non-operative management of the athletic shoulder and
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Non-OperativeManagementoftheAthleticShoulderand
OverheadAthleteInjuries
RehabilitationProtocol*SeemoredetaileddescriptionsonnextpagesEvaluation:- SubjectiveHistory:- ObservationofMovementandPosture:o Posture,shoulder,spinal,&scapularpositionassessmentso Scapulartests:
§ ScapularAssistanceTest(SAT)§ ScapularRetractionTest(SRT)• Alternatetest:ScapularRepositionTest
§ FlipSign
o GlenohumeralROM:AROMandPROM§ IRandERat30°and90°ofabduction(inside-lying)§ Forwardflexion,ScapularPlaneElevation,Abduction,Adductionacrossthebody§ FunctionalROM:ApleyScratchTest(IR+Ext,Abd+ER)§ ConsiderationofROMdifferenceswithoverheadathletes§ GlenohumeralInternalRotationDeficit(GIRD)
o ManualMuscleTesting(MMT):
§ ForearmMMTandGripStrengthmeasurements§ Supraspinatus:FullCanTest,&DiagonalHorizontalAdductionTest§ Infraspinatus:StandardMMTtesting§ TeresMinor:PatteTest§ Subscapularis:Lift-offTest§ SerratusAnterior:ModifiedWallPush-upTest§ RhomboidsMMT:StandardMMTtesting§ UpperTrapezius:ShoulderShrug§ MiddleTrapeziusMMT:StandardMMTtesting§ LowerTrapeziusMMT:StandardMMTtesting§ PectoralisMajorMMT:StandardMMTtesting§ LatissimusDorsiMMT:StandardMMTtesting§ Deltoid(Anterior,Middle,&Posterior)MMT:§
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o ShoulderSpecialTest:§ ImpingementTests:• NeerImpingementTest:(passive)• Hawkins-KennedyImpingementSign:(passive)• YocumImpingementTest:(active)• CoracoidImpingementSyndromeTests:
o CoracoidImpingementTesto Cross-ArmAdductionImpingementTest
o BonyInstabilityTests:
§ BonyApprehensionTest§ Inferior/MultidirectionalInstability(MDI)SulcusTest§ AnteriorandPosteriorTranslation(Drawer)Tests
o TendinopathyTests:
§ ExternalRotationLagSign§ Belly-offSign§ Belly-PressModifiedTest§ LateralJobeTest§ BearHugTest(Subscapularis)
o LabralTearTests:
§ ModifiedDynamicLabralShearTest
o SuperiorLabrumAnteriorPosterior(SLAP)Tests:§ PassiveCompressionTest§ PassiveDistractionTest§ JobeRelocationTest§ ActiveCompressionTest§ TheDynamicSpeed’sTest§ ThePronatedLoadTest§ ResistedSupinationExternalRotationTest
o LongHeadoftheBicepsTests:§ Yergason’sTest
o OtherTests:
§ Olecranon-ManubriumPercussionTest§ ShrugSign§ BeightonHypermobilityIndex:(SeeChart)
o FunctionalMovementTests:
§ SeatedRotationalTest§ RollingAssessment:(4directions-supine<->proneUEorLEonly)§ SelectiveFunctionalMovementAssessment(SFMA)§ FunctionalMovementScreen(FMS)§ Y-BalanceAssessment
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Rehabilitation:o Phase1:AcutePhase:§ Goals:
• 1-Decrease/eliminatepainandinflammation• 2-Improveflexibility/mobilitythroughouttheshoulder,scapula,andspine(cervical,
thoracic,andlumbar)• 3-Improve/Retrainstrengthofdynamicstabilizers(musclebalance)• 4-Controlfunctionalstressors,compensatorypatterns,andpoorposture
§ Treatment:
• FollowedexpectedpassiveROMforindividualathletes(comparedtototalarcofmotion),andexpectedalterationsinshoulderROMs,bythesporttheathleteplays.Theseshouldberestoredpriortostrengthening.
• Abstainfromsportingactivitiesthatcouldcompensaterecovery• Modalities,ifwarranted,includingtapingtechniques• ROM:o ImproveIRROMat90°ofabductiontonormalmeasurements,Sleeperstretch,cross-
bodystretcho GraduallyimprovehorizontaladductionandER(donotforceintopainfulER),improve
flexiono Elbow,wristandforearmROM
• Strengthening:o ScapularSerratusAnteriorandLowerTrapeziusretraining/stabilizationexercises
§ RhythmicStabilization,Isometrics,PNF,specificexercises§ Side-lying,Quadruped,Prone,Standing
o RotatorCuffStrengthening(especiallyER):§ Noweight/bands->lightweight/bands->moderateweight/bands§ Inprone,side-lying,quadruped,orstanding
o Elbow,wristandforearmstrengtheningexerciseso Maintain/retraincoreandlowerbodyexercises
- CriteriaforProgressiontoPhase2:o Minimaltonopainorinflammationo NormalROMforIRandHorizontalAdductiono Novisiblesignsofsignificantweakness,scapularwinging,fatiguewithminimalrepetitions
o Phase2:IntermediatePhase§ Goals:
• Tocontinuetoprogressstrengtheningexercises• Restoremuscularbalance/symmetries:left-right,agonist/antagonist• Improveproximalanddynamicstability• Maintain/improveoverallflexibility/mobility• Continueimprovingcoreandlowerbodystrengtheningandconditioning
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§ Treatment:
• Painatrestshouldbeeliminatedbeforebeginningstrengthening(hypertrophy)orplyometricexercises
• ROM:o Continuetostretchandimproveflexibilityforshoulderandspinelimitations,gradually
restorefullshoulderERROM• Strengthening:o Continuetoprogressscapular,rotatorcuffanddynamicstabilizingmuscles(canbeat
endrange)o Maybeginwallstabilizationandpush-upexercises,andUEplyometricPhase1Protocol
(SeeSheet)- CriteriatoProgresstoPhase3:o Full,pain-freeROMo Fullstrengthwithnosignofextremefatiguewithstrengthevaluationtestsorcurrentexercises
o Phase3:AdvancedStrengtheningPhase:§ Goals:
• Beginamoreaggressivestrengtheningprogram• Progressneuromuscularandproprioceptivecontrol• Beginexercisescenteredmorearoundstrength,power,endurance,agility
§ Treatment:
• ROM:o ContinuetomaintainnormalROM/Mobilityo Teachpatientroutineforactivewarm-upstretchespre-work/competition,andstatic
cool-down/post-workoutstretches• Strengthening:Besuretopatientgoesthroughstretchingroutinebeforebeginning
strengtheningexerciseso Continueanypreviousstrengtheningexercisesthatareappropriateo Thrower’sTenProgram->progressedtoAdvancedThrower’sTenProgram:(see
attachedsheets)o BeginPhaseII->IIIofUEPlyometricProtocol(Seeattachedsheets)o PatientmaybeginPhaseIofintervalsportsprograms(ThrowingandTennis)
• Assess/ReassessFunctionalMobility:o FunctionalMovementScreen(FMS)o Y-BalanceUEandLEassessmenta. TrunkTesting:(Seeattachedsheets)
i.DeepNeckFlexorTestii.SegmentalMultifidusTestiii.TrunkCurl-upTestiv.Double-LegLoweringTestv.ProneBridgeTestvi.EnduranceofLateralFlexors(SideBridge)vii.ExtensorDynamicEnduranceTest
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b. UpperExtremityTesting:(Seeattachedsheets)i. AlternativePull-upTestii. Push-upTestiii. BackwardO.H.MedicineBallThrowTestiv. SidearmMedicineBallThrowTestv. SeatedShot-PutThrowTest
- CriteriatoProgresstoReturntoSpecificSportProtocols:o ExpectedactiveROM,withnormalmovementpatterns,shouldberestoredbeforebeginning
hypertrophystrengtheningorplyometricexerciseso Patientshouldbeabletodemonstratepain-freenormalmovementpatternsthroughmulti-
planarmovements,with45-60repetitions(goodendurance),beforeprogressiontoeccentric,plyometric,and/orhighloadexercises
o Patientmustcompleteplyometricprogram(UE&LEifappropriate),Score³16ontheFMSä(withnoasymmetries,Y-Balanceäscoreshouldbeequaltopeersofthesameageandsportalongwithnoasymmetries,score____ontheDASH/PSS(orlow/nodisabilityonchosenselfevaluationassessment)
o Passingofthefunctionaltestslistedabove:Testcanbeovermultiplesessions
• SeeSportSpecificProtocolsClinicalEvaluation:(MoreDescriptiveVersion)- SubjectiveHistory:o GeneralInformation:
§ Age,§ Gender,§ Dominant-handedness,§ Sportplayed&position,§ Numberofyearsplaying,§ Levelofcompetition.
o InjuryInformation:§ Onsetofsymptoms&weretheygradualorsuddenintheironset,§ Historyofpreviousshoulderinjury,§ Locationofsymptoms,§ Description,severity,anddurationofsymptoms,§ Activitiesthatalleviateorworsensymptoms,§ Phasesofthroworswingthatproducethesymptoms,§ Numberofinningspitched/numberofgamesplayedperseason/year,§ Changesincontrol/locationofswings/throws.
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- ObservationofMovementandPostureo Posturalassessment
§ Shoulderheightbilateralcomparison-(typicallythedominateshoulderislowerthanthenon-dominateshoulder,atrest,particularlywithunilaterallydominateathleteslikebaseballpitchersandtennisplayers)
§ Scapularposition(rotation,positionagainstthethoracicwall/tilting,andmovement:(scapulothoracic,andscapulohumeral))righttoleftcomparison• Kiblerdescribes3primarytypesofscapulardysfunctionsandtestedinrestingstance,
handsontheirhips,andduringbilateralactivemovementsinthesagittal,scapularandfrontalplanes(Below)
• Theuseofanexternalload,suchasholdingafreeweightmaybenecessarytoelicitthescapulardysfunctioninathleteswherethescapulardysfunction/pathologymaybesubtle
• *Scapulardissociationawayfromtheribsistypicallyseenwithsloweccentricloweringoftheextremities,sotheclinicianshouldcarefullyobservealldirectionsofmovementcarefully.
• ScapularPositionConsiderationsfortheOverheadAthlete:TheThrowingsidemayhave’dprotractionandanteriortilting,especiallywithfatigue.
CharacteristicsatRest CharacteristicswithMovement AxisofMotionName/Dysfunction InferiorAngle(TypeI) Inferiormedialborderof
thescapularisprominentwhenviewedposteriorly
Inferiormedialborderofthescapulamovesdorsally,superioranteriortiltsandtheacromiontiltsdownwardandmovesventrallyoverthethorax
Sagittalplane
MedialBorder(TypeII) Theentiremedialborderofthescapulaisprominentwhenviewedposteriorly
Entiremedialbordermovesdorsallyawayfromthethorax
Transverseplane
SuperiorBorder(TypeIII) Superiorborderofthescapulaisprominentandoftenelevatedcomparedtothecontralateralside
Ashruggingorsuperiormotionisusedtoinitiatemovementoftheshoulderalongwithprominenceofthescapulacomparedtothecontralateralside
Sagittalplane
*Thescapulardysfunctiondoesnotalwayspresentasclearlyaslistedabove,andinmanycases,becauseofthecomplexityofmovementofthescapulothoracicjoint,thepatientcandemonstratemorethanoneclassificationatatime*
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o (InStanding)Observeshoulderandscapularmuscles-particularlyfocusingonmuscledevelopmentandareasofatrophy.Patientshouldbeobservedwithhandscomfortablebytheirside,aswellas,withhandsontheirhips(placesshouldersin45°-50°ofabductionandslightinternalrotation.ThisallowsthePatienttoletarmsrelaxandwillshowmoreapparentpocketsofatrophyalongthescapularborder.
§ VisibleatrophyintheInfraspinatusfossacouldbeasignsofRotatorCuffDysfunctionorwithsevereatrophytherecouldbesuprascapularnerveinvolvement-furtherdiagnostictestingwouldbewarranted.
- ScapularTests:o ScapularAssistanceTest(SAT):Theclinicianplacesonehandontheinferiormedialaspectof
thescapulaandtheotheronthesuperiorbaseofthescapulatoprovideanupwardrotation(andposteriortilt),whilethepatientelevatedtheirarmeitherinthescapularorsagittalplane.ThetestispositiveifthereisagreaterROMordecreasedpain(eliminationoftheimpingementtypesymptoms),withtheclinician’sassistwithscapularmovement.
o ScapularRetractionTest(SRT):Theclinicianmanuallypositionsthescapulainretraction,(toimprovesupraspinatusstrength,optimizingaweakenedcuffandgivingatruerideaofsupraspinatuspower),andhasthepatientperformanupperextremitymovementthatwouldtypicallyelicittheirsymptoms.
§ TheScapularRepositiontest:(alternativetest):testedwellinastudywith142collegeoverheadathletes.Thistestisperformedwiththepatientinsittingorstanding.Thecliniciangraspsthescapulawiththefingerscontactingtheacromioclavicularjointanteriorlyandthepalmofthehandandthenareminencecontactingthespineofthescapulaposteriorly,withtheforearmobliquelyangledtowardtheinferiorangleofthescapulaforadditionalsupportonthemedialborder.Thepatientwasthenaskedtorepeatamovement/testpositionthatpreviousreproducedtheirpain.Areductionofpainof>1onaVASpainscale,maybeawaytoidentifysuitableinterventionsforaddressingthescapula,suchastaping,strengtheningspecificmuscles,orbracing.
o FlipSign:TheclinicianresistsExternalrotationatthepatient’selbow,whilecarefullymonitoringforapositivetestwhenthescapulaforanysignsofwinging(scapula“flips”awayfromtheribsandbecomesmoreprominent).Apositivetestindicatesalossofscapularstability,andshouldsuggestfurtherevaluationofthescapulamusclesandnerveinnervationsandexerciseintegrationshouldfocusonserratusanteriorandthetrapeziusinitiation/strengthening.Thistestwasoriginallydescribedintestingforspinalaccessorynervelesions.
- GlenohumeralROM:o Goniometricmeasurementsarebestwithscapularstabilizationusinga“C”shapetypegrasp
withfourfingersonthescapulaposteriorlyandthethumbonthecoracoidprocessanteriorly.o MeasurementsshouldbetakenofAROMandPROMofIRandERat90°ofabductionwiththe
patientinside-lying[betterinterandintraraterreliability]:(ERnorm:90°,IRnorm:30°-45°);*seeOHAthleteConsiderationsbelow),scapularplaneelevation:(norm:160°-180°),forwardflexion(norm:160°-180°),abduction:(norm:160°-180°)*documentifpatientexhibitsapainfularc,adductionacrossthebody:(norm:90°),andExtension:(norm:40°-60°).
§ ReliabilityofROMmeasurementsforInternalRotationwasfoundtobehigherwhentakenwiththepatientinthesidelyingposition.Thepatientislyingontheirside,inapositioninwhichtheacromionprocesseswerealignedperpendiculartotheplinth.The
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shouldershouldbein90°offlexionwith0°ofrotationandtheelbowisflexedto90°.Theolecranonprocessshouldbepositionedofftheedgeofthetable.Theclinicianpassivelyrotatesthehumerusintointernalrotation,whilemaintainingtheshoulderandelbowflexionat90°.Comparisonofbothsideswasmade.
o YoushouldalsocheckfunctionalmovementpatternsofIRandextension(T7forwomen,T9forMen),andAbductionandER(spineofcontralateralscapula),likeintheApleyScratchTest,SFMA,orsimultaneousmovementintheFMS.
o OthermotionsthatarerecommendedforathletesareHorizontal(cross-arm)Adduction-Thiscanbedoneindifferentpositions,however,theoptimalpositionispatientsupinewithscapularstabilizationprovidedbytheclinicianatthelateralborderofthescapulatokeepitinretraction,whilethepatient’sarmisguidedintohorizontaladductionwithoutoverpressure.
o *Theuseofadigitalinclinometerhasbeenshowntohavehighreliability.- ConsiderationsofROMmeasurementswithoverheadathletes:o IthasbeenshownthatinbaseballplayersthattheytypicallyexhibitincreasedERanddecreased
IRonthedominantarmshoulderwhencomparedtothenon-dominantside.*However,thetotalarcofrotationalmotionshouldequalonbotharms.(Nogreaterthan+/-5°)
§ Ex.Ifapatientismeasuredat120°ofERand30°ofIRontheirdominantshoulderand90°ofERand60°IRontheirnon-dominantarm,thetotalarcofmotionbothshouldersequals150°andisconsiderednormalforbaseballpitchers.
o Withregardstotennisplayers,Ellenbeckeretal.foundtheyhadsignificantlylessinternalrotationontheirdominantarm,aswellassignificantlylesstotalarcofrotationalmotioncomparedtotheirnon-dominantarminuninjuredathletes.
§ Theyfoundapproximately10°lesswithIRROMandofthetotalarcofrotationalmotioninthedominantarmofnon-injuredathletescomparedtotheirnon-dominantshoulder.
- GlenohumeralInternalRotationDeficit(GIRD):o Thisconditionhasseveraldefinitionsincluding,greaterthan20°-25°lossininternalrotationon
thedominantsidewhencomparedtothenon-dominantside;oralossof10%ormoreofthetotalrotationROMonthedominantsidecomparedtothenon-dominantside,whichismorewidelyused.
§ So,ifstillusingthenumbersfromthelastexamplealossof15°ormoreonthedominantsidewouldconstituteaconclusionofGIRD.
§ Wilketal.reportedthatalossoftotalarcofmotionof>5°wasfoundtoplaceathletesatahighriskofshoulderinjury.
§ Wilketal.Alsoexpressedthatthereisanincreasedriskofshoulderinjurywhenthetotalarcofmotionwasgreateronthethrowing/dominantsideintheoverheadathlete.
• Thetherapistshouldassessthedynamicstabilityoftheglenohumeraljointintheeathletesanddevelopaprogramaccordingly.
o *AcautionwithGIRDisthatthemobilityrestrictionmayactuallybearesultofthoracicspineand/orribshypomobility/dysfunction,whichcouldpresentasafalsepositiveforGIRD/Posteriorcapsuletightness.Thedysfunctionshouldbetreatedoutandmotionreassessed.Whatappearstobeposteriorcapsuletightnessoftheshoulderoftenresolveswithmobilizationoftheribcagetopromotethoracicrotationtotheoppositeside.(SeethemobilizationsectioninSuggestedSpecificExercises).IftheIRROMlimitationisstillpresent,thanjointmobilizationandposteriorcapsularstretching,andappropriatestrengtheningexercisesshouldbeinitiated.
- ManualMuscleTesting(MMT):
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o ForearmStrengthTests:GripStrengthandMMT
o Supraspinatus:Theoptimaltestingposition,foundbyKellyetal.,isseatedwithelevationofthearmto90°inthescapularplane(45°horizontaladductionfromthecoronalplane)withERofthehumerussotheirthumbispointedtowardtheceiling.ThisisalsocalledtheFullCanTestingPosition.Theclinicianresistsanupwardmotionexertedbythepatient.
§ TheEmptyCanPositionTesthasalsobeenfrequentlyused,whichisthesamestartingpatientpositionwiththeexceptionofthehumerusbeinginIRwiththethumbpointingdowntothefloor.*Thesetestsreportgreatpredictabilitywithtestingweakness(whichisthecapacitybeingusedhere),versuspain.Bothtestsareconsideredtohaveequivalentdiagnosticaccuracy,howeverconsideringthepainprovocationistypicallyhigherwiththeEmptyCanTest,andthisistestisbeingusedtotestweaknesstheFullCanpositionispreferred.
§ TheDiagonalHorizontalAdductionTests:Patientisseatedwiththeelbowextendedandtheirarmfullyexternallyrotated,at35°ofshoulderflexion,andthenadductedacrossthepectoralareaofthebody.Thepatientisthenaskedtolifttheirarmup(intohorizontalabduction)andtheclinicianperformsanisometricresistance.Thepatientisaskedtomaintainthecontractionforapproximately5seconds,tofeelforanyweakness.ThistestshouldbeusedinconjunctionwiththeFull-CanTesttoassesssuprspinatusweakness
o Infraspinatus:Theoptimaltestposition,accordingtoKellyetal.,iswiththepatientseatedwith0°ofGlenohumeralJointelevationandin45°ofIRfromneutral.ThenthepatientpushesintoERandtheclinicianresistthemotionwhilemonitoringtheelbow.Testforweaknessandcompensation.
§ ThereisanalternativetestpositionthatwasdescribedbyJenpetal.,inwhichthepatient’sarmisin90°ofelevationinthesagittalplane,withtheelbowbentandpositionedinthehalfwaypointtomaximalERROM.ThiswasnottestedwithEMGlikeKellyetal.,howevermaybeusefulwithsomeoverheadathletesforafurtherevaluationofinfraspinatusstrength.
o TeresMinor:(PatteTest):thepatent’sshoulderispositionedin90°ofabductioninthescapularplaneand90°ofER.ThepatientpushesintoERwhilethecliniciansupportstheelbowandresiststhemovement.Theclinicianshouldbemonitoringforweaknessaswellascompensatorymotions.
o Subscapularis:Kellyetal.,foundtheoptimaltestistheLift-offTestinwhichapatientisstandingwiththearmIR,extendedbehindtheback,sothedorsumortheirhandisrestinginthemiddleoftheirlowback.Theclinicianthenliftsthedorsumoftheirhandawayfromtheirbackandthepatientisaskedtomaintainthisposition.Thecliniciancanalsoaddresistance,ifthepatientisabletoinitiallyabletoholdtheliftoffposition.
§ Analternativeposition,describedbyStefkoetal.,iswiththedorsumofthepatient’shandplacedupneartheinferiorborderoftheipsilateralscapula,wheretheyfoundthehighestmuscularactivity.
o SerratusAnterior:Patientperformsamodifiedpushupagainstthewall.Theclinicianshouldbenoteifpatientexhibitsanyscapularwinging.
o Rhomboids:Patientispronewitharmextendedandslightlyadductedcontractingtherhomboids.Thepatientresists/holdsthispositionasyoutrytomovethescapulafromthe
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medialborderlaterally.Weaknessisifpatientisunableorhasdifficultyholdingthescapulainthatpositionwithorwithouttheresistance.
o Trapezius:§ UpperTrapezius:Patientseatedandperformsashouldershrug.Theclinicianresiststhe
motionandnotesweaknessorinabilitytoevenachieveshrugposition.§ MiddleTrapezius:patientispronewithelbowextendedandabductedto90°inexternal
rotation,sothumbisuptowardstheceiling.Patientisaskedtoholdthepositionagainstresistance.Weaknessisifpatientisunabletoachieveorholdpositionwithorwithoutresistance.
§ LowerTrapezius:Patientispronewithelbowextendedandshoulderabductedto120°inexternalrotationsothethumbistowardtheceiling.Thepatientisaskedtoholdthepositionagainstresistance.Weaknessisifthepatientisunabletoachieveormaintainthepositionwithorwithoutresistance.
o PectoralisMajor:Patientisinsupineorstandingposition.Thepatientadductsthearminabout20°offlexionwiththeelbowslightlybentandresiststheclinician’sforcepushinglaterally.Weaknessiswhenhepatientcannotmaintainpositionwithresistance.
o LatissimusDorsi:Patientisinpronewitharmofthesidebeingtestedofftheedgeofthetable.Thepatientisthenaskedtointernallyrotate,adductslightly,andextendtheshouldertheclinicianthenappliesresistance.Weaknessisifthepatientcannotachieveofholdthepositionwithorwithoutresistance.
o Deltoid:Weaknessisifpatientcannotachieveormaintaintheposition.§ AnteriorDeltoid:Theclinicianresistspatientinforwardflexionoftheirshoulder.§ MiddleDeltoid:Theclinicianresistspatientinabductionwiththeirelbowflexedto90°.§ PosteriorDeltoid:Theclinicianresistspatientinshoulderextensionwiththeelbow
flexedat90°.
o *Thesetestscanalsobeperformedinamoreobjectivemeasurementusingahandhelddynamometer(HHD).Thesehavebeenshowntobereliablestrengthmeasurementsandhavehighinter-andintra-raterreliability.Theyalsogivemoreobjectivenumberstothestrengthmeasurements.StatisticalrelationshipshavebeenshownbetweenERandsupraspinatusstrengthmeasurementswithaHHD,andshoulderinjury.TherewasalsoasignificantrelationshipbetweenIR/ERmuscularstrengthratiosandinjuryrisk.SeeSeparatesheetforHHDInstructions.
o IsokineticMuscleTesting:Thiscanbeusedtogetobjectivemeasurementsofdynamicmuscularstrength.Ellenbeckeretal.,comparedisokinetictestingandMMT.Theyassessed54subjectstoexhibit5/5strengthusingMMT,whileisokinetictestsfound13%-15%bilateraldifferenceinERand28%bilateraldifferenceinIR,despitesymmetricalMMTstrengthassessment.
- ShoulderSpecialTests:(RotatorCuffImpingement,AKA:RTCTendinosis/Tendinopathytests,SubacromialImpingementtests,CoracoidImpingementtests,ACJointImpingementtests,LabralTeartests,SLAPLesionstests,BonyInstabilitytests):o ImpingementTests:(Passive):Theprimarygoalsistoattempttore-createthesubacromial
compressionandsymptoms§ NeerImpingementTest:Theclinicianmonitorsthehumeralheadstabilizesthescapula
andpreventsscapularrotationwithonehand,astheypassivelymovethepatient’sarm
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intomaximalforwardflexion/elevationwiththeotherhand,whichcausesthegreatertuberositytoimpingeagainsttheacromion.Positivetestisreproductionofthepain.
§ Hawkins-KennedyImpingementSign:Theclinicianmonitorsthehumerusandbringsthepatient’sshoulderintoelevatedinthescapularplaneto90°,withtheelbowflexed,andthenforcefullyinternallyrotatesthepatient’sarmrotatingtheshoulder,down,inthesagittalplane.Thetestispositiveifthepatient’spainisreproduced.
§ EvidenceshowsthattheNeerandHawkins-Kennedybothhavehighsensitivitybutlowspecificity,sotheyaresuitableforscreeningbutnotformakingaspecificdiagnosis.Howevertheycanbeusedinaclustertypediagnosisofmultiplepositivetestsincreasethelikelihoodofthediagnosis.
o CoracoidImpingementSyndrome:Patientpresentswithanteriorshoulderpain,withincreasedpainwithforwardelevation,internalrotation,adduction,andpositivefindingswiththenexttwotests.(SeeAttachedAlgorithm)
§ CoracoidImpingementTest:Patientsshoulderispassivelybroughtintoforwardelevation,adductionandinternalrotation.Apositivetestispain,directlyoverthecoracoidprocess,andclickingwiththemovement.
§ Cross-armAdductionImpingement:Patient’sarmisbroughtpassivelyinto90°offlexionandthenforcefullybroughtintohorizontaladductionacrosstheirchest,performedeitherbythepatientortheclinician.Painandlocationisdocumented.ThistestcanshowpossiblecoracoidimpingementorACjointpathology.
o ImpingementTest(Active):§ YocumImpingementTest:Thepatientbeginswiththepalmofthehandofthearm
beingtestedrestingonthetopoftheoppositeshoulder.ThepatientthenmovesintoelevationwithIR,bringingtheirelbowuptowardtheirface.Thistestislookingforprovocationofsymptoms,aswellas,assessesthepatient’sabilitytocontrolthesuperiorhumeralheadtranslationduringactivearmelevation,whileinapositionofimpingement.
- BonyInstabilitytests:o BonyApprehensiontest:Patientiseitherpositionedinsittingorstandingwiththeelbowflexed
to90°.Theclinicianstandsbehindthepatientholdingtheirlateralforearmwithonehandandplacingtheotherhandontheposterioraspectofthehumeralhead.Theclinicianbringsthepatient’sarminto45°ofabductionand45°ofexternalrotation.Apositivetestiswhenthepatientdemonstratesapprehensionwithorwithoutpain.
§ TestRationale:TheauthorchosethepositioningoftheglenohumeraljointtoprovokeinstabilityfromabonyBankartlesionand/oraHill-Sachsbonylesion.Thistestmaybeusedforbothrulinginoroutadiagnosisofbonyinstability.
o Inferior/MultidirectionalInstability(MDI)Sulcustest:Patientisseatedwitharmsinneutraladduction/abductionwiththeirhandsrestingontheirlap.Thecliniciangraspsthedistalaspectofthehumerususingafirmbutnotpainfulgripwithonehand,whiletheotherhandmonitorstheACJoint.Theclinicianthenperformsseveralbriefandrapiddownwardpullsonthehumerusinaninferiordirection.Theclinicianiswatchingforavisiblesulcussign,ortetheringoftheskinbetweentheacromionandtheheadofthehumerus,wideningthesubacromialspace.A>2cmsulcusisconsideredapositivetestandmaybeindicativeofMDI.
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§ TestRationale:Thistest,whenperformedinneutral,assessestheintegrityofthesuperiorGlenohumeralligamentandthecoracohumeralligament,whicharetheprimarystabilizingligamentsagainstinferiorhumeralheadtranslation.ItIalsobelievedthatexcessivetranslationintheinferiordirectionisanindicationthattheremaybeapatternofforthcomingincreasesintranslationintheanteriorandposteriorpositions,hencethetermMultidirectionalInstability.
o AnteriorandPosteriorTranslation(Drawer)tests:Patientisthesupineposition,becauseofgreaterinherentrelaxationofthepatient.
§ ThetestpositionforAnteriorTranslationisperformedbetween0°and30°ofabduction,in30°-60°ofabduction,andat90°ofabductiontotesttheintegrityofthesuperior,middle,andinferiorglenohumeralligaments,respectively.Thetranslationisperformedwithadownwardpressureontheheadofthehumerusalongtheplaneofthejointline(approximately30°inamedialtolateraldirection).
§ ThetestpositionforthePosteriorTranslationisat90°ofabduction,becausethereisnodistinctthickeningofthecapsule,exceptwiththeposteriorbandoftheinferiorGlenohumeralligament.Thecliniciandirectedforceisanteriorlyalongtheplaneofthejoint(approximately30°inalateraltomedialdirection).
§ Positivetestsareifunilateralincreasesintranslationarepresentinoneormoredirections,inthepresenceofshoulderpain.Increasedtranslationwithoutshoulderpainmerelysuggestslaxity.
- Tendinopathytests:o ExternalRotationLagSign:(supraspinatusandinfraspinatusmuscles):Thepatientissittingor
standingwiththeirelbowflexedto90°andshoulderabducted20°withtheforearmsupinatedsothepalmisup.Thecliniciansupportsandmonitorstheelbowastheypassivelyrotatesthepatient’sarmintofullexternalrotation.Apositivetestiswhenthepatientisunabletomaintainpositionoffullexternalrotationoftheaffectedshoulder.
§ TestRationale:Sensitivity=45%-70%,Specificity=91%-100%
o Bellyoffsign:Thepatientisineithersittingorstanding,withtheclinicianstandinginfrontofthepatient,whilepassivelymovingtheaffectedarminflexion,supportingtheelbowin90°flexion,whiletheotherhandbringsthepatient’sarmintomaximalinternalrotation,sotheirpalmisontherebelly.Thepatientisthenaskedtokeeptheirwriststraightandactivelymaintainthispositionofinternalrotationastheclinicianreleasesthewrist(maintainingtheelbowsupport).Apositivetestoccurswhenthepatientisunabletomaintaintheposition,thewristflexesorlagoccursandthehandisliftedofftheabdomen.
§ TestRationale:Thesubscapularismuscleistheprimaryinternalrotatorandthistestevaluatestheintegrityofthemusculotendinousunit.
o BellyPresstestModified:Thepatientispositionedinsittingorstandingwiththehandontheaffectedsideflatontheirabdomenandtheelbowclosetothebody.Theclinicianstandsontheaffectedsideofthepatientandinstructsthepatienttobringtheelbowforwardstraighteningthewrist.Theclinicianmeasuresthefinalangleofthewristandcomparesittothenon-affectedside.Apositivetestisagreaterthana10°differencebetweensides.
§ TestRationale:Sameasthenon-modifiedversion,withthemodifiedversiongivinganobjectivenumberofdysfunction.
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o LateralJobeTest:Thepatientispositionedinsittingorstanding,andtheclinicianinstructsthepatienttoabducttheirshoulderto90°inthecoronalplanewiththeelbowflexedto90°andtheshoulderinternallyrotatedsothatthefingerspointtowardthefloorandthethumbismedial.Theclinicianthenappliesaninferiorforcetothedistalarm.Apositivetestfindingispainorweaknessorinabilitytoperformthetest.
§ TestRationale:Sensitivity=81%,Specificity=89%§ Theevidencesuggeststhatforthelastthreetests(Bellypress,Bellypressmodified,
andLateralJobe)canallbeusedforbothrulinginandoutsubscapularisandrotatorcufftendinopathy,respectively.
o TheBear-Hugtest:(subscapularistear):Thepatientisinstandingwiththepalmoftheinvolvedsideplacedontheoppositeshoulderwithfingersextended(sothepatientdoesnotresistbygrabbingtheirshoulder),withtheirelbowinfrontofthebody.Theclinicianasksthepatienttoholdthepositionastheytrytobringtheforearmintoexternalrotation(resistedinternalrotation),withaperpendicularforcetotheforearm.Thetestisconsideredpositiveifthepatientisunabletomaintainthehandagainsttheshoulderorftheyshowweaknessofgreaterthan20%whencomparedtotheunaffectedside.Ifthepatientexperiencedpainwithoutweaknessitshouldbenoted,becausetheirwassomecorrelationwithpainandsmalluppersubscapularistears,althoughitcan’tbequantified,thesurgeonmaywanttobenotifiedofthefinding.
§ TestRationale:Thesubscapularissuperolateralcornerandtheslingofthebicepssharethesamegeneralinsertionpoint,sothatiftheslingisdisrupted,thebicepsmaysubluxmediallycausingtearingoftheuppersubscapularis.Activationofthesubluxatedbicepsduringthebear-hugtestmaycauseexcessiveshearstressesonanalready-damageduppersubscapularis,explainingthepainandweaknessobservedinapositivetest.
§ Thistesthasaspecificityof92%andsensitivityof60%,showingthistestisgoodforrulingasubscapularistearin,andhadbeenshowntodetecttearsizesaslowas30%.Mostsensitivetestforsubscapularispathology.
- LabralTearTests:o ModifiedDynamicLabralShearTest:Patientisstandingwithelbowflexed90°,abductedinthe
scapularplane>120°andexternallyrotatedtotightness.Theclinicianstandsbehindthepatient,guidingtheinvolvedupperextremityintomaximalhorizontalabductionandprovideashearloadtothejointbymaintainingexternalrotationandhorizontalabductionasthearmisloweredfrom120°-60°ofabduction.Apositivetestisreproductionorpainand/orpainfulclickorcatchintheposteriorjointlinebetween120°and90°.
§ TestRationale:Thearmpositionandloadapplicationforthistestwastotrytomimicthepeel-backphenomenonandthebicepsmovementthatcreatetheshearingmechanismofposteriorcuffontheposterosuperiorlabrum.
- SuperiorLabrumAnteriorPosteriorlesion(SLAP)tests:o DiagnosingaSLAPlesion:
§ Whentakingthesubjectivehistorypatientmayreportahistoryoftraumasuchasafallontoanoutstretchedarm,directblowtotheshoulder,fallingontothepointoftheshoulder,oraforcefultractiononthearm.Inthesecasestherewouldbeasuddenonsetofsymptoms.However,patients,especiallyoverheadathletes,mayreportamoregradualonsetofsymptoms,suchaspopping,clicking,orcatching,alongwithpainduring
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throwing(usuallylatecockingphase),andadecreaseinpowerandaccuracywiththerethrows
o SLAPClassifications:(basic4,however,recentlyadditionalclassificationshavebeenadded):§ TypeI:IsolatedFrayingofthesuperiorlabrum,withafirmattachmentofthelabrumto
theglenoid(typicallydegenerativeinnature)§ TypeII:Adetachmentofthesuperiorlabrumandtheoriginofthelongheadofthe
bicepsbrachiitendonfromtheglenoidcreatinginstabilityofthebiceps-labralanchor§ TypeIII:Abucket-handletearofthelabrumwithanintactbicepsinsertion§ TypeIV:Abucket-handletearofthelabrumthatextendsintothebicepstendon.This
typewillalsohaveinstabilityatthebicep-labrumanchor§ TypeV:SLAPlesionswiththepresenceofaBankartlesionoftheanteriorcapsule
extendingintotheanteriorsuperiorlabrum§ TypeVI:Adisruptionofthebicepsanchorwithananteriorposteriorsuperiorlabralflap
tear§ TypeVII:Lesionsthatextendedanteriorlytoinvolvetheareainferiortothemiddle
glenoidligament§ TypeVIII:AtypeIISLAPtearwithaposteriorlabralextensiontothe6o’clockposition.§ TypeIX:Isacircumferentiallesioninvolvingthefull360°oflabralattachmenttothe
glenoidrim§ TypeX:Ininvolvesasuperiorlabraltearcombinedwithaposteroinferiorlabraltear(a
reverseBankartlesion)§ *ItiscommontohaveconcomitantinjurieswithSLAPlesions,sotheseclassifications
canbebeneficialforcreatingthemotappropriatetreatmentplan*- SpecialTests:o PassiveCompressiontest:Patientisinsidelyingwiththeaffectedsideup.Theclinicianis
standingbehindthepatient,stabilizingtheshoulderbyholdingtheACjointwithonehandandthepatient’selbowwiththeother.Theclinicianexternallyrotatestheshoulderin30°ofabductionandthenpushesthearmproximallywhileextendingtheshoulder.Apositivetestoccurswhenthereispainorapainfulclickintheglenohumeraljoint.
§ TestRationale:Whentheglenohumeraljointisexternallyrotatedandextended(latecockingphase),thelongheadofthebicepstendonisplacedundertensileforceswhilewrappingaroundthelessertuberosityandultimatelyshiftingthesuperiorlabrumfromthesuperiorglenoidrim.Proximalmigrationofthehumerusaggravateshedisplacementoftheunstablelabrumandpassivelydisplacesthesuperiorlabrum.EvidenceshowsthistestcanbeusedforrulingaSLAPlesionin.
o PassiveDistractiontest:Patientissupine,withtheclinicianstandingontheaffectedsideofthepatient.Thepatient’sarmispositionedofftheedgeoftableinto150°abductioninthecoronalplane,withtheelbowextended,theforearmsupinated,andtheupperarmstabilizedtopreventproximalhumerusrotation.Theclinicianthenpronatestheforearm,whilemaintainingtheheadofthehumerusposition.Apositivefindingiswhenthepatientreportspaindeepintheglenohueraljointeitheranteriorlyorposteriorly.
§ TestRationale:Mimicsthepeel-backphenomenonofthesuperiorlabrum.EvidenceshowsthatthistestcanbeusedforbothrulingaSLAPlesioninorout.
o JobeRelocationtest:Thepatientispositionedsupine,withtheirelbowflexedto90°andshoulderabductedto90°.Theclinicianappliesanexternalrotationforce,andanyapprehensionisnoted.Theclinicianthenappliesaposteriorlydirectedforcetotheshoulder.Ifthepatient’s
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painorapprehensionisreducedinthispositionthan,thetestisconsideredpositive.*Itisimportantthatthepatientreleasestherelocationforcebeforebringingthepatientbacktoneutralpositioning,todecreaseriskofdislocation.
§ TestRationale:Thistestwasfoundtohaveahighersensitivity(85%)forposteriorlesionsthanforanteriorlesions.Throwershavebeenfoundtohavea3timesgreaterlikelihoodfordevelopingTypeIIposteriorlesions.Morganetal.
o ActiveCompressiontest:Thepatientisinsittingorstanding,withtheirshoulderplacedin90°orflexionand10°-20°ofhorizontaladduction.Thepatientthencompletelyinternallyrotatestheirshoulderandpronatestheirforearm.Theclinicianthenappliesastabilizingforcedistallyontheextremity,asthepatientisinstructedtoperformanupwardforceintotheclinician’spressure.Theprocedureisthenrepeatedwiththeshoulderandforearminneutralposition.Apositivetestoccurswithpainreproductionorclickingintheshoulderwiththefirstpositionandreduction/absenceinthesecondposition.ThistestisalsonegativewhenareportofpainislocatedovertheACjointortheposteriorshoulder,asitisnotspecificenoughtosuggestalabral(SLAP)lesion.
§ TestRationale:Thistesthasbeenreportedashavingahighersensitivity(88%)foranteriorlesions.Thetraumapatientshavebeenfoundtobe3Xmorelikelytopresentwithanteriorlesions.Morganetal.
o PainProvocationTest:Thepatientissupinewiththeirshoulderabductedto90°-100°.Theirshoulderisthenpassivelyexternallyrotatedwiththeforearmfullypronatedandthenrepeatedwiththeforearmfullysupinated.Thistestisconsideredpositiveifthesymptomswerepresentormoresevereintheexternallyrotatedpronatedpositionversusthesupinatedposition,secondarytotheadditionalstressplacedonthebicepstendonwiththeshoulderexternallyrotatedandforearmpronated.
§ TestRationale:Thistesthasdemonstratedasensitivityof100%,andaSpecificityof90%fordiagnosisaSLAPlesion.
o TheBicepsLoadIITest:Thepatientisinsupinewiththeirshoulderplacedin120°ofabductionandmaximallyexternallyrotated.Whentheshoulderisinmaximalexternalrotationthepatientisaskedtoperformaresistedisometricbicepscontraction.DeepshoulderpainisindicativeofaSLAPlesion.
§ TestRationale:Thistesthasasensitivityof90%,specificityof97%,PositivePredictiveValueof92%,andNegativePredictiveValueof96%.ThistestwasfoundtohaveahighersensitivitythantheBicepsITest,whichisperformedin90°ofshoulderabduction.
o TheResistedSupinationExternalRotationTest:Thepatientisinsupinewiththeirshoulderabductedto90°,elbowflexedto65°-70°,andforearminneutralrotation.Thepatientisaskedtotrytoforcefullysupinatetheirforearmwhiletheclinicianresistsandpassivelyrotatestheirshoulderintoexternalrotation.Thepatientisthenaskedtodescribetheirsymptomsatendrangeexternalrotation.ApositivetestIifthepatientdescribesanteriorordeepshoulderpain,clickingorcatchingintheshoulder,orareproductionofthesymptomstheyexperienceduringthrowing.Itisanegativetestifthepatientdescribesposteriorpain,apprehension,orifnopainwaselicitedwiththemaneuver
§ TestRationale:Itisbelievedthatthistestsimulatesthepeel-backmechanismofaSLAPlesion.Thistesthasbeenreportedtohave82.8%sensitivity,81.8%specificity,92.3%positivepredictivevalue,and64.3%negativepredictivevalue,withadiagnosticvalueof82.5%whencomparedtootherProvocativetestsforSLAPlesions.
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o ThePronatedLoadTest:Thepatientisinsupinewiththeirshoulderabductedto90°-110°andpassivelyexternallyrotated,withthepatient’sforearmfullypronatedtoincreasetensiononthebicepsandlabralattachment.Oncethearmisatmaximalpassiveexternalrotation,thepatientisaskedtoperformaresistedisometricbicepscontraction,inanattempttocreatethepeel-backmechanism.
§ TestRationale:Thistestisacombinationoftheactivebicipitalcontractionofthebicepsloadtestandthepassiveexternalrotationinthepronatedpositionofthepainprovocationtest.Apositivetestisadescriptionofpain/discomfortwithintheshoulder.
- OtherTests:o Olecranon-ManubriumPercussiontest:Thepatientispositionedinsittingorstandingwiththe
elbowsflexedto90°.Theclinicianplacesthestethoscopeoverthemanubriumandpercusseseacholecranonprocess.Theclinicianislisteningforadecreaseinpitchorintensityontheaffectedside,whichwouldindicateapositivetest.
§ TestRationale:Ifthereareanybonyabnormalities,theaffectedsideshouldhaveadullersoundthanthenormalside.
§ Thistestmaybeusedtoruleinoroutbonyabnormalities.
o ShrugSign:Patientisinstandingandtheclinicianinstructsthepatienttoabductboththeirarmsinthecoronalplane,withelbowsflexedto90°.Apositivetestiswhenthepatientelevatesthescapulaorshouldergirdleinordertoachieve90°ofabduction.Theclinicianshouldmeasurewithagoniometer,theanglebetweenthearmandthehorizontalpointatwhichtheshrugmomentbegan(orfrom90°ofabductiontotheangleofthehumeruswhentheshrugbegan).
§ TestRationale:Theshrugsigncandetectshoulderabnormalities,especiallythoseassociatedwithlossofrangeofmotionorweaknessonmanualmuscletesting.
§ Thistestmaybeusedtoruleoutstiffness-relateddisordersaswellasrotatorcufftendinopathy.
o BeightonHypermobilityIndex:(SeeChart):Asimplescoretoquantifyjointlaxityand
hypermobility.Itisa9pointsystem,withthehigherthescorethehigherthelaxity.Cameronetal.foundthatatotalBeightonScalescoreof2orgreaterwerenearly21/2timesmorelikelytohavereportedahistoryofglenohumeraljointinstability.
- FunctionalMobilityTests:o SeatedRotationalTest:(ToIdentifythoracolumbarrotationalmobility/dysfunctional
movement).Patientisseatedwithkneesandfeettogether,supportedonthefloor,withtheirbodyerect,armscrossedacrosstheirchest,andlookingstraightahead.Thepatientisaskedtorotatethetrunktotherightandthentotheleft,asfaraspossible.Theclinicianshouldevaluatetheeaseandfluidityofthemovement,aswellas,measuretheamountofmovementwithagoniometer.Theclinicianislookingforsymmetry/asymmetrycomparingrighttoleftrotation.Normalseatedthoracolumbarrotationis30°bilaterally.
o RollingAssessment:Thesemovementsareevaluatedforcontrolledmobility,corestability,andproperlysequencedloadingofthesegmentsofthebodyrequiredtoperformtherollingexercisecorrectly.
§ Rollingoccursarounddiagonalaxes-theaxisforeachrollingexercisesdoesnotinvolvetheextremitythatinitiatesthemovement,(ex.Rightaxis-LeftUEorLEisinitiatingthemovement).
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1- SupinetoProneleadingwiththeUpperBody:Thismovementisolatesshoulderflexion/horizontaladduction,whichleadstotrunkflexion/rotation,finallytopelvicrotation/hipflexiontobeabletosementallyandsequentialcompletetheroll.Patientislyingsupinewithlegsextendedandslightlyabductedandarmsflexedoverheadandslightlyabducted.Thepatientstartstorollbyliftingtheirheadintoflexionandreachingtheirrightarmacrossthebody,withfacegoingtowardtheiraxilla.Thelowerbodyshouldremainquietandnotcontributetotheroll.Watchthelegsforassistance.Thetherapistshouldbemonitoringthesegmentalqualityofthemovement,abilitytocompletethemovement,substitutionoffromotherareasofthebody,andrespiration(orlackof).Havethepatientrepeattotheoppositeside.Itmayalsoshowjointmobilityissues(shoulder,thoracic,cervical,lumbar,hip)thatneedtobeaddressedbeforecontinuing.
a. Someverbalcuesare:“Lookwithyoureyesandhead”,“Reachyourarmacrossyourbodyandturnyourheadintoyourshoulder”,“Reachthroughyournon-movingarmandlegtoelongatetheaxis”.
2- PronetoSupineleadingwiththeUpperBody:Thismovementbeginswithisolatedshoulderflexion,initiatingtrunkextension/rotation,endingwithpelvicrotationposteriorlytobeabletocompletetherollcorrectly.Patientislyingpronewithbotharmsandlegsstraightandslightlyabductedandheadisinneutralposition.Askthepatienttorolloverontotheirbackusingtherightarmonly,byextendingtheirarmbackandacrossintoadductionwiththeheadfollowing.Thelowerbodyshouldnotcontributetotheroll.Thetherapistshouldbemonitoringthesegmentalqualityofthemovement,abilitytocompletethemovement,substitutionoffromotherareasofthebody,andrespiration(orlackof).Havethepatientrepeattotheoppositeside.Itmayalsoshowjointmobilityissues(shoulder,thoracic,cervical,lumbar,hip)thatneedtobeaddressedbeforecontinuing.
a. Verbalcues:“Liftyourarmandlookupandoveryouroppositeshoulder”,“Reachthroughyournon-movingarmandlegtoelongatetheaxis”
3- SupinetoProneleadingwithLowerBody:Thismovementbeginswithisolatedhipflexion,thenpelvicrotation/lumbarflexion,andfinallywithtrunkflexion/rotationtocorrectlycompletetheroll.Patientislyingsupinewitharmsseparatedoverheadandlegsapart.Askthepatienttorolltothepronepositionstartingwiththeirrightlegonly.Thepatientshouldleadwiththerighthipflexionfollowedbyadductionoftheextendedleg.Theupperbodyshouldnotcontribute.Thetherapistshouldbemonitoringthesegmentalqualityofthemovement,abilitytocompletethemovement,substitutionoffromotherareasofthebody,andrespiration(orlackof).Repeattotheoppositeside.Workwithinthedysfunctionpatternstoimprovemovement.Itmayalsoshowjointmobilityissues(shoulder,thoracic,cervical,lumbar,hip)thatneedtobeaddressedbeforecontinuing.
a. Verbalcues:toreachlongthroughtheaxiswiththenon-movingarmandleg.”4- PronetoSupineleadingwiththeLowerbody:Thismovementbeginswithisolatedhipextension
thenpelvicrotation/lumbarextension,andfinallywithtrunkextension/rotationtocorrectlycompletetheroll.Patientispronewitharmsandlegsslightlyabductedandheadinneutralposition.Askthepatienttorolloverontotheirbackusingtherightlegonly,byextendingandadductingbackacross.Theupperbodyshouldnotcontributetotheroll.Thetherapistshouldbemonitoringthesegmentalqualityofthemovement,abilitytocompletethemovement,substitutionoffromotherareasofthebody,andrespiration(orlackof).Havethepatientrepeattotheoppositeside.Itmayalsoshowjointmobilityissues(shoulder,thoracic,cervical,lumbar,hip)thatneedtobeaddressedbeforecontinuing.
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a. Verbalcues:“Elongatethroughtheaxisofthenon-movingarmandleg.”
o SelectiveFunctionalMovementAssessment(SFMA)&,o FunctionalMovementScreen(FMS):
§ Toevaluateforglobalandcontributorydysfunctionsandasymmetries.(Seeattachedworksheets)
Rehabilitation:Non-OperativeShoulderInjuries,AthleticShoulders:- SubjectiveEvaluations:DisabilitiesoftheArmShoulderandHand(DASH)withthesportmodule,
orPennsylvaniaShoulderScore(PSS)o MinimalDetectableChange(MDC)fortheDASHis13,howeverthereisnoMDCcurrentlyfor
thesportmodulealone.o TheMDCfortheaggregatetotalforthePSSis12points;orbysection:±5.2pointsforthepain
section,±1.8pointsforthesatisfactionsection,and±8.6pointsforthefunctionsection- Treatment-BasedClassification:Treatinginthecontextofpathology:
HighIrritability3/5tocategorize
ModerateIrritability3/5tocategorize
LowIrritability3/5tocategorize
• Highpain(³7/10)• Constantnightorrest
pain• PainbeforeendROM• AROM<PROM• Highdisability-³
DASH/PSS50%
• Moderatepain(4-6/10)
• Intermittentnightorrestpain
• PinatendROM• AROM¹PROM• Moderatedisability-
DASH/PSS26-49%
• Lowpain(</=3/10)• Nonightpainorrest
pain• Minimalpainatend
ROM• AROM=PROM• Lowdisability-
DASH/PSS</=25%
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TreatmentFocus TreatmentFocus TreatmentFocus• Painreduction• RestorationofPROM• Neutralstability
exercises:isometricsandAAROM
• Painreduction• EqualizationofAROM
andPROM• Stabilization(scapular,
rotatorcuffprogram):AROM,limitedresistance
• RestoreendterminalROM,
• Improveshouldergirdleendurance,thenpower,
• Initiatereturntoplay,• Respectively
Takenfrom:Non-operativeManagementoftheAthleticShoulder:Thigpen,C&Jenk,D.HomeStudyCourse2013
o *TheAthleticshouldergirdleishighlyreliantonthemusclesoftherotatorcuffandscapular
stabilizers,aswellasscapulothoracic,thoracicspine,acromioclavicularandsternoclavicularmotions/mobility.
o RotatorCuffDisease:(biceps,subacromialbursitis,rotatorcufftendinits/tendinosis,andpartialrotatorcufftears)
§ Proposedmechanismsofinjuryare;Shoulderimpingement,hookedacromion,weakrotatorcuffmuscles,alteredscapulothoracicpositioningandscapulohumeralkinematics,bonespurs,chronicbursalthickening,rotatorcuffthickeningduetocalciumdeposits,tightnessintheposteriorjointcapsule.Thisleadstoabelievesequenceofeventsstartingwithrepetitivemicrotraumatotherotatorcuff,followedbytendonitis,bursitis,osteophyteformation,andthenfinallyrotatorcufftear.• Impingementcanbefromintrinsicfactors:thoserelatedtothehumanbodyor
extrinsicfactors:suchasoccupationoractivity- Commonrelevantextrinsicfactorsforathletesarerotatorcuffweaknessand
scapulardysfunction.
o Instability:Allcapsulolabralpathologies;SuperiorLabralAnteriorPosterior(SLAP)lesions,Multi-directionalInstability(MDI),oranterior-inferiorcapsulolabrallesions.
§ TypicalorderofprevalenceisAnterior/Inferiorligamentwithandwithlabralinvolvement(Bankart),SLAPtears,MDI,andposteriorinstability.
§ Eachdiagnosishasadistinctrecovery,however,theyallhaveasimilarbasicimbalanceofstaticanddynamicstability,creatingsymptomaticincreasedglenohumeraljointlaxity.• MDI-maydemonstrateincreasedside-to-sideglenohumeralinstabilityinmorethan
onequadrant,creatingasecondaryinvolvementofdynamicinstabilityfromoveractivityorsubstitutionpatternsfromtherotatorcuff,biceps,andscapularstabilizingmuscles.
- Patienttypicallypresentswithposteriorshoulderpain,especiallywithsagittalloading,andsubluxations.
- PatientEducation:Fromday1theirneedstobeongoingeducationandcommunicationwiththeathlete,(parentsifunder18orrequestedbypatient),MD,athletictrainers,coaches,andanyotherinvolvedparties,onprecautions,recommendationsforactivity,short-andlong-termprognosis,homeexercises,andlateroncriteriaforreturntoplay.
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- SpecificInterventions:o ROM:thiswithbebasedonthetreatmentclassificationinthechartabove,however,initially
ROMisapriority,whetheryouarerestoringROMormaintainingfullROM.o MakesureyoutakeintoconsiderationthespecificsporttypicalROMchanges.(See
ConsiderationsofROMmeasurementswithOverheadAthletesSectionintheClinicalEvaluationpartoftheprotocol)
o Inadditiontostretching,athletestypicallyrespondtoavarietyoftechniquesforimprovingmobility,tissueextensibility,jointmobility,andROM.Beforeimplementingtechniques,clinicianshouldbeawareofwhichtissue(s)restrictioniscreatingthelossofROM.Inmanyinstancesacombinationoftechniquesismosteffective.Resultsfromfunctionalassessmentscanbeusedaswelltoguidetreatmentsandprogressionsaswellasotherevaluativefindings.
§ JointMobilizations(ifcapsulerestrictionspresent)GradesI-V• GradesI-II:typicallyfordecreasingpain• GradesIII-V:typicallyfordecreasingcapsularrestrictions.GradeVmobilizations,
thrusttypemanipulation,willmostlybeusedonthecervical,thoracic,lumbarspines,pelvis,andlowerextremitiestomaintain/achievealignmentforproperpostureandjointpositioning.
§ SoftTissueMobilization:MyofascialRelease(MFR),FrictionMassage(DFMorTFM),SoftTissueMassage(STM),MuscleEnergytechnique(MET),DryNeedlingTechnique,Grastonäorotherinstrumentationsofttissuereleasetechniques,ActiveReleaseä,etc.
§ Stretching:Theseshouldnotjustbecenteredontheshoulder.Cervical,thoracic,lumbar,hips,andlowerextremitiesshouldbeevaluatedfortissuerestrictionsandtreatedaccordingly.(SeeSpecificExerciseSheets)forsomeexamplesofexercises/stretches
o MuscleStretching/Retraining:Anyalterationsintiming,recruitment,andenduranceofmuscles
cancauseweaknessanddysfunctions,aswellasdecreaseathletemaximalforceoutputforperformingattheirsport.
§ Usethefindingsfromtheevaluationandtheirritabilityclassificationtodeterminewhenstrengthening/retrainingisbegun,whichmovements/musclesaretreated,andprogression.
§ Painfulunstableshoulderstypicallydemonstrateincreasedactivityintheprimemoversoftheshoulder;pectoralismajor/minor,longheadofthebiceps,deltoids,latisimussdorsianduppertrapezius.Thesearecompensatoryandprotectiveinnature.
§ Overheadathletesalsohaveatendencytopresentwithweaknessanddecreasedtiming/activationofserratusanterior,middle&lowertrapezius,androtatorcuffmusculature.Alterationswiththetiming/activationusuallyreflectanimbalancebetweentheshouldergirdlemusclesresponsibleforstabilizingthescapulothoracicandglenohumeraljoint,andtheprimemoversoftheshoulder.Thiscouldalsobefromjointdysfunctionofthethoracicand/orcervicalspine,aswellasribrotationsorscapularalteredposition.
§ Shoulderstabilizershouldbefacilitatedfirst,rotatorcuff,serratusanterior,andmiddle&lowertrapezius.Oncetheathleteisabletodemonstrategoodstabilization,theexercisescanswitchtofocusingonimprovingtimingandendurance.• Lowresistance(ifany)withhighrepetitionsallowsforre-integrationofmotor
patterns,aswellas,buildingupmuscleendurance.Emphasisisongoodform/motorcontrolandappropriatemusclefiring.
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• Oncethepatientdemonstratesgoodmotorcontrol(absenceof;compensatorypatterns,scapularwinging,anddecreasedERwithelevation),andisabletoperform45-60repetitions,thenthedifficultyoftheexercisecanbeprogressedwithresistance,moreadvancedmovements/exercises,ortoexercisestomimicsport-specificfunctionalmovements.
- PositionalProgressions:§ Supine/side-lying/prone->quadruped->standing->balance/unstable
surface§ Planarmovements->diagonals->overhead->combinedmovements-
>sportspecificpositions§ Targetingindividualmuscles->combinedmuscleactivation->
movementpatterns->sport-specificmovementpatterns§ Noresistance->lightresistance(weights,bands,medicineballs,etc.)-
>heavierresistanceo KineticChainRestoration:Thisisparamounttobeingabletoperformasequential,multi-
segmental,totalbodymovement,alongwithaproductionoftorqueandforcetobeabletopropelaballorabodyforward.Thelegs,trunkandcoredevelopthepoweranditisultimatelytransferredfromthelegsandtrunkoftheathlete->throughthescapulohumeralstructures->tothearm,directingtheforceoutput,->totheball,racquet,bat,club,etc.
§ Restorationofthesepatternsiswheretheuseofthefunctionalassessmenttestshavethemostvalue:SFMAä,FMSä,Y-balanceä/CKCUEST,oranyothertools/teststhatassesfunctionalmovementpatternsthroughoutthebody
§ Thepatientshouldalsobeassessedforcoreactivationandbreathingtechnique.ThisneedstobeaddressedinitiallybecausetheycanaffectabilitytoimproveROM/tissueextensibility,UEandLEmovements,strengthening,stability,forceproduction,etc.• Breathingandcoreactivationshouldbeassessedinallpositions,withandwithout
performanceofexercises§ Basedontheresultsoftheassessments,hipsandpelvisandalltheassociatedstructures
shouldbethesecondaryfocusastheydirectlysupportcorestability§ Glutealmuscles(majorpowergeneratorsaswellasstabilizers),Hipabductors,adductor,
flexors,extensors,androtators§ Balanceandsingle-legstabilityisalsokeyforrestorationoftheentirekineticchain§ Lowerextremitiesfunctioningatanoptimallevelisakeytopropermechanicsallthe
wayupthekineticchainintheoverheadathlete.
- KeystoSuccessfulRehabilitationCriteria-BasedProgressiontobeabletoprogresspatienttoReturntoSpecificSportProtocolso FollowedexpectedpassiveROMforindividualathletes(comparedtototalarcofmotiononthe
non-involvedsideofthebody),andexpectedalterationsinshoulderROMs,bythesporttheathleteplays.Theseshouldberestoredpriortostrengthening.
o Painatrestshouldbeeliminatedbeforebeginningstrengthening(hypertrophy)orplyometricexercises
o ExpectedactiveROM,withnormalmovementpatterns,shouldberestoredbeforebeginninghypertrophystrengtheningorplyometricexercises
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o Patientshouldbeabletodemonstratepain-freenormalmovementpatternsthroughmulti-planarmovements,with45-60repetitions(goodendurance),beforeprogressiontoeccentric,plyometric,and/orhighloadexercises
o Patientmustcompleteplyometricprogram(UE&LEifappropriate),Score³16ontheFMSä(withnoasymmetries,Y-Balanceäscoreshouldbeequaltopeersofthesameageandsportalongwithnoasymmetries,score_”no”-“mild”difficultyonallquestionsontheDASH(sports/Artsmodule),(orlow/nodisabilityonchosenselfevaluationassessment)
o Passingofthefunctionaltestslistedbelow:Testcanbeovermultiplesessionsii. TrunkTesting:(Seeattachedsheets)
1. DeepNeckFlexorTest2. SegmentalMultifidusTest3. TrunkCurl-upTest4. Double-LegLoweringTest5. ProneBridgeTest6. EnduranceofLateralFlexors(SideBridge)7. ExtensorDynamicEnduranceTest
iii. UpperExtremityTesting:(Seeattachedsheets)1. AlternativePull-upTest2. Push-upTest3. BackwardOverheadMedicineBallThrowTest4. SidearmMedicineBallThrowTest5. SeatedShot-PutThrowTest
iv. FunctionalLowerExtremity(Strength/Power,Agility/Quickness,ifneeded)v. *Ifpatientisabaseballorsoft-ballpitcher/player
1. FunctionalThrowingPerformanceIndex(FTPI)Test-bestassessedwithvideoanalysis2. Baseballpitchersonly-PT/ATCfillsoutUpperExtremityThrowingAnalysisForm-to
determineareasofthethrowingmotionthatneedtobeaddressedinthesportspecific/returntobaseballpitchingprotocol
• SeeReturntoSpecificSportProtocols
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