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Phase 2: Intermediate Phase
Along with progression of the strengthening program, the goals of the second phase in dealing with patients with shoulder pain, is to increase the flexibility, mobility, and ROM of the shoulder joint complex and enhance the patients’ overall neuromuscular control.
An EMG data driven exercise program designed by Wilk et al, the Thrower’s Ten, is implemented during this stage to permit a progression to more aggressive isotonic strengthening activities that emphasize the restoration of muscle balance (See Table 2 below).
Because the external rotators are often weak, side-lying shoulder ER and prone rowing into shoulder ER are prescribed as a result of the high EMG activity of the posterior rotator cuff during these movements.
The Thrower’s Ten program is most commonly initiated in the standing position for the glenohumeral joint exercises and in the prone position for scapular exercises. Once proper muscle activation has been established, we recommend performing the Throwers Ten exercises on a stability ball to maximally challenge the upper extremity and core musculature together.
Neuromuscular control and stabilization drills from phase 1 progress toward the end ROM, including PNF exercises in a full arc of the patient’s available pain free ROM. These drills promote endurance training and dynamic stabilization of the rotator cuff. Manual resistance training also can be performed during this stage, which provides the clinician with the ability to vary resistance throughout the movement, incorporate concentric and eccentric contractions, add RS during the exercise, and perform manual cueing for the scapular musculature at the same time.
The scapula is vital for optimal arm function because it provides proximal stability to allow for efficient distal mobility. The significance of its musculature in permitting normal shoulder function has been well described by various authors. Wilk and Arrigo formulated specific neuromuscular exercises designed to normalize the force couples of the scapular musculature and stimulate proprioceptive and kinesthetic awareness to improve the neuromuscular control of the scapulothoracic joint. The scapular retractors, protractors, and depressors are typically emphasized because they are commonly weak in the overhead throwing athlete (Figure 5).
Closed kinetic chain exercises are advanced to include proprioceptive drills, such as planks and table push-ups on a ball or tilt board (Figure 6) because these exercises have been shown to generate more upper and middle trapezius activity, as well as serratus anterior activity, compared with performing a standard push-up exercise.
Stabilization drills also can be performed with the athlete’s hand on a small ball against the wall as the clinician performs perturbation drills against the athlete’s arm (Figure 7).
In this phase, specific exercises may be incorporated to link the shoulder joint complex and core/lower extremity. An effective exercise for this purpose is the side plank with external rotation (Figure 8). This exercise specifically engages the hip abductors and shoulder muscles. Additionally, prone full planks (with 1- to 2-minute holds), upper extremity wall slides for the serratus anterior, and wall circles for lower trapezius activation and anterior shoulder stretching are effective.
During this phase, specific exercises for lower trapezius activation and strengthening are incorporated, such as the modified robbery (Figure 9), table press-downs, and prone scapular lift-offs. Flexibility and ROM exercises for the shoulder joint complex are continued throughout this phase of treatment, along with appropriate stretching for the trunk and lower quarter. Stabilization and strengthening exercises for the abdomen and lower back also should be incorporated into the treatment program. In addition, athletes are encouraged to perform lower extremity strengthening exercises and sport-specific conditioning activities beginning in this phase.
Coming Soon: Phase 3 – Advanced Strengthening Phase