Rehabilitation of Overhead Shoulder Injuries
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1 Rehabilitation of Overhead Shoulder Injuries 16 th Annual Primary Care Orthopaedic & Sports Medicine Symposium January 29, 2016 Jeremy Sherman, PT, MPT
2 Disclosures No financial disclosures to note.
3 Jeremy Sherman, PT Sport & Spine Clinic Edgar Director/Physical Therapist Sports Medicine coverage Edgar High School PT University of Wisconsin Madison Foothills Sports Medicine Phoenix, AZ Internship and Seasonal employee Milwaukee Brewers Baseball Club Maryvale, AZ
4 Objectives Formulate appropriate rehabilitation plans for overhead shoulder injuries Select appropriate exercises based on overhead shoulder diagnoses for return to functional status Improve skills for the management and rehabilitation of overhead shoulder injuries
5 Common Overhead Injuries Subacromial Impingement Overuse Syndrome Tendinitis SLAP Lesions
6 Principles of Overhead Rehabilitation 1. Never overstress healing tissue 2. Prevent negative effects of immobilization 3. Emphasize ER muscular strength 4. Establish muscular balance 5. Emphasize scapular muscle strength 6. Improve posterior shoulder flexibility 7. Enhance proprioception and neuromuscular control 8. Establish biomechanically efficient movements 9. Gradual return to activity 10. Use established criteria to progress
7 Subacromial Impingement Rehabilitation
8 Subacromial Impingement Objective Findings: Painful arc Muscle weakness: abduction, ER, Scaption (+) Impingement Tests: Neer, Hawkins-Kennedy, Crossover, Yocum Point tenderness over supraspinatus, biceps LH Biomechanical dysfunction of scapulo-humeral rhythm Malposture (rounded shoulders, forward head) Altered JPA (decreased inferior glide/posterior glide)
9 Impingement Rehabilitation Decrease inflammation: Ice massage Phonophoresis Iontophoresis
10 Impingement Rehabilitation Restore glenohumeral motion and capsular mobility Decreased inferior glide for abduction Posterior capsular tightness Johnson et. al. The Effect of Anterior Versus Posterior Glide Joint Mobilization on External Rotation Range of Motion in Patients with Shoulder Adhesive Capsulitis. JOSPT Posterior glides more effective than anterior for improving ER ROM.
11 IR Stretch Modified Sleeper Stretch FIGURE 1. Modified sleeper stretch. (A) The athlete is slightly rotated posteriorly (20-30 posterior to the coronal plane of the body) to place the shoulder in the scapular plane as passive internal rotation is performed. (B) This position stabilizes the scapula without causing subacromial impingement complaints.
12 IR Stretch Cross-body Stretch FIGURE 4. Modified cross-body stretch. (A and B) The athlete stabilizes the scapula against the table as the shoulder is horizontally adducted, while external rotation is restricted via counterpressure of the opposite forearm.
13 IR Stretch Horizontal Adduction with IR Figure 8. Horizontal adduction with internal rotation stretch. The patient flexes the arm to 90. The rehabilitation specialist applies a stabilizing force to the lateral border of the scapula while the arm is horizontally adducted and then applies a gentle force into internal rotation.
14 Impingement Rehabilitation Increase dynamic stability of glenohumeral and scapulothoracic joint RTC muscles to compress and stabilize humeral head in glenoid Scapular Strength Scapula during arm elevation = upwardly rotates, retracts, and posteriorly tilts
15 Reinold, Escamilla, Wilk. Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature. J Orthop Sports Phys Ther. 2009
16 Impingement Rehabilitation Impove and correct postural awareness Forward head, rounded shoulders Emphasize scapular retractors Rows, scapular squeezes, w s etc. Gradual return to activity
17 Overuse Syndrome Tendonitis Rehabilitation RTC or Long Head of Biceps or both Often related to fatigue from overuse Discontinue aggravating activity to reduce inflammation and restore strength/rom
18 Overuse Injury Rehab Increase endurance of scapular muscles and RTC musculature for repetitive activities Strengthening exercises RTC Full Can vs. Empty can Lee et al. J Orthop Surg Res Increased supraspinatus activity in conjunction with middle deltoid and subscapularis with empty can Full Can = least amount of surrounding activity for supraspinatus
19 Overuse Injury Rehab Strengthening Exercises RTC Reinold et al. JOSPT Greatest EMG activity of infraspinatus and teres minor = Sidelying ER Prone horizontal abduction at 100 with full ER = maximum supraspinatus, middle, and posterior deltoid activation Eccentrics biceps and RTC
20 Overuse Injury Rehab Scapular Muscles Cools et al. Rehabilitation of Scapular Muscle Balance: which exercises to prescribe?. Am J Sports Med A, B, and C = optimal for restoration of UT/LT imbalances A, B, and D = optimal for UT/MT imbalances
21 Overuse Injury Rehab Restore flexibility of shoulder complex Sleeper stretches, cross-body, horizontal adduction Joint mobilizations Short Pectoralis Minor = stretch it Borstad and Ludewig. JOSPT 2005 Shortened pec minor subjects displayed reduced scapular kinematics.
22 Overuse Injury Rehab Dynamic stabilization exercises for the shoulder Plyometrics Bodyblade Rhythmic stabilization with pertubations Stability ball exercises UE CKC BOSU exercises Mini trampoline, etc
23 Overuse Injury Rehab
24 Rehabilitation of SLAP Lesions Superior Labrum, Anterior and Posterior lesion Involves attachment of biceps LH Fall on an extended arm, repetitive traction with overhead activities High incidence of concurrent rotator cuff tears if > 40
25 UW Health SLAP Rehab
26 SLAP Rehab
27 SLAP Rehab
28 SLAP Rehab
29 SLAP Rehab
30 References Ellenbecker, T Cools, A. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an evidence based review. Br J Sports Med Apr;44(5): Wilk KE, Obma P, Simpson CD, et al. Shoulder injuries in the overhead athlete. J Orthop Sports Phys Ther 2009;39: Wilk, KE, Meister, K, Andrews JR. Current concepts in the rehabilitation of the overhead throwing athlete. Am J Sports Med Jan-Feb;30(1): Wilk, KE, Hooks, T, Macrina, L. The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete. J Orthop Sports Phys Ther Feb;39(2): Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther 2009;39: Borstad JD, Ludewig PM. The effect of long versus short pectoralis minor resting length on scapular kinematics in healthy individuals. J Orthop Sports Phys Ther 2005;35: Cools AM, Dewitte V, Lanszweert F, et al. Rehabilitation of scapular muscle balance: which exercises to prescribe? Am J Sports Med 2007;35: 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 2004;34: Lee et al. Comparison of muscle activity in the empty-can and full-can testing positions using F-FDG PET/CT. J Orthop Surg Res Oct;9:85. Johnson AJ, Godges JJ, Zimmerman GJ, et al. The effect of anterior versus posterior glide joint mobilization on external rotation range of motion in patients with shoulder adhesive capsulitis. J Orthop Sports Phys Ther 2007;37: Uwsportsmedicine.org. Rehabilitation guidelines for SLAP lesion repair. UW Health Sports Medicine Center. March 2011.
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