SHOULDER PAIN LESSONS FROM THE SPORTS FIELD MOVEMENT RESTRICTIONS. Steve McCaig

Transcription

1 SHOULDER PAIN LESSONS FROM THE SPORTS FIELD MOVEMENT RESTRICTIONS 1 Steve McCaig Senior Physiotherapist England Development Programme, ECB, Loughborough, United Kingdom

2

3 Throwing High forces upper limb during throwing 3

4 Why do we get pain with throwing? 4

5 Cocking and Acceleration Phases Max. ER 5

6 6 Internal Impingement

7 Internal impingement Posterior humeral head abuts on posterior superior margin of glenoid Worse with: Scapula protraction Increased H.Ext? Anterior laxity Posterior capsule tightness

8 8 Peel back mechanism

9 Peel back mechanism Labrum peels back from glenoid Worse with Scapula protraction Increased H.Ext? Anterior laxity Posterior capsule tightness

10 Max. ER Contributions from GHJ Scapula Thoracic spine Elbow 10

11 Deceleration phase Large eccentric stress Post. cuff LH biceps 11

12 Deceleration phase Contributions from GHJ Scapula Thoracic spine Elbow Lower limbs 12

13 13 20 % decrease in leg power the shoulder works 33% (Kibler and Chandler, 1995)

14 14 Managing Shoulder Pain

15 What s the pathology? What are the contributing factors? 15

16 Can we diagnose shoulder pathology? Poor sensitivity and specificity of clinical tests Pathology in pain free athletes Poor relationship btn. exam and arthroscopy 16

17 17 Does it matter?

18 18

19 19

20 What are the contributing factors? Mobility Control Strength qualities Local and Distal What is the dysfunction? Is it related to their problem? 20

21 What are the contributing factors? Movement restriction» Loss of mobility» either physiological or accessory motion Control impairment» Inability to control motion at a joint» either physiological or accessory motion Loading impairment» Ability to tolerate load and generate force 21

22 22 What are the contributing factors? Movement restriction» Loss of mobility

23 23 Assessing Mobility

24 Different ends of the continuum Stiff Loose 24

25 25 Laxity Instability

26 26 Thoracic Spine Mobility

27 Tx Flexion Tx c.l. LF Tx c.l. Rot Crosbie et al, Clin. Biomech. (2008) 27

28 Thoracic kyphosis and ROM (Lewis et al,2005) Changing posture improved ROM but not pain in SIS 28

29 Thoracic Kyphosis (Lewis et al, JOSPT,2005) What s normal? Total 40 degs (+/-7)» Upper 30 (+/- 5)» Lower 10 (+/-5) 29

30 Thoracic rotation How do you measure it? iphone compass What s normal?»? degs» symmetry within 5 degs Johnson et al JAT, 2012) 30

31 31

32 32 Thoracic Mobility Manual Therapy

33 33 Thoracic rotation- Side-lying windmills

34 34 Thoracic rotation- 4 point kneeling

35 Thoracic rotation- Integrate with lower limbs 35

36 Thoracic extension Assessment What s normal? Depends on how you measure it (Edmonston et al, JOSPT,2011) (+/-5) degs from resting posture 36

37 Combined elevation test What s normal? 18-22cm < 15cm very stiff 37

38 38 Thoracic extension Foam rolling

39 39 Thoracic extension Wall Angels

40 40 Thoracic extension Overhead Squat

41 41 Scapula function

42 Role of the scapula Kibler, AJSM (1998) 1. Centres glenoid under humerus 2. Elevates acromion 3. Optimises rotator cuff length tension 4. Links legs and trunk to upper limb 5. Retraction and protraction to increase upper limb power And 6. Reduces stress on neural tissue 42

43 Scapula function and shoulder pain Can agree on it s presence» McClure and Tate (2009) Can t agree on what dysfunction» Hickey et al (2007) Doesn t tell us who is symptomatic» Tate and McClure (2009) Doesn t tell us who will get hurt» Myers et al (2012) 43

44 Is it adaptive, maladaptive or irrelevant? Adaptive» improving their function» correcting makes pain worse Maladaptive» worsens their function» correcting makes pain better Irrelevant» no impact on pain presentation» correcting makes no difference! 44

45 45 Scapula repositioning tests

46 Influencers of Scapula function Cx-Tx posture GHJ mobility Scapula muscles GHJ muscles Neural tissue Bullock et al (2005) Butler MOTNS,

47 Pec. Minor Length Decreased post. tilt in elevation and increased IR (protraction) Borstad and Ludewig (2006) JOSPT 47

48 Pec. Minor Length - Lewis and Valentine (2007) What s normal?» DOM 6.3cm (+/-1.4) NDOM 5.9cm (+/-1.3)» Range 3-9cm 48

49 49 Pec. Minor soft tissue therapy

50 Pec. Minor manual stretching Cools and Ellenbecker, BJSM,

51 51 Pec. Minor self release

52 Pec. Minor - stretches Borstad and Ludewig JSES (2009) Muraki et al PT (2009) 52

53 53 Glenohumeral Mobility

54 Glenohumeral mobility and injury Shanley et al AJSM(2010)» 25 degs GIRD Wilk et al AJSM(2011)» > 20 degs GIRD» > 5% total ROM deficit

55 Normal adaptations to throwing ERG» External rotation gain GIRD» Internal rotation deficit But total ROM DOM=NDOM

56 Why do these changes occur? Thought due to either soft tissue or bony changes Anterior capsule laxity = ERG Posterior capsule tightness = GIRD Humeral torsion

57 Soft tissue changes - Acute Loose IR after acute bouts of throwing Worsens during first hours (Reinold et al AJSM, 2008) However Quickly regained with manual and soft tissue therapy or stretching Is this consistent with capsule changes?

58 Capsular tightness and Injury Obligate translation Translation of the HOH in the opposite direction of the tight capsule Harryman et al (1990) Matsen et al ed. The shoulder 3 rd ed.(1998)

59 Glenohumeral translations and Injury Excessive humeral head translations linked to injury Sub-acromial impingement Internal impingement peel back mechanism

60 60 Glenohumeral joint - capsule

61 61 Glenohumeral joint inferior capsule

62 62 Posterior capsule

63 Posterior Inferior capsule In Abd and ER» PI capsule moves anteriorly and inferiorly» HOH moves post. and sup. 63

64 Assessing Glenohumeral mobility IR and ER in 90 degs abd. total range concept

65 Total Range concept What s normal? Side ER IR Total DOM NDOM * SD Approx. +/- 5 degs

66 Posterior shoulder tightness If DOM< NDOM and GIRD > ERG consider posterior tightness Side ER IR Total DOM NDOM Confirm this with follow up tests!

67 Anterior laxity If DOM> NDOM and ERG > GIRD consider anterior laxity Side ER IR Total DOM NDOM Confirm this with follow up tests!

68 ? Global tightness If DOM < NDOM and no ERG but IRD consider global or anterior restriction Side ER IR Total DOM NDOM Confirm this with follow up tests!

69 Assessing posterior shoulder mobility Limits:» IR» HF» Flexion» PA glides in different ranges Should all be restricted to some degree if tight

70 Assessing posterior shoulder mobility

71 Assessing anterior shoulder mobility Laxity increases:» ER» H.Ext» PA glides Should all be increased to some degree

72 Assessing inferior shoulder mobility Tightness decreases:» Abduction» Inferior glide in abduction» PI tighter in ER» AI tighter in IR Should all be decreased to some degree

73 Posterior tightness- soft tissue therapy 73

74 74 Posterior tightness manual therapy

75 75 Posterior tightness sleeper stretch

76 76 Posterior tightness cross body

77 77 Posterior tightness cross body

78 78 Posterior tightness band stretches

79 79 Posterior tightness self release

80 Anterior shoulder tightness Stretches and manual therapy 80

81 81 Lat Dorsi

82 82 Lat Dorsi length soft tissue therapy

83 83 Lat Dorsi stretches

84 84

85 85 Lat Dorsi stretches - kneeling

86 Case Study 21 y.o. female bowling all-rounder 12 months SLAP and ant. stabilisation Told back in 6/12 3 yr. Hx of gradual onset P P with throwing Wants to be more stable but feels tight Manual therapy helps but not sustained 86

87 Assessment P EOR elevation sl. P EOR ER in 90 degs Nil effect Scap/HOH repositioning Strong cuff Increased TX Kyphosis Stiff Tx. rotation L <R Pec minor length bil. tight GHJ Rot ROM Tight post. and ant. shoulder Lat. dorsi tight L<R 88

88 Treatment in Assessment Manual therapy Upper Tx. Spine // Elevation B, ER in 90 ISQ Soft tissue therapy Post. Shoulder // Flex/ ER in 90 B, Abd. ISQ Soft tissue therapy Pec. Minor/ Ant. sup. Shoulder // Flex ISQ, Abd and ER in 90 B Exercise then reassess 89

89 Key Lessons Identify relevant dysfunctions Assessment = treatment Use manual therapy to guide exercise selection Few exercises done well! Reassess! 92