Transcript document

Mark Powers, SPT
Armstrong Atlantic State University
[email protected]
Outline
 Epidemiology statistics
 Subacromial space
 RTC impingement progression
 Critical pathways/special tests
 Classification of impingements and appropriate treatments
 Townsend/Moseley exercises and Davies “Top 10 shoulder
exercises”
 30/30/30 IR+ER strengthening position
 MTrP focus
 Questions
Shoulder Epidemiology
 Impingements: 55%
 Post-op repairs: 18%
 Frozen shoulder: 9%
 RTC Tear: 8%
 Shoulder instability: 3%
 S/P fracture: 2%
 Miscellaneous dx: 5%
(Millar, AL, et. al. JOSPT, 36:403-414, 2006)
Subacromial Space
 At 0 degrees of GH elevation the Acromiohumeral
Interval is 11mm
 At 90 degrees of GH elevation the Acromiohumeral
Interval decreases to 5.7mm
 Acromial undersurface and RTC tendons are in closest
proximity between 60-120degrees of elevation
(Flatow, EL et. al. Excursion of the Rotator Cuff Under
the Acromion. AM J Spts Med. 22(6):779-788, 1994.
Subacromial Space-Pain Sensitive
Structures
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Synovium on the RTC tendons
Superior capsule
NV triad
Inferior capsule of AC joint
Periosteum on inferior acromion
Bursa*
RTC tendons*
LHB*
(*-histological studies have demonstrated largest concentration of
pain fibers are located in these three structures.)
(Soifer T.B., Levy, H.J., Soifer, F.M. et al. “Neurohistology of the
Subacromial Space.” J. of Arthroscopy, 12(2):182-86, 1996..)
Propagation Stages
 Neer’s Classification of Rotator Cuff Impingement
Syndromes
 Stage I: edema and hemorrhage
 Typical age: <25
 Diff diagnosis: subluxation, A/C arthritis
 Clinical course: reversible
 Treatment: conservative
 Stage II: fibrosis and tendonitis
 Typical age: 25-40
 Diff diagnosis: frozen shoulder, calcium deposits
 Clinical course: recurrent pain with activity
 Treatment: consider bursectomy, CA ligament division
 Stage III: bone spurs and tendon ruptures
 Typical age: >40
 Diff diagnosis: cervical radiculitis
 Clinical course: progressive, disability appears
 Treatment: anterior acromioplasty, rotator cuff repair
Critical Pathways
 Age >40
 Repetitive overhead activities
 Overuse of arm in unaccustomed activities
 c/o pain in lateral aspect of shoulder
 c/o night pain
 c/o painful arc syndrome
 Painful arc during AROM
 Compensatory shoulder shrug sign
Impingement Special Tests
Test Name
Position
Sens/Spec
Tissues
Implicated
Neer Test
Sitting: 180deg flex .75-.89/.09-.48
Supraspinatus,
LHB
Hawkins-Kennedy
Sitting: scaption to .87-.92/.25-.44
90deg with IR
Supraspinatus
Coracoid
Impingement
Sitting: Flexion to
90deg with IR
Med pain: LHB,
subscap
Lat pain:
Supraspinatus
Cross-over Test
Sitting: 90deg flex
with horizontal
adduction
.92/.25
Med pain: LHB,
subscap
Lat pain:
Supraspinatus
Sup pain: AC joint
Post pain: Inf/teres
minor, post
capsule, Int Imp
Impingement Special Tests
References
 Neer Test/Hawkins-Kennedy/Cross-over test
 Calis M, et al. Diagnostic values of clinical diagnostic tests in
subacromial impingement syndrome. Ann Rheum Dis. 59:44-47, 2000.
 Leroux JL, et al. Diagnostic value of clinical tests for shoulder
impingement syndrome. Rev Rhum Engl Ed. 62:423-428, 1995.
 Litaker D, et al. Returning to the bedside: using the history and
physical examination to identify rotator cuff tears. J Am Geriatr Soc.
48:1633-1637, 2000.
 MacDonald P, et al. An analysis of the diagnostic accuracy of the
Hawkins and Neer subacromial impingement signs. J Shoulder Elbow
Surg. 9:299-301, 2000
 Coracoid: sensitivity and specificity have not been established in any
studies
RTC Tear Special Tests
Test Name
Position
Sens/Spec
Tissues
Implicated
ERLS I
20deg scaption
with ER
.70-1.0/1.0
Infraspinatus
ERLS II
Same
Not determined
Supraspinatus
90/90 Lag Sign I
GH-90deg abd
ER-90deg
Not determined
Infraspinatus
90/90 Lag Sign
II
Same
Not determined
Supraspinatus
IRLS
GH-ext, add, IR
.97/.96
Subscapularis
Rules for Interpretation:
1. AAROM to predetermined position
2. Isometric hold at that position
3. <5-10deg of lag indicates partial RTC tear
4. >10deg of lag indicates full thickness RTC tear
RTC Tear Special Tests References
 Drop Arm Test I/ERLS I/IRLS
 Bryant L, et al. A comparison of clinical estimation,
ultrasonography, magnetic resonance imaging, and
arthroscopy in determining the size of rotator cuff tears.
J Shoulder Elbow Surg. 11:219-224, 2002.
 Hertel R, et al. Lag signs in the diagnosis of rotator cuff
rupture. J Shoulder Elbow Surg. 5:307-313, 1996.
 Walch G et al. The “dropping” and “Hornblowers’s”sign
in evaluation of rotator-cuff tears. J Bone Joint Surg Br.
80(4):625, 1998.
RTC Impingement Classification
Impingement Syndrome
Primary
Secondary
(Hypomobile)
(Hypermobile)
Internal
(posterior)
Primary Impingement
 Most commonly seen
 Due to hypomobility with compression to the RTC
tendons caused by:
 Tendon and bursal thickening
 Subacromial crowding
 Posterior capsule tightness
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Humeral head depressor weakness or fatigue
Scapular rotator/stabilizer weakness or fatigue
Patients are typically over 40 years of age
Involves bursal side of tendons
Primary RTC Impingement Rehab
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Treat the cause of the problem
Hypomobility treatment (TERT, Grade III/IV mobs, heat)
Therapeutic exercise
Neuromuscular dynamic stability
Functional exercises
*Bang et. al. found a combination of manual therapy techniques
and exercise is more effective than exercise alone for increasing
strength, reducing pain, and improving function
*Bang MD, et al. Comparison of supervised exercise with and
without manual physical therapy for patients with shoulder
impingement syndrome. JOSPT. 30:126-137, 2000.
TERT
 Total End Range Time
 Dependent on:
 Intensity (force)
 Time
 Frequency
 Temp
 Studies demonstrate when a joint is held in a moderately
lengthened position for a significant time ROM will increase in
that joint
(Flowers KR, et. al. Effect of total end range time on improving
passive range of motion. J Hand Therapy. 7: 150-157, 1994.)
 In conclusion the increase in PROM of a joint is directly
proportional to the length of time the joint is held at end range
Secondary Impingement
 Results from instability (hypermobility)
 Glenohumeral instability from humeral head depressor
weakness or fatigue
 Overstretching of static stabilizers
 Ages 15-40
 Articular and bursal side of RTC tendons involved
 RTC tendons cannot oppose the superior shear forces
from deltoid muscle resulting in anterior superior GH
translation causing RTC tendons to impinge on CA
arch.
Secondary RTC Impingement
Rehab
 Avoid heating and stretching this patient.
 Focus on entire shoulder complex with:
 Dynamic stability
 Proprioceptive/kinesthetic training
 Neuromuscular reactive training
 Functional rehabilitation
 Re-establish dynamic caudal glide resulting in
dynamic humeral head control.
Dynamic Caudal Glide
 Strengthening the dynamic caudal glide re-establishes
dynamic humeral head control by depressing the
humeral head during overhead activities.
 Muscles working to produce dynamic caudal glide
include inferior fibers of:
 Teres minor
 Infraspinatus
 Subscapularis
 Press downs great exercise for the dynamic caudal
glide.
Internal Impingement
 Undersurface of the supraspinatus and infraspinatus
impinge on the posterior superior labrum
 Occurs on the articular side of RTC tendons
 Main mechanism of posterior internal impingement is
prolonged horizontal extension (ex. Fork lift drivers)
 Can also result in pitchers from hyperangulation during
throwing
 Clinical Presentation:
 Pain in posterior shoulder (deep to post/lat acromion)
 Pain with excessive ER at 90degrees abduction
 + jobe subluxation/relocation test for posterior pain
Internal Impingement Syndrome
Critical Pathways
•Specific c/o pain
in the post
shoulder inferior
to post-lat
acromion
•Pain with
horizontal
extension motion
Test Name
Jobe
subluxation/relocation test
Position
Tissues
Implicated
Supine: 90deg of
GH abduction and
ER
Articular sides of
supraspinatus and
infraspinatus hit
against posterior
superior labrum
Walch G, et al. Impingement of the deep surface of the supraspinatus
tendon on the posterosuperior glenoid rim: an arthroscopic study. J
Shoulder Elbow Surg1992; 1:238 -245
Internal Impingement Rehab
 Identify cause: hypermobility vs. hypomobility
 Hypomobility: treat like primary impingement syndrome
 Hypermobility: treat like secondary impingement syndrome
 Treat the pathological mechanism:
 Excessive humeral translation/acquired instability
 GIRD
 Scapular dyskinesis
(Cools AM, et al. Internal impingement in the tennis player:
rehabilitation guidelines. Br. J sports med. 42:165-171, 2008)
Townsend and Moseley Exercises
 Moseley Scapulo-thoracic exercises:
 Decline bench press/push up plus (Protraction): serratus anterior
 Rowing (Retraction): middle trap, rhomboids
 Press downs (Depressors and DR): lower trap
 Scaption (Elevators and UR): lower and upper trap
 Townsend GH exercises:
 Flexion: anterior delt, corachobrachialis, pec major
 ER with horizontal extension: infraspinatus, post delt, teres minor
 Press downs (GH depression): subscapularis, teres minor, infraspinatus
(inferior fibers)
 Scaption: ant delt, middle delt, supraspinatus
(Townsend H, et al. Electromyographic analysis of the glenohumeral muscles
during a baseball rehabilitation program. Am J Sports Med 19(3):264-272, 1991)
(Moseley JB, et al. EMG analysis of the scapular muscles during a shoulder
rehabilitation program. Am J Sports Med. 20(2):128-134, 1992)
ER/IR 30-30-30 position
 Optimal positions for ER and IR strengthening
 Strengthening exercises should be performed with the arm in
slight abduction and scaption.
 A towel roll or ball should be placed under the arm and
resistance applied in a diagonal direction.
 Reasons for this position include:
 Abduction: decreases wringing out effect, increases blood flow and
nutrients to the area
 Scaption: it’s a functional position, decreases amount of stress on
anterior capsule, pre-stretches ER producing more power
 Adduction: increases EMG of ER, increases subacromial space
leading to decreased pressure
 Diagonal pull: increases power due to muscle fiber orientation,
increased comfort for patient
MTrPs
 Recent research suggests not only do MTrPs cause pain, but they also
affect firing patterns of muscle groups therefore predisposing the pt to
overuse syndromes such as impingement.
 From what we’ve seen in the clinic, MTrP release can yield immediate
gains in pain free PROM.
 We can then train these patients throughout the increased range
therefore gaining functional mobility.
 MTrP release cuts down on manual therapy time; this extra time can
then be used for additional exercises including:
 Rhythmic stab exercises to regain humeral head control
 Neuromuscular re-education for scapular stability
(Lucas KR, Rich PA, Polus BI. Muscle activation patterns in the scapular positioning muscles during
loaded scapular plane elevation: the effects of Latent Myofascial Trigger Points. Clin Biomech
25(8):765-70, 2010. )
MTrP Treatment
 Current research suggests MTP treatment can include:
 Manual trigger point release
 Dry needling
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Evidence suggests that dry needling a primary MTrP inhibits the activity
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in satellite MTrPs situated in its zone of pain referral.
Recent literature also suggests dry needling in athletes with shoulder
injuries can reduce pain and improve function.
 Ultrasound (mixed research)
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Some studies show low-dose ultrasound can evoke short-term segmental
antinociceptive effects on trigger points which can aid in the treatment
of musculoskeletal pain.
One study concluded that US gives no pain reduction, but massage and
exercise reduces the number and intensity of MTrP. The impact of this
reduction on neck and shoulder pain is weak.
MTrP Tx References
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Hsieh YL, Kao MJ, Kuan TS et al. Dry needling to a key myofascial trigger point may reduce the
irritability of satellite MTrPs. Am J Phys Med Rehabil 86(5):397-403, 2007.
Osborne NJ, Gatt IT. Management of shoulder injuries using dry needling in elite volleyball players.
Acupunct Med 28(1):42-5, 2010.
Srbely JZ, Dickey JP, Lowerison M, et al. Stimulation of myofascial trigger points with ultrasound
induces segmental antinociceptive effects: a randomized controlled study. Pain 139(2):260-266, 2008.
Gam AN, Warming S, Larsen LH et al. Treatment of myofascial trigger-points with ultrasound
combined with massage and exercise -- a randomised controlled trial. Pain 77(1):73-79, 1998.
Thank You!
 Any questions?