Shoulder injures

and management
Dr Riafat mehmood 1
Assistant professor
Faculty of MSPT SPT
• DISLOCATION OF THE GLENOHUMERAL JOINT.
• SHOULDER INSTABILITY
• FRACTURE OF THE CLAVICLE
• KINESIO TAPING
• NON-OPERATIVE REHABILITATION FOR
SHOULDER

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 DISLOCATION OF THE
GLENOHUMERAL JOINT

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 The shoulder dislocation (more accurately termed
a glenohumeral joint dislocation) involves separation of
the humerus from the glenoid of the scapula at
the glenohumeral joint.
1. anterior shoulder dislocation (95% of shoulder dislocations)
2. posterior shoulder dislocation
3. inferior shoulder dislocation
 younger: 20-30 years (male to female ratio of 9:1)
 older: 60-80 years (female to male ratio of 3:1

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Clinical presentation

 Patients present with severe pain and restriction of movement

of the shoulder. 
 The majority of people who present with a shoulder dislocation
do so after trauma, e.g. sporting trauma, assault, falls.
 It is useful to determine whether the dislocation is
acute, chronic or recurrent.

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 Increased incidence in patients who have had a previous
shoulder injury, and particularly in those who have dislocated
previously.
 The process of dislocation is massively disruptive to the
labrum, joint capsule, supporting ligaments, and muscles.
 This is particularly true of anterior dislocations where there
can be an injury to the anterior capsule, anterior labrum, or
biceps tendon, or a combination.

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TYPE OF DISLOCATION

 Shoulder dislocations are usually divided according to

the direction in which the humerus exits the joint:
 anterior >95%
 subcoracoid (majority)
 subglenoid (1/3)
 subclavicular (rare)
 posterior 2-4% 
 inferior (luxatio erecta) <1%

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 Radiographic features
 A shoulder x-ray series is sufficient in almost all cases to make the diagnosis,
although CT and MR are often required to assess for the presence of subtle fractures
of the glenoid rim or ligamentous/ tendinous injuries respectively.
 Report checklist
 In addition to reporting the presence of a dislocation a number of features and
associated findings should be sought and commented upon:
 direction of dislocation
 associated fractures/injuries
 Hill-Sachs defect
 bony Bankart lesion
 proximal humeral fracture
 clavicular fracture
 acromioclavicular joint disruption
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 acromial fracture
Treatment and prognosis
 The only treatment option for a dislocated shoulder is a prompt
reduction. This is usually performed in the Emergency Department
following sedation and appropriate analgesia. A number of techniques
can be used to reduce the shoulder.
 The ease of reduction is dependent on the age and build of the patient
(younger, heavily built guys will be more difficult to reduce) and the time
that the joint has been dislocated (the longer it has been out, the more
difficult it is to get back in).
 Rest is required following dislocation, so immobilization is required:
 three weeks for younger patients (<30 years old, who have a very high
rate of recurrence)
 7-10 days in older patients. During this time gentle active motion
should be carried out to preserve range of motion .
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 As a general rule, the shorter the duration of dislocation the fewer
complications (size of Hill-Sachs defect, neurovascular compromise, etc.). 
 Early arthroscopy, labral repair and debridement may be of use, especially
in young patients with anterior dislocation in which there is a high (up to
85%) rate of recurrence.
 Shoulder dislocations can also be associated with large rotator cuff tears in
the older ages groups.
 The incidence starts to increase around age 40 and is especially high in
patients above the age of 60 .
 The major morbidity associated with untreated massive rotator cuff tears in
this age group requires a clinician to ensure actively that these injuries are
not missed.
 This can be done by clinical examination, looking for weakness in the
rotator cuff muscles or radiologically with ultrasound or MRI.
 Best outcomes are achieved with early surgical repair of the rotator cuff
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ANTERIOR SHOULDER DISLOCATION
 One of the most common traumatic sports injuries is acute
dislocation of the glenohumeral joint
 Anterior shoulder dislocation is by far the commonest type
of dislocation and usually results from forced abduction,
external rotation and extension.
 Predisposing factors
 flattened, shallow anterior/anteroinferior glenoid bony contour:
 may predispose to recurrent dislocations

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Radiographic features
 Anterior dislocations can be further divided according to
where the humeral head comes to lie:
 subcoracoid: most common
 subglenoid
 subclavicular
 intrathoracic: very rare
 In anterior dislocations, the humeral head comes to lie
anterior, medial and somewhat inferior to its normal location
and glenoid fossa.
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Treatment and prognosis
 Anterior shoulder dislocations are usually managed
with closed reduction and a period of immobilization (e.g. 6
weeks) to allow adequate capsular healing, although whether
this significantly changes the likelihood of recurrent
dislocation is not certain .
 The key to successful healing and normal eventual function
is a structured course of physical therapy aimed at reducing
muscle wasting and maintaining mobility.
 The emphasis, especially early on, is on isometric exercises,
in which the glenohumeral joint remains immobilized 

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 Surgical repair is not required for dislocation as such, but
rather to treat complications and associated injuries which
include: 
 shoulder instability due to damage to the inferior
glenohumeral ligament (IGHL) 
 Hill-Sachs defect
 Bankart lesion or other anterior glenolabral injuries
 damage to the axillary artery, or brachial plexus
 intraarticular loose body

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Posterior shoulder dislocation
 Mechanism
 Typically the humeral head is forced posteriorly in internal
rotation while the arm is abducted . In adults, convulsive
disorders are the most common cause.
  Occasionally, they can be the result of strength imbalance
within the rotator cuff muscles. Posterior dislocations may
even go unnoticed, especially in elderly patients

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Radiographic features
 Plain film series usually suffices in making the diagnosis, although
cross-sectional imaging (CT  or MRI)  is often used to assess the
presence and extent of articular surface injury (reverse Hill-Sachs
defect), glenoid injury (reverse Bankart lesion) or ligamentous
injury.

 Reporting checklist
 In addition to stating that a posterior dislocation is present, any
evidence of proximal humeral fractures or glenoid fractures should
be sought and commented on

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Treatment and prognosis
 When a posterior dislocation presents to the emergency
department, unlike anterior shoulder dislocations which are relatively
easily reduced, posterior dislocations are more problematic and
attempts at closed reduction should only be performed in
consultation with a treating orthopedic surgeon .
 Additionally, if the shoulder has been dislocated for ≥3 weeks
(particularly common in debilitated elderly patients) or if the anterior
humeral articular injury (reverse Hill-Sachs defect) involves >20% of
the articular surface, then the closed reduction is contraindicated . 
 Fortunately, neurovascular compromise is uncommon, but
associated glenolabral and capsular injuries can lead to
posterior shoulder instability 
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Inferior shoulder dislocation
 It is caused by either of the following mechanisms:
 sudden forceful arm hyper abduction
 less commonly, direct loading force on a fully abducted arm,
with an extended elbow and pronated forearm.
 The humeral head is forced against the acromion, usually
with resultant inferior glenohumeral capsule rupture
and rotator cuff disruption.

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Radiographic features
 The humeral head is displaced directly below and slightly
medial to the glenoid fossa, with the arm often in marked
abduction (luxatio erecta).
 An inferior dislocation can mimic a subcategory of
glenohumeral dislocation known as subglenoid anterior
dislocation, where the humeral head rests directly inferior to
the glenoid in the AP and lateral projections . It is
distinguished from the latter by the humeral shaft's position
parallel to the scapular spine.

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 MRI is performed post-reduction. Common findings include :
 rotator cuff tears
 injuries to the glenoid labrum
 injuries to both the anterior and posterior band of the inferior
glenohumeral ligament (IGHL)
 bone bruises or impaction fractures (Hill-Sachs defect) at
the superolateral aspect of the humeral head.

 Complications
 Inferior dislocations have a high complication rate, with
secondary osseous, soft tissue, vascular, neurological,
tendon, and ligament injuries
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KOCHER'S METHOD OF RELOCATING
A DISLOCATED SHOULDER

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 "Bendthe affected arm at 90º at the
elbow, adducted against the body;
 the wrist and the point of the elbow
can be grasped. Slowly externally
rotate between 70º to 85º until
resistance is felt;
 Lift the externally rotated upper arm
in the sagittal plane as far as
possible forwards now internally
rotate the shoulder this brings the
patient's hand towards the opposite
shoulder".
 The humeral head should now slip
back into the glenoid fossa with pain
eliminated during this process.

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MILCH TECHNIQUE

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 patient prone on a table, pillows are
placed under the pectoral muscles of the
involved shoulder, the arm is allowed to
hang freely.
 Reduction from relaxation can occur
spontaneously in this position.
 However if reduction does not occur the
elbow is then flexed to 90º, and the hand
of the affected arm is the placed over the
forearm of the surgeon, whose fingers and
thumb grasp the patients elbow firmly.
 then performs gentle longitudinal traction,
abduction and external rotation. The
therapist other hand holds the proximal
part of the patients humerus, increases
the gentle abduction and external rotation
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HIPPOCRATIC
METHOD

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 Hippocratic Method begins with the
patient supine,
 Grasps the affected side at the hand and
forearm.
 The stockinged heel of the therapist is
placed in the axilla (not pressed hard)
this acts as a fulcrum whilst the arm is
adducted.
 Potential complication can result in
damage to the axillary nerve

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SHOULDER INSTABILITY

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 Classification of Shoulder Instability

 Stanmore Triangle
 This classification helps the therapist to correctly diagnose the
instability and prioritize the treatment.
 There are three main subgroups in this classification:
 Polar 1: Shoulder instability is directly related to trauma. There is
evidence of a structural deficit in the GH joint
 Polar 2: There is evidence of structural deficit and atraumatic
instability
 Polar 3: No evidence of structural defects. Muscle patterning is
present.

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 BASED ON THE DIRECTION OF SHOULDER
INSTABILITY
 ANTERIOR INSTABILITY
 There occurs translation of the humeral head in the anterior.
direction It is the most common form of shoulder instability.

 POSTERIOR INSTABILITY
 It accounts for 2 to 5 % of instability cases. Usually, the
athletic population is affected by this type of instability who
participate in an overhead activity. Structural issues like
posterior glenoid erosion and glenoid retroversion or
deficiency of rotator interval can predispose patients to
posterior instability.
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 MULTIDIRECTIONAL INSTABILITY (ATRAUMATIC)
 There is a combination of anterior /posterior/inferior instability
at the GH joint. In many cases, this type of instability is
because of generalized laxity throughout the body. Another
cause is repetitive trauma during extremes of motion.
 Mainly the pain is during the mid ranges of shoulder ROM
which indicates main role of altered muscle activation.
Inappropriate position of the scapula can also be the reason
for pain or any other symptoms.

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 Traumatic Unidirectional Instability with
Bankart lesion (TUBS)
 ANTERIOR DISLOCATION
 This is the commonest sports injury in which acute anterior dislocation of
GH joint occurs. The arm is forced into excessive abduction and external
rotation. It damages the anterior part of the labrum (Bankart lesion).
 The patient presentation is arm adduction and internally rotated with loss of
deltoid contour. Posterior sulcus/glenohumeral void is observed. The
humeral head is palpated anteriorly. Radiographs are used to confirm the
diagnosis and rule out other bone injuries.
 One of the three following criteria has to be fulfilled in order to prescribe the
Xray :
 Age>40, first time dislocation, traumatic mechanism of injury
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POSTERIOR DISLOCATION.

It is less common than an anterior dislocation. The

cause is a fall on the outstretched hand or a direct blow
on the shoulder in internal rotation of adduction. The
Cardinal sign is limited external rotation. An X-ray of
lateral view or axillary view is necessary for diagnosis.

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 ACQUIRED SPORT-SPECIFIC
INSTABILITY
This type is commonly seen in overhead athletes when the
anterior capsule has become lax due to overuse. This is also
known as an acquired instability overuse syndrome. Clinical
features are recurrent shoulder pain while throwing, sudden
inability to throw or smash and a feels like 'dead arm', GIRD
/scapular dyskinesia /signs of labral pathology are also seen.
Apprehension /relocation tests are positive.
This condition can turn into impingement due to abnormal
translation of humeral head.

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 ATRAUMATIC

 Abnormal position or motion of the shoulder joint that leads to pain,

subluxation, dislocation and functional impairment.
 Atraumatic (non-traumatic) shoulder instability is a subclassification of
glenohumeral joint instability, encompassing those for whom trauma is
not considered the primary etiology.

 Two main types of atraumatic instabilities:

 Congenital instabilities;
 Laxity of structures in the shoulder which may be present since birth.
 Chronic recurrent instabilities
 May be seen after surgery for shoulder dislocation, due to glenoid rim
lesions.
 Over time, microtrauma can lead to instability of the glenohumeral joint.
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Clinically Relevant Anatomy 
 Glenohumeral stability depends on the combination of
various factors that can be grouped into:
 Capsulo-ligamentary or static stabilizers
 Musculotendinous or dynamic stabilizers

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Clinical Presentation
 Possible signs and symptoms of chronic/recurrent instability

 Anterior Instability

 Clicking
 Pain
 Complain of the dead arm with throwing
 Pain posteriorly
 Possible subacromial or internal impingement signs
 The patient may have a positive apprehension test, relocation test, and/or anterior
release test
 Increased joint accessory motion particularly in the anterior direction
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POSTERIOR INSTABILITY

 Possible subacromial or internal impingement

 Glenohumeral internal rotation deficit (GIRD) may be present
 Pain
 Clicking
 Increased joint accessory motion particularly in the posterior direction

MULTIDIRECTIONAL INSTABILITY

 Antero-inferior laxity most commonly presents with global shoulder pain, cannot pinpoint to a
specific location
 May have a positive sulcus sign, apprehension/relocation test, anterior release tests
 Secondary rotator cuff impingement can be seen with microtraumatic events caused during
participation in sports such as gymnastics, swimming and weight training
 Increased joint accessory motion in multiple planes
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 Red flags

 Trauma, pain and weakness (indicates rotator cuff tear)

 Swelling/mass (Indicates tumor/malignancy)
 Fever or any systemic illness
 Unreduced dislocation
 Infected joint

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 SUBJECTIVE HISTORY

 May have history of: trauma with or without a previous

dislocation; lax joints (consider elbow, knee, thumb
hyperextension, use Beighton scale to evaluate
hypermobility)
 Activities of daily living may be difficult to complete
 Global pain around shoulder

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 PHYSICAL EXAMINATION
 Screen cervical spine and thoracic spine

 Observation/Palpation

 Long head of biceps, supraspinatus tendon, AC joint, SC joint, spine, 1st rib, other
regional muscles
 Posture

 Asymmetry
 Scapular winging
 Atrophy

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Active ROM
 Glenohumeral flexion, extension, abduction, adduction, rotation -
internal & external, scaption
 Look for apprehensive behavior
Passive ROM
 May have pain and/or stiffness
 Apprehension will be present
Functional Testing
 Hand to posterior neck
 Hand to scapula
 Hand to opposite scapula
Joint Accessory Motion Testing
 Increased mobility in the direction of the instability (anterior, posterior,
multidirectional) 45
SPECIAL TESTS

 Possibly sulcus sign,

 apprehension/relocation
 anterior release tests depending on suspected form of instability
 Load and Shift Test

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 MEDICAL MANAGEMENT

 Medical management will hinge on the specifics of the patient

presentation including the mechanism of injury, severity, patient goals,
etc. In some cases, particularly those with a traumatic mechanism,
surgical intervention may be warranted to restore joint stability.

 Types of surgical procedures for traumatic glenohumeral dislocations

 Open capsular shift

 Arthroscopic thermal capsulorraphy
 Labral repair

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 PHYSICAL
THERAPY
MANAGEMENT

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 Education to prevent recurrence
 Postural re-education
 Motor control training of specific muscles during functional
activities (rotator cuff muscles, scapular stabilisers)
 Strengthening in particular the deltoid, rotator cuff muscles
and scapular stabilisers
 Stretching in particular posterior shoulder structures,
pectoralis major and minor and any other muscles with
flexibility impairments
 Manual therapy targeting impairments of mobility in the
glenohumeral, acromioclavicular, sternoclavicular joints and
cervico-thoracic spine
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FRACTURE OF THE CLAVICLE

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 Group I: Fractures of the middle third or midshaft fractures (the most common site),

 Group II: Fractures of the distal or lateral third. A common site for non-union.

 Group III: Fractures of the proximal or medial third.

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 HISTORY AND PHYSICAL EXAMINATION
 A patient may cradle the injured extremity with the uninjured arm.
 A patient may report a snapping or cracking sound when the injury
occurs.
 The shoulder may appear shortened relative to the opposite side and
may droop.
 Swelling, ecchymosis, and tenderness may be noted over the clavicle.
 Abrasion over the clavicle may be noted, suggesting that the fracture
was from a direct mechanism.
 Crepitus from the fracture ends rubbing against each other may be
noted with gentle manipulation.
 Difficulty breathing or diminished breath sounds on the affected side
may indicate a pulmonary injury, such as a pneumothorax.

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 Palpation of the scapula and ribs may reveal a concomitant
injury.
 Tenting and blanching of the skin at the fracture site may
indicate an impending open fracture, which most often
requires surgical stabilization.
 Nonuse of the arm on the affected side is a neonatal
presentation.
 Associated distal nerve dysfunction indicates a brachial
plexus injury.
 Decreased pulses may indicate a subclavian artery injury.
 Venous stasis, discoloration, and swelling indicate a
subclavian venous injury.
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 DIAGNOSTIC PROCEDURES
 Diagnose can often be made by a client's history and
physical examination.
 Radiography of the clavicle and shoulder
 Computed tomography (CT) scanning with 3-dimensional (3-
D) reconstruction
 Arteriography
 Ultrasonography

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 MANAGEMENT

 Clavicle fracture is managed either surgically or

conservatively based upon various factors including the
location (mid-shaft, distal, proximal), nature (displaced,
undisplaced, comminuted) of the fracture, open VS closed
injury, age, and neurovascular compromises.
 Traditionally, the management of clavicle fractures has been
through conservative management with sling immobilization
and subsequent rehabilitation.

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 This continues to provide satisfactory results for undisplaced fractures
but conservative management of displaced mid-shaft clavicle fractures
results in increased rates of re-injury, increased return times to sport
and suboptimal shoulder function, secondary to clavicular mal-union
and shortening, with resultant thoracoscapular dyskinesia.
 Similarly, conservative management of displaced lateral fractures in the
athletic patient has been shown to result in high rates of non-union and
subsequent impairment of shoulder function.

 So for the athletic individual, operative intervention is routinely

performed for displaced lateral fractures and is recommended for mid-
shaft fractures that are completely displaced, shortened >2 cm or
comminuted

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Kinesio Taping

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 Introduction
 Kinesio Taping Method is a therapeutic tool utilised by the
rehabilitation specialists in all programs (paediatric, geriatric,
orthopaedic, neurological, oncology and others).
 levels of care (acute care, inpatient rehabilitation, outpatient,
home care and Day Rehab).
 used in pain management, soft tissue injury, tissues and
joints malalignment, oedema, and more.

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 Properties
 Ability to stretch to 120-140% of its original length
 Recoil back to the anchor that is applied without stretch
 Heat activated adhesive
 Hypoallergenic dyes that make the tape safe for most users
 Latex-free
 Drying time after being wet is about 5-10 minutes
 Can be worn for several days

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Type of Kinesio Tex Tapes
 Kinesio Tex Classic: the original tape that received several upgrades
over time, the most universal as it can be used for all applications and
ideally on healthy skin.
 Kinesio Tex Performance+: different, looser pattern on the tread,
polyester and cotton blend best for sensitive skin when higher tensions on
the tape are desired.
 Kinesio Tex Gold: special distribution of adhesive allowing good
attachment without requiring large surface area, good for low tension
applications and available only for trained professionals.
 Kinesio Tex Gold Light Touch Plus: adhesive distributed to allow
gentle grip, does not last as long as other types so it is used for short term
applications and usually for children and older adults with fragile skin.
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 Basics of Application
 Follow contraindications and precautions when choosing
Kinesio Taping Method
 Apply the tape on dry skin, free of oils and lotion
 Remove body hair if possible by trimming or shaving the area
 Follow the tension guidelines
 Round all the edges of the tape to prevent premature peeling
 Avoid touching the adhesive side of the tape after removing
the backing as this may decrease the adhesive strength on
the skin
 Once the tape is applied, activate the heat-sensitive adhesive
by rubbing the surface of the tape for a few seconds  65
 Reassess to determine post-application results
 Inform the patient to defer activities that cause perspiration
for 30 minutes if possible
 Inform the patient to remove the tape if itching or burning
sensation occurs or if the pain increases
 Teach the patient and caregiver how to remove the tape if
needed
 Provide the patient with informed consent and an information
sheet with a description including:
 sign and symptoms of skin irritation and skin allergy
 instruction on tape removal

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General contraindications are:
 Malignancy
 Infection, cellulitis
 Open wound
 DVT
 Previous allergic reaction to Kinesio Tex Tape

General precautions are:

 Diabetes
 Congestive heart failure (CHF)
 Patient receiving dialysis/Kidney disease
 Organ transplants
 Pregnancy
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 Types of Applications
 Type of tape used (Classic, Perfomance+, Gold, Gold Light Touch Plus, )
 Tape cut (Y, I, X, Fan, Web, Donut, Jelly Fish, Snowflake, )

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 Tape length and width
 Technique used
 (Fascia Correction, Mechanical Correction, Space Correction, Lymphatic Correction,
Overactive or Underactive Muscle, Ligament and Tendon Correction)

 Patient's position during application

 Tension used on the tape (described in %)

 Tape direction (proximal or distal)

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 Type of Application Stretch
 The target tissue should be elongated prior to the tape application.
Various amounts of stretch on the tape can be used and it depends on
the tissue we choose to affect.

 Ultra light 0-5% (epidermis)

 Super light 5-10% (dermis)
 Paper-off 10-15%(superficial fascia)
 Moderate 25-50% (deep fascia)
 Severe 75% (tendon)
 Full 100% (ligament)
 For percentage, stretch refer to the percentage of the available stretch.
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TAPPING FOR ROTATOR CUFF INJURY

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APPLICATION OVERVIEW
 cause of rotation cuff injury may included overuse, tear,
motion beyond normal limits or poor throwing form.
 KT Tape can help treat this condition by providing support
and stability,
relieving pressure to reduce pain, and increasing circulation

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 WHAT YOU NEED
 3 STRIPS of KT Tape
 2 full 10” strip
 1 full 10”strip cut in half

 BEFORE YOU START

 Apply before activity
apply one hour before beginning activity .
 Clean skin
clear dirt , oils and lotion from area .
 Activate adhesive
after application rub tape vigorously

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STRIP ONE :
0% STRETCH
ANCHOR : anchor a full strip slightly under the
point of pain as shown without stretch .
25 % STRETCH
APPLY : Apply the tape around the shoulder and
under the shoulder blade with 25% stretch.
0% STRETCH
FINISH : apply the last two inches of the tape
without stretch.

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STRIP TWO :

80% STRETCH
ANCHOR: Anchor the middle of a
half strip of tape across the first strip
and shown with 80% stretch.
0% STRETCH
APPLY: lay ends down without
stretch.

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STRIP THREE
80% STRETCH
ANCHOR: anchor the middle of a
second half strip across the first strip
as shown with 80% stretch.
0% STRETCH
APPLY: lay ends of tape down
without stretch.

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Rotator cuff
injuries/tear

supraspinatus

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 Non-Operative
Rehabilitation for
Shoulder

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PHASE I–ACUTE PHASE
Goals:

 Decrease pain/inflammation

 Re-establish non-painful ROM

 Retard muscle atrophy

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 DECREASE ROM EXERCISES
PAIN/INFLAMMATION

 Therapeutic modalities o Pendulum

(ice,heat,electrotherapy,etc.) o Rope and pulley
o L-Bar
 NSAIDs
 Flexion
 Abduction
 GENTLE joint mobilization  Horizontal abduction
 External rotation

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 PHASE II –INTERMEDIATE PHASE
 Goals:
 Regain and improve muscular strength
 Normalize arthrokinematics
 Improve neuromuscular control of shoulder complex

 Criteria to Progress to Phase II:

 Full ROM
 Minimal pain and tenderness
 Initiate Isotonic Strengthening
 Flexion
 Abduction to 90 degrees
 External rotation
 Internal rotation (from external rotation to 0 degrees)
 Supraspinatus
 Extension
 Horizontal abduction (prone)
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 Push-ups
Initiate Eccentric (surgical tubing) Strengthening
External rotation (from 0 degrees to full external rotation)
Internal rotation (from full external rotation to 0 degrees)
Normalize Arthrokinematics of Shoulder Complex
Continue joint mobilization
Patient education of mechanics of activity/sport
Improve Neuromuscular Control of Shoulder Complex
 Initiate proprioceptive neuromuscular facilitation
 Rhythmic stabilization drills
Continue Use of Modalities (as needed)
 Ice, electrotherapy modalities, etc.

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 Phase III –Advanced Strengthening
Phase
Goals:
o Improve strength/power/endurance
o Improve neuromuscular control
o Prepare athlete for activity

Criteria to Progress to Phase III

o Full non-painful ROM
o No palpable tenderness
o Continued progression of resistive exercises

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 Continue use of modalities as needed
 Continue anterior capsule stretch
 Continue isotonic/eccentric strengthening
 Emphasize PNF
 Initiate Isokinetics
 Flexion/extension o Abd/adduction o Internal/external rotation o Horizontal
Abd/adduction
 • Initiate plyometric training
 o Surgical tubing
 o Medicine ball
 o Wall push-up
 • Initiate Military Press

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Phase IV –Return to Activity
Goals:
o Maintain optimal level of strength/power/endurance
o Progressively increase activity level to return patient/athlete for full
functional return to activity/sport
Criteria to Progress to Phase IV
o Full ROM
o No pain or tenderness
o Satisfactory clinical exam o Satisfactory isokinetic test

Continue all exercises as in Phase III • Initiate and progress to interval

program as needed 94