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1 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 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. Vyne Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity. Session 101: Why All Painful Shoulders Are Impinged & the Evidence Behind Their Treatment Terry Trundle, PTA, ATC, LAT Leading the Way in Continuing Education and Professional Development. Impingement Primary Structural Anatomical (Spurs/ DJD) Soft Tissue Hypomobility (Posterior vs Anterior Tightness) Weakness of the Rotator Cuff (Superior Migration of the Humeral Head) Secondary Mechanical Instability of the Glenohumeral Joint Impairment of Muscle Function Core Weakness of the Scapular Stabilizers 1

2 Causes of Pathology for Impingement Compressive forces against the acromion Mechanical irritation of the tendon Thickening or fibrosis Subacromial bursa alterations Bone spurs to tendon rupture Mechanical compression Glenohumeral instability Humeral head translation 2

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7 Primary Impingement Syndrome Structural/Biomedical Anatomical Crowding Spurs/DJD Posterior Shoulder Tightness Anterior Shoulder (pect. wall) Tightness Excessive Superior Migration of the Humeral Head Secondary to Depressor Deficiency weakness of the rotator cuff Result: Sub acromial Encroachment Clinical Impingement Screening NEER: Elevation with internal rotation Compression of rotator cuff against the coracoacrominal arch Hawkins Kennedy: 90 forward elevation (scapular plane) Internal Rotation Over Pressure Rotator Cuff Muscle Testing Supraspinatus Full can vs. empty can Infraspinatus/Teres Minor External rotation lag Subscapularis: Lift off vs Belly press Palm on opposite pect. wall decrease pect. major involvement Muscle Testing: Optional Rating System 1. Normal Equal resistance no pain vs with pain 2. Reduced mild to moderate weakness 3. Markedly Reduced strength deficit with little or no resistance painful test with possible rotator cuff pathology 7

8 Acromial Architecture Type I Flat Type II Curved Type III Hooked (highest % of Rotator Cuff Tears) Impingement Non Operative Intervention (exercises) Mobility Scapula R/O Scapular Dyskinesis Inferior, Posterior & Lateral Glenohumeral glides Anterior Capsule Pect Wall Re lengthening Posterior Capsule Modified Sleeper Stretch Scapula Stabilization Retraction/Protraction Rotator Cuff Strengthening Prone Series Scaption Sidelying external rotation Wall Push ups closed kinetic chain Rhythmic Stabilization Shoulder Sphere Static protocol Progress to dynamic protocol Elastic Resistance Exercises Reference: Ellenbecker TS, Cools A Br J Sports Med 2010 Hanratty CE, et. al, 2016 (PT) 8

9 FUNCTIONAL REHABILITATION OF THE SHOULDER Open Kinetic Chain Rehabilitation Challenge Mobility range of motion Recruitment neuromuscular control Stabilization tri plane functionality Three Phases of Rehabilitation Pre functional Mobility Return to Function Recruitment Return to Activity Tri Plane Stabilization References: T.L. Trundle. 2011, 2016 Schmidt, DT; Harris, BA; Aimee, K, 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,

10 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 Clinical application: Elevation Hike Dysfunction 1. Rotator Cuff Weakness 2. Loss of transverse plane motion Reference: Tate AR. et. al. JOSPT (40) 2010 Trundle, TL 2016 Scapulo thoracic articulation Not a true joint Mobile structure stabilized by muscle Scapula functions as a sesamoid reaction True core of the Upper Kinetic Chain (T. Trundle/2016) Scapular positional movement 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 Scapular Dyskinesis Clinical Examination Review Scapula thoracic Static examination Anterior tilting Inferior angle Kibler Type I seen in primary impingement Internal rotation Medial border Kibler Type II commonly found in throwing athletes (pitchers) Elevation Superior glide Kibler Type III present in hypomobile pathology abhesive capsulitis Reference: McQuade KJ, Burstad J, Siriani de Oliveira A, 2016 (PT) Plummer HA et. Al. JOSPT

11 Scapular Dyskinesis Does this play a role as an indicator of instability? What does it really mean in the symptomatic shoulder? Scapular Dyskinesis may not be supported in current research as it is linked to pathology Systematic review of 10 studies linking scapular kinematics and impingement indicates there is no ideal scapular position that causes or contributes to impingement References: Thomas et al. J. Sports Rehab 2013 Ratcliffe et al. Br J Sports Med 2014 Michener LA et al. JOSPT 2017 Presentation at CSM Clinical Applications Greatest risk for shoulder impingement is when the scapula is internally rotated and anteriorly tilted Based on EMG studies, shoulder impingement is demonstrated by an increased EMG activity in the upper trapezius, but decreased activity in the serratus anterior muscles during elevation Restoration of normal scapulohumeral rhythm requires exercises that balance the trapezius and serratus anterior muscles Serratus anterior and trapezius weakness will reduce upward scapular rotation and increase the risk of rotator cuff and bicipital impingement Active Stabilization 11

12 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) distal marker: thumb up Horizontal abduction above 90 (3) Abduction modified scaption Clinical Concerns of Early Motion 1. Gravity point concept 2. Manual motion should begin in a scaption angle Rotation before Elevation 3. Counter contraction decompression Manual Exercises: The misunderstood component Questions we should be asking: What are the three vital motion patterns? The missing link in Glenohumeral motion is? Do we need to reconsider how to design capsular mobility changes? Does mobilization of the shoulder decrease pain? Reference: Desjardins Charbonneau A., Roy JS, et al. JOSPT May 2015 Cornwell MS, Tragord BS JOSPT 2015 Glenohumeral Preparation Glides Inferior Glide Rotational Glide Posterior glide Lateral glide Anterior glide Reference: Trundle, T.L., 2011,

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15 Traditional Sleeper Stretch Quantifying Range of Motion Changes Across 4 Simulated Measurements of the Glenohumeral Joint Posterior Capsule: An Exploratory Cadaver Study Greatest ROM change was with flexion (elevation) and internal rotation Maximum reduction were observed at interior rotation at 40 and 60 degrees of flexion (elevation) Optimum test for assessment of the posterior capsule should consider internal rotation with elevation Reference: Dashottar A, Borstad J. JOSPT Dec

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17 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. SA GH Rotator cuff LA ST Scapular stabilization (advanced) 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): Protraction Serratus Anterior Clinical Application Preparation for Elevation Press up plus ceiling punch Level 3 Standing scaption to 120 Level 4 Wall push ups plus Level 2 Push ups plus floor Level 4 Dynamic hug Level 3 Highest activity of the serratus anterior occurred at 55 degrees of elbow extension during the concentric phase of traditional pushup and not at the plus phase of the exercise. Reference: San Juan JG, Suprak DN, Roach SM: BMC Musculoskeletal Disord, Castelein B, Cagnie B, Parlevliet T, Cools A JOSPT

18 The Missing Link of Shoulder Rehabilitation Modes of Contraction: Isometric static Concentric shortening/acceleration Eccentric lengthening/deceleration W = F x D Muscle Work = recruitment x (+/ ) ROM Eccentric exercise negative training: O₂ oxygen debt ATP energy challenges EMG Activity less active fibers to dissipate load DOMS = Delayed Onset of Muscle Soreness Progressive Repetitive Protocol Needed 2 3 sets of 5 2 sets of 10 3 set of 10 18

19 Muscle Type Composition of Rotator Cuff Muscles Type I slow twitch: resistant to fatigue Type II fast twitch: type II A, type II X Muscles disuse is associated with a type I to type II shift. Endurance exercise protocols may result in an increase of type I fibers. Losing muscle mass, strength, injured or post operative muscles are likely to be more fatigable due to fiber changes with disuse atrophy. Clinical Concept: Missing link is eccentric strengthening of external rotation. Reference: Lovering, Russ. JOSPT

20 Prone extension: teres minor and deltoid (post) > 60% MVIC Ref: Evans NA, Dressler EV, Uhl T, JOSPT (CSM 2017) 20

21 Positional Recruitment Scaption neutral thumb up position Level 3 Prone Scaption Series Level 3 References: Castelein B, Gagnie B, Parlevliet T, Cools A, JOSPT

22 Prone Scaption Series 1. Scaption at Scaption at 120 Short arc ROM for rotator cuff recruitment 3. Long arc ROM for advanced scapular stabilization with increase of activation of the lower trapezius, used in advanced stages of exercises EMG Level 4 Positional Recruitment Super Eight Therapeutic Value Sidelying external rotation progressive repetitions Scaption Standing to 90, 120 Prone extension to hip Prone scaption 100, 120 Prone horizontal abduction with rotation SA LA Prone external rotation 90/90 position Short-arc Elastic Resistance Rotation 22

23 Muscle Activation and Perceived Loading During Rehabilitation Exercises: Comparison of Dumbbells and Elastic Resistance Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude and perceived loading with increasing resistance. At the individually maximal level of resistance for each exercise defined as the 3 repetitions maximum normalized EMG activity of the prime muscles was not significantly different between dumbbells (59% 87%) and elastic tubing (64% 86%). Perceived loading was moderately to very strongly related to normalized EMG activity (r=.59.92). Therapeutic Value: The authors conclude that comparably high levels of muscle activation were obtained during resistance exercises with dumbbells and elastic tubing. Average Force (pounds) for Thera band Elastic band % Elongation Yellow Red Green 50% % % % Reference Page, et al JOSPT

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25 Non Operative Treatment Rehabilitative therapy: Mobility posterior lengthening Modified Sleeper stretches Anterior re lengthening (Horz. Abd.) Scapular stabilization Rotator cuff decompression Reference: Wilk KE, Hooks TR, Macrina LC : 2013 Christiansen DH, et al. 2015, 2016 Bailey LB, Thigpen CA, Hawkins RJ, Beattie PF, Shanley E Sports Health 2017 Vital Five Home Exercise Program Scapular retraction with resistance Press up plus protraction Prone extension to hip Scaption to 90 Side lying external rotation to neutral Reference: Christiansen DH, Frost P et. Al (PT) Healthy Cuff Program Mobility: Posterior and Anterior capsular length Positional Recruitment 1. Sidelying External Rotation 2. Standing Scaption thumb up 3. Prone Extension 4. Prone Scaption Prone Scaption Prone Horizontal Abduction with rotation 7. Rhytmic Stabilization Shoulder Sphere and Body Blade Stabilization means pain free elevation 25

26 Secondary Impingement Acquired Pathology through Glenohumeral Translational Instability What does stabilization mean to a surgeon? Surgery may be more indicated for the higher activity levels of patients Surgery for symptomatic instability Patients level of activity may be a risk factor for failure of operative stabilization References: Zremski, JL et al. B. J. Sports Med 2016 Brophy RH, Hettrich CM, et al. Sports Health 2016 Moroder, P. Odorizzi, et al. J. Bone Joint Surgery AM, 2015 Secondary Impingement Syndrome Why secondary impingement is so difficult to assess subjective assessment outweighs objective findings Mechanical Instability Impairment of muscle coordination Repetitive strain to the rotator cuff. Weakness of the Scapular Stabilizers (pivotors) Pathological Laxity due to Translation of G H joint 26

27 Secondary Impingement Pathologic condition caused by excessive contact of the greater tuberosity of the humeral head with the posterosuperior aspect of the glenoid when the arm is abducted and externally rotated Related pathology based on MRI findings reported in the literature Articular sided partial thickness rotator cuff tears of the supraspinatus, infraspinatus or both Posterior or superior labral lesions (SLAP) Humeral head lesions or cysts (Hill Sachs lesions) Posterior glenoid bony lesions Secondary Impingement At Risk Sports Baseball and softball Other throwing athletes (waterpolo & football) Tennis Racquetball Volleyball Swimming Lacrosse Golf What does stabilization mean? Stability is the degree to which the musculoskeletal system can return to proper orientation of movement Instability is characterized by mobility that exceeds physiological limits with adequate control Essential concepts of stabilization may include: Corrective or protective mobility Selective exercises based on mode of muscular recruitment Open Kinetic Chain challenge of tri plane stabilization Reference: McQuade KJ, Borstad J, de Oliveira, A S PTJ

28 Post Op Guidelines Phase I Pre functional Immobilization: 2 4 weeks Pain, edema, inflammation control Protective range of motion ER with abduction angle Week Week IR positional IR at hip Post Op Guidelines Phase I Pre functional Immobilization: 2 4 weeks Pain, edema, inflammation control Protective range of motion ER with abduction angle Week Week IR positional IR at hip Elevation 70 week week week 5 6 Horizontal Abduction Anterior pect wall lengthening Always a negative number progress slowly over time to neutral position of 0 degrees Scapula mobility as needed 28

29 Begin scapula stabilization with retraction repositioning and upper core strengthening Retraction setting week 1 Resistive retraction with tubing week 2 Isometric deltoids and rotation Progress to light strengthening with elastic tubing Arm control exercises for protraction Rhythmic stabilization Shoulder Sphere exercises Level 1 Phase II Return to Function Longest Phase of Rehab Range of Motion ER progressive to 70 between 6 7 weeks, 90 between 8 9 weeks IR spine level marking with upper core elevation (stick your chest out) Elevation: WFL to full at weeks Horizontal abduction to 0 12 weeks Mobility needs: Posterior capsular modified sleeper stretch Anterior capsular pect wall re lengthening Strengthening Isotonic functional progression using positional recruitment No heavy biceps loading Prone series: prone extension to the hip Prone scaption Prone horz. Abd. ER. < 45 emphasize eccentric control Scaption to 90 Sidelying ER to neutral past neutral at 9 weeks Internal Rotation (short arc) Protraction: PRE CKC wall pushups, transverse plane Progressive elastic tubing exercises for scapula and rotator cuff strengthening Shoulder Sphere progressive protocol 29

30 Progressive Exercises for Phase II Advanced scapula stabilization for retraction and protraction Progressive prone series: horz. Abd. ER > 45 toward 90 Prone scaption 120 Sidelying ER past neutral to Manual exercises for rhythmic stabilization long lever arm: PNF manual resistance Advanced Shoulder Sphere dynamic protocol Phase III Return to Activity Advance strengthening: upper core stabilization Isotonic high reps training Total arm strengthening based on need Increase time on Bodyblade exercises with tri plane positioning Plyo toss progression endurance training Advanced closed kinetic chain exercises uneven surface Modified throwers ten exercise program Healthy Cuff Program Return to sports: interval throwing High velocity/high reps impulse training Goals for Discharge Functional ROM pain free Elevation Strength goals met Acceptable clinical exam no pain Scapula Cuff Stabilization using the three P s Pivoters Scapula Stabilizers Protectors Rotator Cuff Decompression Positioners controlled elevation end product of function 30

31 Ending Thought Know how much to do, without doing too little and avoiding doing too much, and understanding the evidence of application between these two points. TL Trundle Pre retiring quotation of the future 31