Should Doctors Work for Hospitals? From the Atlantic Magazine

Hospitals are buying up medical practices at a feverish pace. According to data from the American Hospital Association, the number of physicians employed by hospitals grew by 34 percent between 2000 and 2010, and the pace shows no signs of slackening. In reviewing its data for the past decade, a large physician recruiting firm found that in 2004 only 11 percent of physician searches were conducted by hospitals, but by 2013 that figure had risen to 63 percent.

There are a number of reasons hospitals want to employ physicians. A major aim is to funnel patients to the hospital’s facilities. By law, it is illegal for hospitals to offer physicians inducements to refer patients to their facilities unless the physicians are hospital employees. A term that some hospitals use to describe the referral of patients to providers and facilities outside their system is “leakage.” Such leakage represents lost revenue, and by employing physicians hospitals hope to plug up the holes.

Of course, there are other factors. One is the ability to hospitals to charge more for a variety of procedures than independent physicians, by tacking on “facility fees.” By buying a physician practice, a hospital can charge more for the same test or procedure, even though it is performed in the same place by the same physician. In some cases, such facility fees can raise prices to Medicare by as much as 70 percent compared to what would be paid to an independent physician.

Increasingly, physicians find themselves working for individuals that have never trained in the health professions or cared for the sick.

Another factor is negotiating clout with healthcare payers. When a hospital employs a greater proportion of physicians in a healthcare market, it can often negotiate more favorable payment rates with health insurers. The Federal Trade Commission has taken an interest in this trend, lodging complaints against hospitals for employing too high a percentage of local physicians. In some cases, the FTC has even filed lawsuits against such hospitals.

Hospitals also argue that by employing physicians, hospitals can achieve greater integration of care. For example, they say they can reduce needless variations in practice, including the use of different medical devices for the same procedure, such as knee joint replacement. They also argue that they can ensure better coordination of care between different medical specialties, as well as between physicians and other hospital-employed health professionals such as nurses.

This is not the first time that hospitals have gone on a medical practice buying spree. Something similar took place in the 1990s when the rise of managed care made it appear that hospitals needed to exert more control over patient referral patterns. But widespread public revolt against managed care quickly led to the opening up of such network restrictions. Moreover, as physicians became employees, their productivity fell. Before long, hospitals began divesting themselves of physician employees.

Hospitals hope that this time will be different. For one thing, more sophisticated information systems enable hospitals to do a better job of tracking physician behavior. Even if hospitals lose money on a per-physician basis, they hope that more favorable payment rates and control of referrals will enable them to make up the difference. If successful, they would both get more patients and generate more revenue per patient.

But there is another pitfall in physician employment. Compared to the independent physicians of 20 years ago, today’s employed physicians often exhibit poor morale. It is easy to see why. When physicians become employees, they forfeit a substantial degree of professional autonomy. They are subjected to more institutional rules and regulations, feel increasing pressure to practice according to prescribed patterns, and often labor under escalating productivity quotas.

A related danger is a loss of autonomy on the part of the entire profession of medicine. Increasingly, physicians find themselves working for non-physicians, individuals who never trained in the health professions or cared for the sick. As the trend toward physician employment continues, the people in charge of medical practices are less likely to sport white coats and stethoscopes and more likely to be in business suits. Many physicians feel they are losing control of their profession.

A sense of control can exert a profound effect on morale, energy, and even health. One of the best-known social psychology experiments of the 1970s compared residents of different floors of a nursing home. On one floor, residents were encouraged to make decisions for themselves. For example, they were allowed to choose where to receive visitors, what movies to watch, and how to care for a houseplant they had been given.

The most important factor in promoting professional fulfillment among physicians is providing high-quality care to patients.

On another floor, residents were told that the nursing staff would take care of them. They were not allowed to make choices about where to receive visitors or what movies to watch. They were given houseplants, but were not allowed to determine where to position them or how to care for them. Instead they were told that the staff would take care of things. In contrast to the first group, they were encouraged to see themselves as dependent on the nursing staff.

The two groups were followed for 18 months. At the end of this period, striking differences emerged. The members of the first group were more alert, active, and cheerful than the second group. They were also significantly healthier. In fact, less than half as many members of the first group had died as in the second group. The findings strongly suggest that our ability to choose for ourselves plays an important role in our psychological and physical well-being.

There is a lesson here for physicians and hospitals. A recent nationwide surveyshowed that the single most important factor in promoting professional fulfillment among physicians is providing high-quality care to patients. Where the health of medicine is concerned, infringing on physicians’ ability to care for patients as they think best can prove toxic. By contrast, one of the best tonics is ensuring that physicians can continue to care for patients as they see fit.

In the short term, hospitals may reap financial rewards by employing large numbers of physicians. Over the longer term, however, the vitality of both individual physicians and the entire profession of medicine seems likely to decline, with deleterious consequences for patient care. To protect and promote the future health of the medical profession, it is important that physicians continue to base their decisions primarily on what is best for the patient, not what is best for the hospital.

Intra-articular distal radius fracture. Not a shoulder and not an elbow problem but....

In a shoulder and elbow blog the post of a distal radius fracture is without a doubt not relevant. The following case is a female in her 40s who presented in the office complaining of pain to the wrist after a fall on an outstretched hand while playing volleyball. I have always been amazed by the incredible design of the plates that have been introduced in the treatment of distal radius fractures and I have to admit that it is one of the injuries that is interesting in treating and studying due to the "many personalities" of this fracture. In addition, I prefer to offer operative treatment for these fractures in the young and active patients always in accordance with the criteria that have been developed by the AAOS (please see following link). I would strongly encourage surgeons who encounter patients with fractures of the distal radius to refer them in a timely fashion to experienced surgeons for assessment and treatment. The reason lies that based on this study (click here) it is the number one reason for malpractice lawsuits. Watching a fracture collapse with serial XRs is the most common mistake made in the treatment of these fractures. (J Bone Joint Surg Am. 2013 Feb 20;95(4):e201-8. Lessons regarding the safety of orthopaedic patient care: an analysis of four hundred and sixty-four closed malpractice claims.
Matsen FA 3rd1, Stephens L, Jette JL, Warme WJ, Posner KL).

To go back to the case that was seen in our office, the following radiographs demonstrate an intra-articular distal radius fracture with a lunate facet fragment which is displaced and intra-articular gapping. Based on this study (Corrective osteotomy for isolated malunion of the palmar lunate facet in distal radius fractures. Ruch DS, Wray WH 3rd, Papadonikolakis A, Richard MJ, Leversedge FJ, Goldner RD. J Hand Surg Am. 2010 Nov;35(11):1779-86.) a displaced lunate facet leads to significant loss of forearm supination and disability and for this reason needs to be addressed surgically. In addition, the intra-articular gapping necessitates restoration of the smoothness of the articular surface. 

We elected to use a volar locking plate for this fracture, restore the smoothness of the articular surface and reduce the displaced lunate facet fragment.

Lateral view

10 degree tilted lateral view

immediate postop AP Xray

immediate postop oblique Xray

The following drawing is taken from the Textbook Rockwood and Wilkins Fractures in Adults. It indicates that dorsal plates may result in hardware prominence due to the Lister's tubercle on the dorsum of the wrist. On the contrary, volar plates can be manufactured in a way that they follow the contour of the bone, can be low profile and have less chances of prominence. It seems that most surgeons use volar plates for the treatment of these fractures.

  

Shoulder dislocation resulting in massive traumatic rotator cuff tear.

In the recent years there has been discussion about the indications and contra-indications of repair of degenerative tears of the rotator cuff. Cost analysis studies have been published in major orthopaedic journals (JBJS) and the treatment algorithms continue to evolve. A recent study demonstrated that postoperative aggressive physical therapy is equally effective to conservative or slow rehab treatment with no negative impact on shoulder function, patient satisfaction and re tear rate. A few years ago studies demonstrated that rotator cuff repair without or with acromioplasty have the same outcome. Although there is a debate on the treatment of degenerative rotator cuff tears and while the indications for treatment continue to be explored, there is general agreement among orthopaedic surgeons that traumatic rotator cuff tears that result in loss of motion or strength to the rotator cuff need to be addressed surgically if the patient has no contra-indications to surgery. Timing is important as scarring, retraction and atrophy develop with time. Generally, the sooner are repaired the better the chances for successful healing and treatment. 

The following case is a patient who is in his 30s and presented in the office 2 months after a traumatic dislocation of his shoulder which resulted in weakness in shoulder abduction, forward elevation of the shoulder to 90 degrees with pain and no instability. He already had an MRI by another orthopaedic provider that indicated a ruptured biceps, Hill Sachs lesion and a torn retracted rotator cuff. The XRs after the dislocation and MRI after reduction of the dislocation are shown below:

Scapular Y XR demonstrates anterior dislocation of the shoulder

AP Xray shows the dislocation

MRI without contrast shows the retracted tear of the rotator cuff

MRI of the shoulder shows on the axial views Hill Sachs lesion and "empty" bicipital groove indicative of torn biceps tendon.

Due to his young age and his active lifestyle we elected to proceed with an attempt for arthroscopic repair with a backup plan of partial repair or just debridement in case of significant retraction, loss of tendon elasticity or atrophy. Arthroscopic images are shown below. A total of 4 anchor were used for repair of his rotator cuff in a double row configuration as it has been demonstrated that a double row repair is biomechanically more stable compared to a single row repair.

Prior to repair the entire footprint of the rotator cuff is seen exposed. The glenoid is seen from the subacromial space through the lateral portal. The picture above demonstrates what is left after debridement of the tear to stable margins

Double row repair completed with four anchors. Each anchor has 4 sutures thus a total of 16 sutures were passed through the rotator cuff.

For more information about the treatment of massive rotator cuff tears please refer to the American Academy of Orthopaedic Surgeons website by clicking on the link below.

Massive cuff tears have multiple repair options

By Peter Pollack

ASES Specialty Day symposium examines four common treatments 

Rotator cuff repair postoperative rehabilitation protocol

REHABILITATION PROTOCOL FOR ROTATOR CUFF REPAIR
POSTOPERATIVE INSTRUCTIONS


Anastasios Papadonikolakis, MD, PhD

PERIOD 1: First to 7 days after surgery

GOALS:

1. Protect the repaired tendons of the rotator cuff
2. Begin early shoulder motion

What to do:

After the operation

1. After surgery you will be taken to the post anesthesia care unit where the nurses will evaluate you and make sure that your pain is under control. The arm will be immobilized in a sling.
2. After you go home or to your hospital room you should get out of bed and move around as much as you can but with assistance the first day of surgery. Sit on the side of the bed before you start walking to avoid losing your balance and having a fall
3. Elevate with a pillow your hand with a pillow under the arm. Move your fingers and wrist to avoid swelling
4. Apply cold packs to the operated shoulder to reduce pain and swelling. Make sure that the ice does not come in contact with the skin (we suggest wrapping the ice in a towel)
5. You can remove your sling while keeping your elbow touching to your belly (no shoulder motion) and move your fingers, hand and elbow to increase circulation.
6. You will receive a prescription for pain medication for when you go home (it will make you
constipated if you take it for a long time). Make sure you drink 2-3 liters of water daily and that you take the stool softener as well.


Day 1 after the surgery

1. The large dressing can be removed and a small bandage applied.
2. Remove the sling several times a day to gently move the arm in a pendulum motion: lean
forward and passively swing the arm.

What  you can do at home 

1. Please remove  the bandages. Leave the small pieces of tape (steristrips) in place. 

2. You may shower and get the incision wet. To wash under the operated arm, bend over at the 

waist and let the arm passively come away from the body. It is safe to wash under the arm in 

this position. This is the same position as the pendulum exercise. DO NOT TAKE BATHS

3. Apply cold to the shoulder for 20 minutes at a time as needed to reduce pain and swelling. 

4. Remove the sling several times a day: move the elbow wrist and hand. Lean over and do 

pendulum exercises for 3 to 5 minutes every 1 to 2 hours. 

5. DO NOT lift your arm at the shoulder using your muscles. 

6. Because of the need for your comfort and the protection of the repaired tendon, a sling is 

usually necessary for 4 to 6 weeks, unless otherwise instructed by your surgeon. 

When to see the doctor: 

Please arrange to see your surgeon in the office 3-10 days after surgery for suture removal and 

further instructions. If you have questions or concerns regarding your surgery or the rehabilitation 

protocol and exercises call the office.

Rehabilitation after Rotator Cuff Repair 

Phase One: 0 to 6 weeks after surgery 

Goals: 

1. Protect the rotator cuff repair 

2. Ensure wound healing 

3. Prevent shoulder stiffness 

4. Regain range of motion 

Activities: 

1. Sling 

Use your sling most of the time. Remove the sling 4 or 5 times a day to 

do pendulum exercises. 

2. Use of the affected arm 

You may use your hand on the affected arm in front of your body but DO 

NOT raise your arm or elbow away from your body. It is all right for you 

to flex your arm at the elbow. Also: 

-No Lifting of Objects. Nothing heavier than a cup of coffee.

-No Excessive Shoulder Extension 

-No Excessive Stretching or Sudden Movements 

-No Supporting of Body Weight by Hands 

3. Showering 

You may shower or bath and wash the incision area. To wash under the 

affected arm, bend over at the waist and let the arm passively come away 

from the body. It is safe to wash under the arm in this position. This is 

the same position as the pendulum exercise. 

Exercise Program 

ICE 

Days per Week: 7 As necessary 15- 20 minutes 

Times per Day: 4-5 

STRETCHING / PASSIVE MOTION 

Days per Week: 7 Times per day: 4-5 

Program: 

Pendulum exercises 

Supine External Rotation 

Supine passive arm elevation 

Scapular retraction

Shoulder shrug 

Ball squeeze exercise 

Starting at 3rd week after surgery: 

Behind the back internal rotation

PERIOD 2: 6 to 12 weeks after surgery

Goals:
1. Protect the rotator cuff repair
2. Improve range of motion of the shoulder 
3. Begin gentle strengthening

Activities
1. Sling
Your sling is no longer necessary unless your doctor instructs you to continue using it.
2. Use of the operated arm
You should continue to avoid lifting your arm away from your body, since this is the action of the tendon that was repaired. You can lift your arm forward in front of your body but not to the side. You may raise your arm to the side, if you use the good arm to assist the operated arm.
3. Bathing and showering
Continue to follow the instructions from phase one and the instructions above.

Exercise Program
The exercises listed below may be gradually integrated into the rehabilitation program under the supervision of your doctor and/or physical therapist.

STRETCHING / ACTIVE MOTION

Days per week: 5-7
Stretching

Times per day: 1-3

Pendulum exercises
Supine External Rotation
Standing External Rotation
Supine passive arm elevation Active-Assisted Arm Elevation
Behind the back internal rotation
Supine external Rotation with Abduction External rotation @ 90o abduction Supine Cross-Chest Stretch
Wall slide Stretch
Overhead pullies


Active Motion
Side-lying External Rotation
Prone Horizontal Arm Raises “T”
Prone row

Prone scaption “Y”
Prone extension
Active-assisted Arm Elevation progressing to:
Standing Forward Flexion (scaption) with scapulohumeral rhythm
Resisted forearm supination-pronation Resisted wrist flexion-extension Sub-maximimal isometric exercises: internal and external rotation at neutral with physical therapist
Rhythmic stabilization and proprioceptive training drills with physical therapist

Phase 3: 12-18 weeks after surgery
Goals:

1. Protect the rotator cuff repair
   
2. Regain full range of motion
   
3. Continue gentle strengthening
   

Activities:
Use of the operated arm
You may now safely use the arm for normal daily activities involved with dressing, bathing and self-care. You may raise the arm away from the body; however, you should not raise the arm when carrying objects greater than one pound. Any forceful pushing or pulling activities could disrupt the healing of your surgical repair.
Exercise Program
The exercises below form a list that may be gradually integrated into the rehabilitation program under the supervision of your doctor and/or physical therapist. Resistance for the dynamic strengthening exercises can gradually be added starting with 1 lb and should not exceed 3 lb at this time.

STRETCHING / ACTIVE MOTION / STRENGTHENING

Days per week: 3
Stretching

Times per day: 1

Pendulum exercises
Supine external Rotation 
Standing external Rotation 
Supine passive arm elevation 
Behind the back internal rotation 
Hands-behind-the-head stretch 
Supine cross-chest stretch 
Sidelying internal rotation stretch 
External rotation at 90° abduction stretch
Wall slide Stretch
Theraband Strengthening
External Rotation Internal Rotation Standing Forward Punch Shoulder Shrug Dynamic hug
“W”’s Seated Row Biceps curl

Dynamic Strengthening
Side-lying External Rotation
Prone Horizontal Arm Raises “T” Prone scaption “Y”
Prone row
Prone extension
Scapulohumeral rhythm exercises Standing forward flexion (scaption) PNF manual resistance with physical therapist
Propriocetion drills

Phase 4: 18 to 26 weeks after surgery

Goals:
1. Continue to protect the repair by avoiding excessive forceful use of the arm or lifting excessively heavy weights.
2. Restore full shoulder motion
3. Restore full shoulder strength
4. Gradually begin to return to normal activity
Activities:
1. Sports that involve throwing and the use of the arm in the overhead position are the most demanding on the rotator cuff. Your doctor and sports physical therapist will provide you with specific instructions on how and when to return to golf, tennis, and volleyball, swimming and throwing.
2. For people who wish to return to training with weights, you’re your doctor will give you guidelines regarding the timing and advice when returning to a weight-training program.
3. The following timetable can be considered as a minimum for return to most activities:

Ski
Golf
Weight Training 
Tennis 
Swimming 
Throwing

              6 -8 months

Before returning safely to your activity, you must have full range of motion, full strength and no swelling or pain.
Your doctor or physical therapist will provide you with a specific interval-training program to follow when it is time to return the above activities.

STRETCHING / ACTIVE MOTION / STRENGTHENING 
Days per week: 3 
Times per day: 1

Stretching
Behind the back internal rotation
Standing External Rotation / Doorway Wall slide Stretch
Hands-behind-head stretch
Supine Cross-Chest Stretch
Sidelying internal rotation (sleeper stretch) External rotation at 90° Abduction stretch

Theraband Strengthening
External Rotation Internal Rotation Standing Forward Punch Shoulder Shrug Dynamic hug
“W”’s
Optional for Overhead Sports:
External rotation at 90° Internal rotation at 90° Standing ‘T’s Diagonal up
Diagonal down
Dynamic Strengthening
It is recommended that these exercises be limited to resistance not to exceed 5lb.
Side-lying External Rotation
Prone Horizontal Arm Raises “T”
Prone scaption “Y”
Prone row
Prone extension
Standing Forward Flexion
Standing forward flexion “full-can” exercise Prone external rotation at 90° abduction “U’s Push-up progression
Plyometric Exercises
Your doctor or physical therapist will provide you with a specific plyometric-training program to follow when appropriate.
Weight Training
See weight training precautions

Illustrations
The exercises illustrated and described in this document should be performed only after instruction by your physical therapist or doctor.
Pendulum exercise

Bend over at the waist and let the arm hang down. Using your body to initiate movement, swing the arm gently forward and backward and in a circular motion.

Shoulder shrug

 

Shrug shoulders upward as illustrated.

Shoulder blade pinches
Pinch shoulder blades backward and together, as illustrated.

Supine passive arm elevation
Lie on your back. Hold the affected arm at the wrist with the opposite hand. Using the strength of the opposite arm, lift the affected arm upward, as if to bring the arm overhead, slowly lower the arm back to the bed.

Supine external rotation
Lie on your back. Keep the elbow of the affected arm against your side with the elbow bent at 90 degrees. Using a cane or long stick in the opposite hand, push against the hand of the affected arm so that the affected arm rotates outward. Hold 10 seconds, relax and repeat.

Behind-the-back internal rotation
Sitting in a chair or standing, place the hand of the operated arm behind your back at the waistline. Use your opposite hand, as illustrated, to help the other hand higher toward the shoulder blade. Hold 10 seconds, relax and repeat.

Supine cross-chest stretch
Lying on your back, hold the elbow
of the operated arm with the opposite hand. Gently stretch the elbow toward the opposite shoulder. Hold for 10 seconds.

Sidelying internal rotation stretch
Lie on your side with the arm positioned so that the arm is at a right angle to the body and the elbow bent at a 90o angle. Keeping the elbow at a right angle, rotate the arm forward as if to touch the thumb to the table. Apply a gentle stretch with the opposite arm. Hold 10 to 15 seconds.

External rotation at 90o abduction stretch
Lie on your back. Support the upper arm, if needed, with towels or a small pillow. Keep arm at 90 degrees to the body and the elbow bent at 90 degrees. Using a stick and the opposite arm, stretch as if to bring the thumb to
the corner of the table adjacent to your ear. Hold for 10 seconds, and then return to the starting position

Wall slide stretch
Stand facing a wall; place the hands of both arms on the wall. Slide the hands and arms upward. As you are able to stretch the hand and arm higher, you should move your body closer to the wall. Hold 10 seconds, lower the arm by pressing the hand into the wall and letting it slide slowly down.

Seated/Standing Forward Elevation (Overhead Elbow Lift) During this phase, you can stand or sit in a chair. If it is easier, begin lying on your back until you achieve maximal motion, then use the standing or seated position. Assume an upright position with erect posture, looking straight ahead. Place your hands on either thigh with the operated thumb facing up and your elbow straight. In the beginning, this stretch is not performed solely with the operated arm, but uses the uninjured hand for assistance going up and coming down. As you become stronger, you can raise and lower your arm without assistance. The operated arm should be lifted as high as possible, or to your end-point of pain. Try to raise the arm by hinging at the shoulder as opposed to raising the arm with the shoulder blade.

Standing forward flexion
Stand facing a mirror with the hands rotated so that the thumbs face forward. Raise the arm upward keeping the elbow straight. Try to raise the arm by hinging at the shoulder as opposed to raising the arm with the shoulder blade. Do
10 repetitions to 90 degrees. If you can do this without
hiking the shoulder blade, do 10 repetitions fully overhead.

Isometric internal and external rotation
Stand facing a doorjamb or the corner of a wall.
Keep the elbow tight against your side and hold the forearm at a right angle to the arm. For internal rotation, place the palm against the wall with the thumb facing up. For external rotation, place the back of the hand against the wall with the thumb facing up.
Pull or push against the wall and hold for 5 seconds

Ball squeeze exercises
Holding a rubber ball or tennis ball, squeeze the ball and hold for 5 seconds

Prone rowing
The starting position for this exercise is to bend over at the waist so that the affected arm is hanging freely straight down. Alternatively, lie face down on your bed with the operated arm hanging freely off of the side. While keeping the shoulder blade ‘set’, raise the arm up toward the ceiling while bending at the elbow. The elbow should be drawn along the side of the body until the hands touch the lower ribs. Always return slowly to the start position.

Prone horizontal abduction (‘T’s)
The starting position for this exercise is to bend over at the waist so that the affected arm is hanging freely straight down. Alternatively, lie face down on your bed with the operated arm hanging freely off of the side. Rotate your hand so that the thumb faces forward. While keeping the shoulder blade ‘set’ and keeping the elbows straight, slowly raise your arm away from your body to shoulder height, through a pain-free range of motion (so that your hand now has the thumb facing forward, and aligned with your cheek). Hold that position for 1 to 2 seconds and slowly lower. Limit the height that you raise the arm to 90 degrees, or in other words, horizontal to the floor.

Prone horizontal abduction with external rotation
The starting position for this exercise is to bend over at the waist so that the affected arm is hanging freely straight down. Alternatively, lie face down on your bed with the operated arm hanging freely off of the side. Rotate your hand so that the thumb faces outward. While keeping the shoulder blade ‘set’ and keeping the elbows straight, slowly raise your arm away from your body to shoulder height, through a pain-free range of motion (so that your hand now has the thumb facing forward, and aligned with your cheek). Hold that position for 1 to 2 seconds and slowly lower. Limit the height that you raise the arm to 90 degrees, or in other words, horizontal to the floor.

Prone scaption (‘Y’s)
The starting position for this exercise is to bend over
at the waist so that the affected arm is hanging freely straight down.
Alternatively, lie face down on your bed with the operated arm hanging freely off of the side. Keep the shoulder blade ‘set’ and keep the elbows straight. Slowly raise the arm away from your body and slightly forward through a pain-free range of motion (so that your hand now has the thumb facing up, and is aligned with your forehead). Hold that position for 1 to 2 seconds and slowly lower. Limit the height that you raise the arm to 90 degrees,or in other words, horizontal to the floor.

Prone extension
The starting position for this exercise is to bend over at the waist so that the affected arm is hanging freely straight down. Alternatively, lie face down on your bed with the operated arm hanging freely off of the side. While keeping the shoulder blade ‘set’ and keeping the elbow straight, raise the arm backward toward your hip with the thumb pointing outward. Do not lift your hand past the level of your hip.

Prone external rotation at 90 o Abduction
Lie face down on a table with your arm hanging over the side of the table. Raise the arm to shoulder height at a 90o angle to the body. While holding the arm in this position, rotate the hand upward, until the hand is even with the elbow. Hold one second and slowly let the hand rotate to the starting position and repeat.

Sidelying external rotation
Lying on the non-operated side, bend your elbow to a 90-degree angle and keep the operated arm firmly against your side with your hand resting on your abdomen. By rotation at the shoulder, raise your hand upward, toward the ceiling through a comfortable range of motion. Hold this position for 1 to 2 seconds, and then slowly lower the hand.

Standing forward flexion (‘full-can’) exercise
Stand facing a mirror with the hands rotated so that the thumbs face forward. While keeping the shoulder blade ‘set’ and keeping the elbows straight, raise the arms forward and upward to shoulder level with a slight outward angle (30°). Pause for one second and slowly lower and repeat.

Lateral Raises
Stand with the arm at your side with the elbow straight and the hands rotated so that the thumbs face forward. Raise the arm straight out to the side, palm down, until
the hands reach shoulder level. Do not raise the hands higher than the shoulder. Pause and slowly lower the arm.

Theraband Strengthening
These resistance exercises should be done very slowly in both directions. We want to strengthen you throughout the full range of motion and it is very important that these exercises be done very slowly, not only when you complete the exercise (concentric), but also as you come back to the start position (eccentric). The slower the motion, the more maximal the contraction throughout a full range of motion.

External Rotation
Attach the theraband at waist level in a doorjamb or other. While standing sideways to the door and looking straight ahead, grasp one end of the band and pull the band all the way through until it is taut. Feet are shoulder width apart and the knees are slightly flexed. The elbow is placed next to the side with the hand as close to your chest as possible (think of this elbow as being a hinge on a gate). Taking the cord in the hand, move the hand away from the body as far as it feels comfortable. Return to the start position.

Internal Rotation
Attach the Theraband at waist level in a doorjamb or other. While standing sideways to the door and looking straight ahead, grasp one end of the handle and pull the cord all the way through until it is taut. Feet are shoulder width apart and the knees are slightly flexed. The elbow is placed next to the side and is flexed at 90 degrees (think of this elbow as being a hinge on a gate). Taking the cord in the hand, move the hand toward the chest as far as it feels comfortable. Return to the start position.

Shoulder Shrug
Stand on the theraband with your feet at should width apart and look straight ahead. Next, straighten up, keeping the knees slightly flexed, with your arms straight down at the sides (palms in). Slowly raise
the shoulders in a shrug (toward the ears), then rotate the shoulders backward in a circular motion, and
finally down to the original position. This movement is completed while keeping constant tension on the cord.

Seated / Standing Row
Attach the theraband in a doorjamb or other. Sit or stand facing the door. Use a wide flat—footed stance and keep your back straight. Begin with the arms slightly flexed, hands together at waist level in front of your body, thumbs pointing upward, and with the cord taut. You are producing a rowing motion. Pull the cord all the way toward the chest. While pulling the cord, the elbows should be drawn along the side of the body until the hands touch the lower ribs. Always return slowly to the start position.

Standing Forward Punch
Attach the theraband at waist level in the doorjamb. Facing away from the door, stand in a boxing position with one leg ahead of the other (stride position). Do not bend at the waist and remain in an upright position. If the right shoulder is the injured extremity, you will want to grasp the handle in the right hand and step out until the cord is taut. If you use the right hand, the left foot should be forward in the stride position. Begin with your right arm at waist level and bend the elbow at a 90 degree angle, with the elbow remaining near your side. Slowly punch forward while slightly raising the right arm in a forward, upward punching motion. The hand should reach approximately neck level with the right arm almost straight.

Biceps Curls
Place your feet on the cord, shoulder width apart, knees slightly bent. Keeping your elbows close to the sides of your body, slowly bend the arm at the elbow and curl towards the shoulder.

Dynamic Hug
With the tubing attach behind you at shoulder height, grip both ends of the tubing in your hands with the tubing on the outside of your shoulders. Pull the band forward and slightly downward in a ‘hugging’ motion, or as if you were wrapping both arm around a small tree. Pause and return slowly to the starting position.

‘W’s
With the tubing attached in front of you, stand with the tubing in both hands with the elbows bent at 90o and fixed at your side. Pull the band outward, keeping the elbow at your side. The arms rotate outward making the shape of a ‘W’.

Standing ‘T’s.
Stand with the theraband attached in front of you. Stand with the arm flexed forward at shoulder height with the elbow straight. While keeping the elbow straight, pull the arm toward the rear until the arm is by your side.

Theraband external rotation at 90o.
Stand with the theraband attached in front of you. Keeping the arm elevated to 90 degrees and the elbow at a 90-degree angle, rotate the hand and arm slowly backward and then return slowly to the start position.

Theraband internal rotation at 90o.
Stand with the theraband attached behind you. Keeping the arm elevated to 90 degrees and the elbow at a 90-degree angle, rotate the hand and arm slowly forward and then return slowly to the start position.

Theraband diagonal-up
Stand with the theraband attached on your left side for your right hand. Start with your right hand on the left hip with the thumb facing the hip. Start by pulling the band so that your hand travels up and behind your head.

Theraband diagonal-down
Stand with the theraband attached behind you at shoulder level. Start with your arm in throwing position. Pull the band down and across your body so that your thumb faces the opposite hip.