Table 1 Phased Criteria for Progression of Therapeutic Exercise
Phase I: Weeks 0–2 No activities that cause pain > 3/10. | Goal: Decrease inflammation and pain Goal: Improve glenohumeral and scapulothoracic ROM Goal: Address soft tissue restriction as it relates to postural positioning (i.e. Pectoralis Minor and Posterior Capsule) Goal: Improve scapular neuromuscular control | Sample activities may include: PROM and/or AAROM activities to address range of motion deficits; Pectoralis Minor stretch on foam roll, cross body adduction stretch, thoracic mobilization on foam roll, postural corrective exercises, scapular setting with ROM activities in supine and progressing to standing; resisted scapular retraction; resisted scapular depression; resisted serratus anterior activities Criteria to progress to Phase II: - Demonstration of proper postural alignment with scapular setting - minimal upper trap activation, no scapular winging, or, if winging is present it must be asymptomatic with negative retraction and assistance tests - Able to achieve full pain free passive flexion in supine. - 80 % active flexion against gravity - worst pain 5/10 or less during normal ADLs |
Phase II: Weeks 3–5 Progress from AAROM to AROM in progressively gravity dependent positions. Closed chain exercises, resistance exercises below 90 degrees elevation, and stabilization exercises. | Goal: full pain free AROM in all planes with good mechanics Goal: Increase strength/motor control of scapular and rotator cuff muscles for active use of arm | Sample activities may include: 90/90 Pectoralis Minor stretch, sleeper stretch, AROM activities with focus on proper movement pattern; prone mid trap and lower trap strengthening; resisted periscapular strengthening; resisted rotator cuff strengthening below shoulder height; closed chain stabilization activities with progressive weight bearing as long as scapula is stable and not winging under load. Criteria to progress to Phase III: - full pain free AROM shoulder flexion with symmetric mechanics and no or asymptomatic scapular dyskinesia - 5/5 MMT of scapular and rotator cuff musculature or within 10 % of uninvolved upper extremity as measured with HHD |
Phase III: Weeks 6–8 Education to perform functional exercises maintaining postural awareness and scapular stabilization. Advance rotator cuff and scapular strengthening exercises. | Goal: Normalize rotator cuff and scapular strengthening; restore pattern-generated movements Goal: maintenance of posture and alignment to become subconscious Goal: Integrate kinetic chain activities pertinent to sport/work demands Goal: Return to normal function with ADLs and recreational activities | Sample activities may include: strengthening and stabilization activities above 90 degrees; diagonal patterns; dynamic activities to improve performance during functional and/or athletic tasks; core, balance, and endurance activities needed for work/sport Criteria for discharge: - Maintain full and pain-free AROM in all planes in seated or standing position with good mechanics (no or asymptomatic scapular dyskinesia) - Demonstration of 5/5 MMT or 10 % margin as measured with HHD for shoulder flexion, abduction, rotator cuff, scapular stabilizing muscles - MCIDDIC of outcome measures will demonstrate significant change in function - Patient demonstrates independence with home exercise program and strategies for self-management of symptom resolution should they arise |