posterior shoulder impingement rehab

Stage: hallmarked by the complaint of pain during the late cocking phase of the throwing cycle. Questions regarding the progress In all types of impingement listed above, scapular dysfunction either can be the underlying cause or can greatly exacerbate the impingement process with altered scapular kinematics in patients with both rotator cuff instability and impingement.2426 Initial rehabilitation begins with the protection of the rotator cuff from stress but not function. To further illustrate the role of ROM and passive stretching during this phase of the rehabilitation, Figures 15 and 16 show versions of clinical IR stretching positions that utilize the scapular plane and can be performed in multiple and varied positions of glenohumeral abduction. default A large spectrum of mobility can be encountered when treating the patient with glenohumeral impingement. While shoulder impingement can be painful and affect your daily activities, most people make a full recovery within a few months. In many cases, youll just need some rest and physical therapy. If those dont provide relief, you may need surgery, which can add a few months to your recovery time. shoulder internal impingement non-operative guidelines The following internal impingement guidelines were developed by HSS Rehabilitation and are categorized into five phases with the Paley et al22 also published a series on arthroscopic evaluation of the dominant shoulder of 41 professional throwing athletes. Your doctor may recommend non-operative or operative treatments to treat internal impingement of the shoulder. First, non-operative interventions are recommended such as: Cessation from throwing and resting your shoulder until the pain is controlled. Additionally, Crockett et al45 have shown unilateral increases in humeral retroversion in throwing athletes, which would explain the increase in ER with accompanying IR loss. In the grading technique designed by Altchek,37 grade I is considered normal motion within the glenoid (typically 8 to 10 mm38), and a grade II translation is when the clinician-guided stress produces movement of the humeral head over the glenoid rim posteriorly with relocation of the humeral head into the glenoid when stress is removed. Dines JS, Frank JB, Akerman M, Yocum LA. position of 90 degrees of ER and 90 degrees of abduction. The typical age range for this stage of injury is 25 to 40 years. With the arthroscope inserted in the glenohumeral joint, they found that 41 out of 41 dominant shoulders evaluated had posterior undersurface impingement between the rotator cuff and posterior superior glenoid. As the arm elevates the humeral head shifts posteriorly and when these structures are tight ( teres minor, infraspinatus, posterior capsule) the humeral head compresses them into the fossa, causing pain.TRY THIS:The sleeper stretch is essentially a static stretch into internal rotation, while the gelnohumeral joint is being compressed by bodyweight. 3 Rehabilitation of Macro-Instability Primary impingement, also known as compressive disease or outlet impingement, is a direct result of compression of the rotator cuff tendons between the humeral head and the overlying anterior third of the acromion, cora-coacromial ligament, coracoid, or acromial-clavicular joint.1,2 The physiologic space between the inferior acromion and superior surface of the rotator cuff tendons is termed the subacromial space. hbbd``b`$V m@$`I,] .{D0)be y "$R$@ O@"Hf`bd|``ak 6] Total Rotation Range-of-Motion Concept Note: All measurements are expressed in degrees.ER, external rotation; IR, internal rotation; SEM, standard error of the mean. 12) can be initiated to provide muscular co-contraction in a functional position. Recent research has compared the effects of the cross-arm stretch to the sleeper stretch in a population of recreational athletes, some with significant glenohumeral IR range of motion deficiency.56 Four weeks of stretching produced significantly greater IR gains in the group performing the cross-body stretch as compared with the sleeper stretch. The development of the concept that impingement could occur secondary to instability, rather than as a primary cause, has had significant ramifications altering evaluation methods and treatment/rehabilitation.15,16 A very common pathology in overhead-throwing athletes is posterior shoulder pain resulting from internal impingement. Initial Phase Indications for Treatment: Subacromial impingement with rotator cuff tendinopathy is a very common condition adobe:docid:indd:d426ab4c-3564-11de-9476-80770b4263da fraying of posterior rotator cuff (supraspinatus-infraspinatus interval) posterior and superior labral lesions. If the sciatic nerve is involved, then neuropathic symptoms may present down the posterior leg. Biomechanical analysis of the shoulder has produced theoretical estimates of the compressive forces against the acromion with elevation of the shoulder. Primary Impingement or Compressive Disease Neers stage III impingement lesion, termed bone spurs and tendon rupture, is the result of continued mechanical compression of the rotator cuff tendons. The second important test to determine the presence of IR ROM limitation is the assessment of physiological ROM. Figure 11(A, B) Manual scapular stabilization in sidelying position for scapular retraction (A), and protraction (B). 513 0 obj <>stream xmp.did:048011740720681188C6C22164859945 Patients presenting with a limitation in IR ROM who have grade II translation should not have posterior glide accessory techniques applied to increase IR ROM due to the hyper-mobility of the posterior capsule made evident during this important passive clinical test. hypertrophy and adobe:docid:indd:d426ab4c-3564-11de-9476-80770b4263da Questions regarding the progress of endstream endobj startxref Bilateral comparison of IR ROM is taken with careful interpretation of isolated glenohumeral motion. nonsurgical treatment for shoulder impingement. Figure 12 Rhythmic stabilization performed with scapular protraction. One rather consistent finding present during the examination of the overhead athlete is increased dominant arm ER as well as reduced dominant arm glenohumeral joint IR.33,4143 I have found that this relationship is only identified under conditions where the glenohumeral joint rotation was measured with the scapula stabilized.44 Failure to stabilize the scapula may not produce glenohumeral joint IR ROM limitations even though they are present, possibly due to scapular compensation. First, non-operative interventions are recommended such as: Cessation from throwing and resting your shoulder until the pain is controlled. In contrast, we tested 117 elite male junior tennis players.33 In these tennis players, significantly less IR ROM was found on the dominant arm (45 degrees versus 56 degrees), as well as significantly less total rotation ROM on the dominant arm (149 degrees versus 158 degrees). The examiner is careful to utilize a posterolaterally directed force (in the direction of the arrow) along the line of the glenohumeral joint. Lucas7 estimated this force at 10.2 times the weight of the arm. Several proposed mechanisms have been discussed attempting to explain this glenohumeral ROM relationship of increased ER and limited IR.33,45,46The tightness of the posterior capsule as well as the muscle tendon unit of the posterior rotator cuff has been believed to limit internal glenohumeral joint rotation. Evaluation and treatment of internal impingement of the shoulder in overhead athletes. With a regular routine of these three stretches (#24), you can improve your thoracic mobility and promote better posturecrucial for combating the pain of shoulder impingement. To determine the tightness of the posterior glenohumeral joint capsule, an accessory mobility technique to assess the mobility of the humeral head relative to the glenoid is recommended. 6 Classification and Treatment of Scapular Pathology Adobe PDF Library 15.0 This is meant to be held for a longer period of time so the inert posterior capsule can also make the appropriate changes.Visit our website: http://themuscledoc.com/Check out my Tweets: https://twitter.com/the_muscle_docLike us on Facebook: https://www.facebook.com/themuscledoc/Follwow me on Instagram: https://www.instagram.com/the_muscle_doc/Check out our videos: https://www.youtube.com/channel/UCzXqjJB345oP7LqrTUB52XQCome see us at: The Muslce Doc241 Polaris Avenue,Mountain View CA, 24043P: (408) 966-7690 A key technique in the early management of rotator cuff impingement is scapular stabilization. 487 0 obj <> endobj The Biceps Tendon: A mistreated and misunderstood friend, Robotic Joint Center | Partial & Total Knee Replacement, shoulder fitness and rehab videos with over 20 different exercises to strengthen your shoulder, Book a Physical Therapy Appointment (Online). You may also view our shoulder fitness and rehab videos with over 20 different exercises to strengthen your shoulder. The posterior deltoids angle of pull compresses the humeral head against the glenoid, accentuating the skeletal, tendinous, and labral lesions. xmp.id:7fce4b75-b173-4b39-b5eb-6a3a0a8d4c3c It should be pointed out that incorrect use of this posterior glide assessment technique may lead to the false identification of posterior capsular tightness. Posterior Impingement Test | Internal Impingement. Neers Stages of Impingement Rehabilitation ofSpecific Shoulder Pathologies Stage Iedema and hemorrhageresults from the mechanical irritation of the tendon; this is caused by impingement incurred from overhead activity. Phase I Protection Phase (weeks 0-4): Review videos for shoulder immobilizer and passive ROM (Codmans pendulum, passive flexion). 0 Bennett described a posterior shoulder pain syndrome in baseball pitchers related to the repetitive traction of the posterior capsule and triceps tendon.7 Walch et al described the posterosuperior impingement (PSI) for the first time in 19928 and emphasised HWnH}G i):x'^KI{_IbL [O;}7iYt~3M69Mo(chcx4Mz}o0ooA3thrOFsNimR:_.>S T2Pk;k4]?t~}uL3tb1} #covZG40}Lv^}tKs|']dz5l]7Ia2#AXh*[v|ZfdL_ieRpS!(]*(]|Tuk Phase I - Maximal Protection Acute Phase Goals: Relieve pain and inflammation Normalize range of motion . Research by Kibler et al47 and Roetert et al48 has identified decreases in the total rotation ROM arc in the dominant extremity of elite tennis players correlated with increasing age and number of competitive years of play. This occurs from repeated episodes of mechanical inflammation and can include thickening or fibrosis of the subacromial bursae. Burkhart et al34 have termed this IR loss GIRD-glenohumeral internal rotation deficitand define it as a loss of internal rotation of 20 degrees or more compared with the contralateral side. Range-of-Motion Exercises. Rehabilitation of Rotator Cuff ImpingementInitial PhaseTotal Rotation Range-of-Motion ConceptTotal Arm Strength PhaseDischarge Considerations Stage Iedema and hemorrhageresults from the mechanical irritation of the tendon; this is caused by impingement incurred from overhead activity. "&fJiv@A" ,5U Em 388 0 obj <>stream endstream endobj 344 0 obj <. Rotator cuff injury A more severe cause of posterior shoulder pain could be a rotator cuff injury. To determine the tightness of the posterior glenohumeral joint capsule, an accessory mobility technique to assess the mobility of the humeral head relative to the glenoid is recommended. Camp C, Dines D, et al. proof:pdf The position of the shoulder in forward flexion, horizontal adduction, and internal rotation (IR) during the acceleration and follow-through phases of the throwing motion is likely to produce subacromial impingement due to abrasion of the supraspinatus, infraspinatus, or biceps tendon against the overlying structures.9 These data provide scientific rationale for the concept of primary impingement or compressive disease as an etiology of rotator cuff pathology. Anterior Internal Impingement Solem-Bertoft et al28 has shown the importance of scapular retraction posturing by reporting a reduction in the width of the subacromial space when comparing scapular protraction posturing to scapular retraction. Your physical therapist may use manual techniques, such as gentle joint movements, soft-tissue massage, and shoulder stretches to get your shoulder moving properly, so that the tendons and bursa avoid impingement. Solem-Bertoft et al28 has shown the importance of scapular retraction posturing by reporting a reduction in the width of the subacromial space when comparing scapular protraction posturing to scapular retraction. In all types of impingement listed above, scapular dysfunction either can be the underlying cause or can greatly exacerbate the impingement process with altered scapular kinematics in patients with both rotator cuff instability and impingement.2426 Initial rehabilitation begins with the protection of the rotator cuff from stress but not function. Step 3. Additionally, with this technique a protracted scapular position can be utilized to increase the activation of the serratus anterior muscle30,31; several studies have identified decreased muscular activation of this muscle in patients diagnosed with glenohumeral impingement and instability.25,32. Among several other pathologies, calcific tendinopathy of the rotator cuff tendons is frequently observed during the ultrasound examination of patients with painful shoulder. Primary impingement, also known as compressive disease or outlet impingement, is a direct result of compression of the rotator cuff tendons between the humeral head and the overlying anterior third of the acromion, cora-coacromial ligament, coracoid, or acromial-clavicular joint.1,2 The physiologic space between the inferior acromion and superior surface of the rotator cuff tendons is termed the subacromial space. In a series of 10 patients with traditional impingement signs and anterior-based pain presentations, Struhl23 arthroscopically confirmed contact between the fragmented undersurface of the rotator cuff tendons and the anterosuperior labrum during the Hawkins impingement test, viewed from a posterior arthroscopic portal. Halbrecht et al21 has confirmed via magnetic resonance imaging (MRI) that physical contact of the undersurface of the supraspinatus tendon against the posterior-superior glenoid was found in 10 collegiate baseball pitchers when their pitching arm was placed in the position of 90 degrees of ER and 90 degrees of abduction. %PDF-1.5 % Results showed even submaximal contractions increased perfusion during all 1-minute contractions; but they also produced a postcon-traction latent hyperemia following the muscular contraction. Elbow Flares Lie on your back in a comfortable position and put both hands behind your head Stretch the front of your shoulder by letting your elbows drop out to the side, down as close to Observed in younger, more athletic patients, it is a reversible condition with conservative physical therapy. This more-posterior orientation of the tendons aligns them such that the undersurface of the tendons rubs on the posterior-superior glenoid lip and becomes pinched or compressed between the humeral head and the posterosuperior glenoid rim.19 In contrast to patients with traditional outlet impingement (either primary or secondary), the area of the rotator cuff tendon that is involved in posterior or undersurface impingement is the articular side of the rotator cuff tendon. Lucas7 estimated this force at 10.2 times the weight of the arm. 2017-11-09T08:49:39-06:00 Significant advances in basic research in the anatomy and biomechanics of the human shoulder have led to the identification of multiple types of impingement, each with underlying pathomechanical causes. A common error in this exam technique is the use either of the coronal plane for testing or of a straight posteriorly directed force by the examiners hand rather than the recommended posterolateral force. hbbd```b`` "WI[ fH` R1DJ?LAdd\bHYLLA"@$o` - #5. Adobe InDesign CC 13.0 (Macintosh) It is important to use consistent measurement techniques when documenting ROM of glenohumeral joint rotation. One study highlights the importance of early submaximal exercise to increase local blood flow. Specific changes in the program will be made by the physician as appropriate for the individual patient. The posterior deltoids angle of pull compresses the humeral head against the glenoid, accentuating the skeletal, tendinous, and labral lesions.18 Walch et al19 arthroscopically evaluated 17 throwing athletes with shoulder pain during throwing and found undersurface impingement that resulted in eight partial-thickness rotator cuff tears and 12 lesions in the posterosuperior labrum. A number of different theories have been proposed to explain internal impingement. Measured using anteroposterior radiographs, it was 7 to 13 mm in size in patients with shoulder pain3 and 6 to 14 mm in normal shoulders.4 Flatow et al5 have shown that elevation of the humerus leads to predictable and reproducible patterns of subacromial impingement of the rotator cuff tendons against the overlying acromion and coracoacromial ligament. Your doctor may recommend non-operative or operative treatments to treat internal impingement of the shoulder. Several proposed mechanisms have been discussed attempting to explain this glenohumeral ROM relationship of increased ER and limited IR.33,45,46The tightness of the posterior capsule as well as the muscle tendon unit of the posterior rotator cuff has been believed to limit internal glenohumeral joint rotation. Recently, my colleagues and I measured the bilateral total rotation ROM in both professional baseball pitchers and elite junior tennis players.33 Our findings showed the professional baseball pitchers to have greater dominant arm ER and significantly less dominant arm IR when compared with the contralateral nondominant side. Explore all your options. With more-extensive amounts of posterior capsular tightness, the humeral head was found to shift posterosuperiorly. Measured using anteroposterior radiographs, it was 7 to 13 mm in size in patients with shoulder pain3 and 6 to 14 mm in normal shoulders.4 Flatow et al5 have shown that elevation of the humerus leads to predictable and reproducible patterns of subacromial impingement of the rotator cuff tendons against the overlying acromion and coracoacromial ligament. If measurement of that patients nondominant extremity rotation, however, reveals 90 degrees of ER and 60 degrees of internal rotation, the current recommendation based on the total rotation ROM concept would be to avoid extensive mobilization and passive stretching of the dominant extremity because the total rotation ROM in both extremities is 150 degrees (120 ER + 30 IR = 150 dominant arm/90 ER and 60 IR = 150 total rotation non-dominant arm). San Francisco, CA 94123, United States. The second important test to determine the presence of IR ROM limitation is the assessment of physiological ROM. Jobe defined three stages in the clinical presentation of internal impingement. Impingement of the undersurface of the rotator cuff on the posterosuperior glenoid labrum may be a cause of painful structural disease in the athlete practicing sports with overhead movement. They found, with either imbrication of the inferior aspect of the posterior capsule or imbrication of the entire posterior capsule, that humeral head kinematics were changed or altered. Learn about procedures that can help you return to sports & delay or avoid an artificial shoulder replacement. Research by Kibler et al47 and Roetert et al48 has identified decreases in the total rotation ROM arc in the dominant extremity of elite tennis players correlated with increasing age and number of competitive years of play. Anterior internal impingement has recently been described as a source of pain in patients with a stable shoulder and positive traditional impingement signs.23 Struhl23 reported this phenomenon during arthroscopic evaluation of patients who had clinical signs of traditional outlet impingement and anterior-based pain presentations. I %%EOF An additional type of impingement more recently discussed as an etiology for rotator cuff pathology that can often progress to an undersurface tear of the rotator cuff in the shoulder of a young athletic patient is termed posterior, internal or inside, or undersurface impingement.18,19 This phenomenon was originally identified by Walch et al19 upon performing shoulder arthroscopy with the shoulder placed in the 90 degrees of abduction and 90 degrees of external rotation (ER) (90/90) position. Patients with secondary rotator cuff impingement due to underlying instability cannot receive accessory mobilization techniques to increase mobility because this would only compound their existing capsular laxity. The examiner is careful to utilize a posterolaterally directed force (in the direction of the arrow) along the line of the glenohumeral joint. Pathologies such as internal impingement, SLAP lesions, UCL elbow sprains, and subacromial impingement syndrome have been associated with PST. Rehabilitation Guidelines for Posterior Shoulder Reconstruction with or without Labral Repair PHASE III (begin after meeting Phase II criteria, usually 8 weeks after surgery) Appointments Clinical features. The total rotation ROM, however, was not significantly different between extremities in the professional baseball pitchers (145 degrees dominant arm, 146 degrees nondominant arm). 12) can be initiated to provide muscular co-contraction in a functional position. Manual techniques allow the clinician to interface directly with the patients scapula to bypass the glenohumeral joint and permit repetitive scapular exercise without inducing undue stress to the rotator cuff in the early phase. Figure 13 Posterior glenohumeral joint translation test at 90 degrees of abduction in the scapular plane. Hold 5 seconds and repeat 10 times, Sitting or standing up straight, arms down at sides, rotate arms outward while trying to extend downward at the same time. The examiner then feels for translation of the humeral head along the glenoid face. Dr. Stone was trained at Harvard University in internal medicine and orthopaedic surgery and at Stanford University in general surgery. The range of motion is small. Stage : consists of stiffness and difficulty in warming up, but no complaints of pain. The treatment involves a combination of skilled therapy and surgery for optimal outcome. Download a Guide to our Shoulder-Saving Procedures. Neutral position of the back, shoulders, and spine should be maintained during standing, sitting, and lifting activities. One rather consistent finding present during the examination of the overhead athlete is increased dominant arm ER as well as reduced dominant arm glenohumeral joint IR.33,4143 I have found that this relationship is only identified under conditions where the glenohumeral joint rotation was measured with the scapula stabilized.44 Failure to stabilize the scapula may not produce glenohumeral joint IR ROM limitations even though they are present, possibly due to scapular compensation. The posterior deltoids angle of pull compresses the humeral head against the glenoid, accentuating the skeletal, tendinous, and labral lesions.18 Walch et al19 arthroscopically evaluated 17 throwing athletes with shoulder pain during throwing and found undersurface impingement that resulted in eight partial-thickness rotator cuff tears and 12 lesions in the posterosuperior labrum. One study highlights the importance of early submaximal exercise to increase local blood flow. The total rotation ROM did differ between extremities. Impingement of the undersurface of the rotator cuff on the posterosuperior glenoid labrum may be a cause of painful structural disease in the athlete practicing sports with overhead movement. 3727 Buchanan St #300 If you would like help relieving your shoulder pain, our team of highly-trained therapists can alleviate the pain with personalized 1:1 physical therapy sessions. If you would like help relieving your shoulder pain, our team of highly-trained therapists can alleviate the pain with personalized 1:1 physical therapy sessions. Recently, my colleagues and I measured the bilateral total rotation ROM in both professional baseball pitchers and elite junior tennis players.33 Our findings showed the professional baseball pitchers to have greater dominant arm ER and significantly less dominant arm IR when compared with the contralateral nondominant side. Direct visualization during arthroscopy revealed undersurface tears of the rotator cuff due to the contact that occurs between the anterosuperior labrum and undersurface of the rotator cuff, similar to that described by Walch et al19 in posterior impingement. The development of the concept that impingement could occur secondary to instability, rather than as a primary cause, has had significant ramifications altering evaluation methods and treatment/rehabilitation.15,16, Attenuation of the static stabilizers of the glenohumeral joint, such as the capsular ligaments and labrum from the excessive demands incurred in throwing or overhead activities, can lead to anterior instability of the glenohumeral joint. Shoulder impingement usually takes about three to six months to heal completely. More severe cases can take up to a year to heal. However, you can usually start returning to your normal activities / Biomechanics and theories of pathology. Hence, despite bilateral differences in the actual IR and/or ER ROM in the glenohumeral joints of baseball pitchers, the total arc of rotational motion should remain the same. %PDF-1.6 % The loss of IR ROM is significant for several reasons. Rehabilitation Protocol for Shoulder Impingement I. Clinical application of the total rotation ROM concept is best demonstrated by a case presentation of a unilaterally dominant upper-extremity sports athlete. What is a rotator cuff? Table 11 contains the descriptive data from the professional baseball pitchers and elite junior tennis players.33 More research including additional subject populations is needed to outline the total rotation ROM concept further. Wall Slides. This more-posterior orientation of the tendons aligns them such that the undersurface of the tendons rubs on the posterior-superior glenoid lip and becomes pinched or compressed between the humeral head and the posterosuperior glenoid rim.19 In contrast to patients with traditional outlet impingement (either primary or secondary), the area of the rotator cuff tendon that is involved in posterior or undersurface impingement is the articular side of the rotator cuff tendon. Patients may present with an insidious onset of posterior hip or buttock pain. In the presence of posterior capsular tightness, the humeral head will shift in an anterior-superior direction, as compared with a normal shoulder with normal capsular relationships. The game that everyone can play, and all can get hurt. Dr. Sameer Nagda, MD is an Orthopedic Surgery Specialist in Alexandria, VA. To have a numerical representation of the total rotation range of motion available at the glenohumeral joint, the glenohumeral joint IR, and ER ROM measure are added together. 1) The increase in Horizontal Abduction (elbow moving behind shoulders) creates a pinching/closing angle fulcrum of the deep structures of the posterior shoulder The examiner then feels for translation of the humeral head along the glenoid face. Keeping your elbows locked, actively lower your upper body toward the floor by squeezing your shoulder blades together. There can be additional harm caused by the posterior deltoid if the rotator cuff is not functioning properly. 1 Rehabilitation of Shoulder Impingement: Primary, Secondary, and Internal Your Shoulder Impingement ExercisesThoracic Extensions On A Foam RollWall SlidesProne Lift OffQuadruped forward rocking. Use Up/Down Arrow keys to increase or decrease volume. Question: What questions do you have about Shoulder Impingement? Additionally, Burkhart et al34 have clinically demonstrated the concept of posterior-superior humeral head shear in the abducted externally rotated position with tightness of the posterior band of the inferior glenohumeral ligament. The primary symptoms and physical signs of this stage of impingement or compressive disease are similar to the other two stages and consist of a positive impingement sign, painful arc of movement, and varying degrees of muscular weakness.2 Neer1,2 has outlined three stages of primary impingement as it relates to rotator cuff pathology. The straight posterior force compresses the humeral head into the glenoid because of the anteverted position of the glenoid; this would inaccurately lead to the assumption by the examining clinician that limited posterior capsular mobility is present. To have a numerical representation of the total rotation range of motion available at the glenohumeral joint, the glenohumeral joint IR, and ER ROM measure are added together. Contact us at (415) 563-3110 for an appointment. Clinical application of the total rotation ROM concept is best demonstrated by a case presentation of a unilaterally dominant upper-extremity sports athlete. endstream endobj 3 0 obj <> endobj 5 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 6 0 obj <>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 7 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 8 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]>>/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 9 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]>>/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 10 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]>>/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 11 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 41 0 obj <>stream Hold this for 2030 seconds 23 times a day. Hold 15 seconds and repeat 5 times, Holding onto a table with fingertips and arm relaxed, stand up and away from arm to distract arm from shoulder. Figure 12 Rhythmic stabilization performed with scapular protraction. Shoulder disorders are very common in clinical practice. 365 0 obj <>/Filter/FlateDecode/ID[<4A4E3F3BA7CB234F94F7D87A37576B23><7ABB4B68D9A2F54499B0AE6B22F14F8A>]/Index[343 46]/Info 342 0 R/Length 104/Prev 66714/Root 344 0 R/Size 389/Type/XRef/W[1 2 1]>>stream If you've dislocated your shoulder, it means it Collarbone (clavicle) fractures are painful and personalized 1:1 physical therapy sessions, The Changing Approach to Rotator Cuff Repair. 343 0 obj <> endobj The goal of treatment for shoulder impingement syndrome is to reduce your pain and restore shoulder function. Re-establish muscular Adobe InDesign CC 13.0 (Macintosh) Modalities such as electrical stimulation, ultrasound, and iontophoresis can be applied to promote improved blood supply and decrease pain levels; however, a clearly superior modality or sequence of modalities for the early management of tendon pathology in the human shoulder is lacking. The deposition of hydroxyapatite calcium crystals should not be considered as a static process but rather a dynamic pathological process 2017-11-09T08:49:37-06:00 In elite tennis players, the total active rotation ROM can be expected to be up to 10 degrees less on the dominant arm before an extensive clinical treatment to address IR ROM restriction would be recommended or implemented. Placement of the shoulder in the 90/90 position causes the supraspinatus and infraspinatus tendons to rotate posteriorly. This can occur from repetitively moving the shoulder into a stressful or suboptimal positioncommon in climbing. 14), care must be taken to stabilize the scapula, with the patient supine so that the patients body weight can minimize scapular motion as the examiner uses a posteriorly directed force on the anterior aspect of the coracoid and shoulder. reversing GIRD in those with posterior shoulder tightness, creating improved dynamic stabilization of the glenohumeral The relationship between IR ROM loss (tightness in the posterior capsule of the shoulder) and increased anterior humeral head translation has been identified.49,50 The increase in anterior humeral shear force reported by Harryman et al51 was manifested by a horizontal adduction cross-body maneuver, similar to that incurred during the follow-through of the throwing motion or tennis serve. In addition to the early scapular stabilization and submaximal rotator cuff exercise, ROM and mobilization may be indicated based on the underlying mobility status of the patient. The presence of anterior translation of the humeral head with maximal ER and 90 degrees of abduction, which has been confirmed arthroscopically during the subluxation-relocation test, can produce mechanical rubbing and fraying on the undersurface of the rotator cuff tendons. 4 Rehabilitation of Adhesive Capsulitis 572 0 obj <> endobj Peak forces against the acromion were measured in a range of motion (ROM) between 85 degrees and 136 degrees of elevation.8 This position is a functionally important one for daily activities, sport-specific movements,9,10 and situations commonly encountered on a job as well. In this chapter, the main types of rotator cuff impingement are discussed together with both general and specific rehabilitation principles and strategies based on the available evidence. Contact us at (415) 563-3110 for an appointment. One area that has received a great deal of attention in the scientific literature is the presence of an IR ROM limitation, particularly in the overhead athlete with rotator cuff dysfunction.33,34 To determine the course of treatment for the patient with limited IR ROM, clinical assessment strategies must be employed to determine whether the limitation and subsequent treatment strategy to address the limitation in glenohumeral joint IR should be targeted for the muscletendon unit or the posterior capsule. It should be pointed out that incorrect use of this posterior glide assessment technique may lead to the false identification of posterior capsular tightness. The specific shape of the overlying acromion process is termed acromial architecture and has been studied in relation to full-thickness tears of the rotator cuff.11,12 Bigliani et al11 described three types of acromions: type I (flat), type II (curved), and type III (hooked). A common error in this exam technique is the use either of the coronal plane for testing or of a straight posteriorly directed force by the examiners hand rather than the recommended posterolateral force. Paley et al, mobility technique to assess the mobility of the humeral head relative to the glenoid is recommended. The shoulder is known as a ball and socket joint; this type of joint is comparable to a golf ball on its tee. posterior shoulder pain, especially in the late cocking phase. Stage II compressive disease outlined by Neer is termed fibrosis and tendonitis. Full-thickness tears of the rotator cuff, partial-thickness tears of the rotator cuff, biceps tendon lesions, and bony alteration of the acromion and acromioclavicular joint may be associated with this stage.12 In addition to bony alterations that are acquired with repetitive stress to the shoulder, the native shape of the acromion is of relevance. Its extra-articular, internal impingement is intra-articular. A key technique in the early management of rotator cuff impingement is scapular stabilization. The position of the shoulder in forward flexion, horizontal adduction, and internal rotation (IR) during the acceleration and follow-through phases of the throwing motion is likely to produce subacromial impingement due to abrasion of the supraspinatus, infraspinatus, or biceps tendon against the overlying structures.9 These data provide scientific rationale for the concept of primary impingement or compressive disease as an etiology of rotator cuff pathology. This technique is most often referred to as the posterior load and shift or posterior drawer test.35,36 Figure 1-3 shows the recommended technique for this examination maneuver whereby the glenohumeral joint is abducted 90 degrees in the scapular plane (note the position of the humerus 30 degrees anterior the coronal plane). It is important to use consistent measurement techniques when documenting ROM of glenohumeral joint rotation. Impingement or compressive symptoms may be secondary to underlying instability of the glenohumeral joint.13,14 Though relatively common knowledge today, this concept was not well understood or recognized in the medical community even through the mid- to late 1980s. In this chapter, the main types of rotator cuff impingement are discussed together with both general and specific rehabilitation principles and strategies based on the available evidence. An additional type of impingement more recently discussed as an etiology for rotator cuff pathology that can often progress to an undersurface tear of the rotator cuff in the shoulder of a young athletic patient is termed posterior, internal or inside, or undersurface impingement.18,19 This phenomenon was originally identified by Walch et al19 upon performing shoulder arthroscopy with the shoulder placed in the 90 degrees of abduction and 90 degrees of external rotation (ER) (90/90) position. Results showed even submaximal contractions increased perfusion during all 1-minute contractions; but they also produced a postcon-traction latent hyperemia following the muscular contraction. Manual Therapy. How do you repair it? Burkhart et al34 have termed this IR loss GIRD-glenohumeral internal rotation deficitand define it as a loss of internal rotation of 20 degrees or more compared with the contralateral side. Shoulder impingement is a common condition believed to contribute to the development or progression of rotator cuff disease (van der Windt et al., 1995, Michener et al., 2003).A number of impingement categories have been identified including subacromial impingement or external impingement; internal impingement, which can be further divided Posterior, Internal, or Undersurface Impingement Hence, in guiding patients through the rehabilitation process, an accurate ROM measurement and informed decision making are essential to the clinician. Use of examination procedures to assess the accessory mobility of the glenohumeral joint is of critical importance in guiding this portion of the treatment. The rotator cuff must be protected against mechanical compression by the overlying coracoacromial arch or posterior glenoid; this can be done by modifying ergonomic, sport-specific postures and movement patterns as well as those related to activities of daily living (ADL). Go until tension and hold for 3 seconds and repeat 5 times, Holding the band with both hands and with it wrapped around a doorknob, pinch shoulder blades and pull back towards you as if rowing a boat. Observed in younger, more athletic patients, it is a reversible condition with conservative physical therapy. However, patients with primary impingement often present with underlying capsular hypo-mobility and are definite candidates for specific mobilization techniques to improve glenohumeral joint arthrokinematics. Significant advances in basic research in the anatomy and biomechanics of the human shoulder have led to the identification of multiple types of impingement, each with underlying pathomechanical causes. Further research is needed to better define the optimal application of these stretches; however, this research does show improvement in IR ROM with a home stretching program.56, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Rehabilitation of Shoulder Impingement: Primary, Secondary, and Internal, Primary Impingement or Compressive Disease, Posterior, Internal, or Undersurface Impingement, Rehabilitation of Rotator Cuff Impingement. Additionally, Crockett et al45 have shown unilateral increases in humeral retroversion in throwing athletes, which would explain the increase in ER with accompanying IR loss. Activation of the serratus anterior and lower trapezius force couple is imperative to enable scapular upward rotation and stabilization during arm elevation.29 Rhythmic stabilization applied to the proximal aspect of the extremity progressing to distal with the glenohumeral joint in 80 to 90 degrees of elevation in the scapular plane (Fig. A type III or hooked acromion was found in 70% of cadaveric shoulders with a full-thickness rotator cuff tear, whereas a type I acromion was only associated with 3% of this group. Described by Dr. Stone as a "gift to his patients," this short, weekly blog focuses on sports, performance, & orthopaedic care. In these professional throwing athletes, 93% had undersurface fraying of the rotator cuff tendons and 88% showed fraying of the posterosuperior glenoid. In the grading technique designed by Altchek,37 grade I is considered normal motion within the glenoid (typically 8 to 10 mm38), and a grade II translation is when the clinician-guided stress produces movement of the humeral head over the glenoid rim posteriorly with relocation of the humeral head into the glenoid when stress is removed. Sitting or standing up straight, pinch shoulder blades together as if pinching a peanut between them. 2016;7(12):776. So its on the undersurface of the rotator cuff now. Dull ache in the front or side of the shoulder. The specific shape of the overlying acromion process is termed acromial architecture and has been studied in relation to full-thickness tears of the rotator cuff.11,12 Bigliani et al11 described three types of acromions: type I (flat), type II (curved), and type III (hooked). Figure 14 Technique used to measure more isolated glenohumeral joint internal rotation with the shoulder in 90 degrees of abduction in the coronal plane. These findings have provided the rationale for the early use of internal and ER isometrics or submaximal manual resistance in the scapular plane with low levels of elevation to prevent any subacromial contact early in the rehabilitation process. Several authors recommend measurement of glenohumeral IR with the joint in 90 degrees of abduction in the coronal plane.3941 During IR ROM measurement (Fig. Patients presenting with a limitation in IR ROM who have grade II translation should not have posterior glide accessory techniques applied to increase IR ROM due to the hyper-mobility of the posterior capsule made evident during this important passive clinical test. Internal 2017-11-09T08:49:37-06:00 The rotator cuff must be protected against mechanical compression by the overlying coracoacromial arch or posterior glenoid; this can be done by modifying ergonomic, sport-specific postures and movement patterns as well as those related to activities of daily living (ADL). nonsurgical treatment for shoulder impingement. A type III or hooked acromion was found in 70% of cadaveric shoulders with a full-thickness rotator cuff tear, whereas a type I acromion was only associated with 3% of this group.11 Additionally, in a series of 200 clinically evaluated patients, 80% with a positive arthrogram confirming a full-thickness rotator cuff tear had a type III acromion.12 Posterior Impingement of the shoulder is a very common malady of overhead athletes of all disciplines and is something that can be easily managed when identified. If you think about the rotator cuff, its classic impingement with a rotator cuff pathologies is technically external, which means its on the outside or the top layer of the rotator cuff. Additionally, with this technique a protracted scapular position can be utilized to increase the activation of the serratus anterior muscle30,31; several studies have identified decreased muscular activation of this muscle in patients diagnosed with glenohumeral impingement and instability.25,32 SHOULDER INTERNAL IMPINGEMENT NON-OPERATIVE GUIDELINES Phase 1: Recovery (Weeks 1-2) Restoration of posterior shoulder flexibility . If, like many of our patients, you don't live in the Bay Area, we offer a complimentaryphone consultation service. If measurement of that patients nondominant extremity rotation, however, reveals 90 degrees of ER and 60 degrees of internal rotation, the current recommendation based on the total rotation ROM concept would be to avoid extensive mobilization and passive stretching of the dominant extremity because the total rotation ROM in both extremities is 150 degrees (120 ER + 30 IR = 150 dominant arm/90 ER and 60 IR = 150 total rotation non-dominant arm). The total rotation ROM did differ between extremities. To rehabilitate the patient with glenohumeral joint impingement requires a careful, systematic evaluation to identify the type of impingement and, more importantly, to determine the underlying cause of the impingement to ensure that an evidence-based nonoperative rehabilitation program can be developed. Placement of the shoulder in the 90/90 position causes the supraspinatus and infraspinatus tendons to rotate posteriorly. Due to the increased humeral head translation, the biceps tendon and rotator cuff can become impinged secondary to the ensuing instability.13,14 A progressive loss of glenohumeral joint stability is created when the dynamic stabilizing functions of the rotator cuff are diminished from fatigue and tendon injury.14,17 The effects of secondary impingement can lead to rotator cuff tears as the instability and impingement continue.3,14. It is beyond the scope of this chapter to discuss the complex and comprehensive evaluation methods specifically; however, a detailed and systematic approach to shoulder and upper-extremity evaluation must be undertaken both to identify the specific type of rotator cuff impingement as well as to determine the often-subtle underlying causes. This technique is most often referred to as the posterior load and shift or posterior drawer test.35,36 Figure 1-3 shows the recommended technique for this examination maneuver whereby the glenohumeral joint is abducted 90 degrees in the scapular plane (note the position of the humerus 30 degrees anterior the coronal plane). Koffler et al53 studied the effects of posterior capsular tightness in a functional position of 90 degrees of abduction and 90 degrees or more of ER in cadaveric specimens. %%EOF In contrast, we tested 117 elite male junior tennis players.33 In these tennis players, significantly less IR ROM was found on the dominant arm (45 degrees versus 56 degrees), as well as significantly less total rotation ROM on the dominant arm (149 degrees versus 158 degrees). hb```f``Z ,@Q=wC%EsJ(ix~hK- & D!& iYp)821!,@4r10@t77## tQxAFf*v *: Figure 14 Technique used to measure more isolated glenohumeral joint internal rotation with the shoulder in 90 degrees of abduction in the coronal plane. Summary In a series of 10 patients with traditional impingement signs and anterior-based pain presentations, Struhl23 arthroscopically confirmed contact between the fragmented undersurface of the rotator cuff tendons and the anterosuperior labrum during the Hawkins impingement test, viewed from a posterior arthroscopic portal. World J Orthop. Traditional impingement involves the superior or bursal surface of the rotator cuff tendon or tendons and typically produces anterior and anterolateral pain distributions.20 Conversely, individuals presenting with posterior shoulder pain brought on by positioning of the arm in 90 degrees of abduction and 90 degrees or more of ER, typically from overhead positions in sport or work activities, may be considered as potential candidates for undersurface impingement. In these professional throwing athletes, 93% had undersurface fraying of the rotator cuff tendons and 88% showed fraying of the posterosuperior glenoid. Activation of the serratus anterior and lower trapezius force couple is imperative to enable scapular upward rotation and stabilization during arm elevation.29 Rhythmic stabilization applied to the proximal aspect of the extremity progressing to distal with the glenohumeral joint in 80 to 90 degrees of elevation in the scapular plane (Fig. 0 Rehabilitation ofShoulder Impingement:Primary, Secondary,and Internal Specific changes in the program will be made by the physician as appropriate for the individual patient. The typical age range for this stage of injury is 25 to 40 years. 2017-11-09T08:49:39-06:00 Figure 11A shows the specific technique I use with my patients to resist scapular retraction manually. Patients with secondary rotator cuff impingement due to underlying instability cannot receive accessory mobilization techniques to increase mobility because this would only compound their existing capsular laxity. Phase II Motion Phase (weeks 5-8): Review videos for active ROM,overhead pulley and isometric strengthening (flexion, extension,abduction, external Each utilizes an inherent anterior hand placement; this gives varying degrees of posterior pressure to minimize scapular compensation and to provide a check against anterior humeral head translation during the IR stretch. from application/x-indesign to application/pdf Internal (posterosuperior) impingement syndrome is typified by a painful shoulder due to impingement of the soft tissue, including the RC, joint capsule and the posterosuperior part of 598 0 obj <>stream %PDF-1.6 % The primary symptoms and physical signs of this stage of impingement or compressive disease are similar to the other two stages and consist of a positive impingement sign, painful arc of movement, and varying degrees of muscular weakness.2. The straight posterior force compresses the humeral head into the glenoid because of the anteverted position of the glenoid; this would inaccurately lead to the assumption by the examining clinician that limited posterior capsular mobility is present. 2 Rehabilitation of Micro-Instability Modalities such as electrical stimulation, ultrasound, and iontophoresis can be applied to promote improved blood supply and decrease pain levels; however, a clearly superior modality or sequence of modalities for the early management of tendon pathology in the human shoulder is lacking. One area that has received a great deal of attention in the scientific literature is the presence of an IR ROM limitation, particularly in the overhead athlete with rotator cuff dysfunction.33,34 To determine the course of treatment for the patient with limited IR ROM, clinical assessment strategies must be employed to determine whether the limitation and subsequent treatment strategy to address the limitation in glenohumeral joint IR should be targeted for the muscletendon unit or the posterior capsule. It has been hypothesized that shoulder pain seen in swimmers may be the result of anterior internal impingement; the pain is frequently reported at hand entry into the waterin this position, the humeral position is similar to that of the Neer and Hawkins test.23 Stage II compressive disease outlined by Neer is termed fibrosis and tendonitis. The presence of anterior translation of the humeral head with maximal ER and 90 degrees of abduction, which has been confirmed arthroscopically during the subluxation-relocation test, can produce mechanical rubbing and fraying on the undersurface of the rotator cuff tendons. With the arthroscope inserted in the glenohumeral joint, they found that 41 out of 41 dominant shoulders evaluated had posterior undersurface impingement between the rotator cuff and posterior superior glenoid. Attenuation of the static stabilizers of the glenohumeral joint, such as the capsular ligaments and labrum from the excessive demands incurred in throwing or overhead activities, can lead to anterior instability of the glenohumeral joint. Jensen etal27 studied the effects of submaximal [5 to 50% maximum voluntary contraction (MVC)] contractions in the supraspinatus tendon measured with laser Doppler flowmetry. Call for information or to book an appointment to see us in person. In elite tennis players, the total active rotation ROM can be expected to be up to 10 degrees less on the dominant arm before an extensive clinical treatment to address IR ROM restriction would be recommended or implemented. Traditional impingement involves the superior or bursal surface of the rotator cuff tendon or tendons and typically produces anterior and anterolateral pain distributions.20 Conversely, individuals presenting with posterior shoulder pain brought on by positioning of the arm in 90 degrees of abduction and 90 degrees or more of ER, typically from overhead positions in sport or work activities, may be considered as potential candidates for undersurface impingement. This occurs from repeated episodes of mechanical inflammation and can include thickening or fibrosis of the subacromial bursae. Remember this number: 25%. If, during the initial evaluation of a high-level baseball pitcher, the clinician finds a ROM pattern of 120 degrees of ER and only 30 degrees of IR, some uncertainty may exist as to whether that represents a range of motion deficit in IR that requires rehabilitative intervention via stretching and specific mobilization. Equally important is which extremity should not experience additional mobility due to the obvious harm induced by increases in capsular mobility and increases in humeral head translation during aggressive upper-extremity exertion. Protocol R1 Non-Operative Rehabilitation Program for Acute Glenohumeral Joint Dislocation. Outcomes Painful to lie on the shoulder. Direct visualization during arthroscopy revealed undersurface tears of the rotator cuff due to the contact that occurs between the anterosuperior labrum and undersurface of the rotator cuff, similar to that described by Walch et al19 in posterior impingement. 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General surgery fibrosis and tendonitis Acute phase Goals: Relieve pain and restore shoulder function tendinopathy of glenohumeral... Frequently observed during the late cocking phase of the posterior shoulder impingement rehab forces against the acromion with elevation the!

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