Muscle Assessment of Shoulder

• Global postural assessment• Architecture ie position of thumb / olecranon• Muscle bulk at shoulder and spine

– Lateral deltoid atrophy

• Scapular symmetry• Cervical spine

Muscle Assessment of Shoulder

• Static scapular position– Normal slight ABD/ER

• Winging– Medial - serratus anterior– Rotatory - rhomboids, levator scapula, trapezius, lat

dorsi– Inferior angle - tight pec minor, LFT weakness

Muscle Assessment of Shoulder

• Scapulohumeral rhythm in ABD– Scapular and GH force couples

• 0 to 80 ABD– GHJ- deltoid and supraspinatus– Scapular - upper trap and upper SA– ICOR- root scapula– more GH mov’t than scapular

Muscle Assessment of Shoulder

• 80 to 140 ABD– Continued UFT/ upper serratus and

deltoid/supraspinatus force couples– 90 ABD- additional rotatory force lower trap

and lower Serratus anterior– ICOR moves laterally to ACJ– More scapular mov’t than GHJ– Significance of scapular control in range where

most impingement occurs.

Muscle Assessment of Shoulder

• 140 to 180 ABD– Less UFT in inner range elevation– Ongoing deltoid/supraspinatus– Increased lower trap and serratus to rotate scapula– mid trap retracts scapula, counteracted by serratus

protraction– More GHJ mov’t than scapular

Muscle Length Tests

• Scapular quadrants

• Latissimus Dorsi– crk lying, post pelvic tilt, arms OH to bed with

ER.

• Pec minor– Measure distance post acromion off bed– stabilize ribs 3,4,5 and push coracoid to bed.

• Pec major– Clavicular- horiz ext at 90 ABD, arm flat table– Sternal- ABD 165, arm flat table

• Levator Scapula– Neck Flexion, SB/Rot away. Stabilize superior

medial scapula

• Upper trapezius– Neck flexion. SB away/Rot towards. Stabilize

superior scapula

Muscle Length Tests

• Scalenes– Anterior- SB away, slight Rot towards– Mid- SB away.– Posterior- SB away, slight Rot away

Functional Scapular Tests

• Isometric scapular retraction– trouble holding position and “burning” in less

than 15 seconds + for weakness• Wall push up• Scapular assistance test

– stabilize scapula and provide ER as elevatearm- ?impingement symptoms relieve

– Simulates SA and LFT force couple

Functional Scapular Tests

• Scapular dyskinesia “hitch or jump”– especially in descending phase of elevation

• 4 point palpation• Kiblers

– Hands side-little muscle activity– Hands on hips-low level LFT and SA– 90 abd- 40% max work of LFT, SA, UFT,

rhomboids

“Best Exercises” RA Ekstrom et al 2003, Moseley et al 1992

• Upper trap– Shoulder shrug

• Mid trap– Prone horizontal extension (with ER)

• Low trap– Prone arm raise overhead– Prone horizontal extension with ER– Rowing

• Rhomboids– Prone horizontal extension in neutral

• Serratus Anterior– Shoulder flexion, horizontal flexion, and ER

• Dynamic hug position– Abduction in scapular plane above 120– Push up with plus– Punch

• Lower Trap and Serratus Anterior– Prone: arm raise overhead– Abduction in scapular plane above 120

• Supraspinatus– Scaption “thumbs up”, 90 to 125 degrees– Flexion, 90 to 125 degrees

• Empty vs full can position– Empty can- impingement position, superior migration– EMG full can better ( Kelly: AJSM 1996)

• Infraspinatus/Teres Minor– Sidelying ER– Prone rowing ER– Prone horizontal ABD/ER 90/90 position

• Subscapularis– “lift off” movement– Forehand tennis serve IR at 45 Abduction– IR at 0 Abduction

Neuromuscular Rehabilitation

• All muscles of RC and deltoid activethroughout full range of ABD and FLEX– RC creates humeral head compression, and

counteracts the vertical force of deltoid.

• If RC dynamic stabilizers fatigue, getsuperior migration of humeral head leadingto impingement.– Vertical vector deltoid unopposed

• Focus on endurance component of RC withstrength training

• Contraction posterior RC reduces anteriorcapsule strain by pulling humeral headposterior during ER

• ER should be 65 -70% strength of IR

• If IR’s much stronger contributes to pullinghumeral head anterior.

• Consider doing IR/ER strength in scapularplane vs coronal– Higher ER torque in scapular plane– Functional plane

• Bias posterior shoulder strengthening– Subscapularis emphasis may promote anterior

HH translation

• Improve flexibility posterior shoulder– Tight post capsule, or decreased flexibility post

RC will cause anterior migration of HH

• Improve dynamic caudal glide provided byRC muscles/ LH biceps– Prevent superior migration of HH.

• Importance of trunk stability and LQstrength on shoulder function– Especially for sport

• Open and closed chain work– Facilitate joint proprioceptors to enhance

stability and dynamic control• Early introduction easy CKC exercises

– Axial loading to increase non contractilestability

– Facilitates co contraction around joint

Sequence of Strength Exercises

• Scapular stabilization• Humeral head stabilization• Advanced scapular and GH exercises• Return to function/sport specific exercises• Plyometric exercises

Scapular stabilization• Scapular control neuromuscular drills• Sidelying

– Active scapular PRO/RET/ELEV/DEP• Feldenkrais- hand on table

– Progress manual resistance– Progress to scapular diagonals/circles– Can apply rhythmic stabilization and slow

reversals in various ranges• Sitting- tubing/pulleys

Scapular stabilization• Isolate specific muscles that tested weak• Serratus anterior

– Sidelying- arm on ball, punching• Progress- remove ball

– Supine- on roll• Punch - bilateral to unilateral - progress circles• Shoulder flexion,horizontal flexion, and ER

– Promotes scapular external rotation– Add tubing

Scapular stabilization• Serratus anterior

– Sitting- distal arm on ball punching• Manual resist scapular ER• Do circles

– Sitting- bilateral punching with tubing– Sitting- arm abduction in scapular plane on

table above 120 ( force couple with LFT)– Prone: arm raise overhead ( F. couple with

LFT)

Scapular stabilization

• Mid and lower trap/ Rhomboids– Sidely to sitting- arm on ball, and retract

• Manual resistance, tubing– Stand face wall- horizontal extension (+/- ER)– Stand face wall - karate chop slide/lift– Stand face away wall-push back arms in ER, move

through 60-90 ABD

Scapular stabilization

• Mid and Low trap/Rhomboids– Prone over roll- arm dangle at 90 flex and

retract– Prone horizontal extension ( + ER)– Prone rowing– Prone arm raise overhead

• 10 mm lift arms from scapula– Sitting- arm abduction in scapular plane on

table above 120

Humeral head stabilization• Start with isometrics

– sub maximal, through range.– Short lever arm to start

• Include elbow flexion• Emphasis ER/IR 0 degrees• Abduction 0/30/60• Scaption 30/60 thumb up

Humeral head stabilization

• Start easy CKC exercise as soon as you can– Isometric WB hands on table– Isometric WB hands on wall– With above add:

• wt shift, hand slide, rhythmic stabilization,movement vs resistance

Humeral head stabilization

• Short arc concentric/eccentric strength• Abduction approaching 90 degrees• Scaption abduction up to 90 degrees, thumb up• Flexion up to 90• IR/ER with rolled towel in scaption• Biceps with shoulder in 35-40 flexion

Humeral head stabilization

• Specific supraspinatus– Scaption “thumbs up”, 90 to 125 degrees– Flexion, 90 to 125 degrees– Military press

Humeral head stabilization

• Specific infraspinatus / Teres Minor– Sidelying ER– Prone rowing ER– Prone horizontal ABD 90/elbow 90

Humeral head stabilization

• Specific subscapularis– IR From 45 ABD scaption plane so less lats and

pec minor contribution.

Advanced exercises

• D2 PNF pattern– Supine– Sitting/standing

• Manual resistance, rhythmic stabilization, slowreversals, theraband

• Supine- ABD/ER 90– Drop ball in hand

Advanced exercises

• Closed chain progressions• Standing, use table

– Isometric WB hands on wobble board– Isometric WB hands on ball

• Large to small• Hands move from side to top of ball, then one hand on top of

other

- progress 4 pt to 3 point– Add perturbations

Advanced exercises

• Progress CKC exercises– Push up with a plus (S. Anterior)

• Start with mini elbow bends– Sitting push up (Lower traps)

• Walk out feet on ball– Do scapular protraction/retraction bilateral– Lift one hand

• Push ups– Wall--> table--> chair--> floor– large to small ball– Feet on chair– Feet on ball– Feet on ball, and hands on balance board….

• Walk up stairs on hands• Walk on treadmill on hands• Hands on pro fitter

• Progress sports and work specific activities