Shoulder Surgery Rehabilitation A Teamwork Approach MASUD PDF

Giovanni Di Giacomo
Silvia Bellachioma
Editors
Shoulder Surgery
Rehabilitation
A Teamwork Approach
123
Shoulder Surgery Rehabilitation
Giovanni Di Giacomo • Silvia Bellachioma
Editors
Shoulder Surgery
Rehabilitation
A Teamwork Approach
Editors
Giovanni Di Giacomo Silvia Bellachioma
Concordia Hospital for Special Surgery Concordia Hospital for Special Surgery
Rome Rome
Italy Italy
ISBN 978-3-319-24854-7 ISBN 978-3-319-24856-1 (eBook)

DOI 10.1007/978-3-319-24856-1
Library of Congress Control Number: 2016934463
Springer Cham Heidelberg New York Dordrecht London

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To my mom, the most important person of my life, who was and still is able to
make the impossible possible. Thank you for having believed in me, and for
making every day of my life unique and special. With much love,
Silvia Bellachioma
To my friend Giovanni Danieli for his skill, professionalism, and passion for
his work.
Giovanni Di Giacomo
Foreword
It is a pleasure to have the opportunity to write a foreword for Shoulder Surgery Rehabilitation:
A Teamwork Approach on behalf of Doctors Di Giacomo and Bellachioma. Having worked
personally with Doctors Di Giacomo and Bellachioma, I can attest to their skill and profes-
sionalism in what they do in their respective fields. Now they document how to work as an
orthopedic surgeon-physiotherapist team. This text will enhance communication between
treating healthcare professionals including orthopedic surgeons, non-orthopedic physicians,
and physical therapists. It is well organized, provides excellent explanations of functional anat-
omy and biomechanics, discusses treatment options available and the rationale for decision-
making, as well as possible complications.
With beautiful, meticulous illustrations of anatomy, pathology, and surgical procedures, and
well-demonstrated rehabilitation techniques and exercises, this text will enhance the knowledge
of what is involved in shoulder surgical procedures, and help physical therapists understand
the rationale behind the recommended protocols and modification of protocols for each proce-
dure, depending on the surgical variables. The importance of rehabilitation of the shoulder in
the context of the kinetic chain, rather than in isolation is well supported, and is consistent with
the way that Doctors Di Giacomo and Bellachioma have successfully worked together for many
years. Each chapter clearly elucidates the roles of the orthopedic surgeon and physical therapist
to insure a seamless recovery from injury whether or not surgery is involved.
Ben Rubin, MD
Orthopaedic Specialty Institute Medical Group of Orange County
Orange, CA, USA
vii
Foreword
It is an exciting honor for me to help welcome the collaborative effort of this new textbook.
The shoulder is a unique joint in that it is so dependent on soft tissue and muscular input, and
this dependence is often underappreciated by orthopedic surgeons as we care for injuries
around the shoulder joint. There has long been the need for our textbooks to approach the
shoulder from a team-centered perspective. It is a pleasure to see this text and commend Doctor
Di Giacomo and his team in capturing the collaboration between the surgeon and the therapist
throughout the course of care. This textbook has captured the essence of multidisciplinary
teamwork in the ideal approach to the shoulder. With a highly respected international group of
authors, this text leverages the thought leaders from multiple nations, which gives it a world-
wide relevance for surgeons and therapists wherever they live. I believe the reader will find this
text extremely well illustrated, and with a combination of in-depth discussion with emphasis
on key take-home points that will be valuable for readers at every level of training – from the
young therapist to the seasoned orthopedic surgeon, there is something to be learned by all of
us in this text. I believe it will become a well-referenced tool and a go-to reference for the
entire shoulder team across the spectrum of care, and congratulate the editors on advancing our
ability to care for the injured shoulder with this text.
John M. Tokish, MD
Steadman Hawkins Clinic of the Carolinas
Greenville, South Carolina, USA
ix
Preface
Over the past decade, important advances in shoulder joint imaging and surgery have led to
more accurate patient selection and constant updating of surgical procedures. On the rehabili-
tation front, too, functional anatomy and neurophysiology studies have combined with state-
of-the-art biomechanics to improve rehabilitation protocols.
If positive postoperative outcomes are to be achieved, it is absolutely necessary that surgery
and rehabilitation go hand in hand. Indeed, the recent acquisitions of know-how should ensure
a seamless “cultural overlap” between orthopedics and rehabilitation. The physiotherapist
must be familiar with indications for surgery, surgical techniques, and their possible complica-
tions in order to establish an appropriate rehabilitation protocol that caters for individual
patient requirements and must also be able to interact effectively with the surgical team.
Similarly, the orthopedic surgeon must be aware of the new rehabilitation possibilities that
allow the achievement of better subjective and objective results.
The editors hope that this manual – developed together with surgical teams that have always
attributed great importance to the rehabilitation phase – will meet the needs of physiothera-
pists, rehabilitation specialists, and surgeons and facilitate effective teamwork.
Rome, Italy Giovanni Di Giacomo

Rome, Italy Silvia Bellachioma
xi
Contents
1 Proximal Humeral Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Giovanni Di Giacomo, Silvia Bellachioma, and Elena Silvestri
2 Shoulder Replacement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
John E. Kuhn, Rebecca N. Dickinson, and Woodley Desir
3 Traumatic Anteroinferior Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Giovanni Di Giacomo, Todd S. Ellenbeker, Elena Silvestri,
and Silvia Bellachioma
4 Rehabilitation Following Rotator Cuff Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
W. Ben Kibler and Aaron Sciascia
5 The Athlete’s Shoulder: Surgical Treatment and Rehabilitation . . . . . . . . . . . . 183
Kevin E. Wilk, Todd R. Hooks, and James R. Andrews
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
xiii
Proximal Humeral Fractures
1
Giovanni Di Giacomo, Silvia Bellachioma,
and Elena Silvestri
Contents 1.6 Rehabilitation following Hemiarthroplasty ................ 46

1.7 Complications ................................................................ 49
1.1 Epidemiology ........................................................................ 2 1.7.1 Neuroanatomical and Neuromechanical
1.2 Classification .................................................................. 4 Aspects of the Shoulder following
1.2.1 Vascular Supply............................................................... 10 Proximal Humeral Fractures ........................................... 49
1.2.2 Vascular Patterns ............................................................. 12 1.7.2 Complications Following ORIF ...................................... 49
1.7.3 Complications following Hemiarthroplasty .................... 52
1.3 Biomechanics Related to Proximal
Humerus Fracture ......................................................... 16 1.8 Sequelae of Proximal Humeral Fractures ................... 54
1.3.1 Concept of “Fulcrum” and “Engine” .............................. 16 1.9 Rehabilitation Pearls ..................................................... 61
1.4 Conservative Treatment................................................ 20 1.9.1 Information Strategy ....................................................... 61
1.4.1 Rehabilitation in Conservative Treatment ....................... 22 1.9.2 Rehabilitation Strategy .................................................... 61
1.4.2 When to Begin Physiotherapy ......................................... 22 1.10 Correct Information Feedback .................................... 62
1.4.3 Healing Progression Criteria ........................................... 23
References .................................................................................... 63
1.5 When to Choose Surgical Treatment? ......................... 28
1.5.1 Surgical Treatments ......................................................... 28
1.5.2 Rehabilitation following Surgical Treatments................. 39
G. Di Giacomo () • S. Bellachioma

Concordia Hospital for Special Surgery, Rome, Italy
e-mail: [email protected]; [email protected]
E. Silvestri
fisiosmart, Rome, Italy
[email protected]
© Springer International Publishing Switzerland 2016 1

G. Di Giacomo, S. Bellachioma (eds.), Shoulder Surgery Rehabilitation: A Teamwork Approach,
DOI 10.1007/978-3-319-24856-1_1
2 G. Di Giacomo et al.
1.1 Epidemiology study, displaced fractures made up 58 % of the total number

and surgical management was necessary 21 % of the time [4].
According to Horak and Nilsson 5 % of all fractures in the The lack of relationship between the percentage of dis-
human body are fractures of the proximal humerus (PHF) [1]. placed fractures (58 %) compared to the percentage of surgi-
In terms of frequency, PHF are the 7° in adults and 3° cally treated fractures (21 %) is a sign of the difficulties of
in patient over 65 following wrist and femoral neck frac- managing this population, which is usually in poor general
tures [4]. condition (Table 1.2).
Majer et al. reported that, with respect to the incidence, 15 % Comorbid diseases increase the risk factors for PHF
of all PHF are complex 3-part and 4-part fractures [2–16]. (Table 1.3).
Court- Brown et al. found that 70 % of all 3–4 part frac- The main cause of fractures in men 55 % of the time was
tures are seen in patient aged over 60 years and 50 % in due to a simple fall and 45 % of the time was from a high-
patients aged over 70 years [3]. energy kinetic trauma. In women the cause was a simple fall
These results conclude that poor bone quality and in 82 % of all cases (Table 1.4) [4].
advanced osteoporosis will be found in the majority of High-energy injuries such as motor vehicle accidents usu-
patients with humeral head fractures. ally produce significant associated injuries.
PHF are more frequently osteoporotic fractures affecting Moderate falls causing severe injury, such as a fall in the
women over 70 years of age. home, are suspicion of osteoporosis call for preventive
The severity of the fracture increases proportionally with measures.
the age of the population (Table 1.1). Persistent pain after fall, even with an initially negative
There are two types of risk factors: radiograph, should alert the physician to repeat the investiga-
tion with additional views.
• Fragile bones Often hidden fractures of the tuberosities will be revealed
• Patient-specific risk of falls (CT SCAN or MRI can help).
Adequate neurological and vascular investigation may
Roux reported that the mean age of PHF occurring was 70 also be necessary.
(16–97), the fractured shoulder was on the right side 48 % Palvanen and Kannus [5] found a threefold increase over
and of the left 62 %, and the fracture affected dominant side a 33-year period in the incidence of PHF resulting from low-
in 48 % cases [4]. energy trauma in people aged 60 and above. The same author
Analysis of the distribution of fractures through the year demonstrated an increase in the annual fracture rate of
showed that the most of the fractures occurred during the 13.7 % over the past every year.
cold season, with 60 % occurring between October and The incidence is increasing, and these fractures tend to be
March. more severe [6–8].
Roux also reported that in 325 patients with 329 fractures, The management of these often debilitating injuries is
hospitalization was necessary in 43 % of the cases. In their based on various classification systems [8, 9].
1 Proximal Humeral Fractures 3
Table 1.1 Table 1.3

Number of fractures by age group Risk factors for fractures Number for patient %
120 Osteoporosis 85 34
Number of fractures by
age group 99 History of falling 82 33
100
Limited physical activity 75 30
History of femoral neck fracture in 31 12
80 mother
67
Trouble walking 62 25
60
46 Pain in the lower limb 47 19
43
Trouble seeing 66 26
40
23 24 Trouble hearing 41 16
20 Alcoholism 37 15
6 8 9
Tobacco use 71 28
0
1 2 3 4 5 6 7 8 9
Table 1.4
Cause of fracture Total Men Women
Table 1.2 Falling from standing height 189 37 152
Comorbidities Number of patients % Road accident 34 18 16
Diabetes 27 10 Violent fall 17 7 10
Epilepsy 7 3 Aggression 9 3 6
Depression 53 21 Suicide attempt 1 0 1
Dementia 26 10
Parkinson’s disease 4 1.6
Psychosis 8 3
Cardiopathy 21 8
HTA 10 4
History of stroke 8 3
1.2 Classiﬁcation humerus into 3 parts, and one fracture type dividing the
humerus into 4 parts [15].
The proximal humerus can be divided into four anatomic • The 4° system, by Resch. This is a proposed addendum of
areas: humeral head, greater tuberosity, lesser tuberosity, and the Codman-Hertel classification system and addresses the
shaft (Fig. 1.1) [9, 10]. fracture angulation and the pathomechanics of the injury.
The average humeral neck-shaft angle, that is, the angle
between the neck of the humerus and the shaft, measures at It describes three biomechanical planes of injury classi-
approximately 140°. The humeral head version, on the other fied by the observer [this distinction is crucial for reduction
hand, is quite variable depending on which anatomic land- and fixation]:
marks are used [11, 12].
Historically 30° of humeral head retroversion is consid- 1. Impaction/Distraction
ered normal. • Impaction: an impaction injury occurs when the length
The tuberosities, the diaphysis, and the humeral head are of the position of the fracture of the greater tuberosity
subjected to different compression and tractive forces, due to is unchanged and the total length of the humerus is
the muscles acting as lever. Following a fracture event, cer- reduced due to the impact to the head [16].
tain forces may determine different patterns and different • Distraction: a distraction injury is defined as an increase
degrees of displacement (Fig. 1.2a, b). in distance on the lateral side between shaft and head
A fracture classification should aim to improve the under- fragment (subcapital fractures) or between the shaft
standing and therefore the management of fractures, based and the fractured greater tuberosity (subcapital frac-
on the morphology, the biology, and mechanical behavior. It tures accompanied by a greater tuberosity fracture).
should also strive to provide therapeutic guidelines based on 2. Varus /Valgus/Neutral
clinical outcomes and be comprehensive with all fractures • In varus-type fractures, the head is disrupted from the
types which are classifiable, and its application should lead shaft and remains in the varus position as a result of the
to reproducible results [13]. persisting attachment of the rotator cuff muscles. In the
The main criterion for a good classification system is that case of an additional fracture of the greater tuberosity,
it addresses the clinically relevant questions. the head may follow the subscapularis muscle and rotate
Literature reports four PHF classification systems that are into an internally rotated position (3-part fracture accord-
in use or have the potential for use: ing to Neer) [9]. An investigation of 200 consecutive
cases showed that 2 varus types could be differentiated:
• The Neer system, which groups each fracture by the num- – Varus distraction type: the head fragment is in varus
ber of fracture segments and describes the fractured ana- position and completely separated from the shaft in
tomic segments as a part [9]. an anteromedial position. The varus distraction
• The AO system, which describes each fracture as a being with additional fracture to the greater tuberosity
1 of 3 types with 3 subdivisions each. presents cute often with the head in an internally
Type A indicates extra-articular unifocal fractures, rotated position.
type B extra-articular bifocal fractures, and type C articu- – Varus impaction type: is characterized by the impac-
lar fractures. The 3 subdivisions are related to the pattern tion of the head on the medial side, yet no distraction
of the fractures [13]. occurs on the lateral side. In the sagittal plane, the
• The Codman-Hertel binary fractures (the so-called Lego anterior angulation angle is increased, but in contrast
System of Hertel et al.) [7, 14]. to the distraction type, the shaft is not in a separated
This classification corresponds to the four-part system position. These fractures are characterized by resid-
of Codman with the option of 12 fractures types. There ual primary stability, as a result of the periosteum
are 6 possible fracture combinations dividing the humerus steel being preserved on the lateral side. The calcar
in 2 parts, 5 possible fracture combinations dividing the on the medial side has to be reduced (Fig. 1.3a, b).
Fig. 1.1 Four anatomic areas of proximal

Humeral head
humerus Greater tuberosity
Lesser tuberosity
Shaft
a b
2 4
Fig. 1.2 (a) Displacement forces that occurs in the proximal humerus. (1) Supraspinatus, (2) Subscapularis, (3) Pectoralis major, (4)
Infraspinatus, (5) Teres minor, (6) Deltoid. (b) Forces that can occur during PHF and increase the displacement of the different fragments. (1)
Humeral head, (2) Subscapularis, (3) Greater tuberosity→supraspinatus, (4) Shaft →Pectoralis major
Fig. 1.3 (a) Varus impaction type fractures. (b) Varus impaction type fractures
– Valgus type: is characterized by the impaction of the 3. Flexion/Extension/Neutral

head into the metaphyses of the shaft. The fracture Finally the head-shaft angle in the trans-scapular plane
of the tuberosity remains in the normal longitudinal is assessed and described as flexion, extension, or neutral.
position and is still relatively attached to the shaft Thus addressing fracture angulation may also facilitate
by the undestroyed periosteum (Fig. 1.4). fracture reduction (Fig. 1.6).
This fracture without lateral displacement of the
head in relation to the shaft is easy to reduce,
because only the head has to be raised by an elevator
Take-Home Message
that is introduced between the fractured tuberosi-
ties. The periosteum of the medial side serves as a Imaging: AP view, trans-scapular, and axillary views
mechanical hinge when performing this maneuver. are the standard approach; anyway a CT scan with 3D
In the case of severe lateral displacement of the reconstruction gives tri-planar excellent information
head in relation to the shaft, the mechanical hinge (Fig. 1.7).
periosteum on the medial side is torn and the head
fragment is very unstable and difficult to reduce
(Fig. 1.5) [19].
Take-Home Message
From the study of Solberg et al. [17–19], the varus

deformity of more of 20° should not be left uncor-
rected because this level of deformity is not be toler-
ated by the patient. In comparison to varus deformity,
valgus deformity is better tolerated. Greater tuberosity
displacement of more than 5 mm in any direction
should not be accepted.
Fig. 1.6 Transcapular plane view

Fig. 1.4 Valgus impaction type fractures
Fig. 1.7 3D reconstruction
Fig. 1.5 Severe lateral displacement of the head in relation to the shaft
The Codman-Hertel classification in our experience is This results in 12 basic fracture patterns (Table 1.5).
comprehensive, easy to teach, and easy to learn. It has Evaluation criteria accessories are important additional
proved cogency because it provides clear-cut diagnostic considerations when deciding on the treatment of complex
subgroups, even if the residual difficulty, as with all clas- intra-articular fractures of the proximal humerus.
sification systems, remained in actually recognizing the
fracture lines. This requires adequate radiographs Accessory questions
(anteroposterior and axillary view) and an experienced 6. How long is the posteromedial metaphyseal head extension (mm)?
eye [7]. 7. How large is the displacement of the shaft with respect to the
Codman-Hertel System: head (displacement measured between posteromedial edge of the
The system describes five basic fracture planes that can head and posteromedial shaft fracture line “mm”)?
Medial or lateral displacement of the shaft?
be identified by answering the following questions:
8. How long is the displacement of the tuberosities with respect to
the head (displacement measured of transition zone between the
1. Is there a fracture between the greater tuberosity and the tuberosity and the cartilaginous fracture line “mm”)?
head? 9. Amount of angular displacement of the head (under consideration
2. Is there a fracture between the greater tuberosity and the of the £-dimensional position)? Varus or valgus?
shaft? 10. Is there a glenohumeral dislocation (Y/N)?
3. Is there a fracture between the lesser tuberosity and the Anterior or posterior?
11. Is there a head impression fracture (Y/N)?
head?
Anterior or posterior?
4. Is there a fracture between the lesser tuberosity and the
12. Is there a head split component (Y/N)? >20 % of the head
shaft? involvement (Y/N)?
5. Is there a fracture between the lesser tuberosity and the With two intra-articular fracture planes (Y/N)?
greater tuberosity? With one intra-articular fracture plane (Y/N)?
With the permission of Elsevier Saunders
Table 1.5 Codman- Hertel classification system
Humeral head Lesser tuberosity Greater tuberosity Shaft

1.2.1 Vascular Supply tently larger in diameter than the anterior circumflex
humeral artery. In a cadaver study, Hettrich et al. [23] quan-
Vascularity of the proximal humerus is an important factor titatively assessed the vascularity of the proximal humerus
in assessing fracture pattern severity; thus a thorough and found that the posterior circumflex humeral artery con-
knowledge of the vascular anatomy is important. tributes 64 % of the blood supplied to the proximal humerus,
Historically the anterior circumflex humeral artery and its whereas the anterior circumflex humeral artery contributes
terminal branch, the arcuate artery, have been noted as the just 36 %.
preeminent sources of perfusion to the proximal humerus The vascular supply to the greater tuberosity is provided
[20]. In a cadaver study, Brooks et al. [21] investigated the through intraosseous connections between the arcuate artery,
vascularity of the humeral head using a four-part fracture the posterior humeral circumflex artery, the metaphyseal
model. The authors noted that the primary source of perfu- vessels, and the vessels of the greater and lesser tuberosities.
sion to the proximal humerus was via the anterior circum- The arterial network provides a rich blood supply to the
flex humeral and arcuate arteries, with significant greater tuberosity which provides a good healing environ-
intraosseous anastomoses existing between the arcuate ment for greater tuberosity fractures. Unlike fractures of the
artery and the posterior circumflex humeral artery, the anatomic neck of the humerus, isolated fractures of the
metaphyseal arteries, and the vessels of the greater and greater tuberosity do not typically compromise the blood
lesser tuberosities (Fig. 1.8). supply to the humeral head [21].
The authors also reported that, in most cases, a four-part
PHF disrupts perfusion to the humeral head. They also noted
that the posteromedial vessels play a vital role in maintaining
proximal humeral perfusion in certain fracture patterns. Take-Home Message
However, debate continues regarding whether the anterior Note that in the metadiaphyseal region, the blue bound-
circumflex humeral artery is the dominant source of perfu- ary (Fig. 1.9a, b) represents the “entry point” of the
sion to the humeral head. Recent studies have demonstrated anterior and posterior circumflex.
that the posterior circumflex humeral artery plays a greater In PHF, if this region remains in continuous with
role than the anterior circumflex artery does in supplying the fractured element of the head, the risk factors for
blood to the proximal humerus (Fig. 1.9a, b) [22, 23]. aseptic necrosis are diminished. On the contrary, if no
Duparc et al. [22] argued that the posterior and anterior continuity exists between the head and the metadiaph-
circumflex humeral arteries are equally important in ysis, the risk factors for aseptic necrosis will be
humeral head perfusion. Interestingly the authors noted increase.
that the posterior circumflex humeral artery was consis-
Fig. 1.8 Vascular supply of the proximal humerus. (1) Axillary

Artery, (2) Thoraco Acromial Artery, (3) Subscapularis Artery, (4)
Anterior Circumflex Artery, (5) Ascending branch of the anterior
Circumflex, (6) Posterior Circumflex Artery, (7) Brachial Artery
a b
Fig. 1.9 (a) Anterior and posterior circumflex artery and its relationship with the medial hinge. (b) Magnification
1.2.2 Vascular Patterns metaphyseal head extension of the humeral head perfusion
(Fig. 1.10a, b).
The perfusion of the fractured segments is the main problem The purpose of the Hertel classification is also to evaluate
to analyze the right decision-making of surgical program, if predicting factors of fractures that potentially could induce
needed. humeral head ischemia:
The classification systems give an important prospective
view of the status of the fracture and help to decide what may • Destruction of the medial hinge is a critical factor for
be correct to do but at the same time is not enough. fractures with a medial metaphyseal extension below
To make a good prediction of the result, we must to con- 8 mm. Related to the vascular status, the integrity of the
sider the perfusion of the fractured segments and the real medial hinge is also an important hide in fracture reduc-
capacity of these to maintain a good biologic vascular tion and stabilization. It is crucial for reduction and inter-
response [24]. nal fixation.
Preservation of proximal humeral vascularity is important • Another important element that is related as good predic-
when distinguishing between valgus-impacted and varus- tor of ischemia besides the length of the metaphyseal
angulated three- and four-part PHF. The valgus impacted head extension <8 mm and the integrity of the medial
fracture is characterized by intact medial soft tissue, which hinge is the basic fracture pattern for combined types 2-9-
can potentially preserve the blood supply to the humeral 10-11-12 (fracture types with an anatomic head compo-
head. nent) (Table 1.5).
In the markedly displaced four-part PHF with significant
varus malalignment, disruption of the medial soft tissue
envelope can potentially compromise perfusion to the Take-Home Message
humeral head; at this purpose the Hertel classification is also • The metaphyseal head extension (also called calcar
to evaluate. segment) part of the metaphysis remains attached to
Hertel hypothesized that in the PHF, when a metaphy- the head. The metaphyseal extension was most
seal extension remained attached to the head, a degree of often located posteromedially (Fig. 1.10a).
residual perfusion provided by the posterior circumflex • Medial hinge is defined as the pivot point of the
humeral head vessels could be anticipated. It seems that head at the level of the posteromedial fracture line
one of the key points is to evaluate the impact of fracture (Fig. 1.10b).
morphology including the position and the size of the
Fig. 1.10 (a) Length of the medial metaphyseal head exsension (red line), the more likely the head is perfused. (b) Integrity of the medial hinge
(red line) is a predictor of both ischemia and practical feasibility of reduction
Importance intermediate: Anatomical findings [21, 22, 26] and clinical observation
[27–30] seem to confirm that perfusion derived from the
• 3–4-part fractures. posterior circumflex vessels alone may be sufficient for
• Angular displacement >45°. head survival.
• Amount of displacement of the tuberosities over 10 mm. The most relevant predictors of ischemia, according to
• Head-split component. Hertel et al. [7], are the length of the dorsomedial metaphy-
• The mean displacement of the shaft with respect of the seal extension, the integrity of the medial hinge, and the
head can also be considered a predictor of ischemic head basic fracture type determined with the binary description
when it is around 13 mm especially if it is medial (Fig. 1.11). system.
According of Trupka et al., fracture dislocation is not

associated with an increased incidence of avascular necrosis
Take-Home Message
of the humeral head (Fig. 1.12) [25].
Gerber et al. [31] stated that in the case of an existing
Perfusion of the head fragment is essential but not the
avascular necrosis, it is the deformity rather than
only element for decision-making.
necrosis that causes disability. Therefore, the risk of
Despite an ischemic head (Fig. 1.13), a head-preserving
limited blood supply of the articular fragment does not
treatment is an option when revascularization can be expected
influence our decision-making in terms of treatment.
and/or when a two-staged management protocol is required
Like Gerber et al. [31], we believe that the align-
for local or systemic reasons (first-stage osteosynthesis and
ment of the tuberosities is very important in cases in
second-stage hemiarthroplasty should avascular necrosis not
which prosthetic replacement might be necessary as a
tolerated) (Fig. 1.14).
secondary procedure because of head necrosis.
Generally head-preserving surgery is indicated when the
bone quality is good enough to ensure the stable osteosynthesis
in order to allow healing (especially of the tuberosities) in an
anatomic position.
1 1 1 Fracture line
Fracture line
2 2 2
4 4 4
6
6 6
5
5 5
3 3 3
7 7 7
(1) Arterial supply of the rotator cuff from the thoracoacromial and suprascapular arteries. (2) Ascending branch of the anterior circumflex
artery. (3) Intraosseous metaphyseal artery. (4) Ascending branch of the posterior circumflex artery. (5) Anterior circumflex artery. (6) Axillary
artery. (7) Circumflex artery
Fig. 1.11 Medial displacement of the shaft Fig. 1.13 Fracture sequelae of PHF with head avascular necrosis
Fig. 1.12 Fracture dislocation
Fig. 1.14 Prosthetic replacement as secondary procedure

1.3 Biomechanics Related to Proximal 1.3.1 Concept of “Fulcrum” and “Engine”

Humerus Fracture
We define the fulcrum as the convex surface of the head of
Different than other pathologies of the shoulder, the third the humerus that rotates inside the concave surface of the
proximal humeral fractures generally occur from a sudden glenoid.
traumatic event, and for this reason, this condition affects the The rotation movement is guaranteed by a valid engine
joint from a functional anatomical standpoint. that is represented by the rotator cuff, its bone insertions
Therefore after the trauma, only the proximal humeral (greater and lesser tuberosities), and also by the deltoid.
region is altered from the anatomical and biomechanical It is stated that the shoulder can maintain a stable “ful-
point of view. crum” of motion only when it maintains balance force cou-
We assume also that the other joints that make up the ples in both the coronal plane (inferior portion of rotator cuff
shoulder (the acromioclavicular, the sternoclavicular, and below the center of rotation creates a moment that must bal-
particularly the scapulothoracic joints) are functional. ance the deltoid moment) (Fig. 1.15a) and transverse plane
We want, therefore, to focus our attention exclusively to (the subscapularis anteriorly is balanced against the infraspi-
the glenohumeral joint and introduce the concept of biome- natus and teres major posteriorly) (Fig. 1.15b).
chanics that, if well understood, will be extremely helpful in
making a short or long term: the concept of fulcrum and
engine.
Fig. 1.15 (a) Note the “Fulcrum” (humeral head) and the Coronal tuberosity and infraspinatus- greater tuberosity) represents the gleno-
plane force couple (“a” and “A”). “o” correspond to the centre of rota- humeral “Engine” “b” transverse plane force couple. “o” correspond to
tion. (b) Transverse plane force couple( S,I). The anatomic and func- the centre of rotation. “R” and “r” corresponds to the ray. “s” and “I”
tional integrity of the cuff and of the tuberosities (subscapolaris-lesser corresponds to the subscapolaris and infraspinatus couple force.
By a rotator cable that works as a stress shielding, a supra- Proximal humeral fractures that affect the insertions of
spinatus muscle even with a tendon tear can still exert its the rotator cuff (lesser tuberosity and greater tuberosity) tem-
compressive effect on the shoulder joint by means of its dis- porarily compromise the “engine” and, in case of poor
tributed load along the span of the suspension bridge con- healing and bone reabsorption, can affect the function over
figuration [32]. time (loss of engine). It results in a severe damaging event
For this reason, the integrity of the rotator cuff, the infra- that, from the biomechanical point of view, may be partially
spinatus and its insertion (greater tuberosity) and the sub- replaced by a reverse prosthesis (Fig. 1.17a, b).
scapularis and its insertion (lesser tuberosity), represents the We cannot retain valid the functional biomechanics of the
“engine.” shoulder without the following conditions:
The anatomical integrity of the fulcrum (humeral head)
and engine (the greater and the lesser tuberosity) are essen- • Adequate neuromuscular patterns and proprioception of
tial to ensure the movement of the glenohumeral joint and the scapulothoracic joint
therefore of the shoulder. • Integrity of the rotator cuff and of its osseous insertions
The functional integrity of the cuff and of the tuberosities (integrity of “engine”)
(subscapularis, lesser tuberosity, infraspinatus, greater tuber- • Integrity of the articular surfaces (integrity of “fulcrum”:
osity) represents the glenohumeral engine. head and glenoid surface)
Proximal humeral fractures that affect the head can tem- • Synergistic action between the subscapularis and the
porally compromise the “fulcrum,” and in case of aseptic infraspinatus which have to guarantee a sufficient balance
necrosis or comminution, it can affect the function of the to stabilize the “fulcrum”
joint over time (loss of fulcrum that can be replaced by a • A well-functioning deltoid muscle that interacts with the
prosthetic element) (Fig. 1.16a, b). cuff during elevation of the arm [33–35]
Fig. 1.16 (a) Normal humeral head → FULCRUM. (b) Aseptic necrosis of the humeral head → LOSS OF FULCRUM
a b
Fig. 1.17 (a) Greater tuberosity in green → ENGINE dx: right side. (b) Reabsorption of greater tuberosity sequelae of PHF → LOSS OF ENGINE
1.4 Conservative Treatment a period of immobilization as traditional teaching would

suggest [38].
Nonoperative management is best suited for those fractures When considering the extent and duration of initial immo-
that have a high chance of union and will be amenable to an bilization after fractures, a balance is needed between the
adequate outcome for each specific patient. advantages of pain relief and avoidance of fracture displace-
These fractures are commonly those in a stable configura- ment, as the consequence of immobilization are notably joint
tion and which exhibit minimal displacement (<30° varus/ stiffness and muscle atrophy.
valgus angulation of the diaphyseal shaft in relation to the There is limited evidence that the particular type of
humeral head) (Fig. 1.18). bandage used neither influences the time to fracture union
Conservative management routinely consists of a brief nor the functional end result, although an arm sling is
period of immobilization in a sling (from one to three weeks), found to be generally more comfortable than a body ban-
in order to attain adequate pain control, prior to mobilization dage [39].
under the guidance of physiotherapist (Fig. 1.19). Patients should be followed with serial radiographs at two
It is common for a patient to find comfort in resting in the weeks (prior to initiation of motion) and then again at 4–6
sitting position and this may even extend to times of sleep, weeks to ensure fracture stability [40].
particular early on in the fracture healing process.
It should be reiterated to the patient and associated carers
alike that prolonged period of immobility is detrimental to
the outcome [36]. Take-Home Message
Shorter periods of immobilization are associated with When conservative treatment is indicated?
lower pain scores in the short term; however, at 6 months,
there is no difference [37]. • Stable configuration
More recently, Lefevre-Colau and colleagues found that • Minimal displacement
early mobilization for impact proximal humerus fractures • No vascular risk
was safe and more effective for performance restoration than
Fig. 1.18 Rx of stable configuration fracture
Fig. 1.19 Rest in sling

1.4.1 Rehabilitation in Conservative of the fracture is important, the accuracy of the information
Treatment gathered from the patient is essential too.
The shoulder is likely the one joint more than any other for
which rehabilitation represents a true challenge both with the 1.4.2 When to Begin Physiotherapy
conservative approach and after surgical ones.
It is universally recognized that non-displaced fractures In literature, when to begin physiotherapy is very controver-
can be treated conservatively. In these fractures, the surround- sial; in our experience, besides the patients’ age and comor-
ing soft tissues are generally intact, and the periosteum, rota- bidities, the key points are:
tor cuff, and joint capsule serve to stabilize the fracture.
Valgus-impacted fractures are also a good indication for • The stability of the fracture (patterns)
conservative treatment. • Quality of the bone
The conservative treatment of non-displaced or mildly • Compliance of the patient
displaced fractures generally yields good results.
Rehabilitation in conservative treatment after PHF is influ- The following week-based rehabilitation protocol for
enced by a variety of factors, in particular the age of the patient. conservative treatment, ORIF (Open Reduction Internal
Consider that in young patients it can be on an accelerated Fixation), hemiarthroplasty, and reverse shoulder arthro-
protocol based on maintaining the validity of the different links plasty gives a general indication of the time frames
of the kinetic chain and adding, after healing is completed, the involved. The timetable may have to be varied to a greater
glenohumeral link to the chain as Kibler learns [70]. or lesser extent depending on individual tissue healing
On the other hand, different is the treatment of the same times (implant-bone, bone-bone, tendon-bone, etc.) that
fracture in the category of patients that are more frequently must be monitored by imaging techniques and clinical
the victims of this pathology: the peri-/postmenopausal assessment by the surgical team and weighed against the
women and men over 70. often patient-specific response to rehabilitation.
In these cases, once a course of rehabilitation is chosen, it Usually we advise to begin no earlier than one week
is essential to keep in consideration the associated comor- immediately after the trauma (one week off therapy).
bidities, in particular musculoskeletal. This is important for pain control and also because of the
A treatment which is too aggressive could in fact bring motional patient’s adaptation to this new situation, especially
out cervical or low back disease, pathological fractures, etc., in the older one. On the other hand, we advise not to begin
complicating and stunting recovery. rehab more than three weeks after the trauma to avoid cap-
We want to pay attention to these elements to underline sular contracture, muscle atrophy, and loss of the postural
that as well as the correct approach to the specific treatment control (Table 1.6) [41].
Table 1.6
Healing progression criteria
Healing
Mobility Capsular release Proprioception Scapular control Muscolar strenght
Time
zero
inflammation Pain Tightness

1.4.3 Healing Progression Criteria have to be, as traditional protocol [72], of 90° to allow
the arm to be in perpendicular line to the ground and
According to this, the protocol is divided into three sections not subjected to cutting forces.
of work: There are different movements that we can ask to the
patient: lean over the table, and support body with the
1. Early management (0–4 weeks) Goal → Pain control and uninvolved arm. Let the involved arm hang straight down
progressive recovery of range of motion (ROM); this in a relaxed position; gently swing arm in circles, clock-
phase includes some different steps: wise and counterclockwise, then in a pendulum motion
• Control pain and inflammation with immobilization, forward-backward and side to side (Fig. 1.23a, b).
modalities, analgesics, and nonsteroidal anti- • Scapular control exercises [70]: after the trauma, we
inflammatory drugs. have to pay attention to avoid losing the correct scapular
Pain, during rehab program, is one of the key points kinematics and to maintain the correct scapular rhythm
because all the exercises have to be relatively pain-free. with exercises that do not necessarily require motion of
It’s difficult to progress a painful joint and it is a sign the shoulder. Restoration of the normal posture and scap-
that either the wrong exercise is being done for that time ular retraction, after the trauma, should be achieved in an
in the recovery process or it is being done improperly. upright position with the feet on the ground so as to
• The education to prevent inappropriate shoulder restore normal physiology and proprioception. All exer-
movement patterns. cises should be initiated with the patient in the “ideal
• Pain-free passive shoulder flexion on scapular plane position,” with good postural alignment, the pelvis lev-
exercise until evidence of fracture healing is present. eled, and the scapular retracted and depressed [74, 75].
Early joint mobilization plays an important role in Once the healing process of the fracture has been
the rehabilitation of the injured shoulder for the accomplished, glenohumeral rehabilitation can pro-
return of normal kinematics and shoulder function, ceed, with restoration of capsular mobility and rotator
avoiding capsular contracture. Prolonged immobili- cuff activation to restore normal concavity/
zation may predispose patients to muscle atrophy and compression.
poor neuromuscular control (Figs. 1.20, 1.21, and The scapular control is crucial to regain the correct
1.22) [71]. range of motion, being the scapular balance essential
• Codman’s pendulum exercises (when there is evidence to the arms’ elevation (proximal stability to distal
of fracture healing): gravity-assisted pendulum exer- mobility) (Fig. 1.24).
cises are commonly prescribed after PHF to provide
decreased pain, increased flow of nutrients into the 2. Intermediate management (4–8 weeks) Goal → active
joint space, and early joint mobilization [73]. mobility recovery and to regain complete range of motion.
Shoulder protocols, as well as Codman [72–78] him- It is preferable, in our experience, to have the patient
self, suggest that weight may be added to these pendu- due a little bit frequently rather than overloading muscle
lum exercises as rehabilitation progresses. In the early tendon units, ligaments, and callus progression. It is more
management, we suggest to not use weight to avoid important that patients progress steadily than that they
compromising the fracture’s fragment stabilization. reach landmarks at specific times. The rationale and the
The exercise have to follow specific postural condi- quality of the exercise are more important than the quan-
tions: the degree to which the trunk is flexed at the hips tity being performed.
Exercises have to be done until the muscles fatigue 3. Late management (after XR follow-up) Goal is to regain
which is when mechanics become abnormal, rather than the shoulder functional mobility and strength. This phase
completing a specified number of sets and repetitions. includes some steps:
Progression from submaximal to maximal effort over the • Passive stretching of any remaining soft tissue tightness,
course of the program is desirable. The preferred progres- usually abduction/external rotation and adduction/inter-
sion in strengthening is isometric to eccentric to concen- nal rotation: in this phase we have to regain the last
tric training. Closed-chain precedes open-chain exercise. degrees of motion and we can use a more aggressive
As more exercises are added, the easier ones should be approach (pain-free) (Figs. 1.20, 1.21, and 1.22).
eliminated to prevent boredom on the part of the patient. • Isometric rotator cuff muscle activation (Fig. 1.29a, b)
This phase includes some steps: [79, 80].
• Supervised active/assisted shoulder exercise in the • Progressing to full activity against gravity.
supine position: the regain passive motion is the start • Increase focus on isotonic strengthening, restoring
point to ask to our patient to begin to make this upper extremity motion into the kinetic chain.
movement in autoassisted way. The reason is the
importance of the recovery of the functional motion The perils of nonunion, symptomatic malunion, and avas-
and of the muscle activation. The supine position is cular necrosis of the humeral head are the main protagonists
preferable to maintain a low activation of upper in preventing a positive outcome.
trapezius during exercises and avoid scapular improper
movements. In addition, the patient, especially after
the trauma, prefers the lying position to relax the back Table 1.7 Conservative treatment of proximal humeral fractures
during the new proposed exercises. In this specific Week Treatment
kind of exercise, doing the exercise in lying position 1st Gilchrist arm sling,
helps the patient to regain the range of motion beyond Elbow and hand exercise
90°, because we have used gravity on purpose to help 2nd–3rd Pendulum exercises
the patient to guide the arm to the maximal range of Scapular control exercises
motion out of pain (Figs. 1.25, 1.26, and 1.27) 4th–7th Progressive active assisted physiotherapy
[76–98]. 8th Free mobilization
• Light functional exercises without exacerbating pain.
• Use a gentle massage therapy for muscles pain relief
(Fig. 1.28) [81, 82, 85].
Figs. 1.20, 1.21, and 1.22 Passive shoulder flexion/abduction and external/internal rotation in pain-free stretching
a b
90° 90°
Fig. 1.23 (a, b) Codman’s pendulum exercises → gently swing arm in circles clockwise and counterclockwise, forward- backward and
side-to-side
Fig. 1.24 Basic Scapular control exercise → close the scapula emphasizing the lower trapezium contraction
Figs. 1.25, 1.26, and 1.27 Supervised passive and active- assisted exercises in supine position made to increase ROM
Fig. 1.28 Use a gentle massage therapy for

muscle pain relief and to reduce tissue
tightness [81, 82, 85]
Fig. 1.29 (a, b) Double press exercise → Push the elbow against the ball maintaining the scapula in the correct retracted position and, at the same
time, press the ball with the hand. The isometric exercise is important to increase the muscles strength safeguarding the tendon structures [79, 80]
1.5 When to Choose Surgical Treatment? Surgical approach and the type of implant depend on the
pattern of the fracture, the quality of the bone encountered
In decision-making, patient expectations are important: (osteoporosis, pathologic fractures), the patient’s goals, and
the surgeon’s familiarity with the techniques.
• Young individuals who need to regain preexisting levels An adequate surgical technique will minimize complica-
of functional requirements tions and an accelerated rehabilitation regime, if possible,
• Elderly patients who wish to resume their activities and will ensure the best possible result [33].
their functional autonomy The two main operative approaches are:
• Reduction and internal fixation may be indicated in about
20 % of cases comprising both standards under the fol- • The deltopectoral approach (Fig. 1.30a)
lowing condition: • The lateral trans-deltoid (AO) (Fig. 1.30b)
– Tuberosities are displaced over 10 mm.
– Risk factors for avascular necrosis (see above vascular
patterns).
Take-Home Message
The influence of the surgical approach, if rightly per-
1.5.1 Surgical Treatments formed, from the rehabilitation point of view doesn’t
have a great consequence because the deltopectoral
Ideally the following should be applied: approach creates a cleavage between the deltoid and
pectoralis major.
• The principle reconstruction of the articular fracture. The lateral trans-deltoid approach, used for iso-
• The head and tuberosities should be carefully reposi- lated tuberosity fractures, creates a cleavage across the
tioned to avoid weakness due to shortening of musculo- deltoid raphe, so it doesn’t create any iatrogenic lesion.
tendinous units and a decreased moment arm. Dedicated attention has to be payed to the execution
• Restoration of the anatomy and stable fixation. of this approach, concerning the distal extension of the
• Stable fixation avoids stiffness to allow immediate pas- deltoid cleavage that can’t be more than 4 cm from the
sive treatment so that adhesive scarring is limited and lateral border of the acromion to avoid the axillary
recovery of function is possible with minimal muscle nerve that could drastically irreversibly compromise
atrophy. the functional recovery.
• Respect of the soft tissue and the vascular supply.
a b
Fig. 1.30 (a) Delto-pectoral approach (blue line). (b) Lateral trans deltoid approach (blue line)
Reduction and Internal Fixation: Treatment Newer designs of implants (locking compression
Options plate) have screwheads which lock into the plate, thus
• Transosseous fixation → is indicated for two-part greater allowing angular stability of the screws in relation to the
tuberosity fractures and also when a surgical neck frac- plate. This type of implant gives improved stability and
ture exists [42]. may therefore speed bony healing and functional
Nonabsorbable sutures are used to capture rotator cuff recovery.
tissue fragments anteriorly, laterally, and posteriorly. Initial data on the specific locked fixation devices plate
The displaced humeral head or greater tuberosity are nearly eliminated complications due to hardware failure
reduced and fixated to the shaft through drill holes or and subacromial impingement with good functional out-
suture anchors [43]. comes if correct surgical technique is employed.
• Closed reduction and percutaneous stabilization → is a Osteosynthesis is indicated for 2-, 3-, and 4-part frac-
minimally invasive technique with limited indications. tures in appropriate patients (Fig. 1.33a).
Amenable fracture patterns include 2-part proximal Exceptions include some 4-part fractures, head-split-
humerus fractures, ideally of the surgical neck, and 3- or ting fractures, and fracture-dislocations, which are candi-
4-part fractures with adequate bone stock. dates for prosthetic replacement.
Theoretically, this technique limits iatrogenic vascular The fragments of the fracture must be carefully identi-
compromise, postoperative pain, operative time, and fied and tagged with stay sutures at the tendon-bone inter-
blood loss while improving aesthetics. face using the long head of biceps as a landmark.
• Intramedullary fixation → These devices can be used for Usually it will be possible to reposition the fragment of
fixation of 2-, 3-, and 4- part fractures. Most successful the head on the metaphysis and to obtain provisional fixa-
outcomes occur in 2-part fractures. Intramedullary nail tion with Kirschner wires.
fixation with indirect reduction has the benefit of decreased This is especially true of fractures which are aligned in
soft tissue stripping. Some surgeons are reticent about varus, while in valgus-impacted fractures, if the impaction
intramedullary nailing in the younger patient due to is extreme, the head may be unimpacted and held in place
reported rotator cuff damage and persistent shoulder pain. by an intercalated bone graft.
This can be minimized by meticulous placement of the In this situation, and when using this technique, care
entry point, avoiding the footprint of the supraspinatus must be taken not to disturb the soft tissue attachments of
tendon. Ensuring the nail is well buried under the bone the medial head-neck junction, as reported previously it is
also helps prevent postoperative discomfort and subse- in this area that the medial circumflex artery penetrates
quent need for nail removal. the humeral head and this tissue may carry the remaining
Complications of intramedullary nailing include screw good supply.
penetration, nail impingement, hardware migration, and The greater and/or lesser tuberosities are also reduced
failure of fixation (Fig. 1.31a–d). and a contoured T-plate is applied, taking care not to
injure the long head of biceps.
• Open reduction and internal fixation with locked plate Screws are then inserted and the suture bays are either
(Fig. 1.32a–c). Indications have expanded with the intro- removed or tied into the plate holes or transosseously
duction of locking plate technology. (Fig. 1.33b).
Fig. 1.31 (a, b) PHF with integrity of the tuberosities and intramedullary fixation. (c, d) Valgus fracture and intramedullary fixation.
dx: right side sx: left side
a b
Greater tuberosity
Humeral head
Shaft Reduction
Fixation
Fig. 1.32 (a) PHF. (b) Open reduction of the PHF. (c) ORIF internal fixation with locked plate
Fig. 1.33 (a) PHF with medial displacement of the shaft.

(b) ORIF with locked plate a
b
Hemiarthroplasty The importance of anatomical restoration of the tuberosi-

Hemiarthroplasty for proximal humerus fractures is a good ties including secure fixation and restoration of humeral
surgical option for low-demand elderly patients or fractures length and retroversion cannot be overemphasized.
that are not amenable to ORIF (open reduction internal Ideally, the humeral implant should have a low-profile lat-
fixation). eral fin to facilitate proper positioning and suture fixation of
Significant controversy exists as to the best surgical inter- the tuberosity (Fig. 1.36a, b).
vention for 3- or 4-part fractures in the elderly osteoporotic Malunion, nonunion, or reabsorption of the tuberosities
patient (Fig. 1.34a, b) [44]. (Fig. 1.36c) is the most common and perhaps most serious
These patients have been shown to have significantly less complication that can occur after hemiarthroplasty in dis-
pain after hemiarthroplasty compared with nonoperative placed PHF (loss of “engine”).
treatment, although range of motion is similar [45]. Loss of anatomic landmarks makes the restoration of
Patients who present with initial varus angulation greater humeral height difficult. Shortening the humerus decreases
than 30° are at increased risk for fixation failure, and thus the lever arm of the deltoid muscle and therefore decreases
hemiarthroplasty may decrease their need for reoperation [46]. the motion and power of the muscle in forward elevation.
Further, fracture-dislocations may do poorly following Lengthening may contribute to superior humeral migration
osteosynthesis and thus should be treated with arthroplasty, and impingement and/or nonunion of the tuberosities.
except in the young patients. Most authors recommend 30–40° of retroversion, typi-
It is also important to consider the degree of underlying cally with use of the bicipital groove as the landmark for
shoulder pathology, including symptomatic glenohumeral orientation of the prosthesis [50], although an individualized
osteoarthritis or rotator cuff arthropathy; if present, these approach has been proposed in which the contralateral
could potentially predispose the patient to poor outcomes humerus is used for comparison to estimate the proper
following osteosynthesis. amount of retroversion for each patient [51].
Thus, the presence of osteoarthritis or rotator cuff pathol- The tendency is to position the humeral head in excessive
ogy should influence the surgeon’s choice away from ORIF retroversion because of imprecise landmarks and the desire
and toward either hemiarthroplasty or reverse total shoulder to prevent anterior dislocation. Placement of the head in too
arthroplasty. much retroversion may lead to excessive posterior rotator
Hemiarthroplasty : the prosthetic element restore the ful- cuff tension, suture pullout, and malunion or nonunion of the
crum and the healing of anatomic tuberosity enables a func- greater tuberosity. Another point to remember is that restora-
tional rotator cuff (engine) and is critical for patient satisfaction tion of the epiphyseal width is critical to reproduce the soft
and functional outcomes following hemiarthroplasty. tissue tension of the deltoid and supraspinatus muscle; the
Boileau et al. found that tuberosity malpositioning opposite shoulder can be used as a template to gauge the
occurred in half of all patients who underwent hemiarthro- epiphyseal width.
plasty for PHF. This was also highly correlated with Factors that have been shown to be associated with tuber-
unsatisfactory results, prosthesis malalignment, decreased osity malunion include:
range of motion, and residual pain.
Tuberosity healing and outcomes may be improved by • Poor intraoperative positioning of the prosthesis (exces-
use of a fracture-specific humeral component (79 %) sive height and /or retroversion)
compared with those treated by a conventional stem • Initial tuberosity position
(66 %) [47]. • Patient age in excess of 75 years
The mean head-to-tuberosity distance (and standard devi- • Female gender [47]
ation) should be 8 ± 3 mm as shown by Frankle et al. [48] and
Mighell et al. [49]. The optimal timing of hemiarthroplasty is also
Treatment of PHF with HEMI is a demanding operation, important.
and many variables, including patient factors, surgical tech- Most recent reports [49–52] have shown that acute treat-
nique, and rehabilitation, can influence outcome after this ment is generally preferable to delayed response because
procedure. acute hemiarthroplasty is technically easier to perform; how-
To maximize the probability of an optimal outcome, sur- ever, one study found no difference between early or late
geons should play particular attention to two important goals: treatment when a breakpoint of thirty days after injury was
used [53].
• Restoring the tuberosities to an anatomical position There is debate in the literature as to hemiarthroplasty
(Fig. 1.35a) versus reverse total shoulder arthroplasty for acute PHF.
• Placing the humeral component in the correct amount of Currently indications for a reverse total shoulder arthro-
version and height (Fig. 1.35b) plasty in PHF are limited to rotator cuff deficiency and severe
tuberosities comminution with intact axillary nerve recognize those risk factors previously described that can
(Fig. 1.37a, b). compromise the healing of the tuberosities and the
Recently outcomes showing data comparing hemiarthro- humeral head.
plasty with reverse for acute PHF showed superior function When surgery is needed and the general clinical condition
in a patient who underwent reverse total shoulder arthro- of the patient is not critical, the tendency, therefore, is to pre-
plasty [54, 55]. serve the anatomy (ORIF).
In a patient where there is concern for tuberosities healing If the fracture is characterized by a significant comminu-
due to comminution, as well in patients with glenohumeral tion of the humeral head (loss of “fulcrum”), we opt for a
arthritis, a reverse shoulder arthroplasty avoids reliance on hemiarthroplasty.
the rotator cuff and provides the patient with a functional With a significant damage of the tuberosities and espe-
shoulder. cially of the greater tuberosity (loss of “engine”), the only
The role of the surgeon, when he matches with PHF, is alternative is the inverse prosthesis that represents the new
to correctly interpret the pattern of the fractures to “fulcrum” and the deltoid the new “engine” (Fig. 1.38a, b).
Treatment algorithm for PHF based on age
Legend:
Fisiologic age for PHF RF = Risk Factor
Age Young patients Middle age 50-70 Elderly

<50 >70
2 part Conservative Conservative Conservative

or or or
ORIF according to ORIF according to ORIF according to
RF RF RF

or or or
RF RF RF
or
HEMI

or or or
RF RF RF
or
HEMI
5 head split ORIF ORIF vs HEMI HEMI
6 fracture ORIF ORIF vs HEMI HEMI

dislocation
Fig. 1.34 (a) PHF in osteoporotic patient. (b) Treatment with hemiarthroplasty
a b
Fig. 1.35 (a, b) In surgical approach with hemiarthroplasty the healing between the tuberosities and the shaft is crucial to obtain a valid “engine”
because the “fulcrum” is represented by the new prosthetic component
a c
Fig. 1.36 (a, b) There are some skilled prosthesis that presents anchor points especially designed for the osteosynthesis of the tuberosities.
(c) PHF sequelae treated by hemiarthroplasty with important tuberosities reabsorption → loss of “engine”
Fig. 1.37 (a) PHF with severe tuberosities comminution. (b) Reverse prosthesis for fracture a. sn: left side
Fig. 1.38 (a, b) In the reverse prosthesis

the “fulcrum” is represented by the a
prosthesis itself (humeral concavity and
glenoid convexity), the “engine” is
represented exclusively by the deltoid
b
1.5.2 Rehabilitation following Surgical 2–9°day → Even if the international literature reports aggres-
Treatments sive treatment protocols advising to begin passive exer-
cises from the second postsurgical day [76], on the other
Rehabilitation Following ORIF hand, according to our experience, in older patients we
The rehabilitation after treatment of PHF presents many prefer to wear a brace in neutral position for 7–10 days
variables not to be underestimated, even if the choice in sur- after the surgery to adapt to this new physical and emo-
gical treatment allows for early mobilization for the stability tional situation; after that we begin the rehab protocol.
of the bone fragments obtained by the synthesis. Anyway in younger patients with stability of the fracture
We need to take in to consideration the fact that if the and good quality of the bone and of the soft tissue, we
surgeon opted for the surgical treatment, evidently the pat- also follow an accelerated protocol.
tern of the fracture was at risk for biomechanics (displaced
fractures) and biology (reabsorption of the humeral head and The rehabilitation protocol should be rolled out in line
of the tuberosities) or the patient presented with comorbidi- with each individual patient’s progress, which in turn is
ties which rendered him or her at risk candidate for conserva- closely linked to compliance and tissue healing times.
tive treatment. The following protocol must therefore be modulated not
For this reasons, in the postsurgically rehabilitative only in terms of the specific exercise to be chosen for a spe-
approach, the physical therapist must monitor diligently the cific purpose but also when to introduce an exercise, a deci-
progression of the rehabilitation in a way to readily identify the sion that should be taken in agreement with the surgeon.
patients that warrant a reexamination from the surgical team. Although goal achievement rates will closely depend on
In the postsurgical patient treated with ORIF, the pain team experience, patient progression can be based on the fol-
management and the progression criteria of the rehabilita- lowing three-phase strategy:
tion protocol overlap with the rational that we underlined in
the conservative treatment chapter. • Phase 1
10° days to 6 weeks → on removal of stitches (12 days)
Sling Use (Fig. 1.39b): rehabilitation protocol starts. What are the
In the postsurgical treatment, to relieve pain and as a protec- goals?
tive mechanism, we advise the use of an arm sling (neutral Confidence: Create a sound patient-therapist relation-
rotation to avoid stress on greater or lesser tuberosity ship based on trust and empathy.
(Fig. 1.39a)) for 7–10 days during which, however, the arm Pain Control: The sling may cause the patient to adopt
sling can and should be removed temporally for flexion and defensive antalgic posture (anterior scapula tilting) with
extension of the elbow. In the case of elderly osteoporotic consequent contraction of the peri-scapular muscles and
patients, another 3 weeks of sling to protect the fracture heal- shortening of the anterior muscles (pectoralis minor). The
ing could be (Fig. 1.39). physiotherapist can help in this with:
• Gentle massage of the peri-scapular muscles to avoid
1° day → In the immediate postoperative period, control of or eliminate antalgic contracture
pain is a primary concern. Patients should benefit from • Stretching
scalene block performed immediately before operation PROM: We start passive range of motion on the scapu-
[33], and if possible, the catheter should be left in place lar plane in relation to pain. The physical therapist’s role is
and the pain controlled by PCA (patient-controlled anes- crucial (Fig. 1.40a, b). The main aim in this phase is to
thesia) computerized pump. regain passive ROM; therefore the rehabilitation program
Pain in the initial post-op period is due to the iatrogenic must be tailored to patient compliance and expectations as
injury made necessary by the surgical procedure and to well as to the quality and stability of the reconstruction. Is
muscles that have become shortened and contracted, giving advised. in this phase, to propose the PROM and the auto-
rise to defensive antalgic posture. Although NSAID admin- assisted exercises in supine position to mantain a low acti-
istration will help relieve pain, the physiotherapist is key to vation of upper trapezius during the shoulder movement
pain management in the preliminary rehabilitation phase. and avoid to activate scapulars’ imballances. [76–98]
Conditions can delay the beginning of passive range of Active Assisted: Once the patient has achieved 90°
motion: pain-free passive range of motion with stable, X-ray doc-
• Poor screw adhesion in osteoporotic bone umented, osteosynthesis, active/assisted kinesis in the
• Problems relative to healing of the soft tissue (tendon scapular plane can be started. Care should, however, be
or ligamentous) taken with external rotation if there are any concerns
• Other particular conditions (as in closed reduction and about the lesser tuberosity and with internal rotation if the
percutaneous stabilization) stability of the greater tuberosity is in doubt.
Proprioception Exercises: Proprioceptive control (the

ability to identify, control, and coordinate the different Take-Home Message
body segments in relation to each other, with or without We suggest in the first postoperative weeks repeated
visual afference) is crucial for functional recovery. clinical controls to identify those patients who for
Neuromuscular exercises develop the basic stability that varying reasons are predisposed to postsurgical capsu-
must underpin range of motion recovery. lar retraction. If these patients who present with this
Scapulothoracic: Proprioception exercises can be com- individual predisposition are identified early, an accel-
bined with scapulothoracic exercises extending to less than erated treatment plan (if allowed to stability of the
90° so as to ensure gradual, gentle recovery; these exercises fracture) and hydrotherapy is a valuable adjunct.
aim to maintain peri-scapular neuromuscular control so as
to allow progression to the next rehabilitation phase.
HEALING PROGRESSION
Phase 1 Phase 2 Phase 3
Passive mobilization
Active/assisted mobilization
Active mobilization
Time zero 90°of PROM, Bone

(10 day) stable stability
osteosynthesis
and pain –free
• Phase 2 Advanced Scapulothoracic Exercises: while always

6–10 weeks: Goals → To achieve satisfactory passive taking into account patient ability and compliance,
ROM, approximately 80/90 % of the contralateral arm. advanced scapulothoracic exercises extending beyond
This part of the rehab program aims to improve activation 90° aim to increasingly recruit and strengthen the scapu-
of the rotator cuff and scapulothoracic muscles to regain lar muscles and improve the dynamic stability of the
kinetic chain shoulder function once there is documented shoulder joint (Fig. 1.41a–c).
evidence of tuberosity healing. Exercise progression cri- Isometric Exercises: isometric exercises actively
teria are the following: recruit the rotator cuff and deltoid muscles, the latter
Passive and Active Assisted Mobilization: passive being the “engine” of the system. They pave the way for
mobilization in this phase aims to achieve 90 % ROM the full active functional recovery to be obtained in the
while the assisted active exercises started in Phase 1 are subsequent phase (Fig. 1.41d, e).
progressively increased with a view to regaining active
mobility in Phase 3.
• Phase 3 patient is pain-free and has achieved almost com-

10–12 weeks: Goals → Once PROM is 90–100 % of the plete motion.
contralateral arm and there is X-ray evidence of healing, – Balance stabilization exercise’s (Fig. 1.44a, b) purpose
the goal of rehabilitation becomes regaining full correct is for muscle and strength activation.
functional capacity. This phase will proceed with: → If at this point the passive ROM is under 80 % with
Active Exercises: Progressive strengthening exercises respect to the contralateral, we advise for a clinical and
are added to the regime at this point. radiographic evaluation to rule out unstable fixation:
Gradually the patient is taught to use operative arm • Unstable fixation →specific orthopedic treatment
more and withdraw assistance from the contralateral arm • Stable fixation with good healing →emphasize stretch-
during therapy. ing program
– Patients are allowed and encouraged to perform activi- Usually the shoulder takes about a year to achieve opti-
ties of daily living. mum function, but this may still improve for a further 12
– Theraband resistance (Fig. 1.42a–c) exercises and months.
light weight (Fig. 1.43a–e) are begun when the
What must I know? Symptoms Solutions

Postsurgical phase Unrelenting pain that lasts in postsurgical days, Seek assistance from the referring surgeon
specifically resistant to medical treatment → must be a sign
of alarm
Rigidity in internal and /or external rotation during the
first phase of the rehabilitation → can be a sign of capsular
retraction.
Alterations in sensation, accompanied by a severe pain,
can mean → movements of the plate or fragments
migration → advise to examine radiographically
Since surgery to 10 weeks Pain that extends down the arm and into the hand in the Seek assistance from the referring surgeon
first postsurgical weeks → can be a sign of algo-neuro-
dystrophy reflected or incipient or can be a sign of unmask
of a cervical-brachial pain
Since 10 weeks to 1 year If the active range of motion is limited but passive is Seek assistance from the referring surgeon.
normal → one may assume reabsorption of the tuberosity Advise radiographic consultation and eventually
(loss of engine) CT scan
Progressive degradation of the articular range of motion,
also after a year, can have significant → avascular necrosis
of the head of the humerus (loss of fulcrum)
Take-Home Message In patients in their 70s and 80s with osteoporotic

• The final objective is to regain functionally and bone, the post-surgically management is extremely
strength. delicate and must be managed with a clear and pre-
The worse the initial fracture is and the older cise communication between the surgeon and the
patient, the more the possibility exists of left over rehabilitation team.
rigidity of the joint. The surgeon must inform the phisioterapist
• Fundamentally in the rehabilitation postsurgical about the quality of the bone, about the bone-plate
timing is the balance between the need of biological stability complex and on the evolution of the cal-
healing of bone tissue, that doesn’t have to be lous formation monitoring with periodic x-ray
stressed too much, and the need to mobilize the exams. The therapist, on the other hand, correctly
joint in order to avoid a capsular stiffness that can informed by the surgeon, mobilizes the shoulder
be complication of this type of fracture. joint according to the parameters given by the surgi-
In a young patient with a good bone quality and cal staff, representing fundamental feedback for the
stable plate, we can opt for a relatively aggressive surgeon on how the patient is responding to
functional rehabilitation. treatment.
Fig. 1.39 (a) Rest in sling in

a b
netural position. (b) Delto-pectoral
approach
a b
Fig. 1.40 (a, b) Passive stretching playing attention to the internal and external rotation in relation to the healing of the tuberosities. (c) Active
assisted exercises
Fig. 1.41 (a-c) Slide ball exercise → Push forward the ball sliding it and come back pushing the scapula in the correct retracted position [70].
(d, e) Isometric exercises
Fig. 1.42 (a–c) Scapular control exercises using tube with the PT assistance paying attention to the scapular retraction. We have to put in back
the scapula in the kinetic chain → for this reason we must to emphasize the trunk and the hip stabilization [70]
d e
Fig. 1.43 (a–e) Scapular control exercises using light weights. After 10 weeks we can use the weights to emphasize the scapular retraction with
the PT assistance [70]
Fig. 1.44 (a, b) Body Blade stabilization → This exercise is helpful to improve the muscle balance and the stability of the shoulder in the final
phases of the physical therapy [83, 84]
1.6 Rehabilitation and if repair of the lesser tuberosity was performed, avoid
following Hemiarthroplasty early external rotation.
Gentle active motion of the wrist and elbow is encour-
While hemiarthroplasty after proximal humeral fractures has aged immediately postoperatively to avoid stiffness and
been shown to provide good pain relief, the achievement of pain due to immobilization.
excellent range of motion with this method has been less Pendulum exercises are allowed to the patient, as we
predictable. explain in previous rehabilitation paragraph, if
Rehabilitation, particularly passive range of motion in the pain-free.
early stage and long-term active range of motion and strength- • 6/8 WEEK → Active/assisted forward elevation and exter-
ening, is considered essential to the achieving an optimal out- nal rotation exercises are delayed until radiographic evi-
come after shoulder hemiarthroplasty [51, 53, 56]. dence of tuberosity healing is present (Fig. 1.47).
Immediately after surgery, the affected extremity is placed Once tuberosities healing is confirmed radiographi-
in a sling in a slight external or neutral rotation to relieve cally, gentle isometric rotator cuff and scapular strength-
stress on the greater tuberosity. ening can begin, typically at 6–8 weeks following surgery
The following week-based timetable is only a general (Figs. 1.48 and 1.49).
postsurgical rehabilitation program since work will be con- The rehabilitation program have to obtain the regain of
ditioned by individual tissue healing times (implant-bone, the functional utilize of the arm and improve the articular
bone-bone, tendon-bone, etc.) that must be monitored by range of motion as well as possible emphasizing the scap-
imaging techniques and clinical assessment by the surgical ular control to restore the correct kinematic and validity
team and weighed against the often patient-specific response of the kinetic chain in relation to the real general condi-
to rehabilitation. tion and comorbidities of our patient (Fig. 1.50).
In general, rehabilitation begins within the first week. The estimated maximum level of improvement can be
achieved 9 to 12 months postoperatively.
• 1/6 week → The decision to initiate passive ROM exercise
should be individualized to the patient and it depends on
the surgeon’s confidence in the strength of tuberosity
fixation. Take-Home Message
Passive ROM exercises to 90° of forward elevation on The rehabilitation time in hemiarthroplasty as well as
the scapular plane, very gentle external rotation, and in the case of ORIF of the PHF, are given by a biologi-
paying attention to internal rotation to avoid stress on the cal healing time bone to bone. In the prosthetic the two
greater tuberosity are performed with the patient supine bone components that must necessarily heal are
(Fig. 1.45a, b and 1.46) [99]. the greater TUBEROSITY and the DIAPHYSIS
With tenuous tuberosity fixation, ROM exercise can be (Fig. 1.32a).
delayed for 2–3 weeks to minimize stress on the repair,
Fig. 1.45 (a, b) Passive ROM exercises on scapular plane and gentle external rotation
Fig. 1.47 Active/assisted forward activation
Fig. 1.46 Pay attention to internal rotation

Fig. 1.48 Isometric exercises
Fig. 1.49 Scapular control exercises
Fig. 1.50 Arm stretching elevation

1.7 Complications about 1 cm from the base of the scapula spine and courses
2 mm posterior to the glenoid rim [95].
1.7.1 Neuroanatomical and Neuromechanical The nerve is particularly vulnerable to traction injury at
Aspects of the Shoulder following two distinct locations: its branch-point from the upper trunk
Proximal Humeral Fractures and at the suprascapular notch where it runs deep to the
transverse scapular ligament.
Mechanical stresses and loads potentially can injure special-
ized connective tissues of the shoulder.
The pain felt at the shoulder as a result of mechanical 1.7.2 Complications Following ORIF
stresses after a proximal humeral fracture is often also due
to the physical distortion of nociceptors that lie within these A favorable outcome is generally achieved if some compli-
tissues or is a consequence of chemical activation of the cations can be avoided: AVN (Avascular Necrosis), non-
resident nociceptive free nerve endings that are depolarized union and tuberosities mal- union, post-operative infections.
as a result of damage to the cell walls of the tissues These can be sequelae of either the original injury of sub-
(DEAFFERENTATION). sequent management:
Nociceptors are the biological transducers that convert
physical and chemical energy stimuli into action potentials. 1. AVN is more commonplace in comminuted fractures,
When muscles, tendons capsuloligamentous structures although associated dislocation also increases the risk
are damaged partial deafferentation leads to proprioceptive of impairment of vascular supply to the humeral head.
deficit. As previously mentioned, the infero-medial portion of
In addiction to injury to the specialized connective tissue or the head is believed to be a critical area with regards to
damage to the muscolotendinous tissues, pain felt within the maintaining adequate blood supply. Pain and loss of
shoulder after a trauma that lead to a PHF may be caused by function are commonly seen in those patients who
several other neuroanatomical or neurophysiological factors. develop AVN.
The axillary nerve is the most frequently injured nerve in How to search?
proximal humerus fractures, and the suprascapular nerve is • Plain radiographs may show changes somewhere on a
the second most commonly injured [94]. spectrum between sclerotic patches to collapse and
The axillary nerve enters the quadrangular space along resorption of the affected bone.
with the PCHA at an average distance of 1.7 cm from the • MRI is commonly used to further evaluate the extent
surgical neck [95]. of damage.
In the quadrangular space, the nerve divides into anterior What to do?
and posterior branches, the latter of which provides motor input • Core decompression has been advocate in early dis-
to the posterior and middle heads of the deltoid before termi- ease, however most require humeral head replacement
nating as the superior lateral brachial cutaneous nerve [95]. [31, 57].
The anterior branch of the axillary nerve continues along 2. NON UNION OR MAL UNION :The normal contributory
the undersurface of the deltoid, crosses the anterior deltoid factors for non- union apply to PHF as well such as infec-
raphe, the avascular region separating the anterior and mid- tion are poor physiological reserve, smoking, diabetes,
dle heads of the deltoid, at an average of 3.5 cm from the inadequate fracture stabilization and excessive soft tissue
lateral prominence of the greater tuberosity and 6.3 cm from stripping [58, 59]. Mal- union is common after these frac-
the anterolateral border of the acromion [96]. tures. The elderly population tend to cope well, undoubt-
Gardner and colleagues showed that this nerve can be edly due to lower expectation demands. Younger patients
reliably palpated as a cord-like structure at this location. would notice a decrease in function particularly when the
The proximity of the axillary nerve makes it particularly tuberosities and their adjoining cuff insertions are
vulnerable to both traumatic and iatrogenic injury [97]. involved.
The suprascapular nerve runs posteroinferiorly through Though some amount of stiffness is expected after
the suprascapular notch to supply the supraspinatus and these fractures, other significant limitation should be
infraspinatus muscles, the motor branch of the nerve arises investigated and treated.
Capsular tightness, tuberosities mal-union or reabsorp- How to search?

tion, (Fig. 1.51) impingement secondary to plate misplace- • Radiological evidence
ment, screw protrusion (Fig. 1.52a–c) and cuff dysfunction • Biological evidence with intra-articular aspiration that
can all contribute to a stiff shoulder. could show if the infection is acute (<3 weeks), inter-
How to search? mediate (between 3 and 8 weeks) or chronic (>8 weeks).
• Radiographs may show the non-union, but a CT scan What to do?
may be required for confirmation and also provides In this situation an intravenous antibiotic regime must to
useful information for pre-operative planning. be started preferably under the guidance of an infectious
What to do? diseases’ specialist.
• If a non-union is present either shoulder hemiarthro- • Acute infections → The implant may be left in place if
plasty or ORIF with bone grafting is usually required. it contributes to stability
3. POSTOPERATIVE INFECTION is always a possibility • Intermediate infections → in this situation a secondary
and must be kept in mind at all times. The signs and intervention may be contemplated, such as a fusion or
symptoms may be minor, such as loss of GO joint space reimplantation of the prostheses.
accompanied by persistent pain and discomfort. These • Chronic infections → Removal of the implants is
symptoms could be the first indication of infection. mandatory.
Fig. 1.51 Tuberosity mal union and reabsorption

Fig. 1.52 (a) Screws protrusion. (b) Solution

1.7.3 Complications In general antibiotic prophylaxis has been shown to

following Hemiarthroplasty reduce the incidence of hemiarthroplasty shoulder infections
and to be cost effective.
The literature describes some different complications that Surgical side preparation with an antiseptic prophylaxis
can occur after hemiarthroplasty. antibiotic administration before the start of procedure will
Bigliani et al. [60] identified tuberosities non-union as the predictably eradicate the offending organism.
most common cause of failure in a series of 29 failed shoul- Shaving and draping the axilla have been proposed as
ders in which hemiarthroplasties were performed to manage additional means of reducing the incidence of surgical site
acutely displaced PHF. infections, but the efficacy of this intervention has not be
In a meta-analysis of 810 failed shoulders hemiarthro- proved [64, 65].
plasties, complications included superficial and deep infec-
tion, heterotopic ossification (8.8 %), and proximal migration Symptoms: Symptoms usually develops within a few days
of the humeral head (6.8 %) (Fig. 1.53) [61]. after surgery and are characterized by localized wound
In general the most common complications that we can erythema and skin sensitivity.
manage are just two: Tuberosity non-union and the infection Deep infections are more difficult to recognize and may
of the implant. present in an early or delayed manner.
Increased pain and stiffness are the most common symptoms
1. TUBEROSITY NON-UNION : is the most common and associated with deep soft tissue [63, 66, 67, 69].
devastating cause of poor outcomes following for dis- Systemic symptoms (fever and chills) are less common.
placed 3–4 part PHF treated with Hemiarthroplasty. Diagnosis:
Boileau et al. found that [47] tuberosity malposition- – Radiological evidence: with early pyogenic infection,
ing occurred in half of patients who underwent hemiar- radiographic findings are typically normal. In con-
throplasty for PHF, and this was also correlated with trast, radiographs in sub-acute and delayed case may
unsatisfactory results. Prosthesis malalignment decreases show osteopenia, lucencies around a prosthetic com-
range of motion and residual pain. ponent and pseudo-subluxation of a prosthetic
How to search? humeral head [68].
• Radiographs control and CT scan – Biological evidence: aspiration of the GO joint with a
What to do? synovial fluid analysis should be considered in all
• Reverse total shoulder arthroplasty cases of suspected deep infection. White cell blood
2. Infection: The risk of periprosthetic shoulder infection count >50,000 cells/mm with more than 75 % poly-
increases when the operation is performed for fractures, morphonuclear cells are highly suggestive of
cuff arthroplasty, or radiation induced osteonecrosis. infection.
These infections are specifically influence by: The peripheral blood leukocyte count in a deep
• Obesity infection is rarely abnormal whereas the erythrocyte
• Malnutrition sedimentation rate (ESR) and C- reactive protein
• Systemic steroids (CPR) level are frequently elevated [62, 63, 66, 67].
• Malignancy Treatment:
• Chemotherapy – Systemic approach: antibiotic suppression
• Diabetes mellitus – Local approach: debridement with retention of the
• Synchronous infection prosthesis, resection arthroplasty, arthrodesis, direct
• Postoperative hematoma formation prosthesis exchange with temporary placement of anti-
• Revision surgery biotic spacer.
The varied management approaches, absence of
The most common species of isolated organisms from the uniform protocols and the use of multiple outcomes
cultures of postoperative shoulder infections are: measures make it difficult to draw definitive conclu-
Staphylococcus Aureus, S Epidermitis, Propinobacterium sions regarding treatment of infected shoulder
acnes, and Corynebacterium [62, 63]. arthroplasties.
Fig. 1.53 Proximal migration of humeral head in HEMI for PHF treatment
1.8 Sequelae of Proximal Humeral Category 1:

Fractures • Intracapsular impacted fracture sequelae: in which an
osteotomy of greater tuberosity is not required.
The treatment of complex humeral fractures or fracture dis- – Type one → Cephalic collapse and/or necrosis
locations presents several challenges. Late complications (Fig. 1.54a, b): integrity of engine (greater and the
such us mal-union, avascular necrosis or non-union are fre- lesser tuberosity), we have only to change the fulcrum
quent and often lead to articular incongruence. (humeral head) → HEMI
Patient can be severely handicapped, presenting with – Type two → Locked dislocations or fracture disloca-
considerable pain, stiffness, and important functional tions (Fig. 1.55a, b): integrity of engine, we have only
impairment. to change the fulcrum → HEMI
Stiff shoulders with distorted proximal humerus, soft Category 2:
tissue damage, a scarred deltoid and rotator cuff tears • Extracapsular disimpacted fracture sequelae: in which a
make shoulder arthroplasty a challenging procedure often humeral implant cannot be inserted without osteotomy
with unpredictable results and a high risk of and repositioning of the greater tuberosity.
complications. – Type three→ Non-union of the surgical neck
The overall results of patients with old trauma are inferior (Fig. 1.56a, b): conservative surgical treatment is pos-
to the results currently obtained in patients with primary sible→ PEG BONE GRAFT (Fig. 1.61b) + ORIF or
osteoarthritis or with recent 4-part fractures who are treated INTRAMEDULLARY FIXATION (with or without
initially with humeral head replacement. In symptomatic osteotomy)
fracture sequelae there are different surgical approaches that – Type four→ Severe tuberosity mal-union (Fig. 1.57):
we are going to discuss. loss of fulcrum and engine→ REVERSE
Among these fracture sequelae, some cases of avascular
necrosis with subchondral bone collapse, certain locked dis- Cephalic collapse and/or necrosis and chronic fracture
locations and fracture- dislocations, some non-unions of the dislocations (Category 1) are usually associated with
surgical neck with a small osteoporotic head fragment, and impacted intracapsular fracture sequelae, in which to perform
some mal-unions of the tuberosities with incongruity of the an arthroplasty osteotomy of the greater tuberosity is not
humeral articular surface may be indications for the insertion required.
of a shoulder prosthesis [86–89]. On the other side, non-unions of the surgical neck and
From a surgical point of view, fracture sequelae can be severe mal-union of the tuberosities (Category 2) are associ-
distinguished whose natural history, functional outcomes, ated with disimpacted extracapsular fracture sequelae in
and prognosis are very different [92]. which a humeral implant cannot be inserted without osteot-
The sequelae of PHF can be divided into moderate and omy and repositioning of the greater tuberosity.
major, depending on the impaction/disimpaction of the
humeral head and the connection/disconnection of the
tuberosities especially of the greater tuberosity. The disim-
paction of the humeral head and the disconnection of the Take-Home Message
greater tuberosity from the shaft are more frequent in case Reverse prosthesis is advised in cases of fracture
of extracapsular fractures of the proximal humerus as sequelae in which distortion of the proximal humeral
Boileau observed [86]. anatomy around the cuff insertion result in the func-
Boileau et co-authors have also classified sequelae of tional unless cuff.
PHF in two categories and four types:
Category and type Possible sequelae Biomechanic implications Solution

Category 1 Type 1 Cephalic collapse or necrosis Integrity of ENGINE HEMI
(Fig. 1.58a, b) →change the FULCRUM
Category 1 Type 2 Locked dislocations and Integrity of ENGINE HEMI
(Fig. 1.59a–c) fracture dislocations →change the FULCRUM
Category 2 Type 3 Non-union or mal-union of conservative surgical PEG BONE GRAFT + ORIF or
(Figs. 1.60a, b and 1.61a, b). the surgical neck treatment is possible INTRAMEDULLARY FIXATION
Category 2 Type 4 Severe tuberosity mal-union Loss of FULCRUM and REVERSE
(Fig. 1.62a, b) ENGINE
The results of shoulder hemi/non-constrained arthroplas- All of the excellent and good post operative Constance
ties (NCA) for old trauma are much less favorable than those scores are obtained in Type 1 and Type 2 sequelae in which
of primary osteoarthritis or HEMI performed for acute frac- osteotomy of the greater tuberosity is not required.
tures. On the basis of a literature review [90], satisfactory Patients in Type 3 and Type 4 who require a greater tuber-
results may be expected in 15–72 % of the cases, with pain osity osteotomy, have either fair or poor results and do not
relief in more than 85 %. regain active elevation above 90°. It is general consensus that
Motion is usually limited with an active anterior elevation shoulder arthroplasty for the treatment of the sequelae of
around 110° and an active external rotation around 20°. The proximal humerus fractures should be performed without an
complication rate is usually higher than that for other osteotomy of the greater tuberosity. If prosthetic replacement
etiologies. is possible without an osteotomy, surgeons should accept the
The percentage of complications varies from 20 to 48 % distorted anatomy of the proximal humerus and adapt the
depending on the series. The revision rate varies from 3.5 to 35 %. prosthesis and their technique to the modified anatomy.
Several factors seem to influence the final results [93] In 2008 Boileau at al [93].compared the results of non-
(NCA): constrained arthroplasty (NCA) to reverse shoulder arthro-
plasty (RSA) in the treatment of fracture sequelae:
1. The role of the initial fracture treatment (initial conserva-
tive treatment with better outcome when compared to ini- • In Type 1 the result of RSA were equivalent to those
tial surgical treatment). observed with NCA except for external rotation which
2. The type of sequelae with better results are reported after was lower. Therefore it’s recommended preferring NCA
post-traumatic arthritis without any distortion of the prosthesis in this cases in order to restore bought active
tuberosities, as the best outcomes occurred in cases of elevation and external rotation; only patient with muscle
isolated necrosis of the humeral head. atrophy or rotator massive cuff tear may benefit from
3. Outcomes is also good and predictable in patients with Reverse (Fig. 1.58a, b).
valgus deformity. In contrast, the outcomes in patients • In Type 2 bought Anatomical (NCA) and Reverse (RSA)
with varus malunion is significantly poorer than those in can be indicated although a NCA may be preferred for
patients with valgus malunion Two hypotheses could posterior dislocation, a RSA must be preferred in case of
explain this difference. It is technically more difficult to chronic anterior dislocation in which anterior stability
implant a humeral head prosthesis in a patient with sub- may be a problem with NCA (Fig. 1.59a–c).
stantial varus deformity because of the risk of greater • In Type 3 RSA produced unexpected poor functional result.
tuberosity or diaphyseal fracture. In addition, the humeral Therefore patients with isolated surgical neck non-union
medialization resulting from the varus deformity leads to should be considered as a group at risk for Anatomic and
circumferential tightening of the soft tissues and a Reverse arthroplasty. The most adapted procedure is fixa-
severely stiff shoulder. The presence of fatty infiltration tion of the non –union with bone PEG graft and internal
of the rotator cuff muscles is also associated with signifi- fixation (Fig. 1.60a, b and 1.61a, b). In cases where surgical
cantly poorer clinical outcomes. On the basis of the neck non- union is associated with tuberosity non-union,
results of the present study, different authors [91] consider severe humeral head cavitation or osteoarthritis, other
patients with type-1 fracture sequelae with varus mal- option such us humeral head replacement and tuberosity
union and/or fatty infiltration of the rotator cuff muscles fixation with bone graft should be considered.
to be poor candidates for an anatomic prosthesis. In these • In Type 4 NCA demonstrated that prosthetic implantation
situations, reverse shoulder arthroplasty may be prefera- required greater tuberosity osteotomy. This option has
ble, especially if the patient is elderly. clearly been identified as pejorative on the final outcome.
RSA provided better early results than those achieve with
The most significant factor affecting functional outcomes NCA with acceptable results despite non-union or mal-
is greater tuberosity osteotomy. union of the greater tuberosity (Fig. 1.62a, b).
a b
TYPE 1
Fig. 1.54 (a, b) Cephalic collapse or necrosis
a b
TYPE 2
Fig. 1.55 (a, b) Locked dislocation and/or fracture dislocation

a b
TYPE 3
Fig. 1.56 (a, b) Surgical neck non-union
TYPE 4
Fig. 1.57 Fracture dislocation

Fig. 1.58 (a) Type 1-Fracture sequelae. (b) Surgical solution with HEMI
Fig. 1.59 (a) Type 2- Fracture sequelae. (b) Locked fracture dislocation. (c) Because the integrity of Engine (tuberosities), we performed HEMI
to regain the Fulcrum and bone graft on the glenoid (Latarjet) to restore the Glenoid track
a b
Fig. 1.60 (a) Type 3- Surgical neck fracture. (b) PEG bone graft
Fig. 1.61 (a) Type 3- sequelae of surgical neck fracture. (b) Surgical solution with ORIF
Fig. 1.62 (a) Type 4-fracture sequelae with severe tuberosity mal-union (loss of Engine). (b) Surgical solution Reverse. sn: left side
1.9 Rehabilitation Pearls Putting him/herself in the hand of a dedicated surgical and
rehabilitation team allows the patient to best manage the
Rehabilitation and patient management after surgery for recovery timeframes involved. Straightforward information
PHF are complex procedures, clearly illustrating the need for given by professional in a simple manner is generally well
physiotherapy and orthopedic professionals to work in understood and reinforces the relationship of trust between
concert. the patient and the healthcare team.
Post-op PHF patients are best managed by a team com- Feedback and exchange between the surgical and rehab
prising the orthopedic surgeon, physiatrist, physiotherapist team is key. The surgeon must inform the rehabilitator of the
and radiologist specialist in these conditions. patient’s clinical history, on the reasons for opting for sur-
Patient management is particularly delicate also from the gery, patient bone and soft tissue quality, and the state of any
emotional standpoint since patients may have often previ- fixation plates or prostheses. By the same token, the rehabili-
ously had unsuccessful surgery and/or undergone several tator is required to keep the surgeon informed of any initial
months rehabilitation. clinical signs that could signal infection, fibrous adhesions or
While the team must make it their business to encourage neuromuscular disorders.
patients, a first essential step to ensuring good post-operative
recovery and rehabilitation, care should also be taken to
provide each patient with a realistic picture of potential com- 1.9.2 Rehabilitation Strategy
plications and the possibility of achieving only partial func-
tional results. The surgical management options for sequelae are: open
reduction internal fixation (ORIF), HEMI or Reverse.
Post-surgery rehab protocols align with the indications
1.9.1 Information Strategy given in the specific chapters. It should, however, be borne in
mind that poor quality bone and soft tissue are characteristic
Explain to the patient the complexity of the fracture he/she sequelae of fracture. It follows that the pace of the rehabilita-
has suffered and that the complications of conservative and/ tion program must be patient specific, taking into account the
or surgical treatment are due to biological reasons that are need to balance the requirements of the biological deficit while
not always easy to predict or interpret. preventing fibrous reactions and the formation of adhesions.
1.10 Correct Information Feedback
General emotional and medical info

about the patient
Specific disease info: history of the
fracture
Explain reason of surgery and choice of
treatment
Neurological and biological info:
- Quality of the bone
- Quality of the soft tissue
- Risk of adhesion
- Risk of infection
- Neurological status
Specific case risk factors
Emotional and compliance of the patient

Progress of ROM and pain relief
Eventually local sign of infection
Neuromuscular and proprioception specific
response
Kinetic chain restoration and functional
outcomes
Latent conditions becoming overt with
altered shoulder biomechanics (especially in
reverse)
Neuro-algodystrophy
References 23. Hettrich CM, Boraiah S, Dyke JP, Neviaser A, Helfet DL, Lorich
DG (2010) Quantitative assessment of the vascularity of the proxi-
mal part of the humerus. J Bone Joint Surg Am 92(4):943–948
1. Horak J, NilssonBE (1975) Epidemiology of fracture of the upper
24. Edwin R, Cadet MD, Christopher S, Ahmad MD (2012)
end of the humerus. Clin Orthop Relat Res Vol 112, 250–253
Hemiarthroplasty for three- and four- part proximal humerus frac-
2. Stimson B (1947) A manual of fractures and dislocations, 2nd
tures. J Am Acad Orthop Surg 20:17–27
edn. Lea & Febiger, Philadelphia
25. Turpka A, Wiedemann E, Ruchholtz S et al (1997) Dislocated
3. Court- Brown CM, Grag A, McQueen MM (2001) The epidemiol-
multiple fragment fractures of the head of the humerus. Does dis-
ogy of proximal humeral fractures. Acta Orthop Scand
location of the humeral head fragment signify a worse prognosis?
72:365–371
Unfallchirurg 100:105–110
4. Roux A, Decroocq L, El Batti S, Bonnevialle N, Moineau G,
26. Coudane H, Fays J, De la Selle H, Nicoud C, Pilot L (2000)
Trojani C, Boileau P, de Peretti F (2012) Epidemiology of proxi-
Arteriography after complex fractures of the upper extremity of
mal humerus fractures managed in a trauma center. J Orthop
the humerus bone. A prospective study- preliminary results.
Trauma Surg Res 98:715–719
J Shoulder Elbow Surg 9:548
5. Palaven M, Kannus P, Niemi S, Parkkari J (2006) Update in the
27. Esser RD (1994) Treatment of three and four-part fractures of the
epidemiology of proximal humerus fractures. Clin Orthop Relat
proximal humerus with a modified cloverleaf plate. J Orthop
Res 442:87–92
Trauma 8:15–22
6. Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG
28. Jakob RP, Miniaci A, Anson PS et al (1991) Four –part valgus
(2007) The importance of medial support in locked plating of
impacted fractures of the proximal humerus. J Bone Joint Surg Br
proximal humerus fractures. J Orthop Trauma 21:185–191
73:295–298
7. Hertel R, Hempfing A, Stiehler M, Leunig M (2004) Predictors of
29. Resh H, Povacz P, Frohlich R, Wambacher M (1997) Percutaneaos
humeral head ischemia after intracapsular fracture of proximal
fixation of three- and four- part fractures of the proximal humerus.
humerus. J Shoulder Elbow Surg 13:427–433
J Bone Surg Br 79:295–300
8. Resh H, Beck E, Bayley I (1995) Recostruction of the valgus-
30. Vandenbussche E, Peraldi P, Naouri JF, Rougereau G, Augereau B
impacted humeral head fracture. J Shoulder Elbow Surg 4:73–80
(1996) Four part valgus impacted fractures of the upper extremity
9. Neer CS (1970) Dispiace proximal humerus fractures.
of the humerus: ilium graft reconstruction. Apropos of 8 cases.
Classification and evaluation. J Bone Joint Surg Am
Rev Chir Orthop Reparatrice Appar Mot 82:658–662
52:1077–1089
31. Gerber C, Hersche O, Berberat C (1998) The clinical relevance of
10. Codman E (1934) The shoulder: rupture of the supraspinatus ten-
post-traumatic avascular necrosis of the humeral head. J Shoulder
don and other lesion in or about the subacromial bursa. Privately
Elbow Surg 7:586–590
Printed, Boston
32. Burkhart Stephen S, Lo Ian D (2006) Arthroscopic rotator cuff
11. Boileau P, Bicknell RT, Mazzoleni N, Walch G, Urien JP (2008)
repair. J Am Acad Orthop Surg 14:333–346
CT scan method accurately assesses humeral head retroversion.
33. Hoffmeyer P (2002) The operative management of displaced frac-
Clin Orthop Relat Res 466(3):661–669
tures of the proximal humerus. J Bone Joint Surg Br
12. Hernigou P, Duparc F, Hernigou A (2002) Determining humeral
84(B):469–480
controversion with computed tomography. J Bone Joint Surg Am
34. Poppen NK, Walker PS (1983) Force at the glenohumeral joint in
84(10):1753–1762
abduction. Clin Othop 135:165–170
13. Muller ME, Nazarian S, Koch P, Schatzker J (1990) The compre-
35. Poppen NK, Walker PS (1976) Normal and abnormal motion of
hensive classification of fractures of long bones. Springer, Berlin,
the shoulder. J Bone Joint Surg Am 58-A:195–201
pp 120–121
36. Widnall JC, Dheerendra SK, Jacob George Malal J, Waseem M
14. Hertel R (2005) Fractures of the proximal humerus in osteoporotic
(2013) Proximal humeral fractures: a review of current concepts.
bone. Osteopors Int 16(Suppl2):S65–S72
Open Orthop J 7(Suppl 3: M12):361–365
15. Codman EA (1934) Fractures in relation to the subacromial bursa.
37. Kristiansen B, Christensen SW (1986) Plate fixation of Proximal
In: Codman EA (ed) The shoulder, rupture of the supraspinatus
humeral fractures. Acta Orthop Scand 57(4):320–323
tendon and others lesion in or about the subacromial bursa.
38. Lefevre- Colau MM, Babinet A, Fayad F et al (2007) Immediate
Krieger Publishing, Malabar, pp 313–331
mobilization compared with conventional immobilization for the
16. Majed A, Macleod I, Bull AMJ, Zyto K, Resh H, Hertel R, Reilly
impacted nonoperatively treated proximal humeral fractures: a ran-
P, Emery RJH (2011) Proximal humeral fracture classification
domized controlled trial. J Bone Joint Surg Am 89(12):2582–2590
system revisited. J Shoulder Elbow 20:1125–1132
39. Deldycke J, Rommens PM, Heyvaert G, Broos PL (1993)
17. Solberg BD, Moon CN, Franco DP, Paiement GD (2009) Surgical
Conservative study between the classical Desault- bandage and
treatment of three four part proximal humeral fractures. J Bone
the new Gilchrist- bandage. Unfallchirurgie 232:145–146
Joint Surg Am 91:1689–1697
40. Hutten TT, Launonen AP, Pihlajamaki H, Kannus P, Mattila VM
18. Solberg BD, Moon CN, Franco DP, Paiement GD (2009) Locked
(2012) Trends in the surgical treatment of proximal humeral frac-
plating of 3 and 4-part proximal humerus fractures in older
tures- a nationwide 23-year study in Finland. MBC Muscoloskeletal
patients: the effect of initial fracture pattern on outcome. J Orthop
Disord 13:261
Trauma 23:113–119
41. Ellenbecker TS (2004) Clinical examination of the shoulder.
19. Herbert Resh MD (2001) Proximal humeral fractures: current
Elsevier Saunders, St. Louis. 2014
controversies. J Shoulder Elbow Surg 20:827–832
42. Nho SJ, Brophy RH, Barker JU, Cornell CN, MacGillivray JD
20. Gerber C, Schneeberger AG, Vinh TS (1990) The arterial vascu-
(2007) Management of proximal humeral fractures based on cur-
larization of humeral head: An anatomical study. J Bone Joint
rent literature. J Bone Joint Surg 89(Suppl 3):44–58
Surg Am 72(10):1486–1494
43. Khmelnitskaya E, Lamont LE, Taylor SA, Lorich DG, Dines DM,
21. Brooks CH, Revel WJ, Heatley FW (1993) Vascularity of the
Dines JS (2012) Evaluation and management of proximal humerus
humeral head after proximal humeral fractures: an anatomic
fractures. Hindawi Publ Corp Adv Othop; Art ID 861598
cadaver study. J Bone Joint Surg Br 75(1):132–136
44. Cadet ER, Ahmad CS (2012) Hemiathroplasty for three- and four-
22. Duparc F, Muller JM, Fregér P (2001) Arterial blood supply of the
part proximal humerus fractures. J Am Acad Orthop Surg
proximal humeral epiphysis. Surg Radiol Anat 23(839):185–190
20(1):17–22
45. Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J (2011) 64. Athwal GS, Sperling JW, Rispoli DM, Cofield RH (2007) Deep
Hemiarthroplasty versus non operative treatment of displaced infection after rotator cuff repair. J Shoulder Elbow Surg
4-part proximal humeral fractures in elderly patient: a randomized 16(3):306–311
controlled trial. J Shoulder Elbow 20(7):1025–1033 65. Herrera MF, Bauer G, Reynolds F, Wilk RM, Bigliani LU, Levine
46. Sudkamp NP, Audige L, Lambert S, Hertel R, Konrad G (2011) Path WN (2002) Infection after mini-open rotator cuff repair. J Shoulder
analysis of factors for functional outcome in one year in 463 proxi- Elbow Surg 11(6):605–608
mal humerus fractures. J Shoulder Elbow Surg 18(8):1207–1216 66. Kalainov DM, Bisson LJ, Brause BD, Figgie MP, Weiland AJ
47. Boileau P, Krishnan SG, Tinsi L, Walch G, Coste JS, Molè D (1996) Management of infected shoulder arthroplasties. Orthop
(2002) Tuberosity malposition and migration : reason for poor Trans 20:411–412
outcomes after hemiarthroplasty for displaced fractures of the 67. Themistocleous G, Zalavars C, Stine I, Zachos V, Itamura J (2007)
proximal humerus. J Shoulder Elbow Surg 11(5):401–412 Prolonged implantation of an antibiotic cement spacer for the
48. Frankle MA, Ondrovic LE, Markee BA, Harris ML, Lee WE 3rd management of shoulder sepsis in compromised patients.
(2002) Stability of tuberosity reattachment in proximal humeral J Shoulder Elbow Surg 16(6):701–705
hemiarthroplasty. J Should Elbow Surg 11:413–420 68. Brems JJ (2002) Complication of shoulder arthroplasty: infection
49. Mighell MA, Kolm GP, Collinge CA, Frankle MA (2003) instability and loosening. Instr Course Lect 51:29–39
Outcomes of hemiarthroplasty for fractures of the proximal 69. Coste JS, Regis S, Trojani C, Berg M, Walch G, Boileau P (2004)
humerus. J Shoulder Elbow Surg 12:569–577 The management of infection in arthroplasty of the shoulder.
50. Kontakis GM, Damilakis J, Christoforakis J, Papadakis A, Katonis J Bone Joint Surg Br 86(1):65–69
P, Prassopopulus P (2001) The bicipital groove as a landmark for 70. Kiber WB, Press J, Sciascia AD (2006) The role of the core stabil-
orientation of the humeral prosthesis in cases of fractures. ity in Athletic Function. Sports Med 36(3):189–198
J Shoulder Elbow Surg 10:136–139 71. McCann PD, Wootten MF, Kadaba MP, Bigliani LU (1993) A
51. Christoforakis JJ, Kontakis GM, Katonis PG, Stergiopopulus K, kinematic and electromyographic study of shoulder rehabilitation
Hadjipavlou AG (2004) Shoulder hemiarthroplasty in the manage- exercises. Clin Orthop Related Res 288:179–188
ment of the humeral head fractures. Acta Orthop Belg 70:214–218 72. Codman EA (1934) The shoulder. Thomas Todd Company, Boston
52. Becker R, Pap G, Machner A, Neumann WH (2002) Strength and 73. Kisner C, Colby LA (1996) Therapeutic exercises: foundations
motion after hemiarthroplasty in displaced four-fragment fracture and techniques, 3rd edn. FA Davis Co, Philadelphia,
of the proximal humerus: 27 patient followed 1–6 years. Acta pp 283–284
Orthop Scand 73:44–49 74. Kibler WB (1991) Role of the scapula in the overhead throwing
53. Parkash U, McGurty DW, Dent JA (2002) Hemiarthroplasty for motion. Contemp Orthop 22(5):525–532
severe fractures of the proximal humerus. J Shoulder Elbow Surg 75. Kibler WB (1998) Shoulder rehabilitation. Principle and practice.
11:428–430 Med Sci Sports Exerc 30(4):S40–S50
54. Garrigues E, Johnston PS, Pepe MD, Tucker BS, Ramsey ML, 76. Levine WN, Marra G (2003) Fractures of the shoulder girdle.
Austin LS (2012) Hemiarthroplasty versus reverse total shoulder Marcel Dekker, New York, p 126
arthroplasty for acute proximal humerus fractures in elderly 77. Inman VT, Saunders JB, Abbott LC (1944) Observation of the
patients. Orthopaedics 35(5):703–708 function of the shoulder joint. J Bone Joint Surg 26(1):1–30
55. Boyle MJ, Youn SM, Frampton CM, Ball CM (2013) (in press) 78. Ellsworth AA, Mullaney M, Tyler TF, McHugh M, Nicholas SJ
Functional outcomes of reverse shoulder arthroplasty compared (2006) Electromyography of selected shoulder musculature dur-
with hemiartroplasty for acute proximal humeral fractures. ing un-weighted and weighted pendulum exercises. North Am
j shoulder and elbow surg 1:32–7 J Sports Phys Ther 1(2):73–74
56. Kralinger F, Schwaiger R, Wambacher M, Farrel E, Menth-Chiari 79. Faulkner JA (2003) Terminology for contractions of muscles dur-
W, Lajtai G, Hubner C, Resch H (2004) Outcome after primary ing shortening, while isometric, and during lengthening. J Appl
hemiartroplasty for fracture of the head of the humerus. A retro- Physiol 95(2):455–459
spective multicenter study of 167 patient. J Bone Joint Surg Br 80. Faulkner JA, Larkin LM, Claffin DR, Brooks SV (2007) Age-
86:217–219 related changes in the structure and function of skeletal muscles.
57. Doetsch AM, Faber J, Lynnerup N et al (2004) The effect of cal- Clin Exp Pharmacol Physiol 34:1091–1096
cium and vitamin D3 supplementation on the healing of the proxi- 81. Hemmings B, Smith M, Graydon J, Dyson R (2000) Effects of
mal humerus fracture: a randomized placebo- controlled study. massage on physiological restoration, perceived recovery, and
Calcif Tissue Int 75:183–188 repeated sports performance. Br J Sports Med 34:109–114
58. Healy WL, Jupiter JB, Kristiansen TK, White RR (1990) Non 82. Crane JD, Ogborn DI, Cupido C, Melov S, Hubbard A, Bourgeois
union of the proximal humerus: a review of 25 cases. J Orthop JM, Tarnopolsky MA (2012) Massage therapy attenuates inflam-
Trauma 4:424–431 matory signaling after exercise-induced muscle damage. Sci
59. Rooney PJ, Cockshott WP (1986) Pseudoarthrosis following Transl Med 4(119):119
proximal humeral fractures: a possible mechanism. Skeletal 83. Moreside JM, Vera-Garcia FJ, McGill SM (2007) Trunk muscle
Radiol 15:21–24 activation patterns, lumbar compressive forces, and spine stability
60. Bigliani LU, Flatow EL, Cluskey M, Fisher RA (1991) Failed when using the bodyblade. Phys Ther 87(2):153–163
prosthetic replacement of displaced proximal humerus fractures. 84. Buteau JL, Eriksrud O, Hasson SM (2007) Rehabilitation of a gle-
Orthop Trans 15:747–748 nohumeral instability utilizing the body blade. Physiother Theory
61. Kontakis G, Koutras C, Tosounidis T, Giannoudis P (2008) Early Pract 23(6):333–349
management of proximal humeral fractures with hemiartroplasty: 85. Tidus PM (1997) Manual massage and recovery of muscle func-
a systematic review. J Bone Joint Surg 90(11):1407–1413 tion following exercise: a literature review. J Orthop Sports Phys
62. Mirzayan R, Itamura JM, Vangsness CT Jr, Holtom PD, Sherman Ther 25(2):107–112
R, Patzakis MJ (2000) Management of deep infection following 86. Boileau P, Trojani C, Walch G, Krishnan SG, Romeo A, Sinnerton
rotator cuff repair. J Bone Joint Surg Am 82(8):1115–1121 R (2001) Shoulder arthroplasty for the treatment of the sequelae of
63. Sperling JW, Kozak TK, Hanssen AD, Cofield RH (2001) fractures of the proximal humerus. J Shoulder Elbow Surg
Infection after shoulder arthroplasty. Clin Orthop Relat Res 10(4):299–308
382:206–216
87. Cofield RH (1987) Shoulder replacement:prognosis related to Kempf JF. “Shoulder concepts 2008- proximal humeral factures and
diagnosis. Shoulder Replace 157–161 sequelae” under the direction of p. Sauramps Médical. pp 265–269
88. Neer CS. Old trauma in genohumeral arthroplasty. Shoulder 94. Perlmutter GS (1999) Axillary nerve injury. Clin Orthop Relat Res
reconstruction. Philadelphia Saunders; 1990. pp 222–234 (368):28–36
89. Tanner MW, Cofield RH (1983) Prosthetic arthroplasty for frac- 95. Rockwood C, Masten FA III, Wirth M, Lippitt S (2008) The
tures and fractures dislocations of the proximal humerus. Clin shoulder, 4th edn. Saunders Elsevier, Philadelphia
Orthop 179:116–128 96. Gardner MJ, Griffith MH, Dines JS, Briggs SM, Weiland AJ,
90. Mansat P (2006) Les sèquelles traumatiques ostéo-articulares de Lorich DG (2005) The extended anterolateral acromial approach
l’articulation gléno-humérale. Sauramps Mèdical, Montpellier allows minimally invasive access to the proximal humerus.
91. Moineau G, Mc Celland WB, Trojano C, Rumian A, Walch G, Clinical Orthop Relat Res (434):123–129
Boileau P (2012) Prognostic factors and limitations of anatomic 97. Kim SH, Szabo RM, Marder RA (2012) Epidemiology of proximal
shoulder arthroplasty for the treatment of post-traumatic cephalic humerus fractures in the United States: nationwide emergency
collapse or necrosis (Type 1 proximal humeral fracture sequelae). department sample, 2008. Arthritis Care Res 64(3):407–414
J Bone Joint Surg Am 94:2186–2194 98. Cools AM, Dewitte V, Lanszweert F, Notebaert D, Roets A,
92. Boileau P, Walch G, Trojani C, Sinnerton R, Romeo AA, Veneau Soetens B, Cagnie B, Witvrouw EE (2007) Rehabilitation of scap-
B (1999) Sequelae of fractures of the proximal humerus: surgical ular muscle balance. Which exercises to prescribe? Am J Sports
classification and limits of shoulder arthroplasty. In: Walch G, Med 35(10):1744–1751
Boileau P (eds) Shoulder arthroplasty. Springer, Berlin/Heidelberg 99. Ishigaki T, Yamanaka M, Hirokawa M, Tai K, Ezawa Y, Samukawa
93. Boileau P., Neyton L (2008) Reverse shoulder arthroplasty in proxi- M, Tohyama H, Sugawara M (2014) Rehabilitation exercises to
mal humerus fracture sequelae. Constrained or noncostrained pros- induce balanced scapular muscle activity in an anti-gravity pos-
thesis? In: Walch BG, Molé D, Favard L, Lévigne C, Sirveaux F, ture. J Phys Ther Sci 26(12):1871–1874
Shoulder Replacement
2
John E. Kuhn, Rebecca N. Dickinson, and Woodley Desir
Contents 2.12 Reverse Shoulder Arthroplasty.................................... 78

2.12.1 Deltopectoral Approach .................................................. 78
2.1 Introduction ................................................................... 68 2.12.2 Superior Approach .......................................................... 78
2.2 History of Shoulder Arthroplasty ................................ 68 2.12.3 Latissimus Transfer ......................................................... 80
2.3 Non-arthroplasty Management 2.13 Rehabilitation after Shoulder Arthroplasty:

and Rehabilitation ......................................................... 70 General Comments........................................................ 80
2.13.1 Protect the Subscapularis ................................................ 80
2.4 Indications for Shoulder Arthroplasty 2.13.2 Avoid Positions that Lead to Instability .......................... 80
Osteoarthritis ................................................................. 70 2.13.3 Sequence of Activity and Return to Sports or Work ....... 80
2.5 Rheumatoid Arthritis.................................................... 72 2.14 Total Shoulder Arthroplasty Rehabilitation: Author’s
Protocol .......................................................................... 81
2.6 Avascular Necrosis......................................................... 72 2.14.1 Postoperative (Weeks 0–4) .............................................. 81
2.7 Posttraumatic Arthritis................................................. 72 2.14.2 Postoperative (Weeks 4–8) .............................................. 84
2.14.3 Postoperative (Weeks 8–12) ............................................ 88
2.8 Rotator Cuff Tear Arthropathy ................................... 74 2.14.4 Postoperative (Weeks 12+) .............................................. 88
2.9 Contraindications for Shoulder Arthroplasty ............ 74 2.15 Reverse Shoulder Arthroplasty Rehabilitation:
2.10 Surgical Approaches for Shoulder Arthroplasty........ 74 Author’s Protocol .......................................................... 90
2.11 Hemiarthroplasty and Total Shoulder 2.16 Complications ................................................................ 90

Arthroplasty................................................................... 76 References .................................................................................... 91
2.11.1 Approach to the Subscapularis ........................................ 76
J.E. Kuhn, MD, MS ()

Kenneth D. Schermerhorn Professor of Orthopedics and
Rehabilitation, Chief of Shoulder Surgery, Director of the Division
of Sports Medicine, Vanderbilt University Medical Center,
Nashville, TN, USA
e-mail: [email protected]
R.N. Dickinson, DPT, COMT
Department of Orthopedic Surgery and Rehabilitation,
Vanderbilt University Medical Center, Nashville, TN, USA
W. Desir, MD
Fellow, Division of Sports Medicine, Vanderbilt University
Medical Center, Nashville, TN, USA

DOI 10.1007/978-3-319-24856-1_2
68 J.E. Kuhn et al.
2.1 Introduction arthritis. This constrained prosthesis shared similar design

with the hip replacement components at that time.
Arthroplasty of the glenohumeral joint has revolutionized In the United States, Dr. Charles S. Neer II developed an
the treatment for painful advanced degenerative diseases of unconstrained Vitallium (chrome-cobalt alloy) prosthesis for
the shoulder. Although shoulder joint replacement is less the treatment of complex proximal humerus fractures [4].
common than knee or hip replacement, it is just as successful These devices improved the patient’s level of function and
in relieving joint pain for a variety of arthritic disorders. reduced pain more effectively than resection arthroplasty,
Shoulder pain is one of the most common complaints in pri- which was the standard treatment at the time.
mary care and in rheumatologic, orthopedic, rehabilitation, The improved success of total hip arthroplasty during this
and other practice settings [1]. Shoulder pain originates from era influenced Dr. Neer to design a total shoulder prosthesis
a range of pathoanatomic entities including involvement of for joints with advanced osteoarthritis (The Neer II
the rotator cuff tendons, bursae, and glenohumeral joint Prosthesis). This prosthesis was composed of an all-
structures. Most shoulder disorders respond to conservative polyethylene glenoid component and newly designed metal
management with medication and rehabilitation. Patients humeral component with a variety of humeral stem lengths
with advanced, symptomatic, disabling glenohumeral joint and humeral head sizes.
arthritis are typically candidates for total shoulder arthro- During this time, a number of innovators developed vari-
plasty (Fig. 2.1a, b). ety of implants for the shoulder. These included constrained
implants (where the glenoid fits tightly over the humeral
head), and metal-backed and hooded glenoid components,
2.2 History of Shoulder Arthroplasty and even early models of a reverse shoulder arthroplasty [5].
High failure rates of these different designs led to their aban-
The earliest documented report of prosthetic shoulder donment and the adoption of the Neer II unconstrained
replacement dates back to 1893, when the French surgeon implant.
Jules-Émile Péan inserted a prosthesis composed of plati- The next advance in shoulder arthroplasty involved
num and rubber for glenohumeral joint damaged by tubercu- attempts at replicating the patient’s anatomy, by making the
losis infection [2]. Advancement of modern-day shoulder implants more modular [6, 7]. These “Anatomic” prostheses
replacement has evolved from both European and American became popular in the 1990s. In the current decade, newer
influences. In Europe during the 1950s, at Royal National implants are designed to improve glenoid fixation (center
Orthopedic Hospital in Stanmore, surgeons used a prosthetic pegs to allow bone ingrowth), to preserve proximal humeral
replacement for tumors of the proximal humerus. This pros- bone, and to use computer-assisted navigation to more accu-
thesis had poor function but the long-term survival was good rately position the glenoid.
[3]. The Stanmore group later designed a prosthetic shoulder
replacement for patients with osteoarthritis and rheumatoid
2 Shoulder Replacement 69
Fig. 2.1 (a) Osteoarthritis (b) Shoulder arthroplasty

70 J.E. Kuhn et al.
2.3 Non-arthroplasty Management case reports. While more cost-effective [16] and associated
and Rehabilitation with fewer complications than arthroplasty [17], the clinical
effectiveness of arthroscopic debridement is limited, and as
Before surgery is considered, nonoperative management such, arthroscopic treatment may not provide much benefit
should be offered to patients with osteoarthritis. Medical for patients with glenohumeral osteoarthritis [18, 19].
management includes the use of nonsteroidal anti-
inflammatory drugs (NSAIDs) that help relieve pain and
inflammation. In general, trials comparing paracetamol or 2.4 Indications for Shoulder Arthroplasty
placebo to NSAIDs suggest that NSAIDs are more effective Osteoarthritis
[8, 9]; however NSAIDs have more gastrointestinal and car-
diac risk, which is especially concerning in the elderly Osteoarthritis of the shoulder is very common affecting over
patients with arthritis. 30 % of people over age 60 [20, 21] (Fig. 2.2a, b).
Intra-articular injections are commonly used. Osteoarthritis of the shoulder increases with age and women
Corticosteroids have a limited effect [10] and should be lim- are more susceptible than men [22]. This is a very debilitat-
ited to three or four per year. These may be best used for ing condition and patients perceive the impact of shoulder
acute flares of symptoms, but not for long-term management. arthritis to be similar to other chronic medical ailments like
Intra-articular injections of hyaluronic acid have also been diabetes, heart failure, and myocardial infarction [23].
found to be helpful in patients with glenohumeral joint The indications for surgery are essentially based on the
arthritis [10–12]. severity of the patient’s symptoms. Contraindications include
Rehabilitation for shoulder arthritis has not been studied younger age, higher activity levels, and patients with neuro-
well. Most authors recommend a program that includes muscular disease. Patients with irreparable rotator cuff tears
improving glenohumeral joint motion, strengthening the are subject to higher rates of early glenoid loosening and
rotator cuff, and strengthening the scapula-stabilizing mus- should avoid standard total shoulder replacement, with
cles (lower trapezius and serratus anterior) [13–15]. Until reverse arthroplasty preferred.
more evidence is available, no standard protocol can be Some patients may have dysplastic or biconcave glenoids.
recommended. These circumstances make total shoulder arthroplasty less
Arthroscopic debridement and capsular releases for successful as stable fixation of the glenoid may be difficult to
shoulder arthritis may have some benefit, but the data sup- obtain, even in the face of eccentric reaming of the glenoid or
porting arthroscopy is low level evidence and derived from bone grafting in severe cases [24].
a b
Fig. 2.2 (a) Severe osteoarthritis. (b) Total shoulder arthroplasty

72 J.E. Kuhn et al.
2.5 Rheumatoid Arthritis noid involvement) [30]. Humeral head replacement may be
used as a treatment for avascular necrosis in patients with
Rheumatologic diseases affect the shoulder commonly, and humeral head, but no glenoid involvement. When the disease
disease progression characterized by joint destruction and has reached stage V, and the glenoid is involved, total shoul-
rotator cuff deterioration is expected [25]. Interestingly, the der arthroplasty is recommended. Generally, patients over
severity of the rotator cuff involvement seems to predict the age 65, those with posttraumatic avascular necrosis, postra-
patient status best [25]. diation avascular necrosis, and preoperative restrictions in
Arthroscopic synovectomy with capsular release if motion have poorer outcomes after arthroplasty [31].
needed can be helpful in relieving pain and restoring func-
tion [26]. Both hemiarthroplasty and total shoulder arthro-
plasty can be performed in patients with intact rotator cuffs, 2.7 Posttraumatic Arthritis
whose symptoms warrant arthroplasty. Results after arthro-
plasty demonstrate better pain relief and motion if total While avascular necrosis is known to occur when fractures
shoulder arthroplasty is performed [27]. When the rotator of the proximal humerus disrupt the blood supply, malunited
cuff is deficient, reverse arthroplasty can be very helpful in intra-articular fractures or significant trauma to the cartilage
this population [28, 29]; however, patients with rheumatoid of the glenoid or humeral head may produce posttraumatic
arthritis are more likely to be at risk for fracture and may arthritis (Fig. 2.3a, b). Glenohumeral joint arthritis is also
have severe glenoid erosion requiring bone grafting. known to occur as a result of frequent glenohumeral joint
dislocations [32]. Additionally, patients who underwent
instability surgery are at increased risk for developing gleno-
2.6 Avascular Necrosis humeral joint osteoarthritis [33] (Fig. 2.4a, b).
All of these patients may be successfully treated with
Shoulder arthroplasty is an accepted treatment for patients shoulder arthroplasty. It is important to recognize that
with avascular necrosis of the humeral head. Avascular patients who have had open anterior surgery for instability
necrosis can develop after trauma or may be related to sickle may have limited external rotation, and these patients may
cell disease, systemic lupus erythematosus, alcohol abuse, require lengthening of the anterior capsule and/or subscapu-
and oral corticosteroid use. Avascular necrosis is staged laris tendon to improve their range of motion. As a result,
based on the severity of the disease, from stage I (no radio- additional protection of the subscapularis in the postopera-
graphic changes) to stage V (humeral head collapse and gle- tive period may be required.
a b
Fig. 2.3 (a) Iatrogenic arthritis. (b) Arthroplasty
a b
Fig. 2.4 (a) Posttraumatic arthritis. (b) Hemiarthroplasty

74 J.E. Kuhn et al.
2.8 Rotator Cuff Tear Arthropathy Patients with irreparable rotator cuff tears are subject to
higher rates of early glenoid loosening and should avoid
Rotator cuff tear arthropathy is a special type of arthritis that standard total shoulder replacement, with reverse arthro-
develops in conjunction with a massive rotator cuff tear. In plasty preferred.
this patient, the rotator cuff is unable to keep the humeral
head centered in the glenoid, and the deltoid pulls the
humeral head superiorly. Over time, the eccentric wear on 2.10 Surgical Approaches for Shoulder
the glenoid and humeral head leads to arthritis [34]. Because Arthroplasty
the rotator cuff tear in these patients is massive, a total shoul-
der arthroplasty would be contraindicated, as the eccentric The therapist charged with managing a patient after arthro-
loads on the superior prosthetic glenoid would lead to early plasty must have an understanding of the surgical approach
failure. Instead, a hemiarthroplasty replacing the humeral and the implant design in order to protect the surgical proce-
head or a reverse shoulder arthroplasty would be recom- dure and obtain the best result. In general, there are three dif-
mended [35]. ferent types of approaches to the prosthetic replacement of
the shoulder: hemiarthroplasty (Fig. 2.5a, b) where only part
of the glenohumeral joint is replaced, typically the humeral
2.9 Contraindications for Shoulder head; anatomic total shoulder arthroplasty (Fig. 2.6a, b)
Arthroplasty where the humeral head and glenoid are replaced with
implants that resemble the patient’s normal anatomy; and
Contraindications for shoulder arthroplasty include younger reverse shoulder arthroplasty (Fig. 2.3) where the glenohu-
age, higher activity levels, active infection, and patients with meral joint is flipped such that the ball is placed on the gle-
neuromuscular disease and/or Charcot arthropathy [36]. noid and the cup part of the joint is placed on the humerus.
a b
Fig. 2.5 (a) Two implants are shown. A stemmed implant (Bottom) and a resurfacing implant. (b) Radiograph of resurfacing hemiarthroplasty
a b
Fig. 2.6 (a) Implants. (b) Radiograph of implants

76 J.E. Kuhn et al.
2.11 Hemiarthroplasty and Total Shoulder the lesser tuberosity requiring a tendon-to-tendon stump
Arthroplasty repair, or the tendon can be removed with a piece of the
lesser tuberosity (lesser tuberosity osteotomy), which
The deltopectoral approach is the most commonly used requires repair of the lesser tuberosity to the shaft of the
approach for exposing the glenohumeral joint. The anatomy humerus. Studies have failed to show a significant statistical
and the different approaches to the subscapularis were difference between these techniques in terms of functional
recently reviewed by Gadea et al. [37]. The skin incision is score, clinical outcome, or subscapularis fatty degeneration
made on the anterolateral aspect of the shoulder, directly [39–41] (Fig. 2.7a, b).
above the coracoid process and toward the deltoid insertion, Recently, some authors have experimented with a
avoiding the axilla. The inter-nervous plane between the del- subscapularis-sparing approach by working above the sub-
toid (axillary nerve) and pectoralis major (lateral and medial scapularis through the rotator interval, or below the subscap-
pectoral nerve) is then opened. The cephalic vein is a land- ularis by opening the inferior capsule, but to date, the results
mark that is typically found in this interval. The cephalic have been disappointing as implants may be positioned
vein has many branches to the deltoid and is typically poorly and/or osteophytes may be retained [42–45].
retracted laterally; however in large or muscular patients, the After the subscapularis has been taken down, the gleno-
vein may be retracted with the pectoralis major to avoid humeral joint capsule is released. There are a number of
injury from excessive retraction. At this point, the conjoined ways to release the capsule, but exposure of the glenoid may
tendon is exposed. The fascia on its lateral border is released, require significant and nearly circumferential releases, par-
exposing the subscapularis tendon and muscle. ticularly in the patient with severely restricted preoperative
motion.
The implant is then inserted. Each implant maker has dif-
2.11.1 Approach to the Subscapularis ferent tools for inserting the implant that are specific to their
own implant design. The important considerations from a
In order to gain access to the glenohumeral joint, the sub- rehabilitation perspective relate to how the implant is secured
scapularis must be violated to some extent. There are a num- to the bone. If the implant is cemented in place, the rehabili-
ber of approaches to the subscapularis, but in general, it must tation program does not require modification. If the implant
be detached, then later repaired. This repair requires postop- is coated with materials such that bone ingrowth is expected,
erative protection and directs much of the postoperative the surgeon may prefer waiting a few weeks—particularly
physical therapy restrictions (see below), as subscapularis with regard to loading the shoulder—to allow bony ingrowth
failure is a devastating complication after total shoulder to occur.
arthroplasty [38]. After the implant is inserted, the subscapularis is closed
The subscapularis tendon can be peeled off of the lesser with nonabsorbable, strong suture to prevent its failure
tuberosity, then later repaired with sutures through bone; it (Fig. 2.8a, b). The deltopectoral interval is re-approximated
can be opened with a tenotomy, leaving a tendon stump on and the skin is closed.
a b
Fig. 2.7 (a) Posterior looked discretion. (b) Subscapularis reinsertion with suture anchor in hemiarthroplasty
a b
Fig. 2.8 (a) Chronic locked posterior dislocation. (b) hemiarthroplasty

78 J.E. Kuhn et al.
2.12 Reverse Shoulder Arthroplasty A longitudinal or horizontal incision along the Langer
lines is used, centered on a point just posterior to the antero-
Two techniques are commonly used for inserting a reverse lateral edge of the acromion. Skin flaps are developed, the
shoulder arthroplasty. These are the deltopectoral and the deltoid raphe is identified, and the deltoid is split between the
superior approach (Figs. 2.9a, b, 2.10a, b, 2.11a, b). anterior and middle thirds distally up to 4 cm. Splitting del-
toids beyond 4 cm increases the possibility of axillary nerve
injury. The anterior deltoid can be damaged from excessive
2.12.1 Deltopectoral Approach deltoid origin release or axillary nerve injury during the del-
toid split. The axillary nerve can be within 2–2.5 cm from the
The deltopectoral approach is described above. In patients anterior acromion, with some cadaveric studies showing
with rotator cuff tear arthropathy, the subscapularis may be 25 % shoulders can be less than 4 cm away for the axillary
torn or may be unable to be repaired. In some implant nerve [48, 49].
designs, the failure to repair the subscapularis may lead to The coracoacromial ligament is taken with the deltoid off
instability of the implant, and in other designs, a repair of the of the acromion as a single layer. The biceps tendon—if
subscapularis is not as important [46]. present—is tenotomized or tenodesed. The insertion of the
subscapularis is preserved, but the anterior capsule along the
glenoid may be released to facilitate exposure. This tech-
2.12.2 Superior Approach nique gives excellent exposure of the anterior and superior
glenoid and the humeral head. It is generally recommended
The anterosuperior approach utilizes for reverse total shoul- for patients with rotator cuff tear arthropathy as the rotator
der arthroplasty used by many surgeons [47]. In rotator cuff cuff is absent making visualization excellent. While many
arthropathy, there may be significant superior escape of the surgeons prefer the anterosuperior approach, the risk for
humeral head; this procedure takes advantage of the defec- component malpositioning (superior glenoid tilt and valgus
tive supraspinatus and preserving the majority of subscapu- stem insertion) is higher [50].
laris, therefore, allowing faster rehabilitation and improved
postoperative stability [47].
a b
Fig. 2.9 (a) Cuff arthropathy. (b) Reverse arthroplasty

a b
Fig. 2.10 (a) Acute fracture. (b) Trauma reverse arthroplasty
a b
Fig. 2.11 (a) Fracture sequelae. (b) Reverse arthroplasty

80 J.E. Kuhn et al.
2.12.3 Latissimus Transfer 2.13.1 Protect the Subscapularis
Many patients with rotator cuff tear arthropathy have little or The standard surgical approach for shoulder hemiarthro-
no rotator cuff function. This can severely limit the ability of plasty, total shoulder arthroplasty, and, for many surgeons,
the arm to externally rotate. To try to improve on this, some reverse arthroplasty is an anterior deltoid splitting approach
surgeons will transfer the tendon of the latissimus dorsi (an (see above). To enter the joint, some method of violating the
internal rotator) to the humeral shaft to make the muscle subscapularis is required. As such, rehabilitation efforts must
function as an external rotator [51]. Certainly, if this is done, protect the subscapularis to allow healing.
the surgeon would require protection of this transferred mus- Most authors have their patients wear either a shoulder
cle in the early phases of rehabilitation; resisted external immobilizer or sling for 4–6 weeks postoperatively and rec-
rotation should be avoided as should extremes of internal ommend limitations in external rotation, which are eased
rotation of the humerus. over a 6–8-week period. Similarly, reaching behind the
back—which places the subscapularis under tension—is
restricted during this period as is any strengthening of the
2.13 Rehabilitation after Shoulder internal rotators of the rotator cuff.
Arthroplasty: General Comments
Physical therapy is an essential element to allow patients to 2.13.2 Avoid Positions that Lead to Instability
regain their range of motion. However, there is a lot of varia-
tion in the reported outcomes in the literature regarding In an anatomic shoulder arthroplasty, postoperative proto-
patients’ final shoulder movements [52, 53]. The cols limit abduction and external rotation for 6–8 weeks
rehabilitation program contributes significantly in reaching postoperatively.
the optimal clinical outcome after shoulder arthroplasty. The reverse arthroplasty is at risk for instability when the
There are few comparative trials to guide us with regard arm is adducted and extended. As such, many authors avoid
to finding the best postoperative protocol for treating patients this position in the first 6–8 weeks postoperatively. This may
who have undergone shoulder arthroplasty [54, 55]. Eriksson require the use of a sling or abduction sling. It is important to
et al. compared two approaches to postoperative rehabilita- stress to reverse arthroplasty patients that they should not
tion after shoulder arthroplasty in patients who lived far from reach behind to push themselves out of a chair.
their hospital [56]. One group had standard supervised phys-
ical therapy in the patient’s hometown; the other did therapy
at home while maintaining contact using videoconferencing 2.13.3 Sequence of Activity and Return
with the surgeon’s therapist. Interestingly, the telemedicine to Sports or Work
group had better Constant scores, shoulder function scores,
and less pain than the other group [56]. In a population of Most authors recommend early mobilization (passive and
patients who underwent total shoulder arthroplasty, Mulieri active assisted), minimizing fulltime immobilization, and
et al. [54] compared standard supervised physical therapy to achieving maximal passive range of motion prior to advanc-
a physician-directed home-based program with substantially ing to the strengthening phase. The return to sporting activi-
fewer restrictions. They found no differences in ASES or ties or work is typically between 4 and 6 months after
SST score, or patient satisfaction, but interestingly the home surgery. Healy et al. surveyed the American Shoulder and
therapy group had better motion [54]. These studies suggest Elbow Surgeons to get their recommendations on return to
that intensive, supervised physical therapy may not be sport after anatomic shoulder arthroplasty [59]. Football,
required as long as the patient is able to follow a specific gymnastics, hockey, and rock climbing were not recom-
home program with appropriate instruction. mended. Golf, ice skating, shooting sports, and downhill
There are numerous published rehabilitation protocols for skiing were recommended in experienced players. Other
postoperative treatment of patients after shoulder arthro- sports, including cross-country skiing, swimming, doubles
plasty [54, 57, 58]. It is widely accepted that a successful tennis, canoeing, and dancing, were allowed [59]. It is
outcome depends on effective communication between the important to note that surgeon variation is extensive with
surgeon and the therapist. With regard to the postoperative regard to participation [60], and as such, recommendations
physical therapy, most authors who offer their protocols in should come from the surgeon on what is permissible and
print provide similar postoperative restrictions. what is not.
2.14 Total Shoulder Arthroplasty 2.14.1 Postoperative (Weeks 0–4)

Rehabilitation: Author’s Protocol
Initial rehabilitation goals include pain control, restoration of
Shoulder arthroplasty is performed to reduce pain in the range of motion of the glenohumeral joint through both pas-
arthritic shoulder to allow for improved functional mobility. sive and active-assistive exercises, and light muscle activa-
Rehabilitation following shoulder arthroplasty should be tion of the glenohumeral and scapulothoracic joints.
focused on improving range of motion and increasing In the first postoperative visit, the dressing is removed and
strength, motor control, and proprioception of the upper wound inspection is performed. The patient should be edu-
quadrant to restore the best possible return to functional cated in sling donning/doffing and icing. A home exercise
mobility and activities of daily living. program is started including pendulum exercises (all
Time for recovery following shoulder arthroplasty is gen- motions), active range of motion exercises of the wrist and
erally 9–12 months. In this procedure, the subscapularis is elbow, and active-assistive exercises of the glenohumeral
detached for exposure of the glenohumeral joint and then joint into flexion, abduction, and external rotation up to 20°
reattached after the surgery is complete. This reattachment to protect the subscapularis repair. These active-assistive
must be protected for 6 weeks. During this time, strengthen- exercises can be performed with cane exercises (Figs. 2.12
ing activities that stress the subscapularis such as resisted and 2.13) or table walkouts (Fig. 2.14). The patient should
internal rotation or excessive stretching into external rotation also start scapular mobility in the sling including elevation
must be avoided. and depression (Fig. 2.15) and scapular retraction (Fig. 2.16).
A sling should be worn for the first 48–72 h for protec- At 1 week, the patient may start submaximal isometric
tion while the effects of anesthesia, possible nerve blocks, exercises into flexion, extension, abduction, and external
and other medications wear off. After 3 days, the sling can rotation (Figs. 2.17, 2.18, and 2.19). No internal rotation is
be removed for light activity such as deskwork as long as performed at this time for continued protection of the sub-
the hand is kept in front of the body. Sling should be worn scapularis. Patient may also begin prone scapular retraction
as needed during the day, whenever the patient is active or (Fig. 2.20). Use of the upper body ergometer and overhead
in an unprotected environment; it should always be worn at pulleys may be added as patient tolerance allows (Fig. 2.21).
night for the first 6 weeks. The sling can be discontinued Passive range of motion is performed in the clinic by the
completely at 6 weeks postoperatively. Active range of physical therapist, taking care not to place stress on the sur-
motion of the glenohumeral joint is allowed starting around gical implant or soft tissue structures that have been affected
week 4. by the procedure.
Fig. 2.13 Supine cane external rotation—towel roll to maintain

Fig. 2.12 Supine cane flexion motion in the scapular plane
82 J.E. Kuhn et al.
Fig. 2.16 Scapular retraction
Fig. 2.14 Table walkouts—with hands on the table, slowly walk back-
ward and lean forward for passive shoulder flexion to tolerance
Fig. 2.15 Scapular elevation and depression can be performed in or out Fig. 2.17 Isometric shoulder flexion
of the sling
Fig. 2.18 Isometric shoulder extension
Fig. 2.20 Prone scapular retraction—with arm suspended off edge of

table—scapula is retracted
Fig. 2.19 Isometric shoulder abduction/external rotation
Fig. 2.21 Pulley flexion

84 J.E. Kuhn et al.
2.14.2 Postoperative (Weeks 4–8) At 6 weeks, the patient may continue all active range of
motion with external rotation allowed to 45° or as directed
At 4 weeks, the patient may start active range of motion based on repair. Internal and external rotation may be initi-
on the glenohumeral joint. Suggested exercises include ated at low resistance with a towel roll under the arm to
but are not limited to supine serratus punches (Fig. 2.22), eliminate the wringing out effect to the rotator cuff
prone rows, abduction and extension with focus on mid- (Figs. 2.32 and 2.33). The patient may also begin wall
dle and lower trapezius recruitment with motion push-ups plus for serratus strengthening (Fig. 2.34), as well
(Figs. 2.23, 2.24, and 2.25), lawn mower exercise for as dynamic stabilization exercises either through body
scapular stabilization (Figs. 2.26 and 2.27), and side- blade exercises in neutral (Fig. 2.35) and double arm at 90°
lying external rotation with towel roll under arm flexion (Fig. 2.36) or through manual rhythmic stabiliza-
(Fig. 2.28). Patient will also need to initiate active flex- tion exercises with therapist in supine flexion (Figs. 2.37
ion and scaption. This may be better accomplished start- and 2.38) with progressions in speed, intensity, and angula-
ing in supine or side-lying position with focus on good tion of flexion as tolerated.
motor control, with progression into upright position At this point in their recovery, the patient may begin
(Figs. 2.29, 2.30, and 2.31). Any active external rotation work on proprioceptive exercise. For example, a laser
should be limited to 30° or as directed by physician based pointer can be attached to the arm and the patient is asked
on operative technique. Passive range of motion should to perform tasks such as moving between two set positions
be continued until full range is achieved in all other marked on the wall, tracing previously drawn circles, etc.
motions. (Fig. 2.39).
Fig. 2.22 Supine serratus punches Fig. 2.24 Prone abduction with focus on middle and lower trapezius
Fig. 2.23 Prone row with focus on good middle trapezius recruitment Fig. 2.25 Prone extension with focus on middle and lower trapezius
Fig. 2.29 Side-lying active-assistive flexion
Fig. 2.26 Lawnmower starting position—cue to pull up like starting a

lawn mower
Fig. 2.27 Lawn mower ending position—with scapula retraction Fig. 2.30 Supine shoulder flexion
Fig. 2.31 Supine active flexion on incline—initial incline at 20–30°

with progression to upright
Fig. 2.28 Side-lying external rotation
86 J.E. Kuhn et al.
Figs. 2.32 and 2.33 Resisted external rotation with towel roll
Fig. 2.34 Wall push-ups with serratus plus Fig. 2.36 Bodyblade in 90° flexion—double hand
Fig. 2.35 Bodyblade in neutral at side Fig. 2.37 Rhythmic stabilization—patient holds arm still in serratus
plus—therapist changes direction of pressure
Fig. 2.38 Rhythmic stabilization progression into increased flexion Fig. 2.39 Proprioception exercises with laser pointer
88 J.E. Kuhn et al.
2.14.3 Postoperative (Weeks 8–12) exercises (Fig. 2.42). Exercises should also reflect more
functional movement strength such as diagonal patterns
At this point, full passive and active range of motion with (Figs. 2.43 and 2.44). Bodyblade exercises can also be
the restriction of 60° of exercise rotation should be progressed into higher angles of elevation (Figs. 2.45 and
obtained. If more aggressive stretching or mobilization is 2.46).
indicated, it may be done as long as attention is paid to the
postoperative integrity of the anterior structures.
Progressive resistive exercises and proprioceptive activi- 2.14.4 Postoperative (Weeks 12+)
ties continue for the rotator cuff and periscapular muscu-
lature with body blade exercises progressing into higher Focus at this point should be returning the patient to their
angles of elevation. Scapular control exercises in closed- individual goals, recreational activity, and job duties if appli-
chain position should be initiated as well (Fig. 2.40). As cable. Patient will most likely be on a home program by this
the patient shows improved strength and motor control, point for gradual return to full strength and regular daily
closed chained activities can be moved into quadruped activities. Sport- or recreational activity-specific exercises
(Fig. 2.41). Weakness may still be present in the subscap- should be part of the overall program.
ularis if it was resected during surgery, so attention should
be paid to restore strength with dynamic hug-type Postoperative Exercises—Weeks 8–12
Fig. 2.40 Patient can perform circles, serratus press/scapular retrac- Fig. 2.42 Dynamic hug exercise—cue is to reach around like a hug
tion, or rhythmic stabilization with therapist
Fig. 2.41 Quadruped position for serratus plus or rhythmic stabiliza-

tion with therapist
Figs. 2.43 and 2.44 Medicine ball diagonals
Fig. 2.45 Bodyblade at 90° abduction—single hand Fig. 2.46 Bodyblade at 90° flexion—single hand
90 J.E. Kuhn et al.
2.15 Reverse Shoulder Arthroplasty exercises listed in the arthroplasty guidelines would there-
Rehabilitation: Author’s Protocol fore be inappropriate. A latissimus dorsi and/or teres major
transfer may be performed in some cases to help restore
Reverse shoulder arthroplasty is most commonly performed in external rotation strength. If this is the case, special precau-
the painful shoulder that has significant nonoperative rotator tions will need to be taken to protect the transferred muscu-
cuff damage. Postoperative guidelines for the reverse arthro- lature during healing phases.
plasty are similar to those for the shoulder arthroplasty in
terms of when to introduce passive, active-assistive, and active
range-of-motion activities and when is it safe to start progres- 2.16 Complications
sive-resistive exercises. The previous arthroplasty guidelines
and exercises may be followed for the reverse arthroplasty Shoulder arthroplasty is one of the fastest growing areas in
except for the following specific considerations. joint replacement surgery, and the prospects for future
Dislocation is a real concern due to the shape and mechan- growth appear assured as the population of elderly expands
ics of the implant. Avoidance of shoulder extension past neu- rapidly over the next few decades.
tral and the combination of shoulder adduction and internal As with other total joint replacement procedures, total
rotation should be avoided for 12 weeks postoperatively. shoulder arthroplasty can have a number of complications
Activities such as tucking in a shirt or performing bathroom/ [61]. The literature reports great variations in complication
personal hygiene with the operative arm should be avoided. rates (0–55 %), with a mean complication of 10–15 % [62].
Care during passive range of motion and exercises such as For total shoulder arthroplasty, the number of reported com-
prone rows past neutral extension should be avoided as well. plications has decreased tremendously in recent decades
The shoulder will now have to rely on the deltoid for ele- [63]. The most common complications include glenoid loos-
vation. More time will most likely be spent going through ening (11.5 %), secondary rotator cuff pathology (4.6 %),
gradual incline shoulder elevation exercises with this proce- glenohumeral instability (3.1 %), stiffness (1.6 %), neuro-
dure. Once active range of motion can be initiated, shoulder logical complications (1.6 %), humeral loosening (1.5 %),
elevation can start in supine, and once this position is per- intraoperative fracture (1.4 %), infection (1.2 %), and post-
formed with ease, the incline of the table can be raised operative humeral fracture (0.9 %) [64].
20–30° and the patient performs active-assistive exercises at Complications for reverse arthroplasty can be similar to
this level until active elevation can be performed. Again, anatomic shoulder arthroplasty and include neurologic
once this becomes easy, the incline can be raised again and injury, periprosthetic fracture, hematoma, infection, loosen-
so on until the patient is upright or standing. ing of the implant, and dislocation. Unique to reverse shoul-
Due to rotator cuff damage, the patient will most likely der arthroplasty are the complications of scapular notching
have decreased or no external rotation strength so some and acromion fracture [65].
References 21. Petersson CJ (1983) Degeneration of the gleno-humeral joint. An

anatomical study. Acta Orthop Scand 54(2):277–283
22. Cushnaghan J, Dieppe PA (1991) Study of 500 patients with limb
1. Rekola KE, Keinanen-Kiukaanniemi S, Takala J (1993) Use of pri-
joint osteoarthritis. I. Analysis by age, sex, and distribution of
mary health services in sparsely populated country districts by
symptomatic joint sites. Ann Rheum Dis 50(1):8–13
patients with musculoskeletal symptoms: consultations with a phy-
23. Gartsman GM, Brinker MR, Khan M, Karahan M (1998) Self-
sician. J Epidemiol Community Health 47:153–157
assessment of general health status in patients with five common
2. Lugli T (1978) Artificial shoulder joint by Pean (1893): the facts of
shoulder conditions. J Shoulder Elbow Surg 7(3):228–237
an exceptional intervention and the prosthetic method. Clin Orthop
24. Denard PJ, Walch G (2013) Current concepts in the surgical man-
Relat Res 133:215–218
agement of primary glenohumeral arthritis with a biconcave gle-
3. Burrows HJ, Wilson JN, Scales JT (1975) Excision of tumours of
noid. J Shoulder Elbow Surg 22(11):1589–1598
humerus and femur, with restoration by internal prostheses. J Bone
25. van der Zwaal P, Pijls BG, Thomassen BJ, Lindenburg R, Nelissen
Joint Surg Br 57-B:148–159
RG, van de Sande MA (2014) The natural history of the rheumatoid
4. Neer CS (1955) Articular replacement for the humeral head. J Bone
shoulder: a prospective long-term follow-up study. Bone Joint
Joint Surg Am 37-A:215–228
J 96-B(11):1520–1524
5. Lee DH (2009) History of shoulder arthroplasty. Chapter 1. In:
26. Kanbe K, Chiba J, Inoue Y, Taguchi M, Iwamatsu A (2015)
Total shoulder arthroplasty. American Society for Surgery of the
Analysis of clinical factors related to the efficacy of shoulder
Hand, Rosemont, pp 1–15
arthroscopic synovectomy plus capsular release in patients with
6. Boileau P, Walch G (1997) Three-dimensional geometry of the
rheumatoid arthritis. Eur J Orthop Surg Traumatol 25(3):
proximal humerus: implications for surgical technique and pros-
451–455
thetic design. J Bone Joint Surg Br 79-B:857–865
27. Barlow JD, Yuan BJ, Schleck CD, Harmsen WS, Cofield RH,
7. Walch G, Boileau P (1999) Prosthetic adaptability: a new concept
Sperling JW (2014) Shoulder arthroplasty for rheumatoid arthritis:
for shoulder arthroplasty. J Shoulder Elbow Surg 8(5):443–451
303 consecutive cases with minimum 5-year follow-up. J Shoulder
8. Zhang W, Jones A, Doherty M (2004) Does paracetamol (acetamin-
Elbow Surg 23(6):791–799
ophen) reduce the pain of osteoarthritis?: a meta-analysis of ran-
28. Holcomb JO, Herbert DJ, Mighell MA, Dunning PE, Pupello DR, Pliner
domised controlled trials. Ann Rheum Dis 63(8):901–907
MD, Frankle MA (2010) Reverse shoulder arthroplasty in patients with
9. Pincus T, Koch G, Lei H et al (2004) Patient Preference for Placebo,
rheumatoid arthritis. J Shoulder Elbow Surg 19(70):1076–1084
Acetaminophen (paracetamol) or Celecoxib Efficacy Studies
29. Young AA, Smith MM, Bacle G, Moraga C, Walch G (2011) Early
(PACES): two randomised, double blind, placebo controlled, cross-
results of reverse shoulder arthroplasty in patients with rheumatoid
over clinical trials in patients with knee or hip osteoarthritis. Ann
arthritis. J Bone Joint Surg Am 93(20):1915–1923
Rheum Dis 63(8):931–939
30. Cruess RL (1985) Corticosteroid-induced osteonecrosis of the
10. Merolla G, Sperling JW, Porcellini G (2011) Efficacy of Hylan G-F 20
humeral head. Orthop Clin North Am 16:789–796
versus 6-methylprednisolone acetate in painful shoulder osteoarthritis:
31. Harreld KL, Marker DR, Wiesler ER, Shafiq B, Mont MA (2009)
a retrospective controlled trial. Musculoskelet Surg 95(3):215–224
Osteonecrosis of the humeral head. J Am Acad Orthop Surg
11. Silverstein E, Leger R, Shea KP (2007) The use of intra-articular
17(6):345–355
hylan G-F 20 in the treatment of symptomatic osteoarthritis of the
32. Brophy RH, Marx RG (2005) Osteoarthritis following shoulder
shoulder: a preliminary study. Am J Sports Med 35(6):979–985
instability. Clin Sports Med 24(1):47–56
12. Kwon YW, Eisenberg G, Zuckerman JD (2013) Sodium hyaluro-
33. Papalia R, Osti L, Del Buono A, Denaro V, Maffulli N (2010)
nate for the treatment of chronic shoulder pain associated with gle-
Glenohumeral arthropathy following stabilization for recurrent
nohumeral osteoarthritis: a multicenter, randomized, double-blind,
instability. Br Med Bull 96:75–92
placebo-controlled trial. J Shoulder Elbow Surg 22(5):584–594
34. Macaulay AA, Greiwe RM, Bigliani LU (2010) Rotator cuff defi-
13. Boselli KJ, Ahmad CS, Levine WN (2010) Treatment of glenohu-
cient arthritis of the glenohumeral joint. Clin Orthop Surg
meral arthrosis. Am J Sports Med 38(12):2558–2572
2(4):196–202
14. McCarty LP III, Cole BJ (2005) Nonarthroplasty treatment of gle-
35. Ramirez MA, Ramirez J, Murthi AM (2012) Reverse total shoulder
nohumeral cartilage lesions. Arthroscopy 21(9):1131–1142
arthroplasty for irreparable rotator cuff tears and cuff tear arthropa-
15. Maybach A, Schlegel TF (1995) Shoulder rehabilitation for the
thy. Clin Sports Med 31(4):749–759
arthritic glenohumeral joint: preoperative and postoperative consid-
36. Caniggia M, Fornara P, Franci M, Maniscalco P, Picinotti A (1999)
erations. Semin Arthroplasty 6(4):297–304
Shoulder arthroplasty. Indications, contraindications and complica-
16. Spiegl UJ, Faucett SC, Horan MP, Warth RJ, Millett PJ (2014) The
tions. Panminerva Med 41(4):341–349
role of arthroscopy in the management of glenohumeral osteoar-
37. Gadea F, Bouju Y, Berhouet J, Bacle G, Favard L (2015)
thritis: a Markov decision model. Arthroscopy 30(11):1392–1399
Deltopectoral approach for shoulder arthroplasty: anatomic basis.
17. Sayegh ET, Mascarenhas R, Chalmers PN, Cole BJ, Romeo AA,
Int Orthop 39:215–225
Verma NN (2015) Surgical treatment options for glenohumeral
38. Miller BS, Joseph TA, Noonan TJ, Horan MP, Hawkins RJ (2005)
arthritis in young patients: a systematic review and meta-analysis.
Rupture of the subscapularis tendon after shoulder arthroplasty:
Arthroscopy 31(6):1156–1166.e8
diagnosis, treatment, and outcome. J Shoulder Elbow Surg
18. Skelley NW, Namdari S, Chamberlain AM, Keener JD, Galatz LM,
14(5):492–496
Yamaguchi K (2015) Arthroscopic debridement and capsular
39. Krishnan SG, Stewart DG, Reineck JR, Lin KC, Buzzell JE,
release for the treatment of shoulder osteoarthritis. Arthroscopy
Burkhead WZ (2009) Subscapularis repair after shoulder arthro-
31(3):494–500
plasty: biomechanical and clinical validation of a novel technique.
19. Namdari S, Skelley N, Keener JD, Galatz LM, Yamaguchi K (2013)
J Shoulder Elbow Surg 18(2):184–192
What is the role of arthroscopic debridement for glenohumeral arthritis?
40. Scalise JJ, Ciccone J, Iannotti JP (2010) Clinical, radiographic, and
A critical examination of the literature. Arthroscopy 29(8):1392–1398
ultrasonographic comparison of subscapularis tenotomy and lesser
20. Kerr R, Resnick D, Pineda C, Haghighi P (1985) Osteoarthritis of
tuberosity osteotomy for total shoulder arthroplasty. J Bone Joint
the glenohumeral joint: a radiologic-pathologic study. Am
Surg Am 92(7):1627–1634
J Roentgenol 144(5):967–972
92 J.E. Kuhn et al.
41. Lapner PLC, Sabri E, Rakhra K, Bell K, Athwal GS (2010) 53. Torchia ME, Cofield RH, Settergren CR (1997) Total shoulder
Comparison of lesser tuberosity osteotomy to subscapularis peel in arthroplasty with the Neer prosthesis: long-term results. J Shoulder
shoulder arthroplasty: a randomized controlled trial. J Bone Joint Elbow Surg 6:495
Surg Am 94(24):2239–2246 54. Mulieri PJ, Holcomb JO, Dunning P, Pliner M, Bogle RK, Pupello
42. Lafosse L, Schnaser E, Haag M, Gobezie R (2009) Primary total D, Frankle MA (2010) Is a formal physical therapy program neces-
shoulder arthroplasty performed entirely thru the rotator interval: sary after total shoulder arthroplasty for osteoarthritis? J Shoulder
technique and minimum two-year outcomes. J Shoulder Elbow Elbow Surg 19(4):570–579
Surg 18(6):864–873 55. Fusaro I, Orsini S, Stignani S, Creta D, Cava FC, Benedetti MG,
43. Savoie FH 3rd, Charles R, Casselton J, O’Brien MJ, Hurt JA 3rd Società Italiana di Chirurgia della Spalla e del Gomito (2013)
(2015) The subscapularis-sparing approach in humeral head Proposal for SICSeG guidelines for rehabilitation after anatomical
replacement. J Shoulder Elbow Surg 24(4):606–612 shoulder prosthesis in concentric shoulder osteoarthritis.
44. Ding DY, Mahure SA, Akuoko JA, Zuckerman JD, Kwon YW Musculoskelet Surg 97 Suppl 1:31–37
(2015) Total shoulder arthroplasty using a subscapularis-sparing 56. Eriksson L, Lindström B, Gard G, Lysholm J (2009)
approach: a radiographic analysis. J Shoulder Elbow Surg Physiotherapy at a distance: a controlled study of rehabilitation
24(6):831–837 at home after a shoulder joint operation. J Telemed Telecare
45. Simovitch R, Fullick R, Zuckerman JD (2013) Use of the subscapu- 15(5):215–220
laris preserving technique in anatomic total shoulder arthroplasty. 57. Friedman RJ (1994) Biomechanics of total shoulder arthroplasty.
Bull Hosp Jt Dis (2013) 71 Suppl 2:94–100 In: Friedman RJ (ed) Arthroplasty of the shoulder. Thieme,
46. Routman HD (2013) The role of the subscapularis repair in reverse New York, pp 27–40
total shoulder arthroplasty. Bull Hosp Jt Dis (2013) 71 Suppl 2:108012 58. Brems JJ (1994) Rehabilitation following shoulder arthroplasty. In:
47. Molé D, Wein F, Dézaly C, Valenti P, Sirveaux F (2011) Surgical Friedman RJ (ed) Arthroplasty of the shoulder. Thieme, New York,
technique: the anterosuperior approach for reverse shoulder arthro- pp 99–112
plasty. Clin Orthop Relat Res 469(9):2461–2468 59. Healy WL, Iorio R, Lemos MJ (2001) Athletic activity after joint
48. Loukas M, Grabska J, Tubbs RS, Apaydin N, Jordan R (2009) replacement. Am J Sports Med 29(3):377–388
Mapping the axillary nerve within the deltoid muscle. Surg Radiol 60. Golant A, Christoforou D, Zuckerman JD, Kwon YW (2012)
Anat 31(1):43–47 Return to sports after shoulder arthroplasty: a survey of surgeons’
49. Gurushantappa PK, Kuppasad S (2015) Anatomy of axillary nerve preferences. J Shoulder Elbow Surg 21(4):554–560
and its clinical importance: a cadaveric study. J Clin Diagn Res 61. Cox CL, Kuhn JE (2009) Complications in shoulder arthroplasty
9(3):AC13–AC17 surgery. Chapter 10. In: Total shoulder arthroplasty. American
50. Gillespie RJ, Garrigues GE, Chang ES, Namdari S, Williams GR Jr Socity for Surgery of the Hand, Rosemont, pp 1–15
(2015) Surgical exposure for reverse total shoulder arthroplasty: 62. Bohsali KI, Wirth MA, Rockwood CA Jr (2006) Complications of
differences in approaches and outcomes. Orthop Clin North Am total shoulder arthroplasty. J Bone Joint Surg Am 88:2279–2292
46(1):49–56 63. Chin PY, Sperling JW, Cofield RH, Schleck C (2006) Complications
51. Puskas GJ, Catanzaro S, Gerber C (2014) Clinical outcome of reverse of total shoulder arthroplasty: are they fewer or different? J Shoulder
total shoulder arthroplasty combined with latissimus dorsi transfer for Elbow Surg 15:19–22
the treatment of chronic combined pseudoparesis of elevation and 64. Boileau P, Sinnerton RJ, Chuinard C, Walch G (2006) Arthroplasty
external rotation of the shoulder. J Shoulder Elbow Surg 23(1):49–57 of the shoulder. J Bone Joint Surg 88B:562–575
52. Sperling JW, Cofield RH, Rowland CM (1998) Neer hemiarthro- 65. Cheung E, Willis M, Walker M, Clark R, Frankle MA (2011)
plasty and Neer total shoulder arthroplasty in patients fifty years old Complications in reverse total shoulder arthroplasty. J Am Acad
or less: long-term results. J Bone Joint Surg Am 80:464 Orthop Surg 19:439–449
Traumatic Anteroinferior Instability
3
Giovanni Di Giacomo, Todd S. Ellenbeker, Elena Silvestri,
and Silvia Bellachioma
Contents 3.4 First-Time Anterior Shoulder Dislocation .................. 106
3.1 Introduction ................................................................... 94 3.5 Recurrent Traumatic Anteroinferior Instability:

3.1.1 Key Concepts in Shoulder Rehabilitation Algorithm of Treatment and Rehab ............................ 111
for Instability ................................................................... 94 3.5.1 Arthroscopic Bankart Repair........................................... 114
3.5.2 Evaluation of the Shoulder following Arthroscopic
3.2 Traumatic Anteroinferior Instability .......................... 96 Bankart Reconstruction ................................................... 116
3.2.1 Understanding Stability Mechanisms ............................. 96 3.5.3 Rehabilitation following Arthroscopic Bankart .............. 121
3.3 Bone Loss ....................................................................... 97 3.6 Latarjet Technique ........................................................ 139
3.3.1 Glenoid Bone Loss .......................................................... 97
3.7 Rehabilitation following Latarjet Technique .............. 142
3.3.2 Hill-Sachs Lesion ............................................................ 99
3.3.3 Hill-Sachs Orientation..................................................... 101 3.8 Physical Examination at Outset ................................... 145
3.3.4 Hill-Sachs Location......................................................... 102
References .................................................................................... 160
3.3.5 Size of Hill-Sachs Lesions .............................................. 103
3.3.6 Bipolar Bone Loss Lesion ............................................... 103 Further Reading .......................................................................... 164
G. Di Giacomo (*) • S. Bellachioma

Concordia Hospital for Special Surgery, Rome, Italy
e-mail: [email protected]; [email protected]
T.S. Ellenbeker, DPT, MS, SCS, OCS, CSCS
Clinic Director, Physiotherapy Associates Scottsdale Sports Clinic,
National Director of Clinical Research, Physiotherapy Associates
Vice President, Medical Services ATP World Tour,
Scottsdale, Arizona, USA
E. Silvestri
Fisiosmart, Rome, Italy

DOI 10.1007/978-3-319-24856-1_3
3.1 Introduction components of the glenohumeral joint and enhances activa-

tion of the posterior rotator cuff through length-tension
Treatment of patients with glenohumeral joint instability is a enhancement compared with function in the coronal plane [1,
complex process and involves a complete understanding of 2]. Placement of the glenohumeral joint in the scapular plane
the functions and role of both the static and dynamic stabiliz- optimizes the osseous congruity between the humeral head
ers of the glenohumeral joint. Additionally, a thorough and the glenoid and is widely recommended as an optimal
knowledge of the surgical concepts and procedures outlined position for the performance of various evaluation techniques
throughout this fine text to address the compromised ana- and for the use during many rehabilitation exercises [1, 4].
tomical structures in the patient with glenohumeral instabil- Another important general concept of relevance for this
ity is of critical importance as well. The purpose of this chapter is that of muscular force couples. One of the most
chapter is to review the rehabilitative concepts and protocol important biomechanical principles in shoulder function is
for the treatment of the patient following arthroscopic the deltoid rotator cuff force couple [5]. This phenomenon,
Bankart reconstruction and latarjet technique. known as a force couple, can be defined as two opposing
muscular forces working together to enable a particular
motion to occur, with these muscular forces being syner-
3.1.1 Key Concepts in Shoulder gists or agonist/antagonist pairs [5]. The deltoid muscle
Rehabilitation for Instability provides force primarily in a superior direction when it
contracts unopposed during arm elevation [6]. The muscle-
One of the key concepts in upper extremity rehabilitation is tendon units of the rotator cuff must provide a compressive
the scapular plane concept. The scapular plane has ramifica- force, as well as an inferiorly or caudally directed force, to
tions in treatment, in evaluation, and even in functional activ- minimize superior migration and to minimize contact
ity in sports. According to Saha, the scapular plane is defined or impingement of the rotator cuff tendons against the over-
as being 30° anterior to the coronal or frontal plane of the lying acromion [5].
body [1]. This plane is formed by the retroversion of the Failure of the rotator cuff to maintain humeral congru-
humeral head, which averages 30° relative to the shaft of the ency leads to glenohumeral joint instability, rotator cuff ten-
humerus, coupled with the native anteversion of the glenoid, don pathology, and labral injury [7]. Imbalances in the
which is also 30° in relation to the scapular plane [2, 3]. deltoid rotator cuff force couple, which primarily occur dur-
It is important for clinicians to recognize this relationship ing inappropriate and unbalanced strength training, as well
during humeral head translation testing and exercise position- as during repetitive overhead sports activities, can lead to
ing because of the inherent advantages of this position development of the deltoid without concomitant increases in
(Fig. 3.1). With the glenohumeral joint placed in the scapular rotator cuff strength and can increase the superior migration
plane, bony impingement of the greater tuberosity against the of the humeral head provided by the deltoid, leading to rota-
acromion does not occur because of the alignment of the tor cuff impingement.
tuberosity and the acromion in this orientation [1]. In addition Additionally, the serratus anterior and trapezius force
to the optimal bony congruency afforded in the scapular couple is the primary muscular stabilization and prime mover
plane, this position decreases stress on the anterior capsular of upward rotation of the scapular during arm elevation.
3 Traumatic Anteroinferior Instability 95
Bagg and Forrest have shown how the upper trapezius and the proposed range of 55–70° of humeral elevation in the scap-
the serratus anterior function during the initial 0–80° of arm ular plane (trunk-humeral angle) at a mean trunk-humeral
elevation, providing upward scapular rotation and stabiliza- angle of 39.33°. This corresponded to 45 % of the available
tion [8]. Because of a change in the lever arm of the lower ROM of the cadaveric specimens.
trapezius that occurs during the lateral shift of the scapulo- Anterior posterior humeral head translations and maximal
thoracic instantaneous center of rotation with arm elevation, total rotation ranges of motion were significantly less at 0° of
the lower trapezius and the serratus anterior function as the abduction and near 90° of abduction, respectively, in the
primary scapular stabilizer in phases II and III (80–140°) of plane of the scapula, and were greatest near the experimen-
elevation [8]. tally measured resting position of the glenohumeral joint
Knowledge of the important muscular force couples in (39.3°).
the human shoulder and scapulothoracic region is imperative This study provides key objective evidence for the clini-
and can lead to proper evaluation and ultimately treatment cian to obtain the maximal loose-pack position of the gle-
provided via strengthening and monitoring of proper strength nohumeral joint by using the plane of the scapula and
balance in these important muscular pairings. Finally, the approximately 40° of abduction. This information is impor-
concept of glenohumeral resting position deserves discus- tant to clinicians who wish to evaluate the glenohumeral
sion in this section of the chapter because of its relevance joint in a position of maximal excursion or translation and
both in evaluation of the shoulder and in the application of to determine the underlying accessory mobility of the joint.
treatment, specifically mobilization and interventions per-
formed to improve glenohumeral motion. The resting posi-
tion of the human glenohumeral joint generally is considered
to be the position where there is maximum range of motion
(ROM) and laxity, caused by minimal tension or stress in the
supportive structures surrounding the joint [9]. This position
has been referred to as the loose-pack position of the joint as
well. Kaltenborn and Magee both have reported that the rest-
ing position of the glenohumeral joint ranges between 55°
and 70° of abduction (trunk-humeral angle) in the scapular
plane [10, 11].
This loose-pack position is considered to be a “midrange”
position, but only recently has it been subjected to experimen-
tal testing. Hsu et al. measured maximal anterior posterior dis-
placements and total rotation ROM in cadaveric specimens,
with altering positions of glenohumeral joint elevation in the
plane of the scapula [9]. Their research identified the loose-
Fig. 3.1 Scapular plane position: Rehabilitation application using a
pack position, where maximal anterior posterior humeral head physioball with rhythmic stabilization and perturbation applies in a
excursion and maximal total rotation ROM occurred within position 30° anterior to the coronal plane of the body
3.2 Traumatic Anteroinferior Instability head centered in the glenoid socket; and enlarged joint
volume with a thin joint capsule, which makes maintaining
3.2.1 Understanding Stability Mechanisms negative intra-articular pressure difficult are all causes of
midrange instability.
The design of the shoulder makes it the most mobile and • In the end range of shoulder motion, in abduction and
least constrained joint of the musculoskeletal system. maximum external rotation and maximum horizontal
The forces acting on it may be divided into static and extension, the anteroinferior capsule becomes tight and
dynamic constraints [12]. plays a role as a stabilizer (Fig. 3.3).
It is important to consider the instability which may arise Hence, disruption of this capsule, for example, in a
in the midrange or end range of shoulder motion [13]. Bankart lesion, will result in a reduction in end-range sta-
bility. Another important pathology in the context of end-
• In the midrange, the lax capsule-ligamentous structures do range stability is the large Hill-Sachs lesion which
not contribute to stabilization of the joint, which is instead engages with the anterior rim of the glenoid; this concept
achieved either by negative intra-articular pressure (hang- is very important for a proper understanding of the patho-
ing-arm position without muscle contraction) or by the physiology associated with bony defects of the glenoid
concavity-compression effect caused by muscle contrac- and the humeral head.
tion force against the glenoid concavity (Fig. 3.2) [14].
Any pathological process which compromises these sta- It is well established that patients with soft tissue incom-
bilizing mechanisms will lead to midrange instability, for petence [15, 16], humeral head deficiencies [17–19], and/or
example, a large bony defect of the glenoid, resulting in glenoid bone loss [15, 20–22] have higher failure in conser-
an insufficient concavity-compression effect; muscle vative and surgical rates than those in which these lesions are
imbalance, which makes it difficult to keep the humeral not present.
Fig. 3.3 At the end of range of motion, the anteroinferior capsule

Fig. 3.2 In the midrange the capsule-legamentous structures do not becomes tight and stabilizes the joint
contribute to the stabilization of the joint
3.3 Bone Loss Burkhart and De Beer have suggested that acute glenoid
rim fractures seen in rugby players may be the result of
3.3.1 Glenoid Bone Loss excessive axial load on the glenoid when the injury takes
place (Fig. 3.4) [31].
The prevalence of glenoid rim fracture or erosion in anterior Smaller rim avulsions, on the other hand, may occur fol-
shoulder instability has been reported to range from 8 to lowing episodes of low-energy trauma associated with less
95 % [21, 23–30]. axial load and more translation and shearing of the humeral
In surgical observations of 158 cases of anteroinferior head over the glenoid rim, a mechanism which may also be
shoulder dislocation, 116 (73 %) were found to have a bony responsible for the compression fractures without bony
defect of the glenoid rim, 65 (41 %) had an erosion-type fragments associated with attritional or erosive bone loss due
defect, and 51 (32 %) had a fragment-type defect [21, 23]. to repeated or recurrent episodes of instability [32, 33].
In patients with recurrent anterior shoulder dislocation Although there are no natural history studies of glenoid
studied with 3D (best-fit circle), 40 % -> had an erosion-type bone loss, the basic science literature suggests that a bony
bone loss, 50 % had a fragment-type bone loss, and 10 % had Bankart lesion and subsequent resorption may precede attri-
intact bone [24, 30]. tional bone loss [34].
Fig. 3.4 (a) Excessive axial load on the glenoid can lead to glenoid
fracture. (b) different angles of stress at the glohumeral joint on the
axial plan (orizontale extension) a>b
According to Boileau et al. [15], an episode of instabil- difficult irrespective of the method adopted and may in any
ity will lead to rim avulsion (Fig. 3.5) without significant case be meaningless. Measurement of surface area is one of
stretching of the joint capsule provided that the latter is the methods which have gained the widest acceptance and
“strong” and of “good” quality, whereas a “weak” capsule is currently used to quantify glenoid bone loss of all types
will be subject to elongation and thus recurrent sublux- [35, 36].
ations or dislocations will lead to compression and erosion In a study carried out by Sugaya et al. [36], 3D CT was
of the glenoid rim (Fig. 3.6). This means that in the clinical used to evaluate bony Bankart lesions in 50 cases of recur-
context, traumatic anterior instability is likely to lead to rent anterior instability: one large fragment (>20 % of the
only two types of glenoid lesion: rim fractures or avulsions glenoid fossa), 27 medium fragments (5–20 %), and 22 small
and compression fractures or erosive bone loss. A wide fragments (<5 %) were found. A more recent study (d’Elia
range of noninvasive imaging methods have been used to et al. [37]) found a glenoid rim lesion in the preoperative 2D
evaluate glenoid bone loss quantitatively but determining CT results of 64 (80 %) of 80 patients with recurrent anterior
the extent of a rim avulsion or compression fracture remains instability.
Fig. 3.6 Recurrent subluxations or dislocations will lead to compres-

Fig. 3.5 An episode of instability with “strong” and of “good” quality sion and erosion of the glenoid rim
ligaments can lead to rim avulsion
3.3.2 Hill-Sachs Lesion of the Hill-Sachs lesion in young patients with an initial
anterior shoulder dislocation was 47 %.
In 1861, the “anatomical lesion” found on the articular The incidence of this lesion is also known to increase with
humeral head posterior to the greater tuberosity in cases the number of dislocations: it ranges from 65 to 67 % after
of anterior dislocation was described by Flower as a the first dislocation and rises to 84–93 % in cases of recurrent
“groove” [38]. dislocations [17, 42–45].
In 1880 Eve reported a case of subcoracoid dislocation When the humeral head is driven anteriorly, the capsule-
with formation of a “groove” on the posterior surface of labral structures of the shoulder become stretched and often
the humeral head; this became known as the “typical tear, the humeral head translates further anteriorly, and a
defect” [39]. compression fracture occurs along the postero-supero-lateral
The first well-documented cases of a “typical defect” aspect of the humeral head as it impinges on the dense corti-
occurring after initial anterior dislocation were described in cal bone of the anterior glenoid rim. Hill and Sachs also
1934 by Hermodsson [40], who noted that (a) the defect described [8] the “line of condensation,” which is a sharp
occurs frequently; (b) the longer the humeral head is dislo- line detectable on x-ray with the arm in internal rotation; this
cated, the larger the defect will be; (c) the defect is generally line represents “the compression or compaction into a nar-
larger with anteroinferior dislocation than with anterior dis- row medial border of the spongy bone previously occupying
location; and (d) the defect is generally larger in recurrent the space of the defect” (Fig. 3.7) [19].
dislocations [19, 40, 41]. It is important to be able to distinguish between the nor-
Calandra et al. [17] established a classification of these mal anatomical structures of the posterior humeral head and
defects based on arthroscopic evaluation: grade I is a defect the characteristic features of Hill-Sachs lesions. As Richards
in the articular surface down to, but not including, the sub- et al. [23] have described, the “bare spot” of the humeral
chondral bone; a grade II lesion includes the subchondral head has no direct attachment of the rotator cuff tendons; it
bone; and a grade III lesion signifies a large defect in the sub- is the anatomical groove of the humeral head and flattening
chondral bone. This study also found that the true incidence of the head as it progresses caudally to become the shaft.
Fig. 3.7 Note “line of condensation” on the humeral head with the
internal rotation
Recurrent instability renders the damaged anterior soft likely that the relatively softer cancellous bone of the humeral
tissue structures particularly problematic as the static gleno- head will sustain continued damage as it impacts repeatedly
humeral constraints (i.e., capsule, labrum) are progressively with the harder cortical bone of the glenoid [24], with spe-
weakened with each episode. This attenuation makes it more cific orientation, location, and size (Fig. 3.8).
Fig. 3.8 Orientation, location (red arrow), and size of Hill-Sachs lesion (yellow arrow) (Courtesy of Paolo Baudi)
3.3.3 Hill-Sachs Orientation Conversely, it’s engaging if the long axis of the Hill-Sachs
lesion (Fig. 3.10) is parallel to the anterior glenoid with the
A non-engaging Hill-Sachs lesion (Fig. 3.9) was defined by shoulder in a functional position of abd/ext, so that the lesion
Burkhart and De Beer [31] as having its long axis at a diago- engages with the corner of the glenoid. This kind of fracture
nal, nonparallel angle to the anterior glenoid with the shoulder makes the shoulder susceptible to recurrent dislocation and
in a functional position of abd/ext. In this situation the articu- subluxation even after arthroscopic repair and tends to be
lar surfaces are in continual contact, and the Hill-Sachs lesion especially if a glenoid defect is also present or if there is
does not engage with the anterior glenoid. Unless there is sig- medial extension of the lesion beyond the medial margin of
nificant glenoid bone loss or poor soft tissue quality, there will the glenoid track.
be no functional articular-arc deficit, and therefore the lesion
will be amenable to arthroscopic Bankart repair.
Fig. 3.9 The long axis of the Hill-Sachs lesion in the “non-engaging” Fig. 3.10 The long axis of the Hill-Sachs lesion in the “engaging” pat-
pattern is not parallel to the glenoid with the shoulder in a functional tern is parallel to the glenoid with the shoulder in a functional position
position of abduction and external rotation of abduction and external rotation
3.3.4 Hill-Sachs Location The distance from the medial margin of the contact area
to the medial margin of the rotator cuff attachment onto the
The glenoid track concept was first proposed by Yamamoto humerus was 18.4 ± 2.5 mm or 84 ± 14 % of the glenoid
et al. [46] following their three-dimensional (3D) computed width with the arm at 60° of abduction to the scapula or 90°
tomography (CT) study of the area of contact between the of abduction to the trunk (Fig. 3.11b, c).
humeral head and the glenoid with regard to shoulder dislo- Both the integrity of the glenoid track and the location of
cation. They found that the area of contact moved from the the Hill-Sachs lesion with respect to its medial margin are of
infero-medial to the superolateral aspect of the posterior vital importance in the identification of those bipolar bone
articular surface of the humeral head when the arm was lesions which are at risk when Bankart repair or other stan-
raised and defined the zone of contact thus created as the dard stabilization procedures are being considered (“on-
glenoid track. Bone stability is guaranteed when there is no track” and “off-track” lesions are discussed in greater detail
significant bone loss and the glenoid tract is intact in Sect. 3.3.6) [47, 48].
(Fig. 3.11a).
Fig. 3.11 (a) AB is the glenoid track; it guarantees the bone stability head (AB) is medial to the medial margin of the rotator cuff attachments
when the arm is raised. (b) The glenoid track is 84 ± 14 % of the glenoid (Courtesy of Paolo Baudi)
width (Courtesy of Paolo Baudi). (c) The glenoid track on the humeral
3.3.5 Size of Hill-Sachs Lesions 3.3.6 Bipolar Bone Loss Lesion
Both Boileau et al. [15] and Rowe et al. [18, 21] identified large Both the integrity of the glenoid track and the location of the
Hill-Sachs lesions as a risk factor for recurrent shoulder instabil- Hill-Sachs lesion with respect to its medial margin are of
ity, but did not elaborate further on possible quantitative defini- vital importance in the identification of those bipolar bone
tions of “large.” In biomechanical studies, Kaar et al. [49] lesions, which are at risk when Bankart repair or other
showed that glenohumeral stability is substantially decreased by standard stabilization procedures are being considered
defects of five-eighths of the humeral head radius, while Sekiya (Fig. 3.12a, b).
et al. [50] demonstrated that a defect of 25 % of the radius of the Although we believe that the definition of engaging ver-
humeral head decreased the stability. sus non-engaging Hill-Sachs lesions remains very important
Cho et al. [51] observed that engaging Hill-Sachs lesions in discerning significant bone loss, it is also our opinion that
were significantly wider and deeper than non-engaging it requires clarification in terms of how these lesions relate to
lesions, demonstrating a close correlation between the size the glenoid track and their behavior after capsular labral
of the Hill-Sachs lesion and its engagement. repair.
a b
c d
Fig. 3.12 (a) The “bipolar” bone loss lesion. (b) The “bipolar” bone loss lesion in TC axial view. (c) Glenoid bone loss with sottraction of the
humeral head. (d) Bone loss on humeral head 3D recostruction posterior view (Hill-Sachs lesion)
Burkhart and De Beer’s concept [31] of engaging versus anterior translation related to the Bankart lesion and
non-engaging lesions is consistent with and complimentary involves assessment of the glenoid track, including the
to that of the glenoid track proposed by Itoi et al. [46], as effect of associated glenoid bone loss and the role of the
each evaluates the interaction of bipolar bone loss during location of the Hill-Sachs lesion with respect to the glenoid
dynamic shoulder function. track itself.
Both Warner et al. [52] and Provencher et al. [53] main- Glenoid bone loss will result in a reduction of the width of
tain that as engagement is required for the formation of the the glenoid track. Under these circumstances, glenoid track
Hill-Sachs lesion, all Hill-Sachs lesions would engage pro- width can be determined by subtracting the width of the
vided that the exact mechanism and sufficient energy were defect from 83 % of the glenoid width, which is the width of
reproduced. the glenoid track in the absence of a glenoid defect [35]. In
Kurokawa et al. [54] supported this idea, recommending this way, the bone defects of the glenoid and humeral head
that evaluation of engaging Hill-Sachs lesions should be per- can be assessed with regard to each other. When the medial
formed using the glenoid track concept rather than dynamic margin of a Hill-Sachs lesion lies within the glenoid track,
intraoperative assessment. Although the latter is almost the lesion has adjacent bone support and is on track; con-
always carried out prior to Bankart lesion repair, its use may versely, a Hill-Sachs lesion with a medial margin which is
lead to overdiagnosis of engaging Hill-Sachs lesions because medial to the glenoid track will lack bone support and is off
of excessive anterior translation of the humeral head permit- track (Figs. 3.13, 3.14, and 3.15).
ted by ligament insufficiency, which would facilitate engage- Having established that the orientation of the Hill-Sachs
ment of the humeral defect with the glenoid rim. Such lesion (engaging or non-engaging) and its position on the
anterior translation of the humeral head during motion in the humeral head (on track or off track) are crucial in guarantee-
horizontal plane has been shown experimentally [55]. ing bone stability, it is essential to understand how this lesion
According to Kurokawa et al. [54], a “true engaging Hill- is created (if it occurs after the first dislocation), its relation-
Sachs lesion” is one which either engages after Bankart ship to the mechanism of lesion formation, and, in particular,
repair or extends over the glenoid track. how it evolves morphologically and topographically with
Arthroscopic evaluation of the dynamic interaction of subsequent episodes of dislocation.
bipolar bone loss carried out before repairing a Bankart lesion We will therefore focus our attention on the orientation
may reproduce a less than entirely reliable situation, which and location of the Hill-Sachs lesion and its relationship to
does not correspond either anatomically or biochemically to the first mechanism of lesion formation, characteristics with
the context of a shoulder with an intact capsule-ligamentous an important predictive value in the identification of cases
complex. On the other hand, post-repair arthroscopic assess- following a first traumatic anteroinferior dislocation which
ment of engagement, despite being more correct from ana- have a risk of recurrence or are amenable to tailored surgical
tomical and functional points of view, risks compromising the techniques.
repair itself by overstressing the newly repaired capsule- Most published decision analysis studies in the field of
labral complex in abduction and external rotation. orthopedics are intended to serve as a guide for both physi-
The arthroscopic assessment currently carried out prior cians’ recommendations and patients’ treatment decisions.
to Bankart repair in order to distinguish engaging from A key aspect of modern patient-centered care is shared
non-engaging Hill-Sachs lesions should therefore be decision-making, with active involvement of patients in the
replaced by a new approach which does not consider the decision-making process.
a b
Fig. 3.13 (a) When the medial margin of the Hill-Sachs lies within the “glenoid track,” the lesion has adjacent bone support and is on-track. (b)
3D reconstruction of Hill-Sachs on-track . The blue line is medial of lateral borders of Hill-Sachs (Courtesy of Paolo Baudi)
Fig. 3.14 When the medial margin of the Hill-Sachs lies medial to the
“glenoid track,” the lesion has not adjacent bone support and is off track
a b
Fig. 3.15 (a) The bone loss on the glenoid reduces the width of the “glenoid track,” and a “on-track” lesion can be transformed in a “off-track”
lesion. (b) 3D reconstruction of Hill-Sachs off track. The blue line is medial of lateral borders of Hill-Sachs red dotted line is medial margin of the
glenoid track (Courtesy of Paolo Baudi)
3.4 First-Time Anterior Shoulder Bankart lesions, 27.2 % had free ALPSA lesions, 12.1 % had
Dislocation bony Bankart lesions, 57.5 % had Hill-Sachs lesions, and
12.1 % had fractures of the greater tuberosity of the humerus.
Traumatic first-time anterior shoulder dislocation (FTASD) It has been reported that lesions of the humeral head,
does not lead to recurrent instability in all patients; indeed, which are usually larger are more likely to lead to subsequent
there is increasing evidence that early surgical stabiliza- redislocations [54], account for up to 80 % of all first-time
tion in young, active individuals, collision sports, the mili- dislocations [6, 7, 55].
tary context, and extreme activities may achieve excellent These lesions are important both from the standpoint of
results [56]. their influence on treatment options for recurrent disloca-
However, initial non-operative treatment should be seri- tions and also as a risk factor after first-time dislocations.
ously considered in many patients with anterior shoulder In fact, the size of humeral head bony defects, their orien-
instability, including selected cases in seasonal athletes, tation, their location, and dynamic interaction with glenoid
older low-demand patients, and those who prefer to adopt bone loss, if present (on/off track), all have an effect on gle-
appropriate activity modification, as well as cases in which nohumeral stability [43, 47], which has been shown to
there is no obvious history of trauma. worsen with further instability events.
It is important to establish elements which may assist in In order to identify high-risk patients, we must improve
the identification of patients susceptible to recurrence after our knowledge concerning prognostic factors following
FTASD, as repeated episodes may compromise soft tissue FTASD, besides age, sex, traumatic sport, professional, and
stabilizers, lead to further attritional glenoid bone loss, and hyperlaxity [65]. One way to learn more about acute disloca-
enlarge Hill-Sachs lesions; essentially the severity of the tions and to optimize treatment, when bipolar bone loss is
lesions which accompany the first episode may be increased suspected, may be to evaluate bone lesions of the intra-
by further dislocations and subluxations of the joint. articular head of the humerus according to the mechanism of
Following FTASD, it is therefore necessary to furnish the the lesion.
epidemiological, clinical, anatomical, and pathological ele- An in-depth study of the mechanism of the lesion, accu-
ments which, according to their various combinations, can rately described in the capsule-ligamentous pathologies of
be used to tailor treatment to the specific circumstances of the knee, elbow, and ankle, allows the best possible interpre-
the case and the requests of the patient. tation and determination of the location of soft tissue prob-
A correct interpretation of the risk factors for recurrence lems and any associated lesions. The literature concerning
will make it possible to identify patients who may benefit FTASD reports lesion mechanisms as the history of trau-
from conservative treatment rather than surgery following matic events in contexts such as military training, tackling
FTASD. and falls when playing football, falling from motorcycles,
It is generally accepted that the rate of recurrence of insta- etc., but these descriptions are too generic and inaccurate.
bility after first-time dislocation is higher in younger patients, According to Broca and Hartmann [66], periosteal strip-
males, those who participate in contact sports, and in cases ping occurs in shoulder dislocations brought about by direct
where there are other associated pathological conditions. trauma mechanisms (with external force applied to the
Recurrence rates as high as 90–95 % have been reported shoulder like a tackle or a fall), and shoulder dislocation with
in patients younger than 25 years of age [57–60]. capsular tearing can only occur due to indirect trauma (with-
In a 2003 study of 32 pure traumatic anterior dislocations out any external force applied to the shoulder like ABER
in adolescents aged 11–18 years, Deitch et al. [61] found the position during throwing) with the arm abducted or elevated,
recurrence rate to be 75 %, while the recurrence rates with failure of the posteroinferior capsular structures when
reported by Rowe [62] were 100 % for patients under the age this is associated with internal rotation, but failure of the
of 10, 94 % for those aged between 10 and 20, and 79 % for anteroinferior capsular structures when external rotation
those aged between 20 and 30. occurs as well. Delorme [67] maintained that the state of
It is increasingly the case that athletes dedicate them- humeral rotation when trauma occurs determines the type of
selves to only one sports and sub-specialize in that sports lesion that is caused by an indirect trauma mechanism in
progressively earlier in their careers. Exceptional demands hyperabduction. When the arm is rotated internally, the
may therefore be placed on the musculoskeletal systems of greater tubercle impinges on the coracoid process, which
these young athletes, especially on the shoulders of those acts as a fulcrum for levering the humeral head downward
who participate in high-energy sports which involve physical out of the joint through a lesion of the inferior glenohumeral
contact or an overhead position of the arm [63]. ligament. In the case of external rotation, movement is lim-
In a study designed to investigate lesions accompanying ited by inferior glenohumeral ligament tension, and the
primary anterior dislocation, Doo-Sup Kim et al. [64] greater tubercle is thus prevented from touching the coracoid
observed that 24.2 % of patients in the study group had process. The inferior glenohumeral ligament itself acts as a
fulcrum and tears, usually from its glenoid insertion; tearing Inclusion criteria consisted of first-time anterior shoulder
of the middle glenohumeral ligament only occurs when sud- instability, a complete set of radiographic images, studies
den extension is added to abduction and external rotation. (3D CT scan of the shoulder with the humeral head digitally
As the likelihood of further dislocations following an ini- disconnected), documented physical examination confirm-
tial anteroinferior episode also depends on the topographic ing anterior shoulder instability, and patient able to fully
and morphological characteristics of the Hill-Sachs lesion, it describe the lesion mechanisms that caused the dislocation,
is essential to determine in each case whether the mechanism ABD position versus ADD.
of lesion (ABD vs ADD) is related to a specific humeral bone With this method, 102 patients met the inclusion criteria:
loss. If this were to be demonstrated, an accurate patient his- 89 male (87.2 %) and 13 female (12.8 %), the mean age
tory of the trauma which provoked the initial or recurrent being 32 years (range 17–38, SEM 0.50). [In regard to mech-
episode, combined with CT imaging, could provide the phy- anism, a total of 45 (44.1 %) attributed it to a movement in a
sician with another useful prognostic tool [68]. functional position (ABD) and 57 (55.9 %) to a fall with the
We performed a multicentric consecutive patient retro- arm at the side.]
spective review of all first-time traumatic anterior shoulder Hill-Sachs lesion occurs during the dislocation at a spe-
dislocations, during a period from 2010 to 2014. cific angle (α angle) between the anterior glenoid (A–B) and
The initial injury lesion mechanism was classified accord- the humeral diaphysis (C–D); the same angle is between the
ing to Burkhart and De Beer [31] in ABD (a position defined long axis of the Hill-Sachs (A–B) and humeral diaphysis
as 90° abduction combined with external rotation in the (C–D), so if we measure this angle (α), we know at what
range between 0° and 135°) and ADD (with the arm in glenohumeral angle the Hill-Sachs lesion is created
adduction and some extension). (Fig. 3.16a, b).
a b
Fig. 3.16 (a, b) The angle between axis of the humerus (CD) and anterior glenoid margin (AB) at which the Hill-Sachs is created is the same angle
between the long axis of the Hill-Sachs (AB) and the axis of the humerus (CD)
We have found that when the first episode occurs with the value of 7 % for “off-track” lesions in recurrent cases
ADD mechanism, the Hill-Sachs lesion is formed with a gle- reported in the literature, we may infer that the recurrent
nohumeral angle of approximately ±16° (Fig. 3.17a) and episodes are responsible for reducing the glenoid track, as a
therefore tends to be relatively parallel to the axis of the result of concurrent glenoid bone loss, which increases with
humeral diaphysis; thus in the ABD position, the lesion each recurrence, and greater medial extension of the Hill-
becomes diagonal to the glenoid and non-engaging. On the Sachs lesions [54].
other hand, when the mechanism of the first episode is ABD, These phenomena may be related to the fact that patients
the Hill-Sachs lesion is formed at a glenohumeral angle of with a first lesion mechanism in ADD acquire anteroinferior
approximately 31° (Fig. 3.17b), and it is more oblique with instability, supported by the subequatorial capsule-
respect to the diaphyseal axis; it is therefore more parallel to ligamentous lesion and may therefore also redislocate more
the anterior margin of the glenoid in the ABD position and easily in ABD, thus creating a greater confluent Hill-Sachs.
engaging. At the same time, further dislocations and the total disloca-
The high percentage of “on-glenoid-track” Hill-Sachs tion time both tend to medialize the Hill-Sachs lesion and
lesions observed in our cases is related to the fact that we produce increased glenoid bone loss, thus increasing the pos-
only assessed first episodes. Comparing our results with the sibility that the Hill-Sachs lesion may become off track [54].
a b
Fig. 3.17 (a) With ADD mechanism of lesion, the Hill-Sachs lesion is Sachs lesion is oriented 32.4° ± 4.7° with respect to the axis of the
oriented 16.1° ± 2.9° with respect to the axis of the humerus and is in a humerus and is in a more engaging position
less engaging position. (b) With ABD mechanism of lesion, the Hill-
Having confirmed that, after an initial episode, the Hill- closer to the side (Fig. 3.19a, b). The specific characteris-
Sachs lesion is formed in ADD at around 16.1° ± 2.9°, and in tics will, however, depend on the mechanism of
ABD at around 32.4° ± 4.7°, we were able to break the dislo- dislocation.
cation times down into four phases: If dislocation occurs in abduction, in the repositioning
phase a Hill-Sachs engages with the anteroinferior gle-
• Phase 1: is dynamic. It depends strictly on the mechanism noid and induces protraction and internal rotation of the
of the lesion. It is the time period in which dislocation of scapula, in an appearance of adduction. The humeral head
the humeral head from the center of rotation of the gle- rotates like a fan on the anteroinferior glenoid rim (the
noid to its anterior margin takes place (when Bankart and/ “hand fan effect”) resulting in latero-medial and supero-
or bony Bankart lesions are created); the posterosuperior inferior enlargement of the Hill-Sachs lesion, with abduc-
head could potentially engage with the anteroinferior tion to adduction on the frontal plane and external to
glenoid. internal rotation on the axial plane, usually patients pres-
If a Hill-Sachs lesion is present, this is its starting point ent at the emergency room holding the involved arm in
(Fig. 3.18). varying degrees of abduction by supporting it at the elbow
• Phase 2: is the reposition phase. Aided by gravity, patients with the contralateral hand. If the trauma occurs in adduc-
with dislocation of the humeral head gradually take the tion, the repositioning phase is obviously limited, and the
arm from the point of dislocation to a less painful position patient’s arm is in true adduction.
Fig. 3.18 Phase 1 → starting position of the Hill-Sachs
a b
Fig. 3.19 (a, b) Phase 2 → reposition phase

• Phase 3: is relatively static. At the conclusion of phase 2, the glenoid is obscured by changes in position of the scap-
with the patient in the “dislocated position,” there are two ula). The second consideration is the length of time for
important considerations. The first of these is the orienta- which the compressive force of the humerus acts against
tion of the humerus to the anterior glenoid (H-S angle), the anterior glenoid, which would appear to be the most
which will remain unchanged at 16.1° ± 2.9° in the ADD important determinant of the depth of the Hill-Sachs
and 32.4° ± 4.7° in the ABD until the dislocation is lesion (Fig. 3.20).
reduced (the true clinical relationship of the humerus to • Phase 4: is dynamic. The reduction time (Fig. 3.21).
Fig. 3.20 Phase 3 → static phase during which the Hill-Sachs is really Fig. 3.21 Phase 4 → reduction time
formed
3.5 Recurrent Traumatic Anteroinferior It is also interesting to note that all the Hill-Sachs lesions
Instability: Algorithm of Treatment were on track, not only because they were lateral to the gle-
and Rehab noid track but also because in no case was glenoid bone loss
sufficiently pronounced as to transform an “on-track” lesion
The values which we obtained for the H-S angle after the into one which was “off track.”
first dislocation episode correlate closely with whether the The movement associated with lesion mechanisms in
lesion mechanism occurred in the ABD or ADD position, as FTASD is often, but not always, one of abduction, external
reported by Burkhart [31]. rotation, or extension. In this case the Hill-Sachs lesion in the
Data obtained during an FTAD show that the humerus ABD position is orientated parallel to the glenoid (engaging
and scapula are orientated at specific angles when the Hill- lesion); if the lesion mechanisms of subsequent episodes are
Sachs lesion is formed, depending on the lesion also in the ABD position, the morphology, location, and ori-
mechanism. entation of the humeral bony lesion will be repeated.
When the dislocation occurs in the ADD position, the H-S However, after an FTASD with the arm at side, the orien-
angle is smaller (16.1° ± 2.9°), and the longitudinal axis of tation of the Hill-Sachs lesion in the ABD position is non-
the Hill-Sachs is not parallel but, with the joint in the func- engaging, but the joint is unstable in the anteroinferior
tional position of external rotation and abduction, passes direction because of the capsule-ligamentous lesion, and fur-
diagonally across the anterior glenoid. It is improbable that ther episodes may result in a lesion with a different orienta-
the glenoid rim will be engaged; these non-engaging lesions tion and location with respect to the previous one, creating
are therefore not as likely to contribute to recurrent an overlap that forms a confluent Hill-Sachs lesion.
instability. The application of these observations to the clinical con-
In cases of dislocations in ABD, the H-S angle is larger text, particularly after a first episode of anteroinferior gle-
(32.4° ± 4.7°), and the longitudinal axis of the Hill-Sachs nohumeral dislocation, involves, where possible, studying
lesion is more oblique with respect to that of the humerus the mechanism of formation of the Hill-Sachs lesion (ABD
and parallel to the glenoid. These lesions are termed engag- mechanism of lesion Hill-Sachs lesion is more engaging
ing and are more likely to result in symptomatic shoulder versus ADD mechanism) and confirming its morphological
subluxation or dislocation. and structural characteristics by means of CT imaging.
With correct interpretation, this information, together with that subsequent dislocation episodes may lead to enlarge-
other predictive factors (age, sex, sport, glenoid bone loss, ment of the Hill-Sachs lesion or keep it confluent, in some
soft tissue quality, associated lesions, etc.), may be used to cases surgery is indicated after an initial episode in order to
orient the patient more precisely toward either conservative prevent an on-track Hill-Sachs lesion from becoming off
treatment or tailored surgical intervention. Bearing in mind track.
Algorithm of surgical treatment in recurrent

ant/inf instability
Hill sachs
“On-track” “Off-track”
Glenoid bone Glenoid bone Glenoid bone Glenoid bone

loss <20 % loss >20 % loss <20 % loss >20 %
Open capsular shift Isolated Bankart repair Latarjet

Isolated Bankart repair Remplissage
Latarjet
IIiac crest bone graft
J span technique
The increased recognition of the HSL in recurrent insta-

Take-Home Message bility highlights the need to better address the bone defi-
• The “cutting edge” of the glenoid bone loss in inter- ciency of the humeral head in addition to the arthroscopic
national literature is described to be around Bankart repair (repair of the torn anterior glenoid labrum and
20/21 %, even if in recent reports it seems to be capsule). In 2008 Wolf and colleagues [69] described an
lower around 13/14 %. arthroscopic method of filling the HSL by infraspinatus
• Of course, in the same anatomical pathological con- tenodesis and posterior capsulodesis, currently known as
ditions, different surgical techniques can lead to “remplissage” (Fig. 3.22).
excellent clinical results. Further studies will focus This technique has rapidly gained popularity as an
attention to improve the indication, patient selec- arthroscopic technique to manage large HSLs and although
tion, timing of surgery, surgical techniques, and most clinical studies on the procedure have found it to be
biological issue. successful [69–76].
The primary stabilization feature of the remplissage pro-
cedure is that the infraspinatus and joint capsule form a
mechanical block that contacts the glenoid rim at the “gle-
Surgical Treatments: Algorithm noid track,” limiting the humeral head’s lateral translation.
This impediment to translation, however, may also lead to a
• Hill-Sachs lesion is on track, and glenoid bone loss ranges restriction of ROM in the apprehension position.
from 0 to 20 %; the treatment is arthroscopic Bankart
repair. • Hill-Sachs lesion is “off track,” and glenoid bone loss
• Hill-Sachs lesion is on track, and glenoid bone loss is ranges >20 %; the treatment is Latarjet (Fig. 3.23)
over 20 %; there are different treatments that are interna- because of its triple effect due to:
tionally recognized: open capsular shift, Latarjet, iliac 1. The bone support of the coracoid graft, that enlarge
crest bone graft, and J span technique. the platform of the inverted pear glenoid
• Hill-Sachs lesion is off track, and glenoid bone loss 2. The sling effect, because the common tendon and infe-
ranges <20 %; the treatment is isolated Bankart repair rior part of the subscapularis that stabilize the antero-
and remplissage (infraspinatus tenodesis to fill the inferior glenohumeral joint in ABER position
humeral head defect avoiding the engaging of the Hill- 3. If fixed, the capsular repair with the coracoacromial
Sachs with the anterior glenoid). ligament attached to the graft
Fig. 3.22 Remplissage
Fig. 3.23 Triple effect of the Latarjet technique. (1) Coracoid. (2)
Common tendon. (3) Subscapularis and capsula
3.5.1 Arthroscopic Bankart Repair The key point in this surgery is to repair with a shift
from south to north the soft tissue lesion (Bankart lesion) to
The essential pathoanatomic lesion of a traumatic dislocation the subequatorial glenoid (soft tissue to bone healing)
is the capsulolabral avulsion of the anteroinferior glenohu- (Fig. 3.25).
meral ligament complex (Bankart lesion); this lesion typically The goal is reached through suture anchors that have to be
worsen with repeated injuries as previously described. able to withstand the forces required for rehabilitation until
Anatomical reconstruction procedures have been aimed at the normal bone to tissue interface is restored (Fig. 3.26).
reconstructing the anterior labrum using suture anchors. Post-surgery rehabilitation must take the following into
It is well documented that restoration of stability can be account:
reliably obtained by Bankart repair; if this is successful,
however, there is some morbidity associated with it. 1. Biological-specific healing rates of the surgical proce-
The following description of the arthroscopic Bankart dure: skin incision (arthroscopic portals); in this case
repair procedure indicates in “small caps” the elements the healing process of the soft tissue (Bankart lesion) to
that take about 15 days to heal and in “bold small caps” the the glenoid rim is crucial (Fig. 3.27) and of the infraspi-
elements that take more than 6 weeks to heal. natus to the Hill-Sachs if remplissage is performed
In an effort to restore stability to the shoulder while avoid- (Fig. 3.22).
ing this morbidities, arthroscopic shoulder stabilization 2. Neuromuscolar and proprioceptive recovery: must be
procedures have been developed and offer a number of gradual in the case of the affected body part and consis-
advantages over traditional open techniques: tent with biological heeling timeframe, but can be faster
for the kinetic chain links outside the involved shoulder.
• Smaller incisions (arthroscopic portals) (Fig. 3.24) 3. Return to working and/or sports activity.
• Less muscle dissection (avoiding the iatrogenic lesion of
the subscapularis is one of the main advantages of this
technique)
• Excellent visualization of the entire joint (allowing clear
surgical management of the pathology and of all the pro-
cedure’s steps)
• Less postoperative pain
Fig. 3.24 Arthroscopic portals
Fig. 3.26 Restoration of the ligaments to the bone
Fig. 3.25 Shift from south to north of the inferior capsule-ligamentous Fig. 3.27 Final view of the Bankart repair
complex
3.5.2 Evaluation of the Shoulder with the arms at rest and in the hands on hips position consti-
following Arthroscopic Bankart tute a static scapular evaluation and can indicate the need for
Reconstruction the inclusion of early scapular exercise in the rehabilitation
program. McMahon et al. [82] has shown that patients with
While it is beyond the scope of this chapter to completely glenohumeral joint instability have decreased muscular
review the comprehensive evaluation procedures applied in activity in the serratus anterior during active elevation than
shoulder rehabilitation, it is however very important to dis- normal control subjects. The common association of scapu-
cuss the most important portions of the objective evaluation lar dysfunction and shoulder instability has been reported in
applied following surgery. several clinical investigations [83].
Evaluation of the patient’s static posture provides impor- Dynamic scapular evaluation is also very important but
tant information on scapular function and is one of the pri- is often not possible in the immediate postoperative evalu-
mary areas of initial focus in the initial evaluation ation due to patient’s inability to perform large arcs of
postoperatively. Research has shown that the dominant active movement. Kibler et al. [83] has provided a clini-
shoulder is often lower than the non-dominant, not only in cally useful classification of scapular dysfunction identify-
normal populations but can be significantly lower in the ing three distinct types or patterns of scapular dysfunction.
overhead athlete [77]. Understanding this typical relation- Table 3.1 lists the three types in their classification. Patients
ship is important for the clinician as patients presenting after in the immediate postoperative phase often present with
dominant shoulder surgery who hold their shoulder in a posi- type III superior scapular dysfunction due to force couple
tion higher than the non-dominant shoulder may be guarding imbalance and the characteristic “shrug” sign during
and or have upper trapezius hypertonicity and may require attempts at arm elevation (Fig. 3.29). Additionally,
rehabilitative interventions to address this compensatory increases in medial (internal) rotation are also common
condition. Additionally, observation of the patient in the rest- with instability as well [83] (Fig. 3.30).
ing position with the arms at the side and viewing the shoul- Despite limitations in the ability to perform large arcs of
der girdle and scapular region posteriorly will allow for active elevation in the initial postoperative evaluation of the
inspection of the muscular structure and bulk in the periscap- patient following arthroscopic Bankart, revisiting the full
ular region. Specific focus is given to the rotator cuff and evaluation of the scapula complete with dynamic assessment
scapular musculature for visual observation. Indentation of scapulothoracic motion and further classification using
over the infraspinous fossa of the scapula is common in over- the Kibler system is indicated later in the rehabilitation
head athletes [78, 79] and can be particular evident after process.
dislocation and chronic instability indicating rotator cuff In addition to scapular evaluation, careful assessment of
weakness and focused rehabilitation on the rotator cuff. range of motion provides an indication of joint capsular sta-
Prominence of the scapular spine coupled with indentation tus and identifies potential areas of motion restriction. The
within the infraspinous fossa is key indicator of infraspinatus physiotherapists evaluation of range of motion should
atrophy [78, 79]. The use of the hands on hips position if the include objective documentation of movement most often
patient can assume this position (gently resting the hands on involves the use of a goniometer or inclinometer and specific
the hips with the thumbs pointing posteriorly) can accentuate standardized movement techniques to enhance accuracy and
the visual appearance of the atrophy if present in this region reliability. The motions of primary importance in the evalua-
(Fig. 3.28). Patients with more severe atrophy may have tion following arthroscopic Bankart are forward flexion,
suprascapular nerve involvement [78, 79]. Impingement of coronal plane and scapular plane abduction, and internal and
the suprascapular nerve can occur at the suprascapular notch external rotation. Measurement of humeral rotation should
and the spinoglenoid notch and form paralabral cyst forma- include the use of scapular stabilization to prevent scapular
tion commonly found in patients with superior labral lesions compensation and dilution of the glenohumeral measure-
[80]. Particular attention is focused on this part of the visual ment [84, 85]. Initial measurement of the postoperative
observation in the evaluation process. extremity most often includes passive range of motion in all
Additionally, prominence of the scapular borders both at planes and measurement of humeral rotation with 45° of
rest and in the hands on hips position can indicate scapular abduction (Fig. 3.31). Baseline measures on the dominant
dysfunction [81] and alert the clinician to the need for addi- extremity can include active flexion and abduction, as well as
tional early focus and attention on the scapular stabilizers in humeral rotation passively without overpressure in 45° and
the rehabilitation program. This visual observation technique 90° of abduction.
Table 3.1 Kibler scapular classification

Summary of visually observed
Type Plane of dysfunction dysfunction
I Sagittal Inferior angle of the scapula
prominent
Increase anterior tilting of the
scapula
II Transverse Medial border of the scapula
prominent
Increased internal rotation of the
scapula
III Coronal Increased superior translation of
the scapula excessive superior
movement of the scapula during
active arm elevation, superior
border prominent
Fig. 3.28 Visual identification of Infraspinatus atrophy with the

patient in the hands on hips position
Fig. 3.30 Medial (type II) Kibler scapular pathology
Fig. 3.29 Superior (type III) Kibler scapular pathology
Fig. 3.31 Measurement of humeral external rotation in 45° of abduc-

tion in the early postoperative evaluation
Special Tests Used in the Postoperative joint. Excessive translation in the inferior direction during
Evaluation this test most often indicates a forthcoming pattern of
Several special tests can be applied in the initial evaluation excessive translation in an anterior or posterior direction
that can provide useful information on the baseline status of or in both anterior and posterior directions [86]. This test,
the shoulder following stabilization surgery. These include when performed in the neutral adducted position, directly
the dis-association test, the sulcus sign, and anterior poste- assesses the integrity of the superior glenohumeral liga-
rior humeral head translation tests. Additionally, applying ment and the coracohumeral ligament [87]. These liga-
the Beighton Hypermobility Index can provide an estimate ments are the primary stabilizing structures against
of the patient’s systemic mobility status. inferior humeral head translation in the adducted GH
position [88]. To perform this test, it is recommended that
• Dis-Association Test: This maneuver involves performing a the patient be examined in the seated position with the
very simple circumduction movement of the humerus and arms in neutral adduction and resting gently in the
assessing the patient’s ability to dis-associate the humerus patient’s lap. The examiner grasps the distal aspect of the
from the scapula. Patients with significant glenohumeral humerus using a firm but unassuming grip with one hand,
joint hypomobility and early apprehension toward move- while several brief, relatively rapid downward pulls are
ment will simply move their entire body and scapula along exerted to the humerus in an inferior (vertical) direction.
with the examiner’s movement of the humerus and also A visible “sulcus sign” (tethering of the skin between the
exhibit much apprehension with this early movement. lateral acromion and the humerus from the increase in
Patients with less restricted capsular status and no appre- inferior translation of the humeral head and the widening
hension toward subtle movement will simply allow the subacromial space) is usually present in patients with
examiner to perform the circumduction maneuver while MDI [89]. The presence of a positive MDI test postopera-
maintaining a normal posture (Fig. 3.32). tively would indicate the need for a slower progression of
• Multidirectional Instability (MDI) Sulcus Test: A very range of motion interventions postoperatively and even
important test used to evaluate the stability of the shoul- help dictate the amount of immobilization needed. Early
der is the MDI sulcus test (Fig. 3.33). This test is the pri- aggressive rehabilitation in a patient who presents with a
mary test used to identify the patient with MDI of the GH sulcus sign would be contraindicated.
Fig. 3.33 Multidirectional instability (MDI) sulcus test
Fig. 3.32 Shoulder dis-association test

• Anterior and Posterior Translation (Drawer) Tests: translation) for this test is performed using the classifica-
Gerber and Ganz [90] and McFarland et al. [86] have tion of Altchek and Dines [91]. This classification system
reported on the anterior and posterior translation tests and defines grade I translation as humeral translation within
recommend their use in the supine position due to greater the glenoid without edge loading or translation of the
inherent relaxation of the patient. The use of the supine humerus over the glenoid rim. Grade II represents transla-
position also allows the patient’s extremity to be tested in tion of the humeral head up over the glenoid rim with
multiple positions of GH joint abduction, thus selectively spontaneous return on removal of the stress. The presence
stressing specific portions of the GH joint anterior capsule of grade II translation in an anterior or posterior direction
and capsular ligaments. Figure 3.34 shows the supine without symptoms does not indicate instability but instead
translation technique for assessing and grading the trans- merely represents laxity of the GH joint. Unilateral
lation of the humeral head in the anterior direction. It is increases in GH translation in the presence of shoulder
important to note that the direction of translation must be pain and disability can ultimately lead to the diagnosis of
along the line of the GH joint, with an anteromedial and GH joint instability [4, 92]. Grade III translation, which is
posterolateral direction used because of the 30° version of not seen clinically in orthopedic and sports physical ther-
the glenoid [1]. This is accomplished by ensuring that the apy, involves translation of the humeral head over the gle-
examiner places the patient’s GH joint in the scapular noid rim without relocation upon removal of stress.
plane as pictured. Testing for anterior translation is per- Ellenbecker et al. [93] tested the intrarater reliability of
formed in the range between 0° and 30° of abduction, humeral head translation tests and found improved reli-
between 30° and 60° of abduction, and at 90° of abduc- ability when using the main criterion of whether the
tion to test the integrity of the superior, middle, and infe- humeral head traverses the glenoid rim. Similar to the
rior GH ligaments, respectively [87, 88]. Posterior findings of the MDI sulcus test, increases in humeral head
translation testing typically is performed at 90° of abduc- translation identified postoperatively would again indi-
tion because no distinct thickenings of the capsule are cate the need for less emphasis on early postoperative
noted, with the exception of the posterior band of the infe- range of motion and greater immobilization of the extrem-
rior GH ligament complex [88]. Grading (assessing the ity. This will be discussed later in this chapter.
Fig. 3.34 Anterior humeral head translation test

• Beighton Hypermobility Index: In addition to the previ- individual tests must be positive to rate an individual as
ously mentioned translation and provocation tests used for hypermobile with no overwhelming consensus [97]. Some
instability testing of the patient with shoulder dysfunction, studies have used 2 of the 9 measures as positive to grade
a series of tests to assess the overall mobility or presence of the individual as hypermobile with other research using 4/9
generalized hypermobility are valuable during clinical to achieve this hypermobile rating [4, 97]. This scale can be
evaluation of the shoulder in the overhead athlete [92]. The used as an important classification for patients with GH
Beighton Hypermobility scale or index was originally joint instability or in patients where an understanding of
introduced by Carter and Wilkinson [94] and modified by underlying mobility status is important to determine pro-
Beighton and Horan [95]. This scale is comprised of nine gression rates for ROM or mobilization [4]. Patients with a
individual tests each assessed bilaterally (except for trunk positive Beighton Hypermobility Index would again be
flexion) which are used to assess the generalized hypermo- progressed more slowly with their range of motion and
bility of the individual. These tests include: passive hyper- stretching following surgery in the initial postoperative
extension of the 5th MCP joint; passive thumb opposition phase of the rehabilitation protocol. This summary pro-
to the forearm; bilateral elbow, and knee hyperextension; vides only a small portion of the key parts of the complete
and standing trunk flexion with knees fully extended evaluation of the patient following arthroscopic Bankart
(Fig. 3.35a–c). Several authors have documented the psy- reconstruction. The evaluation of neurological status
chometric properties of the Beighton scale with reliability including extremity light touch sensation, proprioception,
estimates ranging from 0.74 to 0.84 [96]. Several cutoff distal grip strength, and vascular (capillary) refilling is and
criterion have been used to determine how many of the additional important component.
Fig. 3.35 (a–c) Several positive components of the Beighton Hypermobility Index
3.5.3 Rehabilitation following Arthroscopic with abduction pillow is now commonplace to more opti-
Bankart mally position the extremity in the scapular plane with
approximately 30° of abduction. Patients are commonly
Individual patient progression following surgical repair of a referred to physical therapy at 10 days to 2 weeks postopera-
Bankart lesion is applied during all stages of the rehabilita- tively to begin their rehabilitation progressions.
tion process; however, for the purposes of this chapter and Following the initial evaluation as outlined earlier in this
also prevalent in many clinical and research applications, a chapter, the patient initiates their rehabilitation with a pri-
protocol-based presentation of the critically important steps mary focus on the following specific activities (Table 3.3).
will be outlined in this section of the chapter. Knowledge of The application of modalities to increase local blood flow
and close communication of the specific surgical procedures and decrease postoperative pain is indicated and applied in
performed between the orthopedic surgeon and the physio- rehabilitation protocols [99]. The use of electrical stimula-
therapist are of critical importance [98]. This allows for a tion and moist heat to prepare the joint and the soft tissues
complete understanding of the structures involved and also for both range of motion and muscular activation interven-
alerts the physio of any concomitant surgical procedures and tions is recommended by several authors [99]. While not a
anatomical structures that were addressed. Examples of con- major focus, these modalities can be utilized to enhance
comitant surgical procedures that have a significant effect on patient comfort and improve soft tissue extensibility [99].
postoperative rehabilitation procedures are: superior labrum
anterior posterior (SLAP) repair, acromioplasty, distal cla- • Range of Motion Progression: Early protected ROM is
vicular excision, rotator cuff debridement and/or repair, cap- one of the most specific progressions followed during
sular plication/shifting, biceps tenodesis, or tenotomy. the initial 4–6-week period after surgery. Specifically,
this protected ROM progression involves the limitation
Goals of Rehabilitation following Arthroscopic of external rotation ROM to minimize tensile stress to
Bankart the anteroinferior aspect of the labrum, which was
repaired during the Bankart reconstruction as well as
• The surgical repair of the Bankart lesion coupled with the minimize tensile loading and stress to the anteroinferior
concomitant capsular shortening to address redundancy capsule, specifically the inferior glenohumeral liga-
when applicable creates several challenges to the rehabili- ment, which has often been plicated or shifted during
tation specialist. These are outlined in Table 3.2. the surgical reconstruction to address redundancy of
patency. Typically there are little or no restrictions
placed upon forward flexion and scapular plane abduc-
Initial Rehabilitation Phase: (Weeks 2–6) tion as well as internal rotation. Research guides the use
Patients are initially immobilized in a sling for the first 4–6 of a specific ROM of external rotation and the perfor-
weeks following surgery and often are instructed to perform mance of that external rotation in positions of abduction
gentle active assisted exercises such as Codman’s that specifically limit stress to the anteroinferior joint
(Pendulums) and elbow range of motion. The use of a sling capsule and labrum. In addition to the actual amount of
Table 3.2 Goals of rehabilitation following arthroscopic Bankart

Goals
Gradually progress glenohumeral joint range of motion to address postoperative limitations in functional movement
Enhance scapular stabilization to ensure proper glenoid positioning during functional humeral ranges of motion
Significantly improve rotator cuff strength to provide primary dynamic stabilization of the glenohumeral joint to protect the repaired
structures and safely minimize unwanted humeral translations
Progress the patient through evidence-based rehabilitation progressions that allow for transition to an interval functional sports and activity
return program
Table 3.3 Interventions emphasized in the initial phase of rehabilitation

Modalities to decrease pain and postoperative inflammation
Manual scapular stabilization and scapular exercise progression
Protected range of glenohumeral joint range of motion
Initiation of rotator cuff strengthening using protected movement patterns and positions
external rotation used in the initial rehabilitation, the Additionally, when comparing the effects of Bankart
position of abduction used during external rotation repair alone to Bankart repair with capsular shortening in the
ROM is also important, with basic science research pro- position of external rotation and abduction, it produced sig-
viding guidance from the literature. Both Pagnani et al. nificant differences (4.6 versus 17.7). Therefore, knowledge
[87] and O’Brien et al. [88] have eloquently performed of whether capsular shortening (plication or shifting) was
basic science research that identifies which portions of performed during surgery does have an effect on the ana-
the anterior glenohumeral capsule are under tension tomical stress applied during both abduction and abduction
based on the position of glenohumeral abduction. with external rotation following surgery.
During 90° of abduction, these studies have identified The progression of external rotation following surgery
the inferior glenohumeral ligament as the primary follows a progression from occurring in approximately
restraint to anterior translation. This directly stresses 30–45° of abduction while the humerus is placed in the scap-
the capsule where the Bankart repair has occurred. ular plane (Fig. 3.36) during the first 2–6 weeks post-op to
External rotation in the first 30° of abduction at the occurring in 90° of abduction after week 6–8 based on mobil-
patient’s side places more specific tensile loading near ity status of the patient (Fig. 3.37). The study by Penna et al.
the superior glenohumeral ligament and superior capsu- [101] objectively supports this gradual progression as the
lar structures. These basic science studies provide much values generated representing anteroinferior capsulolabral
of the specific information applicable to rehabilitation stress with Bankart reconstruction with capsular shortening
of the patient following Bankart reconstruction. increase from 5.3 N with no abduction to 17.7 N with abduc-
tion. These studies help the clinician to understand the inter-
Black et al. [100] studied capsular tension in Bankart nal capsular ramifications of limited external rotation ROM
repairs in cadavers at 0° of abduction in the coronal plane. and provide rationale for the safe progression of external
They identified a “low-tension zone,” which occurred in the rotation ROM in the patient with anterior instability. Using
first 46.5° of external rotation in this position. After 45° of this initial range of external rotation allows the patient to per-
external rotation, researchers found a significant rise in ten- form a functional ROM without jeopardizing the labral repair
sion in the anterior capsule. Additionally, research by Penna by exposing it to increased tensile loading.
et al. [101] provides additional support for the limitation of The use of accessory joint mobilization during the initial
external rotation following Bankart reconstruction. Their rehabilitation consists of grade I oscillations to modulate
study provided additional insight by testing cadaveric speci- pain, with particular avoidance of accessory mobilizations in
mens in multiple positions of abduction as well as following anterior directions to protect the capsulolabral repair. Other
Bankart reconstruction and Bankart reconstruction with cap- directions of joint mobilization in progressive grades can be
sular shortening. Specifically, stress on the anteroinferior applied (i.e., posterior glide, caudal glide) if the patient pres-
capsulolabral complex following Bankart repair along versus ents with significant range of motion limitation from the ini-
Bankart repair with capsular shortening was significantly tial period of immobilization postoperatively. Typically only
different with external rotation (1.1 N versus 5.3). lower grades of mobilization (Maitland grades I, II) are
Fig. 3.36 External rotation ROM in the scapular plane with 30° of Fig. 3.37 External rotation ROM progression performed in 90° of
abduction used in the early postoperative rehabilitation abduction in the scapular plane performed after 6–8 weeks
applied unless significant capsular hypomobility has devel- Manual techniques are initially recommended to directly
oped. An important concept to emphasize during the early interface the clinician with the patient’s scapula, to bypass
phase of rehabilitation of the previously unstable shoulder the GH joint and allow for repetitive scapular exercise with-
that has undergone arthroscopic Bankart reconstruction is out undue stress to the rotator cuff in the early phase.
the distinction between range of motion and stretching. In Figure 3.38 shows a specific technique recommended and
the early phase of rehabilitation, many patients simply used by this author to manually resist scapular retraction.
require range of motion of the shoulder, without aggressive Activation of the serratus anterior and lower trapezius force
end-range overpressure to protect the capsular tissue and couple is imperative to enable scapular upward rotation and
repaired labrum. Early stretching is not necessarily a com- stabilization during arm elevation [83]. Rhythmic stabiliza-
mon practice again unless the patient does present with sig- tion applied to the proximal aspect of the extremity, pro-
nificant range of motion limitations. Careful objective gressing to distal with the GH joint in 80–90° of elevation in
monitoring of glenohumeral joint range of motion with com- the scapular plane, can be initiated to provide muscular co-
parison to the contralateral extremity is warranted to ensure contraction in a functional position. Additionally, with this
that postoperative rehabilitation is not re-creating a hyper- technique, a protracted scapular position can be utilized to
mobile environment and is instead restoring optimal range of enhance the activation of the serratus anterior [103, 104], due
motion and capsular tension. to research identifying decreased muscular activation of this
muscle in patients with glenohumeral joint instability [82].
• Scapular Stabilization and Early Rotator Cuff Activation: Kibler et al. [105] have published several key exercise
In the initial phase of rehabilitation, specific procedures movements that recruit the serratus anterior and lower trape-
can be used to activate the stabilizing musculature of the zius and can be used early in rehabilitation due to the lower
glenohumeral joint and scapular articulation. These levels of elevation and external rotation inherent in these
occur with very controlled, low loading schemes, and movements. This minimizes subacromial impingement and
higher repetition bases to improve local muscular endur- capsulolabral stress and makes the exercises well tolerated
ance [102]. by patients early in rehabilitation. Figures 3.39 (Robbery)
Fig. 3.38 Manual scapular resistive exercise performed by the physio

to illicit early force couple activation for scapular stabilization
Fig. 3.39 Robbery

and 3.40 (lawnmower) exercises have extensive EMG verifi- cations. This allows for increased challenge and specificity
cation by Kibler et al. [105] and Tsurike and Ellenbecker in the exercise progression. This progression is particularly
[106]. The lawnmower exercise can even be applied with the useful in postoperative rehabilitation following arthroscopic
patient’s arm in a sling to provide early scapular stabilization Bankart.
exercise with minimal capsulolabral stress. The serratus One study highlights the importance of early submaximal
punch performed in supine (Fig. 3.41) is utilized and found exercise in increasing local blood flow. Jensen et al. [109]
to elicit 60 % or greater MVIC levels in the serratus anterior studied the effects of submaximal (5–50 %) maximum volun-
musculature [107]. tary isometric contraction (MVIC) contractions in the supra-
According to Davies [108], an initial resistive exercise spinatus tendon measured with laser Doppler flowmetry).
progression for the rotator cuff often commences with iso- Results showed that even submaximal contractions
metric exercise followed by isotonic exercise and then finally increased perfusion during all 1-min contractions but pro-
more functional plyometric and isokinetic resistance appli- duced a post-contraction latent hyperemia following the
Fig. 3.40 Lawnmower exercise
Fig. 3.41 Serratus punch exercise

muscular contraction. These findings have provided a ratio- An initial isotonic rotator cuff exercise progression recom-
nale for the early use of IR and ER isometrics or submaxi- mended to increase rotator cuff strength is shown in Fig. 3.42.
mal manual resistance in the scapular plane with low levels These exercises are based on electromyographic (EMG)
of elevation to prevent any subacromial contact and capsu- research, showing high levels of posterior rotator cuff activa-
lar stress early in the rehabilitation process. Figure 3.43 tion [113–117], and they place the shoulder in positions well
shows an early application of isometric exercise for the tolerated by patients in the initial stage of rehabilitation.
posterior rotator cuff called “dynamic isometrics” where Resistance is not initially applied performing only active
elastic resistance is used to provide known loading in an range of motion and based on patient tolerance resistance lev-
isometric format as a step is taken by the patient away from els are progressed in ½ pound increments (0.25 KG). In
the attachment point of the band/tubing to increase resis- patients following arthroscopic Bankart, side-lying ER and
tance accordingly. The use of elastic resistance with known, prone extension with an externally rotated (thumb out) posi-
calibrated elongation resistance values allows the clinician tion are utilized first, with progressions to prone horizontal
to safely prescribe isometric exercise dosing appropriately abduction occurring at 6–8 weeks following surgery. The use
for the patient. A towel roll is used under the axilla to most of the exercise prone ER with scapular retraction can only be
appropriately position the patient’s shoulder for rotator cuff added later in the rehab progression once the patient has
exercise [110–112]. regained the abduction/external rotation motion inherent in
Fig. 3.42 Rotator cuff isotonic

exercise program
this exercise and higher levels of rotator cuff and scapular

strength are present. Prone horizontal abduction is used at 90°
of abduction to minimize the effects resulting from subacro-
mial contact [118]. Research has shown that this position cre-
ates high levels of supraspinatus muscular activation [115,
116], making it an alternative to the widely used empty can
exercise, which often can cause impingement through the
combined inherent movements of IR and elevation. Three sets
of 15–20 repetitions are recommended to create a fatigue
response and improve local muscular endurance [102].
It is important to point out the importance of emphasizing
proper scapular positioning during rotator cuff exercises
such as side-lying external rotation, prone extension, and
prone horizontal abduction. Cools and colleagues [111] have
shown enhanced activation of the rotator cuff during exercise
conditions where emphasis was placed on proper scapular
positioning. The author of this chapter recommends careful
monitoring of naturally occurring scapular motion during
rotator cuff exercise as opposed to attempts to lock the scap-
ula in a retracted position during humeral motion (rotator
cuff exercise patterning).
The efficacy of these rotator cuff exercises in a 4-week
training paradigm has been demonstrated, and 8–10 %
increases have been noted in IR and ER strength measured
isokinetically in healthy subjects [119–121]. Training of the
rotator cuff and scapular musculature has resulted in modifi-
cation and improvement of the ER to IR ratio, improved
strength, and endurance of the rotator cuff and performance
enhancement [119–122].
All exercises for ER strengthening in standing and side-
lying are performed with the addition of a small towel roll Fig. 3.43 External rotation at the side with elastic resistance
placed in the axilla as pictured (Fig. 3.43). In addition to assist-
ing in isolation of the exercise and controlling unwanted move- scapulohumeral rhythm was encountered during abduction
ments, this towel roll application has been shown to elevate or adduction isometric contractions. Results from this
muscular activity by 10 % in the infraspinatus muscle when research can be applied for the patient with impingement
compared with identical exercises performed without towel during humeral rotation exercise. The use of the towel roll
placement [116]. Another theoretical advantage of the use of a can facilitate an adduction isometric contraction in patients
towel roll to place the shoulder in approximately 20–30° of who may need enhanced subacromial positioning due to
abduction is that it prevents the “wringing out” phenomena impingement during the humeral rotation exercise [123].
shown in cadaver research investigating shoulder microvascu- Research by Bitter et al. [124] has provided guidance
larity. Rathburn and MacNab [110] showed enhanced blood regarding the use of resistive exercise in shoulder rehabilita-
flow in the supraspinatus tendon when the arm was placed in tion. They measured EMG activity of the infraspinatus and
slight abduction as compared with complete adduction. Finally, middle and posterior deltoid during ER exercise in healthy
another research study has further supported the use of a towel subjects. Muscular activity was monitored during ER exercise
roll or pillow between the humerus and the torso under the at 10, 40, and 70 % activation levels (percentage of maximal).
axilla during a humeral rotational training exercise. This important study found increased relative infraspinatus
Graichen et al. [123] studied 12 healthy shoulders using activity when the resistive exercise level was at 40 % of maxi-
MRI at 30°, 60°, 90°, 120°, and 150° of abduction. A 15 N mal effort, indicating more focused activity from the infraspi-
force was performed, which resulted in an abduction isomet- natus and less compensatory activation of the deltoid. This
ric contraction or an adduction isometric contraction. study supports the use of lower-intensity strengthening exer-
Adduction isometric muscle contraction produced a signifi- cise to optimize activation from the rotator cuff and to de-
cant opening or increase in the subacromial space in all posi- emphasize input from the deltoid and other prime movers,
tions of GH joint abduction. No change in scapular tilting or which often occurs with higher-intensity resistive loading.
Ramiﬁcations of Concomitant Surgical Intermediate Phase (Weeks 6–12)

Procedures Objective characteristics of patients capable of progressing
Patients who undergo arthroscopic Bankart reconstruction often the intermediate phase of rehabilitation are outlined in
have other surgical procedures that have specific implications in Table 3.4. Typical timeframes for this transition occur
the rehabilitation protocol. Patients who in addition to anteroin- between 6 and 8 weeks based on the degree of initial range
ferior labral detachment also have superior labral detachment of motion loss, concomitant surgical procedures, and the
and subsequent SLAP repair have specific guidelines and limi- patients’ tolerance to the initial phase of postoperative
tations in their immediate postoperative care. Active contraction rehabilitation.
and resistance to the bicep are indicated in patients who have Progression of range of motion to terminal ranges occurs
concomitant superior labral repair. This includes holding all during this phase of rehabilitation in all planes. Range of
elbow flexion resistance exercises including rowing, upper body motion is particularly progressed for external rotation now
ergometry, and forearm supination exercise to limit bicep acti- in 90° of functional abduction in the scapular and eventu-
vation. This is deferred for the first 6–8 weeks following surgery ally coronal plane. Clinicians are guided by the baseline
[122]. Progression to external rotation with 90° of glenohumeral range of motion in the contralateral extremity for goal set-
joint abduction is also delayed until after 6–8 weeks following ting as well as the patient’s preoperative instability history,
surgery to minimize the effects of the peel back mechanism and presence of bone loss, and arm dominance. These factors
ultimately protect the repair of the superior labrum [125]. may indicate through collegial consultation with the refer-
Patients who also had rotator cuff repair have limitations ring surgeon, setting range of motion limitations less than
in early strengthening of the rotator cuff based on tear size the contralateral extremity to further protect and provide a
and degree of tendon involvement. Additionally, patients who more stable and limiting capsular component following
also undergo subacromial decompression and or distal cla- surgery. For example, patients with extensive preoperative
vicular excision may have greater pain and a delayed return of dislocation histories, presence of glenoid or humeral
pain-free elevation and horizontal adduction, respectively, bone loss, and decreased abduction external rotation func-
due to the osseous reaction to the surgical procedure and need tional ergonomic or athletic demands may be considered
for additional healing time for these structures. While these for less complete range of motion return. Care must be
concomitant procedures do not preclude the patients’ ability taken however not to leave the patient with range of motion
to progress and follow the protocol for arthroscopic Bankart limitations that could lead to obligate translations [126]
reconstruction, they do require modification and altered pro- and predispose the patient for future capsulorraphy arthrop-
gression rates due to the involvement of additional anatomi- athy [127].
cal structures in the surgical procedure.
When remplissage is performed because a medial Hill-
Sachs that is off track, we have to consider that the infraspi-
natus tendon is repaired into the humeral head bone loss; Table 3.4 Objective characteristics of patients progressing to the
some precautions need to be underlined: intermediate phase
Achievement of 45–60° of external rotation ROM in 45–60° of
• Restriction of the internal rotation and horizontal adduc- abduction
tion, pushing movements, and bench press, etc. Ability to functionally elevate the shoulder to 90°
• Immediate motion for external rotation at 45° abduction Tolerance of initial rotator cuff and scapular exercise progression
and flexion PROM to 90° for 4 weeks (>3+/5 grade MMT)
• Initiate internal rotation ROM at 6–8 weeks post-op Ability to tolerate basic ADL’s outside the sling with minimal to no
• Full ROM at 8–12 weeks (loss of external rotation expected) pain
Progression of Rotator Cuff and Scapular performed by the therapist with hand placements directly on
Stabilization the scapula as well as the use of the 90° elevated closed-
Additional scapular stabilization exercises in this phase of chain exercise (Fig. 3.1) consisting of the patient’s hand
rehabilitation include ER with retraction (Fig. 3.44), an over a small Swiss ball with perturbations applied to add
exercise shown to recruit the lower trapezius at a rate 3.3 proprioceptive feedback and stimulate co-contraction in this
times greater than the upper trapezius and to utilize the functional position, are all used during this rehabilitation
important position of scapular retraction [128]. Once non- phase. For patients who perform a significant amount of
guarded, external rotation is present, this exercise can be work or sports activity in a closed-chain upper extremity
applied with scapular retraction being emphasized during environment, rhythmic stabilization progressions are
execution. Multiple seated rowing variations, continued applied starting in quadruped (Fig. 3.45) to enhance proxi-
manual scapular protraction/retraction resistance exercise mal stabilization.
Fig. 3.45 Quadruped rhythmic stabilization exercise for closed-chain

co-contraction of the shoulder musculature
Fig. 3.44 External rotation with scapular retraction bilateral with elas-
tic resistance
Rotator cuff exercise is progressed to include shows the initial exercise applied for external rotation
oscillation-based interventions such as external rotation strengthening in 90° of abduction with elastic resistance.
oscillation (Fig. 3.46) and side-lying body blade Pertubations can be applied by the physio in the 90/90
(Fig. 3.47). These exercises are time based, starting with position to further invoke muscular activity and co-
sets of 30 s to improve endurance. Chen et al. [129], contraction in the functional 90/90 position. This 90/90
Ebaugh et al. [130] have both shown the negative effects exercise with elastic resistance is also accompanied by the
on scapular positioning and humeral head translational prone 90° abducted ER exercise (see Fig. 3.42) to facili-
control with rotator cuff fatigue. In addition to the more tate the rotator cuff and lower trapezius and other scapular
challenging exercises added during this phase of rehabili- stabilizers during rehabilitation [107, 114–116]. The
tation, the position of humeral elevation is now increased external rotation focus in strengthening of the rotator
during rotator cuff and scapular exercise. Figure 3.48 cuff is based on basic science research showing how the
Fig. 3.47 Side-lying body blade oscillation exercise
Fig. 3.46 External rotation oscillation
Fig. 3.48 External rotation at 90° of abduction in the scapular plane

with physio applied perturbation
posterior rotator cuff is active in preventing anterior Return to Function Phase (12–16 Weeks)
translation during glenohumeral motion. The posteriorly Objective characteristics for patients making the important
directed force supplied by the posterior rotator cuff can transition to the final “return to functional phase” are listed
provide key stabilization to limit anterior translation and in Table 3.5. This phase emphasizes the continued restora-
limit stress to the repaired labrum and capsulolabral com- tion of functional range of motion as well as extensive higher
plex [131]. Internal rotation strengthening is also added level rotator cuff and scapular exercise focused to return the
during this phase of the rehabilitation. Exercises for inter- patient to their full functional level. Some of the key resistive
nal rotation include elastic resistance internal rotation exercise additions during this phase of rehabilitation are the
with the arm in neutral adduction with a towel roll under functional plyometric exercise progression and isokinetic
the shoulder, as well 90° abducted internal rotation. An resistance application for shoulder internal and external rota-
exercise application to stimulate contraction of the inter- tion. The addition of isokinetic exercise (if available) not
nal rotators in a functionally rapid way can be achieved by only provides optimal accommodating resistance throughout
ball dribbling at 90° of elevation with 90° of elbow flexion the range of motion but allows for detailed testing and mus-
(Fig. 3.49). The addition of rhythmic stabilization by the cular balance measurement (ER/IR ratio) not possible with
physio is also indicated and applied during rest periods manual muscle testing. The use of a handheld dynamometer
with this exercise. Close monitoring occurs of the ER/IR can also provide critically important objective strength data
muscular strength ratio for patients with glenohumeral [133] to direct ER/IR normalization and guide exercise
joint instability and rotator cuff pathology. administration and end stage program development.
Ellenbecker and Davies [122] have provided a signifi- Plyometric exercise progression is initiated at this time
cant review of this topic, and the literature has estab- in the rehabilitation progression. Several studies reported
lished a key ratio of 2:3 for the ER/IR ratio with the in the literature show increases in upper extremity function
external rotators being 66 % as strong as the internal with plyometric exercise variations [119–134]. The func-
rotators in a normal healthy shoulder. Byram et al. [132] tional application of the eccentric pre-stretch, followed by
have shown this ER/IR ratio to be predictive of serious a powerful concentric muscular contraction, closely paral-
shoulder injury in elite overhead athletes further rein- lels many upper extremity sports activities and serves as an
forcing the guidance of this key ratio in strength pro- excellent exercise modality for transitioning the active
gramming during rehabilitation. Biasing the ratio to patient to the interval sports return programs. Figures 3.50
include values greater than 66 % has been recommended and 3.51 show two plyometric side-lying external rotation
[122] to ensure that posterior rotator cuff strength can
off-set the larger internal rotational stresses during func- Table 3.5 Objective characteristics of patient’s transitioning to the
tional activities. A range between 2:3 and 3:4 has been return to activity phase
recommended for this ratio, and thus the 66–75 % ER/ No apprehension with end range of motion all planes
Ratio has become a dynamic stabilizing reference to ROM levels within approximately 10 % of contralateral side
guide the amount of internal rotation strengthening and Tolerance of 90/90 functional position with resistive exercise and
optimal muscle balance during shoulder rehabilitation by perturbations
many clinicians [120–122]. Muscle strength at 4/5 all planes without pain provocation
Fig. 3.49 Internal rotation plyometric ball dribbles with rhythmic

stabilization Fig. 3.50 Side-lying plyometric ball drops
exercises used to develop posterior rotator cuff strength effects of an 8-week training program of plyometric upper
with Figs. 3.52 and 3.53 showing similar versions of plyo- extremity exercise and ER strengthening with elastic resis-
metric exercise in the 90/90 position. These exercises have tance performed at 90° of glenohumeral joint abduction.
been studied by Ellenbecker et al. [134], who demonstrated They found increased eccentric ER strength and concentric
high levels of peak EMG activity of the lower trapezius IR strength and improved throwing velocity in collegiate
(118–131 % MVIC) and infraspinatus (85–103 %) during baseball players, thus showing the positive effects of plyo-
these important exercises. Carter et al. [119] studied the metric and elastic resistance training in overhead athletes.
Fig. 3.51 Side-lying plyometric reverse catches Fig. 3.52 90/90 prone plyometric ball drops
Fig. 3.53 90/90 prone plyometric reverse catches

For the athlete returning to contact sports such as basket- motion during the acceptance phase of the exercise with a
ball and football, internal rotation plyometrics can also be medicine ball. Figures 3.55 and 3.56 show standing varia-
used to provide an abduction external rotation stress requir- tions of plyometric exercises for internal rotation strength
ing muscular recruitment and stabilization to counter the development that assist with the return to functional activi-
negative potential effects of the abduction external rotation ties such as throwing. Functional activity or sports simula-
stress. Figure 3.54 shows the initial application of this type tion drills are added during this phase as well for golf
of provocational plyometric performed at 45–60° of abduc- (Fig. 3.57a, b) and tennis (Fig. 3.58) using the controlled
tion in the supine position with support provided by the floor progression of medicine balls and a plyoback machine or
or additional padding to limit the external rotation range of partner.
Fig. 3.54 Supine internal rotation provocational plyometric ball tosses Fig. 3.55 Internal rotation standing plyometrics in neutral ab/adduc-
tion position
Fig. 3.58 Sports-specific tennis groundstroke plyometric
Fig. 3.56 Internal rotation standing plyometrics with 90° of

abduction
a b
Fig. 3.57 (a, b) Sports-specific golf plyometric

As the patient tolerates isotonic exercise with 2–3 lb overhead athletes [108, 136–138]; thus, greater rehabilitative
(Fig. 3.45) and also can perform rotational training without emphasis may be required to achieve this level of documented
pain using medium-level elastic resistance, isokinetic rota- “dominance.” Progression of the patient to the 90/90 position
tional exercise is initiated in the modified base position. This for isoinertial exercise (Impulse, Inc, Noonan Georgia)
position places the GH joint in 30° of flexion and 30° of (Fig. 3.60) as well as on an isokinetic dynamometer (Fig. 3.61)
abduction, and it uses a 30° tilt of the dynamometer relative to with the shoulder elevated 90° in the scapular plane further
the horizontal (Fig. 3.59) [108, 135]. This position is well tol- provides an optimal training stimulus to increase rotator cuff
erated and allows the patient to progress from submaximal to strength in sports and activity-specific positions [122–139].
more maximal levels of resistance at velocities ranging A predominance of IR/ER patterning is used during iso-
between 120° and 210° per second for nonathletic patient kinetic training. This focus IR/ER exercise is based on an iso-
populations and between 210° and 360° per second during kinetic training study by Quincy et al. [140], who showed that
later stages of rehabilitation in more athletic patients. The use IR/ER training for a period of 6 weeks not only can produce
of the isokinetic dynamometer is also important to quantify statistically significant gains in IR and ER strength but can
objectively muscular strength levels and, most critically, mus- improve shoulder extension/flexion and abduction/adduction
cular balance between the internal and external rotators [108, strength as well. Training in the patterns of flexion/extension
135]. Achieving a level of IR and ER strength equal to that of and abduction/adduction over the same 6 weeks produced
the contralateral extremity is an acceptable initial goal for only strength gains specific to the direction of training. This
many patients; however, unilateral increases in IR strength of overflow of training allows for a more time-efficient and
15–30 % have been reported in many descriptive studies of effective focus in the clinic during isokinetic training.
Fig. 3.59 Internal/external rotation in the modified base position on

the Biodex Isokinetic Dynamometer
Fig. 3.61 Isokinetic internal/external rotation training position with

90° of elevation in the scapular plane
Fig. 3.60 Isoinertial external rotation exercise on the impulse trainer

Objective Criterion to Progress to Sports important exercise position and movement pattern modifica-
and Functional Activities tions (Table 3.7). Limitation in range of motion with bench
One of the most challenging aspects of the rehabilitation of presses and removal of all behind the head exercises such as
the patient following arthroscopic Bankart is the clinical lat pull and military press with modified movement pattern
decision-making that occurs prior to progressing the patient recommendations are recommended for patients following
back to their sports or functional activity. The use of objec- Bankart reconstruction.
tive data is recommended to guide this decision. Table 3.6 Also of key importance with the weightlifter is for them
outlines the important components and findings of a return to to continue with rotator cuff and scapular exercise training to
activity evaluation for patients following Bankart repair. maintain the ER/IR muscle balance and ensure key levels of
The use of objective testing outlined in Table 3.6 allows rotator cuff stabilization forces remain following discharge
the clinician to base the individual’s functional return on from physical therapy.
objective parameters that can be measured and re-assessed as Characteristics of an interval sports return program for
needed during the later stages of rehabilitation. Future pro- tennis include alternate-day performance, as well as gradual
spective studies will provide key evidence basis for the use progressions of intensity and repetitions tennis activities. For
of guidelines such as those listed and their ability to predict the interval tennis program, the initial use of a foam ball and
successful functional activity and sports performance progressing to a series of low compression tennis balls both
following both non- and post-surgical shoulder injury and used during the teaching process of tennis to young children
subsequent rehabilitation. are recommended and followed. These balls are recom-
mended for use during the initial phase of the return to tennis
Interval Sports and Functional Activity Return program and are thought to result in a decrease in impact
Programs Following Arthroscopic Bankart stress and increased patient tolerance to the early tennis spe-
While it is beyond the scope of this chapter to review and pro- cific activity. Additionally, performing the interval program
vide all return to activity programs following stabilization sur- under supervision, either during physical therapy sessions or
gery, several key concepts will be discussed and recommendations with a knowledgeable tennis teaching professional or coach,
given for a return to traditional fitness weightlifting and tennis allows for the biomechanical evaluation of technique and
program to provide examples of the characteristic stepwise pro- guards against over-zealous intensity levels, which can be a
gressions applied to minimize re-injury risk and optimize suc- common mistake in well-intentioned, motivated patients,
cess and functional performance ratios. especially adolescents. Using the return program on alternate
Returning a patient following arthroscopic Bankart to tra- days, with rest between sessions, allows for recovery and
ditional weightlifting requires modification and education decreases the risk re-injury.
regarding increased stress from inherent glenohumeral posi- This interval tennis program has been published previ-
tions which place the shoulder in excessive amounts of hori- ously [143], and a modified version is included (Table 3.9) in
zontal adduction and with some exercises excessive elevation. this chapter. It includes updated information on the use of the
These exercises can increase anterior capsulolabral stress different tennis ball progressions and takes the player through
and impingement, respectively. Bleacher and Ellenbecker a series progressing from groundstrokes to volleys and
[141] and Gross et al. [142] have provided guidelines for finally serves and overheads. Additionally, having the
patients with instability and rotator cuff disease regarding patient’s racquet and string type/tension evaluated by a qual-
the return to traditional weightlifting. General concepts such ified tennis teaching professional is recommended as certain
as alternate-day performance (rest between strength training racquet and string characteristics may be indicated for
sessions), lower weight and higher repetitions, and most patients when returning from shoulder injury.
Table 3.6 Objective guidelines for return to sports and functional activity
Pain-free range of motion without apprehension at end range of motion
Range of motion within 10 % of contralateral extremity unless anatomical factors supersede it
Muscular strength within 10 % of the contralateral extremity for IR and ER strength with isokinetic testing or hand held dynamometer
Manual muscle testing (MMT) great 5-/5 for all planes of motion without pain provocation
ER/IR muscular strength ratio >66 % with objective testing
Table 3.7 Modifications of traditional weight lifting for patients following anterior stabilization
Exercises Shoulder pathology Modification(s)
Flat bench press Anterior instability Grip <1.5 biacromial width
ROM limitations <15° shoulder extension (towel on chest, to block motion, or use of
physio ball, smith machine to limit ROM)
Cable Fly’s Anterior instability Hand spacing (1–1.5 biacromial width)
ROM limitation – shoulder extension, horizontal abduction anterior to coronal plane
Glenohumeral abduction angles <90° maintaining
Elbows below shoulder level
Pec deck Anterior instability ROM limitations – shoulder horizontal abduction anterior to coronal plane
Glenohumeral abduction angles <90° adjusting seat level
Dumbbell Fly’s Anterior instability ROM limitations – shoulder horizontal abduction, extension anterior to coronal plane
(Swiss ball or wide bench limiting movement)
Glenohumeral abduction angles between 45° and 70°
Elbow flexion angles 70–90°
Traditional push-up Anterior instability Hand spacing: <1.5 xs biacromial width
ROM limitations – shoulder horizontal abduction anterior to coronal plane (medicine
ball, 45 cm Swiss ball at sternal level)
Glenohumeral abduction 45–70°
End range – “plus” position
Lat pull down Anterior instability Perform with bar in front of head, NOT behind the head
Front and lateral raise Anterior instability Humerus in external rotation (thumb up) position and block ROM to 0–90 only to
minimize rotator cuff stress
Military press Anterior instability The use of dumbbells, not barbell, limits ROM to 90–120° of elevation maximum,
always in front of head, never behind head
Outcomes Following Arthroscopic Bankart preventing recurrent instability and returning patients to work
One final concept to discuss in closing section of this chapter as compared to arthroscopic procedures. Petrera et al. [146]
is outcomes following arthroscopic Bankart reconstruction. conducted a specific meta-analysis to compare arthroscopic to
The rehabilitation concepts discussed throughout this chap- open Bankart results using suture anchors. They concluded
ter can return functional range of motion and rotator cuff and that there was no significant difference in recurrent instability
scapular strength to patients with unilateral glenohumeral 6 versus 6.7 % between arthroscopic and open Bankart, but
instability for surgical stabilization. Our own outcomes that there were superior functional results among the patients
research on patients following arthroscopic Bankart recon- who had arthroscopic Bankart.
struction obtained via a retrospective review shows an aver- Finally, regarding long-term outcome, the association
age return of 160° of forward flexion, 150° of abduction, and between anterior stabilization surgery and glenohumeral joint
78° of external rotation at 90° of abduction and 42° of inter- arthritis was studied by Castagna et al. [147]. They followed
nal rotation at 90° of abduction. These values compared to up patients after arthroscopic anterior stabilization surgery
the baseline (contralateral extremity) show 5° greater for- (10 year minimum follow-up) and found 29 % with mild
ward flexion, 21° deficits in abduction, and 16 deficits in arthritis and 10 % with moderate arthritis. There was no cor-
internal and external rotation with 90° of abduction. This relation with functional outcome and the presence of glenohu-
ROM data shows nearly full elevation range of motion return meral arthritis. The recurrence of instability following surgery
and the largest deficits in abduction and rotational range of in this long-term outcome study was 16 %. Further long-term
motion. Additional outcomes data published by Kim et al. outcomes research is necessary to best understand the sequela.
[144] specifically deals with the comparison of early aggres-
sive rehabilitation versus immobilization and delayed reha-
bilitation in 62 nonathletic patients who underwent Take-Home Message
arthroscopic Bankart for unidirectional glenohumeral joint Summary
instability in a 3-year follow-up study. The results of Kim This material in this chapter was meant to provide a
et al. [144] show no significant difference in re-dislocation detailed description of an evidence-based protocol for
rate in patients who received more aggressive early rehabili- rehabilitation following arthroscopic Bankart recon-
tation and range of motion intervention. There were improved struction. A thorough understanding of the surgical
patient satisfaction in the immediate motion (aggressive procedure for Bankart reconstruction with and without
rehabilitation) group as well as decreased postoperative pain capsular shift as well as any concomitant surgical pro-
ratings and faster return of range of motion. This study sup- cedures will allow therapists to provide appropriate
ports the application of immediate range of motion as com- and optimal rehabilitation following surgery. Current
pared to a group of patients with delayed ROM and longer outcomes evidence shows high-level functional results
immobilization times following arthroscopic Bankart. and lower recurrence of instability in follow-up stud-
Several meta-analyses have been published comparing the ies. The goals of restoring a functional and stable range
outcomes of open Bankart to arthroscopic Bankart. In a review of motion platform coupled with highly fatigue-
of 2108 studies on shoulder instability in their meta-analysis, resistant scapular stabilization and rotator cuff strength
Lenters et al. [145] concluded that arthroscopic stabilization and key are tenants of a comprehensive rehabilitation
procedures did have significantly higher functional outcomes program for patients following this procedure.
scores, but open stabilization procedures were superior at
3.6 Latarjet Technique cies; this absence is called loss of sclerotic glenoid line
(LSGL) and have used it in clinical practice to document
Latarjet technique is considered a non-anatomical surgical in a easy way bony lesion of the anterior glenoid rim that
procedure; its goal is to stabilize the shoulder by compensat- anyway if present need to be assessed with CT scan.
ing for the capsule-labral and osseous injury with an osseous The following description of the Latarjet surgical proce-
and soft tissue check in that blocks excessive translation and dure indicates in “small caps” the elements that take about
restore stability. 15 days to heal and in “bold small caps” the elements that
Preoperative plain x-ray studies were performed in take more than 6 weeks to heal.
anteroposterior, internal and external rotation, and lateral, Our surgical technique is a modified Latarjet procedure
axillary, and Bernageau views. Preoperative CT scans are using a mini plate developed by the authors.
obtained for all patients to better evaluate the glenoid bone the skin (Fig. 3.63) is incised along the anterior axillary
surface. crease in a longitudinal fashion along the Langers line. The
Anyway because the integrity of the glenoid is one of the incision is placed lateral to the coracoid process. the delto-
elements that defines the surgical treatment, the reliability of pectoral interval is identified, the cephalic vein is
plain radiographs is one of the key points. retracted laterally, and the interval is developed. The clavi-
According to Gerber [148], we look carefully at the pectoral fascia is then incised at the lateral border of the con-
anteroposterior (AP) radiographs of the shoulder where joined tendon at its coracoid attachment, and the
the anterior glenoid rim appears as a subchondral scle- coracoacromial ligament is divided to facilitate exposure of
rotic line. the superior aspect of the capsule and, particularly, the rota-
This sclerotic line can be interrupted for more than tor interval area. The bicipital groove and the lesser tuberos-
5 mm (Fig. 3.62) in patients withanterior glenoid deficien- ity are identified.
Fig. 3.62 (A-P view) note the breakage of the subchondral sclerotic line Fig. 3.63 Skin incision and deltopectoral approach
This procedure is performed using a local bone graft by match between the coracoid bone graft and the glenoid
the osteotomy of the terminal 2 cm of the coracoid process bone surface.
(Fig. 3.64), detaching the insertion of the pectoralis minor It has a figure of eight (8) configuration that allows a bet-
tendon. The coracoid bone graft is decorticated in the infe- ter torsional orientation of the plate on the dorsal-sloped
rior surface until the cancellous bone. After the orizzontal coracoid surface. Four spikes for an improved stabilization
split of the subscapularis tendon (Fig. 3.65) is performed, of the plate-bone block and two screw holes for lag screws
the coracoid bone graft is transplanted along with the con- insertion. These features allow the plate to distribute the load
joined tendon to the anteroinferior glenoid rim that is decor- evenly to the bone.
ticated. The coracoid bone graft is positioned below the Post-surgery rehabilitation must take the following into
equator and no less than 2 mm from the glenoid cartilage account:
(Fig. 3.66).
The coracoid bone graft is laid lengthwise and held in 1. Biological-specific healing rates of the surgical procedure:
place with two bicortical partially treated (diameter 4 mm) skin incision, cleavage plane, capsulotomy, tenotomy, or
cannulated screws and the eventually the mini wedged plate muscle-tendon split; in this case the bone-to-bone healing of
to improve compression (Fig. 3.67). the coracoid graft to the neck of the scapula is crucial.
The mini wedged plate design has specific characteris- 2. Neuromuscolar and proprioceptive recovery: must be
tics, each of which corresponds to a biomechanical func- gradual in the case of the affected body part and consis-
tion. It has a wedged profile. The wedge of the plate if tent with biological heeling timeframes but can be faster
placed medially under compression makes the coracoid for the kinetic chain links outside the involved shoulder.
bone graft rotate medially, thereby improving the bone 3. Return to working and/or sports activity.
Fig. 3.65 Subscapular split
Fig. 3.64 Osteotomy of the coracoid at level of the “knee” in front of

conoid and trapezoid
Fig. 3.66 Positioning of the coracoid between 3 and 6 o’clock
Fig. 3.67 Compression of the coracoid on the scapular neck

3.7 Rehabilitation following Latarjet At discharge from hospital, the patient is taught a gentle
Technique scapular retraction exercise (Fig. 3.69) to maintain cor-
rect periscapular posture and tropism. Since the surgical
Rehabilitation following reconstruction surgery using the procedure involves transplanting the coracoid process
Latarjet procedure plays a decisive role in reinstating muscu- that gives attachment to the short head of the biceps and
loskeletal and proprioceptive functions. The following chap- the coracobrachialis – muscles that are involved in flex-
ter looks at the methods and tools underpinning an appropriate ion and extension of the elbow and in pronation and supi-
rehabilitation protocol for this particular post-op situation. nation of the forearm – any movements involving these
As previously underlined, a good patient rehabilitation proto- must be carried out with care and in no way trigger a
col must involve both orthopedic surgeon and physiotherapist. painful arc. In addition, the patient must be given clear
Importantly, patients enrolled in any rehabilitation proto- instructions that any flexion/extension and pronation/
col must be approached as individuals in their own right with supination are to be performed in a self-assisted fashion
issues that range from the specifics of their post-surgical (Fig. 3.70).
condition to their particular emotional state. • 15th Day: Stitch removal and clinical control
In fact experience advises against applying a standardized On removal of the stitches, it is possible to identify the
rehab protocol but rather the introduction of a series of exer- patients among those with no subcutaneous hematoma or
cises geared to restoring glenohumeral joint function within fever who are likely to develop fibrous adhesions in the
the framework of established goals, but implemented accord- glenohumeral joint – in our clinical practice defined as
ing to the pace of individual physical recovery and the sub- external rotation below 20 %. These adhesion-prone
jective status of each patient. Hydrotherapy could have an patients should start rehabilitation immediately under the
important role in rehabilitation protocol if is managed by supervision of a specialist team. Patients not presenting
specialized equipe. the warning signs of fibrous adhesions will generally
begin physiotherapy on day 21 post-op.
• 0–2 Weeks: Following Laterjet surgery, the patient is • 21th Day: On starting rehabilitation, the patient must be
requested to keep the involved limb in a sling (Fig. 3.68). pain-free or with only minimum pain.
Healing progression criteria
15° day 21° day
Phase 1: Phase 2: Phase 3:

0–2 Weeks 2–3 Weeks
3–9 weeks 9–12weeks 12weeks
Third clinical
control and
Stitch removal Start rehab return to sport
and clinical Second clinical
integration
control control
Signs of fibrous Normal healing

adhesions? progression?
Start rehab Rest in sling until

21° day
Fig. 3.68 Fitting arm sling before discharge

Fig. 3.69 Assisted elbow flexion-extension without sling
Fig. 3.70 Scapular retraction with sling

3.8 Physical Examination at Outset observed in scapular dyskinesia. However, the other
movements proposed by the authors also appropriately re-
• Posture: activate the scapulothoracic muscles. In particular, active
The patient’s posture could be altered on account of the depression of the scapula triggers high electromyographic
protraction induced by the sling (Fig. 3.71). activity in the serratus anterior, while retraction activates
Altered posture must be appropriately dealt with by the lower and middle trapezius.
the rehabilitation team. Restoring correct posture is deci- • ROM: As a rule, residual passive range of motion follow-
sive in this initial phase since it will facilitate subsequent ing surgery should not be less than 50° passive and active
movements, enhance muscle strengthening, and increase elevation in the scapulothoracic plane. Starting progres-
general exercise performance. Correct posture optimizes sive passive kinesis especially of the glenohumeral joint
KINETIC CHAIN STRENGTH, reinforcing the proxi- is essential if capsular contracture is to be avoided and
mal extremities and the DISTAL JOINT muscle struc- joint ROM gradually restored.
tures (Fig. 3.72) [149].
• Scapular Control:
The aim of physiotherapy in this phase is to maintain
good scapular control with specific scapular closing exer-
cises (Figs. 3.74 and 3.75) and allow gentle stretching of
the anterior structures (Fig. 3.73) [150]. These are the first
exercises initiating the physiotherapy procedure. They are
to be performed, however, only if the patient feels no
pain. Early muscle reactivation aims to prevent inhibition
and loss of neuromuscular control [151].
The exercise progression as proposed by Smith is the
scapular clock, with the patient placing his hand on the
wall with the arm elevated less than 90°.
In this case the myoelectric activity of the deltoid and
rotator cuff muscles is negligible, proving it to be a safe
exercise geared specifically to recruiting the middle/lower
trapezius and the serratus anterior.
Propose scapular protraction and retraction and
elevation-depression of the girdle [149, 150, 152].
We prefer the first exercise (scapular protraction and
retraction) (Fig. 3.75) since it has been shown to activate
the lower adn middle trapezius and so is useful to avoid
scapular girdle elevation and the possible compensation
Fig. 3.71 Altered posture after wearing sling for approximately 3

weeks Fig. 3.72 Sequential kinetic chain activation
Fig. 3.73 Stretching of the anterior shoulder structure. Often shorten-

ing or contracture of the pectoral muscle cause anterior scapula tilting
Fig. 3.75 Scapular clock: retraction and protraction
Fig. 3.74 Scapular clock:

elevation and depression
• Evaluate Core Stability: In the first phase, it is important

Take-Home Message to assess patient posture and core stability so as to tailor
Subscapular split versus subscapular tenotomy the right sequence of goals to be obtained over the course
(Fig. 3.76a, b) of rehabilitation. As Kibler explains [156, 157], the vari-
ous body segments play specific roles in the kinetic chain
• Since the subscapular split procedure does not activation sequence. The muscles and joints of the hips,
involve detachment of the subscapularis from the pelvis, and spine (known collectively as the core) are cen-
greater tuberosity, there is no tendon-bone healing trally located and can perform many of the stabilizing
period to be respected. As a result, internal rotation functions that the body requires if the distal segments are
and external rotation exercises can be started earlier to perform their specific functions. Thus “core stability”
on. The subscapular tenotomy procedure, on the provides proximal stability for distal limb mobility and
other hand, requires greater caution up to the 6th function.
postoperative week, with active and passive exter- When assessing core stability and strength, it is impor-
nal rotation and active internal rotation. tant to evaluate the muscles working in an eccentric, load-
absorbing function, the body segments in a closed-chain
situation, and the resultant movements in the 3 planes of
trunk motion. In the standing balance test, the patient is
Take-Home Message asked to stand on one leg and is given no further verbal
cue. A positive test result, known as the Trendelenburg
What is proprioception? sign, is when the hip drops on the unsupported side
(Fig. 3.77a, b). This indicates inability to control the pos-
• Proprioception is a specialized sensory modality ture and suggests proximal core weakness [156].
that gives information about extremity position and
direction of movement. This kind of afferent sen-
sory feedback is probably important in mediating
muscular control of the shoulder joint [153–155].
Rehabilitation goals
Phase1: Phase 2: Phase 3:

3–9 weeks 9–12 weeks 12 weeks
-restore -restore auto/assisted active -Improve muscolar

passive/autoassisted range of motion balance
range of motion
-Restore of muscolar control -Improve control
stability
-Restore proprioception
a b
Fig. 3.76 (a) Subscapular split. (b) Subscapular tenotomy (black dotted line)
a b
Fig. 3.77 (a, b) Trendelenburg sign

Phase I: 3–9 Weeks motion, respecting biological post-op healing timeframes

The focus of rehabilitation is to restore normal joint arthro- and patient pain thresholds, if any.
kinematics and reinstate the shoulder’s physiologic range of
Goals How to do
Protect and preserve the surgical repair Comply with patient biological healing times after surgical reconstruction
Sleep in supine position with a towel under the elbow to prevent shoulder hyperextension
In side-lying sleep, put towel under the axilla to keep the shoulder in a neutral position
Reduction of inflammation and pain Frequent cryotherapy for pain and inflammation
Achieve gradual restoration of passive range of Passive mobilization by physiotherapist and self-assisted exercises by patient keeping
motion (PROM) under 90° elevation in the scapulothoracic plane and 15°/20° external rotation (Fig. 3.78a)
Supine passive arm elevation (Fig. 3.78b)
Enhance/ensure adequate scapular function Scapular clock exercises (Figs. 3.74 and 3.75)
Progress to scapular isometric exercises
Ball squeezes (Fig. 3.85)
Low row (Fig. 3.79) inferior glide (Fig. 3.80)
Restore proprioception Proprioception ball exercise
• Restore ROM: ROM exercising is gradually increased as contralateral leg through the trunk up to the ipsilateral arm,
the connective tissues progressively heal and can success- which helps correct the position of the scapula in retrac-
fully accommodate greater stress. Advancing pain-free tion thanks to the facilitation caused by the hip extension
ROM during this phase is essential to progressing toward together with extension and rotation of the trunk.
full ROM by the next phase. Patients must be encouraged
to complete the articular range with active assisted ROM The robbery exercise (Fig. 3.82a, b) is an OKC exercise,
exercises within a pain-free range and with passive mobi- activating the periscapular district. Here too, the lower trape-
lization (Fig. 3.78a, b). zius and the serratus anterior are recruited, but this time
• Enhance/Ensure Adequate Scapular Function: Kibler through hip and trunk extension and starting from a position
et al. [105] have demonstrated serratus anterior and lower of flexion with bilateral extension of the arms in adduction
trapezius activation in a closed kinetic chain (CKC) and in with the elbows flexed [158].
the absence of ROM with exercises like the low row, which
increases external scapular rotation and posterior tilt, and • Proprioceptive Neuromuscular Control:
the inferior glide, which induces scapular retraction
(Figs. 3.79 and 3.80). Since muscle tone is likely to be The main goal of surgery is to restore not only the
reduced, special neuromuscular facilitation strategies must mechanical restraint lost with joint dislocation but also the
be adopted [150] to reinstate arthrokinematics and prevent proprioceptive deficits arising after joint injury [154].
compensation [149, 150, 152]. Kibler et al. [105] proposes Regaining proprioceptive and neuromuscular control
open kinetic chain (OKC) exercises: the lawnmower must proceed in parallel with recovery of range of
(Fig. 3.81a, b), a diagonal exercise pattern going from the motion.
a b
Fig. 3.78 (a) Passive mobilization in external rotation between 15° affected arm upward, as if to bring the arm until 90°, slowly lower the
and 20°. (b) Lie on the back. Hold the affected arm at the elbow with arm back to the bed
the opposite hand. Using the strength of the opposite arm, lift the
Fig. 3.80 Inferior glide
Fig. 3.79 Low row

a b
Fig. 3.81 (a) Initial position: scapular retraction exercise in closed kinetic chain. (b) Lawnmower final position
a b
Fig. 3.82 (a) Robbery → Start position. (b) Robbery → Final position
To begin with, gentle but very useful neuromuscular con- movement management and control pattern that can be
trol exercises can be implemented, starting from the supine carried out eliminating visual feedback (with eyes closed)
position to avoid activation of the upper trapezius as explaned and flexing the knees to increase kinetic chain energy
in chapter one. (Fig. 3.84).
• The involved limb must be supported by a small towel

(Fig. 3.83a) so as to obtain the right glenohumeral
Take-Home Message
mechanical position in the scapular plane.
• Between the 6th and 12th weeks, increasingly sub-
With the elbow at 90° and with the hand tightly closed,
scapular split and coracoid healing take place. From
the patient is asked to push back against the force applied
this moment, we can begin to strain these structures
by the physiotherapist all along the forearm (Fig. 3.83b).
by biomechanical point of view.
Obviously, this exercise must be done under the patient’s
pain threshold.
Exercise difficulty will be gradually increased. Based on
the patient’s improved response, the exercise will be
increased in terms of resistance applied, proprioceptive Take-Home Message
response, and the adoption of different arm positions in It is important to perform the exercises with the arm
different planes (Fig. 3.83c) abducted at around 20° to the scapular plane to ensure
• Physioball isometric contraction to promote propriocep- the best biomechanical alignment.
tive awareness. The exercise comprises a systematic
a b c
Fig. 3.83 (a–c) Progressively more difficult proprioceptive exercises with the arm unsupported in space
Fig. 3.84 Physioball isometric contraction

Fig. 3.85 Ball squeeze exercises
Phase II: 9–12 Weeks self-assisted mobilization, stretching by the therapist and
After the 9th week, if the patient has acquired joint mobility active exercises above 90° elevation (Fig. 3.86a, b).
of no less than 90° in passive-active elevation on the scapular • Enhance/Ensure Adequate Scapular Function: Equally
plane, in the total absence of pain, he may pass to the next important to strengthen the scapulothoracic muscles is
protocol phase. the exercise of scapula closure, or pinch, shown in
(Fig. 3.86a, b). The patient lies on his side with a towel
Goals How to do support under the upper arm to maintain the correct
Respect patient’s Continue cryotherapy as required shoulder joint position [159] and close the scapula. The
biological healing rate patient is facilitated in his movements by the gravity-
Progressively increase Passive, self-assisted and gradually free side-lying position. In addition, De Mey et al. [160]
both active and passive active mobilization
have shown that this position inhibits the upper trape-
ROM recovery
zius, instead specifically recruiting the middle and lower
Emphasize exercising Emphasize the scapulo thoracic muscles
the lower trapezius, the Exercises in side-lying position with and
fibers of the muscle in order to maintain correct
middle trapezius, and without external rotation to recruit stabilization.
the serratus anterior to middle and lower trapezius (Figs. 3.87
increase scapular and 3.88) Ludewig et al. [161] further confirm the validity of
retraction and establish
Isometric exercises with or without the these exercises, reporting the significantly different acti-
muscular balance
application of force
vation of the upper trapezius and the serratus anterior in
Prone exercises to improve lower and
middle trapezius (Fig. 3.89) the CKC push-up plus exercise (Fig. 3.90). In the plus
Proprioceptive recovery Flex bar phase – when the patient flexes his elbows to move toward
the wall and in so doing pinches his scapulae – all the
• PROM and AROM Recovery: Passive and active ROM muscle fibers of the serratus anterior are maximally
must be continued throughout the second phase with engaged.
a b
Fig. 3.86 (a, b) Gradual recovery of shoulder joint arc of motion

Figs. 3.87 and 3.88 Side-lying position with selective activation of the lower and middle trapezius (Fig. 3.87); subsequently combined with
external rotation (Fig. 3.88)
Fig. 3.89 Full lower and middle trapezius activation

Fig. 3.90 Wall push-up plus

Phase III: 12 Weeks to Sports Integration wall. Hardwick et al. [162] have shown how this exercise
The third clinical check-up is carried out at the outset of is completely painless because carried out in CKC and
phase 3. The physiotherapist should take in consideration has the advantage of especially activating the lower
that bone-to-bone healing takes place in the third month. trapezius.
The surgeon must verify that full ROM is no less than • Progressive Return to Sports Activity and Final Clinical
90 % of the contralateral side before authorizing gradual Check-Up at 6 Months: The final rehabilitation period
and progressive return to the specific athletic movement. includes sports-specific activity involving more intense
In fact the shoulder must not be considered as a single iso- strengthening of pertinent districts, to be decided by the
lated muscle set but as an integral part of a kinetic chain specialist training team, taking into account the surgery
activated by a simple but sophisticated system of concen- undergone by the athlete and the resultant strength and
tric rings that are activated distally and subsequently neuromuscular deficit.
recruit all – even the smallest – proximal muscle fibers
[149, 150]. It follows that this phase should only be initi-
ated in patients who have developed good neuromuscular
control and have completed the CKC exercises, together
with other simple OKC movements like lawnmower and
robbery (Figs. 3.81a, b and 3.82a, b) before passing to the
OKC exercises of phase 3.
Goals How to do
Improve range Active stretching assisted by physiotherapist and
of motion and self-assisted (Fig. 3.91)
regain Full Sleeper stretch exercise (Fig. 3.92)
ROM
Stretch of the anterior structure to avoid stiffness
Wall slide exercise (Fig. 3.93)
Improve Wall push-up plus (Fig. 3.90)
muscular Unilateral serratus anterior punch (Fig. 3.94)
balance
Improve Integrated elastic exercises
proprioception Integrated weight exercises
and muscular
stability
• Enhance/Ensure Adequate Scapular Function: In phase 3

the patient is free to move his arm on any plane. Having
regained ROM (90°), the goal is now to allow the patient
to return to his particular sports activity, which will only
be possible, however, if muscle strength and neuro-
proprioceptive control has been reinstated completely
during the previous phases. Hardwick et al. show how
certain exercises can specifically activate the fibers of the
serratus anterior in positions over 90° ROM.
A perfect example of a closed kinetic chain exercise
involving maximum activation of the serratus anterior is
the wall slide (Fig. 3.93). With arms in the scapular plane,
the patient slides his hands slightly outward against the Fig. 3.91 Improve stretching
Fig. 3.92 Sleeper stretch
Fig. 3.93 Wall Slide

Fig. 3.94 Variation of the

bilateral serratus anterior punch
as proposed by Reinold
Fig. 3.95 Prone position on the ball to activate the scapular muscles thanks to neuromuscular activation on account of ball-induced core
instability
References 25. Bankart ASB (1923) Recurrent or habitual dislocation of the shoul-
der joint. BMJ 2:1132–1133
26. Henry JH, Genung JA (1982) Natural history of glenohumeral dis-
1. Saha AK (1983) Mechanism of shoulder movements and a plea for
location: revisited. Am J Sports Med 10:135–137
the recognition of “zero position” of glenohumeral joint. Clin
27. Hovelius L, Eriksson K, Fredin H et al (1983) Recurrences after
Orthop 173:3–10
initial dislocation of the shoulder: results of a prospective study of
2. Neumann DA (2002) Kinesiology of the musculoskeletal system:
treatment. J Bone Joint Surg Am 65:343–349
foundations for physical rehabilitation. Mosby, St Louis
28. Kralinger FS, Golser K, Wischatta R, Wambacher M, Sperner G
3. Kapandji IA (1985) The physiology of the joints. Upper extremity.
(2002) Predicting recurrence after primary anterior shoulder dislo-
Churchill Livingstone, Philadelphia
cation. Am J Sports Med 30:116–120
4. Ellenbecker TS (2006) Shoulder rehabilitation: non-operative treat-
ment. Thieme, New York 29. Norlin R (1994) Use of Mitek anchoring for Bankart repair: a com-
5. Inman VT, Saunders JB, Abbott LC (1944) Observations on the parable, randomized, prospective study with traditional bone
function of the shoulder joint. J Bone Joint Surg 26(1):1–30 sutures. J Shoulder Elbow Surg 3:381–385
6. Weiner DS, MacNab I (1970) Superior migration of the humeral 30. Townley CO (1950) The capsular mechanism in recurrent disloca-
head. J Bone Joint Surg Br 52:524–527 tion of the shoulder. J Bone Joint Surg Am 32:370–380
7. Burkhart SS, Morgan CD, Kibler WB (2003) The disabled throw- 31. Burkhart SS, De Beer JF (2000) Traumatic glenohumeral bone
ing shoulder: spectrum of pathology Part I: pathoanatomy and bio- defects and their relationship to failure of arthroscopic Bankart
mechanics. Arthroscopy 19(4):404–420 repairs: significance of the inverted-pear glenoid and the humeral
8. Bagg SD, Forrest WJ (1988) A biomechanical analysis of scapular engaging Hill-Sachs lesion. Arthroscopy 16:677–694
rotation during arm abduction in the scapular plane. Arch Phys Med 32. Griffith JF, Antonio GE, Tong CWC, Ming CK (2003) Anterior
Rehabil 67:238–245 shoulder dislocation: quantification of glenoid bone loss with CT.
9. Hsu AT, Chang JH, Chang CH (2002) Determining the resting posi- AJR Am J Roentgenol 180:1423–1430
tion of the glenohumeral joint: a cadaver study. J Orthop Sports 33. Singson RD, Feldman F, Bigliani L (1987) CT arthrographic pat-
Phys Ther 32(12):605–612 terns in recurrent glenohumeral instability. AJR Am J Roentgenol
10. Kaltenborn FM (1989) Manual mobilization of the extremity joints. 149:749–753
Olaf Norlis Bokhandel, Oslo 34. Fujii Y, Yoneda M, Wakitani S et al (2006) Histologic analysis of
11. Magee DJ (2009) Orthopaedic physical assessment, 5th edn. bony Bankart lesions in recurrent anterior instability of the shoul-
Saunders, St Louis der. J Shoulder Elbow Surg 15:218–223
12. Abboud JA, Soslowsky LJ (2002) Interplay of the static and 35. Baudi P, Righi P, Bolognesi D et al (2005) How to identify and
dynamic restraints in glenohumeral instability. Clin Orthop Relat calculate glenoid bone deficit. Chir Organi Mov 90:145–152
Res 400:48–57 36. Sugaya H, Moriishi J, Dohi M et al (2003) Glenoid rim morphology
13. Itoi E, Morrey BF, An KN (2009) Biomechanics of the shoulder. In: in recurrent anterior glenohumeral instability. J Bone Joint Surg
Rockwood C Jr, Matsen FA III, Wirth MA, Lippitt SB (eds) The Am 85:878–884
shoulder, 4th edn. Saunders/Elsevier, Philadelphia, pp 213–265 37. d’Elia G, Di Giacomo A, D’Alessandro P et al (2008) Traumatic
14. Itoi E (2004) Pathophysiology and treatment of a traumatic instabil- anterior glenohumeral instability: quantification of glenoid bone
ity of the shoulder. J Orthop Sci 9(2):208–213 loss by spiral CT. Radiol Med 113:496–503
15. Boileau P, Villalba M, Héry JY, Balg F, Ahrens P, Neyton L (2006) 38. Flower WH (1861) On the pathological changes produced in the
Risk factors for recurrence of shoulder instability after arthroscopic shoulder-joint by traumatic dislocation, as derived from an exami-
Bankart repair. J Bone Joint Surg Am 88:1755–1763 nation of all the specimens illustrating this injury in the museums of
16. Mologne TS, McBride MT, Lapoint JM (1997) Assessment of London. Trans Pathol Soc London 12:17–201
failed arthroscopic anterior labral repairs. Findings at open surgery. 39. Eve FS (1880) A case of sub-coracoid dislocation of the humerus,
Am J Sports Med 25:813–817 with the formation of an indentation on the posterior surface of the
17. Calandra JJ, Baker CL, Uribe J (1989) The incidence of Hill-Sachs head, the joint being unopened; with remarks on the mode of pro-
lesions in initial anterior shoulder dislocations. Arthroscopy duction of fracture of the anatomical neck, with dislocation. Med
5(4):254–257 Chir Trans 63:317–321
18. Rowe CR, Zarins B, Ciullo JV (1984) Recurrent anterior disloca- 40. Hermodsson I (1934) Rontgenologischestudienuber die trauma-
tion of the shoulder after surgical repair. Apparent causes of failure tischen und habituellen schultergelenkverrenkungen nach vom und
and treatment. J Bone Joint Surg Am 66:159–168 nach unten. Acta Radiol Suppl 20:1–173
19. Hill HA, Sachs MD (1940) The groove defect of the humeral head. 41. Neer CS, Rockwood CA (1984) Fracture;-and dislocations of the
A frequently unrecognized complication of dislocations of the shoulder. In: Rockwood CA, Green EP (eds) Fractures in adults.
shoulder joint. Radiology 35:690–700 J.B. Lippincott, Philadelphia, pp 675–985
20. Bigliani LU, Newton PM, Steinmann SP, Connor PM, McIlveen SJ 42. Čičak N, Bilić R, Delimar D (1998) Hill-Sachs lesion in recurrent
(1998) Glenoid rim lesions associated with recurrent anterior dislo- shoulder dislocation: sonographic detection. J Ultrasound Med
cation of the shoulder. Am J Sports Med 26:41–45 17:557–560
21. Rowe CR, Patel D, Southmayd WW (1978) The Bankart procedure: 43. Itoi E, Yamamoto N, Kurokawa D, Sano H (2013) Bone loss in
a long-term end-result study. J Bone Joint Surg Am 60:1–16 anterior instability. Curr Rev Musculoskelet Med 6(1):88–94
22. Ungersböck A, Michel M, Hertel R (1995) Factors influencing the 44. Owens BD, Nelson BJ, Duffey ML, Mountcastle SB, Taylor DC,
results of a modified Bankart procedure. J Shoulder Elbow Surg Cameron KL, Campbell S, DeBerardino TM (2010) Pathoanatomy
4:365–369 of first-time, traumatic, anterior glenohumeral subluxation events. J
23. Richards RD, Sartoris DJ, Pathria MN, Resnick D (1994) Hill- Bone Joint Surg Am 92(7):1605–1611
Sachs lesion and normal humeral groove: MR imaging features 45. Cetik O, Uslu M, Ozsar BK (2007) The relationship between Hill-
allowing their differentiation. Radiology 190(3):665–668 Sachs lesion and recurrent anterior shoulder dislocation. Acta
24. Armitage MS, Faber KJ, Drosdowech DS, Litchfield RB, Athwal Orthop Belg 73(2):175–178
GS (2010) Humeral head bone defects: remplissage, allograft, and 46. Yamamoto N, Itoi E, Abe H et al (2007) Contact between the
arthroplasty. Orthop Clin North Am 41(3):417–425 glenoid and the humeral head in abduction, external rotation, and
horizontal extension: a new concept of glenoid track. J Shoulder 65. Balg F, Boileau P (2007) The instability severity index score. A
Elbow Surg 16:649–656 simple pre-operative score to select patients for arthroscopic or
47. Di Giacomo G, Itoi E, Burkhart S (2014) Evolving concept of open shoulder stabilisation. J Bone Joint Surg Br 89-B:1470–1477
bipolar bone loss and the Hill-Sachs lesion: from “engaging/non- 66. Broca A, Hartmann H (1890) Contribution a l’étude des luxations
engaging” lesion to “on-track/off-track” lesion. Arthroscopy d’épaule (luxations dites incomplĕtes, décollements périostiques,
30(1):90–98 luxations directes et luxations indirectes). Bull Soc Anat
48. Metzger PD, Barlow B, Leonardelli D, Peace W, Solomon DJ, 4:312–336
Provencher MT (2013) Clinical application of the “glenoid track” 67. Delorme DHD (1910) Die Hemmungsbaender des Schultergelenks
concept for defining humeral head engagement in anterior shoulder und ihre Bedeutung fuer die Schulterluxationen. Arch Klein Chir
instability. Orthop J Sports Med 1(2):1–7 92:72–101
49. Kaar SG, Fening SD, Jones MH, Colbrunn RW, Miniaci A (2010) 68. Taylor DC, Arciero RA (1997) Pathologic changes associated with
Effect of humeral head defect size on glenohumeral stability: a shoulder dislocations: arthroscopic and physical examination find-
cadaveric study of simulated Hill-Sachs defects. Am J Sports Med ings in first time, traumatic anterior dislocations. Am J Sports Med
38:594–599 25(3):306–311
50. Sekiya JK, Wickwire AC, Stehle JH, Debski RE (2009) Hill-Sachs 69. Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC
defects and repair using osteoarticular allograft transplantation: (2008) Hill-Sachs “remplissage”: an arthroscopic solution for the
biomechanical analysis using a joint compression model. Am J engaging Hill-Sachs lesion. Arthroscopy 24:723–726
Sports Med 37:2459–2466 70. Boileau P, O’Shea K, Vargas P, Pinedo M, Old J, Zumstein M
51. Cho SH, Cho NS, Rhee YG (2011) Preoperative analysis of the (2012) Anatomical and functional results after arthroscopic Hill-
Hill-Sachs lesion in anterior shoulder instability: how to predict Sachs remplissage. J Bone Joint Surg Am 94:618–626
engagement of the lesion. Am J Sports Med 39:2389 71. Haviv B, Mayo L, Biggs D (2011) Outcomes of arthroscopic “rem-
52. Warner JJP, Gerber C, Itoi E, Lafosse L (2013) Shoulder instability: plissage”: capsulotenodesis of the engaging large Hill-Sachs lesion.
an international perspective on treatment. ICL 107. Presented at the J Orthop Surg Res 6:29
2013 annual meeting of the American Academy of Orthopaedic 72. Koo SS, Burkhart SS, Ochoa E (2009) Arthroscopic double pulley
Surgeons, Chicago, March 2013 remplissage technique for engaging Hill-Sachs lesions in anterior
53. Provencher MT, Abrams JS, Boileau P, Ryu RKN, Tokish JM shoulder instability repairs. Arthroscopy 25:1343–1348
(2013) Challenging problems in shoulder instability: how to get it 73. Nourissat G, Kilinc AS, Werther JR, Doursounian L (2011) A pro-
right the first time and what to do if you don’t. ICL 282. Presented spective, comparative, radiological, and clinical study of the influ-
at the 2013 annual meeting of the American Academy of ence of the “remplissage” procedure on shoulder range of motion
Orthopaedic Surgeons, Chicago, March 2013 after stabilization by arthroscopic Bankart repair. Am J Sports Med
54. Kurokawa D, Yamamoto N, Nagamoto H et al (2013) The preva- 39:2147–2152
lence of a large Hill-Sachs lesion that needs to be treated. J Shoulder 74. Park MJ, Garcia G, Malhotra A, Major N, Tjoumakaris FP, Kelly JDIV
Elbow Surg 22:1285–1289 (2012) The evaluation of arthroscopic remplissage by high-resolution
55. Kelkar R, Wang VM, Flatow EL et al (2001) Glenohumeral magnetic resonance imaging. Am J Sports Med 40:2331–2336
mechanics. A study of articular geometry, contact, and kinematics. 75. Park MJ, Tjoumakaris FP, Garcia G, Patel A, Kelly JD IV (2011)
J Shoulder Elbow Surg 10:73–84 Arthroscopic remplissage with Bankart repair for the treatment of
56. Kirkley A, Werstine R, Ratjek A, Griffin S (2005) Prospective ran- glenohumeral instability with Hill-Sachs defects. Arthroscopy
domized clinical trial comparing the effectiveness of immediate 27:1187–1194
arthroscopic stabilization versus immobilization and rehabilitation 76. Zhu YM, Lu Y, Zhang J, Shen JW, Jiang CY (2011) Arthroscopic
in first traumatic anterior dislocations of the shoulder: long-term Bankart repair combined with remplissage technique for the treat-
evaluation. Arthroscopy 21(1):55–63 ment of anterior shoulder instability with engaging Hill-Sachs
57. Bottoni CR, Wilckens JH, DeBerardino TM et al (2002) A prospec- lesion: a report of 49 cases with a minimum 2-year follow-up. Am
tive, randomized evaluation of arthroscopic stabilization versus J Sports Med 39:1640–1647
nonoperative treatment in patients with acute, traumatic, first-time 77. Priest JD, Nagel DA (1976) Tennis shoulder. Am J Sports Med
shoulder dislocations. Am J Sports Med 30:576–580 4(1):28–42
58. Jones KJ, Wiesel B, Ganley TJ, Wells L (2007) Functional out- 78. Young SW, Dakic J, Stroia K, Nguyen NL, Harris AHS, Safran MR
comes of early arthroscopic Bankart repair in adolescents aged 11 (2004) High incidence of infraspinatus muscle atrophy in elite pro-
to 18 years. J Pediatr Orthop 27:209–213 fessional female tennis players. Am J Sports Med 43(8):1989–1993
59. Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, 79. Safran M (2004) Nerve injury about the shoulder in athletes, part 1.
Thorling J (1996) Primary anterior dislocation of the shoulder in Am J Sports Med 32(3):803–819
young patients. A ten year prospective study. J Bone Joint Surg Am 80. Piatt BE, Hawkins RJ, Fritz RC, Ho CP, Wolf E, Schickendantz M
78:1677–1684 (2002) Clinical evaluation and treatment of spinoglenoid notch
60. Aronen JG, Regan K (1984) Decreasing the incidence of recurrence ganglion cysts. J Shoulder Elbow Surg 11:600–604
of first time anterior shoulder dislocations with rehabilitation. Am J 81. Kibler WB, Uhl TL, Maddux JW, Brooks PV, Zeller B, McMullen
Sports Med 12:283–291 J (2002) Qualitative clinical evaluation of scapular dysfunction: a
61. Deitch J, Mehlman CT, Foad SL, Obbehat A, Mallory M (2003) reliability study. J Shoulder Elbow Surg 11:550–556
Traumatic anterior shoulder dislocation in adolescents. Am J Sports 82. McMahon PJ, Jobe FW, Pink MM, Brault JR, Perry J (1996)
Med 31:758–763 Comparative electromyographic analysis of shoulder muscles dur-
62. Rowe CR (1980) Acute and recurrent anterior dislocation of the ing planar motions: anterior instability versus normal. J Shoulder
shoulder. Orthop Clin North Am 11:253–270 Elbow Surg 5:118–123
63. Simonet WT, Melton LJ, Cofield RH, Iltrup DM (1984) Incidence 83. Kibler WB (1998) The role of the scapula in athletic shoulder func-
of anterior shoulder dislocation in Olmsted County, Minn. Clin tion. Am J Sports Med 26:325–337
Orthop Relat Res 186:186 84. Wilk KE, Reinold MM, Macrina LC, Porterfield R, Devine KM,
64. Kim D-S, Yoon Y-S, Yi CH (2010) Prevalence comparison of Suarez K, Andrews JR (2009) Glenohumeral internal rotation mea-
accompanying lesions between primary and recurrent anterior dis- surements differ depending on stabilization techniques. Sports
location in the shoulder. Am J Sports Med 38:2071 Health 1(2):131–136
85. Ellenbecker TS, Roetert EP, Piorkowski PA, Schulz DA (1996) scapular control in early phases of shoulder rehabilitation. Am J
Glenohumeral joint internal and external rotation range of motion Sports Med 36(9):1789–1798. Epub 9 May 2008
in elite junior tennis players. J Orthop Sports Phys Ther 106. Tsuruike M, Ellenbecker TS (2015) Serratus anterior and lower
24:336–341 trapezius muscle activities during multi-joint isotonic scapular
86. McFarland EG, Torpey BM, Carl LA (1996) Evaluation of shoul- exercises and isometric contractions. J Athl Train 50(2):199–210
der laxity. Sports Med 22:264–272 107. Ekstrom RA, Donatelli RA, Soderberg GL (2003) Surface electro-
87. Pagnani MJ, Warren RF (1994) Stabilizers of the glenohumeral myographic analysis of exercises and serraturs anterior muscles. J
joint. J Shoulder Elbow Surg 3:73–90 Orthop Sports Phys Ther 33(5):247–258
88. O’Brien SJ, Neves MC, Arnvoczky SP et al (1990) The anatomy 108. Ellenbecker TS, Davies GJ (2000) The application of isokinetics
and histology of the inferior glenohumeral ligament complex of in testing and rehabilitation of the shoulder complex. J Athl Train
the shoulder. Am J Sports Med 18:449–456 35:338–350
89. Hawkins RJ, Mohtadi NGH (1991) Clinical evaluation of shoulder 109. Jensen BR, Sjogaard G, Bornmyr S, Arborelius M, Jørgensen K
instability. Clin J Sports Med 1:59–64 (1995) Intramuscular laser-Doppler flowmetry in the supraspina-
90. Gerber C, Ganz R (1984) Clinical assessment of instability of the tus muscle during isometric contractions. Eur J Appl Physiol
shoulder with special reference to anterior and posterior drawer Occup Physiol 71:373–378
tests. J Bone Joint Surg Br 66(4):551–556 110. Rathbun JB, Macnab I (1970) The microvascular pattern of the
91. Altchek DW, Dines DW (1993) The surgical treatment of anterior rotator cuff. J Bone Joint Surg Br 52(3):540–553
instability: selective capsular repair. Oper Tech Sports Med 111. Ellenbecker TS, Cools A (2010) Rehabilitation of shoulder
1:285–292 impingement syndrome and rotator cuff injuries: an evidence
92. Hawkins RJ, Schulte JP, Janda DH, Huckell GH (1996) Translation based review. Br J Sports Med 44(55):319–327
of the glenohumeral joint with the patient under anesthesia. J 112. Sakita K, Seeley MK, Myrer JW, Hopkins JT (2015) Shoulder-
Shoulder Elbow Surg 5:286–292 muscle electromyography during shoulder external rotation exer-
93. Ellenbecker TS, Bailie DS, Mattalino AJ et al (2002) Intrarater cise with and without slight abduction. J Sport Rehabil
and interrater reliability of a manual technique to assess anterior 24:109–115
humeral head translation of the glenohumeral joint. J Shoulder 113. Malanga GA, Jenp YN, Growney ES, An KN (1996) EMG analy-
Elbow Surg 11(5):470–475 sis of shoulder positioning in testing and strengthening the supra-
94. Carter C, Wilkinson J (1964) Persistent joint laxity and congenital spinatus. Med Sci Sports Exerc 28(6):661–664
dislocation of the hip. J Bone Joint Surg Br 46:40–45 114. Ballantyne BT, O’Hare SJ, Paschall JL et al (1993)
95. Beighton P, Horan F (1969) Orthopaedic aspects of the Ehlers- Electromyographic activity of selected shoulder muscles in com-
Danlos syndrome. J Bone Joint Surg Br 51(3):444–453 monly used therapeutic exercises. Phys Ther 73:668–677
96. Juul-Kristensen B, Rogind H, Jensen DV, Remvig L (2007) Inter- 115. Blackburn TA, McLeod WD, White B, Wofford L (1990) EMG
examiner reproducibility of tests and critera for generalized joint analysis of posterior rotator cuff exercises. J Athl Train 25:40–45
hypermobility and benign joint hypermobility syndrome. 116. Reinold MM, Wilk KE, Fleisig GS, Zheng N, Barrentine SW,
Rheumatology (Oxford) 46(12):1835–1841 Chmielewski T et al (2004) Electomyographic analysis of the
97. Cameron KL, Duffey ML, DeBerardino TM, Stoneman PD, Jones rotator cuff and deltoid musculature during common shoulder
CJ, Owens BD (2010) Association of generalized joint hypermo- external rotation exercises. J Orthop Sports Phys Ther
bility with a history of glenohumeral joint instability. J Athl Train 34(7):385–394
45(3):253–258 117. Townsend H, Jobe FW, Pink M, Perry J (1991) Electromyography
98. Ellenbecker TS & Davies GJ (2016) Current Concepts in analysis of glenohumeral muscles during a baseball rehabilitation
Rehabilitation of Rotator Cuff Pathology: Non-Operative and program. Am J Sports Med 19(3):264–272
Post-Operative Considerations Orthopaedic Knowledge Update: 118. Wuelker N, Plitz W, Roetman B (1994) Biomechanical data con-
Sports Medicine 5, Miller M (ed): American Academy of cerning the shoulder impingement syndrome. Clin Orthop
Orthopaedic Surgeons, Rosemont, IL 303:242–249
99. Ellenbecker TS, Manske RC, Kelley MJ (2011) The shoulder: 119. Carter AB, Kaminsky TW, Douex AT Jr, Knight CA, Richards JG
physical therapy patient management utilizing current evidence. (2007) Effects of high volume upper extremity plyometric training
In: Current concepts of orthopaedic physical therapy, 3rd edn. on throwing velocity and functional strength ratios of the shoulder
Orthopaedic Section APTA, LaCrosse rotators in collegiate baseball players. J Strength Cond Res
100. Black KP, Lim TH, McGrady LM, Raasch W (1997) In vitro eval- 21(1):208–215
uation of shoulder external rotation after a Bankart reconstruction. 120. Niederbracht Y, Shim AL, Sloniger MA, Paternostro-Bayles M,
Am J Sports Med 25:449–453 Short TH (2008) Effects of a shoulder injury prevention strength
101. Penna J, Deramo D, Nelson CO, Sileo MJ, Levin SM, Tompkins training program on eccentric external rotation muscle strength
B, Ianuzzi A (2008) Determination of anterior labral repair stress and glenohumeral joint imbalance in female overhead activity ath-
during passive arm motion in a cadaveric model. Arthroscopy letes. J Strength Cond Res 22(1):140–145
24(8):930–935 121. Moncrief SA, Lau JD, Gale JR, Scott SA (2002) Effect of rotator
102. Fleck SJ, Kraemer WJ (1987) Designing resistance training pro- exercise on humeral rotation torque in healthy individuals. J
grams. Human Kinetics Publishers, Champaign Strength Cond Res 16(2):262–270
103. Moseley JB Jr, Jobe FW, Pink M, Perry J, Tibone J (1992) EMG 122. Ellenbecker TS, Davies GJ, Rowinski MJ (1988) Concentric ver-
analysis of the scapular muscles during a shoulder rehabilitation sus eccentric isokinetic strengthening of the rotator cuff. Objective
program. Am J Sports Med 20(2):128–134 data versus functional test. Am J Sports Med 16(1):64–69
104. Decker MJ, Hintermeister RA, Faber KJ, Hawkins RJ (1999) 123. Graichen H, Hinterwimmer S, von Eisenhart-Rothe R, Vogl T,
Serratus anterior muscle activity during selected rehabilitation Englmeir K-H, Eckstein F (2005) Effect of abduction and adduct-
exercises. Am J Sports Med 27:784–791 ing muscle activity on glenohumeral translation, scapular kine-
105. Kibler WB, Sciascia AD, Uhl TL, Tambay N, Cunningham T matics and subacromial space width in vivo. J Biomech 38(4):
(2008) Electromyographic analysis of specific exercise for the 755–760
124. Bitter NL, Clisby EF, Jones MA, Magarey ME, Jaberzadeh S, 143. Ellenbecker TS, Reinold M, Nelson CO (2010) Clinical concepts
Sandow MJ (2007) Relative contributions of infraspinatous and for treatment of the elbow in the adolescent overhead athlete. Clin
deltoid during external rotation in healthy shoulders. J Shoulder Sports Med 29(4):705–724
Elbow Surg 16(5):563–568 144. Kim SH, Ha KI, Jung MW, Lim MS, Kim YM, Park JH (2003)
125. Burkhart SS, Morgan CD (1998) The peel-back mechanism: its Accelerated rehabilitation after arthroscopic Bankart repair for
role in producing and extending posterior type II SLAP lesions and selected cases: a prospective randomized clinical study.
its effect on SLAP repair rehabilitation. Arthroscopy 14:637–640 Arthroscopy 19(7):722–731
126. Harryman DT, Sidles JA, Clark JM, Mcquade KJ, Gibb TD, 145. Lenters TR, Franta AK, Wolf FM, Leopold SS, Matsen FA 3rd
Matsen FA (1990) Translation of the humeral head on the glenoid (2007) Arthroscopic compared with open repairs for recurrent
with passive glenohumeral joint motion. J Bone Joint Surg anterior shoulder instability. A systematic review and meta-analy-
72A(9):1334–1343 sis of the literature. J Bone Joint Surg Am 89(2):244–254
127. Matsen FA, Lippitt SB, Sidles JA, Harryman DT (1994) Practical 146. Petrera M, Patella V, Patella S, Theodoropoulos J (2010) A
evaluation and management of the shoulder. W.B. Saunders, meta-analysis of open versus arthroscopic Bankart repair using
Philadelphia suture anchors. Knee Surg Sports Traumatol Arthrosc
128. McCabe RA, Orishimo KF, McHugh MP, Nicholas SJ (2007) 18(12):1742–1747
Surface electromyographic analysis of the lower trapezius muscle 147. Castagna A, Markopoulos N, Conti M, Delle Rose G, Papadakou
during exercises performed below ninety degrees of shoulder ele- E, Garofalo R (2010) Arthroscopic bankart suture-anchor repair:
vation in healthy subject. N Am J Sports Phys Ther 2(1):34–43 radiological and clinical outcome at minimum 10 years of follow-
129. Chen SK, Simonian PT, Wickeiwicz TL, Otis JC, Warren RF up. Am J Sports Med 38(10):2012–2016
(1999) Radiographic evaluation of glenohumeral kinematics: a 148. Jankauskas L, Rüdiger HA, Pfirrmann CW, Jost B, Gerber C
muscle fatigue model. J Shoulder Elbow Surg 8(1):49–52 (2010) Loss of the sclerotic line of the glenoid on anteroposterior
130. Ebaugh DD, McClure PW, Karduna AR (2006) Scapulothoracic radiographs of the shoulder: a diagnostic sign for an osseous
and glenohumeral kinematics following an external rotation defect of the anterior glenoid rim. J Shoulder Elbow Surg
fatigue protocol. J Orthop Sports Phys Ther 36(8):557–571 19(1):151–156
131. Cain PR, Mutschler TA, Fu FH, Lee SK (1987) Anterior stability 149. McMullen J, Uhl TL (2000) A kinetic chain approach for shoulder
of the glenohumeral joint. A dynamic model. Am J Sports Med rehabilitation. J Athl Train 35(3):329–337
15(2):144–148 150. Kibler WB, McMullen J, Uhl T (2001) Shoulder rehabilitation
132. Byram IR, Bushnell BD, Dugger K, Charron K, Harrell FE, strategies, guidelines, and practice. Orthop Clin North Am
Noonan TJ (2010) Preseason shoulder strength measurements in 32(3):527–538
professional baseball pitchers: identifying players at risk for 151. Smith J, Dahm DL, Kaufman KR, Boon AJ, Laskowski ER,
injury. Am J Sports Med 38(7):1375–1382 Katajarvi BR, Jacofsky DJ (2006) Eletromyographic activity in
133. Riemann BL, Davies GJ, Ludwig L, Gardenhour H (2010) the immobilized shoulder girdle musculature during scapulotho-
Hand-held dynamometer testing of the internal and external rota- racic exercise. Arch Phys Med Rehabil 87(7):923–927
tor musculature based on selected positions to establish norma- 152. Burkhart SS, Morgan CD, Kibler WB (2003) The disabled throw-
tive data and unilateral ratios. J Shoulder Elbow Surg ing shoulder: spectrum of pathology Part III: the SICK scapula,
19(8):1175–1183 scapular duskiness, the kinetic chain, and rehabilitation.
134. Ellenbecker TS, Sueyoshi T, Bailie DS (2015) Muscular activity Arthroscopy 19(6):641–661
during plyometric exercises in 90 degrees of glenohumeral joint 153. Warner JJ, Lephart S, Fu FH (1996) Role of proprioception in
abduction. Sports Health 7(1):75–79 pathoetiology of shoulder instability. Clin Orthop Relat Res
135. Davies GJ (1992) A compendium of isokinetics in clinical usage 330:35–39
and rehabilitation techniques, 4th edn. S & S Publishing, 154. Myers JB, Lephart SM (2002) Sensorimotor deficits contributing
Onalaska to glenohumeral instability. Clin Orthop Relat Res 400:98–104
136. Wilk KE, Andrews JR, Arrigo CA, Keirns MA, Erber DJ (1993) 155. Fuchs E, Holmes P, David I, Ayali A (2012) Proprioceptive feed-
The strength characteristics of internal and external rotator mus- back reinforces centrally generated stepping patterns in the
cles in professional baseball pitchers. Am J Sports Med 21:61–66 Cockroach. J Exp Biol 215:1884–1891, Published by The
137. Ellenbecker TS, Mattalino AJ (1999) Concentric isokinetic shoul- Company of Biologists Ltd
der internal and external rotation strength in professional baseball 156. Sciascia A, Kibler WB (2011) Alterations in the kinetic chain are
pitchers. J Orthop Sports Phys Ther 25:323–328 found in a high percentage of patients. Conducting the “nonshoul-
138. Ellenbecker TS, Roetert EP (2003) Age specific isokinetic gleno- der” shoulder examination. J Musculoskelet Med 28:61–2
humeral internal and external rotation strength in elite junior ten- 157. Kibler WB, Press J, Sciascia A (2006) The role of core stability in
nis players. J Sci Med Sport 6(1):63–70 athletic function. Sports Med 36:189–198
139. Mont MA, Cohen DB, Campbell KR, Gravare K, Mathur SK 158. Maenhout A, VanPraet K, Pizzi L, Van Herzeele M, Cools A
(1994) Isokinetic concentric versus eccentric training of shoulder (2010) Electromyographic analysis of knee push up variations:
rotators with functional evaluation of performance enhancement what is the influence of the kinetic chain on scapular muscle activ-
in elite tennis players. Am J Sports Med 22(4):513–517 ity? Br J Sports Med 44:1010–1015
140. Quincy RI, Davies GJ, Kolbeck KJ, Szymanski JL (2000) 159. Cools AM, Dewitte V, Lanszweert F, Notebaert D, Roets A,
Isokinetic exercise: the effects of training specificity on shoulder Soetens B, Cagnie B, Witvrouw EE (2007) Rehabilitation of scap-
strength development. J Athl Train 35:S64 ular muscle balance: which exercise to prescribe? Am J Sports
141. Bleacher J, Ellenbecker TS (2006) Modification of traditional Med 35(10):1744–1751. Epub 2 Jul 2007
exercises for shoulder rehabilitation and a return to lifting pro- 160. De Mey K, Cagnie B, Danneels LA, Cools AM, Van de Velde A
gram. In: Ellenbecker TS (ed) Shoulder rehabilitation: non-opera- (2009) Trapezius muscle timing during selected shoulder rehabili-
tive treatment. Thieme, New York tation exercise. J Orthop Sports Phys Ther 39(10):743–752
142. Gross ML, Brenner SL, Sonogni JJ (1993) Anterior shoulder 161. Ludewig PM, Hoff MS, Osowski EE, Meschke SA, Rundquist PJ
instability in weight lifters. Am J Sports Med 21:599–603 (2004) Relative balance of serratus anterior and upper trapezius
muscle activity during push-up exercise. Am J Sports Med 166. Wilk KE, Voight ML, Keirns MA et al (1993) Stretch-shortening
32(2):484–493 drills for the upper extremities: theory and clinical application. J
162. Hardwick DH, Beebe JA, McDonnell MK, Lang CE (2006) A Orthop Sports Phys Ther 17:225–239
comparison of serratus anterior muscle activation during a wall 167. Flesing GS, Jameson GG, Cody KE, et al (1998) Muscle activity
slide exercise and other traditional exercises. J Orthop Sports Phys during shoulder rehabilitation exercise. In: Proceedings of
Ther 36(12):903–910 NACOB ’98, the Third North American Congress on biomechan-
ics. Waterloo, 14 Aug 1998, pp. 223–234
168. Hintermeister RA, Lange GW, Schultheis JM et al (1998)
Electromyographic activity and applied load during shoulder
Further Reading rehabilitation exercises using elastic resistance. Am J Sports Med
26:210–220
163. Ogston JB, Ludwig PM (2007) Differences in 3-dimensional 169. Jobe FW, Moynes DR, Tibone JE et al (1984) An EMG analysis of
shoulder kinematics between persons with multi-directional insta- the shoulder in pitching: a second report. Am J Sports Med
bility and asymptomatic controls. Am J Sports Med 12:218–220
35(8):1361–1370 170. Jobe FW, Tibone JE, Jobe CM et al (1990) The shoulder in sport.
164. Kibler WB (1991) The role of the scapula in the overhead throw- In: Rockwood CA Jr, Matsen FA III (eds) The shoulder. W. B.
ing motion. Cont Orthop 22:525–532 Saunders, Philadelphia, pp 961–990
165. DeMey K, Danneels LA, Cagnie B, Huyghe L, Seyns E, Cools 171. Litchfield R, Hawkins R, Dillman CJ et al (1993) Rehabilitation
AM (2013) Conscious correction of scapular orientation in for the overhead athlete. J Orthop Sports Phys Ther 18:
overhead athletes performing selected shoulder rehabilitation 433–441
exercises: the effect on trapezius muscle activation measured by 172. Meister K, Andrews JR (1993) Classification and treatment of
surface electromyography. J Orthop Sports Phys Ther 43(1):3–10 rotator cuff injuries in the overhead athlete. J Orthop Sports Phys
Ther 18:413–421
173. Pappas AM, Zawacki RM, McCarthy CF (1985) Rehabilitation of
the pitching shoulder. Am J Sports Med 13:223–235
Rehabilitation Following Rotator Cuff
Repair 4
W. Ben Kibler and Aaron Sciascia
Contents 4.3 Rehabilitation following Rotator Cuff Repair ............ 168

4.3.1 Acute Stage ............................................................................. 168
4.1 Introduction ................................................................... 166 4.3.2 Recovery Stage ....................................................................... 171
4.2 The Role of the Orthopedic Surgeon 4.3.3 Functional Stage .................................................................... 178
in Rotator Cuff Rehabilitation ..................................... 166 4.3.4 Return-to-Activity Stage ................................................. 181
4.2.1 Optimizing Tissue Anatomy ................................................ 166 Conclusion ................................................................................... 182
4.2.2 Stages of Healing and Rehabilitation Progression ............ 166
4.2.3 Control of Loading ................................................................ 167 References .................................................................................... 182
4.2.4 Communication with Physical Therapists
and Other Rehabilitation Clinicians ................................ 167
W.B. Kibler, MD (*) • A. Sciascia, MS, ATC, PES

Lexington Clinic, Shoulder Center of Kentucky,
1221 South Broadway, Lexington, KY 40504, USA

DOI 10.1007/978-3-319-24856-1_4
166 W.B. Kibler and A. Sciascia
4.1 Introduction posterior. The surgeon must grasp and manipulate both edges
of the “U” to discover which the more mobile segment is and
The goal of rehabilitation following rotator cuff repair is to determine the exact apex of the “L” [2].
restore the functional capability of the shoulder. It requires The apex can then be reduced to the footprint to start the
integrated input from both the surgeon and the rehabilitation repair under minimal tension [2]. Frequently, the tissues at
clinician (physical therapist, occupational therapist, and/or the medial and posterior extents of the “U” will have been
athletic trainer). It is based on the restoration of the anatomy, plastically deformed or stretched in the gradual progressions
but requires restoration of the physiology. It requires adher- of the tear, and these areas can be incised and debrided in
ence to basic principles of tissue healing, muscle flexibility, order to get better quality tissue for the repair and to allow
muscle strength, and progression through rehabilitation more complete mobilization and reduction which create
stages and demands attention to several aspects of functional minimal tension on the entire repair. “Dog ears,” the excess
restoration. This chapter will discuss the role of the surgeon tissue on the edges of the repair, represent incomplete reduc-
and basic principles of the rehabilitation protocol and will tion of the tear, excessive tissue on one side of the repair, and
present guidelines and progressions for physical therapists create nonuniform tension on the tissues [3]. If the surgical
and other rehabilitation clinicians through the protocols. goal is to reproduce the rotator cuff anatomy, then “dog ears”
demonstrate that the goal has not been reached.
Once the type of tear is established, and the tear is mobi-
4.2 The Role of the Orthopedic Surgeon lized to be reduced, there are multiple techniques for attach-
in Rotator Cuff Rehabilitation ment to the footprint. Single-row repair, many variations of
double-row repair, and margin convergence repairs have all
The orthopedic surgeon usually does not prescribe specific been demonstrated to have adequate fixation and healing
exercises, does not supervise the exercise sessions, does not rates [4–8].
provide modalities, and does not see the patient weekly dur- Other more complex rotator cuff patterns include multi-
ing the rehabilitation process following rotator cuff repair. tendon tears, widely retracted tears, chronic tears with poor
However, the orthopedic surgeon plays several key roles that tissue quality, and tears associated with muscle atrophy.
have large effects on the outcomes of the rehabilitation pro- Surgical goals and techniques may need to be modified to
cess. They relate to: address these issues, and the optimal anatomy obtained from
these procedures may be less than ideal. Rehabilitation will
1. Optimizing the tissue anatomy as a basis for repair need to be individually modified in these cases.
integrity In summary, the surgical repair that creates the optimal
2. Knowing the phases of the rehabilitation sequence anatomy, as close to “normal” in alignment and tension,
3. Controlling repair loading during the key 6–8-week time allows rehabilitation to proceed at a physiological pace under
period when the repair is most likely to be disrupted normal physiological constraints.
4. Communicating effectively with the rehabilitation
clinicians
4.2.2 Stages of Healing and Rehabilitation
Progression
4.2.1 Optimizing Tissue Anatomy
There are several methods to organize the stages of rehabilita-
Many factors that are not under the surgeon’s direct control tion. This protocol uses three stages based on healing of the
affect the healing capability of the rotator cuff repair. repair, baseline preparation of all of the tissues to return to
However, the surgeon does control the technical aspects of function, and a sport- or activity-specific return to function.
how the rotator cuff tissue is mobilized, aligned on the There are specific goals, activity progressions, and criteria for
humerus, repaired within the tendon, and attached to the progression to the next phase. The surgeon has input into the
bone. The goal of surgery is to create a repair that is properly decisions regarding how rapidly to move through each stage
mobilized, reduced in an anatomic alignment, and firmly and when it is appropriate to move to the next stage.
attached across the footprint with minimal tension or shear
force. This repair heals more frequently and can be rehabili- 1. The ACUTE STAGE involves the surgical repair and the
tated relatively quickly in a standardized protocol. The early postoperative period, usually 6–8 weeks. The objec-
majority of symptomatic full-thickness rotator cuff tears are tive of this stage is to protect the repair sufficiently to
what is considered U-shaped tears [1]. The “U” is most com- create stable, healing local tissues, and optimal joint
monly an L-shaped tear that has undergone some retraction health and also to start early restoration of proximal
under tension. The apex of the “L” can be either anterior or kinetic chain function.
4 Rehabilitation Following Rotator Cuff Repair 167
2. The RECOVERY PHASE involves a relatively long period volume, and tissue mechanics are all decreased with result-
of time starting around 6–8 weeks postoperatively during ing decrease in healing rates in repairs subject to excessive
which the repair is completely healed. The kinetic chain compression during early healing [10, 14]. Excessive com-
is restored, and the local tissue inflexibilities, strength, pression occurs from dynamic downward and forward tilt of
and strength balance are restored. Entry into this phase the acromion, which occurs during scapular protraction [15,
assumes the tissues can be safely loaded in tension and 16]. This mainly occurs in the presence of scapular dyskine-
compression. Force couple restoration, full range of sis, which can occur from multiple causes, including exces-
motion, and scapular stability are also addressed. sive sling use; tight pectoralis major and/or minor, upper
3. The FUNCTIONAL STAGE will focus on restoring any trapezius, and latissimus dorsi muscles; weak serratus ante-
further biomechanical deficits or strength imbalances and rior or lower trapezius muscles; and weak core muscles.
include exercises that relate to optimal function in the The surgeon should evaluate the patient for scapular dys-
desired activities. They should simulate the motions, kinesis by clinical observation of the medial scapular border
forces, loads, and durations of the activity. The functional [15] and examination for periscapular muscle tightness or
stage will allow the return to activity or play and should weakness. Exercises to correct the dyskinesis and place the
also include a maintenance program to condition the scapula in stable retraction and the acromion in posterior tilt
shoulder after return to activity. should be instituted both preoperatively and in the early post-
operative stages. Care must be taken to keep passive range of
motion below 90° of elevation or abduction because higher
4.2.3 Control of Loading angles of arm motion are associated with decreased acromial
upward rotation, leading to more compression [16].
Repair healing can be affected by the amount of mechanical
load placed on the repair construct [9]. This is especially true
in the first 6–8 weeks, when inflammation and tissue healing 4.2.4 Communication with Physical
stages of the tendon process are predominant [9–13]. Excessive Therapists and Other Rehabilitation
loading can alter the tissue properties, decrease the volume of Clinicians
healing tissue, and alter expression of growth factors for heal-
ing [9, 13]. The orthopedic surgeon, by overseeing the timing The basis for integrated functional rehabilitation of rotator
of exercises and exercise progressions, by limiting the ranges cuff repair is effective communication between the surgeon
of allowable motion, by limiting the types of exercises, and by and rehabilitation clinician. It is good to establish a general
regulating the placement of the scapula and humerus, can agreement regarding expectations of rehabilitation progress,
affect both tensile and compression loading of the repair. patterns of exercises, types of motions and positions, and
Excessive tensile loading is a known risk factor for failure exercise content in each stage. An information sheet cover-
of tendon healing [9]. It can create either a complete re-tear ing these areas of concern should be given to each patient
or an elongation of the healing tissue, both resulting in an and the treating clinician. There are various methods through
incompetent repair. Excessive tensile loading can occur from which the ongoing communication regarding rehabilitation
a weight in an outstretched hand, gravity on an outstretched progress could go, including telephone communication,
hand, ranges of motion greater than tissue repair flexibility, mobile text messaging, website literature, and face-to-face
continued muscle activation after muscle fatigue, and exces- discussion, but the most common method is the exercise pre-
sive eccentric activations [9, 11, 12]. Surgeons should be scription either completed by hand or electronic copy. The
cautious about prescribing these activities in the first 4–6 prescription should include as appropriate:
weeks:
1. Pertinent information about the repair anatomy (number
1. Active or passive range of motion greater than 90° in any of tendons, tissue quality, security of the repair, etc.)
plane 2. Allowable ranges of motion (below 60° flexion and flex-
2. Unsupported pendulum (Codman) exercises (hand should ion, up to 90°, less than 30° external rotation)
be supported on a ball or other object) 3. Types of exercises (closed chain, Codman’s on ball or
3. Active or passive exercises that involve a long lever arm other supportive device, humeral head depression)
(exercises performed with the elbow extended) 4. Mechanics of exercises (short lever arm, plyometric, slow
4. Exercises to muscle fatigue speed, horizontal/diagonal)
5. Open-chain exercises with a weight in the hand 5. Exercises for other body areas (core stability/strengthen-
ing, scapular retraction)
Compressive loading is also deleterious to tendon repair 6. Any specific limits or progressions including advance-
healing. Animal studies have shown tissue quality, tissue ments to the next stages of rehabilitation
4.3 Rehabilitation following Rotator Cuff 4.3.1 Acute Stage

Repair
The acute stage is concerned with protecting the healing tis-
The physical therapist and other rehabilitation clinicians are sues while maintaining general body function. Passive arm
responsible for arranging and applying the content of the motions should be monitored and should stay below 90°.
exercises and modalities to fulfill the goals of the prescrip- Scapular retraction should be emphasized to avoid excessive
tion, providing feedback regarding progress or limitations, compression loading in this vulnerable time. Closed chain
readying the patient for progression to the next stage, and exercises, by supporting the hand and emphasizing proximal
overseeing the functional progressions to allow return to co-contractions, are effective at decreasing tensile loading.
activity or play. The object of rehabilitation following rotator Immobilization may be useful in the first 4–6 weeks, but
cuff repair is to restore the deltoid/rotator cuff force couple many studies demonstrate that short-term immobilization
to dynamically center the humeral head in the glenoid socket (2–3 weeks) and controlled passive motion (less than 90°)
throughout all the ranges of arm motion. The following pro- are more effective than longer-term immobilization in
tocol contains goals, guidelines, and suggestions for exer- regaining motion with no difference in healing rates
cises that can be used. [17–19].
Stage I: Acute stage (weeks 1–3)

Pearls Goals
Acquire motion Decrease stiffness while protecting repair
Upper extremity: Establish trunk/hip motion and strength for quality scapular motion
Table slides (Fig. 4.1a, b) later
Physioball progression (Fig. 4.2a–d)
Lower extremity:
Hip rotation
Hip extension
Hip flexors
Other maneuvers as needed
Establish core strength and stability
Lower extremity strengthening focusing on hip abduction and
extension recommended:
Lateral step
Step downs
Lunge progression
Fig. 4.1 (a, b) Table slides for early closed-chain motion. The patient should be instructed to flex (a) and extend (b) the trunk in order to facilitate
arm motion. Both flexion and abduction (not pictured) can be performed
Fig. 4.2 (a–d) Physioball motion program. The program requires use of the larger kinetic chain muscles (legs/trunk) to initiate the restoration of
arm motion using the directions of flexion (a), extension (b), abduction (c), adduction (d), and rotation (not pictured)
4.3.2 Recovery Stage actively. Integration of scapular control and rotator cuff
strengthening exercises reestablishes the stable scapular base
The recovery stage is concerned with restoring the full range for maximal rotator cuff activation. Proprioceptive neuro-
of motion and strength capability of the rotator cuff and inte- muscular facilitation and closed-chain exercises are effective
grating it with the kinetic chain functional capability. Ranges early in the stage, and open-chain exercises can be added as
of motion can be extended above 90° and can be assisted strength increases.
Stage II: Recovery stage (weeks 4–6)

Pearls Goals
Facilitate critical kinetic chain links Lower extremity driving upper extremity motion
Facilitate retraction with arm close to body Full active range of motion
Lawn mower (Fig. 4.3a, b) Adequate scapular control to progress to longer lever exercise
Robbery (Fig. 4.4a, b) maneuvers
Utilize closed- to open-chain exercise
Closed chain
Table slides (for integrated motion)
Low row (Fig. 4.5a, b)
Inferior glide (Fig. 4.6)
Open chain
Low row with step back (Fig. 4.7a, b)
Lawn mower with step back (Fig. 4.8a, b)
Robbery with step back (Fig. 4.9a, b)
Fig. 4.3 (a, b) Lawn mower exercise. The lawn mower begins with the hip and the trunk flexed and the arm slightly forward elevated (a). The
patient instructed to extend the hips and trunk and to “place elbows in the back pockets,” holding this final position for 5 s (b)
Fig. 4.4 (a, b) Robbery exercise. The robbery maneuver begins with the knees and trunk flexed and the arms held away from the body (a). The
patient is instructed to extend the hips and trunk and to “place the elbows in the back pockets,” holding this final position for 5 s (b)
Fig. 4.5 (a, b) Low-row exercise. The patient is positioned standing with the hand of the involved arm against the side of a firm surface and legs
slightly flexed (a). The patient should be instructed to extend the hips and trunk to facilitate scapular retraction and hold the contraction for 5 s (b)
Fig. 4.6 Inferior glide. This maneuver encourages co-contraction of

local and global muscles resulting in depression of the humeral head
Fig. 4.7 (a, b) Low row with posterior step. The posterior step back requires hip and trunk extension which facilitates scapular retraction and
depression
Fig. 4.8 (a, b) Lawn mower with lateral step. By adding the step, the patient is forced to utilize the hip abductors making the exercise more
functional
Fig. 4.9 (a, b) Robbery exercise with posterior step. Utilizing the step allows the lower extremity to drive the upper extremity
4.3.3 Functional Stage balance, and generation of power and endurance are the key
goals. As the patient acquires these capabilities, mainte-
The functional stage is concerned with establishing the nance conditioning for the activity should be included.
capabilities to respond to the specific activity demands of Functional progression testing may be done to simulate the
the patient, whether it be work, recreation, or athletic play. body’s ability to withstand the sport- or activity-specific
Maximal ranges of motion, dynamic muscle strength demands.
Stage III: Functional activity stage (weeks 7±)

Pearls Goals
Work in multiple planes Fine-tune scapular motion to alleviate all dyskinesis
Integrated motion Increase strength and endurance of rotator cuff and scapular-stabilizing
Punching muscles
Power position (Fig. 4.10)
Power position with step back (Fig. 4.11)
Traditional rotator cuff exercises
Scaption
Horizontal abduction
Internal and external rotation
Fig. 4.10 (a, b) Power position. The athlete is positioned standing maintaining the 90/90 position of the arm (b). The forearm should be
with dominant arm in 90/90 position and forearm pronated (a). The allowed to supinate to imitate the act of the overhead throwing
athlete is instructed to rotate the trunk without moving the feet while
Fig. 4.11 (a, b) Power position with step back. This maneuver requires stability of the lower extremity in order for the upper extremity position-
ing to be achieved
4.3.4 Return-to-Activity Stage
Specific criteria should be established to return to activity

[20]. This should involve restoration of functional capability,
objectively demonstrated through range of motion and
strength measurement and by physical performance testing
[21], rather than by time or imaging.
Stage IV: Return-to-activity stage (weeks 10±)

Pearls Goals
High repetition exercises designed to increase lower extremity Optimal kinetic chain links (pelvis control over planted leg, effective
muscle endurance hip, and trunk extension)
Utilize integrated sport-specific exercise to encourage use of the Scapular retraction achievement while controlling scapular protraction
improved lower extremity muscle strength and endurance to help Proper flexibility of upper and lower extremity
facilitate upper extremity muscle activation Advancement through functional progressions without regression of
Address upper extremity power and endurance via high repetition, prior deficits/symptoms
long lever exercises performed in standing and prone positions
9. Thomopoulos S, Williams GR, Soslowsky LJ (2003) Tendon to

Conclusion
bone healing: differences in biomechanical, structural, and compo-
Rehabilitation after rotator cuff repair can only be accom- sitional properties due to a range of activity levels. J Biomech Eng
plished by an integrated approach involving the skills and 125:106–113
participation of surgeons and rehabilitation clinicians. Each 10. Carpenter JE, Thomopoulos S, Flanagan CL, DeBano CM,
Soslowsky LJ (1998) Rotator cuff defect healing: a biomechanical
has specific roles to play, each must understand the anat-
and histologic analysis in an animal model. J Shoulder Elbow Surg
omy and physiology underlying the whole process, and 7(6):599–605
each must communicate well so the central focus of the 11. Galatz LM, Charlton N, Das R, Kim M, Havlioglu N, Thomopoulos
process, the patient, will obtain the best functional result. S (2009) Complete removal of load is detrimental to rotator cuff
healing. J Shoulder Elbow Surg 18:669–675
12. Killian ML, Cavinatto L, Galatz LM, Thomopoulos S (2012) The
role of mechanobiology in tendon healing. J Shoulder Elbow Surg
21:228–237
References 13. Reuther KE, Thomas SJ, Tucker JJ, Yannascoli SM, Caro AC, Vafa
RP et al (2014) Scapular dyskinesis is detrimental to shoulder ten-
1. Sallay PI, Hunker PJ, Lim JK (2007) Frequency of various tear pat- don properties and joint mechanics in a rat model. J Orthop Res
terns in full-thickness tears of the rotator cuff. Arthroscopy 32(11):1436–1443
23(10):1052–1059 14. Hettrich CM, Gasinu S, Beamer BS, Stasiak M, Fox A, Birmingham
2. Burkhart SS, Lo IK, Brady PC (2006) Burkhart’s view of the shoul- P et al (2014) The effect of mechanical load on tendon-to-bone
der: a cowboy’s guide to advanced shoulder arthroscopy. Lippincott healing in a rat model. Am J Sports Med 42(5):1233–1241
Williams and Wilkins, Philadelphia 15. Kibler WB, Ludewig PM, McClure PW, Michener LA, Bak K,
3. Ryu KJ, Kim BH, Lee Y, Lee YS, Kim JH (2014) Modified suture- Sciascia AD (2013) Clinical implications of scapular dyskinesis in
bridge technique to prevent a marginal dog-ear deformity improves shoulder injury: the 2013 consensus statement from the “scapula
structural integrity after rotator cuff repair. Am J Sports Med summit”. Br J Sports Med 47:877–885
43(3):597–605 16. Ludewig PM, Reynolds JF (2009) The association of scapular kine-
4. Boyer P, Bouthors C, Delcourt T, Stewart O, Hamida F, Mylle G matics and glenohumeral joint pathologies. J Orthop Sports Phys
et al (2015) Arthroscopic double-row cuff repair with suture- Ther 39(2):90–104
bridging: a structural and functional comparison of two techniques. 17. Chang KV, Hung CY, Han DS, Chen WS, Wang TG, Chien KL
Knee Surg Sports Traumatol Arthrosc 23:478–486 (2015) Early versus delayed passive range of motion exercise for
5. Freehill MT, Rogers JP, Mannava S (2015) Shoulder and rotator arthroscopic rotator cuff repair: a meta-analysis of randomized con-
cuff repair: single vs double row. Oper Tech Orthop 25:23–32 trolled trials. Am J Sports Med 43(5):1265–1273
6. Lapner PLC, Sabri E, Rakhra K, McRae S, Leiter J, Bell K et al 18. Huisstede BMA, Koes BW, Gebremariam L, Keijsers E, Verhaar
(2012) A multicenter randomized controlled trial comparing single- JAN (2011) Current evidence for effectiveness of interventions to
row with double-row fixation in arthroscopic rotator cuff repair. treat rotator cuff tears. Man Ther 16:217–230
J Bone Joint Surg Am 94:1249–1257 19. Lee BG, Cho NS, Rhee YG (2012) Effect of two rehabilitation pro-
7. Mascarenhas R, Chalmers PN, Sayegh ET, Bhandari M, Verma NN, tocols on range of motion and healing rates after arthroscopic rota-
Cole BJ et al (2014) Is double-row rotator cuff repair clinically tor cuff repair: aggressive versus limited early passive exercises.
superior to single-row rotator cuff repair: a systematic review of Arthroscopy 28(1):34–42
overlapping meta-analyses. Arthroscopy 30(9):1156–1165 20. Sciascia A, Cromwell R (2012) Kinetic chain rehabilitation: a theo-
8. Millett PJ, Warth RJ, Dornan GJ, Lee JT, Spiegl UJ (2014) Clinical retical framework. Rehabil Res Pract 2012:1–9
and structural outcomes after arthroscopic single-row versus double- 21. Reiman MP, Manske RC (2011) The assessment of function: how is
row rotator cuff repair: a systematic review and meta-analysis of level it measured? A clinical perspective. J Man Manipulative Ther
I randomized clinical trials. J Shoulder Elbow Surg 23:586–597 19(2):91–99
The Athlete’s Shoulder: Surgical
Treatment and Rehabilitation 5
Kevin E. Wilk, Todd R. Hooks, and James R. Andrews
Contents 5.6 Rehabilitation following Posterior Bankart ................ 193
5.1 Postoperative Rehabilitation ........................................ 185 5.7 Rehabilitation following Arthroscopic Capsular
Plication.......................................................................... 195
5.2 Factors Affecting the Rehabilitation Program ........... 186
5.8 Rehabilitation following Arthroscopic Glenoid
5.3 Principles of Rehabilitation .......................................... 187 Labrum Procedures ...................................................... 195
5.4 General Rehabilitation Guidelines after Surgery ...... 188 5.9 Rehabilitation following Proximal Biceps Tendon
5.5 Rehabilitation following Arthroscopic Anterior Procedures...................................................................... 195
Bankart Repair .............................................................. 191 References .................................................................................... 196
K.E. Wilk, PT, DPT, FAPTA (*)

Champion Sports Medicine, Birmingham, AL, USA
Associate Clinical Professor, Marquette University,
Programs in Physical Therapy, Milwaukee, WI, USA
T.R. Hooks, PT, ATC, OCS, SCS, NREMT-1, CSCS
Assistant Athletic Trainer/Physical Therapist,
New Orleans Pelicans Basketball Team, Metaire, LA, USA
J.R. Andrews, MD
Andrews Sports Medicine and Orthopaedic Center, AL, USA

DOI 10.1007/978-3-319-24856-1_5
184 K.E. Wilk et al.
Overhead athletes are susceptible to shoulder joint pathology Most shoulder injuries in athletes can be successfully
due to the repetitive nature of throwing activities and the treated nonoperatively to allow the athlete to return to com-
unique and sports-specific pattern of the sporting activities. petition. Although varying degrees of pathology can be pres-
Extreme forces are placed upon the glenohumeral joint as a ent, the overhead athlete typically has involvement of the
result of anterior shear forces that approach 50 % body rotator cuff, glenohumeral joint capsule, and biceps brachii
weight that occur as a result of high angular velocities that as a result of repetitive movements, whereas, athletes
reach 7250°/s during the throwing motion [1–3]. High levels involved in contact sports have acute distributions of either
of muscular activity are generated during the throwing the rotator cuff or glenohumeral capsule. When athletes have
motion that approaches 120 % maximal volitional isometric failed conservative measures and continued to have pain and
contraction (MVIC) [4]. A delicate balance between ade- inability to perform athletic activities, surgical intervention
quate mobility and inherent shoulder stability is required to is often warranted. The specific surgical procedure indicated
effectively perform overhead activities and to minimize the is dependent upon the nature and extent of the pathologies
potential for shoulder pathology. present to adequately address the athlete’s condition.
5 The Athlete’s Shoulder: Surgical Treatment and Rehabilitation 185
5.1 Postoperative Rehabilitation introduce applied forces and loads to the healing tissues
while avoiding overstressing these tissues. The rehabilita-
Rehabilitation plays a vital role in the functional outcome tion programs for athletes with instability are based on sev-
following shoulder injury for both the overhead and the eral key factors (Table 5.1) and each athlete’s unique
contact sports athlete. The goal of the postoperative treat- characteristics (Table 5.2) that serve to classify each patient
ment is to restore the delicate balance between the mobility in order to minimize postoperative complications. It is the
and stability that is required to perform athletic activities in intent of these programs to serve as merely a guideline;
the overhead-throwing athlete as they exhibit functional therefore, based on both the athlete’s presentation and the
stability while allowing extreme motions necessary to surgical intervention, the clinician will be able to make
throw effectively. The rehabilitation programs we utilized appropriate adjustments to each program. Additionally, the
are a criteria-based treatment approach that are divided into rehabilitation program should be continually modified
four progressive phases with each phase consisting of spe- based on tissue type, healing rate, and specific surgical
cific goals and exercises that are designed to systematically procedure.
Table 5.1 Shoulder instability classification Table 5.2 Patient variables and factors
Onset Patient’s tissue status
Traumatic, atraumatic, repetitive microtrauma Hyperelasticity ↔ hypermobility
Frequency Dynamic stabilizer status
Acute, recurrent, chronic (fixed) Muscle – bone
Direction Muscular strength and balance
Anterior, posterior, multidirectional Proprioceptive ability
Degree Classification of instability
Dislocation, subluxation, silent subluxation Previous activity level
Volition Desired activity level (expectations)
Voluntary, involuntary Healing abilities
Rapid healers, slow healers
5.2 Factors Affecting the Rehabilitation traumatic injuries that can result in unidirectional instability.
Program The patient’s tissue status is the third factor that should be
considered. We advocate progressing patients with congeni-
The clinician should consider several factors before design- tal instability or acquired laxity (overhead athlete) slower
ing and implementing a postsurgical rehabilitation program than someone who forms collagen more rapidly after surgery
(Table 5.3). It is imperative the clinician understand the exact (i.e., “fast healer”) as they should be monitored and acceler-
surgical procedure as well as the fixation method including ated to prevent loss of motion.
any concomitant procedures to the supporting structures The status of the athlete’s dynamic stabilizers should be
including the rotator cuff, glenoid fossa, and/or the labrum. considered; therefore, an athlete who has good to excellent
The progression of ROM, strengthening exercises, and muscular development, strength, dynamic stability, and pro-
closed-chain activities will be based upon the healing con- prioceptive awareness will naturally progress more rapidly
straints of all tissues involved. The clinician should consider than someone who has an underdeveloped musculature and
the type and degree of instability exhibited by the patient. decreased dynamic stability. The athlete’s particular sport/
Overhead athletes generally have an appreciable degree of position and level of participation should be considered as
congenital laxity that can be observed on examination of the well as the philosophical approach of the surgeon as this has
contralateral shoulder; therefore, the greater the degree of often been shaped by his training and previous personal expe-
congenital laxity the slower the progression of range of riences. We institute all of these factors carefully before imple-
motion. It is the experience of the authors that individuals menting a postsurgical rehabilitation program to allow the
who exhibit a positive sulcus on their uninvolved shoulder appropriate formulation of an appropriate treatment program
rarely have difficulty gaining motion with their operative for the progression of ROM, strengthening exercises, and the
shoulder, whereas athletes that play contact sports often have initiation of functional activities and interval sports programs.
Table 5.3 Factors affecting the rehabilitation program

Type of surgical procedure
(Exposure, specific procedure, tissue used)
Method of fixation
Type of instability
(Instability classification)
Patient’s tissue status
(Hyperelasticity, normal, hypoelasticity)
Patient’s response to surgery
Patient’s dynamic stabilization
(Muscular strength, dynamic stability, proprioception)
Patient’s activity level
(Past, present, desired goals)
Physician’s philosophical approach
5.3 Principles of Rehabilitation motion. The clinician should continually monitor the quality
of end feel throughout the rehabilitation by applying a slight
There are six basic principles that are employed when overpressure at the end range of passive ROM. If a firm or
designing a postsurgical rehabilitation program (Table 5.4). hard end feel is noted, the clinician may accelerate the rate of
First, healing tissues should never be overstressed; therefore, ROM progression, whereas with a soft or empty end feel, the
the program must be progressive and sequential with each patient’s stretching program will be slowed. Third, the
phase progressing from the prior phase. Based upon the patient must fulfill specific criteria to progress from one
authors’ experience of poorer outcomes following prolonged phase to the next; this allows the rehabilitation program to be
immobilization immediately followed by a rapid progression individualized based on the athlete’s unique healing rate and
of ROM, we implement the immediate implementation of constraints. Finally, a successful outcome is related to a team
ROM in a gradual, systemic format with stretching precau- effort, with the physician, physiotherapist, and athlete all
tions for the first 8–10 weeks following surgery. Second, the working together toward a common goal. The key to a team
effects of immobilization must be minimized especially in approach is communication; it is the role of the physician to
the overhead athlete. Often after shoulder stabilization sur- communicate with the rehabilitation team, providing infor-
gery, a short period of immobilization may be indicated to mation regarding the type of surgical procedure, the method
allow initial healing; however, the clinician can incorporate of fixation, the integrity and quality of the patient’s tissue,
mild dynamic stabilization drills, gentle restricted passive and the expectations of the physician for that specific athlete.
motions, and submaximal isometrics to enhance dynamic This information is invaluable in designing and implement-
stability, assist in collagen organization, and prevent loss of ing a rehabilitation program.
Table 5.4 Basic principles of rehabilitation

Healing tissue should never be overstressed
The effects of immobilization must be minimized
The patient must fulfill specific criteria to progress
The rehabilitation program should be based on current scientific and
clinical research
The rehabilitation program must not be a cookbook
Team approach – physician, therapist, and patient
5.4 General Rehabilitation Guidelines functional activities, for example, throwing and swimming,
after Surgery the athlete should reestablish muscular balance, and
dynamic joint stability should be achieved to allow adequate
The first phase, the immediate postoperative period, begins generation and dispersion of forces (Fig. 5.3). During this
with immediate restricted motion that serves to prevent loss phase, eccentric muscle training and proprioceptive training
of motion and neurological complications, nourish cartilage, are emphasized (Fig. 5.4). Plyometric training drills are uti-
and assist in collagen synthesis, organization, alignment, and lized to increase the athlete’s functional mobility and to
enhancement of tensile strength [5–12]. gradually increase the functional stresses onto the shoulder
The primary goal of this phase is to prevent excessive joint. Wilk et al. [13, 25] have described a plyometric pro-
scarring without the utilization of aggressive stretching to gram that systematically introduces stresses upon the heal-
compromise the surgical repair. Therefore, following ante- ing tissues beginning with two-handed drills such as chest
rior stabilization, motions such as extension and ER are lim- pass, side-to-side throws, side throws, and overhead soccer
ited or restricted to minimize stress upon the anterior capsule, throws. Upon successful completion of these two-handed
whereas scapular plane elevation as opposed to shoulder drills, the athlete can progress to one-handed drills such as
abduction. Submaximal and sub-painful isometric contrac- standing one-handed throws, wall dribbles, and plyometric
tions are initiated during phase 1 to stimulate muscle train- step and throws [26]. Voight et al. [27] reported a relation-
ing, neuromodulate pain, and prevent muscle atrophy that ship between diminished shoulder proprioception and mus-
occur as a result of immobilization (Fig. 5.1) [13, 14]. cle fatigue. Muscular endurance training is therefore
Phase II, the intermediate phase, emphasizes the gradual performed to enhance dynamic functional joint stability and
progression of shoulder mobility. We utilize the incorpora- to prevent fatigue-induced instability [27]. This can be
tion of AAROM and PROM exercises into the treatment pro- accomplished by progressing the athlete with the advanced
gram to gradually increase the patient’s ROM. The athlete’s Thrower’s Ten program to improve strength, endurance, and
ROM and capsular end feel will be used to determine rate of posture (Fig. 5.5) [28]. An interval sports program is imple-
progression; consequently, patients with sufficient ROM and mented during this phase of treatment [29]. Sports-specific
a soft end feel will be progressed slower than a patient with programs (golf, tennis, football, baseball, softball, etc.) are
restricted ROM and a hard end feel. If one side of the capsule intended to systematically introduce quantity, intensity, and
is excessively tight, the humeral head will displace exces- duration of sporting activities to allow an athlete to return to
sively in the opposite direction away from the tightness; sporting activities while minimizing the recurrence of injury
thus, joint-mobilization techniques are used to restore nor- and pain with activities.
mal motion and to correct asymmetric capsular tightness Phase IV is the return-to-activity phase that is imple-
(Fig. 5.2). When treating an overhead athlete, the physio- mented to gradually and progressively increase the func-
therapist will progress the stretching exercises to allow the tional demands on the shoulder to prepare for the return to
athlete to obtain “thrower’s motion” of approximately unrestricted sports or daily activities. Upon successful com-
115° ± 5° ER to allow the athlete to return to throwing. pletion of the rehabilitation program and achieving the afore-
During this phase, we usually initiate the “Thrower’s Ten mentioned goals, the athlete may initiate a gradual return to
exercise” program that includes isolated rotator cuff and sports activity in a controlled manner. The physiotherapist
scapular exercises that are based upon EMG data to ensure should consider the healing constraints based on surgical
restoration of muscle balance in the treatment of the over- intervention and the patient’s tissue status before a functional
head athlete [15–24]. The physiotherapist can progress treat- program is initiated. The clinician should ensure the athlete
ment to include dynamic stabilization drills, manual maintains muscular strength, dynamic stability, and shoulder
resistance training, and PNF drills with rhythmic functional motion established in the previous phase; there-
stabilizations that serve to enhance neuromuscular control fore, the patient is encouraged to maintain a stretching and
aimed to reestablish muscular balance. strengthening program on an ongoing basis to maintain and
Phase III is intended to maintain shoulder ROM and continue to improve optimal shoulder function. Athletes are
mobility while improving strength, power, and endurance. continued on the Thrower’s Ten program to maintain flexi-
Strengthening exercises are progressed to restore optimal bility and shoulder strength throughout this program to con-
sufficient muscle ratios (Table 5.5). Prior to initiating tinue to ensure adequate postural awareness and shoulder
aggressive strengthening exercise such as plyometrics or function.
Fig. 5.1 Rhythmic stabilization drills for internal and external rotation
to facilitate rotator cuff activation and neuromuscular control
Fig. 5.2 Glenohumeral joint

mobilizations performed for
the posterior capsule
performed in a posterior-
lateral direction
Table 5.5 Isokinetic shoulder strength criteria for overhead athletes

Bilateral comparison (dominant arm versus nondominant arm)
Velocitya ERb IRc Abduction Adduction
180 98–105 % 110–120 % 98–105 % 110–128 %
300 85–95 % 105–115 % 96–102 % 111–29 %
Peak torque (ft-lb)-to-body weight (lb) ratios
Velocitya ERb IRc Abduction Adduction
180 18–23 % 28–33 % 26–33 % 32–38 %
300 12–20 % 25–30 % 20–25 % 28–34 %
Unilateral muscle ratios
Velocitya ERb/IRc Abduction/ ERb/abduction
adduction
180 66–76 % 78–84 % 67–75 %
300 61–71 % 88–94 % 60–70 %
a
Degrees per second
b
ER external rotation
c
IR internal rotation
5.5 Rehabilitation following Arthroscopic Therapeutic exercises are initiated with shoulder isomet-
Anterior Bankart Repair rics at 1–2 days following surgery while scapular isotonics
and ER/IR strengthening exercises begin at postoperative
Following surgery, the patient will don a sling during the week 4 and 6, respectively. The Thrower’s Ten program
day for 3–4 weeks while sleeping in an immobilizer brace which is progressed to include dynamic stabilization drills
for 4 weeks. Shoulder ROM will be monitored for eleva- such as rhythmic stabilization drills concomitantly with tub-
tion, ER, extension, and horizontal abduction limit motions ing exercises and closed-chain stabilization ball on wall
as these can stress the anterior capsule. Passive and active- drills continues to augment the isotonic strengthening and
assisted ROM exercises for the shoulder begins on postop- dynamic stability program of the shoulder joint complex
erative day within a prescribed motion permitting shoulder (Fig. 5.6). Sports-specific drills can begin during this phase
ER and IR ROM at 30° of abduction. The athlete will con- to include plyoball throwing (Functional Integration
tinue with a gradual restoration of glenohumeral ROM as Technologies, Watsonville, CA) for overhead athletes or
ER and IR ROM is performed at 90° of abduction at week swinging a golf club or tennis racket. A return-to-activity
7. Full functional ROM is achieved by week 8–9 allowing phase is usually initiated around 28 weeks following surgery
160° of flexion, 90–100° of ER, and 70–75° of IR at 90° of that allows a gradual restoration to prior level of function and
abduction. sports participation.
Fig. 5.3 Push-ups performed

on an unstable surface with
concomitant manual rhythmic
stabilizations to facilitate
dynamic stability of the
shoulder and core
musculature
Fig. 5.4 Manual stabilizations performed as the athlete performs ball

dribbles with the shoulder maintained at 90° abduction
5.6 Rehabilitation following Posterior 90° of abduction is initiated at week 10 progressing to 60°
Bankart by week 12. The mobility of the glenohumeral capsular
mobility can be assessed beginning at 5–6 weeks following
The rehabilitation following posterior capsular reconstruc- surgery, allowing anterior and inferior mobilizations as
tion is progressed relatively slower as compared to an ante- deemed appropriate; however, posterior glides should be
rior stabilization procedure due to the decreased thickness cautioned as to not create deleterious stresses of the poste-
and tensile properties of the posterior capsule for restoration rior capsule.
of glenohumeral ROM and return to function. In order to Shoulder isometrics are begun 2 weeks following surgery,
refrain from movements that place stress upon the posterior progressing to isotonic strengthening for the rotator cuff and
capsule, the athlete is instructed to strictly avoid internal scapular musculature at week 4 with IR ROM limited to only
rotation and horizontal adduction for the first 6–8 weeks fol- neutral rotation. Muscle strength of the posterior rotator cuff
lowing surgery, and these movements will continue to be and the scapular musculature is emphasized prior to the del-
controlled throughout the rehabilitation program. Following toid to increase dynamic stability of the posterior capsule.
surgery, the athlete will be placed in an abduction immobili- The clinician will avoid stressing the posterior capsule by
zation sling that is maintained at approximately 30° of ER delaying activities and exercises that create posterior transla-
for 6 weeks in order to minimize stress on the posterior cap- tion upon the humerus (such as push-ups, bench press) for
sule. As a result of the detachment of the infraspinatus with 12–14 weeks. Machine resistance training can begin weeks
open procedures, the initiation of ER strengthening exercises 13–20 following surgery; these exercises (lat pull, seated
may be delayed as compared to an arthroscopic procedure. rows, seated bench press) are initiated within a monitored
Shoulder passive ROM is initiated week 2 after surgery range of motion as to reduce both tensile stress on the poste-
with goals of 125° of shoulder flexion; external rotation is rior capsule and posterior humeral translation at end ranges
initiated at 90° of shoulder abduction to minimize stress of movement. Sports-specific training can begin at approxi-
upon the posterior capsule and is progressed to 90° of ER at mately 4–6 months following surgery and progressed to
6 weeks postoperative. Range-of-motion exercises will con- allow most athletes to return to full activity between 9 and 12
tinue as flexion is progressed to 165° by week 8 and IR at months postoperatively.
Fig. 5.5 Alternate sustained isometric holds performed on a stability ball to facilitate stabilization of the core musculature
Fig. 5.6 External rotation tubing performed on a stability ball with concomitant rhythmic stabilizations to promote neuromuscular control, core,
and dynamic stability
5.7 Rehabilitation following Arthroscopic 6–8 weeks to allow adequate healing. Elevation range-of-
Capsular Plication motion activity is restricted for the first 4 weeks below 90°.
Internal and external rotation is performed passively in the
The patient is instructed to sleep in an immobilizer and to scapula plane to approximately 10–15° of external rotation
avoid elevation and ER ROM for 6 weeks and limit overhead and 45° of internal rotation for the first 2 weeks and is pro-
activities for 12 weeks following surgery. During the early gressed to 90° of abduction at week 5–6. No excessive exter-
stages of rehabilitation following capsular plication, an over- nal rotation, extension, or abduction is allowed until week
all conservative approach in restoring glenohumeral ROM is 5–6, when a light isotonic strengthening program is initiated.
taken due to the congenital laxity that is present, as limited Motion is gradually increased to restore full range by 8–10
ROM exercises will be delayed until 2 weeks following sur- weeks and progressed to thrower’s motion at week 10–12.
gery. ROM is initiated at 2 weeks and is limited to 90° shoul- Plyometric exercises are initiated at week 12 and the ITP at
der flexion and ER performed in the scapular plane to 0°. At week 16. Return to play following surgical repair of a type II
4 weeks following surgery, shoulder range of motion is grad- SLAP lesion occurs at approximately 9–11 months.
ually progressed to allow 145° of flexion and 45° of ER. ER
ROM is performed at 90° of abduction to 70° at 6 weeks and
flexion is performed to 160°. The restoration of ROM will be 5.9 Rehabilitation following Proximal
restored as needed based upon the patient’s functional goals; Biceps Tendon Procedures
therefore, overhead athletes will continue a gradual progres-
sion of motion allowing for thrower’s motion at 10–12 weeks Depending upon the extent of pathology and contributing
postsurgical, while the general MDI patient may discontinue factors, multiple surgical procedures can be performed to
ROM and stretching exercises. address the long head of the biceps. For partial tears includ-
Isometric exercises for the rotator cuff and scapula are ing delamination and fraying of less than 25 % of the tendon
integrated into the early stages of rehabilitation, while light in the athlete, debridement of the intra-articular portion of
isotonics can be initiated 4 weeks postoperatively as well as the biceps tendon maybe performed [30–32]. However, with
closed-chain rhythmic stabilization exercises to emphasize extensive tendinopathy or gross instability, either a biceps
co-contraction of the rotator cuff. The athlete can continue to tenotomy or tenodesis is performed. Biceps tenotomy is per-
progress the strengthening program by initiating the formed by sectioning the long head of the biceps tendon at its
Thrower’s Ten program at week 7–8 that will be gradually origin at the supraglenoid tubercle and superior labrum, as
progressed to incorporate overhead dynamic strengthening compared to a biceps tenodesis that also includes the distal
at week 12. Interval sporting activities below shoulder level anchoring of the surgically released tendon. The rehabilita-
can begin at week 14, whereas overhead activities are initi- tion program following biceps debridement is progressed
ated at week 16. The athlete is usually able to return to con- relatively quicker in regaining motion and function with full
tact sports 6–7 months following surgery, while overhead range of motion of the shoulder and elbow is expected by
athletes may return 7–9 months following surgery. 10–14 days postoperatively. Shoulder isometrics are initiated
immediately following surgery and allowed to begin internal
and external rotation; tubing exercises are initiated at day 10
5.8 Rehabilitation following Arthroscopic and are allowed to progress and incorporate isotonic strength-
Glenoid Labrum Procedures ening at 2 weeks following surgery and progressed
throughout week 8. The athlete is allowed to initiate an ITP
The specific rehabilitation program following surgical inter- at week 8–12.
vention of the superior glenoid labrum is dependent on the The rehabilitation following either a tenodesis or tenot-
type and severity of the pathology. omy is similar, although a more cautious approach is utilized
Following a simple arthroscopic debridement of the in following a biceps tenodesis. The rehabilitation following
frayed labrum, the rehabilitation program is somewhat a tenotomy will be advanced more quickly due to a decreased
aggressive in restoring motion and function with full range protection required for the healing tissue. An overly aggres-
of motion expected by 10–14 days postoperatively. Internal sive approach could risk the athlete to a Popeye deformity
and external rotation tubing exercises are initiated at day 10 that has been reported to be present in 62–70 % of patients
and are gradually progressed to incorporate isotonic strength- following a tenotomy [33, 34]. Patients undergoing a biceps
ening between weeks 2 and 8 and allowing the athlete to tenodesis will be progressed more slowly by utilizing a sling
begin an ITP at week 8–12. and refraining from isolated biceps activity for 8 weeks to
The rehabilitation following a type II SLAP lesion is allow soft tissue healing as the patient will be instructed to
more cautious for the first 4 weeks by having the athlete abstain from resisted biceps and forearm supination move-
sleeping in an immobilizer and wearing a sling during the ments and activities. The athlete will begin shoulder passive
day and by not permitting isolated biceps strengthening for range of motion with the elbow slightly bent to minimize
strain upon the biceps tendon progressing to functional full 15. Wilk KE, Andrews JR, Arrigo C (2001) Preventive and rehabilita-
range of motion at 6 weeks while minimizing movements tive exercises for the shoulder and elbow, 6th edn. American Sports
Medicine Institute, Birmingham
that stress the biceps such as shoulder external rotation and 16. Blackburn TA, McLeod WD, White B et al (1990) EMG analysis of
extension. Shoulder isometrics can be initiated immediately posterior rotator cuff exercises. Athl Train J Natl Athl Train Assoc
following surgery and progressed to include rotator cuff 25:40–45
training at weeks 2–3 following surgery. Shoulder elevation 17. Decker MJ, Hintermeister RA, Faber KJ, Hawkins RJ (1992)
Serratus anterior muscle activity during selected rehabilitation
exercises can begin at week 4 and gradually progressed to exercises. Am J Sports Med 7(6):784–791
the Thrower’s Ten Program at week 6–8. The athlete can 18. Fleisig GS, Jameson GG, Cody KE et al (1998) Muscle activity
begin to perform plyometric activities at 12–14 weeks post- during shoulder rehabilitation exercises. In: Proceedings of
surgery with a gradual return to sporting activities following NACOB’ 98, The Third North American Congress on Biomechanics,
Waterloo, 14 Aug 1998, pp 223–234.
a return-to-activity phase. 19. Hintermeister RA, Lange GW, Schultheis JM et al (1998)
Electromyographic activity and applied load during shoulder reha-
bilitation exercises using elastic resistance. Am J Sports Med
References 26:210–220
20. Jobe FW, Tibone JE, Jobe CM et al (1990) The shoulder in sports.
In: Rockwood CA Jr, Matsen FA III (eds) The shoulder. WB
1. Fleisig GS, Andrews JR, Dillman CJ, Escamilla RF (1995) Kinetics Saunders, Philadelphia, pp 961–990
of baseball pitching with implications about injury mechanisms. 21. Jobe FW, Moynes DR, Tibone JE, Perry J (1984) An EMG analysis
Am J Sports Med 23(2):233–239 of the shoulder in pitching. A second report. Am J Sports Med
2. Fleisig GS, Barrentine SW, Escamilla RF, Andrews JR (1996) 12(3):218–220
Biomechanics of overhand throwing with implications for injuries. 22. Moseley JB Jr, Jobe FW, Pink M, Perry J, Tibone J (1992) EMG
Sports Med 21(6):421–437 analysis of the scapular muscles during a shoulder rehabilitation
3. Escamilla RF, Barrentine SW, Fleisig GS, Zheng N, Takada Y, program. Am J Sports Med 29(2):128–134
Kingsley D, Andrews JR (2007) Pitching biomechanics as a pitcher 23. Pappas AM, Zawacki RM, McCarthy CF (1985) Rehabilitation of
approaches muscular fatigue during a simulated baseball game. Am the pitching shoulder. Am J Sports Med 13(4):223–235
J Sports Med 35(1):23–33 24. Townsend H, Jobe FW, Pink M, Perry J (1991) Electromyographic
4. DiGiovine NM, Jobe FW, Pink M, Perry J (1992) An electromyo- analysis of the glenohumeral muscles during a baseball rehabilita-
graphic analysis of the upper extremity in pitching. J Shoulder tion program. Am J Sports Med 19(3):264–272
Elbow Surg 1(1):15–25 25. Carpenter JE, Blasier RB, Pellizzon GG (1998) The effects of mus-
5. Coutts RD, Toth C, Kaita JH (1984) The role of continuous passive cle fatigue on shoulder joint position sense. Am J Sports Med
motion in the rehabilitation of the total knee patient. In: Hungerford 26(2):262–265
DS, Krackow KA, Kenna RV (eds) Total knee arthroplasty: a com- 26. Wilk KE (2000) Restoration of functional motor patterns and func-
prehensive approach. Williams and Wilkins, Baltimore, pp 126–132 tional testing in the throwing athlete. In: Lephart SM, Fu FH (eds)
6. Dehne E, Torp RP (1971) Treatment of joint injuries by immediate Proprioception and neuromuscular control in joint stability. Human
mobilization. Based upon the spinal adaptation concept. Clin Kinetics, Champaign, pp 415–438
Orthop Relat Res 77:218–232 27. Voight ML, Hardin JA, Blackburn TA, Tippett S, Canner GC (1996)
7. Haggmark T, Eriksson E (1979) Cylinder or mobile cast brace after The effects of muscle fatigue on and the relationship of arm domi-
knee ligament surgery. A clinical analysis and morphologic and nance to shoulder proprioception. J Orthop Sports Phys Ther
enzymatic studies of changes in the quadriceps muscle. Am J Sports 23(6):348–352
Med 7(1):48–56 28. Wilk KE, Yenchak AJ, Arrigo CA, Andrews JR (2011) The
8. Noyes FR, Mangine RE, Barber S (1987) Early knee motion after Advanced Throwers Ten Exercise Program: a new exercise series
open and arthroscopic anterior cruciate ligament reconstruction. for enhanced dynamic shoulder control in the overhead throwing
Am J Sports Med 15(2):149–160 athlete. Phys Sportsmed 39(4):90–97
9. Perkins G (1953) Rest and movement. J Bone Joint Surg Br 29. Reinold MM, Wilk KE, Reed J, Crenshaw K, Andrews JR (2002)
35-B(4):521–539 Interval sport programs: guidelines for baseball, tennis, and golf.
10. Salter RB, Hamilton HW, Wedge JH et al (1984) Clinical applica- J Orthop Sports Phys Ther 32(6):293–298
tion of basic research on continuous passive motion for disorders 30. Barber FA, Byrd JW, Wolf EM, Burkhart SS (2001) How would
and injuries of synovial joints: a preliminary report of a feasibility you treat the partially torn biceps tendon? Arthroscopy
study. J Orthop Res 1(3):325–342 17:636–639
11. Salter RB, Simmonds DF, Malcolm BW, Rumble EJ, MacMichael 31. Barber FA, Field LD, Ryu R (2007) Biceps tendon and superior
D, Clements ND (1980) The biological effect of continuous passive labrum injuries: decision-marking. J Bone Joint Surg Am
motion on the healing of full-thickness defects in articular cartilage. 89:1844–1855
An experimental investigation in the rabbit. J Bone Joint Surg Am 32. Sethi N, Wright R, Yamaguchi K (1999) Disorders of the long head
62(8):1232–1251 of the biceps tendon. J Shoulder Elbow Surg 8:644–654
12. Wilk KE, Voight ML, Keirns MA, Gambetta V, Andrews JR, Dillman 33. Boileau P, Baque F, Valerio L, Ahrens P, Chuinard C, Trojani C
CJ (1993) Stretch-shortening drills for the upper extremities: theory (2007) Isolated arthroscopic biceps tenotomy or tenodesis improves
and clinical application. J Orthop Sports Phys Ther 17(5):225–239 symptoms in patients with massive irreparable rotator cuff tears.
13. Wilk KE, Arrigo CA (1992) An integrated approach to upper J Bone Joint Surg Am 89:747–757
extremity exercises. Orthop Phys Ther Clin North Am 1:337–360 34. Kelly AM, Drakos MC, Fealy S, Taylor SA, O’Brien SJ (2005)
14. Wilk KE, Arrigo CA, Andrews JR (1997) Current concepts: the sta- Arthroscopic release of the long head of the biceps tendon: func-
bilization structures of the glenohumeral joint. J Orthop Sports tional outcome and clinical results. Am J Sports Med
Phys Ther 25(6):364–379 33:208–213
Index
A post-surgery rehabilitation, 114, 115

Abduction rehabilitation
arm motion, 170 goals, 121
dislocation in, 109 initial phase (weeks 2–6), 121–126
internal rotation standing plyometrics intermediate phase (weeks 6–12), 127–130
in neutral, 132 return to function phase (12–16 weeks), 130–137
isometric shoulder, 83 repair, 113–115
prone, 84 shoulder reconstruction evaluation
shoulder position, 101, 119 scapular evaluation, 116–117
Acromioplasty, 121 special tests, 118–120
Active/passive exercises, 167 surgical procedures, 127
Acute stage, rotator cuff repair rehabilitation, 166, 168–170 Arthroscopic shoulder surgery rehabilitation
Adduction anterior Bankart repair, 191–192
arm motion, 170 capsular plication, 195
horizontal, 127, 136 glenoid labrum procedures, 195
internal rotation standing plyometrics in neutral, 132 Athlete’s shoulder injury
isometric contractions, 126 instability classification, 185
Anterior and posterior translation (drawer) tests, 119 nonoperative treatment, 184
Arm stretching elevation, 48 patient variables and factors, 185
Arthritis rehabilitation
glenohumeral, 35 arthroscopic anterior Bankart repair, 191–192
iatrogenic, 73 arthroscopic capsular plication, 195
posttraumatic, 72–73 arthroscopic glenoid labrum procedures, 195
rheumatoid, 68, 72 factors affecting rehabilitation program, 186
rotator cuff tear arthropathy, 74 phases, 188–190
Arthroplasty posterior Bankart, 193–194
contraindications, 74 postoperative treatment, 185
reverse shoulder, 78 principles, 187
acute fracture, 78, 79 proximal biceps tendon procedures, 195–196
cuff arthropathy, 78 surgical treatment, 184
deltopectoral approach, 78 Avascular necrosis (AVN), 49, 54
fracture sequelae, 78, 79 of humeral head, 24
latissimus transfer, 80 PHF sequelae with head, 15
rehabilitation, 90 shoulder arthroplasty, 72
superior approach, 78 Axillary nerve, 35, 49, 76, 78
trauma, 78, 79
shoulder, 68, 69
avascular necrosis, 72 B
complications, 90 Balance stabilization exercise, 41, 45
contraindications, 74 Bankart lesion, 96, 104, 106, 114, 121
historical background, 68 Bankart repair, arthroscopic, 191–192
osteoarthritis, 69, 70 Beighton Hypermobility Index, 120
posttraumatic arthritis, 72, 73 Bench press, 127, 137, 193
rehabilitation, 80 range of motion limitation in, 136
rheumatoid arthritis, 72, 73 Biceps tenodesis, 121, 195
surgical approaches, 74–75 Biceps tenotomy, 121, 195
total shoulder, 71, 76–77 Biodex Isokinetic Dynamometer, 134
rehabilitation, 81–89 Body blade exercises
Arthroscopic Bankart angles of elevation, 86, 89
ligaments restoration to bone, 114, 115 in neutral at side, 86
outcomes, 138 stabilization, 41, 45

DOI 10.1007/978-3-319-24856-1
198 Index
Bone loss serratus punch, 124

bipolar bone loss lesion, 103–105 side-lying body blade oscillation, 129
glenoid bone loss, 97–98 supervised active/assisted shoulder, 24, 26
Hill-Sachs lesion, 100 External rotation, 101, 106, 107, 111, 117, 121, 193
characteristic features, 99 abduction, 132
incidence, 99 active, 55, 84
location, 102 gentle, 46, 47
non-engaging and engaging pattern, 101 isoinertial, 135
off-track lesion, 104, 105 isokinetic training position, 134, 135
on-track lesion, 104, 105 isometric shoulder, 83
size, 103 lower and middle trapezius activation, 154, 155
90° of abduction, 129
oscillation, 129
C passive mobilization in, 149, 150
Capsular plication/shifting, 121 passive stretching playing, 42
Closed-chain precedes open-chain exercise, 24 resisted, 86
Closed kinetic chain (CKC) exercises, 149, 157 rhythmic stabilization drills for, 189
Codman-Hertel classification system, 4, 8–9 ROM, 122
Codman’s pendulum exercises, 23, 25 scapular retraction bilateral with elastic resistance, 128
Communication, physical therapists, 167 side-lying, 84, 85
Compression fractures, 98 side with elastic resistance, 126
Core stability, 147 supine cane, 81
Corticosteroids, 70, 72 tubing exercises, 194, 195
Criteria-based treatment approach, 185 External rotation exercises, 147
isoinertial exercise, 134, 135
D
Deltopectoral approach, 28–29, 42, 76 F
Dislocation, 90, 97–99, 107. See also First-time anterior First-time anterior shoulder dislocation (FTASD)
shoulder dislocation (FTASD) in contact sports participants, 106
in abduction, 109, 111 direct trauma mechanisms, 106–107
ADD position, 111 Hill-Sachs lesion, 107–110
chronic locked posterior, 77 lesions in, 106
fracture, 14, 15, 30, 34, 54, 56, 57 non-operative treatment, 106
locked, 54, 56, 58 recurrence rates, 106
Distal clavicular excision, 121 Fixation method, 186
Double press exercise, 24, 27 Flexion, 6, 7, 87
Dynamic hug exercise, 88 elbow, 127, 130
forward, 116, 121, 138
isometric shoulder, 82
E passive shoulder flexion in pain-free stretching, 23, 25
Early closed-chain motion, pulley, 83
table slides, 169 side-lying active-assistive, 85
Education, 136 submaximal isometric exercises, 81
preventing shoulder movement pattern, 23 supine active, 85
Elevation exercises, 196 supine cane, 81
Excessive tensile loading, 167 supine shoulder, 85
Exercise(s) Force couple, 94
closed-chain precedes open-chain, 24 Fulcrum (humeral head), 18, 19
closed-to open-chain, 174–177 Functional stage, rotator cuff repair rehabilitation, 167, 178–180
Codman’s pendulum, 23, 25
double press, 24, 27
dynamic hug, 88 G
isoinertial external rotation, 135 Gentle massage therapy, 24, 27
isometric, 27, 40, 43, 48, 124, 125, 154, 195 Glenohumeral (GH) joint, 118–120, 123, 126, 134
lawnmower, 124 arthritis, 72, 138
light functional, 24 different angles stress at, 97
manual scapular resistive, 124 inferior glide, 149, 150, 171, 175
to muscle fatigue, 167 mobilizations, 190
open-chain, 167 Glenohumeral joint capsule, 76, 184
postoperative, 88 Glenoid bone loss, 97–98
proprioception, 40 Glenoid track, 102
quadruped rhythmic stabilization, 128 Greater tuberosity
rotator cuff, 129 integrity of rotor cuff and tuberosities, 18
scapular control, 23, 26 reabsorption of, 18, 19
scapulothoracic, 40 vascular supply, 10
Index 199
H Isokinetic exercises, 130

Hemiarthroplasty Isometric exercises, 27, 40, 43, 48, 124, 125, 154, 195
intact rotator cuffs, 72 Isotonic exercise
and posttraumatic arthritis, 72, 73 patient toleration, 134
proximal humeral fractures rotator cuff, 124, 125, 193
complications, 52–53
optimal timing, 34
in osteoporotic patient, 34, 36 J
rehabilitation, 46–48 Joint-mobilization techniques, 188
vs. reverse total shoulder
arthroplasty, 34–35
tuberosities reabsorption, 34, 36 L
shoulder replacement, 74, 75 Latarjet technique
subscapularis local bone graft, 140
protection to, 80 mini wedged plate, 140
reinsertion with suture anchor, 76, 77 post-surgery rehabilitation, 140
Hill-Sachs lesion, 100, 111–113 rehabilitation
characteristic features, 99 assisted elbow flexion-extension without sling, 144
incidence, 99 fitting arm sling before discharge, 143
location, 102 healing progression criteria, 142–143
non-engaging and engaging pattern, 101 hydrotherapy, 142
off-track lesion, 104, 105 protocols, 142–143
on-track lesion, 104, 105 scapular retraction with sling, 144
size, 103 skin incision and deltopectoral approach, 139
Hyaluronic acid, intra-articular injections, 70 subscapular split, 140
triple effect of, 113
Lateral tans-deltoid approach, 28–29
I Lawnmower exercise, 124, 149, 151
Immobilization Laxity, 95, 119, 186, 195
abduction, 193 Light functional exercises, 24
vs. early aggressive rehabilitation, 138 Loose-pack position, GH joint, 95
in overhead athlete, 187 Loss of fulcrum (humeral head, aseptic necrosis), 18, 19
period of, 20, 122 Loss of sclerotic glenoid line (LSGL), 139
rotator cuff repair, 168 Low-row exercise, 174
Impingement, 50, 126, 136
bony, 94
causes, 126 M
nail, 30 Malunion, 24
rotator cuff, 94 complication, ORIF, 49–50
subacromial, 30, 123 tuberosities
suprascapular nerve, 116 factors associated with, 34
Implant(s), 68, 76, 78, 90 reabsorption, 34, 37, 50
humeral, 34, 54 severe, 54, 57, 60
infection of, 52 Manual scapular resistive exercise, 124
locking compression plate, 30 Maximal volitional isometric contraction (MVIC), 131, 184
radiograph of, 75 Multidirectional instability (MDI) sulcus test, 118
resurfacing, 75 Muscular endurance training, 188
stemmed, 75
types, 28
Internal rotation N
exercises, 130, 147 Neer system, 4
isokinetic training position, 135 Neuromuscular control, 157
at 90° of abduction, 130, 138 early muscle reactivation, 145
paying attention to, 46, 47 exercises, 152
plyometric ball dribbles, 130 proprioceptive, 149
preoperative plain x-ray studies in, 139 90/90 position, 129
provocational plyometric in supine of arm, 179
position, 132 isoinertial exercise, 134
rhythmic stabilization drills for, 189 plyometric exercise, 131
in scapula plane, 195 Nociceptors, 49
standing plyometrics Non-constrained arthroplasty (NCA), 55
with 90° of abduction, 133 Nonoperative treatment
in neutral ab/adduction position, 132 healing progression criteria, 22
strengthening, 130 early management, 23
Irreparable rotator cuff tears, 70, 74 intermediate management, 23–24
Isoinertial external rotation exercise, 135 late management, 24, 25
200 Index
Nonoperative treatment (Cont.) shaft, 4, 5

immobilization in sling, 20, 21 varus /valgus/neutral fractures, 4–7
physiotherapy, 22 vascular pattern, 12–15
rehabilitation, 22 vascular supply, 10–11
stable configuration, 20, 21 comorbid diseases, 2
Nonsteroidal antiinflammatory drugs (NSAIDs), 39, 70 conservative treatment
Non-union, 24 healing progression criteria, 22–27
complications, ORIF, 49–50 physiotherapy, 22
surgical neck, 54, 57 rehabilitation, 22
tuberosity, 34, 52, 55 displacement forces, 5
feedback, 62
frequency in age groups, 2, 3
O incidence, 2
One week off therapy, 22 medial displacement of shaft, 33
Open-chain exercise, 167 occurrence, 2
Open kinetic chain (OKC) exercises, 149, 151, 157 open reduction, 32
Open reduction internal fixation (ORIF), PHF, 22 in osteoporotic patient, 36
complications, 47–51 rehabilitation
internal fixation with locked plate, 32 hemiarthroplasty, 46–48
with locked plate, 33 information strategy, 61
rehabilitation, 39–45, 61 ORIF, 39–45
surgical solution, 59 post-surgery rehab protocols, 61
Osteoarthritis, 68, 69 risk factors, 2, 3
nonoperative management, 70 sequelae
primary, 54, 55 cephalic collapse/necrosis, 54, 56, 58
shoulder arthroplasty, indications for, 70–71 fracture, 15
Overhead athletes, 116, 187, 188, 191, 195 locked dislocation and/or fracture dislocation, 54, 56, 58
congenital laxity, 186 reabsorption of greater tuberosity, 19
hypermobility index, 120 surgical neck non-union/mal-union, 54, 57, 59
internal rotation strength, 134 severe tuberosities comminution, 37
isokinetic shoulder strength criteria, 190 surgical treatment
plyometric and elastic resistance training, 131 complications, 49–53
shoulder joint pathology, 184 decision-making, 28
deltopectoral approach, 28–29
hemiarthroplasty, 34–38
P lateral tans-deltoid approach, 28–29
Physician’s philosophical approach, 186 tuberosities and intramedullary fixation, 31
Physioball motion program, 170 Push-ups, 193
Physiotherapy, 22, 61, 142, 145 shoulder and core musculature stability, 191
Plyometric exercise traditional, 137
golf, 132, 133
internal rotation standing variation, 132, 133
90/90 prone plyometric ball drops, 131 Q
90/90 prone plyometric reverse catches, 131 Quadruped rhythmic stabilization exercise, 128
side-lying plyometric ball drops, 130
side-lying plyometric reverse catches, 130, 131
tennis, 132, 133 R
Plyometric training drills, 188 Range of motion (ROM), 26, 95, 145
Postsurgical rehabilitation program, 186, 187 assessment of, 116
Power position, 178, 179 external rotation, 122
Power position with step back, 178, 180 external rotation limitation, 121, 122
90/90 prone plyometric ball drops, 131 passive, 39–41, 46
90/90 prone plyometric reverse catches, 131 progressive, 186, 187
Proprioception, 147 protected, 121
Proximal humeral fractures (PHF) recovery of, 23
biomechanics, 16–19 restoration of, 149, 191, 193, 195
causes, 2, 3 shoulder, 188, 191, 193
classification total rotation, 95
AO system, 4 Recovery stage, rotator cuff repair, 167
Codman-Hertel system, 8–9 inferior glide, 175
greater tuberosity, 4, 5 lawn mower exercise, 172
humeral head, 4, 5 lawn mower with lateral step, 176
impaction/distraction, 4 low-row exercise, 174
Lego System, 4 low row with posterior step, 175
lesser tuberosity, 4, 5 robbery exercise, 173
Neer system, 4 robbery exercise with posterior step, 177
Index 201
Remplissage, 113, 127 Serratus punch exercise, 124

Return to activity (sport), 188, 196 Shoulder dis-association test, 118
arthroplasty, 80 Shoulder instability
contact sports, 132, 195 bone loss (see (Bone loss))
rehabilitation following rotator cuff repair, 181 classification, 185
tennis program, 136, 137 first-time anterior shoulder dislocation
traumatic anteroinferior instability, 157 in contact sports participants, 106
Reverse shoulder arthroplasty (RSA), 55, 68 direct trauma mechanisms, 106–107
acute fracture, 78, 79 Hill-Sachs lesion, 107–110
complications, 90 lesions in, 106
cuff arthropathy, 78 non-operative treatment, 106
deltopectoral approach, 78 recurrence rates, 106
fracture sequelae, 78, 79 loose-pack position, 95
latissimus transfer, 80 muscular force couples, 94–95
rehabilitation, 90 open capsular shift, 113
superior approach, 78 passive-active elevation (9–12 weeks), 154–156
trauma, 78, 79 physical examination at outset
Rheumatoid arthritis, 68, 72 core stability evaluation, 147–148
Rhythmic stabilization, 123, 194, 195 posture, 145
drills, 188, 189, 191 range of motion, 145
internal rotation plyometric ball dribbles, 130 scapular control, 145, 146
physioball with, 95 range of motion (3–9 weeks), 149–153
progression, 84, 87 scapular plane, 94, 95
quadruped, 128 sports integration phase (12 weeks), 157–159
with therapist, 84, 86, 88 traumatic anteroinferior instability
Rim avulsions, 97, 98 arthroscopic Bankart (see (Arthroscopic Bankart))
Robbery exercise, 149, 151, 173, 177 stability mechanisms, 96
Rotator cuff Shoulder replacement
debridement, 121 arthroplasty, 68, 69
exercise, 129–130 contraindications, 74
isometric exercises, 95 historical background, 68
Rotator cuff repair, rehabilitation rehabilitation, 80
goal, 166 reverse (see (Reverse shoulder arthroplasty))
orthopedic surgeon role surgical approaches, 74–75
communication with rehabilitation clinician, 167 hemiarthroplasty, 76–77
controlling repair loading, 167 non-arthroplasty management and rehabilitation, 70
healing stages and rehabilitation total shoulder arthroplasty, 76–77
progression, 166–167 rehabilitation, 81–89
optimizing tissue anatomy, 166 Side-lying active-assistive flexion, 85
protocols Side-lying body blade oscillation exercise, 129
acute stage, 168–170 Side-lying plyometric ball drops, 130
functional stage, 178–180 Side-lying plyometric reverse catches, 131
recovery stage (see (Recovery stage, rotator cuff repair)) Side-lying position, lower and middle trapezius
return-to-activity stage, 181 activation, 154, 155
Rotator cuff tear arthropathy, 74, 78, 79 Sleeper stretch exercise, 157, 158
Slide ball exercise, 43
Sling, 81, 82, 193, 195
S altered posture after wearing, 145
Scapula assisted elbow flexion-extension
anterior scapula tilting, 39 without, 142, 144
isometric exercises, 95 effect, 113
in kinetic chain, 43 fitting arm, 142, 143
lower trapezium contraction, 26 immobilization period, 20, 21
placement, 43, 167 scapular retraction with, 142, 144
plane of, 95 uses, 39–45, 121
retraction, 85, 126 Sports-specific golf plyometric, 133
Scapular clock exercises, 145–146 Sports-specific programs, 188
Scapular control exercises, 23, 26, 43, 44, 48, 88 Stemmed implant, 75
Scapular protraction, 46, 128, 145 Strengthening exercises, 41, 126, 171, 186,
Scapular retraction, 23, 43, 44, 81–83, 88, 123, 125, 128, 142, 188, 190, 191, 193
144–146, 149, 151, 168, 174, 175 Stretching exercises, 25, 42, 48, 81, 146, 157, 195
Scapular retraction exercise, 151 Subscapular split, 140, 147, 148
Scapular stabilization exercises, 128 Subscapular tenotomy, 147, 148
Scapular stabilizer, 95, 116, 129 Superior labrum anterior posterior
Scarred deltoid, 54 (SLAP) repair, 121
Sequential kinetic chain activation, 145 Supervised active/assisted shoulder exercise, 24, 26
202 Index
T U
Tenotomy, 76, 121, 195 Unilateral serratus anterior punch, 157, 159
Theraband resistance exercise, 41, 43 Unsupported pendulum (Codman) exercises, 167
Thrower’s Ten Program, 188, 191, 195, 196
Throwing motion, 184
Total shoulder arthroplasty, 70, 71 V
anatomic, 74, 75 Valgus type fractures, 6, 7
and hemiarthroplasty, 76–77 Varus distraction fractures, 4
intact rotator cuffs, 72 Varus impaction type fractures, 4, 5
rehabilitation Varus-type fractures, 4
postoperative (weeks 0–4), 81–83
postoperative (weeks 4–8), 84–87
postoperative (weeks 8–12), 88, 89 W
postoperative (weeks 12+), 88, 89 Wall push-up plus, 156, 157
sling, 81 Wall slide exercise, 157, 158
reverse, 34–35, 52
Trendelenburg sign, 147–148

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Giovanni Di Giacomo

ISBN 978-3-319-24854-7 ISBN 978-3-319-24856-1 (eBook)

Library of Congress Control Number: 2016934463

Springer Cham Heidelberg New York Dordrecht London

Printed on acid-free paper

Springer International Publishing AG Switzerland is part of Springer Science+Business Media (www.springer.com)

Rome, Italy Giovanni Di Giacomo

1 Proximal Humeral Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Contents 1.6 Rehabilitation following Hemiarthroplasty ................ 46

G. Di Giacomo () • S. Bellachioma

© Springer International Publishing Switzerland 2016 1

1.1 Epidemiology study, displaced fractures made up 58 % of the total number

Table 1.1 Table 1.3

Fig. 1.1 Four anatomic areas of proximal

– Valgus type: is characterized by the impaction of the 3. Flexion/Extension/Neutral

From the study of Solberg et al. [17–19], the varus

Fig. 1.6 Transcapular plane view

Fig. 1.7 3D reconstruction

Table 1.5 Codman- Hertel classification system

Humeral head Lesser tuberosity Greater tuberosity Shaft

Fig. 1.8 Vascular supply of the proximal humerus. (1) Axillary

According of Trupka et al., fracture dislocation is not

Fig. 1.12 Fracture dislocation

Fig. 1.14 Prosthetic replacement as secondary procedure

1.3 Biomechanics Related to Proximal 1.3.1 Concept of “Fulcrum” and “Engine”

1.4 Conservative Treatment a period of immobilization as traditional teaching would

Fig. 1.18 Rx of stable configuration fracture

Fig. 1.19 Rest in sling

Healing progression criteria

Mobility Capsular release Proprioception Scapular control Muscolar strenght

inflammation Pain Tightness

Fig. 1.28 Use a gentle massage therapy for

Fig. 1.33 (a) PHF with medial displacement of the shaft.

Hemiarthroplasty The importance of anatomical restoration of the tuberosi-

Treatment algorithm for PHF based on age

Age Young patients Middle age 50-70 Elderly

2 part Conservative Conservative Conservative

3 part Conservative Conservative Conservative

4 part Conservative Conservative Conservative

5 head split ORIF ORIF vs HEMI HEMI

6 fracture ORIF ORIF vs HEMI HEMI

Fig. 1.38 (a, b) In the reverse prosthesis

Proprioception Exercises: Proprioceptive control (the

Phase 1 Phase 2 Phase 3

Time zero 90°of PROM, Bone

• Phase 2 Advanced Scapulothoracic Exercises: while always

• Phase 3 patient is pain-free and has achieved almost com-

What must I know? Symptoms Solutions

Take-Home Message In patients in their 70s and 80s with osteoporotic

Fig. 1.39 (a) Rest in sling in

Fig. 1.47 Active/assisted forward activation

Fig. 1.46 Pay attention to internal rotation

Fig. 1.48 Isometric exercises

Fig. 1.49 Scapular control exercises

Fig. 1.50 Arm stretching elevation

Capsular tightness, tuberosities mal-union or reabsorp- How to search?

Fig. 1.51 Tuberosity mal union and reabsorption

Fig. 1.52 (a) Screws protrusion. (b) Solution

1.7.3 Complications In general antibiotic prophylaxis has been shown to