powerpoint presentation · injury/mvt trauma trauma stress dominance dysfunction muscle +/-joint...

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Optimizing The Function of The Shoulder Girdle; Making Sense of The Dysfunction

Ian Horsley PhD, MCSP, MMACP, CSCS

Overview

1. Revisiting the anatomy. What is its function?

Excellence in musculoskeletal physiotherapy

2. What is the optimal posture for the shoulder. How will sub optimal posture present functionally?

3. Regional Interdependence; Influences on the shoulder

4. Exercise selection in rehabilitation

5. Proprioception ; assessment and rehabilitation

Introduction


• Shoulder pain is common• Annual population prevalence of up to 46.7%• Lifetime prevalence of up to 66.7%.• Third most common (MSK) reason to consult• Up to 3% of adults likely to consult with new shoulder pain annually

Artus et al., BMJ Open 2017

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Terminology• Subacromial pain (SAP)

• Rotator cuff related pain

• Movement related shoulder pain without significant stiffness

• Weak and painful shoulder

• Something hurts in the shoulder syndrome (SHITS)

• Shoulder pain

• Soft-tissue shoulder pain

• Rotator cuff tendinopathy

Clinical Diagnosis


the identification of the nature of an illness or other problem by

examination of the symptoms

• To differentiate between possible causes of symptoms.

• Determine WHAT IT IS NOT

Clinical Diagnosis


X

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THE BLIND MEN & THE ELEPHANT

…these six blind men "disputed loud and long,each in his own opinion ~ exceeding stiff and strong,

though each was partly in the right ~and all were in the wrong!"

it is like a rope?

It is like a huge wall?

it is like a thick

branch of a tree

Physiotherapy- EBP

• “The conscientious, explicit and judicious use of the current best evidence in making decisions about the care of an individual patient” (Sackett)

Evidence-Informed Decision-Making Process

• Does not solely rely on the evidence

• There are occasions where the evidence alone is not sufficient to support a clinical decision(Portney,2004)

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Thoughts

Evidence Based Practice

• “care that takes place when the decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information”

(Hicks,1997)

Evidence-Informed Practice

• Integrates the best available evidence and clinical expertise with the patient’s needs and values to ensure delivery of best practice

(Canadian Physiotherapy Association,2012)

IDENTIFICATION of SPECIFIC REHAB STRATEGIESFUNDAMENTALS

• Rehab & Treatment decisions based on achieving certain pre-determined markers -SPORT SPECIFIC/ACTIVITY SPECIFIC

• Comfort - Pain levels (VAS)

• Respect the irritability

• Respect the pathology

• Understand patient beliefs/expectations

• Control - Movement pattern & Movement assessment- QUALITY

• Strength - ability to tolerate loads / speeds-through range/ concentric/eccentric/isometric

• Injury specific benchmarks- entry/exit criteria


Red Flags

InfectionCancerCardiopulmonaryInflammatory DiseaseNeurological

Specific Conditions

FractureDislocationOACalcific Tendinopathy

Syndromes

ImpingementInstabilityDyskinesisFrozen Shoulder

Persistent Pain

NeuropathicCentral Sensitisation

Neurological

Motor ControlCranial nerveLocal Nerve

Serious Conditions Pathoanatomic Non SpecificPathoanatomic

Non SpecificDysfunction

Neurological Dysfunction

C

O

N

D

I

T

I

O

N

Pt HistoryRisk FactorsWt LossNon Mechanical PainFeverSystemically UnwellNight Pain

B

a

s

e

d

O

n

Clinical ExaminationS&SImaging

Symptoms? Painful ArcObservationPassive Stiffness

SymptomsNeurolophysiologySensory TestingValidated Questionnaires;Pain DetectCentral Sensitisation

Inventory Score

ObservationNeuro ExamCN Facilitation

Adapted from Angela Cadogan

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Management Options

Red Flags

Medical

AppropriateMedical Management

Specific Conditions

Surgical/ NonSurgical

ImmobilizationSurgeryNon surgicalRespect PathologyRestore Function

Syndromes

Non Surgical

Non SurgeryPhysioRespect IrritabilityModify SymptomsRestore FunctionInjections

PersistentPain

MDT

PhysioOTPsycheMedicationCBTMindfulness

Neurological

Non SurgicalPhysio

PhysioMotor Control

Refer Urgent& Early

Ortho Referral/PhysioRespect PathologyTissue Load Capacity

PhysioImpairment BasedSymptom ModificationMotor Control

Refer to Expert PainEducatorPain EducationPain Management

Refer to MovementControl Specialist

Release Non OptimalStrategy

Teach New StrategyAdapted from Angela Cadogan

Excellence in musculoskeletal physiotherapyTousignant-Laflamme et al., 2017 Lee & Lee 2007

Frameworks


“We need to reframe what is currently doable andachievable in the management of manynon-traumatic musculoskeletal presentations,and honest and open conversations regarding the outcome evidence for these disorders needsto be sensitively communicated.”

Lewis J, O'Sullivan P. Br J Sports Med December 2018 ;52(24)

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Putting It Into Context…

• ER + IR = 180o

• Pitching speed = 9000o/ Sec

400 Ft

A Rocket needs a speed of18,000 MPH to achieve orbit

50%

30%

20%

• Hip joint• Pelvis• Knee joint• Ankle joint• 1st MTPJ• Glutes• Hip flexors

• Thoracic spine• Breathing• Abdominals• Lats• Infrasternal angle

• Scapular position• Scapular stabilizers• Rotator Cuff• SCJ• GHJ ROM• Strength???

It’s Not AllAbout The Shoulder Girdle !

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Inflammation from Pain Acute Repetitive Emotional Sympathetic NSInjury/mvt Trauma Trauma Stress Dominance dysfunction

Muscle +/-Joint Pain

Muscle Imbalance& AlteredProprioception

Movement Dysfunction& Avoidance Strategy

Loss of JointCentration

Theoretical & Actual

Significant decrease in serratus EMG and increase in upper trap activity during shoulder flexion with forward head posture

(Weon, 2010; Valizadeh, 2014)

Effects…

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Stacking The Spine

• The Stack: When the thoracic and pelvic diaphragm are relatively atop one another, allows for non-compensatory breathing to occur

Zone of Apposition

OPTIMAL ZOASUB-OPTIMALZOA

Xiphoid Process

11th Rib 12th Rib

Crura of1st, 2nd &3rd Lumbar

vertebrae

CentralTendon

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Obtaining the Stack

• (Relatively)Posteriorly Tilted Pelvis• Infrasternal angle 80o-100o

Infrapubic Angle


Relationship And Outcome


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Testing Infrasternal Angle Variability/ Dynamic Movement

• Patient in Supine Position

• Determine the infrasternal angle

• Patient gradually flexes both shoulders until ribcage begins to “lift off” or roll superiorly towards head, this marks the point where the thorax is tipping backwards and will produce a false rib motion reading.

• Have your hands at the infrasternal angle.

• Get the patient to then take a normal breath in and out.

• Monitor the infrasternal angle during inhalation and exhalation.


Assessment/Observation


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Observation


To exercise the power of vision upon;to search for

In order to see, not only does one look at the object but also understands it,perceives it and pays attention to it

LOOK SEE

Assess Posture (Static)Cervical

Thoracic

Lumbar

Pelvis

Humeral Head

Scapular Resting Position

Sobush et al JOSPT 1996

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Why I think It’s Important


Length-Tension Relationship


Force % MVC

Stability

1-3 25 80

STRENGTH & STABILITY

COMERFORD & MOTTRAM

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Assessment/Observation

• To help stabilize and control movement within the joint, some degree of simultaneous co-contraction of the antagonist also occurs.

• When a muscle becomes shortened, increased tonicity occurs within the muscle (hypertonicity).

• A hypertonic muscle requires a smaller or weaker nerve impulse to activate a contraction (lowered irritability threshold).

• When an individual tries to activate the antagonist at a joint, the reduced irritability threshold of the agonist may prematurely activate the muscle and inhibit the action of the antagonist.


Is scapular symmetry important?

Not supported by research

(Kibler et al., 2013; Smith, Dietrich, Kotajarvi, & Kaufman, 2006;Burkhart et al., 2003; Hebert, Moffet, McFadyen, & Dionne, 2002; Laudner, Jb, Mr, Jp, & Sm, 2006; Paula M. Ludewig, Cook, & Nawoczenski, 1996; P.M. Ludewig & Cook, 2000; Lukasiewicz, McClure, Michener, Pratt, & Sennett, 1999; van der Helm, 1994;Sahrmann, 2002;Ozunlu, Tekeli, & Baltaci, 2011;Schwartz et al., 2014;Cools et al., 2008; Uhl, Kibler, Gecewich, & Tripp, 2009)

From Dr Tanya MacKenzie

Landmarks

CTAa

b

Scapular Downward Rotation Index Clavicular Tilt Angle

SDRI= (a-b)/a x 100Higher value = greaterScapular downward rotation

CTA values; 5.9o +/- 1 (Ludewig et al., 20094.0o (McClure et al.,2004)

(Choi et al.,2014; Ludewig et al.,2009;McClure et al 2004)

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Humeral Head Position

Static Assessment

• Head Position (Front/Side)

• Cervical Spine Lordosis

• Clavicle Tilt Angle

• Humeral Head Position

• Thoracic Kyphosis

• Scapular Downward Rotation Index

• First Rib Position

• SCJ/Manubrium

• Acromion Levels

• Scapular Tilt

• Elbow Resting Position

• ISA

• ASIS

• PSIS

• Gluteal/Popliteal Folds

• Leg/Foot/Ankle Position

Excel lence in musculoskeletal physiotherapy


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Regional Interdependence

• Definition:

• “With respect to musculoskeletal problems, regional interdependence (RI) refers to the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint.” (Wainner et al. 2007 )

Cervical Spine Influence

Cervical Dysfunction

ShoulderDysfunction

FHP; Considerations

• Trapezius

• Serratus Anterior

• Levator Scapulae

• Rhomboid Major

• Rhomboid Minor

• Pectoralis Minor

• Subclavius

• Sternocleidomastoid


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DEEP NECK FLEXORS

• Assess in neutral

• Progressions

• Upper limb involvement

• Position

• Integrate into function

Cervical Spine

Control


ShoulderSymptomModificationProcedure(Lewis,2009)

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Area of Intervention

Change/Improvement

No Change Worse Partial Complete

Cervical Spine

Thoracic Spine

Scapular

Humeral Head

CERVICAL SPINE PROCEDURE

MWM C Spine + Abduction (Mulligan)

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Dynamic Movement

What are we looking for..?

How Is ItProduced?

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Somatosensation

Generates neural impulses thatcontrol the executionof movement based

on responses to inputsFrom our environment

Proprioception

First

• Acquisition of mechanical stimulus

Second

• Conversion of mechanical stimulus into neural signal

Third

• Transmission of neural signal to the CNS

(Lephart & Fu, 2000)

Should We Always Move In Exactly The Same Way?


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Movement Variability

The velocities and ROM differ with each swing, but the joint actions appear to be the same. (Bernstein,1923)

Optimal VariabilityToo Little

• Stuck with an inflexible system that has very limited adaptability

• Lead to overuse injury

Too Much• person may be all over the place

with “noisy movement”

ROM…Glenohumeral Joint ROM (Degrees)

Flexion 180

Extension 60

Abduction 180

Adduction 45

Internal Rotation 70

External Rotation 90

Horizontal Flexion (Adduction) 130

Horizontal Extension (Abduction) 50


Aspetar Sports Medicine Journal

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Shoulder Girdle

Active Movement

• Initiation

• Quality

• Effortless movement

• Scapular motion- 60o upward rotation

• Compensations-Cx/Tx/Lx

• Humeral ER

• Symptoms- where in range/descriptor

Initiation QualityEffortless MovementScapular motion- 60o URCompensations-Cx/Tx/LxHumeral ERSymptoms- Range/Descriptor

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Importance of External Rotation

@back-in-action

Humeral External Rotation

@back-in-actionLudewig et al., 2009

Scapulohumeral Rhythm

• Ratio of the glenohumeral movement to the scapulothoracic movement during arm elevation.

• Overall value is 2:1 (Inman et al., 1944)

• But ratio is not consistent across an entire arc of shoulder elevation (Poppen & Walker, 1976; Bagg & Forrest, 1988; Crosbie et al., 2008)

@back-in-action

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Pattern of Motion During Elevation


Humeral elevation and external

rotation

Clavicular elevation and retraction

Scapular upward rotation, posterior tilt, and external

rotation

Upward Rotation

MiddleTrapezius

LowerTrapezius

SerratusAnterior

@back-in-action

Scapular Movement

External Rotation Posterior Tilt

SerratusAnterior

Rhomboids

SerratusAnterior

LowerTrapezius

@back-in-action

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https://meloqdevices.com/

Dynamic Assessment


Static Posture

Movement Quality

Scapular 3D motion

Humeral External Rotation

Optimal Muscle Resting Lengths

Thoracic Mobility

Optimal Breathing

JOINT REQUIREMENT

Ankle Mobility

Knee Stability

Hip Mobility

Lumbar Spine Stability

Thoracic Spine Mobility

Scapula Stability

Glenohumeral Mobility

The Kinetic ChainMore about this later…

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Special testsAre generally pain provocation tests, so what’s

so “special” about them..?

The clinical performance of single PETS is limited

Bio-psychosocial vision of healthmay guide physiotherapist to make diagnostic triage and to choose the right treatment for the individual patient.

Insufficient evidence upon which to base selection of physical tests for shoulder impingements, and local lesions of bursa, tendon or labrum that may accompany impingement,

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• Pain as a warning rather than tissue injury

• Peripheral/Central sensitisation

Pain Provocation Tests

Examination questionable- so let’s get imaging

Correlation of Imaging With Tissue Damage

• SAIS (55%),Control (52%) (Frost et al., 1999)*

• Asymptomatic baseball pitchers; 79% D, 86% ND (RCT), 79% D, 79% ND (labral involvement) (Miniaci et al.,2002)*

• Asymptomatic tennis/pitchers 40% FFT/PTT (Connor et al.,2003)*

• Tempelhoff et al.,1999;- 13% of people aged 50 to 59• 20% of people aged 60 to 69• 31% of people aged 70-79• 51% of people aged 80 or above

* MRI + Ultrasound

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Lack of uniformity In

DiagnosticLabelling

ControversialInterpretation of

DiagnosticImaging

UntrustworthinessOf

DiagnosticTests

Non CorrelationBetween PainAnd Structural

Factors

Biederwolf, 2013

Where Does That Leave Us?


Name (Littlewood et al., 2019)

• Subacromial impingement

• Subacromial pain

• Rotator cuff related shoulder pain

• Subacromial impingement syndrome

• Sub-coracoid impingement

• Internal Impingement

@back-in-action

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It’s Not A Diagnosis• Compression of the RC/SAB

against anteroinferior of the acromion and coracoacromial ligament.(Neer, 1972; Calis et al., 2000)

@back-in-action

Sub-acromial Impingement TestsTest Image

Hawkins-Kennedy

Neer”s

Horizontal Adduction

Speed’s

Yergason

Painful Arc

Empty Can


Impingement Test Number of Articles Evaluated

Neer 5

Hawkins-Kennedy 7

Painful Arc 2

Cross Body Adduction 2

Speed’s 2

Drop Arm 2

Other Tests 5

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@back-in-action

Bey et al., 2007

@back-in-action

Contributing Factors

• Altered shoulder kinematics secondary to dysfunction of the rotator cuff and scapular muscles

• Capsular tightness

• Poor posture

• Overuse secondary to sustained intensive work

Subacromial Pain

@back-in-action

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@back-in-action

Impingement Tests

Neer Impingement Test SUB ACROMIAL IMPINGEMENT

Hawkins-Kennedy Test; CORACOACROMIAL IMPINGEMENT

@back-in-action

• ).

Supraspinatus was most often in contact, in Ab/IR (coracoacromial ligament) and E/ER (with the anterior acromion).

Subscapularis was most often in contact in F/IR and F/ER (coracoid process)

Infraspinatus was most often in contact in E/ER ( posterior acromion).

@back-in-action

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Shoulder Impingement

• Shoulder impingement is normal- ABER position

• Pinch within SAB between HH and Acromion

• Every time elevate impingement happens

• So is it a “Sub Acromial (no) Space”???

• Reduced subacromial space has been shown in subjects with impingement syndrome compared to healthy subjects using MRI, X-Ray and Ultrasound

(Herbert et al., 2002; Graitchen et al.,1999; Pijls et al.,2010)

@back-in-action

ImpingementSyndrome

SubacromialImpingement(Bursal Side)

InternalImpingement(Articular Side)

ReductionIn

SubacromialSpace

IntrinsicMechanisms(within tendon)

ExtrinsicMechanisms(external to tendon)

Contributing Factors;Tendon HistologyAgeGenetics

Contributing Factors;Muscle extensibility/performanceAnatomical/osseousGHJ kinematicsPosture/ergonomics

TIME

MacKenzie et al., 2015 @back-in-action

Anatomical&

Biomechanical

Pec MinorLength

ScapularMusclePerformance

ThoracicSpineFunction

GHJCapsule

RCMusclePerformance

Seitz et al.2011 @back-in-action

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Independent Variable Population Pearson’s Correlation

AHD with 0o arm abduction Shoulder IR Sportsmen +ve significant weak

Pec Minor Length Sportsmen +ve significant weak

AHD with 60o arm abduction %Reduction in AHD

Pec Minor Length Sportsmen +ve significant weak

Total Arc of Shoulder Rotation Controls +ve significant weak

Shoulder External Rotation Controls +ve significant weak

Shoulder Activity Level Controls +ve significant weak

Shoulder Activity Level Sportsmen -ve significant moderate

Group Number of Shoulders Sport

Male Controls 72

Male Sportsmen 186 90 Golf

30 Gymnasts

16 Canoeists

36 Boxers

14 Archers

Strength of relationship waspopulation specific and

dependent on arm position

MacKenzie et al., 2016

Impingement Not The Same

Bursal/Subacromial EXTRA ARTICULAR Articular/ Internal Impingement

• Caused by contact between the articular side of the supra/infraspinatus and the posterosuperior rim of the glenoid.

• Pain located posteriorly “inside” the joint when in ABER (throwing) position

• Compression caused as a result of a decrease in the subacromial (AHD) space

• Pain generally located over anterior aspect of shoulder with elevation

@back-in-action

SubcoracoidImpingement

• History of dull pain in the anterior aspect of the shoulder

• Exacerbated by shoulder in a forward flexion, adduction and internally rotation

@back-in-action

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CausesA B C

@back-in-action

Intrinsic Mechanisms

• Shear and compressive forces

• Alterations in biology, mechanical properties, morphology, and vascularity

• Normal aging process

Cook and Purdum (2015) @back-in-action

• Concentric /Eccentric Abduction (0-90o) 3x10 reps

• Concentric /Eccentric ER @ 45o (20o IR-25o ER) 3x10 reps

• 60 reps @ 120o/sec

• Fatigue = 35% drop in overall torque

@back-in-action

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Occupation ratio (supraspinatus tendon/ acromiohumeral distance (%)

S/S Thickness Increased @ 1& 6 hrs S/S Thickness Decreased @ 6 hrs

0 hr 1 hr 6 hr 24 hr0 hr 1 hr 6 hr 24 hr

20.00

40.00

60.00

80.00

100.00

20.00

40.00

60.00

80.00

100.00

@back-in-action

Summary

• The S/S responded immediately following fatiguing shoulder exercise

• AHD reduced in both groups, but recovered to baseline more slowly in those with shoulder pain.

• Rehabilitation tendon loading programmes to restore tendon homeostasis are recommended

• Exercise type and dosage titrated to avoid excessive loading to fatigue

• Consider timing of frequency of exercise

@back-in-action



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Change/Improvement


Cervical Spine

Thoracic Spine

Scapular

Humeral HeadMe

anin

gfu

l Tas

k

Shoulder Symptom Modification Procedure (Lewis ,2009)

Scapular Assistance Test Scapular Retraction Test

During the ScapularAssistance Testthe AHD was reportedto increase althoughnot significantly(Seitz et al.,2012).

@back-in-action


Change/Improvement


Cervical Spine

Thoracic Spine

Scapular

Humeral HeadMe

anin

gfu

l Tas

k

@back-in-action

Scapular control and ROM can be assessedon the field with acceptable reliability

Validity of scapular dyskinesis test was demonstrated

The exact role of dyskinesis in creating or exacerbatingShoulder dysfunction is not clearly defined

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Procedure demonstrates a good level of reliability.Not a stand-alone procedure and must be embedded within a complete patient care management programme

Insufficient evidence to recommend SSMP as a reliable or validated tool

SSMP + MTA

SSMP +MTA

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Extensibility

SH BicepsCoracobrachialis

Identify underlying cause

Recruitment

Muscle

(Cools et al., 2013)

Lack of Extensibility


@back-in-action

Scapular Muscles

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Pectoralis Minor


Levator Scapula


SHB/Coracobrachialis


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Posterior Capsular Inflexibility

• Subjects with posterior shoulder tightness (evaluated by measuring glenohumeral internal rotation ROM) demonstrated greater scapular anterior tilt

• Decrease in shoulder internal rotation has been associated with shoulder impingement in overhead athletes (Harryman et al., 1990; Tyler et al., 2000; Borich et al., 2006)

ECKENRODE 2012@back-in-action

GIRD

GIRD is a loss of internal rotation range of motion inthe presence of a loss of total rotational motion

GIRD = (Side-to-side difference in ER) + (Side-to-side difference in IR)

Mikereinold.com

@back-in-action

Managing GIRD

Laudner et al.,2008

@back-in-action

Interventions For Posterior Capsule Tightness

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Latissimus Dorsi Length Assessment

@back-in-action

Latissimus Dorsi Stretch Options


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Lack Of Muscle Performance


Deltoid:Rotator Cuff Force Couple

• I+ Sub line of pull ~ 45o

• Teres Min line of pull ~55o

• 30% reduction in ABD torque

• Fatigue induced superior migration

• Centering effect of cuff decreases

• Need to maximize endurance, synergistic activity & strength of cuff musculature.

• Endurance exercises may reduce impingement symptoms

• NB ER fatigue causes scapula IR

FATIGUE ON HUMERAL HEAD TRANSLATION (CHEN

1999)

Fatigue protocol

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GLENOHUMERAL

OBLIGATE TRANSLATION FIRING Up the Postero-superior cuff

to resist against antero-inferior humeral head displacement and excessive

global medial rotator dominance

Force % MVC

Stability

1-3 25 80

STRENGTH & STABILITY

COMERFORD & MOTTRAM

How is the scapula/rotator cuff working?

Stabilizer Mobilizer

Static Dynamic

Treatment Planning

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What Areas Are Working?• All RC muscles working reciprocally• RC in mover role• All RC working Con & Ecc• All RC working mid to inner ROM• Axioscap muscles working as stabilizers• Sacp UR act as movers

Low Load Humeral Head Control

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Low Load Humeral Head Control

High Load Humeral Head Control

Isometric Shoulder

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Rigidity

Scapular Dyskinesis

In the absence of “normal”, what is “abnormal?

What looks like “abnormal” may well be a “normal” adaptation strategy

Tests used to identify “abnormality” lack construct validity

Measurements are unreliable and prone to bias

A causal relationship between dyskinesis and symptoms has not been established

Scapular control and ROM can be assessedon the field with acceptable reliability

Validity of scapular dyskinesis test was demonstrated

The exact role of dyskinesis in creating or exacerbatingShoulder dysfunction is not clearly defined

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Procedure demonstrates a good level of reliability.Not a stand-alone procedure and must be embedded within a complete patient care management programme

Insufficient evidence to recommend SSMP as a reliable or validated tool

Kibler 2002

Type IIType I

III

SCAPULA DYSKINESIS- What is Wrong?

Type III

Management

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winging scapula.AVI

TypeI scapular Dyskinesis abd.AVI

Type III dyskinesis.MP4

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Does Exercise need to Be Specific?

• Scapular stabilization exercises*

• Rotator cuff resistance exercises*

• Range of motion*

• Stretching exercises* (*Hanratty et al.,2012)

• Proprioceptive exercises (Beaudreuil et al., 2011)

The MECHANISM of Impingement Considerations• Scapular Stability

• Humeral Stability

• Anatomical size changes


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Excellence in

mu

sculo

skeletal p

hysio

thera

py



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RC Muscle Architecture• The supraspinatus (39%) & Infraspinatus (57%)

contribution of total resting passive tension in the anatomic position

• Subscapularis contributed 100% of the total passive tension at maximum abduction & lateral rotation

• Rotator cuff muscles to produce near-maximal ACTIVE tensions in midrange

• Produce passive tensions at rest and in extreme joint positions.

• RC optimum force-producing capacity at approximately 25º abduction and 20º lateral rotation

Strength

• While the most commonly performed clinical assessment of strength is the gross manual muscle test, this method lacks objectivity and presents reliability concerns


Shoulder Strength Ratios• Deltoid: ER: Lower Traps=

3:1.5:1 (McKean 2009)

• Flexion: Extension 1.26:2.22 (depending on abduction angle isometric measure made)

• Abduction: Adduction 1.53-2.63 (depending on abduction angle isometric measure made)

• Extension & adduction movements become weaker with age (Hughes, 1999)


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What’s The Best Position?GH IRs

• Pec Maj

• Lat Dorsi

• Teres Maj

• Subscapularis

GH ERs

• Infraspinatus

• Teres Minor

• Supraspinatus

• Post Deltoid

ER muscle strength in kilogram at different shoulder joint positions (ER muscles shortest in ER).

IR muscle strength in kilogram at different shoulder jointpositions (IR muscles shortest in IR).

Cibulka et al,2014

Less Than £300!!

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At What Speed?Sport Angular Velocity

Baseball Pitching 6000-8000 deg/sec

Tennis Serve 3000 deg/sec

Javelin Throwing 6000-10000 deg/sec

Handball Throwing 3400-4200 deg/sec

Strength (Cools, et al.,2016)

Isokinetic ER:IR

•66%Isometric ER:IR

•75-100%(depending on testing position)

Strength

Functional Deceleration Ratio (FDR)(David et al., 2000;Hess, 2000; Rizio & Uribe, 2001)

Ecc ERCon IR

Balance Ratio (BR) (Wang &

Cochrane, 2001).

•

Con ERCon IR

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Subscapularis Recruitment


35-51% MVIC

External Rotation

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Lateral Rotation Option


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Grip Strength Assessment

• The most common method of assessment for grip strength is the use of a handheld dynamometer

Grip Strength + Lateral Rotation Force

30.00

31.00

32.00

33.00

34.00

35.00

36.00

37.00

38.00

39.00

Left Right Left Right Left Right

Neutral 90 deg abducted 90 deg Abducted &External Rotated

Grip Strength (Kg)

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

11.00

12.00

13.00

14.00

15.00

Left Right Left Right Left Right

Neutral 90 deg abducted 90 deg Abducted &External Rotated

Lateral Rotation strength (kg)

Correlation Left

Hand

Correlation Right

Hand

Neutral Shoulder Rotation 0.91 (R2=0.84) 0.86 (R2=0.66)

90 Degrees Shoulder Abduction 0.82 (R2=0.67) 0.72 (R2=0.52)

90 Degrees Shoulder Abduction &

External Rotation

0.78 (R2=0.61) 0.75 (R2=0.57)

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Assessing Muscle StrengthUpper Trapezius

Middle Trapezius

Lower Trapezius

Serratus Anterior

Infraspinatus/Teres minor

Subscapularis

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Trapezius Roles (Johnson et al., 1994)

SCAPULA SETTING- This is not it!

What Exercises Do You Use to Recruit Upper,Middle & Lower Trapezius?

Upper TrapeziusProne Rowing(Moseley et al.,1992)

Military Press(Moseley et al.,1992)

T(Moseley et al.,1992)

Shoulder Shrugs(Andersen et al., 2008)

Lat Raises(Andersen et al., 2008)

Upright Rows(Andersen et al., 2008)

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Middle TrapeziusProne Shoulder Extension(Moseley et al.,1992; Cools et al 2007)

Prone Rowing(Moseley et al.,1992)

Side Lying ER(Cools et al., 2007)

Side Lying shoulder Flexion(Cools et al., 2007)

T(Moseley et al.,1992)

Lower TrapeziusShoulder Abduction(Moseley et al.,1992)

Bilat ER @ 0o Abduction(McCabe, 2007)

Flexion in Standing/Sitting/Sd Ly(Moseley et al.,1992;Cools et al.,2007)

Prone Ly ER 90o Abduction(Ballentyne et al., 1993; Ekstrom et al.,2003)

Prone Shoulder Rowing(Moseley et .,1992)

Side Lying ER(Ballentyne et al, 1993; Cools et al.,2007)

T with ER(Cools et al., 2007; Ekstrom et al., 2003;Moseley et al.,1992)

Y(Eksrom et al., 2003)

Scapular Muscle Ratios

• Priority should be given to shoulder exercises that produce a high LT/UT/,MT/UT, and SA/UT ratio to allow a more optimal activation of the SA and LT.

• This will reinforce the scapular balance and prevent the development of pathological conditions such as impingement syndrome.

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Scapular Muscle Balance

• UT/MT, UT/LT, UT/SA

• Ratio should be close to 1:1 (Schoryet al., 2016)

• Ratio >1 = greater UT activity

• Ratios <1 = considered ideal

UT/MT

• Ratios <1 = considered ideal

Exercise Ratio Reference

Abduction 60o Eccentric 0.46 Park et al., 2012

Abduction 180o Eccentric 0.38 Park et al., 2012

Flexion 180o Eccentric 0.12 Park et al., 2012

Prone ER 90o Abduction, 90o

Elbow Flexion 0.440.72

Ekstrom et al., 2003Marta et al., 2013

Side Lying ER With Elbow 90o

Flexion 0.370.540.380.44

Cools et al., 2007Huang et al., 2013Marta et al., 2013Park et al., 2012

UT/LTExercise Ratio Reference

High Scapular Retraction Sitting

0.03 De May et al., 2103

High Scapular Retraction Standing

0.28 De May et al., 2013

Prone ER @ 90o Abduction 0.250.79

Ekstrom et al., 2003Marta et al., 2013

Prone Flexion 0.06 Wattanaprakornkul et al., 2011

Ratios <1 = considered ideal

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LEAST OPTIMAL UT/LTExercise Ratio Reference

Abduction to 45o 1.57 Oliveira et al., 2013

Abduction to 90o 1.35 Oliveira et al., 2013

Abduction to 120o 1.361.18

Cools et al., 2007Oliveira et al., 2013

Abduction in Scaption to 45o

1.19 Oliveira et al., 2013





Press Up Standing 2.67 Uhl et al., 2010

Wedge Press Up (Reclined) 5.50 Uhl et al., 2010

Ratios <1 = considered ideal

UT/SAExercise Ratio Reference

Seated Bench Press 0.30 Wattanaprakornkul et al., 2011

Diagonal Exercise 0.66 Ekstrom et al., 2003

Bilateral Scapular Protraction

0.13 Ekstrom et al., 2003

Supine Press 0.110.06

Ekstrom et al., 2003Uhl et al., 2010

LEAST OPTIMAL UT/SAExercise Ratio Reference

Low Row 1 1.01 Cools et al., 2007

Low Row 2 2.12 Cools et al., 2007

Prone Abduction With ER 3.66 Cools et al., 2007

Prone Horizontal Abduction With ER

3.617.333.29

Cools et al., 2007Ekstrom et al., 2003Sciascia et al., 2012

Seated Row 3.321.11

Cools et al., 2007Wattanaprakornkul et al., 2011

Shoulder Shrug 4.414.93

Ekstrom et al., 2003Pizzari et al., 2014

Prone Unilateral Row 4.50 Ekstrom et al., 2003MT only Scapular Stabilizer MORE Active

Than UT

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0

20

40

60

80

100

120

140

UpperTrapezius EMG

MiddleTrapezius EMG

LowerTrapezius EMG

SerratusAnterior EMG

Shoulder Shrug

Prone Rowing

Prone Horizontal Abd at 135°with ER

Prone Horizontal Abd at 90° with ER

Prone External Rot at 90° abduction

D1 Diagonal Pattern flextion, horizontal Abd and ER

Scaption above 120° with ER 'full can'

Scaption below 80° with ER 'full can'

Supine scapular protraction with shoulders horizontally flexed 45° and

elbows fixed 45°

Supine upwards scapular punch

% MVIC

Castelein et al., 2015, in press

Scapular Dysfunction

• Performing scapular exercises with conscious correction of scapular position enhances trap activity (De Mey:JOSPT’13)

• Decreased UR, posterior tilt, external rotation in subjects with shoulder impingement (Struyf Scan J Sport Med ‘11)

• People that develop shoulder pain have significantly less upward rotation at 45o and 90o

of elevation (Struyf: Int J Sports Med ’14)

• Upwards rotation od the scapula is accompanied by up to 30o of scapula posterior tilt (McClure et al.,

2001)

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Correcting Lack of Posterior Tilt

SERRATUS ANTERIOR

• Superior part; 1st-2nd rib-> superior angle: stabilize scapula on initial abduction (ER & UR)

• Intermediate part; 2nd-3rd rib-> medial border; instrumental in protraction(ER)

• Inferior part;4th-9th rib-> medial border + inferior angle; primarily upward rotation/controls downward rotation & posterior tilt

• Upwardly Rotates Scapula• Posteriorly Tilts Scapula• Externally Rotates Scapula• Protracts Scapula

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What Exercises Do You Prescribe For Serratus Anterior?

SA Exercises

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Scapular CKC Upward Rotation


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Scapular Upward Rotation

Think…

Facilitated Functional SA

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SA + Kinetic Chain


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What is Instability?

• …is symptomatic laxity

• A fine balance between static and dynamic structures

• Muscles can contribute to instability as well as stability

What is Instability?

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Stanmore Triangle

• TYPE I; True TUBS (Traumatic Unidirectional Bankart treated Surgically)

• TYPE II; TRUE AMBRII (AtraumaticMultidirectional Bilateral Rehabilitation, Inferior capsular shift

closure of rotator Interval)

• TYPE III; Muscle patterning

Management

Type III (pure muscle patterning)

• Muscle strengthening will REINFORCE patterning

• Need biofeedback

Type I or Type II

• No muscle patterning

• Muscle imbalance secondary to selective weakness

• Increased Pec Maj & Lat Dorsi activity can result in GHJ translation (Labriola et al., 2005; Malone et al., 2006; Konrad et al., 2006)

• Lat Dorsi produces posterior instability

• Pec Maj produces anterior instability (Jaggi 2010)

• RC may have direction-specific recruitment pattern (Wattanaprakornkul et al., 2011)

• Inappropriate activation of Pec Maj & Infraspin in MDI (Barden et al., 2005)

Muscle Activation

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What Exercises Do You See In The Gym..?

Prevalence (Malone, et al., 2004)

• Inappropriate PEC MAJ activity in 73% anterior instability

• Inappropriate LAT and ANT DELTOID activity in 72% posterior instability (with infraspinatus suppression in 19%)

• Symptomatic improvements was achieved in 76% with ANTERIOR instability (no previous surgery-53% previous surgery). Posterior instability eliminated in 85%

MOTOR CONTROL NORMALS

• RC force couples appear to play a role in setting “stiffness” of joint prior to movement

• Stiffness is the ability of something to resist movement

• Important in protection & injury risk mitigation

Hess (2005); HunterDavid (2000);

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EMS In Anterior Instability



TYPE IIIInstability

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Derby Stability Programme


Stiffening

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Stiffening

It’s Child’s play

Forward Flexion

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Muscle Onset Timing

It’s NOT All About Strength



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Post-op Rehabilitation Following Instability of the Shoulder

Dr Ian Horsley PhD MCSP

Stanmore Triangle (Lewis et al, 2004)

Polar Type I

Polar Type IIPolar Type III

TUBS (Torn Loose)*

•Traumatic aetiology

•Unidirectional instability

•Bankart lesion is the pathology

•Surgery is required

AMBRI (Born Loose)*

•Atraumatic: minor trauma

•Multidirectional instability

•Bilateral:

•Rehabilitation ideally

•Inferior capsular shift: surgery

Somatosensation

• Mechanoeceptors (touch, pressure,stretch,vibration)

• Chemoreceptors

• Thermoreceptors (heat/cold)

• (Nociceptors)

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Somatosensation

Generates neural impulses thatcontrol the executionof movement based

on responses to inputsFrom our environment

Internal “conductor" that can preciselyregulate the sequence and duration of the fundamental movements of each of thesesegments

Motor Control

Proprioception

First

• Acquisition of mechanical stimulus

Second

• Conversion of mechanical stimulus into neural signal

Third

• Transmission of neural signal to the CNS

(Lephart & Fu, 2000)

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Ligaments & Capsule = Proprioceptors

• Individuals lacking proprioception have demonstrated an inability to perform multi-joint movements, suggesting that deficits in JPS may detrimentally effect the coordinated movements at the other joints in the kinetic chain

• (Riemann and Lephart, 2002)

Max IR Max ER

InnerRange

MidRange

OuterRange

GTOMechanoreceptor

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Max IR Max ER

InnerRange

MidRange

OuterRange

GTOMechanoreceptor

Post Intervention

ASSESSMENT OF CONTROL- Do You Do It?

• Monitoring Proprioception (Kinaesthesia - detecting the onset of motion & JPS (active & passive) - Nyland et al (1998)

• Observation / Palpation of muscle tonal changes & dynamic postural alignment (Balance Point)

• JPS objective measures - JAR / CLAM / 4 POINT

• Dynamic Rotary Stability Test (DRST) - Magarey (2003)

• Balance Performance & Postural Sway

• Dynamic EMG (Malone 2006)

TTDPMBalance Point

JAR

Assessment of Proprioception

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Proprioception Construct

Detection Organ Strengths Limitations

Active Joint Reposition

• Muscle Spindle• Skin Stretch (Ruffini)

• Joint Limit Detectors

• Functional• No external stimulus

• ? Pain limitation• Needs kinaesthetic

memory• Requires optimal

motor control

Passive Joint Reposition

• Muscle Spindle• Skin Stretch (Ruffini)• Joint Limit Detectors

• Does not require active control

• Possible addedsensory input

from passive device• Needs kinaesthetic

memory

Passive Threshold Detection

• Muscle spindle• Skin mechano

Receptors• Joint Limit Detectors

• Does not requireworking memory

• Thresholds higher for slower movements

Passive Motion Direction Detection

• Muscle spindle• Skin mechano-

receptors• Joint Limit Detectors

• Detect motion AND direction

• Dichotomous therefore 50% chance of guessing correct

Balance Point Test

• Isometric hold @ 90 degrees abduction target angle- humeral head centring ( arm passively positioned

• Active movement through abduction/adduction in frontal plane

• Active reproduction of 90 degree abduction target angle

Assessment of JPS (@100cm)

• 0-4cm error is considered excellent

• 4-8cm error is considered good

• 8-12cm error is considered fair / normal

• Greater than 12cm error is considered poor

Balke et al., 2011

Following shoulder dislocation, proprioception deficit evident at 55o and 135o,abduction not evident at 90o

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Clinical Interventions To Improve Proprioception (Clark et al., 2015)

Braces Taping

Tactile acuity and body schema integrity scorescorrelated with superior performance in ULstability task (Botnmark et al., 2016)

Manual Therapy

Exercise Therapy

Use External Focus cues – attention is drawn toExternal object/mental image away from the shoulder-“touch my hand”

Force Sense Training

CLAM

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Coordination Training Muscle Performance Training

Balance/Unstable Training

SLOSH PIPE

Plyometric Training Rhythmic Stabilization

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SummaryExercise type Exercise

Active joint repositioning (JPS) training ±visual feedback

OKC and CKC shoulder repositioning todifferent points in ROM

Path-of-motion (kinesthesia) training Tracing patterns with laser-pointer

Force sense training Force and effort perception training at set level

Co-ordination training Kinetic Chain

Muscle performance training Isometirc/isotonic/concentric/eccentirc

Balance/unstable surface training CKC on labile surface/OKC with body blade

Plyometric training Clapping press-upsBall throwing/catching against mini-trampoline

Vibration training Push-ups on vibration platform

Shoulder Pain Continuum

Mobility Deficit Stability Deficits

WeakAdhesive Capsulitis GH Instability


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Rebound tennis.mov

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Frozen Shoulder; Do We Have Cold, Hard Facts?


A Rose By Any Other Name…

• Frozen shoulder

• Painful stiff shoulder

• Periarthritis

• Adhesive capsulitis

Prevalence

• Estimated to affect 2% to 5% of the general population

• 20% of diabetics

(Anton1993;Lundberg1969)

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Location Of The Pain

BESS/BOA Patient Care Pathway; Frozen Shoulder

www.njorthclinic.com

Classification

Primary Frozen Shoulder

• Idiopathic

Secondary Frozen Shoulder

• Post Surgery

• Post Stroke

• Post Injury

• Diabetes

• Hyperthyroidism

• Metabolic syndrome

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Differential Diagnosis

• Osteoarthritis (age?)

• Missed posterior dislocation

• Large posterior labral tear

• LHB

• Avascular necrosis

• Tuberculosis

• Metastatic disease

• Bursitis

• RC Pathology

Diagnosis

• Loss of BOTH active and passive movement

• Initially ER in dependent position

• Capsular pattern of Cyriax?

Anatomy of the GHJ

• Intraarticular volume decreases from 15-35cc to 5-6cc (Lundberg,1969)

• Thickening & Fibrosis Rotator Interval

• Contraction& Fibrosis of GHL

• Contraction of IGHL

• Neovascularity

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Capsule

• Allows for 2-3 mm of distraction

• Little contribution to joint stability

• Strengthened by GH ligaments and RC tendons

• Rotator interval• between SGHL and MGHL

(includes CHL &SGHL- resists inferior translation

Effects of Tightening SGHL/CHL

• Increased ant + sup translation with flexion

• Decreased inferior translation @ 0 degrees

• Decreased anterior translation @ 0 degrees

• Decreased posterior translation @ 0 degrees in Flexion/60 degrees Ab/ER

• Humeral Head sits anterosuperiorly

• Small loss of ER @0 degrees

Consideration (Hollman et al., 2018)

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Is It A Motor Control Problem?

• 5 patients with a diagnosis of Frozen Shoulder (51- 64 years )

• Pre-Op ER decreased

• Pre-Op abduction decreased

• Reassessed ER & Abduction post anesthetic

(Hollman et al., 2018)

1 2 3 4 5

pre anaesthesia

47o 70o 53o 90o 63o

post anaesthesia

152o 153o 164o 144o 116o

ROM increase (%)

105o

(223)83o

(119)111o

(209)54o

(60)53o

(84)

Is It A Motor Control Problem?

Rehab Suggestions

• Restore normal muscle recruitment patterns (Motor Control)

• Low load control-> increased load

• Switch muscles off rather than on

• Teach eccentric work

• Normalize breathing

• Consider CBT

Roleroid Injections

• Possible short-term benefit from adding a single intra-articular steroid injection to home exercise for patients with primary Frozen Shoulder of less than 6 months (Maund et al., 2012)

• Injection into the Sub Acromial Space was inferior to intra articular injection @ 12 weeks

• Combination of both injections had an additive effect on increasing ROM IR(C.-H.Cho et al.2016)

Role Of Corticosteriod Injections

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Hydrodilatation/Capsular Release

WWW.shoulderdoc.co.uk

(Buchbinder et al., 2004)

Post Release Considerations

(Paxton et al., 2013)

Nerve Anatomy Differential Diagnosis Clinical Presentation Mechanism Of Injury Sport Associated Injury

Spinal Accessory Nerve (CN XI)

TrapeziusSCM

• Cervical nerve root avulsion

• Long thoracic nerve palsy

• Drooping Shoulder• Overhead weakness• Persistent Ache Post

shoulder/Arm

• Traction• Fall onto Point of

shoulder

WrestlingRugby

Suprascapular Nerve C5,6SupraspinatusInfraspinatus

• SAIS• Rotator cuff

pathology• C5–6 radiculopathy

• Poorly localisedvague Posterior shoulder pain• Weakness abd• Weakness ER

• Traction• Downward

ScapularRotation• Cross Body Addn• Repeated ABER

Baseball, Basketball Cycling ,Weight lifting Tennis, Throwing, Volleyball, Gymnastics, Racquetball

Axillary Nerve C5,6Teres MinorDeltoid

• Glenohumeralfracture/dislocation

• SAIS• Rotator Cuff tear

• Weak Abduction• Weak ER• Sensation Loss

regimental badge area

• Anterior Dislocation• Quadrilateral Space

syndrome *• FOOSH

• Contact Sports• Overhead Throwing

Musculocutaneous Nerve C 5,6,7

BicepsBrachialisCoracobrachialis

• Ruptured distal biceps

• Weakness elbow flexion

• Wasting biceps & brachialis

• Direct trauma ant shoulder

• Fractures of humerus/ clavicle

• Anterior shoulder dislocations

• FOOSH

• Contact Sports• Overhead Throwing

Long Thoracic Nerve C 5,6,7Serratus Anterior

• Trapezius paralysis• Brachial plexus

lesions• Posterior shoulder

instability

• Scapula dyskinesis • Secondary to asynchronous motion arm and scapula.

• Golf• Tennis• Volleyball• Contact sports

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Quality Movement Vs Quantity Movement

Proprioception Kinetic Chain

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50%

30%

20%

• Hip joint• Knee joint• Ankle joint• 1st MTPJ• Glutes• Hip flexors

• Thoracic spine• Breathing• Abdominals• Lats

• Scapular position• Scapular stabilizers• RC• SCJ• GHJ ROM• Strength???

JOINT REQUIREMENT

Ankle Mobility

Knee Stability

Hip Mobility

Lumbar Spine Stability

Thoracic Spine Mobility

Scapula Stability

Glenohumeral Mobility

The Kinetic Chain

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Effect of fatigue on shoulder rotation velocity during overhead throwing (Alex Wolf)

Rotation Non Fatigue Fatigue Difference % DifferenceExternal 4000 °/s 6000 °/s 2000 °/s 50% ↑Internal 6000 °/s 10000 °/s 4000 °/s 66% ↑

Internal Rotation

External Rotation

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Effect of fatigue on shoulder rotation ROM during overhead throwing

1.2.

3.

Rotation Non Fatigue Fatigue Difference % DifferenceP1. 118° 107° 11° 9.32

P2. (max ER) 140° 136° 4° 2.86P3. (max IR) -133° -130° -3° 2.26

Internal Rotation

External Rotation

Under fatigue the throwing shoulder:• decreases total ROM• Increases velocity

• More load through smaller range

• Potential increase risk of injury?

Low Tech Assessment QASLS (adapted from Herrington et al., 2013)

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Sagittal Control Coronal ControlTransverse Control

Kibler et al

SINGLE LEG STEP DOWN

• Participant stands on a 30cm box

• Instructed to step off the box onto a mark, 30cm from the box and 5cm on the contra-lateral side to the mid line

Landing Error Scoring System Item

Operational Definition of Error Scoring

Knee flexion: initial contact The knee is flexed less than 30° at initial contact.

Hip flexion: initial contact The thigh is in l ine with the trunk at initial contact.

Trunk flexion: initial contact The trunk is vertical or extended on the hips at initial contact.

Ankle plantar flexion: initial contact

The foot lands heel to toe or with a flat foot at initial contact.

Medial knee position: initial contact

The centre of the patella is medial to the midfoot at initial contact.

Lateral trunk flexion: initial contact

The midline of the trunk is flexed to the left or the right side of the body at initial contact

Stance width: wide The feet are positioned greater than shoulder width apart at initial contact.

Stance width: narrow The feet are positioned less than shoulder width apart at initial contact.

Foot position: external rotation

The foot is externally rotated more than 30° between initial contact and maximum knee flexion.

Foot position: internal rotation

The foot is internally rotated more than 30° between initial contact and maximum knee flexion.

Symmetric initial foot contact: initial contact

One foot lands before the other foot or 1 foot lands heel to toe and the other foot lands toe to heel.

Knee-flexion displacement The knee flexes less than 45° between initial contact and maximum knee flexion.

Hip-flexion displacement The thigh does not flex more on the trunk between initial contact and maximum knee flexion.

Trunk-flexion displacement The trunk does not flex more between initial contact and maximum knee flexion.

Medial knee displacement At the point of maximum medial knee position, the center of the patella is medial to the midfoot.

Joint displacement the participant demonstrates a large amount of trunk, hip, and knee displacement.

Overall impression Stiff: the participant goes through very l ittle, if any, trunk, hip, and knee displacement.

Excellent: the participant displays a soft landing with no frontal-plane or transverse-plane motion.

DROP JUMP LANDING

• Participant stands on a 30cm box

• Jump two footed off the box landing with feet either side of a line 30cm from the box

• Immediately attempt to undertake a maximum vertical jump reaching up to touch a target held above the line

Landing Error Scoring System Item

Operational Definition of Error Scoring

Knee flexion: initial contact The knee is flexed less than 30° at initial contact.

Hip flexion: initial contact The thigh is in l ine with the trunk at initial contact.

Trunk flexion: initial contact The trunk is vertical or extended on the hips at initial contact.

Ankle plantar flexion: initial contact

The foot lands heel to toe or with a flat foot at initial contact.

Medial knee position: initial contact

The centre of the patella is medial to the midfoot at initial contact.

Lateral trunk flexion: initial contact

The midline of the trunk is flexed to the left or the right side of the body at initial contact

Stance width: wide The feet are positioned greater than shoulder width apart at initial contact.

Stance width: narrow The feet are positioned less than shoulder width apart at initial contact.

Foot position: external rotation

The foot is externally rotated more than 30° between initial contact and maximum knee flexion.

Foot position: internal rotation

The foot is internally rotated more than 30° between initial contact and maximum knee flexion.

Symmetric initial foot contact: initial contact

One foot lands before the other foot or 1 foot lands heel to toe and the other foot lands toe to heel.

Knee-flexion displacement The knee flexes less than 45° between initial contact and maximum knee flexion.

Hip-flexion displacement The thigh does not flex more on the trunk between initial contact and maximum knee flexion.

Trunk-flexion displacement The trunk does not flex more between initial contact and maximum knee flexion.

Medial knee displacement At the point of maximum medial knee position, the center of the patella is medial to the midfoot.

Joint displacement the participant demonstrates a large amount of trunk, hip, and knee displacement.

Overall impression Stiff: the participant goes through very l ittle, if any, trunk, hip, and knee displacement.

Excellent: the participant displays a soft landing with no frontal-plane or transverse-plane motion.

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Tuck Jump1. Knee valgus on landing

- Hip, knee and foot aligned, no collapse of the knee inwards

2. Thighs not reaching parallel (peak of jump)

3. Thighs not equal side to side (during flight)

4. . Foot placement not shoulder width apart-Inside of tape marks

5. Foot placement not parallel (front to back)

6. Foot contact timing not equal- Asymmetrical landing

7. Does not land in same foot print-Consistent point of landing

8. Excessive landing contact noise

9. Pause between jumps

10. Technique declines prior to 10 seconds

1. Knee valgus on landing- Hip, knee and foot aligned, no collapse of the knee

inwards

2. Thighs not reaching parallel (peak of jump)

3. Thighs not equal side to side (during flight)

4. . Foot placement not shoulder width apart-Inside of tape marks

5. Foot placement not parallel (front to back)

6. Foot contact timing not equal- Asymmetrical landing

7. Does not land in same foot print-Consistent point of landing

8. Excessive landing contact noise

9. Pause between jumps

10. Technique declines prior to 10 seconds


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THORACIC SPINE & RIBS

UL injury associated with low trunk rotation ROM(Aragon et al.,2012)

28% lower risk of shoulder injuries when T mobility in programme(Andersson et al.,2016)

Scapula and Thoracic Spine Link

• Scapula can only posteriorly rotate if there is thoracic extension

• Scapula can only externally rotate if there is thoracic rotation

• Thoracic extension is phase-locked to upward rotation of the scapulothoracic joint (Crosby et al,2010)

• Thoracic extension supports posterior rotation of the scapula during shoulder elevation (Kebaetse et al 1999)

• Posterior tilt is also linked to recruitment serratus anterior and the lower trapezius (Ludewig & Braman,2011)

• Thoracic mobility also facilitates recruitment of these muscles (Yamauchi t al, 2015)

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Seated T spine Rotation in front

• Stick across collar bone arms folded

• ** feet on floor touching and small ball between knees


Thoracic Extension Screening (Howe & Read, 2015)

Bilateral Shoulder Elevation Test

Occiput -To -Wall Test

Increase Thoracic ExtensionThrough Extension Mobilization

Increase Functionally RequiredThoracic Extension

Limited Thoracic Extension

Limited Thoracic Extension Capacity

Sufficient Thoracic Extension

SCREENING

INTERVENTION

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Thoracic COMBINED ELEVATION TEST(Dennis et al, 2008)

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Assessment of Rotation

THORACIC SPINE PROCEDURE

THORACIC SPINE PROCEDURE

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T spine mob with towel fixation_NEW.avi

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Thoracic Wall Movement

Diaphragm, external intercostals, levatores costarum Sternocleidomastoid and the scalenes.

Bucket Handle Pump Handle

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Upper Body Motion Limitations

1. Poor Diaphragm PositionWide Infrasternal AngleInsufficient EAOOveractive IAOOveractive Pec MajDiaphragm Descended

2. Limited Upper Chest Breathing AbilityNarrow Infrasternal AngleRibs StraightDiaphragm DescendedOveractive EAOInhibited IAOInhibited Trans Ab

3. Limited Upper Back Breathing AbilitySternum (pump handle) DownFlat ChestNo Abdominal Tone

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Upper Body Motion Limitations• Poor Diaphragm Position

Wide Infrasternal AngleInsufficient EAOOveractive IAOOveractive Pec MajDiaphragm Descended

• Limited Upper Chest Breathing AbilityNarrow Infrasternal AngleRibs StraightDiaphragm DescendedOveractive EAOInhibited IAOInhibited Trans Ab

• Limited Upper Back Breathing AbilitySternum (pump handle) DownFlat ChestNo Abdominal Tone



The Sternoclavicular Joint- Assessment and Rehabilitation of this Often Ignored Joint

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Introduction• The SCJ is the only true

joint connecting the upper limb to the axial skeleton.

• Least constricted joint in the human body

• Scapulothoracic (ST) motion results in motion at the ACJ/SCJ

• Abnormal ST motion MUST be associated with abnormal motion at one or both SCJ/ACJ

(Van Tongel at al., 2012;Dvir & Berme, 1978; Inman et al., 1944)

https://www.verywellhealth.com

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(Negri et al., 2014)

With Permission

Movement At The SCJ

Non Traumatic SCJ Pain and Swelling

ExaminationPain, Swelling ErythemaSkin ChangeOther Joint Abnormalities

OsteoathritisMost Common Pathology

InflammatorySeropositiveRheumatoid Arthritis

SeronegativeASReiter’s SyndromePsoriatic Arthritis

Septic CrystalGoutPseudogout

OtherFreidrick’s DiseaseCondensing OsteitisSAPHOEwing sarcoma (1o)Squamous cellcarcinoma/

adenocarcinoma(2o)

Adapted from Robinson et al; 2008

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cConditions Demographics Clinical/Lab Findings Radiological

Features

Systemic Arthritis

Osteoarthritis >50 YOA Normal OA changes

Rheumatoid Arthritis Women any age

? Rh +ve Normal/erosion

Seronegative Spondyloarthropathies

Men <40 YOA +ve HLA-B27 Normal/erosion

Crystal Arthropathies Men >40 YOA Joint fluidElevated ESR (acute)

? Secondary OA changes. Soft tissue calcification

Infective Conditions

Septic Arthritis/Osteomyelitis

Any age Systemic signs+ve Blood tests

Associated periosteal changes

Joint Specific Conditions

SAPHO Syndrome Middle aged adults

Skin changesESR/CRP mildly elevated

Erosive changesOssification of ligament insertionsAdapted from Robinson et al; 2008

The Clever Clavicle

Traumatic Mechanism

• Direct - force applied to the medial aspect of the clavicle forces it posteriorly (i.e., MVC or when one athlete falls on top of another)

• Indirect - force applied to the shoulder and is transmitted medially

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Signs and Symptoms

• Tenderness to palpation(Van Tongel et al., 2014)

• Local swelling (Buckler, 1955)

• Localised pain with elevation above 100o (Van Tongel et al., 2014)

• Pain with active protraction and retraction (Van Tongel et al., 2014)

Protraction-Retraction (Van Togel et al.,

2014)

SCJ Referral

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Anatomy of SCJ

Lee et al 2014

Wikipedia

Surface Marking

Sternal Angle

Motions Occurring At The SCJ

• Elevation

• Depression

• Protrusion

• Retraction

• Upward and downward rotation

(Dempster, 1965)

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Clavicle Posterior Rotation

Flexion Scaption

Ludewig et al., 2004

ROM ROM

Biomechanics

• Movements of the SCJ must either result in scapular motion on the thorax or be offset by motion at the ACJ

• Posterior clavicular rotation should occur with scapular posterior tilting(Ludewig et al, 2004)

• Protraction/retraction of clavicle should occur with scapular internal/external rotation (Inman et al,1944) Ludewig & Borstad, 2003

Scapular Motion With Elevation

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Biomechanics of SCJ

Protraction Elevation PosteriorRotation

Ludewig & Reynolds., 2009

Must relate to meaningful task

Relevance..?

▪ Clavicle motion @ SCJ▪ Elevation 35o

▪ Protraction/Retraction 35o (Iannotti& Williams ,1999)

▪ Post rotation 45-50o (Ludewig et al.,2004)

• Centre of rotation- prox 1/3 clavicle▪ Small proximal movement, big

distal movement

▪ Small proximal restriction, bigger limitation of distal movement

Considerations In Dysfunctional SC Joint

Articular

• Hypomobile (“stiff” joint)

• Hypermobile (“lax” joint)

• First rib position

Myofascial

• Subclavius

• SCM

• Scaleni

Tends to be Hypomobile without trauma

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Assessment of SCJ

Mobility- Distraction

Assessment of Posterior Glide

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Inferior Glide Assessment

Assessment of Posterior Rotation

SUBCLAVIUS Anatomy

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Sub Clavius Release

First Rib Positional Assessment

Elevation ComparisonRotation-Side flexion

Elevated First Rib MET

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Anterior Scalene

www. Physio-pedia.com

Middle Scalene

www. Physio-pedia.com

Scalene TestsScalene Cramp Test Scalene Relief Test

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Sternocleidomastoid

• Fix shoulder girdle

• Retract cervical spine

• Side flex cervical spine away

• Rotate cervical spine towards

Check Breathing Mechanics

Manual Therapy

Improve Inferior Glide

Find part in range where pain provokedCan mobilize at that positionOr make it an MET

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Treatment To Improve Posterior Glide

Treatment To Improve Posterior Rotation


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Functional Tests/ Physical Performance Tests

• Assessment tools to “closely simulate a given sport or activity” (Reiman & Manske, 2009)

• Athlete performs an activity that represents some aspects of the athletic function such as stability, strength, or power(Hegedus et al., 2015)

Seated Medicine Ball Throw (SMBT)

• Sit on the floor with the head, shoulder and back against the wall

• Legs extended

• 2 kg medicine ball held with both arms in 90 ° of shoulder abduction and elbows flexed

• Throw the medicine ball forward in a straight line and as far as possible

• Head, shoulders and back maintaining full wall contact

Functional Tests

One Arm Hop Test CKCUEST

• 5 times as quickly as possible onto10.2cm step

• Within 6 seconds• Dominant limb has been

shown to complete the test 4.4% faster than the non-dominant limb

1) Number of touches score: number of touches in 15seconds.

2) Normalized score; 1)/subject height 3) Power score: the average number of touches X 68%

of subject’s body weight in kilograms

MDC for CKUEST• Between 2 and 4• Scoring less than 21 touches increased the

likelihood of a shoulder injury during thefootball season

• Range 18-28 touches

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CKCUEST (Goldbeck et al., 2000)

CKCUEST

• Has high test-retest reliability, with an intraclass correlation coefficient of 0.922

• Correlates to rotator cuff strength measured using a handheld dynamometer (both elevation and internal rotation).

• Quick and easy to administer

• Tests in a closed kinetic chain position

• Normative values; MEN:18.5 touches, FEMALES:20.5 touches

Now Here’s The Science…

Score = Average number of lines touchedHeight (inches)

Power = 68% BW x average No lines touched15 seconds

UQ YBT

• Reach in medial/inferolateral & superolateral directions WRT supporting hand without resting

• Maintain balance on one hand• Cannot lift/move balance hand from

platform• Cannot touch down with reach hand• Return reach hand to starting point• Do not shove target (must keep in

contact)• Measure from C7 Sp – tip of longest

finger• With shoulder 90 degrees abduction

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Composite Reach Distance

• (Medial + Inferolateral +Superolat Superolateral) x1003x Limb length

• Right v Left asymmetry of 4cm or greater

• Composite score comparable for similar cohort

• Measure of progression

Overall Test Performance

Upper Limb Rotation Test (DeCleve et al., 2020)

• Modified (on elbows) push-up position

• Elbows flexed at 90o

• Feet shoulder width apart• Shoulder, the elbow epicondyle,

the greater trochanter and the lateral malleolus of the ankle to touch the wall

• As quickly as possible for 15 seconds.

• 45 seconds rest• Repeat 3 times

Shoulder Arm Return To Sport Test (SARTS) (Olds et al, 2019)


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Shoulder Endurance Test (De Cleve)


Concept of Causality

• A cause of a disease is an event, condition, characteristic, or combination of these factors which plays an important role in producing the condition.

• A cause could be sufficient or necessary

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Causality

SUFFICIENT CAUSE

• …sufficient when it inevitably/certainly produces or initiates condition

• Usually a single factor, but often comprises several components

• Not necessary to identify all the components before effective prevention can take place

NECESSARY CAUSE

• …if a component cannot develop in its absence

www.schoolofcalisthenics.com

The Framework

The Framework- Movement

Preparation• Prepare the body for high

quality movement

Patterning• Teach the body to move in new

ways by developing new motor patterns in an environment that is conducive for learning

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Lack of uniformity In

DiagnosticLabelling

ControversialInterpretation of

DiagnosticImaging

UntrustworthinessOf

DiagnosticTests

Non CorrelationBetween PainAnd Structural

Factors

“Effortless Movement”

Summary

• Act local- think global

• Manage pain

• Be pedantic with movement

• Think kinetic chain (always check single leg squat quality)

• Look at starting position (scapular resting position)

• Look for effortless movement

• PROPRIOCEPTION

• Don’t panic !!!

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Horses For Courses

Thank You For Your [email protected]@back-in-action

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mailto:[email protected]

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