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The Sporting Shoulder With Andrea Mosler
B. App. Sc (Physiotherapy) M. App. Sc (Sports Physiotherapy)
Andrea Mosler
- Specialist sports physiotherapist
- Australian Institute of Sport
- Sports medicine coordinator for National women’s Water Polo
- Olympic Water Polo Physiotherapist
since 2000, 2004 and 2008
- Professional interests include management of disorders of the shoulder
complex and hip and groin injuries.
Introduction
four articulations
all move together to provide
synchronous motion
Examine all components of shoulder
complex
Glenohumeral Joint
Ligaments
considerable variation in all studies
primary restraint at EOR
tightening of the capsule results in
coupled translations and rotations
capsular and tonal imbalance can
interfere with these coupled motions
Inferior glenohumeral ligament complex
O’Brien et al 1990
Static stability
ligaments act as static passive restraints at EOR
anterior support shifts from superior to inferior structures with elevation
HOH should remain centred in glenoid except in cocking position (Howell et al 1988, Bowen et al 1992, Shiffern et al
2002)
HOH relocated to the centre of glenoid with horizontal flexion
potential shearing stress on the artic cartilage and labrum
Static stability of HOH
O’Brien et al 1990
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von Eisenhart-Rothe
O’Brien et al 1990
Jobe and Pink 1991
Dynamic stability
• primary stabilising mechanism in mid-range
• resting muscle tone (Shiffern et al 2002)
ROTATOR CUFF
• maintain HOH in glenoid cavity, and ↑capsular stiffness
• large collagen component to subscap tendon
• feedback loop between ligaments and RC
• LHB contributes to anterior stability through ↑ torsional tension
• Emerging evidence!
Rodosky et al 1994
Long head of biceps complex PREVIEW ONLY
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Long head of biceps
Pagnani et al 1996
Anatomical Connections
Scapular rotators
• scapula supported by muscles and ligaments
• full elevation requires adequate stability and
rotation of the scapula
• position the scapula and stabilise it against the
thoracic cage
• place the scapula under the HOH so
movements occur with the maximum stability
Must have effective and balanced function of
all these muscles for normal scapular
motion and scapulothoracic/glenohumeral
synchrony
Scapular Rotators PREVIEW ONLY
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Biomechanics of arm elevation
• Large variation
between and
within individuals
• Overall ratio of 2:1
• 3 phases of rotation
• Axis of scapular rotation moves from
RSS→ACjt
Scapular Mechanics
Kinetic chain
allows generation, summation, transfer and
regulation of forces from legs to the hand and thus to
the object
sequential involvement of each link required to create
the energy, produce the force and stabilise the joints
for optimum performance without injury
shoulder is often the link that breaks
FAILURE IN ONE LINK FAILURE IN ANOTHER
Contributions of the force and
kinetic energy of the chain
Link Acc (m/s) %kinetic
energy
%force
Hip/trunk 13.5 51 54
Shoulder 33 13 21
Elbow 53 21 15
Wrist 65 15 10
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Six stages of throwing
Kvitne et al 1995 Shortcut to VTS_13_1.VOB.lnk
Rizzo 2006.m4v
Martial Arts/Wrestling PREVIEW ONLY
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Sporting Shoulder Injuries
• Acute injuries/contact
• Overuse injuries
• Mixed
• Degenerative conditions
• Arthropathies
Sporting Shoulder Injuries
• Acjt, Scjt injuries
• Snapping scapula
• Rotator cuff/LHB tendinopathy
• Impingement- internal vs SAS;1° and 2°
• Labral Injuries
• Nerve Injuries
• Instability
AC jt injuries
• Mechanism- usually
(70%) from a direct
blow to point of
shoulder, but also
indirect mechanism
from FOOSH
• Injuries classified as
Type 1-6 (Rockwood
1996)
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AC jt injury classification Type I: partial tear AC ligt but no change
in position of the distal clavicle wrt acromion.
Type II: Rupture AC ligt with partial tear of
C-C ligts. Distal end clavicle displaced wrt acromion but < full width of the clavicle
Type III: Rupture AC ligt with partial tear of C-C ligts. Distal end clavicle displaced wrt acromion but >full width of the clavicle
Type IV: Rupture all ligts with post displacement distal clavicle through aponeuroses of trapezius.
Type V: Distal clavicle severely displaced superiorly toward base of the neck, covered only by skin and subcutaneous tissue, complete rupture of the deltoid- trapezius musculature
Type VI: Inferior dislocation of clavicle under either acromion or coracoid process
AC jt injuries
Most studies demonstrate favourable results with
conservative management for all but really
severe injuries (Type 4-6)
Distal clavicle osteolysis (DCO) and
OA can also be cause of
symptoms, especially in
athletes
Beware of stress #
(Constantinou and Kastanos 2008)
Scjt Injuries
• Acute injuries
• Rare, but can be
life threatening!
• Overuse instability
Hoekzema et al 2008
Specific pathomechanics thrower’s
shoulder
• Scarring/tightening posterior shoulder
(?structures) + bony changes →→↓GH internal
rotation range (GIRD)
• Abnormality in coupled movements, migration of
glenoid contact point
• ↑Load dynamic stabilisers
• Dysfunctional sensorimotor acuity
• Damage to labrum
• ?? Stretching of anterior capsule
• ??Uncontrolled translation HOH
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Rotator cuff/LHB pathology
• ??Inflammation (bursa)
• Impingement- cause or effect???
• Degenerative process
• Partial→full thickness tears
• Most tears on articular surface, near
insertion (??critical zone, also area of
↑load) ?poor vascularisation a factor
• trauma can also occur
Rotator Cuff pathological process
• Similar deg process to other tendons
• Large compressive component to load and
?progression of pathology
• Neer- 3 Stages of impinge/RC disease; is
not supported with current literature
• Deg changes ↓ tendon capacity to cope
with tensile and compressive loads
Rotator Cuff tendinopathy
• Need to understand and embrace current
concepts of tendon pathology and
management and apply it to the shoulder
Specifically;
• Mechanotransduction
• Pathological process/staging
• Pain mechanisms
• Adapt current management methods for
tendinopathy in other parts of the body
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AC
SST
HOH
Supraspinatus tendinopathy SAS Impingement PRIMARY- is this a clinical entity?
• Os acromiale
• Variation in acromion shape/size, deg
• CAL thickening
• Acjt degenerative changes
• Swelling, fibrosis and/or thickening of subacromial bursa
SECONDARY
• Xs superior migration of the HOH due to muscle imbalance or structural changes
• Rotator cuff tendinopathy continuum
bony spur on the inferior
surface of the acromion Superior migration of HOH
Congenital or acquired?
Achilles Enthesis organ (Shaw and Benjamin 2007)
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Internal Impingement
Elevation/ER
Pinching between HOH and post-sup edge glenoid rim
Undersurface fraying RC
Labral,?osteochondal changes
Flexion
Sup-ant glenoid and sup translated HOH with type II SLAP
Internal Impingement Labral pathology
• Detachment/Bankart
• Degeneration/splits/tears
• Internal Impingement
• Bennett’s lesion
• SLAP lesions- peel back sign
Bankart lesion Bankart with Hill Sachs lesion PREVIEW ONLY
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Bennett’s lesion
Four
types of
SLAP
lesions
Rodosky et al 1994
Type
II
Further subdivision Type II PREVIEW ONLY
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Peel back mechanism Nerve injuries
• Suprascapular neuropathy- Volleyball
• Quadrilateral space syndrome
• Long thoracic neuropathy
• Brachial plexus injuries/thoracic outlet
(Safran 2004 pt s1 & 2)
Ringel et al 1990
Suprascapular
Nerve Entrapment
• Up to 1/3
volleyballers
• Symptoms variable
• Can lead to a
dangerous
sequelae
• ?subclinical
neuropraxia
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Quadrilateral space
McClelland and Hoy 2008
Quadrilateral space syndrome
• compression of the axillary nerve within
the quadrilateral space- fibrous bands
• Differentiate other causes of axillary nerve
injury
• Pain vague, dull aching or burning over t
lateral and posterior shoulder
• Insidious onset and agg by activity,
• ?weakness with overhead activity,
paraesthesia, wasting deltoid
Instabilities
• Definition- variable
• Classification important as affects management choices!!! (MacFarland et al 2003)
1. Severity –dislocation, subluxation, translational instability
2. Aetiology- Traumatic vs atraumatic, acute vs recurrent
3. Voluntary vs involuntary
4. Direction (ant, post, multi)
5. Structural- mechanical vs functional
Mechanisms of instability
laxity ≠ instability
Three separate categories;
1. Laxity- hypermobility without signs or symptoms
2. Translational instability- loss of centering of HOH
3. True instability- subluxation and dislocation with signs and symptoms of instability
• not all lax shoulders become unstable
• unstable shoulders are not always symptomatic
• ?what causes this progression
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Mechanisms of instability
• IGHLC stretches before tearing, acute pulls on
shoulder (Bigliani et al 1992)
• Pathology doesn’t always match symptoms
• Proprioception is disturbed in unstable
shoulders
• Proprioception controls muscle recruitment
• Synchronisation of muscle activity necessary
for maintenance of stability at the shoulder joint
SENSORIMOTOR ACUITY IS THE KEY!!
Management-
Pathology and symptoms • Traditionally diagnosis-based assessment and management
• Elite athletes don’t fit the mould
• Significant pathology has been demonstrated in asymptomatic shoulders (Jerosch , Miniaci and Connor studies)
• ? Precursor to symptoms or not correlated with symptoms at all
• Pathological shoulders can become asymptomatic WITHOUT correction to pathology (Murrell series)
Articular sided SST tear
Connor et al 2003
Capsuloligamentous Injury
(dislocation or subluxation)
Mechanical
Instability
Glenohumeral
Instability
Repetitive
Injury
Proprioceptive
Deficits
Neuromuscular
Alterations
Surgery
Lephart et al, 1996
Rehabilitation
Pain
Physiotherapy management of
the sporting shoulder BASIC PRINCIPLES
• determine underlying pathology
• determine the effect of associated structures/joints
• examine range and quality of glenohumeral physiological motion
• determine severity and direction(s) of instability (if present)
• examine relevant soft tissue
• Determine deficits of muscle strength, endurance, recruitment, timing and proprioception
• Examine kinetic chain and biomechanical dysfunction
• Determine predisposing factors to injury
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Predisposing factors to injury
• Change in a component of kinetic chain
• Change in technique
• Change in training load
• Fatigue
• Change to weight program
• Age
• Acute injuries
• Cross training/unaccustomed activity
• Change in neural input
Management principles
Place factors in order of importance
Treat ALL positive findings
Assessment findings will often form treatment
techniques
Respect the pathology-many
shoulder problems cannot be “fixed”
by conservative management!!
Management principles
Need to
• get rid of the pain! (Hodges, Crossley, Hess, David)
• restore normal joint kinematics
• restore normal muscle function
How?????
• many ways to skin a cat!
Management principles
Many tools
• Soft tissue techniques
• Acupuncture
• Stretching
• Taping
• Exercise/rehab
• Load management
• Electrotherapy
Rehabilitation program
Must be specific to the;
• pathology
• biomechanical demands of the activity
• demands of the athlete
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Rehabilitation aims
Restore/improve
• Scapular stability and movement with stability
• Normal intra-articular mechanics and physiological joint range
• Mechanics of the kinetic chain
• Rotator cuff and LHB function
• Proprioception and recruitment in response to dynamic stimuli
• Muscle strength and endurance
Normalise muscle function
• Waking up sleeping muscles
• Enhance activation of specific muscles
• True weakness
• Scapular stability and kinesis
Normalise muscle function Proprioception- “..encompasses sensations about body position
and movement that provide information necessary
for optimal control of posture and locomotion” (Edmonds et al 2003)
= limb movement (kinaesthesia)
+ limb position (joint position sense)
Is impaired with shoulder dysfunction but CAN be enhanced!
Sensorimotor acuity = proprioception +
central processing + motor output
Rehabilitation exercises
• HOH centering (isolate RC function)
• Scapular stability and movement with stability
• Sensorimotor acuity
• Closed kinetic chain
• Closed open kinetic chain
• Incorporation of kinetic chain principles
Enhancing sensorimotor acuity
• Getting rid of pain
• Trigger point therapy/acupuncture
• Mobilisation (Vicenzino)
• Taping
• Specific exercises
• Normalise muscle recruitment
• Increase resistance to fatigue
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Exercises to enhance
sensorimotor acuity
• Body blade
• Ball rolling
• Wobble board push ups
• Rhythmic stabilizations
• Plyometric exercises
•Controlled concentrated exercise
Athletes need muscles!!
• Need to work closely with strength and
conditioning coach
• Deltoid like quads of the shoulder
• Ensure that rehab program does not
replace a loaded gym program
• Keep athlete training as functionally as
possible to avoid disuse/loss fitness
Summary
• Complicated joint
• Mechanisms of injury are complex and
multifactorial
• Pathology and symptoms do not always
correlate
• Can change pain and sensorimotor
dysfunction
• Aim to permanently change motor patterns
• Respect the pathology!
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Join us next time:
Physiotherapy Update on Burns
Management Presenter: Dr. Dale Edgar
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