Cross Country Education Leading the Way in Continuing Education and Professional Development.

Size: px

Start display at page:

Download "Cross Country Education Leading the Way in Continuing Education and Professional Development."

Diana Miles
6 years ago
Views:

Manual Therapy Exercises for the Shoulder To comply with professional boards/associations standards: I declare that I or my family do not have any financial relationship in any amount, occurring in

1 Manual Therapy Exercises for the Shoulder To comply with professional boards/associations standards: I declare that I or my family do not have any financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship. Requirements for successful completion are attendance for the full session along with a completed session evaluation form. Cross Country Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity. Manual Therapy for the Shoulder Terry Trundle, PTA, ATC, LAT Cross Country Education Leading the Way in Continuing Education and Professional Development. FUNCTIONAL REHABILITATION OF THE SHOULDER Open Kinetic Chain Rehabilitation Challenge Mobility range of motion Recruitment neuromuscular control Stabilization tri-plane functionality 1

2 Three Phases of Rehabilitation Pre-functional Mobility Return to Function Recruitment Return to Activity Tri-Plane Stabilization References: T.L. Trundle, Schmidt, DT; Harris, BA; Aimee, K, Related Shoulder Anatomy Osteology Humerus Tuberosity Insertion for Rotator Cuff Clavicle Fulcrum for lateral motion Scapula Attachment for 18 muscles, 4 ligaments Clinical Application: Acromio-Ridge- The extension of the spine of the scapula to the AC Joint. Scapula functions as a sesmoid reaction True core of the Upper Kinetic Chain (T. Trundle/2011) Related Anatomy - Arthrology Glenohumeral Center core of motion Acromioclavicular Frontal plane lateral motion Sternoclavicular Synovial articulation to skeleton Scapulo-thoracic articulation Not a true joint Mobile structure stabilized by muscle 2

Related Shoulder Anatomy Passive stabilization Labrum Meniscus of the glenoid Ligaments SGHL, MGHL, IGHL Capsule Fibrous tissue Clinical Application: Lengthening of the anterior pec wall (Horizontal

3 Related Shoulder Anatomy Passive stabilization Labrum Meniscus of the glenoid Ligaments SGHL, MGHL, IGHL Capsule Fibrous tissue Clinical Application: Lengthening of the anterior pec wall (Horizontal Abduction) Concepts of the Three P s Pivoters scapular stabilizers i.e. rhomboids, trapezius, pectoralis minor and serratus anterior Protectors rotator cuff Positioners deltoids, latissimus dorsi, pectoralis major Reference: Ellen m, Rogers DP, Gilhoal JJ: Practitioner Flexibility Strengthens Shoulder Rehabilitation Protocol. Biomechanics, January 2000;

True Function of the Rotator Cuff Dynamic decompression of the humeral head by providing balance of the upper pull of the deltoids and not allowing the scapula to overcome the G-H joint Steer and

4 True Function of the Rotator Cuff Dynamic decompression of the humeral head by providing balance of the upper pull of the deltoids and not allowing the scapula to overcome the G-H joint Steer and stabilize the humerus to the glenoid (Rockwood) Result = smooth rotational movement to allow shoulder elevation primarily in the transverse plane Reference: McClure PW, et. al. Physical Therapy (2004) Tate AR. et. al. JOSPT (40) 2010 Clinical Examination: Motion The Vital Three Motion Patterns Mobility: Short lever arm rotation External rotation in modified scaption (1) Internal rotation spine level Long lever arm movement Elevation transverse plane (2) Horizontal abduction above 90 (3) Abduction modified scaption Clinical Concerns of Early Motion 1. Why pendulum exercises need to be reconsidered 2. Self range of motion with cane or wand is usually performed incorrectly 3. Manual motion should begin in a scaption angle Rotation before Elevation Reference: Long JL et. al. JOSPT (40)

5 Prefunctional Internal Rotation Functional Internal Rotation The Gravity Point 5

6 Counter contraction decompression Horizontal Abduction above 90 6

7 Passive Micro-Mobility Primary Scapular Release with diagonals Lateral Glide and Tilt Glenohumeral Inferior Glide Over the top Finger mobility with passive rotational shift Glenohumeral posterior glide Reference: Kumbhare DA, Basmajian JV, Trundle, T.L.,

8 Two handed glide/tilt 8

9 9

10 10

11 Passive Micro-Mobility Secondary AC and SC joints A-P micro-mobility Glenohumeral lateral glide Reference: Harris, Deyle, Gill, Howes JOSPT (2)

12 Scapular Dyskinesis Normal position of the scapula is to be symmetrical mounted on the ribcage Alteration of normal position or motion directly affect the glenohumeral joint and shoulder positioning is referred to as Dyskinesis Scapula Control RECRUITMENT Retraction sets Theraband Rows Seated Rows with Weights Standing or seated on ball - double arm to single arm Prone Scapular Retraction Prone Horizontal Abduction (Fly) with Retraction Reference: McCabe RA, Orishimo KF, McHugh MP, Nicholas SJ., Oyama, S.; Myers, J.B.; Wassinger, C.A.; Lephart, S.M.,

13 13

Scapular Stabilization Trapezius EMG Based Values Prone Extension and prone horizontal abduction with external rotation exercises promote early activation of the middle and lower Trapezius in

14 Scapular Stabilization Trapezius EMG Based Values Prone Extension and prone horizontal abduction with external rotation exercises promote early activation of the middle and lower Trapezius in relationship to the scapular and glenohumeral prime movers. Ref: Demauk, Gagine B, Van De Velde A, Danneels L, Cools AM. Trapezius Muscle Timing During Selected Shoulder Rehabilitation Exercises. J. Orthop. Sports Phys Ther 2009; 39(10): Scapula Control Protraction Serratus Anterior Press-up plus ceiling punch Standing scaption to 120 Wall push-ups plus Push-ups plus floor Dynamic hug Reference: Ekstrom RA, Bifulco KM, Lopau CJ, Andersen CF, Gough JR Kelly IV JD Manske, RC,

15 15

Four Levels EMG Activity Based on MVIC Level One: 20% of MVIC low Level Two: 21% to 40% of MVIC Moderate Level Three: 41% to 60% of MVIC High Level Four: More than 60% of MVIC Very High Precaution

16 Four Levels EMG Activity Based on MVIC Level One: 20% of MVIC low Level Two: 21% to 40% of MVIC Moderate Level Three: 41% to 60% of MVIC High Level Four: More than 60% of MVIC Very High Precaution Concerning Rehabilitation Therapeutic value of EMG Based Recruitment is a Dynamic Activity Level and Not a Measurement of Tendon Stress. Reference: Uhl, TL; Manual Application for Positional Recruitment Evidence based EMG Studies Sidelying External Rotation Prone Extension to hip Prone Horizontal Abduction with External Rotation Prone 90/90 External Rotation Standing scaption to 90 Prone scaption series Reference: Cricchio M, Frazer C. J. Hand Rehab (2011) 16

17 17

18 Short-arc horizontal abduction external rotation 18

19 19

20 Positional Manual Recruitment Sidelying external rotation SA to past neutral Scaption Standing to 90, 120 (RC/Deltoids/Serratus Anterior) Prone extension to hip Combine posterior RC with scaption Prone scaption - 100, SA-GH LA-ST Prone horizontal abduction with rotation Prone external rotation 90/90 position Eccentric deceleration Reference: Reinold MM, Wilk KE, Fleisig GS, Et Al: Electromyographic Analysis of the Rotator Cuff and Deltoid Musculature During Common Shoulder External Rotation Exercises. J Orthop Sports Phys Ther. 34 (7), 2004; Macrina L, Reinold M. Arm Forces. Training-Conditioning. July-August 2008:46-51 Three Phases of Rehabilitation with Manual Exercises Primary Impingement and Rotator Cuff Repair 20

21 Primary Impingement Syndrome Structural/Biomedical Anatomical Crowding Spurs/DJD Posterior Capsular Tightness Anterior Capsular (pect. wall) Tightness Excessive Superior Migration of the Humeral Head Secondary to Depressor Deficiency-weakness of the rotator cuff Result: Sub-acromial Encroachment Reference: Tate, McClure, Young, Salvatori, Michener JOSPT (40) 2010 Non-Operative Treatment Anti-inflammatory medication Oral Injections Rehabilitative therapy: Mobility posterior capsular lengthening Sleeper stretches GIRD Anterior capsular re-lengthening (Horz. Abd.) Scapular stabilization Rotator cuff decompression 21

22 22

23 23

24 24

27 Short lever arm rhythmic stabilization Long lever arm rhythmic stabilization Manual Exercises for the Three Phases of Rotator Cuff Repair Rehab 27

28 Rotator Cuff Repair Phase I Pre-functional 1-4 weeks Immobilization as needed abduction pillow brace in scaption plane Manual control range of motion ER 45 at 45 of abduction Positional internal rotation Horizontal abduction positioning Elevation short to long lever arm motion Scapula release/glides UER seated glides Scapular retraction sets Sub-max deltoids isometrics week 3-4: short lever arm vs long lever arm Manske RC Wilk, KE; Reinhold, MM; Rotator Cuff Repair Early Post-op R.O.M. External rotation in scapular plane Less tension on repair Repaired supraspinatus increased tension in 30 to 60 of internal rotation Positional internal rotation to hip Elevation in scapular plane Neutral Humeral position with progressive external rotation Reference: Manske, R

29 29

level Horizontal abduction to normal length Elevation 140 to WNL G-H joint glides based on need Standing Extension to hip Resistive

30 Positional Internal Rotation (side view) Positional Internal Rotation (posterior view) Rotator Cuff Repair Pre-Functional Phase 4 8 weeks Manual Exercises Manual control range of motion ER progressive to 90 at 45 abduction to 90 abduction Positional internal rotation to spine level Horizontal abduction to normal length Elevation 140 to WNL G-H joint glides based on need Standing Extension to hip Resistive strengthening scapular retraction Add protraction when ready-arm control Manual exercises rhythmic stabilization short lever arm Isometric Rotation 30

31 Interactive Outcomes Pain report Mobility needs ROM goals met Elevation control muscle recruitment ADL dysfunction Rotator Cuff Repair Return to function Phase longest phase of rehab Isotonic strengthening with positional recruitment Time frame to begin exercises depends on range of motion and muscle control Prone extension to hip Prone scaption 100 Prone scaption 120 Prone horizontal ABD ER short-arc Sidelying external rotation to neutral Scaption to 70 then to 90 - (Full Can) Elevation strengthening Supine position Protraction PRE manual applied force distally (CKC) Placement eccentrics correction of elevation hike dysfunction Advanced scapular stabilization retraction and protraction Rhythmic stabilization (perturbation long lever arm) Reference: Trundle, TL, Strickland, JP; et.al, Manske, RC 31

32 Shoulder hike Standing scaption to 90 32

33 Placement eccentric elevation 33

34 Rhythmic stabilization long-lever arm 34

Rehabilitation Summary Scapula-cuff stabilization using the three p s Pivotors scapular stabilizers, i.e., rhomboids & trapezius serratus anterior Protectors

35 Rehabilitation Summary Scapula-cuff stabilization using the three p s Pivotors scapular stabilizers, i.e., rhomboids & trapezius serratus anterior Protectors rotator cuff decompression Positionors deltoids, latissimus dorsi, pectoralis major controlled elevation Tri-Planar Stabilization end product of function Questions? 35

Today s Shoulder. Session 108: Glenohumeral Stabilization For True Upper Extremity Function

Today s Shoulder. Session 108: Glenohumeral Stabilization For True Upper Extremity Function To comply with professional boards/associations standards: I declare that I (or my family) do not have a financial relationship in any amount, occurring in the last 12 months with a commercial interest