Shoulder rehabilitation
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The document provides guidelines for rehabilitating shoulder injuries. It emphasizes the importance of making an accurate diagnosis that considers local anatomical deficits as well as biomechanical issues. Pain reduction should be prioritized early in rehabilitation through rest, cryotherapy, and medications. Exercises should integrate the kinetic chain from the legs to restore normal movement patterns. Scapular stabilization and early achievement of 90 degrees of abduction are also principles of effective shoulder rehabilitation.
Shoulder rehabilitation
- 1. Rehabilitation of Shoulder Injuries Dr. Usha (PT) Assistant Professor
- 2. Guidelines For Shoulder Rehabilitation ▪ Certain guidelines based on physiology and biomechanics have provided very good outcomes in terms of return to play. ▪ There are probably several protocols that can be used to optimize rehabilitation of the shoulder as long as they conform to the guidelines.
- 3. Make A Complete and Accurate Diagnosis Principle The rehabilitation program can only be as good as the diagnosis. Too often, diagnosis of shoulder injuries is incomplete due to the number of factors that combine to influence shoulder function.
- 4. Practise ▪ The diagnosis must not only include the local anatomical deficit, such as rotator cuff tear, Bankart lesion, labral injury or fracture, but also the local biomechanical deficits that exist either as a result of the injury or of treatment. ▪ These would include inflexibility of internal or external rotation or adduction, force couple imbalance either of the internal and external rotators or of the supraspinatus in relationship to the deltoid, or acquired alterations in shoulder position, such as dropping the arm in the throwing position because of impingement.
- 5. ▪ In addition, the regional deficits that may occur in the AC joint can also inhibit some of the muscle firing patterns. ▪ The position, motion and strength of the scapula and its muscles should be considered in the diagnosis. ▪ Finally, distant deficits should be evaluated as well. Back and hip inflexibility, injuries or strength imbalances should be evaluated. Inflexibilities of hip rotation, hamstrings or the back often commonly contribute to shoulder abnormalities.
- 6. ▪ In addition, alterations in mechanics, whether it be hyperlordosis of the back, lack of rotation of the hip or trunk, or alteration of the plant leg in throwing, need evaluation. ▪ A complete diagnosis identifies not only the clinical symptoms and the tissues that are injured but also the tissues that are overloaded, the functional biomechanical deficits that exist and the subclinical adaptations that the athlete uses to try to maintain performance.
- 7. EARLY PAIN REDUCTION Principle Pain is a major cause of altered shoulder function. Avoidance of painful positions causes the athlete to assume abnormal positions of the arm or back. Pain also creates a high degree of muscle inhibition, which alters muscle firing patterns.
- 8. Practise Pain should be controlled early in rehabilitation. ▪ Strategies to decrease pain include ▪ Relative rest of the area, with ▪ Decreased throwing activities, ▪ Avoidance of painful arcs of motion, ▪ Cryotherapy, ultrasound, galvanic stimulation and medications.
- 9. ▪ This also may include judicious injection into the subacromial space if there are true signs of inflammation, non-steroidal medications and analgesia as needed. ▪ Exercises should be kept within pain-free arcs; these arcs become progressively greater as pain is controlled.
- 10. Integration of The Kinetic Chain into Rehabilitation Principle ▪ It is important to re-establish the kinetic chain early in the rehabilitation process. ▪ In ground-based sports, all of the activities of the shoulder work within a kinetic chain linkage from the ground through to the trunk. ▪ While the shoulder is recovering from the injury or surgery, leg and trunk exercises can be prescribed so that when the shoulder is ready for rehabilitation, the base of the kinetic chain is also ready for link activity.
- 11. ▪ After the shoulder is ready for rehabilitation, activation of the kinetic chain patterns from the legs through the back to the shoulder restores the force-dependent motor activation patterns and normal biomechanical positions. ▪ This then allows normal link sequencing to generate velocity and force.
- 12. Practise ▪ Before starting formal strength rehabilitation, it is important to correct any inflexibilities of the hamstrings, hip and trunk; weakness or imbalances of the rotators of the trunk, flexors and extensors of the trunk and hip; and any subclinical adaptations of stance patterns or gait pattern. ▪ Rehabilitation of the legs and hips should be concerned with generating appropriate sport-specific force and velocity from the lower extremity and should be done in a closed chain fashion.
- 13. ▪ This pattern, which is done with the foot on the ground, simulates the patterns that exist in the throwing or hitting activities. ▪ Eccentric patterns should also be emphasized to absorb the load from jumping forward movement or stopping of the plant leg in the baseball throw.
- 14. ▪ Combined patterns of hip and trunk rotation in both directions, hip and shoulder diagonal patterns from the left hip to the right shoulder and from the right hip to the left shoulder, should also be emphasized as most shoulder activities involve rotation and diagonal patterns. ▪ An excellent exercise involves jumping on a mini-trampoline and simultaneously extending the hips and scapula upon landing. This extensor pattern allows for hip extension, trunk extension and scapular retraction in the same pattern that exists in the cocking phase of throwing activities.
- 17. ▪ Integration of the scapular retraction muscles to the hip is very important because these reactions tend to be coupled in the cocking phases of throwing. Aim to correct abnormal reversal of the thoracic kyphosis and neck lordosis in this preliminary phase to allow normal positioning of the scapula. ▪ Endurance activities in the legs should also be emphasized, as should aerobic endurance for recovery from exercise bouts and anaerobic endurance for agility and power work. ▪ Examples include mini-trampoline exercises, agility drills with running and jumping, jumping jacks and slider or fitter boards
- 18. Scapular Stabilization Principle The scapula is the base upon which all shoulder activities rest. The four main roles of the scapula include: 1. Retraction and protraction in the different phases of throwing motion 2. Elevation of the acromion in abduction of the arm 3. Acting as a socket for the glenohumeral joint 4. Acting as a base of origin for all of the intrinsic muscles of the rotator cuff and the extrinsic muscles of the deltoid, biceps and triceps.
- 19. ▪ In addition, the scapula acts as a platform for shoulder rotation and arm activities. In biomechanics, the glenohumeral joint has been described as the equivalent of a golf ball on a tee due to the size relationships. A more accurate biomechanical description would be of a ball on a seal’s nose. As the ball or humeral socket moves, the seal’s nose or the scapula needs to move to maintain the position of the ball on the glenoid. ▪ Acromial elevation and scapular stabilization is often jeopardized early in the injury process due to pain inhibiting the serratus anterior and lower trapezius, and to subclinical alterations of the position of the scapula to accommodate injury patterns in subluxation or impingement.
- 20. Practise Evaluation of the scapula is a high priority. Evaluate the motion and position of the scapula in various phases of the throwing motion and also assess muscular strength and scapular stabilization. Appropriate exercises early in the rehabilitation process for scapular control include scapular pinch, an isometric activity in which the scapulae are retracted towards the midline. Integration of scapular retraction with rotator cuff co-contractions allows a more normal physiological pattern to redevelop. Most of the scapular control exercises are done through the method of closed chain rehabilitation (see below). Recent studies have shown that four specific exercises selectively activate the scapular stabilizing muscles: the scapular clock, low row, lawn mower and inferior glide (see Fig. 17.33).
- 23. Early Achievement of 90° of Abduction And Improved Glenohumeral Rotation Principle ▪ Most throwing activities in sports demand 90° of shoulder abduction, as throwing activities occur between 85° and 110° of abduction, and require a large arc of glenohumeral rotation. Skilled length dependent motor patterns and force-dependent patterns are based upon the achievement of 90° of abduction. Alteration of the joint position by 15° changes the motor activation patterns. ▪ Therefore, the thrower’s shoulder should be rehabilitated at the 90° position to allow for the normal motor patterns to be recreated. This is the physiological angle for length dependent motor patterns. Furthermore, at 90° of abduction, the inferior glenohumeral ligamentous constraints become taut in this position.
- 24. Practise ▪ Aim to achieve 90° of abduction early in the rehabilitation process by reducing pain from impingement or other sources as quickly as possible. ▪ Maintain scapular stabilizer strength so that acromial elevation clears the acromion from the rotator cuff . Tendinopathy should be minimized to allow the tendons to slide under the coracoacromial arch. ▪ In operative cases, the subacromial space should be cleared of impediments to abduction, such as calcific deposits, bone spurs or excessively thick bursal tissue.
- 25. ▪ When performing surgical reconstruction for shoulder stability, the surgeon must ensure that 90° of abduction can be obtained on the operating table. This will allow early achievement of 90° of abduction without undue stress on the ligaments. ▪ This is analogous to ensuring full extension of the knee in anterior cruciate ligament reconstructions. Specific exercises to achieve 90° of abduction include active-assisted wand maneuvers (Fig. 17.31), gentle joint mobilizations, PNF patterns and passive stretching. ▪ The pace of progression should be relatively slow in the healing phases but may be more vigorous after three to six weeks.
- 27. CLOSED CHAIN REHABILITATION Principle ▪ The predominant method of muscle activation around the shoulder articulation is a closed chain activity emphasizing co-contraction force couples at the scapulothoracic and glenohumeral joint. This results in proper scapular position and stability and allows the rotator cuff to work as a ‘compressor cuff’, conferring concavity–compression and a stable instant center of rotation. ▪ Closed chain activity also simulates the normal proprioceptive pathways that exist in the throwing motion and allows feedback from the muscle spindles and Golgi tendon organs in their proper anatomical positions. Closed chain activity replicates the normal ball and socket kinematics, minimizing translation in the mid ranges of motion. Finally, by decreasing deltoid activation, these activities decrease the tendency for superior humeral migration if the rotator cuff is weak.
- 28. ▪ Open chain activities, which involve agonist antagonist force couples and generate force for the shoulder and the kinetic chain, also are seen around the shoulder articulation but are of secondary importance. ▪ They require deltoid and other extrinsic muscle activation, create shear forces at the glenohumeral joint and require large ranges of motion. Exercises to simulate these activities should be instituted later in rehabilitation as they produce larger forces and require greater motions than the shoulder can tolerate early in rehabilitation. Closed chain rehabilitation provides a stable scapular base and early rotator cuff strength, which allows open chain activities.
- 29. Practise ▪ The exercises are started at levels below 90° of abduction in the early phases of rehabilitation to allow for healing of the tissues. ▪ They may be started at 45° of abduction and 60° of flexion and then proceed to 90° of abduction as tolerated. The hand is placed against some object, such as a table, a ball or the wall, and resistance is generated through the activities of the scapula and shoulder. When the arm can be safely positioned at 90° of abduction, it is placed in either abduction or flexion and a specific progression is started. ▪ The closed chain activities are first started with scapular stabilization. Patterns of retraction and protraction of the scapula are started in single planes and then progress to elevation and depression of the entire scapula and then selective elevation of the acromion (Fig. 17.32).
- 31. ▪ The next progression is on to rotator cuff activity. Joint compression with contraction into the shoulder joint is followed by ‘clock’ exercises, in which the hand is moved to the various positions on the clock face, ranging from eight o’clock to four o’clock (Fig. 17.33a). ▪ This allows for rotation of the humerus with the arm at 90° of abduction, which replicates rotator cuff activity throughout all components of the rotator cuff . ▪ These activities are first done against fixed resistance, such as a wall, and then can be moved to movable resistance, such as a ball or some other movable implement.
- 33. ▪ These exercises may be done early in the rehabilitation phase as they do not put shear on the joint and allow rotator cuff muscles to be activated without being inhibited by pain or deltoid over activity. ▪ Closed chain progressions may be used in later phases of rehabilitation. They include various types of push-ups (wall leans, knee push-ups and regular push-ups; Fig. 17.34) and scapation exercises (Fig. 17.35).
- 36. PLYOMETRIC EXERCISES Principle ▪ Most athletic activities involve development of power. Power is the rate of doing work and, therefore, has a time component. ▪ For most sports, this time component is relatively rapid. Plyometric activities develop the athlete’s ability to generate power by producing a stretch-shortening cycle in which the muscle is eccentrically stretched and slowly loaded. ▪ This pretensioning phase is followed by a rapid concentric contraction to develop a large amount of momentum and force.
- 37. ▪ Because these exercises develop a large amount of strain in the eccentric phase of the activity and force in the concentric phase of the activity, they should be done when complete anatomical healing has occurred. ▪ Similarly, because large ranges of motion are required, full range of motion should be obtained before the plyometric activities are started. These stretch-shortening activation sequences are part of the normal force-dependent patterns that are present in skilled athletes.
- 38. Practise ▪ Plyometrics should be done for all body segments involved in the activity and not just the shoulder. Hip rotation, knee flexion/extension and trunk rotation are all power activities that require plyometric activation. ▪ Plyometric activities for the lower extremity can be done in the early phases of rehabilitation but plyometric exercises for the upper extremity should be instituted in later phases. Many different activities and devices can be utilized in plyometric exercises. Rubber tubing is a very effective plyometric device (Fig. 17.36).
- 39. ▪ The arm or leg can be positioned exactly in the position of the athletic activity and then the motion can be replicated by use of the rubber tubing. Balls are also excellent plyometric devices. ▪ The weight of the ball creates a pre stretch as the ball is caught and creates resistance for contraction forces (Fig. 17.37). ▪ Light weights can also be used for plyometric activities but caution must be used in using heavier weights in a plyometric fashion due to the forces applied on the joint. Plyometric activities with larger weights can be done more easily in the lower extremity than the upper extremity.
- 41. ▪ By reproducing these stretch-shortening cycles at positions of physiological function, these plyometric activities also stimulate proprioceptive feedback to fine tune the muscle activity patterns. ▪ Plyometric exercises are the most appropriate open chain exercises for functional shoulder rehabilitation.
- 42. ROTATOR CUFF EXERCISE Principle ▪ The rotator cuff muscles are very important in creating concavity compression to maintain the humeral head in the glenoid socket. ▪ They do this by participating with the deltoid in the abduction force couple and with themselves in a rotation force couple. Because of their relatively small size, they are frequently overpowered and inhibited by deltoid activity. ▪ For these reasons, they are often the site of overload abnormalities around the shoulder.
- 43. ▪ Rotator cuff weakness is often the final common pathway that leads to clinical symptoms and dysfunction around the shoulder. ▪ However, because many pathological conditions contribute to rotator cuff overload, selective isolated rotator cuff exercises are frequently not successful in relieving the clinical symptoms. The rotator cuff muscles act as a unit in functional shoulder activities.
- 44. Practise ▪ Rotator cuff muscles should be rehabilitated as an integrated unit, rather than as individual muscles. They do not work in isolation in shoulder function, and the anatomical positions and motions that are used for testing are not seen in shoulder function. ▪ Because they require a stabilized scapula to provide a stable base of muscle origin, and because individual rotator cuff activity creates shear across the gleno-humeral joint, early rotator cuff exercises should be done in a closed chain fashion.
- 45. ▪ This allows rotator cuff strengthening without inducing shear on the joint nor allowing deltoid over activity to create impingement. ▪ We have found that closed chain rotator cuff strengthening exercises redevelop the composite rotator cuff effectively and that isolated rotator cuff exercises are increasingly less commonly needed in later stages of rehabilitation. ▪ If rotator cuff deficits are still observed in the later phases of rehabilitation, isolated rotator cuff exercises can be prescribed.
- 46. ▪ Isolated rotator cuff exercises may be very effective as part of a pre- participation conditioning program. The exercises strengthen the individual rotator cuff muscles as part of a spectrum of isolated and integrated conditioning exercises. ▪ A useful clinical sign for deficiencies in rotator cuff rehabilitation is exacerbation of clinical symptoms when rotator cuff exercises are started. ▪ If rotator cuff exercises increase clinical symptoms, this can be traced to abnormalities in other parts of the kinetic chain. Further evaluation of the kinetic chain should be done and the exercises should be directed to the source of weakness. This source is most commonly the scapular stabilizers.
- 47. SUMMARY OF THE PRINCIPLES ▪ These guidelines are very effective in clinical practise. They emphasize a sequence of rehabilitation and address all the functional deficits that may occur in association with shoulder abnormalities. Many different therapeutic exercises can be used to fulfil each of the guidelines. ▪ The exact protocol may be based on the patient’s presentation, the clinical examination, the therapist’s skill and the therapist’s imagination. Adherence to this program requires patient education and guidance from the physician and physiotherapist on the techniques of rehabilitation. ▪ However, most of the physiotherapy can be done by home programs once the exercises have been taught appropriately. Physiotherapy office visits are used for assessment of achievement of the individual goals for the rehabilitation sequence, instruction in the exercises to be done in the next phase and specific guidance as to goals to achieve for the next rehabilitation phase.
- 48. PUTTING IT ALL TOGETHER: SPECIFIC REHABILITATION PROTOCOLS ▪ The general rehabilitation protocol listed is the basic protocol. Deviations from this protocol may be based on the individual needs of the patient and his or her progression. ▪ This protocol assumes, if surgery has been performed, stable repair of the labrum, capsule or rotator cuff and ability to achieve 90° of abduction without impingement or excessive capsular stretch at the time of the operation. ▪ The time frame depends on the severity of the injury or extent of the surgical procedure(s). ▪ The rehabilitation goal is to progress post-operative labral repairs, shoulder reconstructions and acromioplasties to 90° of passive or active-assisted abduction by three weeks and rotator cuff repairs to 90° of passive or active- assisted abduction by four to six weeks.
- 49. ACUTE PHASE The goals of the acute phase are: 1. Tissue healing 2. Reduction of pain and inflammation 3. Re-establishment of non-painful range of motion below 90° of abduction 4. Retardation of muscle atrophy 5. Scapular control• maintenance of fitness in other components of the kinetic chain.
- 50. 1. Tissue healing Tissue healing is the combination of: • Rest • Short-term immobilization • Modalities • Surgery
- 51. 2. Reduce pain and inflammation Aggressive treatment is used to control pain to decrease inhibition-based muscle atrophy and scapular instability due to serratus and/or trapezius inhibition. This is done through: ▪ Medications, either non-steroidal or judicious use of corticosteroids orally or by injection ▪ Modalities, usually ultrasound (two per week every two weeks) ▪ Cold compression devices.
- 52. 3. Re-establish range of motion The range of motion should be started in pain-free arcs, kept below 90° of abduction, and may be passive or active- assisted. The degree of movement is guided by the stability of the operative repair. Range of motion should be re- established by: ▪ Pendulum exercises ▪ Manual capsular stretching and cross-fiber massage ▪ T-bar or ropes and pulleys.
- 53. 4. Retard muscle atrophy Isometric exercises, with the arm below 90° of abduction and 90° of flexion, should be done in patients with labral or capsular repair but not in those with rotator cuff repairs.
- 54. 5. Scapular control The exercises to maintain scapular control include: ▪ Isometric scapular pinches and scapular elevation ▪ low row (fig. 17.33b) ▪ Closed chain weight shift s, with hands on table and the shoulders flexed less than 60° and abducted less than 45° ▪ Tilt board or circular board weight shifts with the same limitations (Fig. 17.38).
- 56. 6. Maintain fitness in rest of kinetic chain Exercises to maintain fitness in the rest of the kinetic chain include: ▪ Aerobic exercises such as running, bicycling or stepping figure 17.38 closed chain weight shift using tilt board ▪ Anaerobic agility drills ▪ Lower extremity strengthening by machines, squat exercises or open chain leg lifts ▪ Elbow and wrist strengthening by isometric exercises or rubber tubing ▪ Flexibility exercises, especially for areas that are shown to be tight on evaluation ▪ Integration of the kinetic chain by leg and trunk stabilization on a ball, employing rotational and oblique patterns of contraction (Fig. 17.39).
- 57. Criteria for movement out of the acute phase The criteria for movement out of the acute phase include: ▪ Progression of tissue healing (healed or sufficiently stabilized for active motion and tissue loading) ▪ Passive range of motion at 66–75% of opposite side ▪ Minimal pain ▪ Manual muscle strength in non-pathological areas of 4+/5 ▪ Achievement of scapular asymmetry of less than 1.5 cm (0.6 in.) ▪ Kinetic chain function and integration.
- 58. Recovery phase The goals of the recovery phase are: 1. Normal active and passive shoulder and glenohumeral range of motion 2. Improved scapular control 3. Normal upper extremity strength and strength balance 4. Normal shoulder arthrokinetics in single and then multiple planes of motion 5. Normal kinetic chain and force generation patterns.
- 59. 1. Normal range of motion Normal active and passive shoulder and glenohumeral range of motion is achieved by: ▪ Active-assisted motion above 90° of abduction with wand ▪ Active-assisted, then active, motion in internal and external rotation with scapula stabilized so that glenohumeral rotation is normalized without substitution movements from the scapula.
- 60. 2. Scapular control- Scapular control is improved by: ▪ Scapular proprioceptive neuromuscular facilitation patterns ▪ Closed chain exercises at 90° of fl exion, 90° of abduction, scapular retraction/protraction and scapular elevation/depression (Fig. 17.32) ▪ Modified push-ups (Fig. 17.34b) ▪ Regular push-ups ▪ Ball catch and push exercises (Fig. 17.37) ▪ Dips ▪ — clock ▪ — low row ▪ — lawn mower
- 61. 3. Upper extremity strength and strength balance Normal upper extremity strength and strength balance is achieved by: ▪ Glenohumeral proprioceptive neuromuscular facilitation patterns ▪ Closed chain exercises at 90° of flexion then 90° of abduction, using the glenohumeral depressors and glenohumeral internal/external rotators ▪ Forearm curls ▪ Isolated rotator cuff exercises ▪ Machines or weights for light bench presses, military presses and pull-downs. The resistance should initially be light, then progress as strength improves. Emphasis is placed on proper mechanics, proper technique and joint stabilization.
- 62. 4. Normal shoulder arthrokinetics Normal shoulder arthrokinetics is achieved by: ▪ Range of motion exercises with arm at 90° of abduction—this is the position where most throwing and serving activities occur; the periarticular soft tissues must be completely loose and balanced at this position ▪ Muscle activity at 90° of abduction—normal muscle fi ring patterns must be re- established at this position, both in organization of force generation and force regulation patterns, and in proprioceptive sensory feedback; closed chain patterns are an excellent method to re-establish the normal neurological patterns for joint stabilization ▪ Open chain exercises, including mild plyometric exercises, which may be built upon the base of the closed chain stabilization to allow normal control of joint mobility.
- 63. 5. Normal kinetic chain and force generation Normal kinetic chain and force generation patterns are achieved by: ▪ Normalization of all inflexibilities throughout the kinetic chain ▪ Normal agonist–antagonist force couples in the legs using squats, plyometric depth jumps, lunges and hip extensions ▪ Trunk rotation exercises with medicine ball or tubing ▪ Integrated exercises with leg and trunk stabilization, rotations, diagonal patterns from hip to shoulder, and medicine ball throws ▪ Rotator cuff strength of 4+/5 or higher ▪ Normal kinetic chain function.
- 64. Functional phase The goals of the functional phase are: ▪ To increase power and endurance in the upper extremity ▪ To increase normal multiple-plane neuromuscular control— locally, regionally and in the entire kinetic chain ▪ Instruction in rehabilitation activities ▪ Sport-specific activity.
- 65. 1. Power and endurance in upper extremity Power is the rate of doing work. Work may be done to move the joint and the extremity or it may be done to absorb a load and stabilize the joint or extremity. Power has a time component and, for shoulder activity, quick movements and quick reactions are the dominant ways of doing work. These exercises should, therefore, be done with relatively rapid movements in planes that approximate normal shoulder function (i.e. 90° of abduction in shoulder, trunk rotation and diagonal arm motions, rapid external/internal rotation).
- 66. The exercises include: ▪ Diagonal and multiplanar motions with rubber tubing (Fig. 17.36), light weights, small medicine balls and isokinetic machines ▪ Plyometrics—wall push-ups (Fig. 17.34a), corner push-ups, weighted ball throws and tubing. Tubing exercises may be used to mimic any of the needed motions in throwing or serving. Medicine balls are very effective plyometric devices. The weight of the ball creates a prestretch and an eccentric load as it is caught. It also creates a resistance for contraction forces, demanding a powerful agonist contraction to propel it forward.
- 67. 2. Increase multiple-plane neuromuscular control The force-dependent motor firing patterns should be re-established. No subclinical adaptations, such as ‘opening up’ (trunk rotation too far in front of shoulder rotation), three-quarter arm positioning on throwing or excessive wrist snap should be allowed. Help in this area can be obtained by watching preinjury videos or by using a knowledgeable coach in the particular sport. Special care must be taken to integrate all of the components of the kinetic chain completely to generate and funnel the proper forces to and through the shoulder.
- 68. 3. Rehabilitation The athlete who is injured while playing a sport will most often return to the sport with the same sports demands. The body should be healed from the symptomatic standpoint and should be prepared for resuming the stresses inherent in playing the sport. The aim of rehabilitation is to improve: ▪ Flexibility—general body flexibility, with an emphasis on sport- specific problems (shoulder internal rotation and elbow extension in the arm, low back, hip rotation and hamstrings in the legs)
- 69. ▪ Strength—appropriate amounts and locations of strength for force generation, trunk rotation strength for sport-specific activities (quadriceps/ hamstring strength for force generation, trunk rotation strength, strength balance for the shoulder) ▪ Power—rapid movements in appropriate planes with light weights ▪ Endurance—mainly anaerobic exercises due to short duration, explosive and ballistic activities seen in throwing and serving. Th ese exercises should be based on the periodization principle of conditioning.
- 70. 4. Sport-specific activity ▪ Functional progressions of throwing or serving must be completed before full completion is allowed. These progressions will gradually test all of the mechanical parts of the throwing or serving motion. ▪ Very few deviations from normal parameters of arm motion, arm position, force generation, smoothness of all of the kinetic chain and pre-injury form should be allowed as most of these adaptations will be bio mechanically inefficient. ▪ The athlete may move through the progressions as rapidly as possible.
- 71. Criteria for return to play The criteria for return to play include: ▪ Normal clinical examination ▪ Normal shoulder arthrokinetics ▪ Normal kinetic chain integration ▪ Completed progressions.
- 72. Thank You