Paradigm shift in shoulder rehab brings new focus on kinetics, stability, alignment

Patient progression should reflect function, not time in rehabilitation.

Issue: October 2006

In light of mounting reimbursement constraints and fewer patient visits, physicians are being forced to rethink shoulder rehabilitation.

At the Arthroscopy Association of North America's 25th Annual Meeting, Benjamin D. Rubin, MD, an orthopedic surgeon at Orthopaedic Specialty Institute in Orange, Calif., outlined what he feels are the principles and phases of functional shoulder rehabilitation for the 21st century.

Ultimately, physicians must think outside the box of traditional rehabilitation, he said.

"You cannot successfully rehabilitate a shoulder unless your box includes scapulothoracic kinematics, core stability and alignment," Rubin said.

This paradigm shift includes identifying patients' mechanical problems and viewing the shoulder as part of an integrated system of joints, called the kinetic chain.

"You cannot successfully evaluate or treat the shoulder unless you consider the kinetic chain," Rubin said. "The traditional analogy of the glenohumeral joint is a golf ball on a tee and this assumes a static relationship between the humeral head and the glenoid. It also assumes that the joint functions in isolation, and neither of these things is true."

Physicians should also understand the principle of core stabilization, which focuses on the importance of the abdominal muscles. According to Rubin, electromyography studies have shown that, "no matter what limb is moving, before it moves, the transversus abdominis fires, which increases the intra-abdominal pressure."

Improving postural alignment during rehabilitation increases performance and joint durability. Similarly, having the correct scapular position proves crucial. A tight pectorialis minor produces a anteriorly tilted scapula, he said.

"If you add an anterior tilt and internal rotation, what we call protraction, it decreases the subacromial space when you elevate the arm, which is probably the most common cause of subacromial impingement that you see in your office," he said.

Physicians should also be aware of soft tissue constraints and measure range of motion with the scapula stabilized, Rubin added. With these principles in mind, Rubin said that a successful rehab program should include the following phases:

proximal kinetic chain;
scapulothoracic;
glenohumeral; and
function-specific.

During the first phase, exercises emphasize proximal stability before distal mobility.

"You can take patients in the sling and have them do lunges and start working on their core and lumbo-pelvic strength," Rubin said. "When they start to [activate] the trunk muscles, it facilitates proper scapular positioning."

The scapulothoracic rehabilitation portion centers on re-establishing correct scapula positioning and control to diminish subacromial impingement and pain. The early rehabilitation phases incorporate closed chain exercises, he said.

"These exercises facilitate glenohumeral compression, decrease the sheer on the glenohumeral joint, and [they] actually improve function of the rotator cuff," Rubin said. The function-specific phase "quiets the rotator cuff down to about 18% when you're doing closed-chain exercises," which can include exercises using balls, he added.

Patients should perform exercises without pain. "Remember that if the joint hurts, it's not going to progress very well," Rubin said. "If there's pain with exercise or range of motion, it's either too inflamed, they're doing the wrong exercises at the wrong time [or] there's improper technique due to fatigue, and this will just reinforce poor mechanics."

Physicians must also remember that patients learn at different speeds, and progression should reflect function, not the time that the patient has spent in rehabilitation. Current rehabilitation protocols require a shift in theory and approach with an eye toward financial limits, he said. Therefore, programs should focus on core stability, alignment and scapulothoracic kinematics.

"Correct the soft tissue restrictions early," he said. "Remember [to strive for] proximal stability before distal mobility, [and] quality is more important than quantity. Teach the patient to isolate the muscle and then train the muscles in groups in coordinated synchronous patterns, and progress from closed to open chain exercises."

For more information:
Rubin BD. Shoulder rehabilitation principles in the 21st century. Presented at the Arthroscopy Association of North America 25th Annual Meeting. May 18-21, 2006. Hollywood, Fla.