Shoulder Rehabilitation

Strategies, Guidelines, and Practice

W. Ben Kibler, MD, John McMullen, MS, ATC, and Tim Uhl, PT, ATC, PhD

Shoulder rehabilitation can best be understood and implemented as the practical application of
biomechanical and muscle activation guidelines to the repaired anatomic structures in order to
allow the most complete return to function. The shoulder works as a link in the kinetic chain of
joint motions and muscle activations to produce optimum athletic function. Functional shoulder
rehabilitation should start with establishment of a stable base of support and muscle facilitation
in the trunk and legs, and then proceeds to the scapula and shoulder as healing is achieved and
proximal control is gained. The pace of this “flow” of exercises is determined by achievement
of the functional goals of each segment in the kinetic chain. In the early rehabilitation stages,
the incompletely healed shoulder structures are protected by exercises that are directed
towards the proximal segments. As healing proceeds, the weak scapular and shoulder muscles
are facilitated in their re-activation by the use of the proximal leg and trunk muscles to
re-establish normal coupled activations. Closed chain axial loading exercises form the basis for
scapular and glenohumeral functional rehabilitation, as they more closely simulate normal
scapula and shoulder positions, proprioceptive input, and muscle activation patterns. In the
later rehabilitation stages, glenohumeral control and power production complete the return of
function to the shoulder and the kinetic chain. In this integrated approach, glenohumeral
emphasis is part of the entire program and is towards the end of rehabilitation, rather than being
the entire program and being at the beginning of the program.
Oper Tech Sports Med 20:103-112 © 2012 Elsevier Inc. All rights reserved.

KEYWORDS shoulder, rehabilitation, kinetic chain, closed chain rehabilitation

C urrent rehabilitation programs for the shoulder should focus

on restoration of functional ability rather than focusing solely
on resolution of symptoms. The orthopedic surgeon and the phys-
kinetic chain activity that optimizes shoulder function. Alterations
in any of the other links of the kinetic chain can affect the
shoulder, and alterations in the shoulder can affect the other
ical therapist must identify and treat all of the structures that are links in the kinetic chain. The existence of this interaction has
limiting this functional return. Rehabilitation is sometimes difficult 2 implications for shoulder rehabilitation: First, the evalua-
in the shoulder, whose complex function involves not only local tion and identification process preceding shoulder treatment
anatomic and biomechanical integrity, but also biomechanical and and rehabilitation should include more than just local shoul-
physiologic contributions from distant body segments. der structures. The evaluation process should result in a com-
The distant segment contributions are key components of the plete and accurate diagnosis of all of the altered structures
sequential activation of body segments that is necessary to accom- throughout the kinetic chain. Second, optimum restoration
plish any athletic activity. The activation sequence is termed a ki- of shoulder function requires activation of all of the kinetic
netic chain. The kinetic chain harmonizes the interdependent seg-
chain segments to reestablish the interactions that existed
ments to produce a desired result at the distal segment. The
before injury.
shoulder does not function in isolation but functions as a link in
This chapter presents an approach to shoulder rehabilitation
that integrates shoulder evaluation and rehabilitation into the
Reprinted with permission from Kibler WB, McMullen J, Uhl T: Shoulder physiologic and biomechanical framework of the kinetic chain
Rehabilitation Strategies, Guidelines, and Practice. Oper Tech Sports model. The rehabilitation protocol will be presented as a series
Med 8:258-267, 2000 (© 2000 Elsevier Inc.). of guidelines, based on basic science studies, and practices that
From the Lexington Sports Medicine Center, and the Division of Athletic
Training, University of Kentucky, Lexington, KY.
implement the basic science knowledge. These practices focus
Address reprint requests to W. Ben Kibler, MD, 1221 South Broadway, on movement patterns rather than isolated muscle exercises.
Lexington, KY 40504. Rehabilitation will be viewed as a “flow” of exercises that will

1060-1872/12/$-see front matter © 2012 Elsevier Inc. All rights reserved. 103
doi:10.1053/j.otsm.2012.03.012
104 W.B. Kibler, J. McMullen, and T. Uhl

Table 1 Rehabilitation Flow Sheet

Weeks (Estimate)
Acute Recovery Functional
Stages (Estimate) 1 2 3 4 5 6 7 8 9 10
Guideline
1. Diagnosis X X
2. Proximal segment control
Step up/step down X X X
Lunges X X X X X
Squats X X X X X X
Hip extension/trunk X X X X X X X X
rotation
3. Scapular rehabilitation
Pect minor/up trap stretch (X) (X) X X
Posterior joint mobilization (X) (X) X X X
Hip/trunk extension:
Scapular retraction: X X X X X
Diagonal rotation:
Scapular retraction: X X X X X X X
Pinches X X
Scapular clock (X) (X) X X X
Low row (X) (X) X
Shoulder dumps X X X X X X
Punches X X X X X X
Table pushup X X X
Normal pushup plus X X X X
4. Glenohumeral rehabilitation
Weight shifts (X) (X) X
Scapular clock (X) (X) X X X
Wall washes (X) X X X
Rotation diagonal X X X X X
Isolated rotator cuff X X
5. Plyometrics
Lower extremity X X X X X X
Medicine ball X X X X X
Rotation diagonals X X X X X
Dumbbell rotations X X X X X
NOTE. ( ) May be performed if indicated by tissue healing.

vary according to stages of healing and reestablishment of cer- other implement. The ultimate velocity of the distal segment
tain key points of muscle and joint function (Tables 1, 2) toward is highly dependent on the velocity of the proximal segments.
normal kinetic chain function. The proximal segments accelerate the entire chain and se-
quentially transfer force and energy to the next distal seg-
ment.1,2,4-6 Because of their large relative mass, the proximal
Basic Science segments are responsible for most of the force and kinetic
The biomechanical model for striking and throwing sports is energy that is generated in the kinetic chain.3 As a result,
an open-ended kinetic chain of segments that work in a prox- lower extremity force production is more highly correlated
imal-to-distal sequence.1-3 The goal of the kinetic chain acti- with ball velocity than is upper extremity force production.7
vation sequence is to impart maximum velocity or force The physiologic model for throwing and striking sports is
through the distal segment (the hand) to the ball, racquet, or a motor program.8 Motor programs activate muscles in coor-
dinated sequences to create joint movements that simplify
and perform movement tasks. These programs are of 2
Table 2 Key points for progression in rehabilitation
types.9 Length-dependent patterns operate locally at 1 joint,
Pelvis control over the planted teg (negative Trendelenburg are responsible for resisting joint pertubations, and result in
sign) co-contraction force couple activation. Force-dependent pat-
Effective hip and trunk extension terns harmonize motions of several joints, create coordinated
Scapular control, especially of retraction joint motions, and use agonist/antagonist force couple acti-
Normal glenohumeral rotation vation to generate force. In combination, these result in mo-
No substitutions for these functions
tor programs for voluntary upper extremity movements that
Shoulder rehabilitation 105

are task oriented and include lower extremity and trunk mus- coracoid and acromion, prominence of the entire medial bor-
cle activation before and during arm motion.10 In addition to der, which simulates classical scapular winging, or superior
generating and transferring force to the distal segments, these translation of the entire scapula, which results in prominence
programs create a stable proximal base for voluntary arm of the superior medial border. Dynamic motion screening
movements, so that the rapid arm movements will not dis- involves evaluation of the same asymme-tries of scapular
turb body equilibrium during throwing or striking.10,11 control with arm abduction and forward flexion, in both
The motor programs rely on specific sensory and propri- ascent and descent. Muscular strength screening is accom-
oceptive feedback for integration and activation.9,12 Rehabil- plished through wall pushups and the lateral scapular slide
itation protocols must be position specific, motion specific, test19 (Fig. 2).
and function specific, and include gravity resistance and joint Shoulder joint evaluation should include the standard bat-
integration to stimulate the proprioceptive feedback that will tery of tests for instability, rotator cuff injury, and joint inter-
cue the appropriate functional patterns.13,14 nal derangement. The acromioclavicular (AC) joint should be
evaluated for arthrosis or instability. Glenohumeral internal/
Guideline 1—Complete external rotation, which is the biomechanically important
component of shoulder rotation, should be screened by bi-
and Accurate Diagnoses laterally assessing humeral rotation on the stabilized scapula
This guideline may seem obvious but is sometimes difficult to (Fig. 3). Internal rotation assessment by the “thumb on the
implement unless the entire kinetic chain is screened for spine” method has 7 degrees of freedom inherent in the test
alterations. The actual shoulder injury is the primary factor and has no correlation with goniometrically measured gleno-
that determines treatment and rehabilitation. This may in- humeral rotation.29
volve tendon injury or tear, instability, or joint internal de-
rangement, whose overt clinical symptoms can be evaluated
by standard diagnostic methods. However, both nonovert Guideline
local alterations and distant alterations are frequently associ- 2—Proximal Segment Control
ated with shoulder clinical symptoms and dysfunction. The
most common local alterations are decreased shoulder inter- Optimum shoulder and arm function in both normal ath-
nal rotation,15,16 which creates altered glenohumeral transla- letic activity and rehabilitation is dependent on activation
tions,16,17 altered strength,16,18 and alterations in scapular of the proximal segments of the kinetic chain—the legs,
motion and position (scapular dyskinesis),16,19-24 which dis- pelvis, and spine. If these segments are altered in posture,
rupt the normal smooth coupling of scapulohumeral motions flexibility, or strength, they should be corrected in the
in voluntary activation25 and are present in most patients early stages of rehabilitation. If and when they are normal,
with shoulder impingement.20,26 Distant alterations include they should be used to initiate scapular and arm activa-
lumbar muscle inflexibility and muscle weakness,27 and hip tion. Early in rehabilitation, the inhibited scapular mus-
and knee inflexibility.16 cles or the injured or inhibited shoulder muscles require a
Because these alterations are common findings in shoulder large degree of facilitation of their activation, so the role of
injury, ranging from 34% (hip tightness)16 to nearly 100% proximal segment control and activation is increased.
(glenohumeral internal rotation deficit and scapular dyskine- These exercises may be started in the early stage of reha-
sis),15,16,20,21 they need to be assessed through a screening bilitation, even in the preoperative stage, because they do
process in the clinical evaluation. This requires a “victims and not rely on shoulder motion or loading.
culprits” approach.28 The site of symptoms is the “victim,” All exercises are started with the feet on the ground and
but the “culprits” may include alterations at other sites. involve hip extension and control. The patterns of activation
are both ipsilateral and contralateral. Diagonal motions in-
Practice volving trunk rotation around a stable leg simulate the nor-
mal patterns of throwing. As the shoulder heals and is ready
The clinical evaluation should include some screening tests for motion and loading in the intermediate or recovery stage
for hip/trunk posture and functional strength. Our screening of rehabilitation, the patterns can include arm motion as the
examination includes standing posture evaluation of legs, final part of the exercise.
lumbar, thoracic, and cervical spine, bilateral hip range of
motion assessment, trunk flexibility assessment, and a one-
leg stability series (Fig. 1), which assesses control of the trunk Practice
over the leg. Any abnormalities can be evaluated in more
detail. Specific exercises include step up/step down with trunk
Scapular evaluation can be accomplished from behind the extension, front and side lunges, l-leg and 2-leg squats,
patient.19 It should assess resting position and note any asym- and hip flexions and extensions with trunk rotations (Fig.
metries in definition of the bony landmarks. The most com- 4). These may be done on a stable surface and may prog-
mon differences are prominence of the inferior medial bor- ress to unstable surfaces for added difficulty and proprio-
der, which is associated with anterior rotatory tilting of the ceptive input.
106 W.B. Kibler, J. McMullen, and T. Uhl

Figure 1 One-leg stability series. (A) One-leg stance. (B) One-leg squat. (C) One-leg step up/step down. (D) “Corkscrew”
with hip varus and rotation caused by loss of hip control.

Guideline ciated with shoulder injury.19,20,21,22,26 This is caused by

inhibition of coupled muscle activation to elevate, de-
3—Scapular Rehabilitation press, retract, and protract the scapula and subsequent
Optimal scapular muscle activation allows proper scapular substitute patterns of muscle activation.19,32,33 The lower
motion and position while maintaining the glenohumeral trapezius and serratus anterior appear to be most affected
instant center of rotation throughout arm motion.19,30,31 by inhibition, and the upper trapezius most commonly
Scapular motion in retraction, protraction, and elevation is becomes overactivated. This creates the most common
multiplanar, and optimal scapular motion maintains rotator manifestation of scapular dyskinesis, lack of effective re-
cuff length tension ratios, thereby improving force produc- traction with a tendency to protraction. Because of its
tion and reducing rotator cuff energy requirements during anatomic position on an ellipsoid thorax, the protracted
arm motion.25,30 Scapular muscle activation precedes rotator scapula also tends to tilt anteriorly, with acromial depres-
cuff activation in the throwing or striking sequence.32 sion, glenoid antetilting, and resultant external and inter-
Loss of scapular control or “scapular dyskinesis” is nal impingement,16,21,26 and increases the strain on the
noted early in shoulder injury and is very frequently asso- anterior-inferior glenohumeral ligament.34
Shoulder rehabilitation 107

Figure 2 Lateral scapular slide measurements. Asymmetries greater than 1.5 cm are significant. (A) Position 1—rest. (B)
Position 2— hands on hips. (C) Position 3—arms elevated close to 90 degrees, maximum internal rotation, no
impingement. This position activates all the scapular stabilizers.

Practice lar retraction (Fig. 5), and isometric scapular pinches. These
all can be done even with the arm in a sling.
Hip and trunk extension patterns are used to initiate and When arm motion is safe, or in nonoperative or preoper-
facilitate scapular control. Scapular control exercises can be ative cases, an extremely effective exercise for initiation of
started in the preoperative or early healing stages of rehabil- scapular retraction and depression is a “low row” (Fig. 6),
itation because they do not require shoulder or arm move- which includes trunk extension, scapular retraction, and
ment. Adjustments in arm position and arm load can occur as shoulder extension with the arm at the side. These may be
shoulder healing proceeds, and scapular control exercises
should be continued throughout the intermediate recovery
and sport-specific functional phases of rehabilitation.35
Early stage exercises to regain scapular retraction control
include ipsilateral and contralateral hip/trunk extension with
scapular retraction, diagonal hip/trunk rotation with scapu-

Figure 3 Goniometric measurement of glenohumeral rotation off of

a stabilized scapula. Figure 4 Hip extension: Trunk rotation.
108 W.B. Kibler, J. McMullen, and T. Uhl

improved by eliminating joint mobility deficits, thereby de-

creasing abnormal joint translations in the mid range of
shoulder motion, by positioning and moving the glenoid
socket in a “ball on a seal’s nose” relation to the moving
humerus so that concavity/compression of the joint is main-
tained,19 and by active rotator cuff contraction.
In this stability role, as well as its role in humeral head
depression, the rotator cuff is essentially operating as a “com-
pressor cuff.” Rotator cuff activation is coupled with and
follows scapular muscle activation25,32 so that the rotator cuff
muscles work off of a stabilized and optimally positioned
base, are physiologically activated, and are mechanically
placed in an optimal length-tension arrangement to create
appropriate joint stiffness.30,34
Maximum rotator cuff strength development requires tis-
sue healing, minimal pain, and no external or internal im-
pingement.
Joint range of motion, muscle flexibility, and adequate
tissue healing are necessary so that the glenohumeral re-
habilitation program will generate minimal substitute pat-
terns. Proximal segment and scapular control are neces-
Figure 5 Hip/trunk rotation: Scapular retraction. sary for glenohumeral motion and facilitation. These
controls are accomplished in the acute and recovery
stages. Glenohumeral emphasis in rehabilitation of “shoul-
started m isometric fashion, and progressed to isotonic, con- der problems” such as impingement, tendinitis, or mild
centric, and eccentric work with rubber tubing. instability is toward the end of the rehabilitation stages,
Scapular exercises that may be done when the shoulder is rather than the beginning (Table 1).
mobile include scapular clock (Fig. 7), which are elevation/ Similarly, because functional rotator cuff activation is in-
depression, and retraction/protraction exercises with the tegrated within its component parts and with the kinetic
hand on a wall or a movable object. Electromyographic chain25,32 and results in the rotator cuff functioning as a com-
(EMG) studies have shown no deltoid activation and mild to pressor cuff, “closed chain” protocols involving axial loading
moderate rotator cuff activation with these exercises, mean- from distal to proximal are the most physiologic way to sim-
ing they can be done in early rehabilitation.35 Other advanced ulate normal rotator cuff function.13,14,22,37,38 Isolated rotator
scapular exercises include shoulder “dumps” (Fig. 8), a trunk
rotation/scapula retraction/shoulder extension exercise, and
punches with dumbbells or tubing (Fig. 9), which load the
serratus anterior and posterior shoulder musculature. The
position of the arm and the height and direction of the punch
will vary the scapulohumeral coupling. Pushups with a plus,
or full protraction, is also an advanced scapular exercise.
They may be done originally on a table, and then advanced to
normal style.36
These exercises require muscular flexibility and joint mo-
bility. The upper trapezius and pectoralis minor are common
sites of myofascial tightness, and shoulder internal rotation is
frequently decreased.15,16 The anterior/superior muscle in-
flexibility creates a tendency for upward and forward tilt, and
posterior tightness creates a “wind-up” situation of pulling
the scapula forward in follow-through.19,20 Manual stretch-
ing, massage techniques, and joint mobilizations must be
used to normalize these alterations.

Guideline 4 —Glenohumeral
Rehabilitation
The 2 major glenohumeral rehabilitation problems are dy-
namic joint stability and rotator cuff deficiencies; often those Figure 6 “Low row”—Hip/trunk extension: Shoulder extension. The
are interdependent. Dynamic glenohumeral stability can be muscle contraction should be felt at the inferior medial scapular tip.
Shoulder rehabilitation 109

Figure 7 Scapular “clock.” (A) Elevation/depression—12 o’clock/6 o’clock. (B) Retraction/protraction—3 o’clock/9
o’clock.

Figure 8 Shoulder “dumps”—Trunk and arm motion simulates

dumping a weight over the shoulder. Differences in arm position Figure 9 Shoulder “punches”—Varying the arm position can repro-
can reproduce different shoulder functions. duce different shoulder functions.
110 W.B. Kibler, J. McMullen, and T. Uhl

Figure 10 Closed chain axial loading on a table.

cuff exercises do not integrate muscle activation, potentially

create shear across the joint, and are usually performed in
nonphysiologic positions.

Practice
Closed chain exercise practices may be started in early reha-
bilitation stages with the hand in a relatively fixed position,
below shoulder level on a table (Fig. 10). Weight shifts on a
table or balance board are safe in this position. When the arm
may be raised toward shoulder height, scapular clock exer-
cises (Fig. 7) are effective axial loading rotator cuff exercises.
These exercises progress by placing the hand on unstable

Figure 12 Internal/external rotation diagonal—This exercise con-

nects all of the kinetic chain segments in functional arcs, (A) Internal
rotation, (B) External rotation.

Figure 11 “Wall washes”—Axial loading with resistance to moving

arm.
Shoulder rehabilitation 111

Guidelines for Progression

Because this type of rehabilitation program focuses on func-
tional return of kinetic chain patterns, there is less emphasis on
specific stages or pathways or specific isolated exercises and
more emphasis on flow and overlap between the acquisition of
function of the various segments. The program must be flexible
enough to be applied over a wide range of the individual apti-
tudes. New exercises are instituted when the segment func-
tion is appropriate. This is illustrated by the flow sheet dia-
gram of Table 1, which represents estimated times and
sequences for the exercises.
Several key points should be checked as markers for safe
progression (Table 2). Normal pelvis control over the planted
leg (negative Trendelenburg sign) is a prerequisite for prox-
imal segment control. Effective hip and trunk extension is
required for proximal segment facilitation of scapula and arm
activation. Scapula control, especially of retraction, allows
coupled shoulder motion and coupled rotator cuff muscle
activation. Normal glenohumeral rotation is required to de-
crease joint translation. If the patient shows substitute activ-
ities for those normal functions, or cannot progress because
of alterations in these functions, rehabilitation should not
Figure 13 Medicine ball plyometrics. progress, and more detailed investigations should be done.

Guidelines for Return to Play

surfaces, such as a ball, or by using “wall washes” (Fig. 11), in
which an axial load is applied through the moving hand. An Return to play requires not only anatomic healing of the
advanced axial loading exercise that shades into open chain injured part but also restoration of the physiologic patterns
and biomechanical motions in the appropriate kinetic chain
activity is the internal/external rotation diagonal (Fig. 12),
of function. “Readiness to play” is indicated by clinical evi-
with the shoulder moving through 90° of abduction and
dence of anatomic healing and completion of the “key points”
using rubber tubing resistance. Isolated rotator cuff exercises
listed in Table 2. Functional progressions of throwing or
may be used if any local deficit is still present. Internal and
striking may be started from the readiness to play functional
external rotation strengthening should be done at the func-
base. Return to play is dependent on completion of the func-
tional position of 90° abduction.
tional progressions.13,35,37

Guideline Summary
5—Plyometric Exercises This framework for rehabilitation is consistent with the prox-
Power is required for shoulder function in throwing or strik- imal-to-distal kinetic chain biomechanical model and applies
ing. Plyometric training, through activation or stretch/short- current concepts of motor control and closed chain exercises.
ening responses in muscles, is the most effective method of This framework approaches the final goal— glenohumeral
power development.39 Because power is generated in the en- motion and function—through facilitation by scapular con-
tire kinetic chain, plyometric training should be done in ev- trol, and scapular control through facilitation by hip and
ery segment. Plyometrics can be instituted in noninjured ar- trunk activation.
eas early in rehabilitation, but must be deferred to later stages This article supplies guidelines for rehabilitation and prac-
in injured areas, because of the large range of required mo- tices to implement the guidelines that have proved effective
tions and large forces developed. in our hands. Other protocols may be effective, as long as
they adhere to several basic concepts of kinetic chain-based
shoulder rehabilitation:
Practice 1. Functional shoulder rehabilitation requires that the
Lunges, vertical jumps, depth jumps, slides, and fitter exer- muscle activations and joint motions follow a proxi-
cises are some methods of lower extremity plyometrics.35 mal-to-distal pathway along the appropriate kinetic
Trunk and upper extremity plyometrics include rotation di- chain.
agonals (Fig. 12), medicine ball rotations and pushes (Fig. 2. Muscles around the shoulder function in an integrated
13), and dumbbell rotations. fashion and should be rehabilitated in integrated pat-
112 W.B. Kibler, J. McMullen, and T. Uhl

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