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● Later ● Maintenance of lower trapezius activity in through-range movement of the arm and more vigorous activities

● Encouragement of serratus anterior activity in producing upward rotation of the scapular

● Maintenance of scapular stability during functional retraining

It is of course difficult to correct a movement pattern that has been laid down over many years. The corrected position will feel abnor- mal to the patient and will be subconsciously resisted.

3) Rotator cuff retraining The rationale Rotator cuff retraining has two stages. Initially the emphasis is on improved control of glenohumeral joint position. Once that has been established the load-bearing capacity of the cuff should be enhanced whilst control is maintained.

It is counterproductive to begin this second phase of training with- out first establishing scapular control.

Indications ● Abnormal resting posture of humerus - usually anterior/internal- ly rotated ● Excessive (ie. >few mm) translation of the head of humerus on resisted muscle activity or on through-range movement. ● Inadequate external rotation of humerus on glenohumeral eleva- tion ● +ve containment / relocation test ● Instability tests - either excessive translation available, indicat- ing a history of poor glenohumeral control, or a reduction in the translation available due to subconscious bracing of the humeral head by the patient.

The therapist is able to help in many ways: a) Electromyography Surface EMG provides an accurate represen- tation of muscle function and timing. It is therefore an excellent feedback tool. Readings are generally taken from upper trapezius and lower trapezius, though it is also possible to sample from middle trapez- ius and serratus anterior.

The patient is encouraged to increase lower trapezius and/or serratus anterior activity without a corresponding increase in upper or middle trapezius activity. Dual channel EMG equipment makes this balance of activ- ity easier to represent and perceive. The specific feedback presented is tailored to the patient’s individual presentation and should be related to improvements in pain and the presenting dysfunction

b) Taping strategies Various taping techniques can be used to: ● Assist realignment of shoulder complex

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Figure 3: Rotator cuff retraining through the use of EMG

It has been shown that the range of movement available on these tests with the patient conscious bears little resemblance to the range available when the patient is unconscious. This implies that the patient has a subconscious ability to restrict the movement of the head of humerus that is undetectable to the person per- forming the test. It seems likely that this presumably protective muscle activity

would be particularly likely to occur if the presenting dysfunction and pain was related to glenohumeral instability.

The treatment ● Initial ● Active correction of glenohumeral posture, with relocation of head of humerus

● Maintenance of alignment through-range progressing from no load to the loaded situation ● Proprioceptive training.

● Later, once confident control of both glenohumeral and scapular control is established: ● Maintenance of alignment through functional loaded activi ties. These activities should be specific to the demands of the activity to which the patient will return.

They may include such things as: ● Reproduction of the stretch-shortening activity of the internal rotators for the overhead athlete ● Closed chain activities of the body moving past the stationary hand for the swimmer ● Hardening of the posterior cuff for the demands of follow- through - eccentric activity under increasing load and speed.

● Assist stabilisation of the glenohumeral joint (Fig.2) ● Facilitate underactive muscles ● Inhibit overactive muscles ● Offload irritated neural structures. Which means that: ● Improved alignment of the shoulder complex can be maintained for long periods of time, and ● The patient’s symptoms can be better controlled

There should be an immediate improvement in symptoms, which will allow the patient to perform at a higher functional level. This should acceler- ate resolution.

Above. Figure 1: Glenohumeral position

Right Figure 2: Glenohumeral

repositioning via taping

c) Neuromuscular stimulation Clinically it would appear that electrical stim- ulation of underactive postural stabilising muscles improves the patient’s ability to recruit them into movement and their ability to reproduce more ideal movement patterns. EMG controlled neuromuscular stimulation, where the volitional activation of a muscle is rewarded spontaneously by stimulation of that muscle, appears particularly effective.