The shoulder joint was designed to move, and, in fact, it is the most moveable joint in the body. But because the ball of the joint is larger than its socket, the shoulder relies heavily on its anchoring muscles, tendons, and ligaments to remain functional.

“Because it is meant more for mobility than for stability, the shoulder can become unstable due to injury or as a result of deconditioning over time,” says Christine Springer, MS, PT, director of physical therapy at Sports Center Physical Therapy in Austin, Tex. “For some individuals, like in an elderly population, activities of daily living can injure the shoulder.”

Doing business as Sports Center since January 2003 (the practice actually evolved from one started 20 years earlier), the team sees more than 260 visits each week. Currently, there are nine full-time staff members, four of whom are PTs.

Working primarily with recreational athletes, Sports Center routinely treats shoulder injuries of all kinds, including rotator cuff damage, tendinitis, and tendinosis. Regardless of how the injury occurred, the PTs use a science-based method called the Sports Center Training SystemSM (SCTS).

TACKLING ALL SIDES OF THE ISSUE

SCTS applies a three-pronged approach to caring for patients: looking at each type of tissue injury, the mechanics involved with that specific region of the body, and the patient’s attitude.

“The first thing we look at is the tissue—to find out what tissue is injured or to determine what we think is causing the symptoms—so we can identify the tissue pathology itself,” Springer explains. “We recognize that it is the metabolic rate of the tissue, what kind of blood flow that tissue has, that will govern how quickly it will respond or change. And that determines the intensity of the program you are going to have.”

For example, if a patient is identified as having a weakness in their rotator cuff muscle, it is critical to develop training that initially targets the tendon.

“If I orient their program toward making their muscle stronger, without first making their tendon stronger, then the tendon will get weaker and hurt more,” she says. “And that occurs sometimes because the tendon’s blood flow is about 16% of what the muscles get, so the tendon requires a lower intensity of exercise over a longer period of time.”

After the final determination has been made of exactly what soft tissue is involved, Springer turns her attention to the pertinent biomechanics, such as posture, range of motion, and strength. Then, the process turns to what Springer believes is one of the most important parts of the evaluation.

“What really makes our system unique is we recognize that attitude affects a client’s outcome of therapy. So we will take into account a patient’s attitude,” she says. “This is the only place that I have worked where we directly address how that can potentially interfere with therapy and progress.”

Attitude is analyzed in two different categories: patient choices and patient inhibitions. Patient choices can be as simple as an individual’s refusal to honor any prescribed limitations or routines. A swimmer with a torn rotator cuff, for instance, who is unwilling to give up time in the pool, is significantly impacting the potential benefits of therapy.

“That choice will negatively affect how quickly he will get better,” Springer says, noting that it’s wise for PTs to adjust their plans for that person. “I would need to change my own expectations and would probably make the program easier in the beginning, recognizing that he will be overdoing it a lot.”

At the other end of the spectrum from noncompliance are patients too timid to do anything. Often, this hesitation comes from a fear of reinjury immediately after surgery or a negative association with therapy in general, perhaps from a bad experience at another facility. The reason doesn’t matter as much as addressing the issue. If overlooked, it is going to limit their rate of progress.

“Whatever we see, we bring it out in a respectful way, not to put it in their face, but just to address it directly,” Springer says. PTs take an observational approach, saying things such as, “I see you’re afraid to move your arms,” or, “I see that you get very emotional when I suggest that you give up swimming,” and asking patients to explain their feelings behind the behavior. “We try to present our observations in as objective a manner as possible, and then ask questions and talk with them from there,” she says.

MOVING FORWARD

Once the nature of the injury and any possible obstacles are attended to, the work starts. At Sports Center, PTs use an exercise-based approach that is tailored to meet the specific needs of each client.

“We use exercise to first relieve pain, so if somebody comes in and they’re hurting a lot, we will create for them a low-intensity form of program,” Springer says. “We might do that for a longer period of time until their symptoms improve. Then, the intensity of the exercise gradually increases, but the time gets a little shorter.”

The exercises are different from what takes place with standard gym equipment, because the PTs train movements and groups of muscles together in a way that they know will mimic the demands placed on the shoulder from that person’s specific sport.

“Our exercises are oriented toward making the rotator cuff work as a stabilizer, so the patient will hold the shoulder still while moving another part of the body,” Springer says. “Traditional weight machines don’t force your shoulder stabilizers to work in the way they will function during a sport. Most machines are oriented toward only one plane of motion, whereas when you are doing a sport, your arm tends to move in three planes and you combine motions.”

For all patients, the rehab goal is to get them back to a condition they were in prior to their injury—enabling them to resume all activities without any fear of reinjury. Knowing exactly what a patient was doing when the shoulder was damaged, as well as what condition that individual was in at the time, can also have an impact on the type and duration of their rehabilitation.

“Based on the way that they injured themselves and what the pain feels like, their history will normally tell me—with about 70% accuracy—what is wrong with them,” Springer says. “The magnitude of their injury, their health before, as well as what they want to get back to doing, those three factors determine how long rehabilitation is going to take.”

Throughout the entire process, the patient’s physician is informed of the progress being made. Every 3 to 4 weeks, PTs will generate a reevaluation report that is shared with the physician. At the same time, the therapist will reexamine and update, as necessary, the overall plan.

“You want everything that you do in training to match, or really even to exceed, the stress they’re going to put on [the shoulder] when they go back to playing tennis or swimming. Eventually, before they leave, we want to take their shoulders through a test drive,” Springer says. “Because you want to train above what you have to do, and then live below it.”

THE NEXT WAVE

One of the biggest changes in the industry that Springer has started to notice is the increase in more severe or more complicated surgeries being done arthroscopically. Because the operation is minimally invasive, the result is considerably less inflammation and a much shorter recovery time.

“Our program doesn’t change a lot in terms of how we manage patients once they get here, but we typically will see them a little sooner,” Springer says.

She has also noticed an increase in the occurrence of repetitive-use injuries in high school students and other very young athletes caused by the trend toward specialization in sports.

“Instead of having three sports that they practice, an athlete who is really good at a sport will train all year round,” Springer says. She gives the example of a high school softball player who played in the fall with one type of league, then participated in the spring with her high school team, and moved on to a summer camp where she was active in a summer league. “That type of constant use will often lead to the development of repetitive-use injuries in very young athletes, and we’re seeing much more of that now.”

The same SCTS approach, however, is applied to caring for these young athletes as well. Adjustments are made to accommodate those younger than 18, with additional physician consultations being made to ensure that the growth plates are closed, for example.

TEAMING UP

The client-focused approach at Sports Center is not practiced just by the therapists. According to Springer, the entire staff is eager to make their patients’ experience second to none.

“We have a very, very team-oriented approach. There is a lot of cohesiveness between the people who work in our front office and handle the administrative workings of our practice with the clinical staff,” she says. “We are all very focused on giving our clients the best experience possible—and our clients tell us they feel very valued and appreciated.”

Dana Hinesly is a contributing writer for Rehab Management. For more information, contact RehabEditor.