Posted on May 21, 2015 by Jenny Cromack

Shoulder Rehabilitation

The shoulder is a very complex joint, most of us will have or will do, at some point, experience shoulder pain. The shoulder itself has a large range of movement and is a highly mobile joint. This large range of movement has its downfalls because the stability is sacrificed to achieve these ranges. There is a limited amount of stability from the passive structures such as the ligaments. This means that the muscles of the shoulder have a lot of responsibility when it comes to stabilising the shoulder. This large responsibility can result in compensations, imbalances and ultimately alterations in function.

Major Anatomy

Bones

The bones of the shoulder make up a series of joints that form the ‘shoulder complex. The humerus (upper arm) meets a small socket like surface on the scapula called the glenoid fossa. This forms the gelno-humeral joint or what is seen as the ball and socket joint of the shoulder.

A bony, hook like, prominence of the shoulder known as the acromion meets the end of the clavicle or collar bone and forms the acromio-clavicular joint or the AC joint as you may have heard people talk about. This joint is commonly ‘popped’ during any falls or sports.

Soft Tissues

There are a whole host of liagments around the shoulder that offer passive stability but without going into specifics we will simply state the main ones.

There is a band of three ligaments over the gleno-humeral joint, known as the gleno-humeral ligaments. These sit around the front, middle and back of this joint. Around the AC joint there are the three ligaments the acromio-clavicular ligament, the coraco-clavicular ligament and part of the coraco-clavicular ligament. These attach the acromion and clavicle together providing stability around this area.

Lining the surface of the glenohumeral joint is a cartillage like tissue called the labrum that basically helps deepen the socket to aid stability. Along with this there is a capsule that encases the gleno-humeral joint again to aid further stability.

Muscles

There are many muscles around the shoulder so we will just state the major ones and offer a brief description.

The main shoulder muscle is the deltoid this helps raise the arm up in front, out to the side, across the body and also pulling it backwards. This muscle is split into three areas – anterior, posterior and medial. 

Major Muscles	Actions
Deltoid	Raising arm out to the side (Abduction) Raising arm out to the front (Flexion) Raising arm backwards (Extension)
Pectoralis Major	Bringing arm across the body (Horizontal Flexion) Helps raise the arm out to the front (Flexion) Rotates arm and shoulder inwards (Internal Rotation)
Latissumus Dorsi	Raising arm backwards (Extension) Bringing arm in to the side (Adduction) Pulls arm horizontally backwards (Horizontal Extension)
Trapezius	Pulls shoulder blades back (Retraction) Lower portion pulls shoulder blades down (Depression) Upper portion lifts Shoulder blades up (Elevation) Rotation of the scapula
Teres Major	Rotates arm and shoulder inwards (Internal Rotation) Bringing arm in to the side (Adduction) Stabilises humeral head
Rhomboids	Pull shoulder blades back (Retraction) Generally hold the shoulder blades onto the ribcage
Rotator Cuff Muscles	Actions
Supraspinatus (Rotator Cuff)	Raising arm to the side for first 15 degrees (Abduction) Stabilise and pull the humeral head into the socket.
Infraspinatus (Rotator Cuff)	Rotates arm and shoulder outwards (External Rotation) Stabilise and pull humeral head down in the socket (Depression of Humeral Head)
Teres Minor (Rotator Cuff)	Rotates arm and shoulder outwards (External Rotation) Stabilises and pulls humeral head down in the socket (Depression of Humeral Head)
Subscapularis (Rotator Cuff)	Rotates arm and shoulder inwards (Internal Rotation) Stabilises and pulls humeral head down and forward when arm is raised
Other Muscles	Actions
Serratus Anterior	Pulls scapula forwards around the ribcage (Protraction) Helps with scapula rotationHelps keeps scapula pulled into the ribcage
Pecotralis Minor	Pulls scapula forward around the ribcage (Protraction) Pulls scapula downwards (Depresses Scapula)Rotates Scapula Downwards
Levator Scapulae	Lifts the scapula (Elevates Scapula)

Rehabilitation for Shoulder Pain

There are a whole host of possible injuries, and complaints that are associated with the shoulder but to discuss all of them individually and provide rehab for them all would take more than a single blog post. Therefore this article will offer advice on a generic shoulder rehabilitation program to provide an idea of the principles that need to be covered.

The rehabilitation process, much like training, has different focuses or phases. These are as follows:

1. Initial Symptom Management

This concerns any acute injury, or onset of pain etc and will depend on the severity of the complaint. After getting clearance from a medical professional, if the injury is more serious, then the aim is to reduce pain and control the swelling and inflammation. The use of ice is in debate at the moment. However, I would suggest the use of some cold therapy to reduce pain. You should also keep the joint in a comfortable position, not fully immobilised (unless advised), and try maintaining simple but pain free movements.

2. Range of Motion and Flexibility Restoration

In order to make sure the joint doesn’t become excessively stiff and restricted gentle stretching should be introduce as well as non-resisted, simple movements of the shoulder. This is important for reducing the length of the rehabilitation. If you are overly stiff and do not address this then the ability to carry out the subsequent exercises will be reduced. By stretching and mobilising the joint helps manipulate scar tissue formation into a more functional arrangement, and optimise muscle length.

Exercises can include the movements described in the muscle actions table.

Example stretches are:

* Overhead Shoulder Stretch – place arm overhead on a door frame and lean forward into a stretch.

* Sleeper Stretch – lie on your side with the bottom upper arm out at 90 degrees and then use your other hand to push the hand down towards the floor.

* Towel Stretch – wrap a towel something at about head height, grasp the towel and turn your palm upwards, then walk your body backwards and shift your weight backwards so the band feels as though it pulls the arm “out of its socket”. Drop your chest towards the floor and rotate the body to loosen the joint capsule. Find areas that feel restricted and work into these.

3. Regaining Control

The scapulae play a very important role in the function of the shoulder, without a normal ‘glide’ of the shoulder blades the shoulder has to compensate to achieve its full range, this leaves us open to more complaints and bad posture.

A few helpful exercises are below:

*Scapula Clocks – stand facing a wall, pull your scapula back together. Then place your hands against the wall. From here slide your hands along the wall simultaneously, you can move around a ‘clock’, so move to each number. Move hands in opposite directions focusing on gliding the scapula.

*Protraction & Retraction – place your arms straight in front of you against the wall (wall press up position), keep the arms straight, drop your chest through your arms so your shoulder blades slide backwards towards each other, then move your chest back up as far away from the wall as possible, feel the shoulder blades slide apart around the rib cage.

*Wall slides – stand with back to the wall, places forearms against the wall and slide arms up aiming for overhead. Don’t force this only work in pain free range and progress from there, keep back flat against the wall.

4. Increasing Strength

This is the aspect everyone thinks of when it comes to rehab, and is an important feature but needs to be balanced with everything else and done in a progressive manner. It is important to strengthen the weakened muscles to ensure the injured tissue is strong enough to serve its purpose within the shoulder.

As you can see from the table there are a lot of muscles in the shoulder so will just provide a couple of good exercises to include.  But you can work out the movements by using the muscle action table.

Examples of a few exercises for specific roles in the shoulder are as follows:

*Seated Row – emphasise initiating the movement by squeezing the scapula together before pulling the elbows in.

*Internal/External Rotations – stand with elbows tucked in, or with upper arm at 90 degrees (depending on pain) and rotate arms in and out from the shoulder in pain free range use theraband or weights as you progress.

*Standing Scaption – make a thumbs up and raise arms up in a v shape (45 degree angle) working in a pain free range, add weights as pain allows. Do not sacrifice range for weight.

*Exercises to work through flexion, extension, abduction and adduction see table for movement ideas and muscles involved.

5. Regaining Power and Neuro-Muscular Function:

Our shoulder needs to react and remain stable in events such as falling, catching objects, raising or lowering ourselves from and to a chair. Athletes or regular exercisers put themselves in unstable positions and therefore there are more scenarios where their shoulder needs to respond to vulnerable or spontaneous activities such as throwing, tackling, or lifting heavy weights etc. This needs to be included to ensure our mind-muscle connection is working properly, so our body can recognise these events and react appropriately. Exercises will include balance and co-ordination movements, and stretch-shortening (power) exercises.

Examples are as follows:

*Full Arm Plank – hold press up position on a yoga ball keeping the body flat and stabilizing the shoulders through (keeping as still as possible).

*Press Up Slides – place a cloth under each hand on a smooth flooring or surface then assume the press up position. Then start to slowly slide your hands apart in all directions maintaining a stable body and shoulder position. Progress the range of movement as ability and pain allows.

*Single Arm Wall-Ball – with a small medicine ball or a weighted ball in hand, stand close to the wall, raise arm to 90 degrees, then repeatedly bounce the ball against the wall using quick short throws

6. Don’t Forget Sport Specifics

This is too varied to give specific examples but you need to retrain sport specific drills for the shoulder to learn again before returning fully to sport and training. This can be drip fed throughout the rehabilitation or brought in at later stages.

Examples may be:

*Specific Lifts – i.e. cleans, deadlift, squats etc.

*Tackling, Passing, Catching Drills

Take Home Message

Take the ideas above and the principles and apply them to your own protection or prevention of shoulder complaints. Ensure all principles are covered throughout any program. This process of rehabilitation is important but for it to be truly effective it needs to be maintained so focus on keeping some of the exercises in your warm ups and cool downs, monitor the state of your muscles i.e. look for tight or weak areas that may be affecting the shoulder. Always seek medical advice before jumping straight into a rehab program.

If you require any further or more specific detail contact me directly.