11/6/2013. Keely Behning, PT, SCS, ATC MNPTA Fall Conference November 16, 2013

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1 Keely Behning, PT, SCS, ATC MNPTA Fall Conference November 16, 2013 Upon completion of this course, attendees should be able to: Understand pertinent anatomy and biomechanics as they relate to specific shoulder pathology Progress an overhead athlete from injury to return to sport Learn specific rehab pearls for improving therapy for shoulder patients. 2 1

2 What is the patient s functional c/o?? How does a healthy shoulder perform that activity?? Why can t your patient perform that activity?? 3 What is the patient s c/o? I can t reach over my head 4 2

3 How does a healthy shoulder reach overhead? 5 Bones and Joints 6 3

4 Bones and Joints 7 Bones and Joints AROM in mutiple planes of elevation Clavicle with respect to thorax: Elevates degrees Retracts degrees Posterior long axis rotation degrees (Ludewig PM, et al., JOSPT, 2004) Viverant 8 4

5 Bones and Joints AROM in scapular plane Average AC joint angles increased: 4.3 degrees of IR 14.6 degrees of upward rotation 6.7 degrees of posterior tilting (Teese RM, et al., JOSPT, 2008) 9 Bones and Joints AROM multiple planes of elevation (transcortical pin placement for motion sensors) Clavicle: elevation, retraction, posterior rotation Clavicular posterior rotation predominated SC Scapula: IR, upward rotation, posterior tilting Scapular posterior tilting predominated AC Humerus: elevation and ER (Ludewig, PM, et al., JBJS, 2009) 10 5

6 Bones and Joints Don t forget the thoracic spine! 11 Bones and Joints R arm Saggital and Scapular plane active elevation in 25 asymptomatic women (45-64 yo) T2-7 demonstrated: Ipsilateral lateral flexion Ipsilateral rotation In 23/25 during saggital plane elevation Extension In 19/25 during scapular plane elevation Extension (Theodoridis D & Ruston S, Clin Biomech, 2002) 12 6

7 Bones and Joints Bilateral arm raise 21 Asymptomatic males (12-28): active bilateral arm elevation 12.8 degrees of thoracic extension between T3 and T11 (Edmondston SJ, JOSPT, 2012) 13 Muscles Shoulder Flexion Anterior delt, pec major, supraspinatus, infraspinatus, serratus anterior, upper and lower trap activated at moderate levels Subscap at low level Activity patterns do not change with increase in load Anterior delt and supraspinatus onset was at same time and prior to movement. Posterior RTC muscles counterbalance anterior translational forces (Wattanaprakornkul D., et al., Clin Anat., 2011) 14 7

8 Muscles Shoulder Flexion Scapular upward rotation, posterior tilting, and ER Middle and lower serratus anterior Medial stabilization and upward rotation of the scapula Middle trapezius Pec minor resists normal rotations of the scapula during elevation RTC stabilizes and prevents excessive superior translation of HH and produces glenohumeral ER during elevation (Phadke V, et al., Rev Bras Fisioter., 2009) 15 Muscles Shoulder Abduction Torque Middle Delt: 434 N Anterior Delt: 323 N Subscap: 283 N Infra: 204 N Supra: 117 N (Escomilla RF, et al., Sports Med, 2009) 16 8

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10 What is most common reason for shoulder shrug? Upper trap to mid/lower trap ratio? Weak RTC (poor force couple)? Restricted GHJ mobility? 19 Retrospective study on 982 who were examined pre-operatively for a shrug sign 51.3% had shrug sign Highest incidence was in adhesive capsulitis (94.7%) Not specific or sensitive for tendonitis, partial RTC tear, full thickness tear, or massive RTC tear if associated with stiffness (snout = rule out), (spin = rule in) Associated with weakness in abduction, night pain, loss of ROM (especially passive abduction) (Jia X, et al., Clin Orthop Relat Res., 2008) 20 10

11 ROM limited? Yes Which joints are contributing? SC/AC screen (scapular mobility) Thoracic screen (double arm compared to single arm) GHJ mobility (PROM, end feels, passive accessory) Treatment options? Joint mobilizations, capsular stretches, etc. 21 Weak muscles? Yes Which muscles? MMT Observation of scapular mechanics 22 11

12 Muscles Force Couples 23 Muscles Cadaveric 0, 30, 60, 90 degrees of abduction with constant 20N superior force on humerus Tensile loads applied sequentially to RTC, lat, teres major, delt, pec major, bicep Depression of HH most effectively achieved with lat and teres major Infra and Subscap showed similar effects Supraspinatus less effective (Halder AM, et al., J Orthop Res., 2001) 24 12

13 Muscles UT:LT and UT:MT ratio Want more LT and MT compared to UT Which exercises are best? Sidelying External Rotation Sidelying Flexion Prone Horizontal Abduction with External Rotation Prone Extension (Cools AM, et al., AJSM, 2007) 25 Muscles Serratus Anterior Wall slide, scapular elevation, and plus portion of push up all good exercises for SA activation at 90 degrees. Wall slide, scapular elevation will increase SA activation with increasing angles > 90 degrees. (Hardwick DH, et al., JOSPT, 2006) Wall push up plus Dynamic hug (Decker MJ, et al., AJSM, 1999) 26 13

14 Muscles RTC Infraspinatus and Teres minor SL ER Supraspinatus, Middle delt, Posterior delt Prone horizontal abduction at 100 degrees and full ER (Reinold MM, et al., JOSPT, 2004) 27 Patient c/o: I can t throw due to pain Your question: How does a normal shoulder throw? 28 14

15 How does a normal shoulder throw? Medically one of the most studied activities in sports With every throw, the shoulder and elbow are brought to their physiologic limits in less than 2 seconds 7000 degrees/sec: Velocity of shoulder rotation during throw one of most studied activities in sports With every throw, shoulder and elbow are brought to their physiologic limits in less than 2 seconds. 7000º/sec = velocity of shoulder rotation during throw 29 ROM Laxity Osseus Adaptations Muscle Strength Posture and Scapular Position 30 15

16 ROM ER greater in throwing arm IR is less in throwing arm Total motion (ER + IR) will be the same Pitchers have greater GIRD (glenohumeral internal rotation deficit) than position players 31 Laxity Throwing shoulder = Non-throwing shoulder Posterior > anterior Does not correlate to ROM measurements (Borsa PA, et al., AJSM, 2005) 32 16

17 Osseus Adaptations Increased retroversion of glenoid and humerus compared to non-throwing arm as well as compared to dominant arm of non-throwing athletes Greatest change in ROM occurs between the ages of 12 and Muscle Strength ER weaker than non-throwing arm IR stronger than non-throwing arm Adduction stronger than non-throwing arm Pitchers and catchers: stronger scapular protractors and elevator muscles compared to position players 34 17

18 Posture and Scapular Position At rest: More protracted More anteriorly tilted At 90º abduction: More upwardly rotated At 90º abduction and maximal IR and ER: More anteriorly tilted 35 Dead Arm Syndrome Any pathologic condition in which the thrower is unable to throw at pre-injury velocity and control because of combination of pain and subjective unease in the shoulder (Burkhart, Arthroscopy, 2003) 36 18

19 Internal or Posterior Impingement Excessive horizontal abduction, anterior translation, and ER in late cocking phase Undersurface RC tearing and possible labral tearing C/o insidious onset of pain, worsens with time, described as dull ache during late cocking. C/o loss of control and velocity. Positive internal impingement sign 37 Internal or Posterior Impingement Treatment Strengthening of RC and scapular stabilizers Neuromuscular control of shoulder Assess throwing mechanics (excessive horizontal abduction?) Stretching posterior shoulder due to GIRD Generally no throwing until pain free and full ROM, improved strength, mechanics, etc

20 GIRD Myers, AJSM, 2006 found collegiate/semi-pro baseball players with internal impingement had significantly greater IR deficit and posterior shoulder tightness than control subjects Routolo, JSES, 2006 found that college baseball players with shoulder pain have a significant decrease in total arc of motion and IR compared with non-dominant shoulder and pain-free throwers. 39 SLAP Lesions Superior labrum anterior to posterior lesions Peel-back lesions, Type II SLAP lesions are most common cause of dead arm syndrome Presents with c/o vague onset of shoulder pain and problems with velocity and control May c/o mechanical symptoms or pain in cocking phase with poor localization Positive O Brien s, Biceps Load, Resisted ER with supination 40 20

21 SLAP Lesions 41 SLAP Lesions Treatment: Non-surgical due to significant improvement with conservative care in 90% of athletes RC strengthening, scapular stabilization, neuromuscular stabilization, stretch posterior shoulder, throwing mechanics 42 21

22 Pre-injury Screening for ROM deficits Team rehab: Sleeper, cross body for those who are tight Everyone scapular stabilization and RTC strengthening. 3 times per week, reps or 2-3 sets of reps, low weight (start with 0-1# working up to 3-5#). Functional core/balance 43 Injury No throwing through pain Must change mechanics of shoulder, stress through injured tissue first Evaluate for ROM, thoracic mobility, dyskinesis, RTC weakness first (later can look into hip and foot ROM, functional core strength, throwing mechanics, etc.) Treat for above deficits Baseball/softball specific rehab when above deficits improved

23 Sport specific UE plyometrics Ball dribble on wall (cannon ball, lacrosse ball) Change surface, 2 feet to 1 Rebounder Functional core Decelleration Return to throw with interval throwing program, focusing on mechanic changes prn 45 Pearls! 46 23

24 Scapular dyskinesis Faulty throwing mechanics Pitch count Thoracic mobility Hip mobility Balance 47 Functional! Make treatment as functional as you can! Mobilize/stretch where they are restricted and in a functional position Strengthening If need scap stability and decelleration strength, why not do the exercise in SLS in follow through position? Core Do planks make you a better thrower? Then do core in a standing or SLS position Balance They must have balance in wind up to progress, functional!! 48 24

25 How are you measuring IR? Horizontal adduction? Functional reach behind back PROM supine at 90 degrees of abduction Palpate coracoid PROM sleeper IR Supine PROM with scapular stabilization into cross body adduction Tim Tyler s posterior shoulder tightness measurement? 49 My Personal Bias: Posterior capsule hypomobility? Older throwing athlete or prolonged GIRD Mobilize with posterior glides of GH joint if hypomobile posterior capsule only Prolonged sleeper stretch Posterior rotator cuff tightness? Most throwers, younger No mobilizations! PNF sleeper stretch 50 25

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