Transcript Musculoskeletal Dysfunction In The Athlete

Musculoskeletal Dysfunction
In The Athlete
(The Shoulder)
John M. Lavelle DO
Spine Physiatrist
Shoulder Dysfunction
• Very common in the athlete.
– Pain, weakness and limited mobility overhead
• Local extremity dysfunction, axial skeletal problem or
combination of both.
• Orthopeadic problem –
– Tendonitis, Impingement, RTC tear, Hill-Sachs deformity,
Dislocation, etc
• Is there a Somatic Component?
Anatomy
• Shoulder:
– Mobile joint with a shallow glenoid
fossa.
– Minimal osseous support.
– Joint of greatest mobility, thus joint
of greatest instability.
• Four joints: Scapulothoracic,
Acromioclavicular, Glenohumeral,
Sternoclavicular
– Restriction in any one of these can
alter proper shoulder mechanics
• Assess them all for any
restrictions in motion.
• RTC:
– Supraspinatous, infraspinatous,
subscapularis, teres minor
• Supraspinatous torn in approx
90% of RTC tendonitis cases
Main Shoulder Motions
Adduction
Extension Int.
Rot
Ext.
Rot
Coracobrachialis Supraspinatous Coracobrachialis
Lat dorsi
Subscap
Infraspinatous
Pec Major
Ant
Deltoid
Post Deltoid
Lat dorsi Teres
Minor
Pec Major
Teres Major
Teres
Major
Teres Major
Lat dorsi
Abduction
Mid Deltiod
Flexion
Pec
Major
Ant
Deltoid
Post
Deltoid
History
• Sport
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Pitching, Golf
Rock climbing
Tennis
Gymnastics
• How long season?, Level of play?, Equipment?
• Why presenting now?: Improving?, Same?, Worse?
• FOOSH injury/Collisions/Trauma - Macrotrauma
• Repetitive Overuse (lifting, bending, twisting, etc)
– Microtrauma
Thoracic Dysfunction
• Somatic dysfunction of the thoracic spine/ribs may
produce shoulder symptoms
– Extended Type II dysfunction common
• Segmental dysfunction alters the scapular stabilizing muscles, affecting
the gliding movement of the scapula over the thoracic cage.
• Only the first 20-30° of shoulder abduction occurs without
scapulothoracic motion.
– RTC muscles become irritable and tender
• The sympathetic autonomic outflow for the UE/neck:
T1-T4.
– Somatic dysfunction in this region can lead to increased
stimulation of the sympathetics.
Cervical Dysfunction
• The cervical spine also affects the shoulder.
– C5-C8 nerve roots exit the c-spine thru intervertebral
foraminae and coalesce in the brachial plexus - innervates the UE.
– Somatic dysfunction of the neck.
• Impingement at the nerve root.
• Compression at the brachial plexus.
– Anterior and middle scalenes, first rib and/or clavicular dysfunction, and
myofascial strain
– RTC patients tend to “hike” shoulder:
• Scalene hypertonicity, upper trap tender points, type II cervical
dysfunction, elevated 1st rib, T1 dysfunction
Latissimus Dorsi
• Connection between the pelvis and the UE through
latissimus dorsi muscle.
– Attaches to the iliac crest, the spinous processes of the
lumbar and lower thoracic vertebrae and the bicipital groove.
– In addition, this muscle often attaches to the inferior angle of
the scapula as it passes over the scapula.
• Somatic dysfunction at the thoracolumbar junction can
lead to dysfunction of the UE.
Functional Examination
• Orthopeadic pathology vs Functional conditions
– Evaluate performing sport specific movement
– Musculoskeletal compensations
• normal vs abnormal
– Consider center of gravity, ground reaction forces,
muscle firing patterns and postural patterns
Osteopathic Exam
• Observation:
– Osteopathic standing structural exam.
• Any asymmetry by comparing the mastoid process, AC
joint, spine of the scapula and inferior angle of the scapula
bilaterally.
• Muscle wasting? - focusing on the supraspinatous,
infraspinatous, trapezius, deltoid muscles, rhomboids,
biceps, triceps and levator scapulae muscles.
– AROM: look at cervical’s and shoulder for restrictions
Osteopathic Exam
• Palpation:
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Compare both shoulders - healthy shoulder first.
Palpate the c-spine - restrictions of movement in PROM
Any segmental, Fryette type II, restrictions in the c-spine.
Palpate the thoracic spine - any somatic dysfunction within
the thoracic vertebrae, ribs or musculature.
• Remember that somatic dysfunction in this area will affect
scapulothoracic motion and thus the motion of the entire shoulder
joint.
Osteopathic Exam
• Palpation:
– Along supraspinatous and infraspinatous muscles
– Subscapularis muscle tender point
• Place your palpating finger anterior to the posterior axillary fold and
palpate the anterior boarder of the scapula.
– Biceps tendon
• Place the patients hand in supination and arm in external rotation to
open the bicipital groove and palpate along the biceps tendon for
tenderness.
– Any medial scapular winging - weakness in the serratus
anterior
• Ask the patient to elevate/flex the arm as you depress the arm with
one hand and palpate the scapula with the other.
Neurological Exam
• Upper extremity neurological testing
– Manual muscle tests, Muscle stretch reflexes, Sensation
Shoulder Exam
• PROM
– shoulder flexion, extension, abduction, adduction,
internal and external rotation.
• MMT
– All planes
• Special Tests…
– Neer, Drop arm, Empty can, Hawkins, O’Brien, Apley
scratch, Lift-off, Speed’s, Yergason’s, Sulcus sign,
Apprehension, Relocation test
OMT
• Shoulder:
– Start with upper thoracics, rib and c-spine
– Stay away from painful arcs of motion
– Postural exercises, scapular stabilization, core strengthening –
then shoulder strengthening.
– Indirect techniques until ROM improves
• Acute – treat distant yet related areas
• Chronic – treat key somatic dysfunction
• Remember phases of healing
– “aggressive conservatism”
Conclusion
• Clincal exam/history gives you most of the
information.
• Further work-up with radiographs.
• Reserve MRI/Electrodiagnostics for when diagnosis is
equivocal, management is in question or surgery is
considered.
• Begin treatment with conservative measures
– OMT, NSAIDS, physical therapy.
Thank You!
• References:
– Nelson KE. Somatic Dysfunction in Osteopathic Family Medicine.
LWW, Baltimore MD, 2007: 139-151.
– Malanga GA. Musculoskeletal Physical Examination. Elsevier,
Philadelphia PA, 2006: 59-115.
– Griffin LY. Essentials of Musculoskeletal Care . AAOS, 2005:145-233
Myofascial Release (MFR):
Scapulothoracic Release
Technique
Kristin Garlanger OMS III, OMM Fellow
Chicago College of Osteopathic Medicine
Scapulothoracic Release Technique
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Dysfunction: Restricted motion of the left scapula on the thoracic cage
Objective: Improve scapular motion
Discussion: This technique can be use for both evaluation and treatment
Patient Position: The patient lies on his/her right side with the affected side up. The
patient’s hips and knees are flexed (for stability) and a small pillow is placed under
his/her head for comfort.
Physician Position: The physician stands along side the table facing the patient.
Procedure:
Drape the patients left arm over your right shoulder
Contact the patient’s medial scapular border with your fingertips. Take one step back
with your caudad foot for increased stability.
Control the scapula with both hands and gently assess its full range of motion. Keep in
mind the muscular restrictions that would cause a loss of motion.
Restriction in motion can be relieved by:
a. Holding against a barrier with traction (load and hold)
b. Holding in a position of ease (unload and follow)
c. ROM/ stretching or articulating against the barrier
Reassess the scapulothoracic motion and treat any remaining restrictions.
HVLA: Knee in the Back
Pratik Shah OMS IV, OMM Fellow
Chicago College of Osteopathic Medicine
Knee in back flexed dysfunction
Knee is on segment below on
opposite side of dysfunction
Knee in back extended dysfunction
Knee is on the dysfunction
Key Considerations:
1. Don’t grasp wrists too firmly
2. Always use a pillow
3. Technique is most effective for T2-T6
4. Keep weight balanced over the ischial tuberosities
5. Engage the barrier with lateral translation primarily
Treating Rib Dysfunction with
Functional Technique
Paula Ackerman OMSV, OMM Fellow
Ohio University College of Osteopathic
Medicine
Treatment
1. Patient is lateral
recumbent
2. Physician stands in
front of patient
3. Arm supported
cephalad to elbow
4. Unsupported elbow
hangs toward the floor
5. Physician monitors at
rib angle
6. Motion input is through
upper extremity
7. Monitor increasing ease
through
“stacking”motion
8. Following successful
release, return to
midline and re-test