This webinar will begin in the next few minutes Need technical support for this live event? Please call 1800 006 293, then press 1 NOTE: You will be initially asked for the email address associated with this webinar account Say I m a webinar attendee I don t have an account Andrew Ellis BSc (Ex. Sci), M. Phty Multidirectional Instability of the Shoulder World Health Webinars CEO World Health Webinars Host Musculoskeletal Physiotherapist Presented by: Jenny McConnell - BAppSci(Phty), Grad Dip Man Ther, M Biomed Eng AM, FACP Will commence LIVE from Sydney, Australia at 8pm AEST Be sure to convert to your own time zone at Click red button to minimise Jenny McConnell You will be muted during every webinar. Make as much noise as you like :) Dodgy computer speakers? Select Telephone and call in toll - FREE to hear the presentation Questions? We ll answer them all at the end Specialist Musculoskeletal Physiotherapist Specialist musculoskeletal physiotherapist Involved in research into patellofemoral, lower limb, shoulder and lumbar spine problems Published widely in these areas, has been an invited speaker at over 100 conferences both nationally and internationally Editorial boards of Clinical Journal of Sports Medicine, British Journal of Sports Medicine, The Knee, Manual Therapy and Physical Medicine and Rehabilitation Awarded the prestigious F.E. Johnson Memorial Fellowship by the NSW Sporting Injuries Committee for outstanding achievement by an established researcher in the field of science and medicine in sport (2006) Need technical support? Please call 1800 006 293, then press 1 You will need to tell them that you are a webinar attendee and do not have an email account with Citrix. Awarded a member of the Order of Australia honour for service to physiotherapy as a practitioner and researcher (2009) 1
Shoulder problems in overhead athletes Multidirectional Instability of the Shoulder Common 25-60% Due to subtle instability, overuse and fatigue Average college swimmer performs > 1 million strokes annually with each arm 90% complaints - shoulder pain Elite tennis players achieve rotational velocities 1500 O /sec (serve) 387 O /sec (f/hand) 895 O /sec (b/hand) serve and smash pain (Kibler, 1995) Glenohumeral joint Limited passive stability 25-35% of humeral head in contact with the glenoid cavity congruent geometry of surfaces plus negative intra-articular pressure allows a suction-like effect increasing passive joint stability Active stabilisers allow only a few millimeters of translation to occur Passive constraints Passive Constraints - Resting Position Passive Constraints Dynamic Situations Glenoid orientation Superior glenohumeral ligament Gravity 2
Dynamic Control - Muscles Biomechanics Superficial - deltoid, clavicular head pectoralis major, coracobrachialis, long head biceps, long head triceps Deep - rotator cuff muscles Remote - latissimus dorsi, sternal head pectoralis major, teres major Overhead activities - tennis, pitching over 50% of total force & kinetic energy is from the leg/hip/trunk link only 13% of total energy & 20% total force comes from shoulder musculature shoulder musculature stabilises rather than generates motion Shoulder problems in overhead athletes Hypothesis Forceful and repetitive nature of overhead activities microtrauma to anterior Full notes capsule anterior available shift after purchase from of humeral head change rotational arc inc ER and dec IR Anatomical abnormalities Encroachment from above Impingement with exercise Poor scapular control Inferior movement of acromion Narrowing of subacromial space Anterior instability Anterosuperior migration of humeral head Swelling of rotator cuff tendon Excessive load on rotator cuff muscles Rotator cuff weakness Imbalance between humeral head elevators and depressors Elevation of humeral head Rotator cuff tendonitis Instability Overuse Abnormal biomechanics Posterior capsule tightness?? Factors involved in the development of ishoulder injuries. Adapted from Brukner & Khan 1993 Shoulder impingement Occurs when the space is narrowed between the A/C joint, acromion and coracoacromial arch above and the glenohumeral joint below Causes mechanical irritation of the rotator cuff tendons haemorrhage and swelling Khan K 2007 Causes of impingement encroachment from above e.g. congenital abnormalities or osteophyte formation swelling of the rotator Slides cuff tendons, are limited. usually an overuse tendonitis - faulty biomechanics excessive translation of the humeral head - chronic anterior instability 3
Shoulder problems rarely due to hypomobility of the glenohumeral joint, but due to hypermobility. shoulder Thoracic PREVIEW spine ONLY lumbar spine ical spine shoulder lumbar sp Thoracic sp shoulder lumbar spine shoulder shoulder Full notes available after Thoracic purchase spine from lumbar spine shoulder Thoracic lumbar spine shoulder spine lumbar spi oracic spine shoulder lumbar spine shoulder lumbar spine Thoracic lumbar spine spine? Thoracic Spine Mobility bilateral shoulder flexion induces spinal extension unilateral shoulder flexion Slides is are accompanied limited. by contralateral side flexion of the spine middle and lower trapezius reinforce spine extensors in maintaining spine extension Causes of subtle instability in athletes Elite overhead athletes exhibit restricted internal rotation increased external rotation in throwing arm? scapular dyskinesis? humeral retrotorsion? tight posterior capsule if limitation IR > the gains ER by >10% of the contralateral side (GIRD) Scapular dyskinesis Glenoid orientation Superior glenohumeral ligament Gravity 4
Intensity and timing of muscle contraction is essential around the shoulder Humeral retroversion Repetitive throwing causes torsional stresses within the proximal physis adaptive remodelling These humeral notes retroversion are a preview. A retroverted humeral head (9.4 o > non throwing arm) decreased strain on the anterior-inferior capsule Throwers with chronic shoulder pain have less humeral retrotorsion more strain on their anterior capsules during overhead activities... develop chronic shoulder pain Anterior translation of the humeral head tight posterior capsule? Throwers show a loss of horizontal flexion or cross-body adduction in the throwing shoulder when compared with the non-throwing shoulder hypothesis of posterior capsule and/or cuff musculature tightness No evidence of reactive scarring or contractures of the posterior-inferior capsule or cuff musculature from anatomic or noninvasive imaging studies (Borsa et al 2008)?Problem with the starting position 5
The effect of tape on glenohumeral rotation range of motion in elite junior tennis players 11 male (mean age 16.8) and 10 female (mean age 14.9) elite junior tennis players Two measurements of passive ER and IR ROM using a universal goniometer with an attached spirit-level on the non dominant side Two measurements of passive ER and IR ROM on the dominant side under three randomly ordered conditions Control Tape Placebo Tape Effect of hand dominance on rotation ROM in elite junior tennis players Internal rotation ROM decreased in the dominant arms c/w non dominant in males (42 o to 53 These o ) notes are a preview. decreased in females (44 Slides o to 58 are o ) limited. External rotation ROM Increased in the dominant arm of the females (92 o to 85 o ) no difference between dominant & non dominant arms in the males (94 o to 91 o ) Total rotation ROM Decreased in male group (136 o to146 o ) Slight trend in female group (135 o to 143 o ) McConnell J McIntosh B, Clinical Journal Sports Medicine 2008 Results effect of tape An investigation into the effect of glenohumeral taping on uninjured and previously injured overhead athletes during throwing Is there a difference in passive and active shoulder rotation ROM between uninjured and previously injured? Subjects 26 elite asymptomatic overhead athletes 17 never been injured 9 previously injured > 12 months (no surgery) Method: Passive Measured in supine with a goniometer Active upper limb and trunk kinematics of a seated throw measured with a VICON system and scaled in OpenSim full-cock ball-release zero-elbow velocity A B C McConnell J, Donnelly C, Hamner S, Dunne J, Besier T, PMR 2012 6
Is there a difference in rotation ROM between uninjured and previously injured? Results No difference in passive rotation ROM between uninjured (143 o +/- 16 o ) and previously These injured notes (142 are o a preview. +/-13 o ) Dynamic rotation ROM significantly greater Full for previously notes available injured after purchase from (197 o +/-25 o ) c/w uninjured (174 o +/-27 o ) McConnell J, Donnelly C, Hamner S, Dunne J, Besier T, PMR 2012 Is there a difference between uninjured and previously injured? Conclusions passive rotation range in the shoulder underestimates These notes the are a preview. dynamic I-E ROM of Slides the shoulder are limited. used in throwing - underestimates by almost Full 30% notes available after purchase from Passive rotation ROM similar uninjured and previously injured previously injured subjects demonstrate almost 15% more dynamic rotation ROM than the uninjured,? greater risk of re-injury Muscle activity scapular dyskinesis Shoulder muscle activation patterns during seated throw Compared with healthy pitchers, pitchers with chronic anterior shoulder instability due to anterior labral injuries exhibit greater muscle activity from the biceps brachii, supraspinatus, infraspinatus (Glousman et al 1988) Subjects 20 elite asymptomatic overhead athletes 11 never been injured 9 previously injured > 12 months (no surgery) Method: upper limb and trunk kinematics of a seated throw measured with a VICON system and scaled in OpenSim Joint angles were calculated at full cocking phase ball release and zero elbow velocity semg recordings of UT,LT, supraspinatus, infraspinatus McConnell J, Donnelly C, Besier T, in press Typical EMG of shoulder throw Maximal EMG of shoulder muscles during a seated throw 7
Maximal EMG of shoulder muscles during a seated throw Maximal EMG of shoulder muscles during a seated throw Maximal EMG of shoulder muscles during a seated throw Management of the traumatic multidirectional instability Relocation of the humeral head Effect of tape on humeral head position in a patient with impingement Pre tape: pain at rest = 8/10 movement limited These to 45 o notes due to pain are a preview. Standing affected side - Slides leg externally are limited. rotated Weight 40kg Full affected notes available side, 50kg after purchase from unaffected side Effect of tape on humeral head position in a patient with impingement Post tape: Pain at rest 1/10 ROM full with slight increase at 130 o Weight bearing even both feet (45kg) Without tape With tape 8
Effect of tape on the shoulder in elite overhead athletes during a seated throw Total passive rotation ROM increased with tape uninjured (144o to 154o) previously injured (143o to 156o) Total dynamic rotation ROM increased with tape in uninjured (174o 180o) decreased with tape in previously injured (197o 190o) Effect of shoulder taping on total shoulder rotation ROM in uninjured vs previously injured athletes 174 o 144 o 180 o 197 o 154 o 143 o 190 o 156 o McConnell J, Donnelly C, Hamner S, Dunne J, Besier T, JOR 2011 McConnell J, Donnelly C, Hamner S, Dunne J, Besier T, JOR 2011 Effects of shoulder taping on shoulder kinematics in the uninjured vs previously injured elite collegiate athletes Uninjured ER increased from 131 o to 135 o with tape IR increased from 42 o to 44 o with tape Shoulder elevation no change with tape Ball velocity no change with tape. Previously injured ER decreased from 143 o to 138 o with tape IR decreased from 54 o to 51 o with tape Shoulder elevation no change Ball velocity no change McConnell J, Donnelly C, Hamner S, Dunne J, Besier T, JOR 2011 Maximal dynamic external ROM after full cock McConnell J, Donnelly C, Hamner S, Dunne J, Besier T, JOR 2011 Maximal dynamic internal ROM at zero elbow velocity What does tape do? Effect of tape on maximum muscle activation during a seated throw Relieves pain Changes muscle activation Slides are patterns limited. 9
Effect of tape on maximum muscle activation during a seated throw Effect of tape on mean muscle activation during a seated throw Effect of taping the shoulder on a seated throwing in the overhead athlete Increases passive rotation range in the shoulder of both uninjured and injured Decreases the dynamic These range notes in previously are a preview. injured Increases dynamic range in uninjured Decreases the Full maximal notes muscle available activity after purchase from required in rotator cuff and scapular stabilisers of both unijured and previously injured during throwing Increases mean scapular stabilier activity Decreases mean rotator cuff activity Management of the traumatic multidirectional instability Relocation of the humeral head Mobilise the stiff thoracic spine Lower trapezius training Endurance training for the rotator cuff at 90 o Latissimus dorsi training Gluteal training Eccentric abdominal control Management of the traumatic multidirectional instability Relocation of the humeral head Mobilise the stiff thoracic spine Lower trapezius training Endurance training for the rotator cuff at 90 o Latissimus dorsi training Gluteal training Eccentric abdominal control In summary The aims of rehabilitation for multidirectional shoulder instability are: Minimise symptoms Restore homeostasis Increase the patient s envelope of function by: increasing the mobility of the less flexible structures improving the stability and control over the mobile segments (specific muscle training) improving the strength and endurance of the lower limb and trunk musculature 10
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