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[ research report ]

PETER K. EDWARDS, MSc1 • JAY R. EBERT, PhD1 • CHRIS LITTLEWOOD, PhD2


TIM ACKLAND, PhD1 • ALLAN WANG, FRACS, PhD3,4

A Systematic Review of Electromyography


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Studies in Normal Shoulders to Inform


Postoperative Rehabilitation Following
Rotator Cuff Repair

R
otator cuff tears are generally considered to be normal, age- after surgery often depends on the size of
related degenerative disorders, with full-thickness rotator cuff the tear; tissue quality; the location, type,
tears evident in approximately 20% of patients over 65 years and chronicity of the tear; previous and/
or concomitant surgery; and individual
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

of age.11,50,58 When rotator cuff tears become symptomatic and


patient factors such as smoking, body
conservative management fails, they are typically repaired surgically. mass, and physical activity.1,12,13,15,17,19,20,36,47
Reports of the incidence of surgery to re- clinical results, reports of repair failure However, the postoperative rehabilita-
pair the rotator cuff show an increase of after surgery can range from 16% to 94%, tion protocol remains one of the more
238% from 1995 to 2009 in the United and those that do fail, or fail to heal, tend important factors in determining a suc-
States9 and of 204% from 1998 to 2011 in to do so within the first 3 to 6 months cessful outcome following rotator cuff
a Finnish population.42 Despite positive postsurgery.26,39 A successful outcome surgical repair.25 Several studies have in-
dicated that avoiding early motion may
UUSTUDY DESIGN: Systematic review. UURESULTS: A search identified 2159 studies. protect the repaired tendon(s) without
Journal of Orthopaedic & Sports Physical Therapy®

UUBACKGROUND: Electromyography (EMG) has After applying the selection criteria, 20 studies detrimental postoperative stiffness,33,44
previously been used to guide postoperative reha- were included for quality assessment, data extrac- while conversely, other studies advocate
bilitation progression following rotator cuff repair to tion, and data synthesis. In total, 43 exercises early passive and active-assisted motion
prevent deleterious loading of early surgical repair. spanning passive range of motion, active-assisted of the operated shoulder to regain func-
UUOBJECTIVE: To review the current literature range of motion, and strengthening exercises were tional mobility.31 As such, both surgeons
investigating EMG during rehabilitation exercises evaluated. Out of 13 active-assisted exercises, 9 and therapists alike remain uncertain and
in normal shoulders, and to identify exercises were identified as suitable (15% MVIC or less) to
conflicted about how to best manage and
that meet a cut point of 15% maximal voluntary load the supraspinatus and 10 as suitable to load
rehabilitate a patient after rotator cuff re-
isometric contraction (MVIC) or less and are the infraspinatus early after surgery. All exercises
pair, particularly, when to introduce and
unlikely to result in excessive loading in the early were placed in a theoretical-continuum model, by
postoperative stages. which general recommendations could be made progress passive and active-assisted exer-
UUMETHODS: An electronic search of MEDLINE via for prescription in patients post rotator cuff repair. cises throughout the early postoperative
UUCONCLUSION: This review identified passive
Ovid, Embase, CINAHL, SPORTDiscus, PubMed, and period without risk of an adverse outcome.
the Cochrane Library for all years up to June 2016 Exercise prescription following rota-
and active-assisted exercises that may be appro-
was performed. Studies were selected in relation to priate in the early stages after rotator cuff repair. tor cuff repair could be based on known
predefined selection criteria. Pooled mean MVICs muscle activity levels elicited during
J Orthop Sports Phys Ther 2017;47(12):931-944.
were reported and classified as low (0%-15% each respective exercise, as these are the
Epub 13 Jul 2017. doi:10.2519/jospt.2017.7271
MVIC), low to moderate (16%-20% MVIC), moderate
UUKEY WORDS: electromyography, exercise,
best available estimate of stress placed
(21%-40% MVIC), high (41%-60% MVIC), and very
high (greater than 60% MVIC). rehabilitation, shoulder on the rotator cuff tendon.51 A number of
studies have investigated muscle loading

The School of Human Sciences, University of Western Australia, Crawley, Australia. 2Keele Clinical Trials Unit and Research Institute for Primary Care and Health Sciences, Keele
1

University, Staffordshire, United Kingdom. 3Department of Orthopaedic Surgery, The University of Western Australia, Perth, Australia. 4St John of God Hospital, Subiaco, Australia.
The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials
discussed in the article. Address correspondence to Mr Peter Edwards, School of Human Sciences (M408), University of Western Australia, 35 Stirling Highway, Crawley, WA 6009
Australia. E-mail: peter.edwards@uwa.edu.au t Copyright ©2017 Journal of Orthopaedic & Sports Physical Therapy®

journal of orthopaedic & sports physical therapy | volume 47 | number 12 | december 2017 | 931


[ research report ]
during an array of therapeutic rotator cuff METHODS cises to ensure that a comparison could
rehabilitation exercises.10,16,35,38,54 These be made between each study. Exercises
studies have evaluated the challenge to Data Sources and Search Strategy were considered relevant and deemed
individual rotator cuff musculature in A comprehensive search of all relevant eligible if a minimum of 2 repetitions of
nonpathological, asymptomatic shoul- literature was undertaken in 5 data- each exercise was performed, to further
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ders using electromyography (EMG) bases: MEDLINE via Ovid, Embase, differentiate between a clinical test and
via a percentage of maximal voluntary CINAHL, SPORTDiscus, PubMed, and an exercise for rehabilitation, and were
isometric contraction (MVIC). Electro- the Cochrane Library for all years up to designed specifically to either load the
myography has previously been used as a June 2016. Search terms were related to rotator cuff or to rehabilitate and restore
pragmatic tool to guide postoperative re- rotator cuff muscles (supraspinatus OR function following rotator cuff repair.
habilitation progression by categorizing infraspinatus OR subscapularis OR teres This included passive, active-assisted,
activation levels as low (0%-20% MVIC), minor OR rotator cuff OR cuff muscles), and active exercises, as these exercises are
moderate (21%-40% MVIC), high (41%- exercise (exercis* or eccentric or concen- commonly performed movements in the
60% MVIC), and very high (greater than tric or iso* or resist* or rehab* or physical early stages following rotator cuff repair.
60% MVIC).16,38,54 From the perspective therapy or strength* or load* or training No restriction on time period or level of
of rehabilitation following rotator cuff or activ* or passive*), and electromyogra- evidence was applied to the search; how-
tendon repair, it is essential to consider phy (electro* or EMG) (TABLE 1). Electro- ever, studies must have been published in
the spectrum of all rotator cuff loading myography was chosen because this is the a peer-reviewed journal.
exercises, given their importance in the most reliable and valid method of mea- Studies whose sample included pa-
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

early postoperative stages to improving suring muscle activation, and has been tients with a history of shoulder patholo-
range of motion (ROM) and motor per- used in previous reviews as a measure to gy, injury, or pain were excluded to reduce
formance of the shoulder without over- establish loading during rehabilitation the unknown influence of these factors on
loading the early surgical repair. Previous exercises.10,14 A manual review of refer- EMG outcomes. However, control groups
reviews have evaluated strengthening ences in key articles was also performed in studies evaluating differences dur-
exercises that optimally load the rotator to ensure that no relevant articles had ing exercises between pathological and
cuff, deltoid, and scapular muscles.10,14 been overlooked or not located in the ini- healthy participants were included. To
However, these reviews have failed to tial search. reduce the potential effects of shoulder
include passive and/or active-assisted pathology on EMG findings, studies that
Journal of Orthopaedic & Sports Physical Therapy®

activities in conjunction with active Selection Criteria and Quality Appraisal had a mean age or upper age limit range
strengthening exercises, and thus do Two reviewers (P.E. and J.E.) indepen- above 50 years were excluded, because-
not provide the information required for dently applied selection criteria to the asymptomatic rotator cuff tears increase
therapists to better prescribe exercises titles and abstracts of the manuscript with age.50 Any study with a specific aim
throughout the entire postoperative re- yield. It was required that studies used to evaluate a clinical test was excluded, as
habilitation timeline. EMG as a primary tool to detect muscle were studies in which rotator cuff mus-
The objective of this systematic re- activity in the rotator cuff during reha- cle activity was examined during activi-
view was to identify and synthesize the bilitation exercises, as this is the gold ties such as occupational tasks, sporting
current literature regarding rotator cuff standard method of measuring such ac- tasks, or specific hand grips, as these were
muscle activation in a normal, uninjured tivity.14 Included studies were required not considered to be exercises that could
cohort during common rehabilitative ex- to undertake EMG analysis of at least 1 be implemented in a clinical rehabilita-
ercises routinely prescribed after rotator rotator cuff muscle, to compare the inten- tion program. While studies evaluating
cuff repair, and to understand how these sity between different rehabilitation exer- 2 or more different rehabilitation exer-
exercises may load a newly repaired ro-
tator cuff tendon. In the absence of de-
finitive evidence regarding postoperative TABLE 1 Search Terms in the MEDLINE Database
rehabilitation, the aim of this review is to
define an optimal postoperative loading
Search Term
protocol within the parameters currently
1 supraspinatus OR infraspinatus OR subscapularis OR teres minor OR rotator cuff OR cuff muscles [Title /
deemed not to expose the repairing cuff
Abstract] AND
to loads that might cause structural fail-
2 exercis* OR resist* OR rehab* OR physical therapy OR strength* OR load* OR training OR activ* OR passive*
ure, and to see whether EMG evidence [Title / Abstract] AND
can help us design more progressive re- 3 electromyo* OR EMG [Title / Abstract]
habilitation protocols.

932 | december 2017 | volume 47 | number 12 | journal of orthopaedic & sports physical therapy


cises were included, individual exercises Data Synthesis MVIC).6,16,38,54 In their biomechanical
not meeting the inclusion criteria were As differences existed in methodology be- study, Long et al35 designated muscle
omitted from this evaluation. Exercises tween the included studies (eg, individual activation greater than 15% MVIC to
that required the addition of external muscles analyzed, exercises tested, exer- be potentially indicative of higher loads
load (eg, dumbbells or resistance bands) cise procedure variations, normalization than desirable in a newly repaired rota-
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were included, provided the load could be procedures), data were not combined tor cuff. Therefore, to permit meaningful
replicated or performed within an inde- in a meta-analysis or directly compared comparisons of EMG activation levels
pendent home-based setting (eg, not re- between studies.7,14 Rather, a qualitative between exercises and to improve the
quiring the use of machine equipment). analysis was carried out to identify the clinical relevance of load stratification,
In studies that presented their results exercises within each study that elicited we chose to employ the following clas-
graphically, data values were estimated maximum muscle activity. As previously sification system for the safe and pro-
from the graph. Studies that did not nor- stated, a comparison of EMG data from gressive implementation of the reported
malize the EMG activity of exercises to an each of the 4 rotator cuff muscles during rehabilitation exercises: low, 0% to 15%
MVIC were excluded, as were studies that each exercise is presented as a percent- MVIC; low to moderate, 16% to 20%
recorded supraspinatus activity via sur- age of the MVIC (percent MVIC) for that MVIC; moderate, 21% to 40% MVIC;
face EMG. Non-English studies, review muscle. For the purpose of this review, in high, 41% to 60% MVIC; and very high,
articles, conference abstracts, non–peer- studies where different resistance loads greater than 60% MVIC.
reviewed studies, case reports, and opin- were included, the maximal load was an-
ion pieces were excluded, as were articles alyzed to record maximal average muscle RESULTS
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

for which the full text was not available. activation during the exercises.

T
Previous studies have previously he comprehensive search of the
Study Review Process categorized activation into levels (low, electronic databases identified 2157
and Quality Appraisal 0% to 20% MVIC; moderate, 21% to studies, and 2 additional studies
The full text of an article was sourced for 40% MVIC; high, 41% to 60% MVIC; were included for evaluation after manu-
review when the title and/or abstract ap- and very high, greater than 60% ally searching through reference lists of
peared to meet the selection criteria, or
did not provide sufficient information
to determine its eligibility and required
Journal of Orthopaedic & Sports Physical Therapy®

Database Search
closer investigation. The full text of the Additional articles identified through
Potentially relevant publications, n = 2159
reference checks, n = 2
articles was appraised for quality using a • MEDLINE, n = 477
standardized quality assessment tool for • Embase, n = 586
• PubMed, n = 619
observational studies, as used by Gan- • CINAHL, n = 186
derton and Pizzari14 in a previous review, • SPORTDiscus, n = 256
that reported each aspect of the qual- • Cochrane Library, n = 33
ity assessment in a raw form instead of Duplicates removed, n = 1245
in a summarized score. Each study was
evaluated by its respective category, such
that quality and validity were not com-
promised. Two reviewers (P.E. and J.E.) Titles and abstracts screened, n = 914
independently assessed the methodologi- Results excluded based on title and abstract,
n = 866
cal quality of the included studies, and
disagreement was resolved by consensus. Full texts excluded, n = 28
• Exercise criteria not met, n = 12
Data Extraction and Analysis Retrieved for full-text evaluation, n = 48 • No full text available, n = 2
One reviewer (P.E.) independently ex- • Age >50 y, n = 1
• Evaluated clinical test position, n = 5
tracted data in relation to study char- • Pathological cohort, n = 3
acteristics, methodological details, • Did not evaluate rotator cuff, n = 1
method of EMG analysis and normal- • Not normalized to % MVIC, n = 3
ization procedure, and the results from Articles included for review, n = 20 • Improper electrodes, n = 1
studies (mean muscle amplitude data
for each rotator cuff muscle during each FIGURE 1. A flow chart of the search strategy used in this review. Abbreviation: MVIC, maximal voluntary isometric
contraction.
exercise).

journal of orthopaedic & sports physical therapy | volume 47 | number 12 | december 2017 | 933


[ research report ]
retrieved papers and systematic reviews
Supine bar-assisted ER38 3
(FIGURE 1). After screening all titles and Upright bar-assisted ER30 3
abstracts and removing duplicates, 48 Washcloth press-up (hands close)54 3
publications were subsequently assessed Washcloth press-up (hands apart)54 4
Supine press-up54 4
in full text. Of these, 20 satisfied the se-
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Wall-assisted ER30 4
lection criteria, were rated as “good qual- Scapular protraction on ball54 5
ity,” and were included for full review. For Forward bow54 5
exercises examined in a single study, we Supine therapist-assisted elevation38 5
reported their individual mean, and for Prone shoulder extension: 0° of ABD56 6
Sidelying elevation16 7
exercises examined in more than 1 study, Standing IR: 0° of ABD38,41 7 (7-10)
we reported the pooled mean and the Incline press-up54 8
range of mean MVIC values. A summary Towel slide (sagittal)16,30 8 (4-12)
of the characteristics and methodological Upright-assisted IR38 9
Supine self-assisted elevation16,38,54 11 (1-17)
quality of the 20 included studies is pro-
Pendulum38 11
vided in TABLE 2 and TABLE 3, respectively. Towel slide (medial)16 12
Electromyographic activity of the 4 rota- Towel slide (scapular)16,54 13 (7-13)
tor cuff muscles was compiled, summa- Supported vertical wall slide57 13

rized, and ranked from lowest to highest


activation to allow for a comparison of
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Ball roll16 16
exercises. Upright bar-assisted elevation16,21,30,38 16 (11-19)
FIGURE 2 depicts the pooled means for Unsupported vertical wall slide57 17
Pulley-assisted elevation16,21,30,38 17 (3-19)
supraspinatus muscle activations dur-
Supported diagonal wall slide57 18
ing passive, active-assisted, active, and Active flexion: elbow bent38 20
strengthening exercises. Overall, 20 ex- Wall walk/slide16,38 22 (21-22)
ercises reported low-level (less than 15% Unsupported diagonal wall slide57 22
Standing resisted shoulder extension41 24
MVIC) muscle activation, and therefore
Supine assisted ER38 27
were deemed appropriate to implement in Standing press-up54 29
early-stage rehabilitation following rota- Active flexion/elevation: elbow straight16
Journal of Orthopaedic & Sports Physical Therapy®

29
tor cuff repair. FIGURE 3 depicts the pooled Standing ER in scapular plane46 32
Standing IR in scapular plane ABD4 33
means for infraspinatus muscle activations
Seated row/pull24 33
during passive, active-assisted, active, and Standing ER: 0° of ABD without towel38,41,46 35 (20-41)
strengthening exercises. Overall, 23 ex- Standing resisted shoulder flexion/elevation41 35
ercises reported low-level (less than 15% Prone flexion: 180° of ABD56 38
MVIC) muscle activation and were there-
fore deemed appropriate to implement in
Standing IR: 90° of ABD41 41
early-stage rehabilitation following rota- Standing ER: 0° of ABD with towel46 41
tor cuff repair. FIGURE 4 depicts the pooled High row41 42
means for the teres minor, the muscle least Low row41 46
Standing row/pull28 46
evaluated, with 15 exercises selected across
Forward punch5,28,41 46
4 studies, all of which were strengthening Sidelying ER46 51
exercises. Only 6 studies evaluated the sub- Standing ER: 90° of ABD41,46 54 (39-57)
scapularis, which is shown in FIGURE 5. Jung Diagonal4 54
et al30 was the only study that measured Dynamic hug4 62
Full-can shoulder ABD3,45 73 (62-90)
the subscapularis (upper) during passive Prone ER: 90°3,46 74 (68-91)
and active-assisted exercises, 3 of which Empy-can shoulder ABD3,45 75 (63-92)
were classified as truly passive. Decker et Prone horizontal ABD: 90°3,45 77 (67-88)
al4 was the only study that compared both Prone horizontal ABD: 100°45 82
Push-up plus4 99
the upper and lower portions of the sub-
0 15 30 45 60 75 90 105
scapularis. The mean amplitudes evaluat- % MVIC
ed in the lower portion of the subscapularis
were not pooled and subsequently exclud- FIGURE 2. Supraspinatus pooled means (range) of percent MVIC ranking of exercises. Abbreviations: ABD, abduction;
ER, external rotation; IR, internal rotation; MVIC, maximal voluntary isometric contraction.
ed from FIGURE 5. The lower portion of the

934 | december 2017 | volume 47 | number 12 | journal of orthopaedic & sports physical therapy



TABLE 2 Characteristics of Included Studies

Study Sample Muscles Assessed Electrode Type Exercises Evaluated


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Boettcher et al3 n = 15 (9 male, 6 female) healthy, asymptomatic participants Supraspinatus, Intramuscular Full-can shoulder abduction
Mean age, 28.4 y; age range, 19-47 y infraspinatus Empty-can shoulder abduction
Dominant shoulder Prone horizontal abduction
Prone ER: 90°
Decker et al4 n = 15 (9 male, 6 female) healthy, asymptomatic participants Supraspinatus, Intramuscular, Dynamic hug
Male mean ± SD age, 28.0 ± 5.1 y; height, 180 ± 10 cm; infraspinatus, surface Forward punch
weight, 87.4 ± 14.6 kg subscapularis Diagonal
Female mean ± SD age, 25.0 ± 2.4 y; height, 160 ± 10 cm; Standing IR: 0°
weight, 58.0 ± 6.9 kg Standing IR: scapular plane
Standing IR: 90°
Push-up plus
Gaunt et al16 n = 15 (7 male, 8 female) healthy, asymptomatic participants Supraspinatus, Intramuscular, Towel slide (sagittal)
Mean age, 23.9 y; age range, 22-28 y; mean ± SD height, 173.4 infraspinatus surface Towel slide (medial)
± 10.6 cm; weight, 74.4 ± 15.9 kg Towel slide (scapular plane)
Supine self-assisted elevation
Pulley-assisted elevation
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Wall walk/slide
Ball roll
Upright bar-assisted forward elevation
Active flexion/elevation, elbow straight
Gurney et al21 n = 28 (15 men, 13 women) healthy, asymptomatic partici- Supraspinatus, Intramuscular Pulley-assisted elevation in sagittal plane
pants infraspinatus, Pulley-assisted elevation in scapular plane
Men mean ± SD age, 33.5 ± 16.4 y subscapularis, Self-assisted elevation
Women mean ± SD age, 26.5 ± 5.0 y teres minor Self-assisted bar elevation
Randomly assigned Therapist-assisted elevation
Ha et al22 n = 30 (24 men, 6 women) healthy participants Infraspinatus Surface Prone ER
Mean ± SD age, 22.6 ± 1.7 y; height, 176.2 ± 4.5 cm; weight, Sidelying wiper
Journal of Orthopaedic & Sports Physical Therapy®

65.6 ± 7.4 kg Sidelying ER


Standing ER
Hintermeister n = 19 healthy males Supraspinatus, Intramuscular, Standing IR: 0°
et al24 Mean ± SD age, 30 ± 6.2 y; height, 179.3 ± 4.6 cm; weight, infraspinatus, surface Seated rowing (middle grip)
78.2 ± 8.4 kg subscapularis Seated rowing (wide)
Dominant shoulder Forward punch
Illyés and Kiss28 n = 16 (12 male, 4 female) healthy participants from control Supraspinatus, Surface Standing row/pull
group infraspinatus Forward punch
Male mean ± SD age, 22.1 ± 1.1 y; height, 182.9 ± 23.9 cm; Active flexion/elevation: elbow straight
weight, 72.1 ± 3.4 kg
Female mean ± SD age, 22.6 ± 2.12 y; height, 164.1 ± 33.3 cm;
weight, 61.1 ± 4.5 kg
Dominant shoulder
Illyés et al27 n = 25 (16 male, 9 female) healthy participants from control Infraspinatus Surface Standing row/pull
group Forward punch
Male mean ± SD age, 28.1 ± 3.1 y; height, 172.9 ± 14.9 cm; Shoulder elevation
weight, 77.1 ± 8.4 kg
Female mean ± SD age, 26.6 ± 3.7 y; height, 168.9 ± 12.3 cm;
weight, 63.1 ± 5.5 kg
Dominant shoulder
Jung et al30 n = 16 healthy male participants Supraspinatus, Intramuscular Towel slide
Median age, 25 y; age range, 21-30 y; median height, 175 cm; infraspinatus, Pulley-assisted elevation
height range, 165-184 cm; median weight, 71 kg; weight subscapularis Upright bar-assisted forward elevation
range, 55-106 kg Upright bar-assisted ER
Wall-assisted ER
Table continues on page 936.

journal of orthopaedic & sports physical therapy | volume 47 | number 12 | december 2017 | 935


[ research report ]

TABLE 2 Characteristics of Included Studies (continued)

Study Sample Muscles Assessed Electrode Type Exercises Evaluated


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Kim et al32 n = 32 healthy participants (18 male, 14 female) Infraspinatus Surface Sidelying ER without towel
Mean ± SD age, 24.7 ± 3.3 y; height, 173.4 ± 10.6 cm; weight, Seated ER at 90° of abduction
74.4 ± 15.9 kg Seated ER at 0° of abduction
Dominant shoulder Prone ER at 90°
Marta et al37 n = 15 (7 male, 8 female) healthy, asymptomatic participants Infraspinatus, teres Surface Prone horizontal abduction at 90° with full ER
Mean age, 23.9 y; age range, 22-28 y minor Prone horizontal abduction at 90°
Prone horizontal abduction at 100° of abduction
Prone ER at 90°
Sidelying ER without towel
Standing ER: scapular plane
Standing ER: 0° with towel
McCann et al38 n = 10 healthy, asymptomatic participants Supraspinatus, Intramuscular Supine self-assisted elevation
Age range, 18-33 y infraspinatus Supine therapist-assisted elevation
Supine bar-assisted ER
Supine assisted ER
Pendulum
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Pulley-assisted elevation
Upright bar-assisted elevation
Wall walk/slide
Upright assisted extension
Upright assisted IR
Active forward flexion/elevation (elbow bent)
Active forward flexion/elevation (elbow straight)
Active abduction
Standing ER at 0° without towel
Standing IR at 0°
Myers et al41 n = 15 healthy male participants Supraspinatus, Intramuscular, Standing IR at 0°
Journal of Orthopaedic & Sports Physical Therapy®

Mean ± SD age, 24.53 ± 2.77 y; height, 177 ± 8 cm; weight, infraspinatus, surface Standing IR at 90°
78.31 ± 8.20 kg subscapularis, Standing ER at 0°
Dominant shoulder teres minor Standing ER at 90°
Standing resisted shoulder flexion/elevation
Standing resisted shoulder extension
High scapular rows
Standing rows/pull
Low scapular rows
Forward punch
Reinold et al46 n = 10 (5 male, 5 female) healthy, asymptomatic participants Supraspinatus, Intramuscular Standing ER at 0° with towel
Mean age, 28.1 y; range, 22-38 y infraspinatus, Standing ER at 0° without towel
Dominant shoulder teres minor Standing ER in scapular plane
Standing ER at 90°
Sidelying ER
Prone ER at 90°
Prone horizontal abduction at 100°
Reinold et al45 n = 22 (15 male, 7 female) healthy, asymptomatic participants Supraspinatus Intramuscular Full-can shoulder abduction
Mean ± SD age, 26.7 ± 7 y; height, 175 ± 10 cm; weight, Prone horizontal abduction at 90°
79 ± 18 kg Empty-can shoulder abduction
Dominant shoulder
Sakita et al48 n = 20 male participants Infraspinatus Surface Standing ER at 0° with towel
Mean ± SD age, 26.0 ± 3 y; height, 180 ± 7 cm; weight, Standing ER at 0° without towel
77 ± 10 kg Sidelying ER with towel
Dominant shoulder Sidelying ER without towel
Table continues on page 937.

936 | december 2017 | volume 47 | number 12 | journal of orthopaedic & sports physical therapy



TABLE 2 Characteristics of Included Studies (continued)

Study Sample Muscles Assessed Electrode Type Exercises Evaluated


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Uhl et al53 n = 18 healthy males Supraspinatus, Intramuscular, Prayer


Mean ± SD age, 22 ± 3 y; height, 175 ± 10 cm; weight, infraspinatus surface Quadruped
73 ± 17 kg Tripod
Dominant shoulder Pointer
Push-up
Push-up with feet elevated
One-armed push-up
Uhl et al54 n = 10 (3 male, 7 female) healthy, asymptomatic volunteers Supraspinatus, Intramuscular Supine self-assisted elevation
Mean ± SD age, 25.0 ± 5 y; height, 171 ± 7 cm; weight, infraspinatus Forward bow
78 ± 15 kg Washcloth press-up (hands close)
Dominant shoulder Washcloth press-up (hands apart)
Towel slide (scapular plane)
Scapular protraction on ball
Supine press-up
Incline press-up
Standing press-up
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Wattanaprakornkul n = 15 (10 male, 5 female) healthy, asymptomatic participants Supraspinatus, Intramuscular Prone flexion at 180° of abduction
et al56 Mean ± SD age, 21.9 ± 3.0 y; height, 170.5 ± 12.2 cm; weight, infraspinatus, Prone extension at 0° of abduction
67.1 ± 13.9 kg subscapularis
Dominant shoulder
Wise et al57 n = 20 healthy participants Supraspinatus, Intramuscular Supported vertical wall slide
Mean ± SD age, 21.7 ± 2.8 y; height, 168.6 ± 23.8 cm; weight, infraspinatus Unsupported vertical wall slide
73.7 ± 17.1 kg Supported diagonal wall slide
Dominant shoulder Unsupported diagonal wall slide
Abbreviations: ER, external rotation; IR, internal rotation.
Journal of Orthopaedic & Sports Physical Therapy®

subscapularis was found to be moderately better inform clinicians in prescribing ymptomatic limb to move the operated
activated during the dynamic hug (39% rehabilitation exercises early postsurgery. limb also generated low-level activation
MVIC), diagonal exercise (38% MVIC), In the case of rotator cuff repair, exercise in both the supraspinatus and infraspi-
and internal rotation in 0° (40% MVIC) prescription respecting tissue healing natus. However, active-assisted exercises
and 45° of abduction (26% MVIC). The and repair maturation, particularly with- using a bar or a pulley to elevate the op-
push-up plus exercise showed the highest in the first 3 to 6 months, when the repair erated limb tended to generate over 15%
activation levels, with very high activation is most vulnerable,26,39 is vital to prevent MVIC, suggesting that their use early in
in the upper subscapularis (121% MVIC) excessive loading at the repair site. Pre- rehabilitation may be inappropriate. The
and high-level activation in the lower sub- vious studies have used EMG studies to pendulum exercise, a passive exercise
scapularis (46% MVIC). guide postoperative rehabilitation pro- commonly employed early in rehabilita-
TABLE 4 depicts a continuum of re- gression in the rotator cuff following tion, demonstrated low levels of supra-
habilitation exercises based on muscle surgery,55 with 15% MVIC considered to spinatus and infraspinatus activation,
activation (percent MVIC) for the supra- be the upper limit of a safe loading range suggesting that it may be appropriate for
spinatus and infraspinatus, modified to during exercises in the early stages fol- inclusion as an early-stage exercise after
match suggested phases of rehabilitation lowing repair. In this review, the pooled rotator cuff repair. However, it has been
for both early and delayed postoperative means of 20 and 25 exercises for the su- shown that incorrectly performed pendu-
motion pathways. praspinatus and infraspinatus, respec- lums, especially large pendulums, gener-
tively, generated activation levels below ated more supraspinatus muscle activity
DISCUSSION this 15% cutoff. The exercises, both pas- in the shoulder than smaller, correctly
sive and active assisted, were intended performed pendulum exercises.35 Fur-

T
he goal of this systematic re- to restore glenohumeral ROM. The bulk thermore, the amount of supraspinatus
view was to highlight rotator cuff of passive ROM exercises demonstrated muscle activation during incorrect pen-
muscle activation during routinely activation levels below the cutoff, and dulum exercises has also been found to
prescribed rehabilitation exercises, to active-assisted exercises using the as- be higher in pathological shoulders when

journal of orthopaedic & sports physical therapy | volume 47 | number 12 | december 2017 | 937


[ research report ]
compared to healthy shoulders.8 Given
Forward bow54 2
the greater activity observed in patho- Towel slide (sagittal)16,30 4 (1-8)
logical shoulders and the importance Scapular protraction on ball54 4
of correct technique during pendulums Supine therapist-assisted elevation38 5
Supine self-assisted elevation38,54 6 (4-8)
with respect to how the supraspinatus
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Prone shoulder extension: 0° of ABD56 6


may be loaded, other exercises to restore Washcloth press-up (hands close)54 7
ROM postoperatively may be more ap- Towel slide (medial)16 7
propriate, especially during times of lack Towel slide (scapular)16,54 7 (4-9)
of supervision, such as with home-based Upright bar-assisted ER30 9
Pendulum38 9
rehabilitation programs. Supine assisted ER38 9
The use of a wall to passively exter- Supine press-up54 9
nally rotate the shoulder activated the Incline press-up54 9
supraspinatus less than passive exter- Supported vertical wall slide57 9
Unsupported vertical wall slide57 10
nal rotation performed in supine with
Supported diagonal wall slide57 10
a bar or stick or by a therapist. Though Sidelying elevation16 10
supraspinatus activity was generally low Pulley-assisted elevation16,30,38 11 (3-20)
for the 3 passive supine external rota- Washcloth press-up (hands apart)54 11
Supine bar-assisted ER38 12
tion exercises, higher activity was ob-
Seated ER: 0° of ABD32 13
served in the infraspinatus and more so
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Standing press-up54 14
in the subscapularis. Therefore, caution Unsupported diagonal wall slide57 15
must be exercised when administering Wall walk/slide16,38 15 (9-19)
these exercises to individuals with tears
involving the infraspinatus and sub- Upright bar-assisted elevation16,30,38 16 (11-27)
scapularis. While the 3 passive external Seated ER: 90° of ABD32 17
rotation exercises imparted low levels of Ball roll16 18
muscle activation on the supraspinatus, Wall-assisted ER30 18
Standing IR: 0° of ABD38,41 20 (3-32)
the supraspinatus tendon was still sub- Self-assisted IR38 22
ject to passive tension, particularly in
Journal of Orthopaedic & Sports Physical Therapy®

Standing IR: 90° of ABD41 24


the anterior region.23 In a cadaver study, Active flexion/elevation16,38 26 (21-29)
Hatakeyama et al23 suggested that ex- Low rows41 29
High rows41 31
ternal rotation up to 60° with the arm
Active flexion: elbow bent38 35
elevated to 30° in the scapular or coro- Standing ER: 0° of ABD with towel37,46,48 39 (39-50)
nal plane can be safely performed dur- Standing ER: 45° of ABD37,46 39
ing postoperative rehabilitation without
excessive tension on the repair site. In
Standing resisted shoulder extension41 41
another cadaver study, external rotation Sidelying ER with towel48 42
increased supraspinatus tension in the Forward punch4,27,28,41 42 (28-50)
anterior tendon region and relaxed the Sidelying ER without towel32,37,46,48 45 (18-62)
posterior region, thus contributing to Prone shoulder flexion: 180° of ABD56 45
Push-up53 49
increased gap formation anteriorly, with Standing ER: 0° of ABD without towel38,41,46,48 50 (40-77)
strain peaking at 30° of external rota- Standing ER: 90° of ABD41,46 50 (50-51)
tion.43 Therefore, clinicians may need to Standing row/pull27,28,41 51 (28-60)
restrict passive external rotation below a Prone ER: 90°3,32,37,46 54 (30-135)
Standing resisted shoulder flexion41 55
range threshold of 30° during the acute
Prone horizontal ABD: 90°3,37,46 64 (39-122)
postoperative phase to avoid compro- Empy-can ABD3 75
mising the integrity of the repair tissue. Full-can ABD3 82
Passive internal rotation was found to Push-up plus4 104
Pendant ER3 125
generate low activation and, along with
0 15 30 45 60 75 90 105 120 135
active internal rotation, has been sug- % MVIC
gested to place excessive tension on the
repair and should be avoided in the early FIGURE 3. Infraspinatus pooled means (range) of percent MVIC ranking of exercises. Abbreviations: ABD,
abduction; ER, external rotation; IR, internal rotation; MVIC, maximal voluntary isometric contraction.
stages of rehabilitation.23

938 | december 2017 | volume 47 | number 12 | journal of orthopaedic & sports physical therapy


Active ROM exercises are contraindi- may also be considered appropriate. Re- on the glenohumeral joint.54 As this study
cated during the early postoperative stag- habilitation programs have also been rec- highlights, in the study by Uhl et al,54 for
es, with some evidence of disruption to ommended to progress from short–lever the supraspinatus, supine and incline
the healing process.34 However, the pres- arm activities to longer–lever arm activi- press-ups did not generate muscle activa-
ent review found that a series of progres- ties, as well as to initiate activities from tion levels above our cutoff of 15% MVIC,
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sive, active elevation exercises in different supine and progress through to incline which allows for a gradual progression
body orientations and below 15% MVIC, and then upright postures, adjusting the that is likely to be safe, though somewhat
such as the supine and incline press-up, effect of gravity, and subsequently load, more demanding, before progressing to
the standing press-up, which was found
Standing ER: 0° with towel37,46 29 (17-46) to generate moderate EMG activity. Fur-
Standing ER: scapular plane37,46 39 (31-55) thermore, by unloading and supporting
the shoulder throughout active ROM,
Prone horizontal abduction: 100°37,46 41 (39-44)
exercises such as the table slide, ball roll,
Prone ER at 90°37,46 45 (43-48)
Standing ER: 0° without towel37,41,46 46 (17-84) and supported vertical wall slide were
Prone horizontal abduction: 90°37 47 found in the present review to impart
Sidelying ER37,46 56 (33-80) low and low-to-moderate muscle acti-
Internal rotation: 90° of ABD41 63
vation on the supraspinatus and infra-
Standing ER: 90°41,46 69 (39-89)
Forward punches41 69 spinatus alike; therefore, these could be
Internal rotation: 0° of ABD41 93 considered as a progression toward tran-
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Middle row41 98 sitioning toward active press-up, flexion,


Low row41 101
and elevation exercises. Activity during
High row41 109
Resisted shoulder flexion41 112
active external rotation exercises ranged
from moderate to high in the supraspina-
0 20 40 60 80 100 120
% MVIC tus (31%-69% MVIC), the infraspinatus
(13%-50% MVIC), and the teres minor
FIGURE 4. Teres minor pooled means (range) of percent MVIC ranking of exercises. Abbreviations: ABD, abduction;
(29%-69% MVIC), and should be pro-
ER, external rotation; MVIC, maximal voluntary isometric contraction.
gressed from a seated position to posi-
tions of standing, sidelying, prone in 90°
Journal of Orthopaedic & Sports Physical Therapy®

Pulley-assisted elevation30 8 of abduction, and, finally, standing in 90°


Table slide30 10 of humeral abduction.
Prone shoulder flexion56 12
The rehabilitation program depicted
Seated row24 14
Wall-assisted external rotation30 15 in TABLE 4 groups exercises based on EMG
activity level of the supraspinatus and
infraspinatus, to anticipate the projected
Upright bar-assisted elevation30 24
stress on the repaired rotator cuff, into
Upright bar-assisted external rotation30 27
Forward punch4,24,41 35 (8-69) phases aligned with tissue healing and
repair site strength.51,52 This is consistent
with a recent consensus statement sug-
Internal rotation: 0° of ABD4,24,41 40 (13-74)
gesting that rehabilitation after rotator
Internal rotation: 45° of ABD4 53
External rotation: 0° of ABD41 57 cuff repair should include a 2-week peri-
External rotation: 90° of ABD41 57 od of strict immobilization followed by a
Dynamic hug4 58 staged introduction of protected, passive
Diagonal4 60
ROM to 6 weeks after surgery, followed
Internal rotation: 90° of ABD4,41 65
Low row41 69
by restoration of active ROM, and then
High row41 74 progressive strengthening beginning at
Standing row41 81 postoperative week 12.51 Fibers respon-
Resisted shoulder extension41 97 sible for binding and healing tendon to
Resisted active elevation/flexion41 99
the bone are not present in any consid-
0 20 40 60 80 100 120
% MVIC
erable number between 6 and 12 weeks,
with repair strength considered only 19%
FIGURE 5. Subscapularis pooled means (range) of percent MVIC ranking of exercise. Abbreviations: ABD, to 30% of normal at 6 weeks and 29%
abduction; MVIC, maximal voluntary isometric contraction.
to 50% of normal at 12 weeks,18 and not

journal of orthopaedic & sports physical therapy | volume 47 | number 12 | december 2017 | 939


[ research report ]

TABLE 3 Quality Appraisal of Included Studies

Internal Validity
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External Validity Performance Selection Bias/Control of Confounding


Appropriate Appropriate Appropriate
Participation Direct Electrode Randomization Randomization Familiarization Normalization Statistical
Representation* Rate Observation Blinding Choice† of Exercises of MVIC Trials of Exercises‡ Procedure Tests
Boettcher et al3 Y Y Y N Y Y N N Y Y
Decker et al4 Y Y N N Y Y N Y Y Y
Gaunt et al16 Y Y Y N Y Y N N Y Y
Gurney et al21 Y Y Y N Y Y N Y Y Y
Ha et al22 Y Y Y N Y Y N Y Y Y
Hintermeister N Y Y N Y Y N Y Y N
et al24
Illyés and Kiss28 Y Y Y N N N N Y Y Y
Illyés et al27 Y Y Y N Y N N Y Y Y
Jung et al30 N N Y N Y Y N N Y Y
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Kim et al32 Y Y Y N Y Y N Y Y Y
Marta et al37 N Y Y N Y Y N Y Y Y
McCann et al38 N Y Y N Y N N N Y Y
Myers et al41 N Y Y N Y Y N N Y N
Reinold et al46 Y Y Y N Y Y N N Y Y
Reinold et al45 Y Y Y N Y Y N N Y Y
Sakita et al48 N Y Y N Y N N Y Y Y
Uhl et al53 N Y Y N Y Y N Y Y Y
Uhl et al54 Y Y N N Y Y N Y Y Y
Journal of Orthopaedic & Sports Physical Therapy®

Wattanaprakornkul Y Y Y Y Y Y Y Y Y Y
et al56
Wise et al57 N Y Y Y Y Y Y N Y Y
Abbreviations: MVIC, maximal voluntary isometric contraction; N, no; Y, yes.
*Representation indicates whether the study sample was representative of a normal, apparently healthy population (eg, both male and female participants, no
pathology, nonathletes).

Appropriate electrode choice indicates whether there were intramuscular electrodes on the supraspinatus, infraspinatus, subscapularis, and teres minor, and
surface electrodes on the infraspinatus.

Familiarization indicates whether participants received practice on performing exercise prior to testing.

suitable for moderate or large, repetitive must be respected, including stratifying as the rotator cuff tear size, tissue qual-
loads. Therefore, exercises must still be those patients presenting with risk fac- ity, and repair integrity, our rehabilitation
applied cautiously throughout this phase tors shown to negatively influence tendon guideline similarly includes 2 pathways,
to almost full maturity at 15 weeks,49 at healing and subsequently increase the based on early and delayed time points to
which time the repair site can tolerate risk for retearing. It has been reported progress exercises.
greater loads. In this phase, we advocate that large, massive tears are nearly at 2 A limitation of our review is that re-
strengthening exercises that elicit be- times greater risk for structural failure sults are solely based on reported values
tween 21% and 50% MVIC, consistent in studies that used an initiation of early from younger (under 40 years), healthy
with previous recommendations.51 Be- motion,52 thus conservative progression individuals performing selected rotator
cause exercises are progressed from pas- and initiation of load should be applied. cuff exercises. The bulk of EMG stud-
sive ROM to active-assistive ROM, active Consistent with the recommendations of ies available used nonpathological, or
ROM, and resisted exercises, it is impor- Thigpen et al,52 which outlined 2 reha- healthy, shoulders to investigate cuff ac-
tant to recognize that these exist along a bilitation pathways adjusting the rate of tivation during rehabilitation exercises.
continuum51,52,54 and that individual dif- rehabilitation progression to account for The common rationale provided was
ferences between patients and repairs individual variation in patient age, as well that EMG amplitudes and muscle acti-

940 | december 2017 | volume 47 | number 12 | journal of orthopaedic & sports physical therapy


Summary and Suggested Continuum of Rehabilitation Exercises, Based on
TABLE 4 Muscle Activation (Percent MVIC) for the Supraspinatus and Infraspinatus,
for Both Early and Delayed Postoperative Motion Pathways
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Time Point Exercises


Phase 1: protection and early Early: weeks 2-6 Passive ROM: flexion
motion phase Delayed: weeks 5-8 Forward bow, supine therapist-assisted flexion, supine self-assisted flexion, sidelying flexion, towel slides, washcloth press-up
EMG activation: ≤15% MVIC Passive ROM: rotation (no IR; ER to 30°)
Wall-assisted ER, supine bar-assisted ER, upright bar-assisted ER
Phase 2: active-assisted to Early: weeks 7-9 Active-assistive ROM: flexion
active motion phase Delayed: weeks 9-12 Ball roll, upright bar-assisted flexion, supported wall walk/slide (progression into unsupported), pulley-assisted flexion
EMG activation: ≤20% MVIC Active ROM: flexion
Supine active press-up, reclined active press-up
Active-assistive ROM: rotation
Continue ER exercises as above. Commence self-assisted IR, bar-assisted IR
Phase 3: strengthening phase Early: week 10 Active ROM: flexion
EMG activation: 21%-50% MVIC Delayed: week 13 Progress to standing press-up/active flexion (short lever, progressing to long lever), resisted active flexion
Active ROM—strengthening: rotation
Progress from seated to standing (in slight abduction to 45° of abduction) to sidelying (with and/or without pillow)
Seated row exercises, progressing to standing row/pulls: forward/scapular punches
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Phase 4: late strengthening Early: week 20 Active flexion/abduction


phase Delayed: week 20 Prone horizontal abduction at 90° and 100°
EMG activation: ≥50% MVIC Strengthening: rotation
Standing ER (in 90° of abduction) to prone (ER) in 90° of abduction
Push-up/push-up plus, dynamic hugs
Abbreviations: EMG, electromyography; ER, external rotation; IR, internal rotation; MVIC, maximal voluntary isometric contraction; ROM, range of motion.

vation patterns may differ due to pain, for differentiating between passive and method to base the progression of ther-
altered shoulder biomechanics, pathol- active, rather than traditional, MVICs. apeutic exercises on likely stress on the
Journal of Orthopaedic & Sports Physical Therapy®

ogy, ROM restrictions, and/or muscular The authors reported that for the supra- repaired rotator cuff.51 Percent MVIC is
disuse in pathological patients or patients spinatus, exercises such as therapist- and the most common method of normalizing
following surgery. Previous literature has self-assisted external rotation, therapist- the EMG signal as a reference value for a
suggested that patients with painful, assisted elevation, pendulums, and iso- given muscle and is usually performed by
symptomatic shoulders activate muscles metric internal rotation and adduction using a manual muscle test to produce a
differently and are unable to remain as can be considered passive, while for the maximum contraction for the muscle of
passive as healthy control subjects.8,40 infraspinatus, no exercises were shown to interest. Given the nature of EMG, subtle
Therefore, caution should be applied in be considered passive, given that all exer- differences in the methodology between
extrapolating data collected from healthy cises exceeded the baseline activity level. included studies may account for varying
subjects and applying results strictly in a Electromyography studies alone can- results, even when performing the same
clinical setting to postoperative patients. not provide definitive guidelines on the exercise. Factors such as variance in par-
Ellsworth et al8 compared muscle activa- relative safety of exercises without know- ticipant characteristics, disparities in the
tion patterns between pathological and ing the specific force levels that cause procedure for normalizing and segment-
healthy participants during the pendu- damage to a repair. Muscle activity level, ing maximal muscle activity data, differ-
lum exercise, and reported that patients along with the plane of motion, cyclic ences in EMG technical procedures such
with shoulder pathology had greater dif- loading, and the weight and length of an as calculating MVIC, and differences in
ficulty relaxing their supraspinatus and individual’s upper limb, are also likely to exercise procedures may all affect report-
upper trapezius than healthy partici- affect the tension on the repair.51 While ed amplitudes.
pants. Murphy et al40 examined patients only moderate correlations have been Large variations in reported am-
postsurgery and reported muscle activa- made between muscle tension and EMG plitudes may also be due to the type of
tion levels during exercises by normaliz- activity,10 in the clinical setting, where electrode chosen for evaluation, as well
ing EMG as a percentage of the activity stress and tension imparted by reha- as its chosen location. This review ex-
observed during rest at baseline, which bilitation exercises cannot be measured, cluded studies in which the supraspi-
was also used as the criterion threshold EMG evidence does offer a pragmatic natus was recorded using surface EMG,

journal of orthopaedic & sports physical therapy | volume 47 | number 12 | december 2017 | 941


[ research report ]
as inaccurate readings of muscle activ- praspinatus and infraspinatus, and very cuff, including passive and active-assist-
ity can occur due to cross-talk between few evaluated the subscapularis and the ed exercises that are unlikely to result
muscles at different depths.14 However, teres minor muscles. Therefore, caution in structural, failure from early to later
given that the infraspinatus is superficial must be taken when applying the guide- stages following surgery.
and easily accessible and produces simi- lines in this review to patients present- CAUTION: It is critical to consider in-
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lar assessments using both surface and ing with repairs of the subscapularis dividual patient characteristics and
intramuscular electrode types,29 this re- and teres minor. There is also a need for risk factors that may negatively influ-
view included studies that measured the future research to focus on the evalua- ence tendon healing and subsequently
infraspinatus by surface EMG. The pres- tion of similar rotator cuff exercises in increase the risk for retear before
ent review pooled the normalized mean individuals with pathology, such as rota- prescribing postoperative exercise.
peak EMG amplitudes from each study, tor cuff disorders, and on exercises that Furthermore, no direct relationship
irrespective of electrode use, which may include more parameters than simply has been established between dynamic
account for the wide range of reported peak muscle activation. Future research electromyography activity and tension
values for the infraspinatus. Previous should continue to focus on bridging the in the respective musculotendinous
studies have also found that the upper gap between conservative rehabilitation structures, and, therefore, the results
and lower portions of the subscapularis protocols and rehabilitation protocols from this review should be only used
muscle have separate functions4 and may that are too aggressive. as a pragmatic guide for the appropri-
require separate rehabilitation exercises, ate selection of exercises to prescribe to
particularly if repaired. In our review, CONCLUSION patients throughout the postoperative
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

only Decker et al4 differentiated and in- timeline after cuff repair.

D
vestigated both upper and lower portions espite the emergence of re-
of the muscle, hence their results were search detailing patient outcomes
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942 | december 2017 | volume 47 | number 12 | journal of orthopaedic & sports physical therapy


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