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1 Website: Treatment of Shoulder Dysfunction: Movement System Impairment (MSI) Follow us on or find WU Program in PT on Facebook Presented by MSI Diagnose and manage musculoskeletal pain problems Based on anatomy & kinesiology Deviations in alignment and the precision of joint motion create microtrauma that can lead to macrotrauma In cases of trauma, alterations of normal movement or alignment will perpetuate the pain MSI Syndromes Emphasis on Cause (movement) vs Source (pathoanatomy) Musculoskeletal (mechanical) pain conditions (syndromes) Life style induced Multiple non-pathological impairments Combine to alter the precision of accessory joint movement Results in Principle Impairment (MSI syndrome) Causes tissue injury that results in pathological changes. Diagnosis PT expertise is the Human Movement System Knowledge of normal alignment & movement pattern is the basis for our practice PTs must establish a diagnosis of the condition they are treating to ensure most effective treatment APTA House of Delegates 1994, 1995 Movement Examination To date, whether the movement impairment is the cause or result of the pain is unknown but if during the exam, correcting the movement impairment immediately alleviates the symptoms, then treatment may be most effectively directed by a movement diagnosis Ludewig PM 2009; Kibler WB 2013 Washington University Program in PT

2 Diagnosis Movement System Diagnosis is derived from the systematic examination Exam = Tests of alignment & movement performed in several positions Analysis of functional activities Symptom behavior Scapular & humeral positioning during these activities Systematic Examination As part of the systematic exam, the patient s preferred alignment & movements are analyzed & correlated with their symptoms The preferred pattern is followed immediately by a secondary test modifying the movement to determine the effect on the symptoms Timing of the movement Amount of movement Length and strength assessments provide additional information = contributing factors Exam The exam is based on symptom alleviation not just provocation Tests designed to identify the involvement of a particular tissue may be done prn Identification of the pathoanatomical structure that is the source of symptoms is not required May be useful for prognosis/staging but does not direct treatment Often > 1 patho-anatomical source Impingement- what is it? Defined differently by PT s and MDs Physicians: anatomical mechanism of reduced subacromial space which requires decompression or acromioplasty PT s: movement related mechanisms that either initiate or contribute to rotator cuff pathology Instability included but surgeons think this is distinctly different condition than impingement Braman JP, 2013 Impingement- what is it? Shoulder impingement has become an obsolete diagnosis There is a mechanical impingement phenomena but the source of pain is not clear Rotator cuff footprint has cleared subacromial space by 70 deg of arm elevation Subacromial space is least usually ~90 deg Maybe pain is from bursae, labrum,? Impingement- what is it? For those conditions that are consistent with a mechanical pinching it seems that classifying into subgroups based on movement impairments may be the most effective! Ludewig PM & Braman JP 2011 Ludewig PM & Braman JP 2011 Washington University Program in PT

3 Exam Diagnosis Combination of exam findings vs algorithym The diagnosis is named according to the impairment(s) observed Frequency Magnitude Production of symptoms Response to modification of movement Treatment Diagnosis directs treatment: Corrective exercise program- individualized to the patient Practice performing movements using the corrected or modified movement strategy Correction of alignment & movement during functional activities Treatment Corrective exercise: emphasis on precise motion by selecting the appropriate level of exercise, often this involves making the exercise easier Requires the skills of a PT Treatment is addressing the cause of pain, therefore pain resolves as stresses on tissues are reduced Recurrence is less likely if the cause of pain has been addressed Key Concepts You get what you train (many strategies to create moments at a joint or within a limb) Presence of a muscle does not mean that it is being appropriately used No magic in an exercise except if the desired motion is evident Does strengthening the serratus improve scapular upward rotation? MSI Diagnoses For many patients it is appropriate to assign a both a scapular and humeral diagnosis MSI Scapular Syndromes Scapular internal rotation (AC joint) with anterior tilt (AC joint) with insufficient UR (SC and AC joint) with abduction (SC joint) Scapular depression (SC joint) Scapular external rotation/adduction (SC and AC joint) Scapular winging (pathological) (AC joint) Scapular elevation (SC joint) Washington University Program in PT

4 MSI Humeral Syndromes Humeral Anterior Glide Humeral Superior Glide Glenohumeral Medial Rotation Glenohumeral Hypomobility Glenohumeral Multidirectional Accessory Hypermobility Definitions of Scapular Movements Adduction (clavicular retraction-sc): the scapula translates medially along the rib cage toward the vertebral column. Abduction: (clavicular protraction-sc) translates laterally During these motions there is associated scapular internal or external rotation occurring at the AC joint. Definitions of Scapular Movements Elevation:(clavicular elevation-sc) a movement in which the scapula translates along the ribcage in a cranial direction. Depression: (clavicular depression-sc) translates in a caudal direction. Scapular Upward & Downward Rotation Axis of motion is perpendicular to the scapula at the AC joint Posterior axial rotation at the SC joint Upward rotation inferior angle moves laterally glenoid fossa rotates cranially Downward rotation inferior angle moves medially glenoid rotates caudally Ludewig PM 2009 Scapular Tilting Anterior/posterior tilt or tipping- occurs about an axis parallel to the scapular spine at the AC joint Anterior tilt/tip- coracoid moves anteriorly & caudally inferior angle moves post & cranially Posterior tilt/tip- coracoid moves posteriorly & cranially inferior angle moves anteriorly & caudally 23 Neumann 2013 Scapular Internal/External Rotation Vertical axis at AC joint Internal rotation- Vertebral border of scapular moves away from thorax glenoid will turn more anterior; the costal surface of the scapula faces more toward the midline of the body External rotation- Scapular vertebral border moves toward posterior thorax glenoid faces lateral Ludewig PM Washington University Program in PT

5 Scapular Winging AC Joint abnormal movement of the scapula about a vertical axis vertebral border moves in a posterior and lateral direction away from the ribcage Hall, CM, Brody LT. Summary - Scapular Motions Upward rotation: Primarily from the SC joint via posterior axial rotation of the clavicle on the sternum Secondarily from the AC joint Minimal from elevation at the SC joint Posterior tilt: Primarily from the AC joint External rotation: SC joint (clavicular retraction) AC joint Ludewig PM 2009 Normal Scapular Motion During Arm Elevation Scapula externally rotates especially at the end ranges. Ludewig PM 2009 Scapula internally rotates until after ~125 and then starts to externally rotate Braman JP 2009 By the end of arm elevation the scapula ER so it is degrees anterior to the frontal plane. Normal Scapular Motion During Arm Elevation Scapula should elevate but only slightly (6-10 ) Ludewig PM 2009 Vertebral border of scapula should remain in contact with thorax Normal GH:ST rhythm: 2.1:1for abduction; 2.4:1 for flexion; 2.2:1 for scapular plane abduction Ludewig PM 2009 Clinical Assessment: Criteria for Normal Scapular Motion By the end range of arm elevation: Acromion should be aligned with C6-7 Root of spine of scapula should be aligned with T3 The vertebral border of the scapula should reach (+ or - 5 ). Normal scapular abduction is 3 from the vertebral spine to the root of the spine of the scapula. Scapula should posteriorly tilt 10 Ludewig PM 2009 Scapula should externally rotate so it is anterior to the frontal plane Ludewig PM 2009 Normal Scapular Motion During Arm Lowering You shouldn t see increased anterior tilting during arm lowering No prominence of vertebral border Scapula had greater posterior tilting (2 ) during arm lowering compared to arm raising Ludewig PM 2009 Washington University Program in PT

6 Normal Scapular/Clavicular Alignment 19 SC joint clavicular retraction 6 SC clavicular elevation 41 scapular internal rotation 5 scapular upward rotation 13.5 scapular anterior tilt 12 subjects; mean age 29.3 Ludewig PM 2009 Normal Humeral Movement: Arm Elevation The humerus laterally rotates relative to the scapula as the arm is elevated in all planes GH LR should be about 60 by the end range of arm elevation GH LR increases the volume of the subacromial space Ludewig PM 2009 During shoulder flexion Movement should primarily be spinning; humeral head should stay centered on the glenoid Neumann DA 2002 Normal Humeral Movement: Rotation During shoulder LR & MR with arm abducted Movement should primarily be spinning; humeral head should stay centered on the glenoid (Neumann DA 2002) Humerus should spin on axis without horizontal abduction Normal Humeral Alignment Humeral head relative to acromion: no > 1/3 of the humeral head anterior to acromion Humerus vertical from lateral view With normal scapular alignment Posterior view: olecrannon should face posterior to slightly lateral Anterior view: antecubital crease should face anterior to slightly medial Scapular Depression Syndrome Primary impairment is scapular depression (SC) Often upward rotation deficit (SC & AC) Depression may be observed at any time during the motion Frequently an alignment fault of scapular depression is observed Scapular downward rotation Scapular Depression Syndrome Poor muscle performance Long, weak, decreased activation Dominance & stiffness of scapular depressors Results in compromise Brachial plexus, glenohumeral joint structures including rotator cuff, acromioclavicular joint, sternoclavicular joint, cervical spine, surrounding muscles Washington University Program in PT

7 Scapular Depression Syndrome Treatment Improve muscle performance- trapezius & serratus Normalize muscle length and stiffness Correct the movement pattern Exercise During function Educate patient Alignment Precautions for function Humeral Anterior Glide Syndrome During arm motion the humeral head moves too far or stays anterior compared relative to the glenoid Impairment is most notable during active humeral abduction and rotation Common scapular impairments: internal rotation with anterior tilt, scapular depression Humeral Anterior Glide Syndrome Subscapularis: long, weak or not activated appropriately Latissimus or pect major: excessive activation Posterior deltoid > infraspinatus & teres minor Posterior GHJ structures: short or stiff Results in Pain at the GHJ, instability less common brachial plexus compromise Humeral Anterior Glide Syndrome Treatment Train for precise pattern of humeral rotation LR: Improve the recruitment of infraspinatus & teres minor Improve performance of subscapularis Lengthen posterior structures of GHJ Address scapular contributions Functional activities Major Contributing Factors The WAY every day activities are performed The type of activities Amount of rotation The frequency of the activities The duration/intensity of the activities Work, recreational, fitness Influences: tissue characteristics (type of collagen, laxity); body proportions (height, weight, body mass distribution, etc) Age Patient Cases Washington University Program in PT

8 Patient 1 Young volleyball player, softball pitcher Pain anterior GHJ and scapular area esp medial, 0-9/10 Onset of constant pain was 4 mos prior although had some pain 1 yr ago resolved with end of season rest Family noted scapula winging No activity for past 3 mos which has helped reduce pain Alignment Patient 1 Shoulder Flexion Shoulder Flexion- Improved Pain decreased with correction of mvmt pattern Note her improved alignment Patient 1 Supine LR anterior glide with increased sx; preventing ant glide reduced sx MR- ant glide and ant tilt with increased sx; correction again reduced sx Muscle length/stiffness Pec minor stiffness noted Pec major- nrl to long but humeral ant glide noted; pain reduced with correcting humeral glide Patient 1 Prone Middle trap test: R 2+, scapula IR & DR; L 3-/5 Lower trap test: R 2+, scapula IR and elevated; L3/5 Shoulder LR- ant glide, scapula IR/wing, depress, sx produced but decreased with correction Shoulder MR- humeral extension, ant glide, scapula IR Sitting Serratus anterior > 3/5 bilat (resistance not applied due to pain) Washington University Program in PT

9 Patient 1 MSI DX: Treatment: Shoulder flexion correcting alignment 1 st then focus on mvmt pattern Prone arm lifts with hands on head Pec minor stretch Supine shoulder MR avoid ant tilt, LR avoid ant glide; both directions with arm abducted 45 Prone MR- focus on precise rotation Patient 1 Progression 2 mos after initial visit, 3 rd visit DASH from 228 to 70 No c/o pain but weakness Prone arm lift progressed to hands off head Prone perform both MR and LR Supine shoulder rotation in more abducted position and use wt for LR Able to try to resume basketball: shots, min of ball handling Patient 1 4 mos after initial visit, final & 5 th visit Not having pain Almost full participation in basketball but still not full duty with farm chores Additional Exercises: Quadruped Bkfo for abdominals Continue with the other exercises Final Visit Patient 1 Final Visit Prone Corrected performance Pitching Washington University Program in PT

10 Patient 2 24 yo grad student c/o neck pain, suprascap pain can radiate into interscapular area Numbness in bilat ulnar f/a & handconstant Migraines 1-2x/wk History 4yr hx of mild neck pain Worse fall 09 after MVA Patient 2 Sx range from 1-7/10 Occas has anterior shoulder pain on R sx with arm elevation, back pack, slouch, end of day Thoracic outlet syndrome Symptom distribution + Tinels at scalenes + arms overhead test + costoclavicular Cervical ROM negative Patient 2 Increased slope of shoulders Cerv & thoracic spine flat Scapula: DR, tilt, adducted and depressed Pt 2 Next? Technique needs adjustment Modification for cubital tunnel Functional correction Patient 2 Young female volleyball player presenting with right shoulder pain and loss of range of motion Winging of scapula noted ~2 yrs prior, 1 yr later she noted a loss of flexion- drove her to seek treatment Diagnosed with labral tear and long thoracic nerve palsy, EMG 1 yr prior Pt was told her nerve would be fine after she stopped Vball; she did stop 1 month after EMG Shoulder subluxations since high school Washington University Program in PT

11 Initial exam: C/o burning pain in scapular region, pain deep in joint and anterior GHJ Since stopping Vball the freq and intensity of GHJ pain decreased but scapular sx same. No improvement in winging over past yr Previously had therapy at another facility Posture: scapula IR and tilt R>L, DR on R, humeral head superior Shoulder flexion: 100⁰, scapula wing/ir, tilt, DR Improved range if shoulder flexed with elbow flexed Shoulder abduction: ~ ⁰ scapula DR & IR then at end-range depress Supine shoulder LR- ant glide humeral head Prone shoulder LR- ant glide humeral head, scapula depress and IR/wing, 3-/5 Prone shoulder MR- humeral extension Prone mid & lower traps- right 3/5, left 3+/5 Serratus muscle performance in sidelying 2/5 2 nd visit Shoulder flexion Shoulder flexion with elbow flexion Shoulder abduction scapula DR & IR then at endrange depress Washington University Program in PT

12 Shoulder flexion- better control with return to starting position Dx: Scapular Winging & Humeral Anterior Glide Syndromes Is it indicated to perform labral tests? Treatment: Stop current HEP: prone rows, prone rhomboids, prone traps, lat pull downs, seated rows, sleeper stretch Avoid back pack or holding other heavy objects on right Use arm support Dx: Scapular Winging & Humeral Anterior Glide Syndromes Treatment goals: Improve serratus performance in gravity lessened position due to weakness (serratus will provide force into scapular ER, posterior tilt and up rotation) Strengthen trapezius mm at the appropriate length (traps will ER scapula) Recruitment pattern of rotator cuff precise rotation Improve strength and increase stiffness of subscapularis Dx: Scapular Winging & Humeral Anterior Glide Syndromes Treatment: Prone shoulder MR/LR Prone arm lifts with hands on head Side-lying shoulder flexion- only focus on scapular UR Side-lying arm lift with hand on head (elbow lift)- focus on holding scapula up and in : 3 rd visit, 3 wks since initial Pain better, 3/10 at worst Functionally able to reach higher/easier Propping her arm/scapula helps Exercises- tried to progress SL arm lift to hand off head, but scapula would DR so increase reps to : 3 rd visit, 3 wks since initial Washington University Program in PT

13 Precision of movement : 3 rd visit, 3 wks since initial Instructing a patient in an exercise does not guarantee correct performance Movement must be monitored until the patient can demonstrate correct movement pattern This turned into a new exercise for her, but only few reps at a time 8 weeks: flex thru half range with elbow extended 4 mos: rarely has burning pain in scapular area, joint line pain (present for yrs) with being active Coaching Vball now 5 th visit, 4 mos later Final Outcomes 8 visits over 7 mos Scapular pain resolved but still had joint pain, more now than a few mos prior b/c more active Pain ant > post joint Running, more coaching of Vball, cannot throw a ball w/o pain. Final Outcomes Cuff mm performance & endurance improved but anterior glide still occurs; posterior deltoid dominates Scapular mechanics are improved but when fatigued scapula will ant tilt/ir Serratus still recovering Needs to avoid repetitive elevation & heavy lifting Referred to surgeon for suspected labral pathology instability Washington University Program in PT

14 During the exam, when a movement does not appear ideal or causes symptoms, try to modify movement Doing this repeatedly during the exam helps to confirm diagnosis Think big picture - how do the findings of exam relate to each other Diagnosing is based on pattern recognition Key Concepts Path of the least resistance for motion Relative flexibility intrinsic joint motion Relative stiffness passive tissue (muscle) resistance Hypermobility is the cause of the pain Excessive accessory/arthrokinematic motion Hypermobility of range & frequency Segment that moves too much is painful Treatment: stop what is moving too much & correct pattern of motion Correct functional activity performance Van Dillen Washington University Program in PT