Tissue Healing Managment

EXERCISE TECHNIQUES DURING ACUTE AND EARLY SUBACUTE STAGES OF TISSUE HEALING

During the protection and early controlled motion phases of management, when inflammation is present or just beginning to resolve and the healing tissues should not be stressed, early motion may be utilized to inhibit pain and muscle guarding and help prevent deleterious effects of complete immobilization. This section describes and summarizes techniques that may be used for these purposes. During the acute and early subacute stages, when motion in the shoulder itself is limited to allow tissues to begin to heal, it is also valuable to treat associated areas such as the cervical and thoracic spine, the scapulae, and the remainder of the upper extremity (elbow, wrist, and hand) to begin correcting faulty posture, relieve stresses to the shoulder girdle, and prevent fluid stasis in the extremity.

Physio Guideline


Early motion is usually passive ROM (PROM) and applied within pain-free ranges. When tolerated, active-assistive range of motion (A-AROM) is initiated.

Early Motion of the Glenohumeral Joint Wand Exercises

Patient position and procedure: Initiate A-AROM using a cane, wand, or T-bar in the supine position to provide stabilization and control of the scapula during the protection and early controlled motion phases. Motions usually included are flexion, abduction, flexion in the plane of the scapula (scaption), and rotation . If it is necessary to relieve stress on the anterior capsule, such as following surgical repair of the capsule or labrum, place a folded towel under the humerus to position the humerus anterior to the midline of the body when the patient performs internal or external rotation . When treating a shoulder impingement (primary or secondary), have the patient grasp the wand with the forearm supinated when flexing and abducting to emphasize external rotation .

Ball Rolling or Table Top Dusting

Patient position and procedure: Sitting with the arm resting on a table and hand placed on a 6- to 8-inch ball or towel and the shoulder in the plane of the scapula. Have the patient initiate gentle circular motions of the shoulder by moving the trunk forward, backward, and to the side, allowing the hand to roll the ball or “dust the table.” As pain subsides, have the patient use the shoulder muscles to actively move the ball or cloth through greater ROMs.

Wall (Window) Washing

Patient position and procedure: Standing with hand placed against a wall supporting a towel or a ball. Instruct the patient to perform clockwise and counterclockwise circular motions with the hand moving the towel or rolling the ball. Progress this activity by having the patient reach upward and outward as far as tolerated without causing symptoms.

Pendulum (Codman’s) Exercises

Patient position and procedure: Standing, with the trunk flexed at the hips about 90_. The arm hangs loosely downward in a position between 60_ and 90_ flexion or scaption A pendulum or swinging motion of the arm is initiated by having the patient move the trunk slightly back and forth. Motions of flexion, extension, and horizontal abduction, adduction, and circumduction can be done. Increase the arc of motion as tolerated. This technique should not cause pain. If the patient cannot maintain balance while leaning over, have the patient hold on to a solid structure or lie prone on a table. If the patient experiences back pain from bending over, use the prone position. Adding a weight to the hand or using wrist cuffs causes a greater distraction force on the GH joint. Weights should be used only when joint stretching maneuvers are indicated late in the subacute and chronic stages—and then only if the scapula is stabilized by the therapist or a belt is placed around the thorax and scapula so the stretch force is directed to the joint, not the soft tissue of the scapulothoracic region.

“Gear Shift” Exercises

Patient position and procedure: Sitting with the involved arm at the side, holding a cane or wand with the tip resting on the floor to support the weight of the arm. Instruct the patient to move the pole forward and back, diagonally, or laterally and medially in a motion similar to shifting gears in a car with a floor shift .

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