Transcript Shoulder Pathologies - Sydney Physiotherapy Solutions

Sydney Physiotherapy Solutions
Matt Crawshaw
Blair Chapman
Chantal Wingfield
Today’s Topic is The Scapular
 Shoulder pathology
 Measuring static and dynamic scapular stabilisation
 Using measurements to screen for prevention of
shoulder injuries and to identify scapular dysfunction
due to injury.
 Using measurements to progress rehabilitation.
Today’s Goal
1. Interact and Share
 discuss shoulder injuries from the Personal Trainers perspective
 discuss shoulder injuries from the physiotherapist perspective
 suggest a framework where the Personal Trainers and the
Physiotherapists can be a team for the client with a focus on
keeping them training with the Personal Trainer through their
injury.
2. Develop trust with you
Framework for Physio’s and PT’s
to work within
When we receive a patient from a PT with a
Shoulder problem
 Our responsibility lies equally between the patient and the
PT.
 We need to establish a diagnosis and prognosis and
communicate that to the patient and the PT.
Framework for Physio’s and PT’s
to work within
 To reduce Symptoms and address the likely poor
scapular stabilising strategy that is present as a reaction
to the injury.
 To give patient back to PT with minimal Sx and a good
scap stabilising strategy for the PT to load that strategy
to regain full strength .
Framework for Physio’s and PT’s
to work within
 Important for the PT to understand how to identify good
and bad scap stabilising strategies and to be able to
monitor this during strength training.
 We need to do this as soon as possible to maintain the
relationship between patient and PT. If there is a longer
period of rest required for the shoulder we need to
provide the PT with safe strengthening exercises to do
during the rehab process.
More detail of this Framework
 Chantal is going to present the pathologies we are
thinking of when a shoulder injury is referred to us from
a PT and how we diagnose this.
 Blair will describe the current understanding of scap
stabilisation and how it is affected by injury. He will
run a small practical session on how to measure and
identify this for screening your clients before strength
training and rehabilitating your clients back into
strength training post injury.
Shoulder Pathologies
 Fracture
Alternative considerations
 Dislocation
 Cervical spine
 Muscle tear
 Thoracic ring dysfunction
 Labral tear
 Thoracic outlet syndrom /
Brachial plexus
 ACJ injuries
 Frozen shoulder
 Arthritis
 Subacromial impingement –
including tendinitis, bursitis
and postural dysfunctions
 Peripheral neuropathies
 Tumors / lung Ca / heart
Dislocation
 Usually traumatic
 Anterior most common
 Be aware of the chronically
unstable shoulder
 Physiotherapy input recommended
and usually imagery required as
recurrence is highly likely
 Surgical stabilisations occasionally
required in presence of structural
defect EG Bankart, unstable SLAP
or Hill Sachs
Muscle tear
 E.g. Rotator cuff but not
exclusive
 Can be traumatic or
degenerative
• Usually causes pain upper arm
• Often but not always complain of weakness
• Needs physio input +/- orthopaedic input depending on
extent of tear/dysfunction & duration of symptoms
• Diagnosed clinically with use of US or MRI as required
• If traumatic, timing is key as better surgical outcomes
within 3 months of injury
Labral Tear
 Can be traumatic or degenerative
 Can be asymptomatic
 Can cause clicking, feelings of instability or deep
shoulder ache
 Physio input recommended with ongoing PT.
 Physio to guide re ex precautions &
rehabilitate shoulder stability whilst training
• Occasionally surgical input required if unstable or fail
conservative input
• Caution with shoulder weight bearing and overhead
loading during initial rehab phase
ACJ
 Usually managed conservatively
 We will grade the injury and guide regarding their rehab and
ongoing training
 Avoid distraction / loading / weight bearing for ~ 2–6 weeks
depending on grade of injury
 Important to ensure normal mechanics post injury as can lead
to secondary problems such as impingement
Frozen Shoulder
 AKA ‘Adhesive Capsulitis’
 Inflammation and scarring
of your joint capsule
 Starts as a painful
shoulder and develops
into a stiff shoulder
 More common in diabetics
• Needs range maintenance exercises and
occasionally onward referral for a corticosteriod
injection or capsular release
Arthritis
 Osteoarthritis is also known
as joint ‘wear and tear’
 Older population
 Stiffness and pain
• Need careful grading of exercises, not too high
loads as indicative that their cuff and labrum are
severely degenerative
• Very occasionally referred for shoulder replacement
but outcomes currently limited. Good pain responses
but ROM and strength outcomes poor so last resort.
Subacromial Impingement – Bursitis /
tendinitis
 Can occur post trauma, with
overuse, sudden increase in
training or gradual insidious onset
as a result of poor biomechanics
• Present with pain during arm elevation at end of range
or often a painful arc and usually HBB also sore
Additional Potential Differentials
 Cervical spine
 Upper lung lobe
 Cervical arteries
 Heart
 Thoracic outlet / brachial plexus
 Peripheral neuropathy
 Thoracic ring dysfunction
 If unsure, refer to us and we will happily assess and give feedback
 We utilise a series of clinical tests, questions and real time ultrasound
to establish our diagnosis and then will develop a collaborative
management plan with both you and the client
Scapular Mechanics
Scapular Movement
Muscle Actions

Upward Rotation


Serratus anterior, UFT,LFT
Downward Rotation

Levator scapula, Rhomboids,
Pec minor



Anterior/Posterior Tilting

Anterior: Pec minor

Posterior: LFT
Protraction/ Retraction

Protraction: Pec minor, serratus anterior

Retraction: Rhomboids, Trapezius as a whole (latissimus dorsi if humerus fixed)
External Rotation


Serratus anterior
Internal Rotation
Common Presentation
 As a result of injury or trauma
 Downward rotation
 Anterior tilt
 Medial rotation
 Which muscles are overactive?
 Secondary Issues?
Visual Assessment

Kibler Classification of Scapular Dysfunction




Type 1 or inferior Dysfunction

Main feature is inferior angle prominence as a result of anterior tilting.

Best seen with hands on hips or eccentric lowering of arms from overhead ( most
common in rotator cuff dysfunction)
Type 2 or medial Dysfunction

Prominence of entire medial border of scapula due to internal rotation of scapula.

Best seen with hands on hips, eccentric lowering from overhead

Common in shoulder joint instability
Type 3 or Superior Dysfunction

Excessive and early elevation of the scapula during elevation.

Ie. Shoulder Shrugging.

Often seen in rotator cuff dysfunction and deltoid rotator cuff force coupling
imbalances
Studies support validity of visual observation of scapular dyskinesis
Rotator Cuff Function
 What is the function of the rotator Cuff?
 Relationship with scapula
 Arm abduction
(Lateral raises, military press)
 Horizontal adduction
(chest press, fly’s)
 Shoulder flexion
(front raises, boxing)
Observation Examples
Summary
Any questions
?