Shoulder Rehabilitation: Equipment

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Julie Eaton
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1 /85/ $02.00/0 THE JOURNAL OF ORTHOPAED~C AND SPORTS PHYSICAL THERAPY Copyright by The Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association Shoulder Rehabilitation: Equipment - - Modifications ANDREW R. EINHORN, PT, ATC* A systematic approach toward weight-training equipment is needed in the physical therapy clinic and in establishing guidelines for the home program. Many different types of exercise equipment are currently being used. With an aggressive patient population, the physical therapist should become familiar with the various types of equipment now available in many of the exercise centers. This article provides equipment modifications based on various shoulder joint pathologies. Exercise alternatives will be discussed. Patient education regarding use of exercise equipment should be provided in the clinic, leading to an independent therapy program at the health club. The physical therapist should be in a position to provide the necessary education to help prevent further shoulder joint dysfunction. The shoulder joint has many articulations, examples of which are the glenohumeral, acromioclavicular, sternoclavicular, as well as the physiological scapulothoracic joint. Interplay between these joints must occur smoothly for complete unincumbered movement. During the first 15-45' of glenohumeral abduction, the scapula may move medially or laterally on the chest wall as it seeks a position of stability.' Various authors indicate this range to be from 0-30' of abduction.' After 45O of glenohumeral abduction the scapula moves laterally, anteriorly, and superiorly. Scapular Rotation and Tilt Rotation of the scapula involves concomitant movement from the sternoclavicular and acromioclavicular joints. Thus, out of the total of the approximately 60' that scapular movement contributes to elevation of the arm, about 30' occurs at the sternoclavicular joint.6 The remaining 30' occurs from the combined effects of clavicular rotation, and the movement that occurs at the acromioclavicular joint.' Clavicular Movement The clavicle protracts 30, elevates 30, and rotates backward around its long axis This movement begins early and is almost complete during the first 90' of elevati~n.~.~.'~ Above 90' of elevation, clavicular rotation oc~urs.~.~,' If viewed from its inferior or superior surface, the clavicle has a shape resembling a crank.5q8 Clavicular rotation in a crankshaft fashion takes place through about ,7.8 This axial rotation is indeed a unique arrangement, for it permits the scapula to remain intimately attached to the clavicl'e by allowing a relative elongation of the coracoclavicular ~igaments.~~' Acromioclavicular Joint Movement of the acromioclavicular joint occurs early in abduction and again when the arm is elevated above 135'.5.8 Movement Summary In summary, of the total 60' of scapular motion, roughly 30' occurs at the sternoclavicular joint, with the remaining 30' resulting from the rotation of the clavicle as well as movement at the acromioclavicular joint. Scapulohumeral Rhythm For each 15' of humeral abduction, 1 O0 occurs * Assistant Director of Physical Therapy, Southern California Center for Sports Medicine, 2760 Atlantic Ave., Long Beach, CA at the glenohumeral joint, and 5' of rotation and

2 248 EINt iorn JOSPT Vol. 6, No. 4 tilt of the scapula on the thorax.= This smooth and rhythmic motion is often referred to as scapulohumeral rhythm and only occurs after the initial 30-45' of humeral abduction. Coracoacromial Arch Active abduction is possible to AS elevation continues above 90, the greater tuberosity approaches the coracoacromial arch.' With the humerus internally rotated, only about 60' of abduction can occur without impingement of the greater tuberosity against the coracoacromial arch.4 As the humerus undergoes external rotation, an additional 30' can be gained. IMPINGEMENT SYNDROME Three possible types of impingement have been discussed by Penny and Welsh.'' Impingement of the critical watershed area of the supraspinatus tendon beneath the coracoacromial arch, impingement of the long head of the biceps, and bony impingement of the greater tuberosity against the acromion occurs when there has been superior humeral head migration. There are various exercise machines designed for increasing deltoid strength. In doing so, subacromial tissues are at risk. For the patient who has suffered from irritation of these tissues, certain exercises should be avoided. Equipment designed to do "lateral raises," or humeral abduction with internal rotation, can cause further inflammation to the subacromial bursa, rotator cuff, or bony impingement of the greater tuberosity into the coracoacromial arch (Fig. 1). The same thing can occur by using dumbbells. To modify this exercise with dumbbells, as abduction occurs the humerus should be externally rotated to provide more space under the coracoacromial arch (Fig. 2). The patient who suffers from impingement, tendinitis, or an unstable long head of biceps, could cause further irritation with the above related technique. Other exercises that bring the patient into the abducted internally rotated position (as seen in Fig. 3), can also irritate subacromial tissues. If the seat height is too low, further stress will be added to these tissues. Equipment modification for this particular exercise would include adjustment of the weight stack, raising the top plate, and replacing the stack pin (Fig. 4). Care must be taken so that the pin hole and weight stack pin are in perfect alignment before taking your hand off the top plate. A pin that has a safety locking device that will not slip out should be used. After completing the exercise, the manufacturer's designed Fig. 2. Mid-position during lateral raises, using external rotation with shoulder abduction. Fig. 1. "Lateral raises," abduction with internal rotation off the Nautilus Double Shoulder Machine. This motion can cause possible subacromial irritation. Fig. 3. The Nautilus Double-chest Machine, showing the starting position; abduction with internal rotation. Subacromial tissues may be at risk.

3 JOSPT JanlFeb 1985 SHOULDER REHABILITATION 249 Fig. 4. The weighi stack pin modification. Top plate on the Nautilus weight stack is raised 5-12 holes before the pin is placed back into the weight stack. Care should be taken to hold the top plate when lowering the stack back to the manufacturer 's starting point. starting point should be assumed so that the next person using the piece of equipment will not injure his/her fingers. ANTERIOR SUBLUXATION/DISLOCATION It is well documented that as the humeral head subluxes, or dislocates, anteriorly out of the glenoid cavity there is some degree of injury to the anterior capsular mechani~m.'.~ Detachment of the anterior portion of the capsule and glenohumeral ligaments from the anterior aspect of the neck of the scapula, detachment of the anterior inferior labrum, and sometimes a bony fragment from the glenoid, a Bankart lesion, can oc~ur.~~~~" Defects in the posterolateral aspect of the humeral head, a Hill-Sachs lesion, have been de- ~cribed.~ The patient who has suffered anterior sublux- ation/dislocation should avoid stretching and stressing soft tissue structures in uncontrolled manners. Any type of exercise machine that forces the glenohumeral joint into an abducted externally rotated position, or hyperflexion external rotation, should be avoided.l6 Figure 5 shows a machine commonly used in health clubs, a "pullover" type exercise which stresses important anterior soft tissue structures. Modification of this exercise with the weight stack pin technique should be used. Care should also be taken to avoid disengaging the "chain or cable" from the pulley system. Another common exercise designed to increase shoulder adduction strength is "behind the neck pull downs." Stress is placed on the anterior shoulder capsule and surrounding anterior muscles. Working in the externally rotated position should be avoided (Fig. 6). Modification of this exercise (Fig. 7) would have the patient pulling the bar down in the front of the body, as opposed to behind the neck. This will take extra stress off the anterior capsule and surrounding structures. Figure 8 shows another chest-related exercise stressing the patient into forced external rotation and abduction. The weight stack pin modification can be used to decrease anterior shoulder stress. The Nautilus (Nautilus, Deland, FL) 10-degree Chest Machine can be used with the weight stack pin modification; the patient starts in the internally rotated position (Fig. 9). Rowing-type exercises should be conducted with internal rotation (Fig. 1 O), while avoiding external rotation (Fig. 11). Augmentation of lower extremity exercises may also be needed. The "bar squat" can also stress the anterior shoulder (Fig. 12). Alternatives would include hack squats, leg press, dumbbell lunges, Universal (Universal Gym, Cedar Rapids, IA) Squat Machine, Nautilus squat (Fig. 13). Gluteal strengthening can Fig. 5. Here the patient is forced into hyperflexion, abduction, and some degree of external rotation off the Nautilus pull-over machine. Patients with anterior instability should use equipment modification with this exercise.

250 EINHORN JOSPT Vol. 6, No. 4 Fig. 6. Behind the back pull-downs, moving the patient into abduction and external rotation can stress anterior shoulder structures. Fig. 8.

4 250 EINHORN JOSPT Vol. 6, No. 4 Fig. 6. Behind the back pull-downs, moving the patient into abduction and external rotation can stress anterior shoulder structures. Fig. 8. Patient is working on a Chest Machine that forces the glenohumeraljoint into passive abduction and external rotation. Use the pin modification technique to decrease force loads on the anterior shoulder structures. be conducted on the Universal Total Hip Machine or a Nautilus Hip/Back Machine. POSTERIOR INSTABILITY Recurrent posterior glenohumeral instability has been reported as the result of trauma in the adducted and internally rotated p~sition.'~~'~ Posterior subluxation has also resulted from injury with the athlete in a forward flexed and abducted shoulder position.1 Exercises in the gym that should be avoided would include bench press on machines or free weights. Even push-ups could be dangerous with a posterior instability. Avoid pulley exercises that cross the body in a pattern of adduction and internal rotation. This would be similar to the follow-through in throwing. BURSITIS PATIENT Exercises that cause the humeral head to migrate superiorly up into the subacromial structures should be avoided (Fig. 14). For some pa- Fig. 7. This patient is working on front pull-downs, using the Nautilus pull-down machine. This exercise takes stress off anterior shoulder structures that are important for stability.

JOSPT JanlFeb 1985 SHOULDER REHABILITATION 251 Fig. 9. The pin modification technique is used here on the 10- degree Nautilus Chest machine. Fig. 12.

5 JOSPT JanlFeb 1985 SHOULDER REHABILITATION 251 Fig. 9. The pin modification technique is used here on the 10- degree Nautilus Chest machine. Fig. 12. The bar squat can accentuate the externally rotated position. If the bar is held in the upper thoracic region, additional stress will be added to the anterior shoulder. Fig. 10. Patient is working on the Nautilus Rowing Machine, conducted with shoulder internal rotation. Fig. 11. Nautilus Rowing done incorrectly with shoulder external rotation. Use the technique in Figure 10 for any patient suffering from anterior instability. tients heavy tricep exercises can cause irritation to the subacromial bursa (Fig. 15). ROTATOR CUFF PATHOLOGY Heavy shoulder joint abduction exercises designed to increase deltoid strength are not en- Fig. 13. The Nautilus Multi-purpose Machine can be used safely for squats. couraged for the injured rotator cuff, with or without repair. This would include exercises with dumbbells or machines (Fig. 16). These exercises increase force loads on the rotator cuff, similar to the full-squat increasing the patella joint reaction force in the knee. Caution should be used when exercising the rotator cuff at 90' of shoulder abduction. Damage to subacromial tissues and an increase in shoulder

6 252 EINHORN JOSPT Vol. 6, No. 4 ~ig. 14. patient is working On hip fl~for strength, but the humerus is forced up into the acromion. Fig. 16. Overhead presses conducted on machines Or free weights should be avoided by patients with rotator cuff dysfunction. Fig. 15. Subacromial structures may be stressed with the triceps extension exercise seen here conducted off the Universal Pull-down Machine. Fig. 17. The patient is working from a low pulley, strengthening the subscapularis and other shoulder internal rotators. Fig. 18. Posterior cuff strengthening from a low pulley, conducted in the neutral shoulder position. impingement symptoms are more likely to occur at this position. Athletes who use the overhead throwing pattern and who are post-rotator cuff rotator cuff from the neutral position. The subrepair, post-rotator cuff repair with decompres- scapularis can also be exercised from the neutral sion, or who have been diagnosed as having an position by working on internal rotation (Fig. 17). impingement syndrome, should strengthen the By using external rotation, the infraspinatus and

JOSPT JanlFeb 1985 SHOULDER REHABILITATION teres minor can also be strengthened from the neutral position (Fig. 18); all can be done from a low pulley-type machine.

7 JOSPT JanlFeb 1985 SHOULDER REHABILITATION teres minor can also be strengthened from the neutral position (Fig. 18); all can be done from a low pulley-type machine. OTHER EQUIPMENT MODIFICATIONS Almost any bench press type machine can be modified using the weight stack pin technique to adjust the starting position. Modifications can be made to strengthen the important serratus anterior muscle (Fig. 19). Fig. 19. End position of serratus anterior strengthening. The patient is working on a Universal Gym Bench Press Machine with pin modification. SUMMARY With an aggressive patient population, exercise equipment guidance and patient education is needed during the rehabilitation phase so that further dysfunction can be avoided once the patient leaves the physical therapy clinic. The author would like to acknowledge the assistance of Sue Ellen Lawson and Tim Simon in the typing and production of this material. REFERENCES Bankart AB: The pathology and treatment of recurrent dislocation of the shoulder joint. Br J Surg 26:23-29, 1983 Bland JH, Merrit JA, Boushey DR: The painful shoulder. Semin Arthritis Rheum 7: Bost FC, lnman VT: The pathological changes in recurrent dislocation of the shoulder. J Bone Joint Surg 24: , 1942 Cailliet R: Shoulder Pain, pp Philadelphia: FA Davis, 1966 lnman VT, Saunders M. Abbott LC: Obse~ation on the function of the shoulder joint. J Bone Joint Surg 1:l (Old Series) Kessler RM, Hertling D: Management of Common Musculoskeletal Disorders, Physical Therapy Principles and Methods. Philadelphia: Harper and Row, 1983 Kummel BM: Spectrum of lesions of the anterior capsular mechanism of the shoulder. Am J Sports Med 7: ,1977 Lucas DB: Biomechanics of the shoulder Joint. Arch Surg 107: , 1973 McGlynn FJ, Caspari RB: Arthroscopic findings in the subluxating shoulder. Clin Orthop 183:73-78,1984 Norwood LA, Terry GC: Shoulder posterior subluxation. Am J Sports Med 12:25-30,1984 Pappas AM, Gross TP. Kleinman PK: Symptomatic shoulder instability due to lesions of the glenoid labrum. Am J Sports Med 11 : Penny JN, Welsh RP: Shoulder impingement syndromes in athletes and their surgical management. Am J Sports Med 9:ll-15, 1981 Saha AK: Recurrent Dislocation of the Shoulder, Ed 2. New York: Thieme-Stratton Inc., 1981 Saha AK: Mechanism of shoulder movements and a plea for the recognition of "zero position" of the glenohumeral joint. Clin Orthop 173:3-10, 1983 Samilson RL, Prieto V: Posterior dislocation of the shoulder in athletes: Clin Sports Med 2: , 1983 Strauss MB, Wrobel W. Nef RS. Cady GW: The shrugged-off shoulder: A comparison of patients with recurrent shoulder subluxations and dislocations. Phys Sportsmed 11:85-97, 1983

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