Teaching Home Exercises for the Rehabilitation of Upper ... · for the Rehabilitation of Upper Extremity Problems ... A program detailing a range of physical exercises and the

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Teaching Home Exercises for the Rehabilitation of

Upper Extremity Problems

Rotator Cuff Impingement, Adhesive Capsulitis, Elbow Epicondylitis

Tim Baldwin, MA, ATCGina Biviano, MA ATCHally Tappan, MA, ATC

December 2, 2017

UCSF DEPARTMENT OF SPORTS MEDICINE

Disclosure

We have nothing to disclose.

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What is an Athletic Trainer?

Unique and multi-skilled health care professionals who collaborate with physicians to optimize activity of physically active patients.

Provide preventative services, emergency care, clinical assessment, therapeutic intervention and rehabilitation of injuries and medical conditions.

ATs improve functional outcomes and specialize in patient education to prevent injury and re-injury.

Employed in a variety of settings.

Objectives

Understand the importance of a Home Exercise Program (HEP) for upper extremity chronic issues

Provide simple instructions on how to teach home exercise programs for common shoulder and elbow injuries

Recognize red flags for orthopedic referral

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What is a Home Exercise Program?

A program detailing a range of physical exercises and the amount of time each exercise should be performed

Not personalized so that it is usable with the largest patient population

Little to no special equipment needed other than household items

Home Exercise Program

Why HEP?

• PT not always necessary or accessible

• Pain control

• Simple instructions for rotator cuff and scapular strengthening

• Correct postural imbalances

• sportsrehab.ucsf.edu

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Improve HEP Effectiveness

Patient Compliance

• Only 35% of patients adhered fully to HEP

‒ Only 19% adherence if chronic illness present (Kravitz, 1993)

‒ 76% followed regimen partly (Sluijs, 1993)

Best if used in addition to formal PT

Causes of Upper Extremity Pain

May be due to:

• Traumatic injury

• Lack of flexibility

• Weakness of shoulder and back musculature

• Overuse

• Biomechanical issues

• Impingement

Posture related factors of shoulder pain

• Rolled forward shoulders

• Poor posture (sitting at computer, reading, writing)

• Tight pectoralis/weak scapula stabilizers

• Repetitive overhead motions (Ludewig and Borstad, 2003)

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Effects of Poor Posture

Muscle Weakness:

• Rotator cuff weakness will lead to unbalanced motion that can cause migration of the humeral head (Ludewig and Borstad, 2003)

• Weak scapular stabilizers can result in altered biomechanics (Voight and Thompson 2000, Kibler 2008)

‒ Abnormal stresses to the anterior capsular structures

‒ Possibility of Rotator Cuff compression

‒ Decreased performance

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What Happens Without Exercises

Scapular Control Issues

Postural Changes

Long Term Motor Control Issues

Connective Tissue Changes—Fibrosis

Chronic Substitution Patterns

• Over-recruit upper trap and levator scap

• Underused lower trap and middle trap

PT Needed to Retrain Motor Control Patterns

Shoulder Pain

3rd most common musculoskeletal condition presenting in primary care (Urwin 1998)

5th most common among injury among high school athletes (Powell 1999)

Approximately 13.7 million people in the US seek treatment from a physician for a shoulder problem each year (Hing 2005)

• Impingement Syndrome is the most common shoulder disorder accounting for 44-65% of all physician visits for shoulder pain (van Der Wint 1995)

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Rotator Cuff Impingement

Rotator Cuff Impingement

Intrinsic Causation

• Muscle Weakness

• Muscle Fatigue

• Overuse

• Degenerative Issues

• Poor Posture

Extrinsic Causation

• Shape of acromion

• Coracoacromial ligament attachment

• AC Joint

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Differential Diagnosis

Labral tear

OA

AC arthritis vs sprain

Distal Clavicle Injury

Biceps tendon rupture/tendinopathy

Calcific Tendonitis

Adhesive Capsulitis

Nerve injury

Spine pathology

HEP- Stretching

Doorway Stretch

Frequency: 3 sets x 1 min 2-3 times per dayGoal: Increased pectorals flexibility/improve posture

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HEP- Stretching

Sleeper Stretch

Frequency: 3 sets x 10 reps 2-3 times per dayGoal: Improve posterior capsule mobility

HEP- Strengthening

External Rotation

Frequency: 3 sets x 10 reps 2-3 times per dayGoal: Increase strength of scapular stabilizing muscles

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HEP- Strengthening

Horizontal Rows

Frequency: 3 sets x 10 reps 2-3 times per day

Goal: Increase strength of the scapular stabilizers

HEP- Lifestyle

Ergonomic Fixes for Postural Issues

• Contact HR about ergonomic evaluation

• Use standing desk

• KT Tape

• Comfort Clavicle Sling

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Adhesive Capsulitis aka “Frozen Shoulder"

• Synovial inflammation & capsular fibrosis

• Leads to contracture of the capsule

• Etiology not clearly understood

Adhesive Capsulitis “Frozen Shoulder"

Causation

• Gradual loss of active and passive ROM

• Most common in women 40-60 years old

• Affects about 2% - 5% of the population

• Strong association with Diabetes Mellitus

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Adhesive Capsulitis

• Full duration of disease is 1-3.5 years

• Presents unilaterally but will often affect the contralateral shoulder

• Initial treatment of HEP combined with OTC analgesia/anti-

inflammatory meds is the most effective to treat this condition (Hsu

2011)

• NSAIDS not effective when compared to placebos


• Impingement, Calcific Tendinitis, and Osteoarthritis – PROM is not painful/restricted in these conditions

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HEP- Stretching

Passive Shoulder Flexion

Frequency: 3 sets x 1 min 2-3 times per dayGoal: Increase Range of Motion

HEP- Stretching

Passive Abduction


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HEP- Stretching

External Rotation


HEP- Strengthening

Active Wall SpidersFrequency: 5x 2-3 times per day

Goal: Increase Range of Motion

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HEP- Strengthening

Isometrics: Flexion/Abduction


Chronic Elbow Pain

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Epicondylitis

Lateral Epicondylitis

• Common in primary care (Annual Incidence 1-3%) (Johnson 2007)

• Repetitive activity at work or in recreation

Medial Epicondylitis

• Less common diagnosis (only 10-20% of all epicondylitis diagnoses) (Ciccoti 2004)

• Similar treatment as lateral epicondylitis


Ulnar nerve disorders, cervical radiculopathy, ulnar collateral ligament injury

'Little League elbow' and fractures of the medial epicondyle

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HEP- Stretching

Wrist Flexor Stretch

Frequency: 3 sets x 1 min2-3 times per day


Wrist Extensor Stretch

Frequency: 3 sets x 1 min2-3 times per day


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HEP- Strengthening

Grip Strengthening

Frequency: 2-3 sets until fatigue 3 times per weekGoal: Increase Grip Strength

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HEP- Strengthening

Wrist Extension Curls

Frequency: 2-3 sets until fatigue 3x per week

Goal: Increase Forearm Strength

Wrist Flexion Curls

Frequency: 2-3 set until fatigue 3x per week

Goal: Increase Forearm Strength

HEP- Strengthening

Hammer twist

Frequency: 2-3 sets until fatigue 3x per weekGoal: Increase Forearm Strength

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What if HEP is not working

Check Patient Compliance

Re-examine Differential

Consider Advanced Imaging

Refer

References

Ciccotti MC, Schwartz MA, Ciccotti MG. Diagnosis and treatment of medial epicondylitis of the elbow. Clin Sports Med. 2004; (23): 693-705.

Hing E, Cherry DK, Woodwell DA, et al. National Amubulatory Medical Care Survey: 2003 Summary. CDC Advance Data. 2005; 365: 1-48.

Hsu, JE, et al. Current Review of Adhesive Capsulitis. Journal of Shoulder and Elbow Surgery. 2011. 20(3): 502 – 514

Johnson GW, Cadwallader K, Scheffel SB, Epperly TD. Treatment of lateral epicondylitis. American Family Physician. 2007; 76(6): 883-848.

Kibler WB, Sciascia AD, Uhl TL, et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. Am J Sports Med. 2008:(36)9:1789–179.

Kravitz RL, Hays RD, Sherbourne CD, et al. Recall of recommendations and adherence to advice among patients with chronic medical conditions. Arch Intern Med. 1993; 153(16):1869-78.

Ludewig PM, Borstad JD. Effects of a home exercise programme on shoulder pain and functional status in construction workers. Occupational and Environmental Medicine. 2003; 60: 841-849.

Powell, JW, Barber-Foss, KD. Injury Patterns in Selected High School Sports: A Review of the 1995-1997 Seasons. J Athl Train. 1999; 34(3): 277–284.

Sluijs EM, Kok GJ, Van der Zee J. Correlates of Compliance in Physical Therapy. Physical Therapy. 1993; 73(11): 771-782.

van der Windt DA, Koes BW, de Jong BA, et al. Shoulder disorders in general practice: incidence, patient characteristics, andmanagement. Ann Rheum Dis.1995;54:959–64.

Voight ML, Thompson BC. The Role of the Scapula in the Rehabilitation of Shoulder Injuries. Journal of Athletic Training. 2000; 35(3): 364-372.

Urwin M, Symmons D, Allison T, et al. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis. 1998; 57(11):649-55.

UCSF Orthopaedic Institute | 1500 Owens Street Ste 170 | San Francisco, CA 94158 | Phone: 415-353-2808 | Fax: 415-353-7593 | orthosurg.ucsf.edu

For instructional videos of this protocol, visit sportsrehab.ucsf.edu

Adhesive Capsulitis PROTOCOL

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• Description

o Typically between ages of 40-65. o Thickening of the capsule around the shoulder.

• Causes o Previous shoulder injury. o Immobilization. o Diabetes. o Thyroid disorders.

• Progression o 1st Stage “Freezing” stage

Increased pain, decreased motion. Can last 1-9 months.

o 2nd Stage “Frozen” stage Decreased pain, but stiffness remains. Can last 4-9 months.

o 3rd Stage “Thawing” stage Slow return of motion. Can last 5 months to 2 years.

PPaassssiivvee FFoorrwwaarrdd FFlleexxiioonn Using a broom or rod, grasp the end with hand 1 and the other end

with hand 2. Use hand 2 to passively raise hand 1 up until a stretch is felt.

Hold the position for 10 seconds and return to starting position.

Frequency: 3 sets of 10 reps. 2-3 times per day. Goal: Increase/Maintain Shoulder Range of Motion

• Conservative Treatment o Symptoms typically resolve on their own

regardless of treatment or no treatment. o Physical therapy. o Medication. o Injections.

PPaassssiivvee EExxtteerrnnaall RRoottaattiioonn Grasp the end of the rod with hand 1 and the middle of the rod

with hand 2. Use hand 2 to passively rotate hand 1 to the side while keeping

the elbow in. Hold the stretch for 10 seconds and return to starting position.


PPaassssiivvee AAbbdduuccttiioonn Grasp the end of the rod with hand 1 and the other end with hand 2.

Use hand 2 to passively raise hand 1 up to the side until a stretch is felt. Hold the stretch for 10 seconds and return to starting position.


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IIssoommeettrriicc:: FFlleexxiioonn // EExxtteennssiioonn Stand with good posture, squeeze shoulders back.

Bend and hold elbow at 90°. Flexion: Push hand into wall.

Extension: Push elbow into wall. Hold 5 sec. Repeat TEN times.

Frequency: 1 set. 3 times per day. Goal: Increase Strength of Deltoid Muscles

FFoorrwwaarrdd WWaallll CClliimmbbeerrss Patient stands facing the wall 2 feet from the wall. Slowly walk fingers up the wall as high as possible. Hold at the top for 10 seconds then slowly lower.

Frequency: 5 times. 2-3 times per day Goal: Increase/Maintain Shoulder Range of

Motion

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SSiiddee WWaallll CClliimmbbeerrss Patient stands with their involved shoulder 2 feet

from the wall. Slowly walk fingers up the wall as high as possible. Hold at the top for 10 seconds then slowly lower.

Frequency: 5 times. 2-3 times per day Goal: Increase/Maintain Shoulder Range of

Motion

IIssoommeettrriicc:: AABBdduuccttiioonn // AADDdduuccttiioonn Stand with good posture, squeeze shoulders back.

Bend and hold elbow at 90°. ABduction: Start hand on stomach.

Push hand away from your stomach. ADduction: Start hand away from stomach.

Pull hand into your stomach. Hold 5 sec. Repeat TEN times.

Frequency: 1 set. 3 times per day. Goal: Increase Strength of Rotator Cuff Muscles

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SSccaappuullaarr RReettrraaccttiioonn ((SShhoouullddeerr BBllaaddee SSqquueeeezzeess)) Relax head and neck.

Stand with good posture, squeeze shoulders back. Avoid shrugging shoulders. Keeps abs tight.

Hold 10 sec. Relax shoulder. Repeat 10 times.

Frequency: 1 set. 3 times per day. Goal: Increase Strength of Scapular Stabilizing

Muscles

SSccaappuullaarr EElleevvaattiioonn ((SShhoouullddeerr SShhrruuggss)) Relax head and neck.

Stand with good posture. Squeeze shoulder up towards your ears.

Keep abs tight and hold 10 sec. Relax shoulders. Repeat 10 times.

Frequency: 1 set. 3 times per day. Goal: Increase Strength of Scapular Stabilizing

Muscles

EExxtteerrnnaall RRoottaattiioonn Attach theraband to a stable object at waist level.

Roll shoulder back and down and maintain this position. Place towel between elbow and side.

Slowly rotate hand AWAY from the abdomen. Hold 5 sec. Repeat 10 times.


SSiiddee NNoottee Do not perform exercises that increase your pain during or after the exercise.

IInntteerrnnaall RRoottaattiioonn Attach theraband to a stable object at waist level.

Roll shoulder back and down and maintain this position. Place towel between elbow and side.

Slowly rotate hand TOWARDS the abdomen. Hold 5 sec. Repeat 10 times.




Elbow Injury PROTOCOL

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• Causes o Overuse activities. o Muscle weakness. o Improper technique or equipment use.

• Related activities o Computer use. o Construction. o Racquet sports.

• Signs and Symptoms o Pain and tenderness on medial or lateral side of elbow. o Pain and weakness with gripping activities. o Pain with rotation/twisting of the wrist. o Pain with lifting objects.

• Conservative treatment o Rest. o Ice 15 minutes. o Stretching exercises. o Strengthening exercises.

WWrriisstt EExxtteennssoorr SSttrreettcchh Begin with elbow extended and palm facing down.

Passive pull the finger and hand towards the ground. Continue until a comfortable stretch is felt.

Frequency: 3 sets x 1 min. 2-3 times per day. Goal: Increase Range of Motion

WWrriisstt FFlleexxoorr SSttrreettcchh Begin with elbow extended and palm facing up.

Passive pull the finger and hand towards the ground. Continue until a comfortable stretch is felt.

Frequency: 3 sets x 1 min. 2-3 times per day. Goal: Increase Range of Motion



Elbow Injury PROTOCOL

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GGrriipp SSttrreennggtthheenniinngg Hold a tennis ball, rubber ball or silly putty in your hand.

Squeeze slowly and hold for five seconds. If the ball is too difficult or painful, try a sock or sponge.

Frequency: 2-3 sets until fatigue. 3 times per week. Goal: Increase Grip Strength

WWrriisstt FFlleexxiioonn CCuurrllss Rest arm on table with elbow extended.

Grasp a small weight with palm facing up. Slowly curl wrist up towards the ceiling.

Hold for three seconds then slowly lower.

Frequency: 2-3 set until fatigue. 3 times per week. Goal: Increase Forearm Strength

WWrriisstt EExxtteennssiioonn CCuurrllss Rest arm on a table with elbow extended.

Grasp a small weight with palm facing down. Slowly curl wrist up towards the ceiling.

Hold for three seconds then slowly lower.

Frequency: 2-3 sets until fatigue. 3 times per week. Goal: Increase Forearm Strength

HHaammmmeerr TTwwiisstt Sit with you arm resting on your knee or table.

Grasp a hammer in your hand. Slowly rotate the hammer side to side.

Grasping the handle further from the head increases difficulty.

Frequency: 2-3 sets until fatigue. 3 times per week. Goal: Increase Forearm Strength



Scapular Stabilization PROTOCOL

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Description

o The scapula is the base of support to the shoulder joint and all movements of the upper extremity.

o Poor scapular stabilization can contribute to a variety of upper quadrant syndromes such as:

shoulder impingement, shoulder instability, cervical strain, nerve entrapments, and muscle strains.

Hints

o While performing exercises, keep shoulder rolled back and down.

SSccaappuullaarr RReettrraaccttiioonn ((SShhoouullddeerr BBllaaddee SSqquueeeezzeess))

Relax head and neck.

Stand with good posture, squeeze shoulders back.

Avoid shrugging shoulders. Keeps abs tight.

Hold 10 sec.

Relax shoulder. Repeat 10 times.

Frequency: 1 set. 3 times per day.

Goal: Increase Strength of Scapular stabilizing

Muscles.

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EExxtteerrnnaall RRoottaattiioonn

Attach theraband to a stable object at waist level.

Roll shoulders back and down and maintain this position.

Place towel between elbow and side.

Slowly rotate hand AWAY from the abdomen.

Hold 3 sec. Repeat 12-15 times.



Muscles

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Scapular Stabilization PROTOCOL

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SShhoouullddeerr DDiiaaggoonnaallss

Patient stands with theraband under their opposite foot.

While grasping theraband, bring shoulders back and down.

With your hand at your opposite hip, slowly raise it up across

your body, as if you are drawing a sword.

Hold 3 seconds and repeat 12-15 times.



Muscles

HHoorriizzoonnttaall RRoowwss

Secure theraband around a stable object, like a pole.

Patient can either kneel or stand.

Grasp both ends of the theraband.

Bring shoulders back and down .

Slowly pull elbows back, squeezing your shoulder blades together.




Muscles

SShhoouullddeerr EExxtteennssiioonn

Secure theraband around a stable object, like a pole.

Patient can either kneel or stand.

Grasp both ends of the theraband, bring shoulders back and down .

With arms extended, slowly pull hands straight down until even

with your hips.




Muscles

AAnnggeell WWiinnggss

Stand with arms overhead.

Keeping elbows to the side, slowly lower arms.

Try put your elbows into back pockets.

Squeeze shoulder blades together.

Hold 10 sec. Repeat 10 times.

Frequency: 3 sets. 3 times per day.

Goal: Increase Scapular Strength

If strengthening exercises become too easy, the repetitions should be increased until muscle fatigue

Documents

Teaching Home Exercises for the Rehabilitation of Upper ... · for the Rehabilitation of Upper Extremity Problems ... A program detailing a range of physical exercises and the