Shoulder injury rehabilitation exercises - the importance of a tailor-made rehabilitation programme

The purpose of this case study is to demonstrate the key requirements of any rehabilitation process – first, that it is vital to ensure that once an accurate diagnosis has been made, the rehabilitation programme is individually tailored to the patient and their sport. Second, the importance of educating both the patient and their coaches cannot be understated. This illustration of a shoulder injury will also provide some good examples of both low and high-level shoulder rehabilitation exercises.

Meet Kim, a 15 year-old state-level tennis player, who almost had to be forced by her coach to attend her initial physiotherapy consultation. She didn't see the need because her shoulder 'only hurt when she served'! When asked how it affected her serve, she said that she couldn't serve as hard, and that sometimes she just didn't practise at all when it hurt. This response immediately suggested to me that to gain Kim's compliance in any sort of rehabilitation programme, education was going to be vital.

Assessment
The initial assessment was quite straightforward. Sharp pain had been present on serving for two months in the anterior superior region of her right shoulder, when she made contact with the ball. Overall, the pain had been progressively getting worse. Pain was reproduced at end of range flexion and on an impingement test (horizontal flexion, then internal rotation of her shoulder). Her humerus was sitting anteriorly and she also demonstrated slight capsular laxity anteriorly on her right shoulder with ligament testing and gently gliding the head of humerus forward in sitting. Internal rotation was decreased by approximately 45 degrees on her right compared to her left, suggesting significant posterior capsule and external rotator cuff tightness. Her scapular control was very poor through abduction, especially on sustaining the 'stop sign' position. In summary, we can conclude that the supraspinatus tendon was 'impinging' (pinching; getting inflamed) under the bony arch of the acromion process, a situation exacerbated during serving.

Ask the athlete
An important, but often-overlooked, aspect of assessing an athlete's injury, is asking the athlete whether or not any technical changes have been made/ are being made in their training. Often technical changes can result in injury because the patient cannot cope with the physical requirement of the technique. If no real changes are being made, then it may help to see if the patient can explain the aspects of their technique they are working on. This could clue you in to the type of injury and what you may need to work on. In this case, Kim had been working on the same thing for the last six months – trying to keep her elbow high as she reached the cocking position on her serve. In tennis or throwing, the shoulder should be abducted to approximately 90 degrees at the end of the cocking phase. Kim was letting it drop well below this. But no matter how much she was cued by her coach or how hard she tried, Kim couldn't do it, and no doubt the effectiveness of her serve was being affected because of this lack of control and strength.

Treatment
Our first treatment session consisted of trigger points to infraspinatus and teres minor. (For a fuller explanation of trigger points, refer to SIB 10, June 2001). This allowed the humeral head to sit back in a better position and to improve her range of internal rotation. Taping the humeral head posteriorly then reinforced a better shoulder posture. This was obviously not going to remedy a chronic shoulder problem, but it served a very important purpose: it proved to Kim that we could significantly decrease her pain.

She could now roll her arm over in a service motion without pain – a feeling she had not had in a while! In addition, it began to teach her where the correct 'normal' position for her shoulder should be: much less rounded and closer to a 'neutral position' – the centre of rotation for her 'ball and socket' joint. Kim then realised how much better she could feel when serving on court. It also gave her confidence in me, which was vital if we were to have a good outcome.

The rest of the session consisted of further education – thoroughly explaining to Kim her injury and using some 'scare tactics'. For Kim, that meant giving her some examples of other tennis players who had had similar injuries as juniors but were not handled properly and had subsequently not had continued success in the sport. This definitely had an impact on the keen young tennis player. At following sessions, she presented to the clinic with her folder in which she kept her list of exercises and reassured me that she had been doing her exercises religiously. Compliance was no longer a problem.

A lack of shoulder awareness
At the same time as I was beginning to see Kim, I had a couple of other patients who had presented with similar problems. I put them all on similar exercises – teaching them to activate their lower trapezius muscle for scapula control and to activate subscapularis to maintain a better posture in the shoulder. This was to form the basis for the range of scapula and rotator cuff control exercises to follow. Kim was demonstrating a real lack of awareness around her shoulder – she didn't seem to have much idea how to do any of the exercises properly. I knew that she had very poor scapula control when abducting her arm, but I hadn't realised how bad it was until I decided to take a look at her holding her arm in the cocking position for a serve. She couldn't hold her arm without shaking and letting her elbow drop. I found it difficult to believe that an elite junior tennis player couldn't perform such a simple task. No wonder she couldn't maintain a good elbow position through cocking phase when serving!

A step back first
Her rehabilitation programme had definitely to take a step back before it could go forward. This clearly illustrates the need to adapt any rehabilitation to the individual, and not to make any assumptions about their skill base. From that point on, we kept Kim's exercises very simple. They included circles with the ball on the wall with the shoulder flexed and abducted to 90 degrees for some basic body awareness, supine position with the shoulder flexed to 90 degrees and pushing to the ceiling (low level serratus anterior exercise) and even just slowly taking her arm back through the wind-up phase of her serve and holding it in the cocking position for 5 sec. Very basic, certainly, but she struggled even to do this at the beginning.

Once some basic awareness was gained, Kim began to progress quite well. Lower trapezius setting exercises were taught in prone initially with the arm resting by her side, and then progressed to sitting and standing. When teaching lower trapezius exercises in prone, begin by asking the patient to completely relax and then lift their shoulder girdle off the bed and in a slight caudal direction (towards the feet). When the correct position is found, ask the patient to gently hold it there by trying to tighten up the muscles around the lower trapezius area. Ensure that they are not using their latissimus dorsi, rhomboids or levator scapulae muscles to do the movement. This is a very helpful technique if the patient is struggling to grasp scapula setting in other positions, just as Kim was.

Internal and external rotation exercises were done with scapula setting, first in a neutral shoulder position with elbow flexed to 90 degrees and then progressed to 90 degrees shoulder abduction (cocking position for serve). The use of a theraband and hand weights for resistance to internal and external rotation were added as Kim's strength and control improved.

The subscapularis muscle plays an important role in stabilising the shoulder joint anteriorly. In athletes who throw, or in sports like tennis or volleyball where the technique is very similar to throwing, there are large forces applied to the anterior stabilising structures of the shoulder. It is therefore important to train the athlete in how to activate the subscapularis muscle to decrease the load on the passive structures that limit anterior humeral head translation, and incorporate it into the rehabilitation programme.

A subscapularis exercise
Kim benefited greatly from this simple exercise to train subscapularis activation: it can be done in prone with the shoulder abducted to 90 degrees and forearm hanging over the edge of the bed. A rolled towel is placed under the biceps to lift the shoulder off the bed. The anterior aspect of the shoulder is then drawn away from the bed without retracting the scapula, and held. To progress this exercise, add external rotation while holding the shoulder position. As athletes improve their level of control, they will be able to hold their humeral head position while getting to end-of-range external rotation.

Serratus anterior exercises were progressed to weight bearing to place more demand on this scapula stabiliser. This was done on all fours by keeping the arms straight and pushing the mid thoracic spine towards the ceiling and holding. This movement requires serratus anterior to protract the scapula and rotate it upwards. Then push the chest to the floor and set the scapula to complete one repetition.

A high-level scapula setting exercise was also added towards the end of the rehabilitation process. This involved setting the scapula with the arm at the contact position for a serve and moving the shoulder through the contact position and slightly beyond. Internal rotation of the shoulder can be added while doing this movement to make the exercise even more functional. A theraband can be added for resistance to increase the demand on the control muscles. Another interesting idea that works with some athletes, is to squeeze a tennis ball while they are going through some of these exercises – this enhances the co-contraction of the rotator cuff via overflow from the forearm muscles.

Beware of fatigue in the rotator cuff
Finally, dynamic exercises with the theraband in the cocking position and contact position were added with close supervision to ensure control. At late cocking phase and early acceleration phase, the internal rotators are contracting eccentrically to decelerate external rotation before they explode into concentric contraction as the racquet accelerates. The theraband is very useful to replicate this stretch shortening cycle that occurs when serving. The speed of these exercises should be progressed as control allows and should be done initially with a low number of repetitions to a set so that fatigue in the rotator cuff doesn't lead to re-injury.

Kim's rehabilitation process emphasises the need to individualise functional programmes. She couldn't be treated in the same way as most other patients. Her programme had to be adjusted to allow for her lack of awareness around the shoulder girdle. She definitely benefited from the initial exercises, which were designed purely to develop body awareness. It is also important to remember that every sport places different demands on the shoulder. This is why every rehabilitation programme should be kept functional to the sport. Late-stage rehabilitation can be made particularly functional and it always seems to make more sense to the patient, which helps with compliance.

Keep in touch with the coach
Being in constant contact with Kim's coach was another vital requirement for her rehabilitation. Although the coach's technical cues for Kim's serve had been exactly right, physically they were too demanding for her. After I explained the situation, the coach then fully understood that until her strength returned, she wasn't going to be able to hold the correct position through the cocking phase. This then gave them both an opportunity to focus on other areas of her game in the meantime. After three months, Kim reported that it was much easier to hold a good position through the cocking phase and also that she felt much stronger on her serve.

The complete rehabilitation process with Kim took approximately five months. However, she was serving without pain under tournament conditions in about 2 months. It is difficult to get juniors to follow through with the complete rehab when they are not suffering any pain. This is where education becomes so important and, in this particular case, I think the scare tactics helped!

Sean Fyfe