Flexibility and Rehab Tips

The Flexibility and Rehab Tips Column provides practical

information on the role of rehabilitation and flexibility on
both performance and the modification of injury risk.
COLUMN EDITOR:
Ben Reuter, PhD, CSCS*D, ATC

External Rotation
Strengthening With Manual
Distraction for Individuals
With Glenohumeral
Osteoarthritis
Nicole D. Nicholas, PT, DPT1 and Steven B. Ambler, PT, DPT, OCS2
Tallahassee Orthopedics and Sports Physical Therapy, Tallahassee, Florida; and 2Center Coordinator of Clinical
Education, School of Physical Therapy and Rehabilitation Sciences, USF Health Morsani College of Medicine,
University of South Florida, Tampa, Florida

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided
in the HTML and PDF versions of this article on the journals Web site (http://journals.lww.com/nsca-scj).

ABSTRACT
OSTEOARTHRITIS CAN LEAD TO
MOVEMENT LIMITATIONS, WHICH
ARE A BARRIER FOR STRENGTH
TRAINING. IN SOME INSTANCES
WHERE IMPROVED STRENGTH IS
KNOWN TO DECREASE SYMPTOMS AND IMPROVE PATIENT REPORTED FUNCTION, THERE EXISTS
A DIFFICULTY IN DEVELOPING
TRAINING ROUTINES THAT
ADDRESS THE WEAKNESS WITHOUT SYMPTOM AGGRAVATION.
THIS ARTICLE AIMS TO DESCRIBE
A TECHNIQUE TO DECREASE PAIN
AND IMPROVE JOINT MOTION
WHILE STRENGTHENING THE
ROTATOR CUFF IN INDIVIDUALS
WITH OSTEOARTHRITIS OF THE
GLENOHUMERAL JOINT. A

80

DESCRIPTION OF THE EXERCISE IS

PROVIDED USING MANUAL DISTRACTION TO REDUCE COMPRESSIVE AND SHEAR FORCES
WHILE ALLOWING FOR PAIN-FREE
PERFORMANCE AND STRENGTHENING OF THE ROTATOR CUFF.

INTRODUCTION

steoarthritis is a degenerative
disease that affects the integrity
of the entire joint, including
articular cartilage, tendons, ligaments,
capsule, and bone (5,7,14,15). While
the direct causes of the disease are still
debated, a relationship between high,
repetitive, or abnormal mechanical
stress and cartilage degeneration exists
(5,8,15). Joint forces can be affected by
sustained postures or repetitive

VOLUME 37 | NUMBER 4 | AUGUST 2015

movements that create an imbalance

of the supporting structures of the joint
(5,8,15). While research has favored
muscle strengthening and exercise to
improve movement patterns and
reduce mechanical stress in osteoarthritic joints of the lower extremity,
evidence for the glenohumeral joint
is lacking, especially in the areas of
pain and function (1,5,13). While it is
unclear whether muscle weakness,
most notably the rotator cuff, is a cause
or consequence of osteoarthritis, there
is a notable correlation (5,13,14). The
rotator cuff, consisting of the supraspinatus, infraspinatus, teres minor, and
subscapularis, functions as a force couple among the larger musculature, such
as the deltoid, surrounding the shoulder girdle. This force couple allows for
uniform compression and a reduction

Copyright National Strength and Conditioning Association

be active secondary to pain. The purpose of this article is to describe a technique using a distraction mobilization
that could allow for reduced or painfree strengthening of the rotator cuff of
an osteoarthritic joint.

Figure 1. (A and B) Starting and ending position. Position the arm in the plane of the
scapula using a towel roll, 308 of abduction and 308 of flexion with the
elbow flexed to 908 to allow easy access for distraction while maximizing
posterior muscle activity. The forearm may be placed 308 below the horizontal plane for comfort.

of sheer forces during physiologic

shoulder motion (3,6,12). Excess of
these sheer forces lead to microtrauma
of the cartilage and eventually macrotrauma characterized by visible
arthritic changes, pain, and functional
limitation (10,14). Specifically, the
external rotators (infraspinatus and
teres minor) have been shown to assist
in maintaining normal glenohumeral
kinematics (4). Furthermore, impairments in the glenohumeral external
rotators have been found in conditions
thought to produce the repetitive

microtrauma, such as impingement,

which are a likely precursor to osteoarthritis in the shoulder (4,5,9). Pain
itself has been suggested to alter the
sensorimotor system causing impairments in muscle strength and motor
control (11). Pain has been suggested,
along with weakness and stiffness, to
cause further alterations in mechanics
and deterioration of the joint (5,11,13).
This creates a paradox for the client
with osteoarthritis, with a condition
that worsens with weakness, but an
inability to strengthen the muscles or

There are many exercises that

strengthen the rotator cuff muscles.
Careful considerations for exercises
that minimize sheer forces and maximize rotator cuff recruitment are
important for the osteoarthritic shoulder (5,13,14). For the purposes of this
article and describing a specific exercise most likely to reduce the sheer
stress producing microtrauma at the
glenohumeral joint, strengthening of
the infraspinatus and teres minor will
be discussed. These muscles are primary movers for external rotation
and decrease anterior and superior
translation of the humeral head
(3,6,12,13). The exercise (see Video,
Supplemental Digital Content 1,
http://links.lww.com/SCJ/A156) performing external rotation at approximately 308 of abduction was chosen
for multiple reasons. First, the infraspinatus and teres major demonstrate
their greatest moment arm with slight
humeral abduction using a towel roll
(3,12). Biomechanical analysis and
electromyographic studies have also
demonstrated maximal muscle recruitment in this position from these
muscles compared with higher degrees
of abduction (3,12). Second, this position reduces the need for dynamic control of the scapulothoracic joint (12).
Many studies have shown poor scapulohumeral control in those presenting
with pain and range of motion restrictions (11). By reducing the potential for
scapulohumeral impairments, there
can be added focus on the correct rotation of the humeral head within the
glenoid until the client can progress
to more functional exercises that may
mimic the clients daily or desired recreational activities. An example of
impingement syndromes helps to
explain the importance of positioning
for this exercise, as well as in describing
the important function of the muscles
that are addressed during this

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Flexibility and Rehab Tips

Figure 2. (A) Scapulothoracic joint positioned in neutral and should not deviate during the exercise: A1, with shirt; A2, without shirt.
(B) Glenohumeral joint positioned in the plane of the scapula and should not deviate during the exercise.

technique. Subacromial impingement

can be characterized by weakness of
the rotator cuff musculature and movement impairments of excessive superior glide of the humerus during
shoulder flexion or abduction (2,12).
The importance of strengthening the
rotator cuff is highlighted in the treatment of the movement impairments
seen with impingement. In addition,
the joint positions chosen for this exercise have been shown to reduce movements associated with impingement,
while maximizing muscle recruitment
(3,12). While evidence demonstrating
a direct association between impingement syndromes and osteoarthritis is
lacking, one can see the link between
rotator cuff weakness, impingement,
and the potential cartilage destruction
associated with osteoarthritis through
an understanding of abnormal movement patterns and its effect on the joint
(5). It is, therefore, important to not
only address the osteoarthritic joint
with an exercise that maximizes muscle
recruitment but that also maximizes

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correct joint mechanics and reduces

mechanical stress.
Performing the exercise (right glenohumeral external rotation with distraction):
 Secure the resistance (elastic resistance band or cable weight stack)
to the left of the client at the height
of the umbilicus.
 Position the arm in the plane of the
scapula using a towel roll, 308 of
abduction and 308 of flexion with
the elbow flexed to 908 to allow easy
access for distraction while maximizing posterior muscle activity.
The forearm may be placed 308
below the horizontal plane for comfort (Figure 1A).
 The client should externally rotate
the glenohumeral joint as far as
they can without substitution and
then return to the starting position
(Figure 1B).
 Do not allow substitutions such as
glenohumeral elevation or horizontal
abduction and trunk rotation during
the motion (Figure 2B).

VOLUME 37 | NUMBER 4 | AUGUST 2015

 The resistance should be present at

the starting position and remain
throughout the entire motion.
 Both concentric movement into
external rotation and the eccentric
return to slight internal rotation
should be at a speed that allows for
correct performance without substitution or compensatory movement
at the glenohumeral and scapulothoracic joints.
 The glenohumeral joint should
remain in the plane of the scapula
with care taken to prevent scapula
dyskinesia during the motion
(Figure 2A).
 The optimal resistance will be
dependent on the phase of participation and individual characteristics of
the client. The resistance level
should be one that can be performed
without participant discomfort or
substitution.
Adding distraction:
 The rehabilitation provider will
place the web space of one hand
under the arm as close to the axillary

 Care should be taken to prevent

rotation of the trunk and a chair
may be used to prevent compensatory trunk movement.
The success of this technique depends
on the severity of osteoarthritis including the anatomical positioning of
degeneration, the available range of
motion of the joint, and the proficiency of the provider in performing
the technique. The distraction component of the exercise is a joint mobilization technique and thus should only be
performed when it falls within the professional purview of the provider, and
when applicable, within their jurisdictional scope. There are many other
considerations for the success of this
technique, including but not limited
to scapular humeral rhythm, postural
alignment, and other rotator cuff and
periscapular muscle performance. The
distraction with strengthening technique can be modified to address these
impairments as well.

Figure 3. (A and B) Lateral distraction is applied manually throughout the motion of

glenohumeral external rotation. Care is taken not to place excessive
compression on the neurovascular structures of the medial arm.

fold as possible while taking care to

prevent compression of the neurovascular structures, such as the brachial plexus and the brachial artery.
The opposite hand should be placed
on the lateral side of the elbow
(Figure 3A).
 The client will start in slight internal
rotation, with their hand in front of
their umbilicus and the forearm in
pronation. Apply a distractive lateral
force with the hand in the axilla and
instruct the client to slowly rotate
the arm clockwise, into external
rotation, while maintaining an
adduction force into the towel. An

adduction force can be added with

the opposite hand at the elbow to
create an increased fulcrum for distraction (Figure 3B). See Supplemental Digital Content 1 (see Video,
http://links.lww.com/SCJ/A156)
for a video demonstration of this
exercise.
Optional modification (Figure 4)
 Clients with balance impairment may
benefit from performance of this technique while sitting (Figure 4A and 4B).
 The client should have adequate
trunk stability since the hip musculature is limited in their ability to
stabilize in this position.

In conclusion, osteoarthritis is a degenerative disease, which causes restrictions in motion and pain.
Conservative management can be difficult and is understudied in this population. For clients wishing to avoid
surgery or those interested in maximizing strength and motion before
surgery, distraction with strengthening is an alternative. Distraction not
only decreases compressive forces
but is also beneficial to the surrounding synovia, which is important for
joint nutrition and the inflammatory
process (7,8,10). While exercise has
not been shown to reverse existing
degeneration of cartilage, stress within
normal mechanics and under acceptable tissue loads can promote remodeling of injured tissue and perhaps
prevent progression of the disease
process (7,8). Perhaps most importantly, by strengthening the appropriate muscles and controlling for
repetitive abnormal and excessive
mechanical stress on the tissues, one
could theoretically break the cycle of
degeneration and subsequent pain
and functional limitation in these individuals (15).

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Flexibility and Rehab Tips

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Subchondral bone remodeling is related
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Figure 4. (A and B) Modification of the exercise and mobilization technique to sitting.

Conflicts of Interest and Source of Funding:

The authors report no conflicts of interest
and no source of funding.
Nicole D. Nicholas is a staff physical
therapist at Tallahassee Orthopedics and
Sports Physical Therapy.
Steven B. Ambler is an Assistant
Clinical Professor in the School of Physical Therapy and Rehabilitation Sciences
at the University of South Florida.
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