!

Pune!Shoulder!Rehabilitation!Program!(PSRP)!
!
Introduction!
Pune!Shoulder!Rehabilitation!Programme!(PSRP)!is!essentially!developed!by!
Dr.Ashish!Babhulkar,!orthopaedic!surgeon!and!who!specialised!in!shoulder.!
After!finishing!his!formal!training!in!his!subject!of!interest!i.e.!shoulder!from!
Liverpool!UK!he!returned!to!Pune,!India!and!during!his!initial!practice!he!
noticed!the!lack!of!knowledge!and!awareness!in!shoulder!rehabilitation!and!it!
provoked!him!for!developing!the!complete!exercise!package!for!shoulder!
rehabilitation!PSRP.!
Its!been!more!than!10!years!that!we!are!practicing!PSRP!and!it!went!thru!lot!of!
modifications!over!the!period!of!10!years.!!
We!have!been!seeing!amazing!results!by!using!PSRP!in!these!10!years!in!
different!shoulder!conditions!ranging!from!simple!Mechanical!postural!
problem,!Rotator!cuff!tendinoses,!Rotator!cuff!tears,!Instabilities,!MDIs,!Nerve!
injuries,!Nerve!impairments,!Brachial!plexopathies,!shoulder!joint!arthritis!to!
different!surgical!interventions!including!Rotator!cuff!repairs,!Bankart!Repairs!
SLAP!repairs!Shoulder!Replacements!Reverse!Shoulder!Replacement.!
We!have!been!seeing!approximately!100/day!of!different!shoulder!conditions.!
And!we!have!been!departing!education!regarding!the!same!thru!one!day!
Didactic!lecture!programme!series!and!A_Z!shoulder!workshop!for!2days!n!10!
days!of!hands!on.!
!
PSRP!basically!consists!of!essence!of!shoulder!rehabilitation.!
It!is!divided!into!III!Phases.!
PHASE!I:!Patient!has!to!perform!the!programme!under!strict!supervision!of!
trained!shoulder!rehabilitation!therapist!which!is!compulsory!of!10!days!
duration.!
PHASE!II:!Patient!has!to!perform!all!the!exercises!at!home!for!6!weeks!and!then!
come!for!the!follow!up!with!Dr.!And!treating!shoulder!rehabilitation!therapist.!
PHASE!III:!These!are!special!exercises!only!for!patients!who!are!into!sports!or!
have!high!demand!activities!of!shoulder.!The!selection!criteria!is!necessarily!
done!by!Dr.!And!trained!shoulder!rehabilitation!therapist.!
!
Core!exercises!are!incorporated!compulsory!for!all!patients.!!

It!includes!activation!of!transverse!abdominus!and!lower!abdominal!muscles!
!
For!Post!Surgery!Patients!
The!demand!of!rehabilitation!is!different!in!post!surgery!patients!hence!we!
follow!slightly!different!protocol.!It!includes!different!exercises!than!only!PSRP!
For!day!1Y3!
For!day!3Yday!15!
For!day!15Yweek!6!
For!week!6!onwards!we!follow!Proper!PSRP.!
!
For!rotator!cuff!arthropathy!patients!or!for!patients!who!have!irreparable!full!
thickness!cuff!tear!we!follow!totally!different!programme!its!called!Cuff!
Substitution!Programme.!
!
Principle!of!PSRP!
Normalize!scapular!muscle!strength!
Normalize!scapuloYhumeral!rhythm!
Pain!relief!
Rotator!cuff!muscle!strengthening!
Restoration!of!ROM!
Restoration!of!function!
Maintaining!posture!and!core!!
!
It!is!imp!to!facilitate!the!optimal!scapular!stability!and!scapuloYhumeral!
alignment!by!reducing!muscle!imbalance!to!reduce!chances!of!impingement!
or!instability.!
Definition!of!PSRP!
This!is!an!exercise!programme!which!includes!exercises!with!lowYresistance,!
highYrepetition!performed!in!subYimpingement!region!for!strengthening!of!
scapular!and!rotator!cuff!muscles.!!!
!

!
!

!
!
Phase&I&
!This!is!a!primary!and!principle!stage!of!PSRP.!It!includes!!
a)!Scapular!setting,!strengthening!!
b)!Rotator!cuff!muscles!strengthening!
c)!Capsular!stretches!
d)!Core!muscle!strengthening!exercises.!
!
Phase!I!is!two!weeks!program!under!strict!supervision!of!trained!
Physiotherapist.!
!
Scapular!setting!exercises!
!
!
Rhomboids&/&Medial&scapular&Muscles&
&
Position:&
Standing!!!(Standing!sets)!!
!Prone!(Prone!sets)!

Techniques:&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

Fig:&1a)&
Fig:1b)&
&
Standing&Position:&Exercise&1&&& &
a) Keeping!arms!in!neutral!position,!!
b) Retract!both!the!shoulders.!Hold!it!there!at!the!maximum!contraction,!as!
both!scapulae!should!come!nearer,!for!the!count!of!ten!and!release!
gradually.!
!
!

!
Fig:&2b)!

Fig:&2&a)&

&

Exercise&2&
a) Keeping!arms!in!neutral!position,!!
b) Retract!both!the!shoulders!same!like!above!and!gradually!extend!both!
arms!and!hold!it!there!for!the!count!of!ten.!
!
Compensations&that&can&occur:&
1. Patient!may!extend!the!neck.!
2. Patient!may!elevate!the!shoulder.!
3. Patient!may!hold!breath.!
4. Patient!may!extend!the!back.!
5. You!may!bend!your!elbow!and!do!the!same!activity!in!exe!2!

If!patient!has!knee!problem!or!back!problem!or!inability!to!stand!he!can!
perform!exercise!in!sitting!position!
!
Prone&Position:!(AntiYgravity)!
Exercise&1&

&&&&&&&&&&&&&&&

Fig:3a)&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

Fig:3b)&
a) Patient!lying!on!stomach!and!keeping!his!hands!by!the!side.!!
b) Retract!both!the!shoulders!in!the!same!position!hold!it!for!10!counts!and!
slowly!relax!
!
Exercise!4!

Fig&4a)!
!

Fig&4&b)!
!

a)!Keeping!arms!in!neutral!position,!!
b)!Retract!both!the!shoulders!and!gradually!extend!both!arms!and!hold!it!
there!for!the!count!of!ten!and!then!slowly!relax.!
Exercise!5!

Fig&5a)&
&
While!in!Prone!position,!elbows!are!flexed!at!90!degrees!and!placed!at!
shoulder!level.!

a) For!Rhomboids!Lower!Fibres:!!!!!!

Fig:5b)&
&
Retract!shoulders!and!placing!the!elbows!down!try!to!raise!forearm!and!
hands!off!the!mat.!Slow!release.!Ten!counts!hold!and!release.!
1) For!Rhomboids!Upper!Fibres:!

!Fig:5c)!
Retract!both!shoulders!and!elbows!flexed!and!placed!as!above.!By!
Keeping!the!hands!touching!down!the!plinth!try!to!raise!the!elbows!up.!
Slow!release.!Ten!counts!hold!and!release.!
Compensations!that!can!occur:!
6. Patient!may!extend!the!neck.!
7. Patient!may!elevate!the!shoulder.!
8. Patient!may!hold!breath.!
9. Patient!may!extend!the!back!

10. EXE!NO!5!a!b!&c!are!not!given!to!patients!who!has!range!restriction!or&

severe!pain!and!impingement!and!cannot!maintain!the!position!
&
Dynamic!Scapular!muscle!strengthening!with!Theraband!
!
1) Rhomboids!(!medial!scapular!muscles)Y!Bruggers!technique!!

!Fig:!6a)!!!!!!!!!!!!!!!!!!!!!!!!!!!

!Fig:6b)!
!
Position:!
Standing!!
Technique:!
a. Keep!shoulder!blades!retracted!and!depressed.!
!

1.
2.
3.
4.

b. Keep!both!the!elbows!flexed!at!90!degrees!and!fixed!to!body,!with!both!
forearms!parallel!to!each!other!and!to!the!ground!also.!
c. Tie!the!TheraYband!above!both!wrists.!
d. Make!a!loop!like!tying!tie!knot!and!take!the!band!in!palm!from!behind!
measure!till!elbow!and!tie!the!loop!to!other!wrist!
e. Keeping!both!elbows!fixed!to!body,!Retract!both!shoulders!slowly!and!
then!pull!the!forearms!apart!against!Theraband!resistance.!!
f. Hold!it!there!at!maximum!for!ten!counts!and!slowly!release!it!to!the!
neutral.!Repeat!this!for!ten!times.!
!
Compensations!to!look!for:!
Patient!may!extend!the!neck.!
Patient!may!elevate!the!shoulder.!
Patient!may!hold!breath.!
Patient!may!extend!the!back!

!
!
!
!

!!!!!ASB!Rhomboids!Technique!:!
a)!

Fig:7!

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Fig&:&7b)&
&
a. In!standing!position,!shoulders!must!be!abducted!and!externally!
rotated!and!then!elbows!must!be!flexed!to!90!degrees.!
b. !Retract!the!shoulders!in!above!position,!and!try!to!extend!the!elbows!
by!concentrating!on!upper!portion!of!medial!scapular!area.!One!should!
feel!maximum!pinch!over!there.!
c. Hold!it!there!at!maximum!pinch!and!release!slowly.!Repeat!it!for!ten!
times.!!
Note:!ASB!Rhomboids!is!a!challenging!technique!and!needs!good!coY
activation!of!the!shoulder!stabilizers.!It!is!to!be!performed!only!after!
basic!exercises!are!mastered.!In!cases!of!severe!impingement!
dislocation!and!range!restriction!in!ABD/ER!this!exercise!is!not!given.!
Compensations!to!look!for!
1. Patient!may!extend!the!neck.!
2. Patient!may!elevate!the!shoulder.!
3. Patient!may!hold!breath.!
4. Patient!may!extend!the!back!
5. Make!sure!patient!does!not!take!the!band!above!ear!level!
!
!
Modified!Bruggers!Technique!
!
a) !Hold!the!band!in!both!the!hands!by!pinching!it!in!thumbs.!Take!reverse!
wrap!in!both!the!hands.!

b) Starting!position!is!like!a!womb!position!fingers!wrist!flexed!elbows!
flexed!and!pronated.!!
c) First!fan!your!fingers!by!extending!and!abducting!them,!then!fan!your!
thumb!!then!extend!both!the!wrists,!then!supinate!and!extend!both!
elbows!and!by!retracting!the!shoulders,!slowly!abduct!and!!extend!
both!the!arms!backwards!by!maintaining!the!above!position.!
d) Hold!it!there!for!ten!counts!and!release!slowly.!Repeat!it!for!ten!times.!!
!
!!
Compensations!to!look!for!
1.
2.
3.
4.

Patient!may!not!maintain!the!angle!of!the!elbows.!
Patient!may!elevate!the!shoulder.!!
Patient!may!hold!the!breath!
Patient!may!extend!the!back!instead!of!retraction!
!
2) !Serratus!Anterior!!
!
Position:!
Standing!

Fig:8a)!

Fig:8b)!
Technique:!
a) !Patient!must!be!standing!straight.!
b) Put!the!band!on!the!upper!back!(on!scapulae)!by!tying!the!ends!of!the!
band!on!both!palms,!while!both!the!elbows!are!flexed!and!hands!close!
to!the!body.!
c) Pull!the!arms!forwards!and!cross!it!at!the!nipple!level!just!before!
complete!elbow!extension.!Avoid!complete!elbow!extension.!(Teddy!
bear!hug)!
d) Hold!it!there!for!ten!counts!and!slowly!release.!Repeat!it!for!ten!times.!
!
Compensations!to!look!for!
1. Patient!may!extend!the!elbows.!
2. Patient!may!elevate!the!shoulders.!
3. Patient!may!sway!back.!
!
3) Supraspinatus!
Position:!!!!!
Empty!Can!/!Full!Can!

Fig:9a)

Fi F

Fig !
Technique:!
a)!Keep!shoulder!blades!retracted!and!depressed!
b)!Arm!completely!internally!rotated!for!Empty!Can.!
!Tie! the! TheraYband! with! 2! knots! at! wrist! and! measure! complete! hand!
length!distance!which!is!the!lever!arm!for!exercise!and!put!your!feet!on!that!
point!then!start!the!exercise.!
c)!!Lift!the!arm!in!45!deg!in!scaption!position!
d)!Hold!for!10!secends!and!very!SLOWLY!take!down.!
e)!Repeat!the!same!for!10!repetitions!
Compensations!to!look!for!
1.
2.
3.
4.
!
Full!Can!

Patient!may!arch!his!back!
Patient!!may!elevate!the!shoulder!
Patient!may!use!the!wrist!or!fingers!to!lift!the!arm!
Patient!may!bend!his!elbow!

!Fig!9:c)!
Keep!the!hand!in!complete!external!rotation!and!then!complete!the!movement!
as!explained!in!empty!can!position!
!
4)!Infraspinatus:!
Position:!
Standing!with!elbow!flexed!at!90!degrees!
!
Technique:!
a) !!Patient!is!standing!with!the!elbow!is!flexed!at!90!degrees.!The!band!is!
tied!on!the!wrist!with!two!knots.!
b) The!other!end!of!the!band!is!tied!to!the!fixed!support!which!should!be!
exactly!at!the!elbow!height.!And!band!length!should!be!equal!length!of!
the!forearm.!!
c) A!small!pillow!or!roll!of!towel!should!be!kept!under!the!elbow!so!as!to!fix!
it!there.!
d) The!exercising!arm!should!be!placed!opposite!to!the!fulcrum.!
e) By!retracting!the!shoulder!in!above!position!patient!should!externally!
rotate!the!forearm!(outward)from!complete!internal!rotation!till!
maximum!external!rotation,!maintaining!body!straight.!!
f) Hold!for!count!of!ten!at!the!maximum!and!slow!release.!Repeat!ten!
times.!!
!

!!!!!!!Compensations!to!look!for!
1.
2.
3.
4.
5.
6.

Patient!is!may!not!maintain!the!angle!of!the!elbows.!
Patient!may!elevate!the!shoulder.!
Patient!may!compensate!with!wrist!extension.!!
Patient!may!turn!the!body.!
Patient!may!extend!elbow.!
May!be!shoulder!and!elbow!are!not!in!a!line!
!
5)!Subscapularis:!
!!Position:!
!!!!Standing!with!elbow!flexed!at!90!degrees!
!
!!Technique:!
a. Patient!is!standing!with!the!elbow!is!flexed!at!90!degrees.!The!band!is!
tied!on!the!wrist!with!two!knots.!
b. The!other!end!of!the!band!is!tied!to!the!fixed!support!which!should!be!
exactly!at!the!elbow!height.!And!band!length!should!be!equal!length!of!
the!forearm.!!
c. Exercising!arm!should!be!placed!to!the!side!of!fulcrum.!
d. By!retracting!the!shoulder!in!above!position!patient!should!internally!
rotate!the!forearm!(inward)!at!maximum,!maintaining!body!straight.!!
e. Hold!for!count!of!ten!at!the!maximum!and!slow!release.!Repeat!ten!
times.!!
!
Note:!!Subscapularis!strengthening!should!be!given!in!exceptional!cases!
such!as!in!Subscapularis!tear/!repair!or!in!surgeries!in!which!
Subscapularis!is!being!handled.!
!
!!!!!!!Compensations!to!look!for!
1.
2.
3.
4.

Patient!is!may!not!maintain!the!angle!of!the!elbows.!
Patient!may!elevate!the!shoulder.!
Patient!may!compensate!with!wrist!extension.!!
Patient!may!turn!the!body.!
!

CORE!EXERCISES!
These!exercises!are!compulsory!for!every!patient.!As!it!works!on!
improving!kinetic!chain!imbalances!and!improve!proprioceptive!ability!of!
body.!!
!
Transverses!Abdominus!(!Core!strengthening)!
!
Position:!
Supine!with!knees!flexed!at!60!degrees!

Techniques:!
1st!technique!
a) !While!patient!lying!in!supine!position!with!knees!flexed,!ask!patient!
to!breathe!in!slowly!with!the!nose!and!slowly!breathYout!with!the!
mouth!as!in!blowing!the!balloon.!!
b) Ask!patient!to!perform!tummy!!tuck!and!perinea!contraction!and!
then!bring!up!the!neck!very!slowly.!
c) Patient!has!to!feel!the!contraction!in!between!two!ASIS.!
d) Hold!for!count!of!ten!at!the!maximum!and!slow!release.!Repeat!ten!
times.!
!
!!!!!!Compensations!to!look!for!
1. Patient!may!hold!the!breathe.!
2. Patient!may!make!the!neck!stiff.!
3. Patient!may!use!other!abdominal!muscles!such!as!Rectus!abdominus.!
!
!!!!!!2nd!technique!(Bilateral!SLR)!
!

Position:!
Supine!with!legs!straight!
Technique:!
a) !Patient!lying!supine!with!legs!straight!and!parallel.!
b) While!breathing!normal,!ask!patient!to!lift!both!legs!at!a!time!at!
maximum!!30!degrees!above!the!ground.!(Or!as!much!as!the!patient!
can).!
c) !Hold!for!count!of!ten!at!30!degrees!and!slow!release.!Repeat!ten!
times.!
!
Compensations!to!look!for!
a) Patient!may!hold!the!breath.!
b) Patient!may!arch!the!back.!
c) Patient!may!use!other!abdominal!muscles!such!as!Rectus!Abdominis.!
!
3rd!Technique!(cycling)!
!

&&
Position:!!
Supine!
!
Technique:!
a) Patient!is!in!supine!position.!Ask!patient!to!perform!tummy!tuck!and!
the!lift!both!legs!at!a!time!at!30!degrees.!
b) Patient! has! to! flex! one! of! the! legs,! while! extending! the! other!
alternately.! Allow! for! an! infinitesimal! pause! at! the! end! of! leg!
extension.!
c) Keep!repeating!till!the!count!of!ten!and!release!it!slowly.!Repeat!for!
ten!times.!
!
Compensations!to!look!for!
i. Patient!may!hold!the!breath.!
ii. Patient!may!arch!the!back.!
iii. Patient! may! exercise! very! fast! thereby! recruiting! other! hip! and!
abdominal!muscles.!
!

!
4th!Technique!(Scissors)!
!

Position:!
Supine!
!
Technique:!
a) Ask! patient! to! perform! tummy! tuck! and! then! to! lift! both! legs! at! a!
time!as!above!to!30!degrees.!
b) Ask! the! patient! to! raise! one! leg! upwards! while! the! other! leg! going!
down!slowly.!And!then!viceYaYversa.!
c) Keep!repeating!very!slowly,!till!the!count!of!ten!and!release!it!slowly.!
Repeat!for!ten!times.!
!
Compensations!to!look!for!
1.!Patient!may!hold!the!breath.!
2.!Patient!may!arch!the!back.!

3.! Patient! may! do! it! very! fast! recruiting! other! hip! and! abdominal!
muscles.!
4.!Patient!may!bend!the!knees!
!
!
Capsular!Stretches!!
!
Inferior!capsular!stretch!
!
Position:!

Supine!
Technique:!
a) !Ask!the!patient!to!clasp!the!hands!properly.!
b) Then! patient! has! to! take! it! overhead! slowly! with! the! help! of! good!
arm.!He!is!supposed!to!take!help!of!good!arm!to!stretch!it!beyond!the!
available!range.!
c) The!stretch!should!be!within!the!limit!of!pain!and!elastic!limit.!
d) Instead!of!using!hands,!patient!can!make!use!of!wand!for!stretching.!
!!!!!!!!!Same!stretch!can!be!performed!in!standing!position!by!fixing!the!body!
to!the!wall.!
Posterior!capsule!Stretch!
Position:!

Sitting!or!Supine!
Technique:!
a) Cross!adduct!the!affected!arm!of!the!patient!with!the!elbow!flexed.!
b) Either!therapist!can!stretch!it!by!putting!the!pressure!on!the!elbow!or!
ask!the!patient!to!apply!it!with!the!opposite!arm.!
c) Maintain! the! stretch! for! count! of! ten! and! release.! Repeat! it! for! 3Y4!
times.!
!
Anterior!Capsule!stretch!
!
Position:!

Standing!!
Technique:!
a) While! in! standing! position,! ask! the! patient! to! face! the! wall! at! its!
corner.!The!arm!should!be!abducted!and!externally!rotated!and!then!
elbow!should!be!flexed!to!90!degrees!and!the!forearm!must!be!fixed!
to!the!wall.!
b) In!above!position!patient!has!to!lean!forward!by!putting!the!opposite!
leg!forward!(stride!stance)!
c) Patient!has!to!feel!the!stretch!anteriorly!at!the!shoulder.!
d) Maintain! the! stretch! for! count! of! ten! and! release.! Repeat! it! for! 3Y4!
times.!
!
Sleepers!Stretch!
Position:!

Side!lying!!
!
Technique:!
a) Patient!has!lie!down!in!lateral!decubitus!with!the!shoulder!abducted!
and! the! elbow! flexed! at! 90! degrees! and! elbow! placed! at! shoulder!
level.!(90Y90!position).!
b) Very!carefully!and!slowly!therapist!has!to!apply!gentle!stretch!inward!
(Posterior!capsule)!and!outward!(anterior!capsule),!alternately.!
c) Therapist!can!also!instruct!patient!carefully,!to!do!these!stretches!at!
home!with!the!help!of!good!arm.!
!
Phase!II!
Phases!II!includes!the!same!exercises!as!Phase!1,!but!patient!has!to!
perform!it!at!home!after!learning!it!properly!by!a!trained!shoulder!
rehabilitation!therapist.!Duration!of!Phase!II!is!about!6!to!8!weeks.!
!
!
!
Phase!III!
!
Phase!III!protocol!is!started!only!after!basic!exercises!are!mastered!and!
principle! shoulder! muscles! like! rotator! cuff! muscles! and! scapular!
muscles!have!got!enough!strength!and!optimal!stability!of!the!shoulder!
complex!is!achieved.!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Sports! persons,! workers! or! individuals! who! are! in!
demand!of!high!intensity,!challenging!and!dynamic!activities,!must!go!for!
Phase!III!.Usually!after!6!to!8!weeks!generous!Phase!I!exercises.!!
!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!These! are! functional! dynamic! multiaxial! exercises!

which!puts!maximum!challenge!on!the!shoulder!muscles!so!as!to!do!any!
functional! activity.! Theraband! are! used! to! perform! PNF! (Proprioceptive!
Neuromuscular!Facilitation)!Patterns.!
D1!Pattern:!
!
Position:!
Standing!!
Technique:!
a) Patient! is! standing! straight! with! band! wrapped! in! the! affected! hand!
and!the!other!end!under!the!foot!with!optimal!tension!maintain!good!
base!of!support.!
b) First!patient!has!to!pull!the!band!in!shoulder!flexion,!adduction!(with!
elbow!and!wrist!flexed)and!external!rotation!as!if!he!is!trying!to!touch!
the! opposite! ear! (! D1Flexion! )! ,! like! in! Tennis! BackYHand! .The!
movement!must!be!smooth!and!slow.!
c) With! a! little! hold! at! the! end,! patient! has! to! take! the! arm! back! in!
shoulder,!elbow!and!wrist!extension,!shoulder!abduction!and!internal!
rotation.!(!D1!Extension)!
d) Repeat!it!for!ten!times.!
!
!
D2!Pattern:!

Position:!
Standing!!
Technique:!
a. Patient! is! standing! straight! with! band! wrapped! in! the! affected! hand!
and! the! other! end! is! tied! to! upper! fixed! point! optimal! tension!
maintaining!good!base!of!support.!
b. First!patient!has!to!keep!the!shoulder!flexion,!abduction!(with!elbow!
and! wrist! flexed)and! external! rotation! while! the! forearm! supinated!
and!wrist!and!fingers!extended.!!
c. Go! as! far! in! each! plane! of! motion! so! as! to! lengthen! all! involved!
muscles.!This!is!the!ending!point!of!D2!Flexion.!!
d. Now! ask! the! patient! to! pull! the! band! so! as! to! rotate! and! move! the!
arm! diagonally! down! and! across! the! body! (putting! the! sword! back!
into! the! scabbard)! with! shoulder,! elbow! and! wrist! flexion,! shoulder!
adduction!and!internal!rotation.!(!D2!Extension)!
e. After! little! holding! at! the! maximum! gradually! come! back! to! D1!
Flexion.!Repeat!it!for!ten!times.!
f. Patient!can!do!it!in!exactly!reverse!way!as!per!the!functional!needs.!
i.e.!put!the!free!end!of!the!band!under!the!opposite!leg.!(!taking!the!
sword!out!of!the!scabbard)!!

!
Compensations!to!look!for!
1.!Patient!may!hold!the!breath.!
2.!Patient!may!arch!the!back.!
3.!Patient!may!rotate!the!body!with!the!arm.!
!
!
90!!90!Rotational!Stability!

!
Position:!
Standing!with!stride!stance!
!
Technique:!
a) First!wrap!the!band!in!affected!hand,!taking!the!longer!free!end!
ulnar!side!of!forearm.!Flex!the!shoulder!and!elbow!at!90!degrees!
and!putting!the!forearm!parallel!to!ground,!take!the!free!end!of!
theband!inside!the!forearm!from!above.!

b) Take! figure! of! eight! wrap! to! middle! arm,! and! put! the! free! end!
under!the!opposite!feet.!!
c) Take! stride! stance! by! putting! the! affected! side! leg! ahead.! This!
the!starting!position!of!this!exercise.!
d) Now!externally!rotate!and!abduct!the!arm!to!90!degrees!keeping!
elbow! at! 90! degrees! of! flexion.! (! elbow! should! remain! at!
shoulder!level)!
e) With!a!little!hold!at!the!end,!gradually!take!the!band!to!neutral.!
!
Compensations!to!look!for&
1.!Patient!may!hold!the!breath!.!
2.!Patient!may!arch!the!back.!
3.!Patient!may!elevate!the!shoulders.!
!
!
Scapular!stabilization!exercises!
These!exercises!are!special!exercises!given!for!correction!of!scapular!positioning!
in!cases!of!scapular!dyskinesia!and!they!improve!force!couple!reaction!my!
reducing!muscle!imbalances!and!improving!proprioception.!
All!these!exercises!are!given!for!repetition!and!practice!has!to!be!performing!as!
many!times!as!possible!thru!out!the!day.!
There!are!approximately!four!types!of!exercises!in!this!type!
!
Setting!in!neutral!
Dissociation!
Scapular!clock!
Wall!washes!
!
!
Setting!in!neutral:!
The!position!of!scapula!has!to!be!at!T6!level!whenever!any!shoulder!movement!
initiates.!Scapula!has!to!be!braced!properly!without!any!protraction!and!anterior!
tilting!when!movement!starts.!

(First!exe!of!scapular!setting!is!similar!to!this)!
Dissociation!
When!scapula!setting!is!achieved!in!neural!even!dynamically!it!should!understand!
to!come!in!neutral!hence!shoulder!dissociation!exercise!is!given.!Patient!in!
standing!position!brace!the!scapulae!and!slowly!lift!the!arm!in!forward!flexion!till!
90!deg!without!any!movement!in!scapula.!Therapist!will!be!giving!verbal!as!well!
as!tactile!feedback!with!the!help!of!finger!when!ever!required;!at!home!patient!
can!use!the!opposite!hand!for!the!same.!
!
If!dyskinesia!is!severe!then!ask!patient!to!lie!down!on!ground!without!any!mat!
and!do!the!same!movement.!Ground!will!be!giving!required!proprioceptive!
feedback!
!
!
!
!

SCAPULAR DISSOCIATION

49

Setting!in!neutral!
!
&
Scapular!clock!
This!exercise!again!improves!proprioception!in!scapulae.!!

To!start!with!ask!patient!to!stand!at!the!wall!keeping!his!hand!above!level!as!if!he!
is!pressing!the!wall!and!then!ask!him!to!perform!protraction!and!retraction!in!the!
same!position!while!maintaining!scapular!position!
This!activity!has!to!be!performed!in!all!four!movements!like!elevation!depression!
protraction!and!retraction!and!hence!imagine!a!clock!on!wall!and!perform!the!
exercise!at!12!,!3!,!6!,!and!9!Oclock!position.!
!
You!can!add!a!basket!ball!in!the!exercise!to!make!it!unstable!and!adding!difficulty!

&
!

!
!

&

Cuff&substitution&programme&
!

It!is!usually!given!for!the!patients!who!are!treated!with!
conservative!treatment!for!full!thickness!cuff!tear.!And!also!
for!patients!who!has!irreparable!cuff!tears!and!cuff!
arthropathy,!
!

In!these!patients!PSRP!is!given!in!the!same!way!except!SUPRASPINTUS!is!
substituted!by!DELTOID!ALL!THREE!Fibers!!
!
Anterior!Deltoid!
Ask!patient!to!stand!straight!with!shoulder!retracted!and!depressed.!!
Tie!two!knots!to!the!wrist!and!then!take!full!hand!length!measurement!and!
stand!on!that!point.!Then!lift!the!arm!in!forward!flexion!without!elevating!the!
scapulae.!

!
Middle!Deltoid!
Ask!patient!to!stand!straight!with!shoulder!retracted!and!depressed.!!
Tie!two!knots!to!the!wrist!and!then!take!full!hand!length!measurement!and!
stand!on!that!point.!Then!lift!the!arm!in!abduction!without!elevating!the!
scapulae.!
Posterior!Deltoid!
Ask!patient!to!stand!straight!with!shoulder!retracted!and!depressed.!!
Tie!two!knots!to!the!wrist!and!then!take!full!hand!length!measurement!and!
stand!on!that!point.!Then!lift!the!arm!in!extension!without!elevating!the!
scapulae.!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
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!

&
Post&operative&exercise&programme&
!

Exercises&for&first&6&weeks&
!
Simple!pendulum!exercises!in!clockwise!and!anti!clockwise!manner!
for!about!10!times!each!three!to!four!times!a!day.!
Lean!on!a!table!with!uninvolved!hand!and!first!move!the!affected!
arm!forward!ten!times!slowly,!then!sideways!slowly!and!finally!round!
and!round!clockwise!and!anticlockwise.!!
Strictly!avoid!rapid!jerky!movements.!
Bracing!as!in!the!military&position&with!the!shoulders!thrust!back!and!
chest!inflated!to!a!count!of!ten!and!repeated!ten!times.!!
While!sitting!one!must!make!a!constant!attempt!to!improve!posture!
by!avoiding!slouching!and!using!the!military&position.!
!

&

Pendulum!Exercises!

From&3rd&week&onwards&
Active!assisted!ex.!
Ask!patient!to!lift!the!arm!with!the!help!of!!stick!in!forward!&!
sideways!direction.!
Lift!only!till!the!shoulder!allows.!You!must!not!have!pain!while!doing!
this!exercise..!IF!it!hurts!then!do!not!do!it.!!Patient!CERTAINLY!should!
NOT!LIFT!the!arm!BEYOND!90.!

!
Static!Exercises!
Anterior!deltoid!
Stand!in!front!of!the!wall!and!face!the!wall.!
Try!to!push!the!wall!with!your!palm.!Hold!for!ten!counts!and!ten!
repetitions!
!
Middle!Deltoid!
Stand!in!front!of!the!wall!and!sideways!the!wall.!
Try!to!push!the!wall!with!your!palm.!Hold!for!ten!counts!and!ten!
repetitions!
!
!
Posterior!Deltoid!
Stand!in!front!of!the!wall!and!face!the!back!towards!the!wall.!
Try!to!push!the!wall!with!your!palm.!Hold!for!ten!counts!and!ten!
repetitions.!
!
After&Six&weeks&
The!patient!must!undergo!a!supervised!rehab!programme!for!ROM!
restoration!with!a!shoulder!physiotherapist.!They!are!advised!to!
Strengthen!Scapular!muscles!(Rhomboids!&!Serratus)!&!The!Rotator!
cuff!muscles!with!Theraband!in!an!eccentric!closed!chain!manner.!
The!supervised!rehab!programme!lasts!for!about!two!weeks!after!
which!the!patient!does!the!exercises!at!home!for!four!weeks!at!least.!
Simultaneously!they!undergo!gentle!stretches!for!restoration!of!
forward!flexion!and!abduction!and!external!&!internal!rotation.!

Attention!to!core!stability!is!also!mandatory!during!the!supervised!
programme.!
&
Landmarks&
After!starting!phase!I!six!weeks!after!the!date!of!surgery!normally!
most!patients!would!attend!a!supervised!rehab!programme!under!
our!accredited!shoulder!physiotherapist.!Following!that!patients!
usually!achieve!a!good!range!of!movement!and!are!essentially!
lacking!in!strength,!Patients!then!leave!for!a!Phase!II!home!
programme!for!a!month!to!six!weeks.!Thus!about!three!months!after!
surgery!they!have!usually!achieved!90%!of!their!movement!and!
decent!strength.!Not!all!patients!follow!the!charted!path!and!there!
are!differences!depending!on!the!extent!of!tear,!the!preceding!
duration!of!illness!and!age.!If!after!Phase!I!patients!are!still!not!
achieved!50%!improvement!and!are!still!in!pain!should!seek!
immediate!advice.!
!
!

Important Tips

On!completion!of!phase!I!the!patient!is!advised!to!proceed!to!!
twice!daily!home!programme!for!all!the!previous!exercises!for!a!
period!of!one!month!when!he/she!is!followed!up.!!

For! initiators! perform! Capsular! stretches! and! Active! assisted!

exercises! with! the! patient! lying! down.! This! helps! stabilise! the!
scapula!automatically,!avoiding!impingement,!!
Scapular! setting! and! proprioception! restoration! are! best!
demonstrated!practically!during!your!actual!programme!to!give!
you!a!placatory!feedback.!!
It! is! important! for! patients! to! report! to! the! physician! of! they!
have!no!improvement!for!a!week!or!if!they!actually!deteriorate.!!

!Most!patients!will!achieve!a!full!pain!free!function!at!the!end!
of!the!four!week!home!programme.!!
!It!is!advisable!to!do!a!UCLA!score!before!phase!I!and!at!the!end!
of!phase!II!to!establish!objective!criteria!of!improvement.!
Strictly! no! STRETCHES! are! given! for! shoulder! replacement! or!
Reverse! replacement! osteoarthritis! and! rheumatic! shoulder!
arthritis!patient.!!
!
Watch! out! for! neighbouring! conditions! which! mimic! shoulder!
problems!!
!
DIFFERENTIAL&DIAGNOSIS&&
!
!Cervical!Disc!Disease!!
!Suprascapular!Nerve!palsy!!
!Long!Thoracic!Nerve!Palsy!!
!Rheumatoid!Arthritis!!
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