resistance exercises that stress the rotator cuff, such as lateral raises and military press, with some basic strengthening in the planes of external rotation. Caution is warranted for proper technique and pace when performing these exercises. Examples of rotator cuff strengthening exercises in a postrehabilitation setting are as follows:

Back to Top | Article Outline

GLENOHUMERAL INSTABILITY

Strength and conditioning specialists working with individuals who have had GH instability need to be aware of the direction of the instability and whether there was a surgical intervention. Individuals with recurrent instability may need to have permanent modifications to their weight-training program to avoid positions of stress to the joint capsule. Additional knowledge of the direction of the instability will provide information as to further precautions (i.e., anterior instability or Bankart repair will need to be gradually progressed in depth of bench press). Weight-training programs should focus on rotator cuff strengthening because of its role in providing dynamic stability at the GH joint. Moreover, programs should be inclusive of closed kinetic chain exercises because of the enhanced proprioception and motor control that these exercises provide. (stability: front [prone] plank [Figure 11a], plank-up [Figure 11b and 11c], and side plank [Figure 12]).

Figure 11

Figure 11

Figure 12

Figure 12

Back to Top | Article Outline

LABRAL PATHOLOGY

Strength and conditioning specialists working with an individual with labral pathology need to be aware of positions and lifts that stress the superior labrum and proximal biceps tendon. Avoidance of the high-five position will reduce stress on the anterior GH joint and decrease the amount of peel-back stress in end-range ER. Additionally, caution is warranted in any exercise that places increased stress on the proximal biceps tendon because of anterior migration of the humeral head. Common exercises that may cause irritation of the biceps tendon or the superior labrum are dips, incline bench press, and military press. Focus of strengthening should be on rotator cuff strength and closed kinetic chain stabilization, as previously mentioned, and scapular strength, stability, and rhythm.

Back to Top | Article Outline

CONCLUSION

All rehabilitation and strength and conditioning professionals need to be on the same page when it comes to managing an individual with shoulder pathology. When managing these individuals, all professionals involved throughout the spectrum of recovery need to have a strong grasp of the functional anatomy and the process of returning the individual to prior level of athletic and recreational activity. Through clear and open communication and education of the complexities of the specific injury, surgical interventions, formal rehabilitation, and complete recovery process, strength and conditioning specialists and rehabilitation professionals will be able to best design effective comprehensive strength and conditioning programs.

Back to Top | Article Outline

REFERENCES

1. Abrams G and Safran M. Diagnosis and management of superior labrum anterior posterior lesions in overhead athletes. Br J Sports Med 44: 311-318, 2010.
2. American College of Sports Medicine. Position stand on the recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in healthy adults. Med Sci Sports Exerc 22: 265-274, 1990.
3. American Physical Therapy Association. Guide to Physical Therapist Practice (2nd ed). Phys Ther 81: 9-744, 2001.
4. Andrews J, Carson W, and McLeod W. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med 13: 337-341, 1985.
5. Baechle T, Earle R, and Wathen D. Resistance training. In: Essentials of Strength Training and Conditioning (3rd ed). Baechle T and Earle R, eds. Champaign, IL: Human Kinetics, 2008. pp. 381-412.
6. Bak K, Cameron EA, and Henderson IJ. Rupture of the pectoralis major: A meta-analysis of 112 cases. Knee Surg Sports Traumatol Arthrosc 8: 113-119, 2000.
7. Baltaci G. Subacromial impingement syndrome in athletes: Prevention and exercise programs. Acta Orthop Traumatol Turc 37: 128-138, 2003.
8. Bell J. Arthroscopic management of multidirectional instability. Orthop Clin North Am 41: 357-365, 2010.
9. Bitter N, Clisby E, Jones M, Magarey M, Jaberzadeh S, and Sandow M. Relative contributions of infraspinatus and deltoid during external rotation in healthy shoulders. J Shoulder Elbow Surg 16: 563-568, 2007.
10. Boettcher C, Ginn K, and Cathers I. Which is the optimal exercise to strengthen the supraspinatus? Med Sci Sports Exerc 41: 1979-1983, 2009.
11. Bottoni C, Wilckens J, DeBerardino T, D'Alleyrand J, Rooney R, Harpstrite J, and Arciero R. A prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic, first-time shoulder dislocations. Am J Sports Med 30: 576-580, 2002.
12. Brislin K, Field L, and Savoie F. Complications after arthroscopic rotator cuff repair. Arthroscopy 23: 124-128, 2007.
13. Brockmeier S, Voos J, Williams R, Altchek D, Cordasco F, and Allen A. Outcomes after arthroscopic repair of type-II SLAP lesions. J Bone Joint Surg Am 91: 1595-1603, 2009.
14. Burkhart S and Morgan C. The peel-back mechanism: Its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy 14: 37-40, 1998.
15. Burkhart S, Morgan C, and Kibler W. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Arthroscopy 19: 404-420, 2003.
16. Cahill BR. Osteolysis of the distal part of the clavicle in male athletes. J Bone Joint Surg Am 64: 1053-1058, 1982.
17. Callanan M, Tzannes A, Hayes K, Paxinos A, Walton J, and Murrell GA. Shoulder instability. Diagnosis and management. Aust Fam Physician 30: 655-661, 2001.
18. Caprise P and Sekiya J. Open and arthroscopic treatment of multidirectional instability of the shoulder. Arthroscopy 22: 1126-1131, 2006.
19. Carreira D, Mazzocca A, Oryhon J, Brown F, Hayden J, and Romeo A. A prospective outcome evaluation of arthroscopic Bankart repairs: Minimum 2-year follow-up. Am J Sports Med 34: 771-777, 2006.
20. Cho N and Rhee Y. The factors affecting the clinical outcome and integrity of arthroscopically repaired rotator cuff tears of the shoulder. Clin Orthop Surg 1: 96-104, 2009.
21. Cohen B, Romeo A, and Bach B. Shoulder injuries. In: Clinical Orthopaedic Rehabilitation (2nd ed). Brotzman SB and Wilk KE, eds. Philadelphia, PA: Mosby, 2003. pp. 125-250.
22. Cools A, Declercq G, Cambier D, Mahieu N, and Witvrouw E. Trapezius activity and intramuscular balance during isokinetic exercise in overhead athletes with impingement symptoms. Scand J Med Sci Sports 17: 25-33, 2007.
23. Costouros J, Porramatikul M, Lie D, and Warner J. Reversal of suprascapular neuropathy following arthroscopic repair of massive supraspinatus and infraspinatus rotator cuff tears. Arthroscopy 23: 1152-1161, 2007.
24. Durall C, Giangarra C, and Humphrey C. Anterior capsulolabral reconstruction. In: Postsurgical Rehabilitation Guidelines for the Orthopedic Clinician. Cioppa-Mosca J, Cahill J, Cavanaugh J, Corradi-Scalise D, Rudnick H, and Wolf A, eds. St Louis, MO: Mosby, 2006. pp. 526-534.
25. Dutton M. The shoulder complex. In: Orthopaedic Examination, Evaluation, and Intervention (2nd ed). Dutton M, ed. New York, NY: McGraw Hill, 2008. pp. 516-519.
26. Ellenbecker T, Bailie D, and Kibler W. Rehabilitation after mini-open and arthroscopic repair of the rotator cuff. In: Postsurgical Orthopedic Sports Rehabilitation: Knee & Shoulder. Manske R, ed. St Louis, MO: Mosby, 2006. pp. 671-677.
27. Ellenbecker T and Cools A. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: An evidence-based review. Br J Sports Med 44: 319-327, 2010.
28. Ellenbecker T and Mattaliino A. Glenohumeral joint range of motion and rotator cuff strength following arthroscopic anterior stabilization with thermal capsulorraphy. J Orthop Sports Phys Ther 29: 160-167, 1999.
29. Ellenbecker T, Roetert E, Bailie D, Davies G, and Brown S. Glenohumeral joint total rotation range of motion in elite tennis players and baseball pitchers. Med Sci Sports Exerc 34: 2052-2056, 2002.
30. Erol O, Ozcakar L, and Celiker R. Shoulder rotator strength in patients with stage I-II subacromial impingement: Relationship to pain, disability, and quality of life. J Shoulder Elbow Surg 17: 893-897, 2008.
31. Escamilla R, Yamashiro K, Paulos L, and Andrews J. Shoulder muscle activity and function in common shoulder rehabilitation. Sports Med 39: 663-685, 2009.
32. Feigenbaum MS and Pollock ML. Prescription of resistance training for health and disease. Med Sci Sports Exerc 31: 38-45, 1999.
33. Galatz L, Ball C, Teefey S, Middleton W, and Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am 86: 219-224, 2004.
34. Garth WP, Allman FL, and Armstrong WS. Occult anterior subluxations of the shoulder in noncontact sports. Am J Sports Med 15: 579-585, 1987.
35. Ghilarducci M and Maxey L. Rotator cuff repair and rehabilitation. In: Rehabilitation for the Postsurgical Orthopedic Patient (2nd ed). Maxey L and Magnusson J, eds. St Louis, MO: Mosby, 2007. pp. 70-84.
36. Goertzen M, Schoppe K, Lange G, and Schulitz KP. Injuries and damage caused by excess stress in bodybuilding and power lifting. Sportverletz Sportschaden 3: 32-36, 1989.
37. Graichen H, Hinterwimmer S, von Eisenhart-Rothe R, Vogl T, Englmeier K, and Eckstein F. Effect of abducting and adducting muscle activity on glenohumeral translation, scapular kinematics and subacromial space width in vivo. J Biomech 38: 755-760, 2005.
38. Gross ML, Brenner SL, Esformes I, and Sonzogni JJ. Anterior shoulder instability in weight lifters. Am J Sports Med 21: 599-603, 1993.
39. Halder A, Zhao K, Odriscoll S, Morrey B, and An K. Dynamic contributions to superior shoulder stability. J Orthop Res 19: 206-212, 2001.
40. Haupt H. Upper extremity injuries associated with strength training. Clin Sports Med 20: 481-490, 2001.
41. Jaggi A and Lambert S. Rehabilitation for shoulder instability. Br J Sports Med 44: 333-340, 2010.
42. Jennings J, Davies G, Tanner S, and Fowler B. Examination, surgical procedures, and rehabilitation procedures for superior labral anterior and posterior (SLAP) injuries. In: Postsurgical Orthopedic Sports Rehabilitation: Knee & Shoulder. Manske RC, ed. St Louis, MO: Mosby, 2006. pp. 613-625.
43. Jobe F, Giangarra C, Kvitne R, and Glousman R. Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports. Am J Sports Med 19: 428-434, 1991.
44. Jobe F, Kvitne R, and Giangarra C. Shoulder pain in the overhand or throwing athlete. The relationship of anterior instability and rotator cuff impingement. Orthop Rev 18: 963-975, 1989.
45. Jobe F, Schwab D, and Brewster C. Anterior capsular reconstruction. In: Rehabilitation for the Postsurgical Orthopedic Patient (2nd ed). Maxey L and Magnusson J, eds. St Louis, MO: Mosby, 2007. pp. 50-56.
46. Jost B, Pfirrmann C, Gerber C, and Switzerland Z. Clinical outcome after structural failure of rotator cuff repairs. J Bone Joint Surg Am 82: 304-314, 2000.
47. Keener J, Wei A, Kim H, Paxton E, Teefey S, Galatz L, and Yamaguchi K. Revision arthroscopic rotator cuff repair: Repair integrity and clinical outcome. J Bone Joint Surg Am 92: 590-598, 2010.
48. Kendall F, McCreary E, Provance P, Rodgers M, and Romani W. Upper extremity and shoulder girdle. In: Muscles: Testing and Function With Pain and Posture. Baltimore, MD: Lippincott Williams & Wilkins, 2005. pp. 328-329.
    49. Kerr Z, Collins C, and Comstock R. Epidemiology of weight-training-related injuries presenting to United States emergency departments, 1990 to 2007. Am J Sports Med 38: 765-771, 2010.
    50. Kibler W, McMullen J, and Uhl T. Shoulder rehabilitation strategies, guidelines, and practice. Orthop Clin North Am 32: 527-528, 2001.
    51. Kibler W and Sciascia A. Current concepts: Scapular dyskinesis. Br J Sports Med 44: 300-305, 2010.
    52. Kibler W, Sciascia A, and Dome D. Evaluation of apparent and absolute supraspinatus strength in patients with shoulder injury using the scapular retraction test. Am J Sports Med 34: 1643-1647, 2006.
    53. Kibler W, Sciascia A, Uhl T, Tambay N, and Cunningham T. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. Am J Sports Med 36: 1789-1798, 2008.
    54. Kim S, Ha K, Kim S, and Choi H. Results of arthroscopic treatment of superior labral lesions. J Bone Joint Surg Am 84: 981-985, 2002.
    55. Kolber MJ, Beekhuizen K, Cheng M, and Hellman M. Shoulder joint and muscle characteristics in the recreational weight training population. J Strength Cond Res 23: 148-157, 2009.
    56. Kolber MJ, Beekhuizen K, Cheng M, and Hellman M. Shoulder injuries attributed to resistance training: A brief review. J Strength Cond Res 24: 1696-1704, 2010.
    57. Kolber MJ, Corrao M, and Hanney W. The relationship between exercise selection and reported shoulder pain during weight-training. Poster presented at: National Strength and Conditioning Association, National Conference; July 2010; Orlando, FL.
    58. Kolber MJ, Beekhuizen K, Cheng MS, and Hellman M. The effect of a 4-week educational intervention on shoulder joint and muscle characteristics in recreational weight-training participants: A pilot study [abstract]. J Orthop Sports Phys Ther 39: OPO2213, 2009.
    59. Kolber MJ. Shoulder Joint and Muscle Characteristics in the Recreational Weight Training Population [dissertation]. Ft. Lauderdale, FL: Department of Physical Therapy, Nova Southeastern University; 2007.
    60. Konig M and Biener K. [Sport-specific injuries in weight lifting]. Schweiz Z Sportmed 38: 25-30, 1990.
    61. Koo S and Burkhart S. Rehabilitation following arthroscopic rotator cuff surgery. Clin Sports Med 29: 203-211, 2010.
    62. Krupp R, Kevern M, Gaines M, Kotara S, and Singleton S. Long head of the biceps tendon pain: Differential diagnosis and treatment. J Orthop Sports Phys Ther 39: 55-70, 2009.
    63. Lestos A, Sagantos D, Michalis M, Baschalis P, and Baltopoulos P. Occult shoulder instability in weight lifters. In: The 14th International Jerusalem Symposium on Sports Medicine: Program and Book of Abstracts. Jerusalem: The Israel Society of Sports Medicine, 1997.
    64. Levinson M. Superior labrum anterior to posterior (SLAP) repair. In: Postsurgical Rehabilitation Guidelines for the Orthopedic Clinician. Cioppa-Mosca J, Cahill J, Cavanaugh J, Corradi-Scalise D, Rudnick H, and Wolf A, eds. St Louis, MO: Mosby, 2006. pp. 546-554.
    65. Levinson M and Altchek D. Capsular shift procedures: Neer and multidirectional instabilities. In: Postsurgical Rehabilitation Guidelines for the Orthopedic Clinician. Cioppa-Mosca J, Cahill J, Cavanaugh J, Corradi-Scalise D, Rudnick H, and Wolf A, eds. St Louis, MO: Mosby, 2006. pp. 551-560.
    66. Lewis A, Kitamura T, and Bayley J. Mini symposium: Shoulder instability (ii). The classification of shoulder instability: New light through old windows! Curr Orthop 18: 97-108, 2004.
    67. Lippitt S and Matsen F. Mechanisms of glenohumeral joint stability. Clin Orthop Relat Res 291: 20-28, 1993.
    68. Lovering R and Russ D. Fiber type composition of cadaveric human rotator cuff muscles. J Orthop Sports Phys Ther 38: 674-680, 2008.
    69. Ludewig P and Borstead J. The shoulder complex. In: Joint Structure and Function: A Comprehensive Analysis. Levangie P and Norkin C, eds. Philadelphia, PA: FA Davis Company, 2005. p. 257.
    70. Oatis CA. Mechanics and Pathomechanics of Muscle Activity at the Shoulder Complex. In: Kinesiology: The Mechanics and Pathomechanics of Human Movement (2nd ed). Oatic, CA ed. Baltimore, MD: Lippincott Williams & Wilkins, 2009. p. 172.
    71. Malanga G, Jenp Y, Growney E, and An K. EMG analysis of shoulder positioning in testing and strengthening the supraspinatus. Med Sci Sports Exerc 28: 661-664, 1996.
    72. Maschi R and Fives G. Rotator cuff repair: Arthroscopic and open. In: Postsurgical Rehabilitation Guidelines for the Orthopedic Clinician. Cioppa-Mosca J, Cahill J, Cavanaugh J, Corradi-Scalise D, Rudnick H, and Wolf A, eds. St Louis, MO: Mosby, 2006. pp. 499-509.
    73. Meister K and Andrews J. Classification and treatment of rotator cuff injuries in the overhead athlete. J Orthop Sports Phys Ther 18: 413-420, 1993.
    74. Meller R, Krettek C, Gosling T, Wahling K, Jagodzinski M, and Zeichen J. Recurrent shoulder instability among athletes: Changes in quality of life, sports activity, and muscle function following open repair. Knee Surg Sports Traumatol Arthrosc 15: 295-304, 2007.
    75. Mohtadi NGH. Advances in the understanding of anterior instability of the shoulder. Clin Sports Med 10: 863-870, 1991.
    76. Moraes G, Faria C, and Teixeira-Salmela L. Scapular muscle recruitment patterns and isokinetic strength ratios of the shoulder rotator muscles in individuals with and without impingement syndrome. J Shoulder Elbow Surg 17: 48S-53S, 2008.
    77. Muraki T, Yamamoto N, Zhao K, Sperling J, Steinmann S, Cofield R, and An K. Effect of posteroinferior capsule tightness on contact pressure and area beneath the coracoacromial arch during pitching motion. Am J Sports Med 38: 600-607, 2010.
    78. Namdari S and Green A. Range of motion limitation after rotator cuff repair. J Shoulder Elbow Surg 19: 290-296, 2010.
    79. National Athletic Trainers' Association. What Is an Athletic Trainer? Available at: http://cf.nata.org/about_AT/whatisat.htm. Accessed: July 1, 2010.
    80. National Strength and Conditioning Association: Strength & conditioning professional standards and guidelines. Strength Cond J 31(5): 14-38, 2009.
    81. Neer C. Impingement lesions. Clin Orthop Relat Res 173: 70-77, 1983.
    82. Nho S, Shindle M, Sherman S, Freedman K, Lyman S, and MacGillivray J. Systematic review of arthroscopic rotator cuff repair and mini-open rotator cuff repair. J Bone Joint Surg Am 89: 127-136, 2007.
    83. Noffal G. Isokinetic eccentric-to-concentric strength ratios of the shoulder rotator muscles in throwers and nonthrowers. Am J Sports Med 31: 537-541, 2003.
    84. Ogston J and Ludewig P. Differences in 3-dimensional shoulder kinematics between persons with multidirectional instability and asymptomatic controls. Am J Sports Med 35: 1361-1370, 2007.
    85. Rathburn J and MacNab I. The microvascular pattern of the rotator cuff. J Bone Joint Surg Am 52:540-553, 1970.
    86. Reinold M, Wilk K, Macrina L, Dugas J, and Andrews J. Rehabilitation after thermal-assisted capsular shrinkage of the glenohumeral joint. In: Postsurgical Rehabilitation Guidelines for the Orthopedic Clinician. Cioppa-Mosca J, Cahill J, Cavanaugh J, Corradi-Scalise D, Rudnick H, and Wolf A, eds. St Louis, MO: Mosby, 2006. pp. 587-604.
    87. Smith J, Dietrich C, Kotajarvi B, and Kaufman K. The effect of scapular protraction on isometric shoulder rotation strength in normal subjects. J Shoulder Elbow Surg 15: 339-343, 2006.
    88. Tyler T, Nicholas S, and Seneviratne A. The Bankart lesion. In: Postsurgical Rehabilitation Guidelines for the Orthopedic Clinician. Cioppa-Mosca J, Cahill J, Cavanaugh J, Corradi-Scalise D, Rudnick H, and Wolf A, eds. St Louis, MO: Mosby, 2006. pp. 569-579.
    89. Tyler T and Zeman C. Superior labral anterior posterior repair (SLAP repair). In: Rehabilitation for the Postsurgical Orthopedic Patient (2nd ed). Maxey L and Magnusson J, eds. St Louis, MO: Mosby, 2007. pp. 97-107.
    90. University of Wisconsin Health Sports Medicine. Rehabilitation Guidelines for Superior Labral Anterior to Posterior Tear (SLAP) Lesion Repair. 2009. Available at: http://www.uwhealth.org/sports-medicine/rehabilitation-guidelines-for-superior-labral-anterior-to-posterior-tear-slap-lesion-repair/20498. Accessed: August 30, 2010.
    91. University of Wisconsin Health Sports Medicine. Rehabilitation Guidelines for Rotator Cuff Repair. 2009. Available at: http://www.uwhealth.org/sports-medicine/rehabilitation-guidelines-for-rotator-cuff-repair/20507. Accessed: August 30, 2010.
    92. Walch G, Boileau P, Noel E, and Donell S. Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: An arthroscopic study. J Shoulder Elbow Surg 1: 238-245, 1992.
    93. Weiser W, Lee T, McMaster W, and McMahon P. Effects of simulated scapular protraction on anterior glenohumeral stability. Am J Sports Med 27: 801-805, 1999.
    94. Wilk K, Crockett H, and Andrews J. Rehabilitation after rotator cuff surgery. Tech Shoulder Elbow Surg 1: 128-144, 2000.
    95. Wilk K, Harrelson G, and Arrigo C. Shoulder rehabilitation. In: Physical Rehabilitation of the Injured Athlete (3rd ed). Andrews J, Harrelson G, and Wilk K, eds. Philadelphia, PA: Saunders, 2004. pp. 545-553.
    96. Yu J and Habib P. Common injuries related to weightlifting: MR imaging perspective. Semin Musculoskelet Radiol 9: 289-301, 2005.
    FIGURE. Ca

    FIGURE. Ca

    Keywords:

    rehabilitation; rotator cuff; shoulder instability; labrum

    © 2011 National Strength and Conditioning Association