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
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-
ical therapist must identify and treat all of the structures that are
limiting this functional return. Rehabilitation is sometimes difﬁcult
in the shoulder, whose complex function involves not only local
anatomic and biomechanical integrity, but also biomechanical and
physiologic contributions from distant body segments.
The distant segment contributions are key components of the
sequential activation of body segments that is necessary to accom-
plish any athletic activity. The activation sequence is termed a ki-
netic chain. The kinetic chain harmonizes the interdependent seg-
ments to produce a desired result at the distal segment. The
shoulder does not function in isolation but functions as a link in
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
links in the kinetic chain. The existence of this interaction has
2 implications for shoulder rehabilitation: First, the evalua-
tion and identiﬁcation process preceding shoulder treatment
and rehabilitation should include more than just local shoul-
der structures. The evaluation process should result in a com-
plete and accurate diagnosis of all of the altered structures
throughout the kinetic chain. Second, optimum restoration
of shoulder function requires activation of all of the kinetic
chain segments to reestablish the interactions that existed
This chapter presents an approach to shoulder rehabilitation
that integrates shoulder evaluation and rehabilitation into the
physiologic and biomechanical framework of the kinetic chain
model. The rehabilitation protocol will be presented as a series
of guidelines, based on basic science studies, and practices that
implement the basic science knowledge. These practices focus
on movement patterns rather than isolated muscle exercises.
Rehabilitation will be viewed as a “ﬂow” of exercises that will
Reprinted with permission from Kibler WB, McMullen J, Uhl T: Shoulder
Rehabilitation Strategies, Guidelines, and Practice. Oper Tech Sports
Med 8:258-267, 2000 (© 2000 Elsevier Inc.).
From the Lexington Sports Medicine Center, and the Division of Athletic
Training, University of Kentucky, Lexington, KY.
Address reprint requests to W. Ben Kibler, MD, 1221 South Broadway,
Lexington, KY 40504.
1060-1872/12/$-see front matter © 2012 Elsevier Inc. All rights reserved.