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Whenever I go see my physical therapist for my shoulder rehab, he is always pushing, pushing, pushing. It's this exercise and that activity. Is it really necessary to do so many different kinds of things to get back to a normal, stable joint? Sometimes I wonder if I saw someone else, if it wouldn't be easier and faster. What do you think?

As the old saying goes, "There's no silver bullet." In other words, there's no easy answer to complex problems. And treatment for the shoulder (glenohumeral) joint is no exception. In fact, the entire shoulder complex involves the humerus (upper arm bone), clavicle (collar bone), and scapula (shoulder blade). The scapula contains the glenoid fossa (shoulder socket) and the acromion (curved bone that goes across the top of the shoulder joint). Together, these components along with all the soft tissues must move in a smooth, coordinated, rhythmical fashion just to raise your arm up and down. That goes for all the other motions your arm makes possible: e.g., scratching the middle of your back, pitching a ball forward, reaching into a back pocket, and so on). Patients are often sent to physical therapy for strengthening when the shoulder joint is unstable. But physical therapists don't prescribe the same exercise program for everyone. That's because there are so many variables to consider. For example, rehab is different depending on whether the patient has anterior instability (shoulder moves forward in and even out of the socket) versus posterior (backward) instability. Sometimes patients have multidirectional instability (unstable in more than one direction). Each one of these situations calls for an individual rehab program. Then there is the scapula (shoulder blade) to consider. How well does it move? Is it moving in a coordinated rhythm with the shoulder? Scapular control is an important part of glenohumeral (shoulder joint) stability. Muscles must be retrained if they are weak, short, or have an altered length-tension ratio. They must be able to generate as well as withstand forces needed for arm movement. And the therapist mustn't forget addressing proprioception (joint sense of position) with a physical therapy program. Restoring these aspects of scapular and glenohumeral motion is vital. This concept is especially important for the athlete who depends on his or her arm for accuracy and strength in motion and function (e.g., think about the need for a baseball pitcher to deliver the ball exactly in the strike zone across the home plate). Finally, the plan of care is designed by the physical therapist for each specific patient. The therapist uses clinical skill, expertise, experience, and evidence-based information to decide which mode (type) of exercise to use. The same decision-making process is involved in determining a starting point for frequency, duration, and intensity of the exercises. More research is needed to verify optimal treatment for shoulder instability whether it's an anterior, posterior, or multidirectional instability. With all the factors, variables, and considerations the therapist must consider, it's no wonder exercise programs are not easy or simple and one program does not "fit all."

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