Joumal of Athletic Training 2000;35(3):329-337

C by the National Athletic Trainers' Association, Inc

www.journalofathletictraining.org

A Kinetic Chain Approach for Shoulder

Rehabilitation
John McMullen, MS, ATC*; Timothy L. Uhl, PhD, ATC, PTt
*Lexington Sports Medicine Center, Lexington, KY; tUniversity of Kentucky, Lexington, KY
Objective: To introduce an approach to shoulder rehabilita- This approach focuses on movement pattems rather than
tion that integrates the kinetic chain throughout the rehabilita- isolated muscle exercises. Pattems sequentially use the leg,
tion program while providing the theoretical rationale for this trunk, and scapular musculature to activate weakened shoulder
program. musculature, gain active range of motion, and increase
Background: The focus of a typical rehabilitation program is strength. The paradigm of kinetic chain shoulder rehabilitation
to identify and treat the involved structures. However, in suggests that functional movement patterns and closed kinetic
activities of sport and daily life, the body does not operate in chain exercises should be incorporated throughout the rehabil-
isolated segments but rather works as a dynamic unit. Re- itation process.
cently, rehabilitation programs have emphasized closed kinetic Clinical Advantages: The exercises in this approach are
chain exercises, core-stabilization exercises, and functional consistent with biomechanical models, apply biomechanical
programs. These components are implemented as distinct and motor control theory, and work toward sport specificity.
entities and are used toward the end of the rehabilitation The exercises are designed to stimulate weakened tissue by
program. motion and force production in the adjacent kinetic link seg-
Description: Kinetic chain shoulder rehabilitation incorpo- ments.
rates the kinetic link biomechanical model and proximal-to- Key Words: glenohumeral joint, closed kinetic chain, scap-
distal motor-activation pattems with proprioceptive neuromus- ula, exercise, function
cular facilitation and closed kinetic chain exercise techniques.

8-11
T he goal of most athletic rehabilitation is to return the lower extremity. Clinicians recognize the need to address
athlete to the activity that caused the injury. Successful the legs and trunk as contributors to shoulder function and for
shoolder rehabilitation depends on an understanding of general conditioning, but their protocols often integrate the
the cause of injury and a complete and accurate diagnosis shoulder with the rest of the body late in the rehabilitation
of the involved tissues. Therefore, a thorough understanding of process. 67 In kinetic chain shoulder rehabilitation, the legs and
the physical demands of the activity is a prerequisite to making trunk are integrated into most of the shoulder exercises from
a complete diagnosis and returning the athlete to safe, pain-free the onset. This reinforces normal movement patterns and
participation.' The kinetic link model, a biomechanical model reduces the challenge of learning new movements during
used to analyze many sport activities, depicts the body as a rehabilitation.
linked system of interdependent segments, often working in a We present an approach to shoulder rehabilitation that
proximal-to-distal sequence, to impart a desired action at the integrates the kinetic link model and normal synergistic mus-
distal segment.23 This model illustrates the contribution of cle-activation patterns with proprioceptive neuromuscular fa-
the entire body during sport activities rather than focusing cilitation (PNF) principles. Rather than isolating the shoulder
on the action of individual segments. Normal, efficient motion and gradually incorporating the rest of the body, this approach
and muscle activation are believed to occur in a proximal-to- focuses on rehabilitating the entire neuromuscular system by
distal sequence.2'4'5 This proximal-to-distal sequencing should integrating multiple body segments throughout the process.
be considered when attempting to restore function via a The segmental integration follows the proximal-to-distal
rehabilitation protocol. movement and muscle-activation sequence consistent with
The shoulder pathology is the primary factor that determines biomechanical upper extremity function.2'5 Clinically, kinetic
the therapeutic treatment. Traditional shoulder rehabilitation chain rehabilitation has been effective in restoring shoulder
after injury includes a phase of rest, control of inflammation, function when other methods of shoulder rehabilitation have
and isolated muscle strengthening.6'7 Additional components failed.
of shoulder rehabilitation programs are scapular-stabilization,
proprioceptive, and closed kinetic chain exercises. However,
these exercise regimens tend to isolate the involved tissue THEORETICAL FOUNDATION
initially while neglecting the contributions of the trunk and A common biomechanical model for striking and throwing
sports is an open-linked system of segments that work in a
Address correspondence to John McMullen, MS, ATC, Lexington proximal-to-distal sequence.2 The goal of these activities is to
Sports Medicine Center, 1221 South Broadway, Lexington, KY 40504. impart a high velocity or force on the distal segment. The distal
E-mail address: [email protected] segment may be the hand of a pitcher, the foot of a soccer

Journal of Athletic Training 329

 athlete, or the hand and racquet of a tennis player. The ultimate produce motion and activate involved muscles throughout
velocity of the distal segment depends on the velocity of the shoulder rehabilitation.
proximal segment and the interaction of these segments.12-14 Shoulder rehabilitation programs incorporate PNF tech-
The proximal segments, the legs and trunk, accelerate the niques to stimulate synergistic patterns of movement.7'22
entire system and sequentially transfer the momentum to the Kinetic chain rehabilitation incorporates 5 important PNF
next distal segment.2 Conservation of momentum explains this concepts. The first is that motor behavior is a sequence of total
segmental interaction. The equation for angular momentum patterns incorporating the head, neck, trunk, and extremities.
is segment inertia times its angular velocity.'3 The initial This is true whether the movement is unilateral, bilateral, or
acceleration of the proximal segment encompasses all the distal reciprocal.23 Motor behaviors such as baseball pitching or
segments as part of its inertia. The sequential deceleration of tennis serving illustrate this concept by generating maximum
the proximal segments conserves momentum by transferring shoulder internal rotation through the transfer of forces from
segmental velocity distally along the kinetic chain.2'13 This the legs, through the trunk to the shoulder. Second, normal
proximal-to-distal linkage provides an efficient and effective goal-directed movement and posture depend on synergies to
system to transfer force and produce greater velocity in a distal balance muscular activity between antagonists. Third, normal
segment. Kinetic chain rehabilitation incorporates this model motor development occurs in a proximal-to-distal direction.
by initiating shoulder exercises through proximal segment Fourth, in movement patterns, stronger component patterns
movement. augment weaker components by the irradiation reflex,23'24
Normal motor patterns of voluntary upper extremity move- which suggests that as the intensity of an applied stimulus
ments while standing include lower extremity and trunk muscle increases, the area of response increases.25 In kinetic chain
activation before the arm motion.4'5 Voluntary movements of shoulder rehabilitation, thoracic extension can stimulate scap-
the upper extremity, such as rehabilitation exercises, are ular retraction. Applying resistance to thoracic extension
primarily task oriented and are controlled via motor should increase this stimulus and elicit an increase in the
programs.15-17 Motor programs are thought to exist for cate- scapular retraction. Fifth, the clinician helps the athlete relearn
gories of movements, such as walking or throwing, rather than the normal movement patterns by selecting and applying
each component of a movement having its own program.17 appropriate stimuli such as positioning, manual contact, or
Motor programs use coordinated groups of muscles and joint resistance. The clinician becomes part of the exercise environ-
movements, or synergies, often in a proximal-to-distal fashion, ment by giving visual, auditory, and tactile feedback.23'24
to simplify and perform movement tasks.45"8 Kinetic chain
shoulder exercises employ these natural motor programs by RATIONALE FOR KINETIC LINK REHABILITATION
focusing on the neuromuscular system rather than on isolated Kinetic chain rehabilitation approaches the shoulder as part
movement and muscle activation. This method uses and
restores normal movement patterns that are familiar to the of a kinetic link system and attempts to address shoulder
neuromuscular system so the rehabilitation occurs within the function in a proximal-to-distal manner.4'5'23'26 The proximal
framework of normal function. trunk segment, rather than the more distal arm, acts as the
Upper extremity motion follows this proximal-to-distal mo- "initiator" for appropriate shoulder motion. Based on this
tor program sequence. Upper extremity motion occurs with
proximal-to-distal premise, quality arm elevation and shoulder
consistent synergistic muscle activation patterns in the legs and
function depend on trunk and scapular control.2'4'5'19 Trunk
and scapular control exercises begin at the onset of therapeutic
trunk.4'5"19 The task of rapidly reaching forward with the right exercise in kinetic chain shoulder rehabilitation, since neither
hand to shoulder level produces a consistent pattern of activa- depends on arm motion. If the goal of an exercise activity is
tion and deactivation of leg and trunk musculature before scapular movement, arm elevation is not required. However,
activation of the anterior deltoid.5 19 This sequential pattern scapular motion and control are prerequisites for proper arm
includes deactivation of the left soleus, activation of the right elevation.27'28
tensor fascia lata and rectus femoris, activation of the left Kinetic chain rehabilitation applies elements of biomechani-
semitendinous and gluteus maximus, and, finally, activation of cal and motor control theories to PNF and closed kinetic chain
the right erector spinae before initial deltoid activity.5 Injury at exercise techniques. By using multiple body segments in the
a distal segment can alter this proximal-to-distal control. exercises, adjacent segments can facilitate the activation of
Proximal hip muscle activation is delayed in patients with involved muscles to develop appropriate shoulder motion and
severe ankle joint injury compared with noninjured controls function (irradiation).2325 Adjustments of posture and the
during hip active extension.20 The possibility that injury to a amplitude of movement by proximal segments can control the
distal segment alters normal motor programs further supports location and intensity of the loads of a given exercise. Early in
the need to incorporate these motor programs throughout the the rehabilitation, the shoulder may require a great deal of
rehabilitation process. facilitation, so the role of the adjacent segments may be
The anticipatory patterns of leg and trunk activation are exaggerated. Decreasing the role of the facilitating segments
associated with segmental joint accelerations that effectively later in the progression increases the load and functional
move the center of gravity forward and up toward the side of demand on the shoulder.
unilateral shoulder flexion.5 These proximal-to-distal synergies Successful acquisition of movement patterns is feedback
are postural adjustments to counteract the disturbance in sensitive and requires consistent observation to avoid compen-
equilibrium caused by the voluntary arm movement.4'5'21 This satory movements.23'24 The training of movement patterns,
pattern of proximal muscle activation before distal movement rather than isolated muscles, often requires verbal and tactile
serves as a foundation for using the trunk and legs to drive the feedback. This immediate feedback may help the athlete to
scapula and shoulder during the rehabilitation process.4,5,21 identify and correct movement errors. Gradual removal of the
Kinetic chain rehabilitation incorporates these synergies to feedback is a form of exercise progression as the athlete gains

330 Volume 35 * Number 3 * September 2000

awareness of appropriate and inappropriate movement pat- PROXIMAL SEGMENT CONTROL
terns. The exercise goal is to find movement patterns the Based on proximal-to-distal sequencing, the arm ulti-
athlete can perform successfully while progressively loading mately depends on the segments proximal to it for move-
deficient tissue anywhere in the kinetic chain. ment. Full arm elevation requires full scapular retraction,
Imbalances in the action of scapular force couples may result which requires spinal extension, hip extension, and so
in scapular dyskinesis (abnormal scapular movement), gleno- on.2,5,24 The large muscles of the hips and trunk thereby
humeral translation, or rotator cuff overload. The function of help position the thoracic spine to accommodate appropriate
the shoulder complex depends upon muscular force couples scapular motion. In many athletic activities, these muscles
about the scapula and glenohumeral joint. Synergistic scapular must provide stability for effective function of the shoulder
muscle actions allow proper positioning and stability of the girdle.' Normal motor patterns of forward arm elevation
scapula while maintaining the glenohumeral center of demonstrate ipsilateral activation of hip extensors before
rotation throughout arm motion.29-31 Due to its anatomical deltoid activation.5 Kinetic chain rehabilitation attempts to
location on an ellipsoid thorax, normal scapular motion is take advantage of this by exaggerating the role of the hip
multiplanar.27 32'33 Scapular motion provides optimal mus- extensors in an athlete with limited forward elevation.
cle length-tension ratios and reduces the muscular energy Forcing hip extension by including an ipsilateral step-up
requirements of the rotator cuff during arm motion.30'34 with a shoulder-flexion exercise seems to facilitate the
Scapular function mediates the demand on the rotator cuff, shoulder flexion (Figure 1). Adding a PNF technique, the
promotes energy conservation in the upper extremity, and verbal queue to "get tall," encourages the thoracic extension
aids in glenohumeral stability.28'29'34 that is necessary for complete arm elevation.24 32 Additional
Appropriate scapular motion requires attention to muscular resistance to the hip extension may stimulate an irradiation
flexibility. The upper trapezius and the pectoralis minor are reflex to synergistic muscles and activate deficient shoulder
common sites of myofascial tightness and hypertonia in ath-
flexors.24'25
letes with shoulder pain and can limit normal scapular mo- Hip and trunk motion can facilitate shoulder motion in
tion.35'36 Throwing athletes commonly present with muscular other planes. Proximal-to-distal muscle activation in rota-
tightness in the external rotators of the shoulder.37'38 Tightness tional patterns consistent with PNF can facilitate shoulder
of the posterior capsule and decreased infraspinatus and teres rotation.23 These types of movement patterns pro-
minor flexibility can create excessive tilting of the scapula into mote sequential muscle activation and coordination of
protraction when the glenohumeral joint internally rotates at proximal segment movement that can be built upon as
900 of abduction.39 These areas of inflexibility may be detri- the shoulder rehabilitation progresses.5'24 A basic exercise
mental to scapular control and mobility. The kinetic chain that illustrates this is the "shoulder dump." To attain right
exercises can aid in attaining flexibility, but stretching, mas- shoulder external rotation and scapular retraction, the ath-
sage techniques, therapeutic modalities, or joint mobilizations lete assumes a left-foot-forward stance and begins with the
may be necessary. left hip flexed, trunk flexed and rotated to the left, and right
Scapular dyskinesis is often present with glenohumeral
pathology, such as instability and rotator cuff impingement
syndrome.40 Muscular weakness, inflexibility, and neuromus-
cular adaptations contribute to this loss of scapular control and
scapular dyskinesis.35'41'42 Rotator cuff strengthening is a
necessary component of the rehabilitation of these gleno-
humeral pathologies.4837384344 The proximal-to-distal
model suggests that effective and efficient rotator cuff
strengthening depends on scapular control. In kinetic chain
shoulder rehabilitation, intervention to normalize scapular
movement precedes attempting to load the rotator cuff.
A primary role of the rotator cuff is to compress the humeral
head in the glenoid and provide dynamic glenohumeral stabil-
ity.45-47 To do this effectively, the rotator cuff must operate
from a stable scapular base and meet minimum strength
requirements.34 39 Exercising the rotator cuff without scapular
stability could increase the risk of glenohumeral translation,
create pain in rehabilitation, and increase the risk of further
injury. Closed kinetic chain exercises promote cocontraction of
rotator cuff musculature at submaximal levels.48'49 Applying
axial compression through the glenohumeral joint, as in closed-
chain exercises, decreases glenohumeral translation at various
levels of elevation.50 Therefore, closed kinetic chain exercises
have an important role in shoulder rehabilitation pro-
grams.9'43'51 In these exercises, the clinician can determine and
control the proximal load and scapular position by varying the
athlete's stance and posture. Early in the rehabilitation process,
closed kinetic chain exercises promote safe, functional cocon-
tractions and can functionally strengthen the rotator cuff in
preparation for open-chain exercises.4850 Figure 1. Shoulder flexion with ipsilateral anterior step-up.

Journal of Athletic Training 331

Figure 2. A, Starting position for the shoulder-dump exercise. Body weight is on the contralateral-side leg with trunk flexion and rotation.
B, Finishing position. Body weight is on the ipsilateral-side leg with thoracic extension.

arm at knee level (Figure 2A). The athlete then shifts weight trunk motion, rather than isolated arm movements, helps
to the rear foot while extending and rotating the trunk to the establish the scapular retraction. The arm can remain in a sling
right. Active retraction of the right scapula and external during this exercise. The starting position is one of gravity-
rotation of the right arm coincides with this weight shift and assisted scapular protraction (Figure 3A). Scapular retraction
trunk extension (Figure 2B). The action simulates dumping accompanies active spinal extension and ipsilateral rotation
a container backward. The degree of arm elevation, or the (Figure 3B). As scapular motion and control improve, reducing
height at which the imaginary container is dumped, depends trunk motion, increasing arm elevation, or adding extrinsic
on the level of recovery and functional ability. loads increases scapular muscular demand.52
In addition to the modified shoulder dump, other scapular
SCAPULAR FUNCTION AND CONTROL exercises include sternal lifts (Figure 4), tubing "fencing,"
(Figures 5A and 5B), and dumbbell or tubing punch and pull.
Kinetic chain rehabilitation exercises use functional move- Sternal lifts involve reciprocal thoracic flexion-extension with
ment patterns to facilitate scapular motion and then to
the emphasis on thoracic extension and scapular retraction. The
strengthen scapular musculature. Complementary movements athlete feel as though he or she is pushing the sternum
by the legs and trunk, postural adjustments, and plane-of- up and should out but avoid lumbar hyperextension (Figure 4). If the
movement modifications attempt to load scapular musculature
and minimize muscular compensations. A common clinical athlete has difficulty pulling the scapula inferiorly and medi-
scapular compensation involves the substitution of the upper ally, the trunk and hip flexion in the reciprocal movement
trapezius, or exaggerated shoulder shrugging, during a scapu- should increase.
lar-retraction exercise. The kinetic chain approach deempha- Tubing fencing is a frontal-plane scapular-retraction exer-
sizes the upper trapezius by concentrating on scapular depres- cise. In the starting position, the athlete reaches for the tubing
sion with the retraction. Clinically, adjustments in the direction with the involved arm in a lateral lunge stance (Figure 5A).
and amount of complementary trunk motion seem to minimize The angle of the tubing should be horizontal or angled
or eliminate muscular compensations so the scapula remains downward, to encourage scapular depression. From the reach-
congruent with the thorax. One technique is to increase trunk ing and lunging position, the athlete pushes off the leg on the
rotation and thoracic extension with scapular retraction. Other involved side and pulls the arm into adduction. In the finished
feedback methods such as verbal queuing to "pull down," position, the elbow of the involved arm is against the ipsilateral
manually tapping on the lower trapezius, or applying manual hip, the shoulder is in approximately 900 of external rotation,
resistance along the medial border of the scapula may assist and the body weight is on the leg of the uninvolved side
active scapular depression and retraction.24 (Figure 5B). The movement is similar to a lunge and parry in
The first goal in obtaining scapular control and function is the sport of fencing. The athlete should focus on thoracic
scapular retraction. One technique to aid in the reeducation of extension in the concentric phase of the exercise and on pulling
this movement is a modification of the previously described the scapula medially without shrugging.
shoulder-dump exercise. By removing the arm movement, this Punches with dumbbells are a protraction exercise that
becomes a trunk-facilitated scapular exercise. Complementary loads the serratus anterior concentrically and the posterior

332 Volume 35 * Number 3 * September 2000

 I

Figure 3. A, Starting, and B, Finishing position for modified shoulder-dump exercise with a sling.

Figure 4. A, Stemal-lift starting position with head and trunk flexed forward. B, Finishing position emphasizing thoracic extension.

shoulder musculature eccentrically. A complementary stride place the greatest load on the rotator cuff, extending the
accompanies the punches, and repetitions should be rhyth- resistance the greatest distance from the shoulder joint.
mic to incorporate the proximal-to-distal activation and
promote reciprocal scapular motion. For example, a con-
tralateral forward stride accompanies a forward punch, and
CLOSED KINETIC CHAIN AND AXIALLY LOADED
an ipsilateral lateral stride accompanies a lateral punch
EXERCISES
(Figure 6). The height and direction of the punch vary the In kinetic chain shoulder rehabilitation, closed kinetic chain
rotator cuff load. By punching to knee level, the punch is exercises are exercises in which the hand is relatively fixed.44
gravity aided and reduces the load. Horizontal punches An example of this is the scapular-clock exercise, in which

Journal of Athletic Training 333

Figure 5. A, Tubing fencing exercise starting position with body weight on the ipsilateral leg. B, Finishing position. Elbow is at the hip;
thoracic extension and scapular retraction are encouraged.

Proper posture and proximal stability are important for these

exercises. The posture should be "athletic," with feet shoul-
der-width apart, weight evenly distributed, slight hip and
knee flexion, back straight, and head up. By assuming an
athletic stance, the athlete can load the hips and trunk during
these static exercises to promote proximal-to-distal activa-
tion patterns (Figure 7). Closed kinetic chain exercises
should stimulate appropriate cocontractions of the shoulder
girdle musculature at safe, pain-free positions within the arc
of motion.
Kinetic chain shoulder rehabilitation includes light, axially
loaded, active-motion exercises to promote active range of
motion and as a transition to open-chain exercises. Decreasing
the weight of the arm, as in upper extremity aquatherapy,
diminishes the activation of the rotator cuff musculature.54
Supporting the arm on a surface and lightly compressing
through the glenohumeral joint may effectively diminish the
weight of the arm as it moves through a range of motion on dry
land. This compression and unloading may decrease the
demand on weakened rotator cuff musculature during arm
motion.
Axially loaded exercises allow the distal segment, usually the
hand, to move while the athlete maintains an axial load through
the glenohumeral joint. Because the distal segment moves delib-
erately, these are not strictly closed kinetic chain exercises.44
Axially loaded exercises can incorporate the entire kinetic chain
Figure 6. Lateral stride of ipsilateral leg with a lateral punch at and may unload the weak shoulder girdle muscles by effectively
shoulder height. reducing the intrinsic weight of the ann. This leads to increased
pain-free shoulder active range of motion and minimized com-
the athlete performs scapular elevation, depression, protrac- pensation patterns. Exercises such as table slides, ball rolling, and
tion, and retraction with the hand fixed on a stable surface wall slides (Figure 8) are axially loaded shoulder exercises. The
at a safe degree of elevation. Additional closed kinetic chain proximal legs and trunk can initiate these exercises, and the
exercises include weight shifts from hand to hand, stabili- sliding hand can follow a flexion, abduction, diagonal, or curvi-
zation on uneven surfaces, and modified push-ups.8'53 linear path, depending on the exercise goal.

334 Volume 35 * Number 3 * September 2000

Figure 7. Athletic stance during ball-stabilization exercise. Figure 8. Axially loaded wall-slide exercise. Motion at the hips and
trunk complements the sliding pattern of the hand.
PROGRESSION GUIDELINES FOR KINETIC CHAIN
SHOULDER REHABILITATION tains appropriate distal movement may allow the athlete to
Safety and appropriate progression are major concerns in develop an internal feedback system. The athlete learns to
any rehabilitation program. A method exists to address these maintain the appropriate shoulder motion as the feedback
concerns in closed kinetic chain functional rehabilitation pro- varies and facilitating motion is reduced to normal levels. The
grams for the lower extremity.55 Many of those principles are exercises, therefore, progress via this reduction in facilitation.
applicable to this upper extremity approach. The clinician The initial emphasis of this rehabilitation approach is quality
needs to monitor exercise volume to avoid overloading the of movement in integrated movement patterns. The movements
involved tissue when integrating multiple segments. When progress from the proximal segments to the distal segments of
scapular exercises include arm elevation, rotator cuff activation the kinetic chain. To progressively load the distal segments, the
will increase. An exercise program may be limited to 5 or 6 exercises advance from static closed kinetic chain to dynamic
integrated exercises to avoid loads that weaken tissue. axially loaded to open kinetic chain. Progressions include
It is important to continually monitor scapulothoracic reducing feedback, adding resistance, changing the stabilizing
rhythm, since this can be an early indicator of a compensation surface, and altering the movement pattern as the athlete gains
pattern. Reevaluation of the complete movement is necessary rotator cuff strength and scapular control. Decreasing an axial
to accurately discern local fatigue from a proximal deficiency load moves the exercises toward open kinetic chain, effectively
as the cause for the compensation. A common proximal increasing the intrinsic resistance to the rotator cuff by requir-
deficiency that limits the proper performance of the shoulder ing it to control more of the arm's weight.54 An example of this
dump is ipsilateral hip extensor or abductor weakness. Failure progression toward shoulder elevation might be standing upper
to achieve solid hip extension or allowing the hip to fall into extremity weight shifts, scapular clock, rhythmic ball stabili-
adduction is a sign that hip weakness may be limiting the zation, wall slides, and dumbbell punches. This distally fo-
athlete's ability to perform the exercise. Including an ipsilat- cused progression would occur concurrently with a proximal
eral-posterolateral stride in the exercise often allows the athlete scapular progression that begins with sternal lifts (Figure 4)
to perform this shoulder movement without compensation. The and the modified shoulder dump (Figure 3).
stride may bring a normally subconscious hip muscle- The exercises become more sport specific as scapular
activation pattern to a conscious level, or the hip may require control, active range of motion, and shoulder strength approach
independent strengthening to adequately contribute to the normal. A goal of these exercises is to fully integrate the
shoulder function. A goal of kinetic chain rehabilitation exer- strengthening of the scapular, rotator cuff, and trunk muscula-
cises is to perform movement patterns without compensations. ture with sport-specific movement patterns. These exercises
Altering the dominant plane of motion, posture, resistance, or are more traditional but continue to involve the kinetic chain,
tactile or verbal feedback can achieve this goal. The exercises scapular control, and glenohumeral motion. Examples include
must then progress to the normal or appropriate movement standing overhead dumbbell presses in all planes and slow and
pattern without exaggerated feedback or proximal facilitation. controlled simulated sport activities. Overhead presses with
Progressively removing this feedback while the athlete main- dumbbells allow the shifting of body weight or striding to

Journal of Athletic Training 335

incorporate the proximal kinetic chain. Slow, controlled swing- 5. Zattara M, Bouisset S. Posturo-kinetic organisation during the early phase
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