MS: RTC tear s/p stem cell treatment: Weekly Follow Ups: Week 4 (9-18-17)

Review of current email report
- Morning routine:
Phase 4: Begin to normalize strength and mobility in all planes to within 80-90% of uninvolved side prior to returning to higher level dynamic and sport specific training that load the shoulder
- This phase will focus on progressing the strength and mobility with continued emphasis on remaining short of pain
  - This should be done cautiously and without pain
- Maintain good body awareness of scapular position and abdominal control because as you fatigue or your shoulder is tight, you will begin to compensate
  - Focus on abdominal control to reduce excessive arch in the low back (Which if you look around in a gym you will see most individuals arching their back with a lack of trunk control)
  - Avoid excessive shrugging of the shoulder, it is ok for your scapula to move upward, but make sure you are focusing on avoiding excessive scapular elevation especially in comparison to your opposite side
- As you go through the circuits, you may notice weakness more on your involved side
  - When possible, attempt to do and extra set in the weaker side with exercises that can bias one side at a time. I will point this out in the circuits below
- It is once again imperative that you feel no pain or pressure in the bicep
  - `If you do feel any pain or pressure in the front or top of the shoulder, try to move very slowly to that point in the range and then quickly move out of that position
  - Emphasis on reps being slow and controlled to maintain control and tension in the correct areas with each rep taking 3-5 seconds IN EACH DIRECTION…that is really slow
  - If you do feel anything in the front or top of the shoulder, you may be able to decrease it by focusing on the shoulder blade position into a back and down pull
- This phase will continue to organize the movements into circuits
  - You will now be given 2 circuits per day
  - You may start the first week with one set of each and progress to a second set as able
  - The movements in the new circuits are more challenging and it is still important to remain in a pain free range
  - These movements are meant to prepare someone for higher level activities
    - It is not necessary for everyone to push their shoulder into some of these positions, but if you desire to return to any repetitive overhead movements, then all of these movements should be addressed
  - Each should be completed 5-20 reps for one set, second time through the circuit complete 1/2 the reps as the first set possibly the second week
  - Once you complete the program you may want to continue utilizing these circuits to continue to progress shoulder strength and mobility
- Ice is recommended after each session 10-20 minutes
Goals:
- Minimize Irritation using ice as needed
- Continue to progress bicep loading carefully, along with progressing other functional lifts
- Continue with this routine until your strength and mobility is comparable to the opposite side
- Progress to active overhead movement building on the movements you have completed thus far
Day 1:
- Mobility Warm Up Circuit:
  - Goal: Get through it without provoking significant pain or soreness
  - Laying Down Humeral Depression with Progression to Pec Stretch VIDEO
    - Do both sides, try to do twice as many reps on the tighter side
    - NEW: Sleeper Stretch->Behind Back with Towel->Reach Opposite Arm VIDEO
      - Try the second part of this video, keep it light
  - Tall Kneel with Scapular Depression/Retraction VIDEO
    - Can be done kneeling or standing
    - Keep tension very light
  - Puppy Pose Progression VIDEO OR Downward Dog Progression From Higher Level to Floor VIDEO
    - Make sure you stay short of pain/pinch/pressure on the top of the shoulder
  - Foam Roll Pec Stretch and Thoracic Extension VIDEO
    - Begin with the roll between the shoulder blades, this can be done with a towel or yoga mat if you do not have a foam roll. You can also lay on a larger exercise ball
Day 2:
- Mobility Warm Up Circuit:
  - Goal: Get through it without provoking significant pain or soreness
  - Laying Down Humeral Depression with Progression to Pec Stretch VIDEO
    - Do both sides, try to do twice as many reps on the tighter side
    - NEW: Sleeper Stretch->Behind Back with Towel->Reach Opposite Arm VIDEO
      - Try the second part of this video, keep it light
  - Tall Kneel with Scapular Depression/Retraction VIDEO
    - Can be done kneeling or standing
    - Keep tension very light
  - Puppy Pose Progression VIDEO OR Downward Dog Progression From Higher Level to Floor VIDEO
    - Make sure you stay short of pain/pinch/pressure on the top of the shoulder
  - Foam Roll Pec Stretch and Thoracic Extension VIDEO
    - Begin with the roll between the shoulder blades, this can be done with a towel or yoga mat if you do not have a foam roll. You can also lay on a larger exercise ball
- Strength Circuit #1
  - Standing Tricep Extension Band VIDEO
    - Be aware of shoulder blade position, especially as you straighten your elbows. When elbows straighten the shoulder blades will want to tip forward as you get tired
    - Band can be attached up high with a knot in the middle and closed in a door, or one arm at a time with end of band closed in the top of door
  - Bicep Loading Progression VIDEO
    - Band will work better then dumbbell
    - This is broken into 5 phases and I encourage you to move gradually through each
  - Table Top Progression VIDEO
    - Isometric tricep, carefully progress movement as tolerable
- Strength Circuit #4
  - Row Band in Lunge/Half Kneel VIDEO
    - Begin with a band and progress to weighted as able
  - Press band in Lunge/Half Kneel VIDEO
    - Begin with a band and progress as able
  - Side Lying Shoulder Abduction Stabilization VIDEO
    - Start with the beginning of the video holding a weight and doing rotations with hand
    - When you transition to the movement of hand towards the head drop to a lighter weight to begin
Day 3
- Mobility Warm Up Circuit:
  - Goal: Get through it without provoking significant pain or soreness
  - Laying Down Humeral Depression with Progression to Pec Stretch VIDEO
    - Do both sides, try to do twice as many reps on the tighter side
    - NEW: Sleeper Stretch->Behind Back with Towel->Reach Opposite Arm VIDEO
      - Try the second part of this video, keep it light
  - Tall Kneel with Scapular Depression/Retraction VIDEO
    - Can be done kneeling or standing
    - Keep tension very light
  - Puppy Pose Progression VIDEO OR Downward Dog Progression From Higher Level to Floor VIDEO
    - Make sure you stay short of pain/pinch/pressure on the top of the shoulder
  - Foam Roll Pec Stretch and Thoracic Extension VIDEO
    - Begin with the roll between the shoulder blades, this can be done with a towel or yoga mat if you do not have a foam roll. You can also lay on a larger exercise ball
Day 4
- Mobility Warm Up Circuit:
  - Goal: Get through it without provoking significant pain or soreness
  - Laying Down Humeral Depression with Progression to Pec Stretch VIDEO
    - Do both sides, try to do twice as many reps on the tighter side
    - NEW: Sleeper Stretch->Behind Back with Towel->Reach Opposite Arm VIDEO
      - Try the second part of this video, keep it light
  - Tall Kneel with Scapular Depression/Retraction VIDEO
    - Can be done kneeling or standing
    - Keep tension very light
  - Puppy Pose Progression VIDEO OR Downward Dog Progression From Higher Level to Floor VIDEO
    - Make sure you stay short of pain/pinch/pressure on the top of the shoulder
  - Foam Roll Pec Stretch and Thoracic Extension VIDEO
    - Begin with the roll between the shoulder blades, this can be done with a towel or yoga mat if you do not have a foam roll. You can also lay on a larger exercise ball
- Strength Circuit #2
  - Scapular Control with Weight Shift Side Plank Progression VIDEO
    - Start with the weight shift onto each arm side to side progressing to a 5-10sec hold on each arm
    - Once again make sure you keep elbow tucked in and shoulder blade down
      - NEW: Progress to Side Plank with Rotation Progression VIDEO
  - Wall Sit Active/Band Abduction VIDEO OR Prone I to T Progression VIDEO
    - Keep the tension in the back of the shoulder staying short of pain/pressure on the top or front of the shoulder
  - Shoulder Flexion & Forward Reach Towel Slide to Ball Roll Out VIDEO
    - Progresses from a basic forward reaching movement to a more challenging movement that coordinates abdominals to coordinate with shoulder blade stability
    - Remain in pain free range
- Strength Circuit #5
  - Band Horizontal Adduction VIDEO
  - Supine to Wall Sit Wide Pull Down VIDEO
  - Shoulder Band ER/IR 2 Positions->Band Pull Press THIS PHASE VIDEO
    - Focus on the elevated arm position internal and external rotation
    - If there is any pain with this, lower your elbow position to be below the height of your shoulder, or do the movement with the higher elbow position lying down
Day 5
- Mobility Warm Up Circuit:
  - Goal: Get through it without provoking significant pain or soreness
  - Laying Down Humeral Depression with Progression to Pec Stretch VIDEO
    - Do both sides, try to do twice as many reps on the tighter side
    - NEW: Sleeper Stretch->Behind Back with Towel->Reach Opposite Arm VIDEO
      - Try the second part of this video, keep it light
  - Tall Kneel with Scapular Depression/Retraction VIDEO
    - Can be done kneeling or standing
    - Keep tension very light
  - Puppy Pose Progression VIDEO OR Downward Dog Progression From Higher Level to Floor VIDEO
    - Make sure you stay short of pain/pinch/pressure on the top of the shoulder
  - Foam Roll Pec Stretch and Thoracic Extension VIDEO
    - Begin with the roll between the shoulder blades, this can be done with a towel or yoga mat if you do not have a foam roll. You can also lay on a larger exercise ball
Day 6
- Mobility Warm Up Circuit:
  - Goal: Get through it without provoking significant pain or soreness
  - Laying Down Humeral Depression with Progression to Pec Stretch VIDEO
    - Do both sides, try to do twice as many reps on the tighter side
    - NEW: Sleeper Stretch->Behind Back with Towel->Reach Opposite Arm VIDEO
      - Try the second part of this video, keep it light
  - Tall Kneel with Scapular Depression/Retraction VIDEO
    - Can be done kneeling or standing
    - Keep tension very light
  - Puppy Pose Progression VIDEO OR Downward Dog Progression From Higher Level to Floor VIDEO
    - Make sure you stay short of pain/pinch/pressure on the top of the shoulder
  - Foam Roll Pec Stretch and Thoracic Extension VIDEO
    - Begin with the roll between the shoulder blades, this can be done with a towel or yoga mat if you do not have a foam roll. You can also lay on a larger exercise ball
- Strength Circuit #3
  - Laying on Back External Rotation Phase 1 VIDEO
    - Focus on feeling tension into the back of the shoulder/arm pit
      - NEW: Progress to Standing Band External Rotation VIDEO
  - Lying on Back Weight Pull Over OR Band Pull Over VIDEO
    - If painful do the movement below instead
      - Band Extension Deadlift VIDEO OR Off Edge of Bed VIDEO
      - NEW: May Progress
  - Full Can/Scaption Supraspinatus VIDEO
    - Begin without weight, add weight as able maintaining slow controlled motion
- Strength Circuit #6
  - Arm Bar VIDEO
    - Focus on scapular control and keeping the neck relaxed
  - Band Low Fly VIDEO
    - Keep shoulders down and focus more on reaching forward instead of upward
  - Basics of Bear with Leg Lift VIDEO