Shoulder Rehabilitation -- Part II

Tendinitis

By Warren Hammer, MS, DC, DABCO

The functional examination will reveal pain and adequate strength on resisted testing of the particular tendon or musculotendinous area. Passive stretching of that tendon will also elicit pain.

The area of involvement will be painful on palpation. Age of the patient is important because in the 18 to 35-year-old population, especially in the overhand throwing athlete, shoulder tendinitis is usually related to an underlying instability, while the over 35-year-old group is usually more related to degenerative processes.¹ The relocation test² will usually indicate an accompanying instability which must be considered to prevent recurrent tendinitis.

The goal of rehabilitation in tendinitis is to create healing scar tissue along the normal lines of stress, rather than an excessive fibrotic cross-linkage that will result in abnormal function. We also, as stated in the previous article (Part I), want to establish normal joint mobility and normal balance between the shoulder force couples.

Initially, we are interested in reducing the inflammation with ice (no longer than 20 minutes at a time) or modalities. In the acute state an almost passive pendulum type or assistive passive exercise can be used. The pendulum exercise consists of a patient leaning over a table with the normal arm allowing the injured arm to hang straight down and move in a counterclockwise and clockwise position and then in a flexion and extension motion. A patient should do 5 sets of 20 repetitions. If the patient is unable to contract their own muscle, electrical stimulation may be necessary. Gradual increase in exercises from isometric to isotonic in different ranges of motion are used within the painless or slightly painful range. Isometric exercises are needed only in the early stages since they lose their benefit when full range of dynamic motion is possible.³ No strengthening to increase bulk should be used until a full painless range of motion and full accessory joint play motion is established. These bulk muscles are the pectoral, deltoid, and scapulothoracic rotators. Shoulder shrugs with weights are for the upper trapezius, push-ups for the serratus anterior, and chin-ups for the latissimus dorsi.

Since the cuff muscles are considered endurance muscles, exercises of low weights (no more than five pounds) and high repetition are recommended or the larger muscles will take over and diminish the specific effect on the rotator muscles.⁴ Each muscle of the rotator cuff should be strengthened individually. Surgical tubing exercises in all the planes including diagonal planes should be used. The use of surgical tubing allows the input of eccentric type exercise. If exercises that reach 90 degrees elevation aggravates, then do not force the patient to work through that range since the subacromial space may still be congested or impinged. Along with strengthening, stretching of the shoulder should take place in all of the cardinal planes, but again, not if pain is produced. It has been found that people with an impingement syndrome often have posterior capsular tightness and relative weak external rotators which may require rehabilitation.⁵ Isokinetic exercise (fixed speed and accommodating resistance) using Cybex is an excellent way to increase strength.

It is recommended⁶ that since dynamic caudal glide (use of internal and external rotators) of the humerus is necessary for abduction to take place, that exercises be carried out in a specific sequence. For example, if the supraspinatus tendon is the principle lesion, then internal and external rotation strengthening should be done first, then flexion and extension, and finally abduction and adduction. Total evaluation of the spine and whole upper and lower extremity, of course, is necessary for complete rehabilitation.

An excellent source for rehabilitative exercises is available for a small fee from American Sports Medicine Institute, P.O. Box 550039, Birmingham, Alabama 35255-0039. They're titled, "Preventive & Rehabilitative Exercises for the Shoulder and Elbow."

Next month, Shoulder Rehabilitation, Part III will deal with shoulder instability and hypomobility rehabilitation.

References

1. Jobe, F. W.; Bradley, J. P. "The Diagnosis and Nonoperative Treatment of Shoulder Injuries in Athletes." Clin in Sports Med 1989; 8(3): pp 419-438.
2. Hammer, W. Functional Soft Tissue Examination and Treatment by Manual Methods: The Extremities. Gaithersburg, Maryland, Aspen Publishers 1991.
3. Ellenbecker, T. S.; Derscheid, G. L. "Rehabilitation of Overuse Injuries of the Shoulder." Clin in Sports Med 1989; 8(3): 583-604.
4. Carson, W. G. "Rehabilitation of the Throwing Shoulder." Clin in Sports Med 1989; 8(3): 657-690.
5. Warner, J. P.; Micheli, L. J., Arslanian, L. E., et. al. "Patterns of Flexibility, Laxity, and Strength in Normal Shoulders and Shoulders with Instability and Impingement." Amer J of Sports Med 1990; 18(4): 366-375.
6. Davies, G. J. A Compendium of Isokinetics in Clinical Usage. LaCrosse, W. I. S & S Publishers 1984.