Shoulder Update 2014 University of Texas at El PasoCentennial Lecture Series

Evidence-based Management Speaker

Eric Robertson PT DPT OCS FAAOMPT

Objectives

bull Attendees will accurately describe diagnostic and prognostic criteria for patients with various should conditions

bull Attendees will integrate predictors of response into examination of patients with shoulder pain

bull Attendees will review evidence supporting manual therapy interventions for patients with shoulder pain

bull Attendees will integrate information about psychologically informed practice into their management of patients with shoulder pain

bull Attendees will review best-evidence interventions for patients with shoulder pain

Shoulder Pain Incidence and Costs

bull $7 Billion annually in US (2000)bull 20-30 of the populationbull Poor perceived recovery rate lt50bull Prognosis is Fair to Poor for incidence of non-specific

shoulder pain

Our PathThings that donrsquot move enoughbull Subacromial Impingementbull Adhesive Capsulitisbull Evidence for Manual Therapy

Things that move too muchbull Shoulder Instabilitybull Evidence-supported exercise

Irsquom getting Emotionalhellip

Impingement Syndrome Concept

Neer 1972bull Altered cuff mechanicsbull Compromised or constricted

bull coracoacromial archbull Stage I II III

The SIS Continuum Neer Classification

Stage I Edema amp Hemorrhage

lt 25 reversible conservative treatment

Stage II Fibrosis amp Tendinopathy

25-40 recurrent pain consider SAD

Stage III Bone Spurs amp Tendon Rupture

gt40 progressive disability sx repair

Impingement Classification

bull Mechanical glenohumeral impingement

bull Alteredreduced sub-acromial space

bull Associated AC joint problems

bull Think ldquoblockrdquo

Primary

bull Uncertain glenohumeral positioning

bull Inherently unstable shoulderbull Mechanicallybull Functional

bull Think Instability

Secondary

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Primary Impingement

bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace

Structures

bull RC weakness or inflammation (also of bursa)

bull RC tendinopathybull Posterior capsule tightnessbull Morphology of acromionbull Postural dysfunction

Causes

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Secondary Impingement

bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace

Structures

bull RC weaknessbull RC tearbull Capsular laxitybull Multidirectional instabilitybull Functional instability or

neuromuscular inhibitionbull Scapular dyskinesia

Causes

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Diagnosis of Primary SIS

bull Historical Factorsbull Pain at night pain with overhead activities

complaints of stiffness

bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)

bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test

Park et al 2005

Diagnosis of Primary SIS

bull Another Perspectivebull A larger test-item cluster

3 or more 5 tests rules in SIS 3 or less 5 rules out SIS

Test SensSpect

+LR-LR

Neer Sens -035

Painful Arc Both +225 -038

Ext Rot Resistance Both +439

Hawkins-Kennedy Both ~1

Empty Can Spec +390

Michener et al APMR 2009

Diagnosis of Secondary SIS

bull Historical Factorsbull Young history of instability pain with overhead

activities hypermobility overhead athlete

bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral

scapular slide test for example)

McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164

Upper Extremity Y-Balance Test

bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper

limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo

P Plisky

bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn

Shoulder Scale pain at rest normal amp strenuous activities

NPRSbull Disability of Arm Shoulder and

Handbull Quick DASH also goodDASH

bull Shoulder Pain and Disability IndexSPADI

MCID 10-15 points

Outcome Measures for SIS

MCID 8-13 points

General Treatment PrinciplesType of SIS Presentation Guiding Principle Management

PrimaryStage I

Stage II

Stage III

Young pain with activity Rest restore mechanics

MT and Exercise

26-40 pain at night prolonged symptoms

Restore sub-acromial space

MT and Exercise possible surgery

Older chronic associated with RC tears

Manage conservatively unless sx indicated

RC strengthening Jt mob surgical

Secondary Multi-directional instability

Stabilize Proprioceptive neuromuscular strengthening

Internal Young impingement in specific range

Strengthen cuff muscles

Rehab or labral repair

Treatment Non-surgical vs Surgical

bull Emphasize preventionbull Current Best Evidence Summary

Bang amp DeyleJOSPT 2000

Bottom Line While both groups improved the MT+Ex

group had greater improvements including strength gains

Considerations MT + Ex group received treatment reinforcing HEP

Design RCTPop N=52 impingement syndromeOutcomes

Baseline 1 amp 2 mo

Strength Pain Functional Assessment Questionnaire (FAQ)

Interventions 6 sessions 3-4 wksbullExercise Group (Ex)

bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)

bullEx as abovebullMan Ther Upper Quarter

ResultsbullPain amp Function

MT+Ex with significantly more improvement

bullStrengthOnly MT+Ex group with significant improvement

Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement

Bergman et al Annals of Internal Medicine 2004

Bottom Line MT + UMC was the winner for achieving ldquofull

recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at

52wks

Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions

UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits

Design Multi-site RCT

Pop N=150 painful shoulder girdle

Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received

InterventionsbullUsual Medical Care (UMC)

Adviceinformation therapy NSAIDSanalgesics amp CSIs

bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)

ResultsbullAt 12 26 52 Wks

ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder

Dysfunction and Pain

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Objectives

bull Attendees will accurately describe diagnostic and prognostic criteria for patients with various should conditions

bull Attendees will integrate predictors of response into examination of patients with shoulder pain

bull Attendees will review evidence supporting manual therapy interventions for patients with shoulder pain

bull Attendees will integrate information about psychologically informed practice into their management of patients with shoulder pain

bull Attendees will review best-evidence interventions for patients with shoulder pain

Shoulder Pain Incidence and Costs

bull $7 Billion annually in US (2000)bull 20-30 of the populationbull Poor perceived recovery rate lt50bull Prognosis is Fair to Poor for incidence of non-specific

shoulder pain

Our PathThings that donrsquot move enoughbull Subacromial Impingementbull Adhesive Capsulitisbull Evidence for Manual Therapy

Things that move too muchbull Shoulder Instabilitybull Evidence-supported exercise

Irsquom getting Emotionalhellip

Impingement Syndrome Concept

Neer 1972bull Altered cuff mechanicsbull Compromised or constricted

bull coracoacromial archbull Stage I II III

The SIS Continuum Neer Classification

Stage I Edema amp Hemorrhage

lt 25 reversible conservative treatment

Stage II Fibrosis amp Tendinopathy

25-40 recurrent pain consider SAD

Stage III Bone Spurs amp Tendon Rupture

gt40 progressive disability sx repair

Impingement Classification

bull Mechanical glenohumeral impingement

bull Alteredreduced sub-acromial space

bull Associated AC joint problems

bull Think ldquoblockrdquo

Primary

bull Uncertain glenohumeral positioning

bull Inherently unstable shoulderbull Mechanicallybull Functional

bull Think Instability

Secondary

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Primary Impingement

bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace

Structures

bull RC weakness or inflammation (also of bursa)

bull RC tendinopathybull Posterior capsule tightnessbull Morphology of acromionbull Postural dysfunction

Causes

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Secondary Impingement

bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace

Structures

bull RC weaknessbull RC tearbull Capsular laxitybull Multidirectional instabilitybull Functional instability or

neuromuscular inhibitionbull Scapular dyskinesia

Causes

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Diagnosis of Primary SIS

bull Historical Factorsbull Pain at night pain with overhead activities

complaints of stiffness

bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)

bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test

Park et al 2005

Diagnosis of Primary SIS

bull Another Perspectivebull A larger test-item cluster

3 or more 5 tests rules in SIS 3 or less 5 rules out SIS

Test SensSpect

+LR-LR

Neer Sens -035

Painful Arc Both +225 -038

Ext Rot Resistance Both +439

Hawkins-Kennedy Both ~1

Empty Can Spec +390

Michener et al APMR 2009

Diagnosis of Secondary SIS

bull Historical Factorsbull Young history of instability pain with overhead

activities hypermobility overhead athlete

bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral

scapular slide test for example)

McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164

Upper Extremity Y-Balance Test

bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper

limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo

P Plisky

bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn

Shoulder Scale pain at rest normal amp strenuous activities

NPRSbull Disability of Arm Shoulder and

Handbull Quick DASH also goodDASH

bull Shoulder Pain and Disability IndexSPADI

MCID 10-15 points

Outcome Measures for SIS

MCID 8-13 points

General Treatment PrinciplesType of SIS Presentation Guiding Principle Management

PrimaryStage I

Stage II

Stage III

Young pain with activity Rest restore mechanics

MT and Exercise

26-40 pain at night prolonged symptoms

Restore sub-acromial space

MT and Exercise possible surgery

Older chronic associated with RC tears

Manage conservatively unless sx indicated

RC strengthening Jt mob surgical

Secondary Multi-directional instability

Stabilize Proprioceptive neuromuscular strengthening

Internal Young impingement in specific range

Strengthen cuff muscles

Rehab or labral repair

Treatment Non-surgical vs Surgical

bull Emphasize preventionbull Current Best Evidence Summary

Bang amp DeyleJOSPT 2000

Bottom Line While both groups improved the MT+Ex

group had greater improvements including strength gains

Considerations MT + Ex group received treatment reinforcing HEP

Design RCTPop N=52 impingement syndromeOutcomes

Baseline 1 amp 2 mo

Strength Pain Functional Assessment Questionnaire (FAQ)

Interventions 6 sessions 3-4 wksbullExercise Group (Ex)

bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)

bullEx as abovebullMan Ther Upper Quarter

ResultsbullPain amp Function

MT+Ex with significantly more improvement

bullStrengthOnly MT+Ex group with significant improvement

Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement

Bergman et al Annals of Internal Medicine 2004

Bottom Line MT + UMC was the winner for achieving ldquofull

recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at

52wks

Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions

UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits

Design Multi-site RCT

Pop N=150 painful shoulder girdle

Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received

InterventionsbullUsual Medical Care (UMC)

Adviceinformation therapy NSAIDSanalgesics amp CSIs

bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)

ResultsbullAt 12 26 52 Wks

ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder

Dysfunction and Pain

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Shoulder Pain Incidence and Costs

bull $7 Billion annually in US (2000)bull 20-30 of the populationbull Poor perceived recovery rate lt50bull Prognosis is Fair to Poor for incidence of non-specific

shoulder pain

Our PathThings that donrsquot move enoughbull Subacromial Impingementbull Adhesive Capsulitisbull Evidence for Manual Therapy

Things that move too muchbull Shoulder Instabilitybull Evidence-supported exercise

Irsquom getting Emotionalhellip

Impingement Syndrome Concept

Neer 1972bull Altered cuff mechanicsbull Compromised or constricted

bull coracoacromial archbull Stage I II III

The SIS Continuum Neer Classification

Stage I Edema amp Hemorrhage

lt 25 reversible conservative treatment

Stage II Fibrosis amp Tendinopathy

25-40 recurrent pain consider SAD

Stage III Bone Spurs amp Tendon Rupture

gt40 progressive disability sx repair

Impingement Classification

bull Mechanical glenohumeral impingement

bull Alteredreduced sub-acromial space

bull Associated AC joint problems

bull Think ldquoblockrdquo

Primary

bull Uncertain glenohumeral positioning

bull Inherently unstable shoulderbull Mechanicallybull Functional

bull Think Instability

Secondary

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Primary Impingement

bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace

Structures

bull RC weakness or inflammation (also of bursa)

bull RC tendinopathybull Posterior capsule tightnessbull Morphology of acromionbull Postural dysfunction

Causes

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Secondary Impingement

bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace

Structures

bull RC weaknessbull RC tearbull Capsular laxitybull Multidirectional instabilitybull Functional instability or

neuromuscular inhibitionbull Scapular dyskinesia

Causes

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Diagnosis of Primary SIS

bull Historical Factorsbull Pain at night pain with overhead activities

complaints of stiffness

bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)

bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test

Park et al 2005

Diagnosis of Primary SIS

bull Another Perspectivebull A larger test-item cluster

3 or more 5 tests rules in SIS 3 or less 5 rules out SIS

Test SensSpect

+LR-LR

Neer Sens -035

Painful Arc Both +225 -038

Ext Rot Resistance Both +439

Hawkins-Kennedy Both ~1

Empty Can Spec +390

Michener et al APMR 2009

Diagnosis of Secondary SIS

bull Historical Factorsbull Young history of instability pain with overhead

activities hypermobility overhead athlete

bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral

scapular slide test for example)

McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164

Upper Extremity Y-Balance Test

bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper

limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo

P Plisky

bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn

Shoulder Scale pain at rest normal amp strenuous activities

NPRSbull Disability of Arm Shoulder and

Handbull Quick DASH also goodDASH

bull Shoulder Pain and Disability IndexSPADI

MCID 10-15 points

Outcome Measures for SIS

MCID 8-13 points

General Treatment PrinciplesType of SIS Presentation Guiding Principle Management

PrimaryStage I

Stage II

Stage III

Young pain with activity Rest restore mechanics

MT and Exercise

26-40 pain at night prolonged symptoms

Restore sub-acromial space

MT and Exercise possible surgery

Older chronic associated with RC tears

Manage conservatively unless sx indicated

RC strengthening Jt mob surgical

Secondary Multi-directional instability

Stabilize Proprioceptive neuromuscular strengthening

Internal Young impingement in specific range

Strengthen cuff muscles

Rehab or labral repair

Treatment Non-surgical vs Surgical

bull Emphasize preventionbull Current Best Evidence Summary

Bang amp DeyleJOSPT 2000

Bottom Line While both groups improved the MT+Ex

group had greater improvements including strength gains

Considerations MT + Ex group received treatment reinforcing HEP

Design RCTPop N=52 impingement syndromeOutcomes

Baseline 1 amp 2 mo

Strength Pain Functional Assessment Questionnaire (FAQ)

Interventions 6 sessions 3-4 wksbullExercise Group (Ex)

bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)

bullEx as abovebullMan Ther Upper Quarter

ResultsbullPain amp Function

MT+Ex with significantly more improvement

bullStrengthOnly MT+Ex group with significant improvement

Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement

Bergman et al Annals of Internal Medicine 2004

Bottom Line MT + UMC was the winner for achieving ldquofull

recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at

52wks

Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions

UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits

Design Multi-site RCT

Pop N=150 painful shoulder girdle

Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received

InterventionsbullUsual Medical Care (UMC)

Adviceinformation therapy NSAIDSanalgesics amp CSIs

bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)

ResultsbullAt 12 26 52 Wks

ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder

Dysfunction and Pain

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Our PathThings that donrsquot move enoughbull Subacromial Impingementbull Adhesive Capsulitisbull Evidence for Manual Therapy

Things that move too muchbull Shoulder Instabilitybull Evidence-supported exercise

Irsquom getting Emotionalhellip

Impingement Syndrome Concept

Neer 1972bull Altered cuff mechanicsbull Compromised or constricted

bull coracoacromial archbull Stage I II III

The SIS Continuum Neer Classification

Stage I Edema amp Hemorrhage

lt 25 reversible conservative treatment

Stage II Fibrosis amp Tendinopathy

25-40 recurrent pain consider SAD

Stage III Bone Spurs amp Tendon Rupture

gt40 progressive disability sx repair

Impingement Classification

bull Mechanical glenohumeral impingement

bull Alteredreduced sub-acromial space

bull Associated AC joint problems

bull Think ldquoblockrdquo

Primary

bull Uncertain glenohumeral positioning

bull Inherently unstable shoulderbull Mechanicallybull Functional

bull Think Instability

Secondary

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Primary Impingement

bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace

Structures

bull RC weakness or inflammation (also of bursa)

bull RC tendinopathybull Posterior capsule tightnessbull Morphology of acromionbull Postural dysfunction

Causes

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Secondary Impingement

bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace

Structures

bull RC weaknessbull RC tearbull Capsular laxitybull Multidirectional instabilitybull Functional instability or

neuromuscular inhibitionbull Scapular dyskinesia

Causes

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Diagnosis of Primary SIS

bull Historical Factorsbull Pain at night pain with overhead activities

complaints of stiffness

bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)

bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test

Park et al 2005

Diagnosis of Primary SIS

bull Another Perspectivebull A larger test-item cluster

3 or more 5 tests rules in SIS 3 or less 5 rules out SIS

Test SensSpect

+LR-LR

Neer Sens -035

Painful Arc Both +225 -038

Ext Rot Resistance Both +439

Hawkins-Kennedy Both ~1

Empty Can Spec +390

Michener et al APMR 2009

Diagnosis of Secondary SIS

bull Historical Factorsbull Young history of instability pain with overhead

activities hypermobility overhead athlete

bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral

scapular slide test for example)

McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164

Upper Extremity Y-Balance Test

bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper

limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo

P Plisky

bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn

Shoulder Scale pain at rest normal amp strenuous activities

NPRSbull Disability of Arm Shoulder and

Handbull Quick DASH also goodDASH

bull Shoulder Pain and Disability IndexSPADI

MCID 10-15 points

Outcome Measures for SIS

MCID 8-13 points

General Treatment PrinciplesType of SIS Presentation Guiding Principle Management

PrimaryStage I

Stage II

Stage III

Young pain with activity Rest restore mechanics

MT and Exercise

26-40 pain at night prolonged symptoms

Restore sub-acromial space

MT and Exercise possible surgery

Older chronic associated with RC tears

Manage conservatively unless sx indicated

RC strengthening Jt mob surgical

Secondary Multi-directional instability

Stabilize Proprioceptive neuromuscular strengthening

Internal Young impingement in specific range

Strengthen cuff muscles

Rehab or labral repair

Treatment Non-surgical vs Surgical

bull Emphasize preventionbull Current Best Evidence Summary

Bang amp DeyleJOSPT 2000

Bottom Line While both groups improved the MT+Ex

group had greater improvements including strength gains

Considerations MT + Ex group received treatment reinforcing HEP

Design RCTPop N=52 impingement syndromeOutcomes

Baseline 1 amp 2 mo

Strength Pain Functional Assessment Questionnaire (FAQ)

Interventions 6 sessions 3-4 wksbullExercise Group (Ex)

bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)

bullEx as abovebullMan Ther Upper Quarter

ResultsbullPain amp Function

MT+Ex with significantly more improvement

bullStrengthOnly MT+Ex group with significant improvement

Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement

Bergman et al Annals of Internal Medicine 2004

Bottom Line MT + UMC was the winner for achieving ldquofull

recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at

52wks

Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions

UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits

Design Multi-site RCT

Pop N=150 painful shoulder girdle

Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received

InterventionsbullUsual Medical Care (UMC)

Adviceinformation therapy NSAIDSanalgesics amp CSIs

bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)

ResultsbullAt 12 26 52 Wks

ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder

Dysfunction and Pain

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Impingement Syndrome Concept

Neer 1972bull Altered cuff mechanicsbull Compromised or constricted

bull coracoacromial archbull Stage I II III

The SIS Continuum Neer Classification

Stage I Edema amp Hemorrhage

lt 25 reversible conservative treatment

Stage II Fibrosis amp Tendinopathy

25-40 recurrent pain consider SAD

Stage III Bone Spurs amp Tendon Rupture

gt40 progressive disability sx repair

Impingement Classification

bull Mechanical glenohumeral impingement

bull Alteredreduced sub-acromial space

bull Associated AC joint problems

bull Think ldquoblockrdquo

Primary

bull Uncertain glenohumeral positioning

bull Inherently unstable shoulderbull Mechanicallybull Functional

bull Think Instability

Secondary

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Primary Impingement

bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace

Structures

bull RC weakness or inflammation (also of bursa)

bull RC tendinopathybull Posterior capsule tightnessbull Morphology of acromionbull Postural dysfunction

Causes

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Secondary Impingement

bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace

Structures

bull RC weaknessbull RC tearbull Capsular laxitybull Multidirectional instabilitybull Functional instability or

neuromuscular inhibitionbull Scapular dyskinesia

Causes

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Diagnosis of Primary SIS

bull Historical Factorsbull Pain at night pain with overhead activities

complaints of stiffness

bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)

bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test

Park et al 2005

Diagnosis of Primary SIS

bull Another Perspectivebull A larger test-item cluster

3 or more 5 tests rules in SIS 3 or less 5 rules out SIS

Test SensSpect

+LR-LR

Neer Sens -035

Painful Arc Both +225 -038

Ext Rot Resistance Both +439

Hawkins-Kennedy Both ~1

Empty Can Spec +390

Michener et al APMR 2009

Diagnosis of Secondary SIS

bull Historical Factorsbull Young history of instability pain with overhead

activities hypermobility overhead athlete

bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral

scapular slide test for example)

McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164

Upper Extremity Y-Balance Test

bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper

limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo

P Plisky

bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn

Shoulder Scale pain at rest normal amp strenuous activities

NPRSbull Disability of Arm Shoulder and

Handbull Quick DASH also goodDASH

bull Shoulder Pain and Disability IndexSPADI

MCID 10-15 points

Outcome Measures for SIS

MCID 8-13 points

General Treatment PrinciplesType of SIS Presentation Guiding Principle Management

PrimaryStage I

Stage II

Stage III

Young pain with activity Rest restore mechanics

MT and Exercise

26-40 pain at night prolonged symptoms

Restore sub-acromial space

MT and Exercise possible surgery

Older chronic associated with RC tears

Manage conservatively unless sx indicated

RC strengthening Jt mob surgical

Secondary Multi-directional instability

Stabilize Proprioceptive neuromuscular strengthening

Internal Young impingement in specific range

Strengthen cuff muscles

Rehab or labral repair

Treatment Non-surgical vs Surgical

bull Emphasize preventionbull Current Best Evidence Summary

Bang amp DeyleJOSPT 2000

Bottom Line While both groups improved the MT+Ex

group had greater improvements including strength gains

Considerations MT + Ex group received treatment reinforcing HEP

Design RCTPop N=52 impingement syndromeOutcomes

Baseline 1 amp 2 mo

Strength Pain Functional Assessment Questionnaire (FAQ)

Interventions 6 sessions 3-4 wksbullExercise Group (Ex)

bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)

bullEx as abovebullMan Ther Upper Quarter

ResultsbullPain amp Function

MT+Ex with significantly more improvement

bullStrengthOnly MT+Ex group with significant improvement

Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement

Bergman et al Annals of Internal Medicine 2004

Bottom Line MT + UMC was the winner for achieving ldquofull

recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at

52wks

Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions

UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits

Design Multi-site RCT

Pop N=150 painful shoulder girdle

Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received

InterventionsbullUsual Medical Care (UMC)

Adviceinformation therapy NSAIDSanalgesics amp CSIs

bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)

ResultsbullAt 12 26 52 Wks

ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder

Dysfunction and Pain

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

The SIS Continuum Neer Classification

Stage I Edema amp Hemorrhage

lt 25 reversible conservative treatment

Stage II Fibrosis amp Tendinopathy

25-40 recurrent pain consider SAD

Stage III Bone Spurs amp Tendon Rupture

gt40 progressive disability sx repair

Impingement Classification

bull Mechanical glenohumeral impingement

bull Alteredreduced sub-acromial space

bull Associated AC joint problems

bull Think ldquoblockrdquo

Primary

bull Uncertain glenohumeral positioning

bull Inherently unstable shoulderbull Mechanicallybull Functional

bull Think Instability

Secondary

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Primary Impingement

bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace

Structures

bull RC weakness or inflammation (also of bursa)

bull RC tendinopathybull Posterior capsule tightnessbull Morphology of acromionbull Postural dysfunction

Causes

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Secondary Impingement

bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace

Structures

bull RC weaknessbull RC tearbull Capsular laxitybull Multidirectional instabilitybull Functional instability or

neuromuscular inhibitionbull Scapular dyskinesia

Causes

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Diagnosis of Primary SIS

bull Historical Factorsbull Pain at night pain with overhead activities

complaints of stiffness

bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)

bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test

Park et al 2005

Diagnosis of Primary SIS

bull Another Perspectivebull A larger test-item cluster

3 or more 5 tests rules in SIS 3 or less 5 rules out SIS

Test SensSpect

+LR-LR

Neer Sens -035

Painful Arc Both +225 -038

Ext Rot Resistance Both +439

Hawkins-Kennedy Both ~1

Empty Can Spec +390

Michener et al APMR 2009

Diagnosis of Secondary SIS

bull Historical Factorsbull Young history of instability pain with overhead

activities hypermobility overhead athlete

bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral

scapular slide test for example)

McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164

Upper Extremity Y-Balance Test

bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper

limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo

P Plisky

bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn

Shoulder Scale pain at rest normal amp strenuous activities

NPRSbull Disability of Arm Shoulder and

Handbull Quick DASH also goodDASH

bull Shoulder Pain and Disability IndexSPADI

MCID 10-15 points

Outcome Measures for SIS

MCID 8-13 points

General Treatment PrinciplesType of SIS Presentation Guiding Principle Management

PrimaryStage I

Stage II

Stage III

Young pain with activity Rest restore mechanics

MT and Exercise

26-40 pain at night prolonged symptoms

Restore sub-acromial space

MT and Exercise possible surgery

Older chronic associated with RC tears

Manage conservatively unless sx indicated

RC strengthening Jt mob surgical

Secondary Multi-directional instability

Stabilize Proprioceptive neuromuscular strengthening

Internal Young impingement in specific range

Strengthen cuff muscles

Rehab or labral repair

Treatment Non-surgical vs Surgical

bull Emphasize preventionbull Current Best Evidence Summary

Bang amp DeyleJOSPT 2000

Bottom Line While both groups improved the MT+Ex

group had greater improvements including strength gains

Considerations MT + Ex group received treatment reinforcing HEP

Design RCTPop N=52 impingement syndromeOutcomes

Baseline 1 amp 2 mo

Strength Pain Functional Assessment Questionnaire (FAQ)

Interventions 6 sessions 3-4 wksbullExercise Group (Ex)

bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)

bullEx as abovebullMan Ther Upper Quarter

ResultsbullPain amp Function

MT+Ex with significantly more improvement

bullStrengthOnly MT+Ex group with significant improvement

Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement

Bergman et al Annals of Internal Medicine 2004

Bottom Line MT + UMC was the winner for achieving ldquofull

recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at

52wks

Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions

UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits

Design Multi-site RCT

Pop N=150 painful shoulder girdle

Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received

InterventionsbullUsual Medical Care (UMC)

Adviceinformation therapy NSAIDSanalgesics amp CSIs

bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)

ResultsbullAt 12 26 52 Wks

ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder

Dysfunction and Pain

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Impingement Classification

bull Mechanical glenohumeral impingement

bull Alteredreduced sub-acromial space

bull Associated AC joint problems

bull Think ldquoblockrdquo

Primary

bull Uncertain glenohumeral positioning

bull Inherently unstable shoulderbull Mechanicallybull Functional

bull Think Instability

Secondary

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Primary Impingement

bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace

Structures

bull RC weakness or inflammation (also of bursa)

bull RC tendinopathybull Posterior capsule tightnessbull Morphology of acromionbull Postural dysfunction

Causes

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Secondary Impingement

bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace

Structures

bull RC weaknessbull RC tearbull Capsular laxitybull Multidirectional instabilitybull Functional instability or

neuromuscular inhibitionbull Scapular dyskinesia

Causes

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Diagnosis of Primary SIS

bull Historical Factorsbull Pain at night pain with overhead activities

complaints of stiffness

bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)

bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test

Park et al 2005

Diagnosis of Primary SIS

bull Another Perspectivebull A larger test-item cluster

3 or more 5 tests rules in SIS 3 or less 5 rules out SIS

Test SensSpect

+LR-LR

Neer Sens -035

Painful Arc Both +225 -038

Ext Rot Resistance Both +439

Hawkins-Kennedy Both ~1

Empty Can Spec +390

Michener et al APMR 2009

Diagnosis of Secondary SIS

bull Historical Factorsbull Young history of instability pain with overhead

activities hypermobility overhead athlete

bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral

scapular slide test for example)

McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164

Upper Extremity Y-Balance Test

bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper

limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo

P Plisky

bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn

Shoulder Scale pain at rest normal amp strenuous activities

NPRSbull Disability of Arm Shoulder and

Handbull Quick DASH also goodDASH

bull Shoulder Pain and Disability IndexSPADI

MCID 10-15 points

Outcome Measures for SIS

MCID 8-13 points

General Treatment PrinciplesType of SIS Presentation Guiding Principle Management

PrimaryStage I

Stage II

Stage III

Young pain with activity Rest restore mechanics

MT and Exercise

26-40 pain at night prolonged symptoms

Restore sub-acromial space

MT and Exercise possible surgery

Older chronic associated with RC tears

Manage conservatively unless sx indicated

RC strengthening Jt mob surgical

Secondary Multi-directional instability

Stabilize Proprioceptive neuromuscular strengthening

Internal Young impingement in specific range

Strengthen cuff muscles

Rehab or labral repair

Treatment Non-surgical vs Surgical

bull Emphasize preventionbull Current Best Evidence Summary

Bang amp DeyleJOSPT 2000

Bottom Line While both groups improved the MT+Ex

group had greater improvements including strength gains

Considerations MT + Ex group received treatment reinforcing HEP

Design RCTPop N=52 impingement syndromeOutcomes

Baseline 1 amp 2 mo

Strength Pain Functional Assessment Questionnaire (FAQ)

Interventions 6 sessions 3-4 wksbullExercise Group (Ex)

bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)

bullEx as abovebullMan Ther Upper Quarter

ResultsbullPain amp Function

MT+Ex with significantly more improvement

bullStrengthOnly MT+Ex group with significant improvement

Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement

Bergman et al Annals of Internal Medicine 2004

Bottom Line MT + UMC was the winner for achieving ldquofull

recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at

52wks

Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions

UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits

Design Multi-site RCT

Pop N=150 painful shoulder girdle

Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received

InterventionsbullUsual Medical Care (UMC)

Adviceinformation therapy NSAIDSanalgesics amp CSIs

bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)

ResultsbullAt 12 26 52 Wks

ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder

Dysfunction and Pain

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Primary Impingement

bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace

Structures

bull RC weakness or inflammation (also of bursa)

bull RC tendinopathybull Posterior capsule tightnessbull Morphology of acromionbull Postural dysfunction

Causes

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Secondary Impingement

bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace

Structures

bull RC weaknessbull RC tearbull Capsular laxitybull Multidirectional instabilitybull Functional instability or

neuromuscular inhibitionbull Scapular dyskinesia

Causes

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Diagnosis of Primary SIS

bull Historical Factorsbull Pain at night pain with overhead activities

complaints of stiffness

bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)

bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test

Park et al 2005

Diagnosis of Primary SIS

bull Another Perspectivebull A larger test-item cluster

3 or more 5 tests rules in SIS 3 or less 5 rules out SIS

Test SensSpect

+LR-LR

Neer Sens -035

Painful Arc Both +225 -038

Ext Rot Resistance Both +439

Hawkins-Kennedy Both ~1

Empty Can Spec +390

Michener et al APMR 2009

Diagnosis of Secondary SIS

bull Historical Factorsbull Young history of instability pain with overhead

activities hypermobility overhead athlete

bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral

scapular slide test for example)

McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164

Upper Extremity Y-Balance Test

bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper

limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo

P Plisky

bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn

Shoulder Scale pain at rest normal amp strenuous activities

NPRSbull Disability of Arm Shoulder and

Handbull Quick DASH also goodDASH

bull Shoulder Pain and Disability IndexSPADI

MCID 10-15 points

Outcome Measures for SIS

MCID 8-13 points

General Treatment PrinciplesType of SIS Presentation Guiding Principle Management

PrimaryStage I

Stage II

Stage III

Young pain with activity Rest restore mechanics

MT and Exercise

26-40 pain at night prolonged symptoms

Restore sub-acromial space

MT and Exercise possible surgery

Older chronic associated with RC tears

Manage conservatively unless sx indicated

RC strengthening Jt mob surgical

Secondary Multi-directional instability

Stabilize Proprioceptive neuromuscular strengthening

Internal Young impingement in specific range

Strengthen cuff muscles

Rehab or labral repair

Treatment Non-surgical vs Surgical

bull Emphasize preventionbull Current Best Evidence Summary

Bang amp DeyleJOSPT 2000

Bottom Line While both groups improved the MT+Ex

group had greater improvements including strength gains

Considerations MT + Ex group received treatment reinforcing HEP

Design RCTPop N=52 impingement syndromeOutcomes

Baseline 1 amp 2 mo

Strength Pain Functional Assessment Questionnaire (FAQ)

Interventions 6 sessions 3-4 wksbullExercise Group (Ex)

bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)

bullEx as abovebullMan Ther Upper Quarter

ResultsbullPain amp Function

MT+Ex with significantly more improvement

bullStrengthOnly MT+Ex group with significant improvement

Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement

Bergman et al Annals of Internal Medicine 2004

Bottom Line MT + UMC was the winner for achieving ldquofull

recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at

52wks

Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions

UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits

Design Multi-site RCT

Pop N=150 painful shoulder girdle

Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received

InterventionsbullUsual Medical Care (UMC)

Adviceinformation therapy NSAIDSanalgesics amp CSIs

bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)

ResultsbullAt 12 26 52 Wks

ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder

Dysfunction and Pain

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Secondary Impingement

bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace

Structures

bull RC weaknessbull RC tearbull Capsular laxitybull Multidirectional instabilitybull Functional instability or

neuromuscular inhibitionbull Scapular dyskinesia

Causes

(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)

Diagnosis of Primary SIS

bull Historical Factorsbull Pain at night pain with overhead activities

complaints of stiffness

bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)

bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test

Park et al 2005

Diagnosis of Primary SIS

bull Another Perspectivebull A larger test-item cluster

3 or more 5 tests rules in SIS 3 or less 5 rules out SIS

Test SensSpect

+LR-LR

Neer Sens -035

Painful Arc Both +225 -038

Ext Rot Resistance Both +439

Hawkins-Kennedy Both ~1

Empty Can Spec +390

Michener et al APMR 2009

Diagnosis of Secondary SIS

bull Historical Factorsbull Young history of instability pain with overhead

activities hypermobility overhead athlete

bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral

scapular slide test for example)

McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164

Upper Extremity Y-Balance Test

bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper

limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo

P Plisky

bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn

Shoulder Scale pain at rest normal amp strenuous activities

NPRSbull Disability of Arm Shoulder and

Handbull Quick DASH also goodDASH

bull Shoulder Pain and Disability IndexSPADI

MCID 10-15 points

Outcome Measures for SIS

MCID 8-13 points

General Treatment PrinciplesType of SIS Presentation Guiding Principle Management

PrimaryStage I

Stage II

Stage III

Young pain with activity Rest restore mechanics

MT and Exercise

26-40 pain at night prolonged symptoms

Restore sub-acromial space

MT and Exercise possible surgery

Older chronic associated with RC tears

Manage conservatively unless sx indicated

RC strengthening Jt mob surgical

Secondary Multi-directional instability

Stabilize Proprioceptive neuromuscular strengthening

Internal Young impingement in specific range

Strengthen cuff muscles

Rehab or labral repair

Treatment Non-surgical vs Surgical

bull Emphasize preventionbull Current Best Evidence Summary

Bang amp DeyleJOSPT 2000

Bottom Line While both groups improved the MT+Ex

group had greater improvements including strength gains

Considerations MT + Ex group received treatment reinforcing HEP

Design RCTPop N=52 impingement syndromeOutcomes

Baseline 1 amp 2 mo

Strength Pain Functional Assessment Questionnaire (FAQ)

Interventions 6 sessions 3-4 wksbullExercise Group (Ex)

bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)

bullEx as abovebullMan Ther Upper Quarter

ResultsbullPain amp Function

MT+Ex with significantly more improvement

bullStrengthOnly MT+Ex group with significant improvement

Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement

Bergman et al Annals of Internal Medicine 2004

Bottom Line MT + UMC was the winner for achieving ldquofull

recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at

52wks

Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions

UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits

Design Multi-site RCT

Pop N=150 painful shoulder girdle

Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received

InterventionsbullUsual Medical Care (UMC)

Adviceinformation therapy NSAIDSanalgesics amp CSIs

bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)

ResultsbullAt 12 26 52 Wks

ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder

Dysfunction and Pain

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Diagnosis of Primary SIS

bull Historical Factorsbull Pain at night pain with overhead activities

complaints of stiffness

bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)

bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test

Park et al 2005

Diagnosis of Primary SIS

bull Another Perspectivebull A larger test-item cluster

3 or more 5 tests rules in SIS 3 or less 5 rules out SIS

Test SensSpect

+LR-LR

Neer Sens -035

Painful Arc Both +225 -038

Ext Rot Resistance Both +439

Hawkins-Kennedy Both ~1

Empty Can Spec +390

Michener et al APMR 2009

Diagnosis of Secondary SIS

bull Historical Factorsbull Young history of instability pain with overhead

activities hypermobility overhead athlete

bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral

scapular slide test for example)

McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164

Upper Extremity Y-Balance Test

bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper

limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo

P Plisky

bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn

Shoulder Scale pain at rest normal amp strenuous activities

NPRSbull Disability of Arm Shoulder and

Handbull Quick DASH also goodDASH

bull Shoulder Pain and Disability IndexSPADI

MCID 10-15 points

Outcome Measures for SIS

MCID 8-13 points

General Treatment PrinciplesType of SIS Presentation Guiding Principle Management

PrimaryStage I

Stage II

Stage III

Young pain with activity Rest restore mechanics

MT and Exercise

26-40 pain at night prolonged symptoms

Restore sub-acromial space

MT and Exercise possible surgery

Older chronic associated with RC tears

Manage conservatively unless sx indicated

RC strengthening Jt mob surgical

Secondary Multi-directional instability

Stabilize Proprioceptive neuromuscular strengthening

Internal Young impingement in specific range

Strengthen cuff muscles

Rehab or labral repair

Treatment Non-surgical vs Surgical

bull Emphasize preventionbull Current Best Evidence Summary

Bang amp DeyleJOSPT 2000

Bottom Line While both groups improved the MT+Ex

group had greater improvements including strength gains

Considerations MT + Ex group received treatment reinforcing HEP

Design RCTPop N=52 impingement syndromeOutcomes

Baseline 1 amp 2 mo

Strength Pain Functional Assessment Questionnaire (FAQ)

Interventions 6 sessions 3-4 wksbullExercise Group (Ex)

bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)

bullEx as abovebullMan Ther Upper Quarter

ResultsbullPain amp Function

MT+Ex with significantly more improvement

bullStrengthOnly MT+Ex group with significant improvement

Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement

Bergman et al Annals of Internal Medicine 2004

Bottom Line MT + UMC was the winner for achieving ldquofull

recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at

52wks

Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions

UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits

Design Multi-site RCT

Pop N=150 painful shoulder girdle

Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received

InterventionsbullUsual Medical Care (UMC)

Adviceinformation therapy NSAIDSanalgesics amp CSIs

bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)

ResultsbullAt 12 26 52 Wks

ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder

Dysfunction and Pain

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Diagnosis of Primary SIS

bull Another Perspectivebull A larger test-item cluster

3 or more 5 tests rules in SIS 3 or less 5 rules out SIS

Test SensSpect

+LR-LR

Neer Sens -035

Painful Arc Both +225 -038

Ext Rot Resistance Both +439

Hawkins-Kennedy Both ~1

Empty Can Spec +390

Michener et al APMR 2009

Diagnosis of Secondary SIS

bull Historical Factorsbull Young history of instability pain with overhead

activities hypermobility overhead athlete

bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral

scapular slide test for example)

McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164

Upper Extremity Y-Balance Test

bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper

limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo

P Plisky

bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn

Shoulder Scale pain at rest normal amp strenuous activities

NPRSbull Disability of Arm Shoulder and

Handbull Quick DASH also goodDASH

bull Shoulder Pain and Disability IndexSPADI

MCID 10-15 points

Outcome Measures for SIS

MCID 8-13 points

General Treatment PrinciplesType of SIS Presentation Guiding Principle Management

PrimaryStage I

Stage II

Stage III

Young pain with activity Rest restore mechanics

MT and Exercise

26-40 pain at night prolonged symptoms

Restore sub-acromial space

MT and Exercise possible surgery

Older chronic associated with RC tears

Manage conservatively unless sx indicated

RC strengthening Jt mob surgical

Secondary Multi-directional instability

Stabilize Proprioceptive neuromuscular strengthening

Internal Young impingement in specific range

Strengthen cuff muscles

Rehab or labral repair

Treatment Non-surgical vs Surgical

bull Emphasize preventionbull Current Best Evidence Summary

Bang amp DeyleJOSPT 2000

Bottom Line While both groups improved the MT+Ex

group had greater improvements including strength gains

Considerations MT + Ex group received treatment reinforcing HEP

Design RCTPop N=52 impingement syndromeOutcomes

Baseline 1 amp 2 mo

Strength Pain Functional Assessment Questionnaire (FAQ)

Interventions 6 sessions 3-4 wksbullExercise Group (Ex)

bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)

bullEx as abovebullMan Ther Upper Quarter

ResultsbullPain amp Function

MT+Ex with significantly more improvement

bullStrengthOnly MT+Ex group with significant improvement

Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement

Bergman et al Annals of Internal Medicine 2004

Bottom Line MT + UMC was the winner for achieving ldquofull

recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at

52wks

Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions

UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits

Design Multi-site RCT

Pop N=150 painful shoulder girdle

Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received

InterventionsbullUsual Medical Care (UMC)

Adviceinformation therapy NSAIDSanalgesics amp CSIs

bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)

ResultsbullAt 12 26 52 Wks

ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder

Dysfunction and Pain

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Diagnosis of Secondary SIS

bull Historical Factorsbull Young history of instability pain with overhead

activities hypermobility overhead athlete

bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral

scapular slide test for example)

McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164

Upper Extremity Y-Balance Test

bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper

limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo

P Plisky

bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn

Shoulder Scale pain at rest normal amp strenuous activities

NPRSbull Disability of Arm Shoulder and

Handbull Quick DASH also goodDASH

bull Shoulder Pain and Disability IndexSPADI

MCID 10-15 points

Outcome Measures for SIS

MCID 8-13 points

General Treatment PrinciplesType of SIS Presentation Guiding Principle Management

PrimaryStage I

Stage II

Stage III

Young pain with activity Rest restore mechanics

MT and Exercise

26-40 pain at night prolonged symptoms

Restore sub-acromial space

MT and Exercise possible surgery

Older chronic associated with RC tears

Manage conservatively unless sx indicated

RC strengthening Jt mob surgical

Secondary Multi-directional instability

Stabilize Proprioceptive neuromuscular strengthening

Internal Young impingement in specific range

Strengthen cuff muscles

Rehab or labral repair

Treatment Non-surgical vs Surgical

bull Emphasize preventionbull Current Best Evidence Summary

Bang amp DeyleJOSPT 2000

Bottom Line While both groups improved the MT+Ex

group had greater improvements including strength gains

Considerations MT + Ex group received treatment reinforcing HEP

Design RCTPop N=52 impingement syndromeOutcomes

Baseline 1 amp 2 mo

Strength Pain Functional Assessment Questionnaire (FAQ)

Interventions 6 sessions 3-4 wksbullExercise Group (Ex)

bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)

bullEx as abovebullMan Ther Upper Quarter

ResultsbullPain amp Function

MT+Ex with significantly more improvement

bullStrengthOnly MT+Ex group with significant improvement

Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement

Bergman et al Annals of Internal Medicine 2004

Bottom Line MT + UMC was the winner for achieving ldquofull

recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at

52wks

Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions

UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits

Design Multi-site RCT

Pop N=150 painful shoulder girdle

Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received

InterventionsbullUsual Medical Care (UMC)

Adviceinformation therapy NSAIDSanalgesics amp CSIs

bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)

ResultsbullAt 12 26 52 Wks

ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder

Dysfunction and Pain

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Upper Extremity Y-Balance Test

bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper

limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo

P Plisky

bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn

Shoulder Scale pain at rest normal amp strenuous activities

NPRSbull Disability of Arm Shoulder and

Handbull Quick DASH also goodDASH

bull Shoulder Pain and Disability IndexSPADI

MCID 10-15 points

Outcome Measures for SIS

MCID 8-13 points

General Treatment PrinciplesType of SIS Presentation Guiding Principle Management

PrimaryStage I

Stage II

Stage III

Young pain with activity Rest restore mechanics

MT and Exercise

26-40 pain at night prolonged symptoms

Restore sub-acromial space

MT and Exercise possible surgery

Older chronic associated with RC tears

Manage conservatively unless sx indicated

RC strengthening Jt mob surgical

Secondary Multi-directional instability

Stabilize Proprioceptive neuromuscular strengthening

Internal Young impingement in specific range

Strengthen cuff muscles

Rehab or labral repair

Treatment Non-surgical vs Surgical

bull Emphasize preventionbull Current Best Evidence Summary

Bang amp DeyleJOSPT 2000

Bottom Line While both groups improved the MT+Ex

group had greater improvements including strength gains

Considerations MT + Ex group received treatment reinforcing HEP

Design RCTPop N=52 impingement syndromeOutcomes

Baseline 1 amp 2 mo

Strength Pain Functional Assessment Questionnaire (FAQ)

Interventions 6 sessions 3-4 wksbullExercise Group (Ex)

bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)

bullEx as abovebullMan Ther Upper Quarter

ResultsbullPain amp Function

MT+Ex with significantly more improvement

bullStrengthOnly MT+Ex group with significant improvement

Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement

Bergman et al Annals of Internal Medicine 2004

Bottom Line MT + UMC was the winner for achieving ldquofull

recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at

52wks

Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions

UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits

Design Multi-site RCT

Pop N=150 painful shoulder girdle

Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received

InterventionsbullUsual Medical Care (UMC)

Adviceinformation therapy NSAIDSanalgesics amp CSIs

bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)

ResultsbullAt 12 26 52 Wks

ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder

Dysfunction and Pain

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn

Shoulder Scale pain at rest normal amp strenuous activities

NPRSbull Disability of Arm Shoulder and

Handbull Quick DASH also goodDASH

bull Shoulder Pain and Disability IndexSPADI

MCID 10-15 points

Outcome Measures for SIS

MCID 8-13 points

General Treatment PrinciplesType of SIS Presentation Guiding Principle Management

PrimaryStage I

Stage II

Stage III

Young pain with activity Rest restore mechanics

MT and Exercise

26-40 pain at night prolonged symptoms

Restore sub-acromial space

MT and Exercise possible surgery

Older chronic associated with RC tears

Manage conservatively unless sx indicated

RC strengthening Jt mob surgical

Secondary Multi-directional instability

Stabilize Proprioceptive neuromuscular strengthening

Internal Young impingement in specific range

Strengthen cuff muscles

Rehab or labral repair

Treatment Non-surgical vs Surgical

bull Emphasize preventionbull Current Best Evidence Summary

Bang amp DeyleJOSPT 2000

Bottom Line While both groups improved the MT+Ex

group had greater improvements including strength gains

Considerations MT + Ex group received treatment reinforcing HEP

Design RCTPop N=52 impingement syndromeOutcomes

Baseline 1 amp 2 mo

Strength Pain Functional Assessment Questionnaire (FAQ)

Interventions 6 sessions 3-4 wksbullExercise Group (Ex)

bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)

bullEx as abovebullMan Ther Upper Quarter

ResultsbullPain amp Function

MT+Ex with significantly more improvement

bullStrengthOnly MT+Ex group with significant improvement

Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement

Bergman et al Annals of Internal Medicine 2004

Bottom Line MT + UMC was the winner for achieving ldquofull

recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at

52wks

Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions

UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits

Design Multi-site RCT

Pop N=150 painful shoulder girdle

Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received

InterventionsbullUsual Medical Care (UMC)

Adviceinformation therapy NSAIDSanalgesics amp CSIs

bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)

ResultsbullAt 12 26 52 Wks

ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder

Dysfunction and Pain

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

General Treatment PrinciplesType of SIS Presentation Guiding Principle Management

PrimaryStage I

Stage II

Stage III

Young pain with activity Rest restore mechanics

MT and Exercise

26-40 pain at night prolonged symptoms

Restore sub-acromial space

MT and Exercise possible surgery

Older chronic associated with RC tears

Manage conservatively unless sx indicated

RC strengthening Jt mob surgical

Secondary Multi-directional instability

Stabilize Proprioceptive neuromuscular strengthening

Internal Young impingement in specific range

Strengthen cuff muscles

Rehab or labral repair

Treatment Non-surgical vs Surgical

bull Emphasize preventionbull Current Best Evidence Summary

Bang amp DeyleJOSPT 2000

Bottom Line While both groups improved the MT+Ex

group had greater improvements including strength gains

Considerations MT + Ex group received treatment reinforcing HEP

Design RCTPop N=52 impingement syndromeOutcomes

Baseline 1 amp 2 mo

Strength Pain Functional Assessment Questionnaire (FAQ)

Interventions 6 sessions 3-4 wksbullExercise Group (Ex)

bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)

bullEx as abovebullMan Ther Upper Quarter

ResultsbullPain amp Function

MT+Ex with significantly more improvement

bullStrengthOnly MT+Ex group with significant improvement

Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement

Bergman et al Annals of Internal Medicine 2004

Bottom Line MT + UMC was the winner for achieving ldquofull

recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at

52wks

Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions

UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits

Design Multi-site RCT

Pop N=150 painful shoulder girdle

Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received

InterventionsbullUsual Medical Care (UMC)

Adviceinformation therapy NSAIDSanalgesics amp CSIs

bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)

ResultsbullAt 12 26 52 Wks

ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder

Dysfunction and Pain

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Treatment Non-surgical vs Surgical

bull Emphasize preventionbull Current Best Evidence Summary

Bang amp DeyleJOSPT 2000

Bottom Line While both groups improved the MT+Ex

group had greater improvements including strength gains

Considerations MT + Ex group received treatment reinforcing HEP

Design RCTPop N=52 impingement syndromeOutcomes

Baseline 1 amp 2 mo

Strength Pain Functional Assessment Questionnaire (FAQ)

Interventions 6 sessions 3-4 wksbullExercise Group (Ex)

bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)

bullEx as abovebullMan Ther Upper Quarter

ResultsbullPain amp Function

MT+Ex with significantly more improvement

bullStrengthOnly MT+Ex group with significant improvement

Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement

Bergman et al Annals of Internal Medicine 2004

Bottom Line MT + UMC was the winner for achieving ldquofull

recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at

52wks

Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions

UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits

Design Multi-site RCT

Pop N=150 painful shoulder girdle

Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received

InterventionsbullUsual Medical Care (UMC)

Adviceinformation therapy NSAIDSanalgesics amp CSIs

bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)

ResultsbullAt 12 26 52 Wks

ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder

Dysfunction and Pain

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Bang amp DeyleJOSPT 2000

Bottom Line While both groups improved the MT+Ex

group had greater improvements including strength gains

Considerations MT + Ex group received treatment reinforcing HEP

Design RCTPop N=52 impingement syndromeOutcomes

Baseline 1 amp 2 mo

Strength Pain Functional Assessment Questionnaire (FAQ)

Interventions 6 sessions 3-4 wksbullExercise Group (Ex)

bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)

bullEx as abovebullMan Ther Upper Quarter

ResultsbullPain amp Function

MT+Ex with significantly more improvement

bullStrengthOnly MT+Ex group with significant improvement

Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement

Bergman et al Annals of Internal Medicine 2004

Bottom Line MT + UMC was the winner for achieving ldquofull

recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at

52wks

Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions

UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits

Design Multi-site RCT

Pop N=150 painful shoulder girdle

Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received

InterventionsbullUsual Medical Care (UMC)

Adviceinformation therapy NSAIDSanalgesics amp CSIs

bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)

ResultsbullAt 12 26 52 Wks

ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder

Dysfunction and Pain

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Bergman et al Annals of Internal Medicine 2004

Bottom Line MT + UMC was the winner for achieving ldquofull

recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at

52wks

Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions

UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits

Design Multi-site RCT

Pop N=150 painful shoulder girdle

Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received

InterventionsbullUsual Medical Care (UMC)

Adviceinformation therapy NSAIDSanalgesics amp CSIs

bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)

ResultsbullAt 12 26 52 Wks

ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder

Dysfunction and Pain

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

McClatchie et alManual Therapy2008

Bottom Line bull Changes in shoulder from treating the

asymptomatic C-spine beyond placebo

Considerations Suggestive of a neurophysiologic effect that treatment

of this area may facilitate recovery in distant regions Not an impairment-based approach

Design RCT cross-over design

Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain

Outcomes Pain (VAS) Painful Arc

Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization

Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Tate et alJOSPT 2010

Bottom Line bull Strong study describing treatment approach

Considerations No cause and effect

Design Case SeriesPop N=10 pts with SIS

Outcomes DASH (50 improvement) GROC

InterventionsbullStandardized treatment program including exercise and manual techniques

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Other Interventions

Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions

Pharmaceutical Management even usual PT all seem to be ineffective

1 PT = Arthroscopic debridement + PT (Brox 1993)

2 CSI may only be beneficial for a sub-group (Bergman et al 2004)

3 Passive Interventions and Modalities not effective (Leduc et al 2003)

4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)

5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)

How does the evidence look for other interventions for SIS

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Musculoskeletal

Somatovisceral

Biopsychosocial

Neurophysiological

Regional Interdependence

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

SIS A Regional Perspective

Cervical Spine forward head muscle tightness

Ribs first and second rib dysfunction

Thoracic Spine attachment for many scapula stabilizers

CNS neuromotor control pain processing core synergies and stabilization

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Eccentric Exercise

bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff

bull Holmgren et al 2012 Reduced need for surgery with ecc

Treatment Control

0

20

40

60

80

Subsequent Surgery

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

SIS Conclusions

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Adhesive Capsulitis

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

What is it

bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease

bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary

bull Intrinsic vs extrinsic

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Differential Diagnosis

bull May present similarly to other common shoulder conditions seen in PT

-Rotator cuff tears

-tendonitis

-osteoarthritis

-labral tear

-subacromial bursitis

Diagnostic imaging usually unnecessary but may be used to rule out other conditions

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Kelley MJ et al JOSPT 39 (2) 2009

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Kelley MJ et al JOSPT 39 (2) 2009

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Natural History

bull Little agreement in the literaturebull ldquoeven the most severe cases recover with

or without treatment in about 2 yearsrdquo Codman ndash 1934

bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Duration of the Disease(with conservative treatment)

bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months

bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months

bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Long Term Effectsbull Reeves ndash 1975

bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation

bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation

bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional

ROMrsquo

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Long Term Effects

bull Summary Full PLOF is not a given

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Oral steroidsCochrane Review Buchbinder 2009

bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks

bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement

bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months

bull Conclusion oral steroids provides significant short-term benefits in pain

range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Steroid InjectionsCochrane Review Buchbinder 2009

bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term

bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Capsular DistensionCochrane Buchbinder 2009

bull Distension methods air air w steroid injection saline and saline w steroid injection

bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)

- May improve pain at three weeks

- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary

injection with steroid

- May not lead to any difference in pain and disability

bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Traditional Manipulation long-lever techniques

bull Common practice in some centers for patients who have failed conservative Rx

bull Sandor ndash 2000

bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001

bull Traditional manipulation risks fracture especially in osteoporotic patients

bull Hannifan - 2000

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo

bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons

bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo

Traditional Manipulation long-lever techniques

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series

bull Subjects (N= 4)bull Average Symptom Duration = 75 mo

bull Treatmentbull Interscalene block followed by impairment-based

mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM

strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)

bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week

(Boyles et al Manual Therapy 2005)

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Patient 1 Patient 2 Patient 3 Patient 40

100

200

300

400

500

600

Pre-Rx

Immediate

Final

De

gre

es

of

PR

OM

Total Passive ROM

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Patient 1 Patient 2 Patient 3 Patient 40

10

20

30

40

50

60

70

Pre-RX

Final

SP

AD

I sc

ore

(0

-10

0)

SPADI Scores (Pre-manipulation to final)

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Results

Post ER

Post AbdPre Abd

Pre ER

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Video Fluoroscopy

6 wk Post- ManipulationPre-Manipulation

>

>

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Case Studies Arthroscopic findings following translational MUAHando B article in write up

bull Arthroscopy performed immediately following translational manipulations

bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months

bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Patient 1 Diabetic male AC x 7 months

Humeral

head

Torn Scar tissue

Glenoid

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Patient 1 Diabetic male AC x 7 months

Humeral head

Scar Tissue

Labrum

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Patient 2Secondary AC x 14 months

Humeral head

lsquoVeilrsquo of scar tissue

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Patient 2Secondary AC x 14 months

Humeral head

Scar tissue

Glenoid

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Intra-articular Findings

bull In both shouldersbull No acute intra-articular

lesions were found

Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Translational Manipulation Theory

bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo

bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo

bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus

Placzek et al Amer J of Orthondash 2004

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Prognosis

bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion

bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with

conservative treatment and require more aggressive management

bull Spontaneous recovery may occur up to 2 years post-onset

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term

bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis

bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs

Clinical Bottom Line

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

>

>

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

MANUAL THERAPY FOR THE SHOULDER

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Green et al Cochrane Database of Systematic Reviews 2003

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for

adhesive capsulitis

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Green et al Cochrane Database of Systematic Reviews 2010

Physiotherapy Interventions for Shoulder Pain

bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis

bull Resultsbull Exercise is effective for short- and long-term recovery in

rotator cuff diseasebull Manual therapy provides added benefit to exercise

bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease

bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review

bull Systematic review of 12 RCTsbull Results

bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery

bull Adding MT to therex provides favorable outcomes compared to therex alone

bull Does not support the use of US as a beneficial treatment

bull Conflicting results in use of acupuncture

Michener LA et al J Hand Ther 2004

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010

Identifying Prognostic Factors for Successful Short-Term Outcomes in

Individuals with Shoulder Pain Receiving Cervicothoracic

Manipulation

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

5 Variables in the CPR

bull Painfree shoulder flexion lt 1270

bull Shoulder IR lt 530 at 900 abduction

bull Negative Neer test

bull Not taking medications

bull Symptoms lt 90 days

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Prognostic Factors for MT

Mintken et al Physical Therapy Jan 2010

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

The Rule

Pre-test Probability of

Dramatic Success with Manipulation

61

3 or more present

bullPainfree shoulder flexion lt 1270

bullShoulder IR lt 530

bullNegative Neer test

bullNot taking medications

bullSymptoms lt 90 days

89

Post-test Probability of

Dramatic Success with Manipulation

+LR = 53

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Prognostic Factors Risk of Persistent Pain

Kuijpers et al Pain J2006

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

In the workshellip

Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial

Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

In the workshellipIn data collection phase

Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial

Rhon Boyles amp Cleland

VS

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

SHOULDER INSTABILITYThings that move too muchhellip

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Epidemiology

66-100 of individuals lt 20 years of age

13-63 of individuals between 20 and 40 years age

0-16 of individuals older than 40 years of age

Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Epidemiology

bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)

bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence

Shoulder Dislocation

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Laxity vs Instability

bull Laxity ndash the extent to which the humeral head can be translated on the glenoid

bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)

Schenk J Am Acad Orthop Surg 1998

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Shoulder StabilityA Result of Multiple Components

bull Bony Congruencybull Enhanced by labrum

bull Negative pressurebull at side amp at rest

bull Muscles amp tendonsbull static and dynamic

bull Ligaments amp capsuleGlenohumeral Elevation

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Shoulder Function

bull G-H joint has uarr mobility but at loss of stability

bull 25 of humeral head contacts glenoid fossa

bull Static Soft tissue constraints bull Capsule G-H ligaments labrum

bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive

mechanisms and scapularhumeral muscles

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Labrum Anatomy

Putz et al Ascopy 1999

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Neuromuscular Stabilization

bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)

The Shoulder A Balance of Mobility and Stability

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Classifying Instability

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Classifying Instability

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Classifying Instability

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Instability Spectrum

TUBS AMBRI

Born LooseTorn Loose

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Clinical Presentation

Traumatic Injury

bull Position of dislocationbull Anteriorposterior shoulder

painbull Apprehensive to moving

arm out from body

Nontraumatic Injury

bull General multi-joint hypermobility

bull Anteriorposterior shoulder pain

bull Loose inferior capsule

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Physical Examination

bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae

bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest

bull Motionbull Unableunwilling to move into endranges of ABD amp ER

bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles

bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Physical Examination

Special testsApprehension test Relocation test

Load amp Shift test Sulcus test

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Non-surgical Management

bull Older patients have lower recurrence therefore better candidates vs younger patients

bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Non-surgical Management

bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing

adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included

strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of

immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior

Traumatic Instability

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Non-surgical Management

bull Role of Exercise bull Again few studies investigating outcomes

bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers

bull Functional coordination exercisebull Lifestyle modification

General Instability Rehabilitation Principles

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Exercise for Selected Shoulder Disorders

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Essential Elements for Dynamic Stability of the Shoulder Complex

bull Adequate compressive forcesbull RC doing its job

bull Scapular basebull Mobilitystability

bull Proprioception and NM control of the entire kinetic chain

bull Muscular endurancebull Train to jobsport specificity

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Shoulder Flexibility Requirements

bull Pectoralis Muscles bull Associated with excessive scapular protraction

and downward rotation both disturbing optimal glenohumeral mechanics

bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal

impingement syndrome in throwing athletes

bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Andersen et al Phys Ther 2010 Apr90(4)538-49

bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance

bull CONCLUSIONS bull Therapists can choose either

resistance method in clinical practice

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

How do we load the shoulder

Myth

bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles

Evidence

bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight

bull Larger muscle groups do not overpower smaller groups such as the rotator cuff

bull Load should be based on the individual goals requirements

Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008

Strength Continuum

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

SCAPULArsquoS ROLE IN SHOULDER STABILITY

bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation

requirements)

bull Stable base of origin for muscles bull Responsible for function and stability

bull Length dependent activation patternsbull Deltoid biceps triceps and RTC

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Evidence Based Scapular Interventions

bull Serratus anterior strengthening or retraining

bull Upper trapezius activation reduction

bull Pectoralis minor stretching

bull Thoracic extension posture and exercise

bull Posterior shoulder stretching

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Scapular Retraining Exercises

bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows

bull Integrate hiptrunk strengthening and stretching throughout rehab

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

What are the best exercises for Muscles around the shoulder

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Recommended Exercises for Rotator Cuff

bull Supraspinatusbull 1 Full can bull 2 Prone full can

bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll

bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

20 participants performed full can and empty can exercises and 3D scapula kinematics were captured

Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN

exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the

supraspinatus

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Infraspinatus and subscapularis activityhellip

bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo

bull Posterior deltoid activity is higher in lsquoempty canrsquo ex

Escamilla et al Sports Med 2009 39 (8) 663-685

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Best Exercise for the Serratus

Ludewig et al Am J Sports Med 2004 32 484-93

SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus

In clinical cases of scapular winging the Standard

Pushup Plus is an optimal exercise

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Recommended Exercises for Serratus

Serratus anterior bull 1 Push-up with plus

bull 2 Dynamic hug

bull 3 Serratus punch 120deg

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Recommended Exercises for Trapezii

bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)

bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER

bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Best Exercises to Minimize Upper Trap

bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended

bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA

bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of

trapezius activity during these exercises

Cools et al Am J Sportsmedicine200735(10)1744-51

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex

bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with

external rotation and bull prone extension exercises

hellipto promote LT and MT activity with minimal activation of the UT part

bull Based on our results we suggest the use of

Cools et al Am J Sportsmedicine200735(10)1744-51

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Recommended Exercises for Rhomboids and Levator

bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER

Escamilla et al Sports Med 2009 39 (8) 663-685

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

General thoughts on therex for shoulder

bull Initial phasebull Pain control edema reduction gentle PROM address

functional problems

bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM

address functional problemsbull Progress to AROM followed by strengthening

bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-

specific exercises

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Program Summaryand Outcomes

Tate et al JOSPT 2010 40(8)

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Instructions

bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets

of 10 reps without substantial pain or fatiguebull T-band standard 35ft long

bull Longer for taller people doing scaption

bull Avoid or modify position of any exercise producing significant symptoms

Tate et al JOSPT 2010 40(8)

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Tate

et

al

JO

SP

T 2

010

40

(8)

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Tate et al JOSPT 2010 40(8)

Phase I

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Tate et al JOSPT 2010 40(8)

Phase II

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Tate et al JOSPT 2010 40(8)

Phase III

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Clinical Bottom Line Exercise for SIS

bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space

bull Correct posturebull Strengthen shoulder stabilizers

bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius

bull Strengthen rotator cuffbull Stretch tight structures

bull Pec major and minorbull Upper trapeziusbull Posterior capsule

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Exercise for Rotator Cuff Tears

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Results bull 4 studies were specific to massive rotator cuff tears

bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full

thickness tear bull Due to the heterogeneity of outcome measures used

it was not possible to combine resultsbull In all studies an improvement in outcome scores

was reportedbull The findings suggest that some evidence exists to

support the use of exercise in the management of full thickness rotator cuff tears

Ainsworth amp Lewis Br J Sports Med 200741200ndash210

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and

a specific exercise program

bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores

and isokinetic strength (P lt 005)

At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo

bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively

Baydar et al Rheumatol Int (2009) 29623ndash628

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive

Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Exercise for Instability

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns

bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception

bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability

bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery

bull (Ginn and Cohen 2005)

bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)

Shoulder Instability Rehab

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Motor Control Alterations with GH Instabity

bull Decreased supraspinatus-subscapularis coactivation

bull Slower biceps brachii activationbull Decreased pectoralis major amp

biceps brachii recruitmentbull Suppressed scapular stabilization

by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et

al 1991 McMahonet al 1996 Myers et al 2004)

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull 6 Subjects with GH Instability bull Significant increases scapular protraction and

anterior tilt bull Activity of the lower trap and serratus delayed

during first part of elevationbull Altered humeral head and glenoid alignment

predispose shoulder instability bull Scapular changes are perhaps due to an inadequate

scapular muscular activitybull Evidence to suggest that the sensorimotor

contributors to joint stability can be restored

The unstable shoulder in arm elevation A three-dimensional and electromyographic study in

subjects with glenohumeral instability Matias R Pascoal AG

Clinical Biomechanics 21 (2006) S52ndashS58

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37

bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on

Swiss ball balancing UE on wobbleboard 10 min daily

Significant improvement movement discrimination

with dislocators ( plt0001)

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation

bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)

Neuromuscular retraining for multidirectional instability of the shoulder -- a case study

Darlow B

NZ J Physiother 200634(2)60-65

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Instability Rehabilitation Implications

bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-

inferior instability

bull Avoid rehabilitation exercises combining abduction and external rotation

bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process

bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations

bull Include proprioceptive exercises to combat loss due to tissue damage

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Advanced phase functional rehabilitation

bull Focus on continued strength and endurancebull Retraining patterns of movement biased

towards functional tasksbull Repetition speed and load may be varied

facilitating feedforward processingbull Dynamic stabilization challenged by pushups

on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest

passes overhead soccer throw and side-to-side throws

bull Bouncing balls off trampoline bull Global upper-limb strengthening

bull Kibler et al Clin Sports Med 2008

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression

Integrating the Shoulder

Return to Function Phase

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Return to sport

bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop

bull Patient should regain 5 key components

prior to return to sport1 Flexibility

2 Strength

3 Balance

4 Proprioception

5 CONFIDENCEbull If confidence is lacking patient at risk of

compensation reinjury and recurrence of instability

Jaggi and Lambert Br J Sports Med 2010445 333-340

Upper Extremity Y-Balance Test

bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo

bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)

bull Men 817823 bull Women 807 807

Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub

Our Path

Things that donrsquot move enough

bull Subacromial Impingementbull Adhesive Capsulitis

bull Evidence for Manual Therapy

Things that move too much

bull Shoulder Instabilitybull Evidence-supported exercise

Irsquom getting Emotionalhellip

Irsquom getting Emotionalhellip

bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes

Evidence for risk factors for chronic pain

bull Measure these fine thingsbull TSK FDAQ FABQ

Kinesiophobia

bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function

Remember to acknowledge and treat chronic conditions as chronic pain

Pain Phenotypes you say

bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)

bull and Psychological factorshellip

bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability

George et al 32014

Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype

Genetically Predisposed

bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing

bull Are predictive of upper extremity disability and depressive symptoms related to pain

Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014

References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement

syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement

syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a

prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train

200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving

cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med

200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J

Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in

overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-

173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind

study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large

pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome

J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement

syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and

pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for

treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder

impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement

syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis

Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in

the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man

Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]

Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787

Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for

shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation

JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide

clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066

bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340

bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190

bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36

bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91

• Shoulder Update 2014 University of Texas at El Paso Centennia
• Objectives
• Shoulder Pain Incidence and Costs
• Our Path
• Impingement Syndrome Concept
• The SIS Continuum Neer Classification
• Impingement Classification
• Primary Impingement
• Secondary Impingement
• Diagnosis of Primary SIS
• Diagnosis of Primary SIS (2)
• Diagnosis of Secondary SIS
• Slide 13
• Outcome Measures for SIS
• General Treatment Principles
• Treatment Non-surgical vs Surgical
• Bang amp Deyle JOSPT 2000
• Bergman et al Annals of Internal Medicine 2004
• McClatchie et al Manual Therapy2008
• Tate et al JOSPT 2010
• Other Interventions
• Slide 22
• SIS A Regional Perspective
• Eccentric Exercise
• Slide 25
• Adhesive Capsulitis
• What is it
• Differential Diagnosis
• Kelley MJ et al JOSPT 39 (2) 2009
• Slide 30
• Slide 31
• Natural History
• Duration of the Disease (with conservative treatment)
• Long Term Effects
• Long Term Effects (2)
• Treatment Options
• Oral steroids Cochrane Review Buchbinder 2009
• Steroid Injections Cochrane Review Buchbinder 2009
• Capsular Distension Cochrane Buchbinder 2009
• Traditional Manipulation long-lever techniques
• Traditional Manipulation long-lever techniques (2)
• Manipulation Following Interscalene Block for Shoulder Adhesive
• Total Passive ROM
• SPADI Scores (Pre-manipulation to final)
• Results
• Video Fluoroscopy
• Case Studies Arthroscopic findings following translational
• Patient 1 Diabetic male AC x 7 months
• Patient 1 Diabetic male AC x 7 months
• Patient 2 Secondary AC x 14 months
• Patient 2 Secondary AC x 14 months (2)
• Intra-articular Findings
• Translational Manipulation Theory
• Prognosis
• Clinical Bottom Line
• Slide 56
• manual Therapy for the Shoulder
• Physiotherapy Interventions for Shoulder Pain
• Physiotherapy Interventions for Shoulder Pain (2)
• Effectiveness of Rehabilitation for Patients with Impingement S
• Slide 61
• 5 Variables in the CPR
• Prognostic Factors for MT
• The Rule
• Prognostic Factors Risk of Persistent Pain
• In the workshellip
• In the workshellip In data collection phase
• Shoulder Instability
• Epidemiology
• Epidemiology (2)
• Laxity vs Instability
• Shoulder Stability A Result of Multiple Components
• Shoulder Function
• Labrum Anatomy
• Neuromuscular Stabilization
• Classifying Instability
• Classifying Instability (2)
• Classifying Instability (3)
• Instability Spectrum
• Clinical Presentation
• Clinical Presentation (2)
• Physical Examination
• Physical Examination (2)
• Non-surgical Management
• Non-surgical Management (2)
• Non-surgical Management (3)
• Exercise for Selected Shoulder Disorders
• Essential Elements for Dynamic Stability of the Shoulder Comple
• Shoulder Flexibility Requirements
• Slide 91
• How do we load the shoulder
• Slide 93
• SCAPULArsquoS ROLE IN SHOULDER STABILITY
• Slide 95
• Evidence Based Scapular Interventions
• Scapular Retraining Exercises
• What are the best exercises for Muscles around the shoulder
• Recommended Exercises for Rotator Cuff
• Slide 100
• Infraspinatus and subscapularis activityhellip
• Best Exercise for the Serratus
• Recommended Exercises for Serratus
• Recommended Exercises for Trapezii
• Best Exercises to Minimize Upper Trap
• Conclusions THESE are good trapezius exercises but they are
• Recommended Exercises for Rhomboids and Levator
• General thoughts on therex for shoulder
• Slide 110
• Program Summary and Outcomes
• Instructions
• Slide 113
• Slide 114
• Slide 115
• Slide 116
• Clinical Bottom Line Exercise for SIS
• Exercise for Rotator Cuff Tears
• Slide 119
• Slide 120
• Slide 121
• Exercise for Instability
• Shoulder Instability Rehab
• Motor Control Alterations with GH Instabity
• Slide 125
• Naughton J et al Upper-body wobbleboard training effects on t
• Slide 127
• Instability Rehabilitation Implications
• Advanced phase functional rehabilitation
• Slide 130
• Return to sport
• Slide 132
• Our Path (2)
• Slide 134
• Pain Phenotypes you say
• Genetically Predisposed
• Slide 137
• References

Our Path

Things that donrsquot move enough

bull Subacromial Impingementbull Adhesive Capsulitis

bull Evidence for Manual Therapy

Things that move too much

bull Shoulder Instabilitybull Evidence-supported exercise

Irsquom getting Emotionalhellip

Irsquom getting Emotionalhellip

bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes

Evidence for risk factors for chronic pain

bull Measure these fine thingsbull TSK FDAQ FABQ

Kinesiophobia

bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function

Remember to acknowledge and treat chronic conditions as chronic pain

Pain Phenotypes you say

bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)

bull and Psychological factorshellip

bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability

George et al 32014

Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype

Genetically Predisposed

bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing

bull Are predictive of upper extremity disability and depressive symptoms related to pain

Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014

References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement

syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement

syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a

prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train

200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving

cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med

200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J

Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in

overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-

173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind

study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large

pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome

J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement

syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and

pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for

treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder

impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement

syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis

Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in

the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man

Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]

Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787

Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for

shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation

JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide

clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066

bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340

bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190

bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36

bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91

• Shoulder Update 2014 University of Texas at El Paso Centennia
• Objectives
• Shoulder Pain Incidence and Costs
• Our Path
• Impingement Syndrome Concept
• The SIS Continuum Neer Classification
• Impingement Classification
• Primary Impingement
• Secondary Impingement
• Diagnosis of Primary SIS
• Diagnosis of Primary SIS (2)
• Diagnosis of Secondary SIS
• Slide 13
• Outcome Measures for SIS
• General Treatment Principles
• Treatment Non-surgical vs Surgical
• Bang amp Deyle JOSPT 2000
• Bergman et al Annals of Internal Medicine 2004
• McClatchie et al Manual Therapy2008
• Tate et al JOSPT 2010
• Other Interventions
• Slide 22
• SIS A Regional Perspective
• Eccentric Exercise
• Slide 25
• Adhesive Capsulitis
• What is it
• Differential Diagnosis
• Kelley MJ et al JOSPT 39 (2) 2009
• Slide 30
• Slide 31
• Natural History
• Duration of the Disease (with conservative treatment)
• Long Term Effects
• Long Term Effects (2)
• Treatment Options
• Oral steroids Cochrane Review Buchbinder 2009
• Steroid Injections Cochrane Review Buchbinder 2009
• Capsular Distension Cochrane Buchbinder 2009
• Traditional Manipulation long-lever techniques
• Traditional Manipulation long-lever techniques (2)
• Manipulation Following Interscalene Block for Shoulder Adhesive
• Total Passive ROM
• SPADI Scores (Pre-manipulation to final)
• Results
• Video Fluoroscopy
• Case Studies Arthroscopic findings following translational
• Patient 1 Diabetic male AC x 7 months
• Patient 1 Diabetic male AC x 7 months
• Patient 2 Secondary AC x 14 months
• Patient 2 Secondary AC x 14 months (2)
• Intra-articular Findings
• Translational Manipulation Theory
• Prognosis
• Clinical Bottom Line
• Slide 56
• manual Therapy for the Shoulder
• Physiotherapy Interventions for Shoulder Pain
• Physiotherapy Interventions for Shoulder Pain (2)
• Effectiveness of Rehabilitation for Patients with Impingement S
• Slide 61
• 5 Variables in the CPR
• Prognostic Factors for MT
• The Rule
• Prognostic Factors Risk of Persistent Pain
• In the workshellip
• In the workshellip In data collection phase
• Shoulder Instability
• Epidemiology
• Epidemiology (2)
• Laxity vs Instability
• Shoulder Stability A Result of Multiple Components
• Shoulder Function
• Labrum Anatomy
• Neuromuscular Stabilization
• Classifying Instability
• Classifying Instability (2)
• Classifying Instability (3)
• Instability Spectrum
• Clinical Presentation
• Clinical Presentation (2)
• Physical Examination
• Physical Examination (2)
• Non-surgical Management
• Non-surgical Management (2)
• Non-surgical Management (3)
• Exercise for Selected Shoulder Disorders
• Essential Elements for Dynamic Stability of the Shoulder Comple
• Shoulder Flexibility Requirements
• Slide 91
• How do we load the shoulder
• Slide 93
• SCAPULArsquoS ROLE IN SHOULDER STABILITY
• Slide 95
• Evidence Based Scapular Interventions
• Scapular Retraining Exercises
• What are the best exercises for Muscles around the shoulder
• Recommended Exercises for Rotator Cuff
• Slide 100
• Infraspinatus and subscapularis activityhellip
• Best Exercise for the Serratus
• Recommended Exercises for Serratus
• Recommended Exercises for Trapezii
• Best Exercises to Minimize Upper Trap
• Conclusions THESE are good trapezius exercises but they are
• Recommended Exercises for Rhomboids and Levator
• General thoughts on therex for shoulder
• Slide 110
• Program Summary and Outcomes
• Instructions
• Slide 113
• Slide 114
• Slide 115
• Slide 116
• Clinical Bottom Line Exercise for SIS
• Exercise for Rotator Cuff Tears
• Slide 119
• Slide 120
• Slide 121
• Exercise for Instability
• Shoulder Instability Rehab
• Motor Control Alterations with GH Instabity
• Slide 125
• Naughton J et al Upper-body wobbleboard training effects on t
• Slide 127
• Instability Rehabilitation Implications
• Advanced phase functional rehabilitation
• Slide 130
• Return to sport
• Slide 132
• Our Path (2)
• Slide 134
• Pain Phenotypes you say
• Genetically Predisposed
• Slide 137
• References

Irsquom getting Emotionalhellip

bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes

Evidence for risk factors for chronic pain

bull Measure these fine thingsbull TSK FDAQ FABQ

Kinesiophobia

bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function

Remember to acknowledge and treat chronic conditions as chronic pain

Pain Phenotypes you say

bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)

bull and Psychological factorshellip

bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability

George et al 32014

Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype

Genetically Predisposed

bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing

bull Are predictive of upper extremity disability and depressive symptoms related to pain

Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014

References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement

syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement

syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a

prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train

200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving

cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med

200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J

Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in

overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-

173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind

study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large

pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome

J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement

syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and

pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for

treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder

impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement

syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis

Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in

the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man

Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]

Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787

Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for

shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation

JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide

clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066

bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340

bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190

bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36

bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91

• Shoulder Update 2014 University of Texas at El Paso Centennia
• Objectives
• Shoulder Pain Incidence and Costs
• Our Path
• Impingement Syndrome Concept
• The SIS Continuum Neer Classification
• Impingement Classification
• Primary Impingement
• Secondary Impingement
• Diagnosis of Primary SIS
• Diagnosis of Primary SIS (2)
• Diagnosis of Secondary SIS
• Slide 13
• Outcome Measures for SIS
• General Treatment Principles
• Treatment Non-surgical vs Surgical
• Bang amp Deyle JOSPT 2000
• Bergman et al Annals of Internal Medicine 2004
• McClatchie et al Manual Therapy2008
• Tate et al JOSPT 2010
• Other Interventions
• Slide 22
• SIS A Regional Perspective
• Eccentric Exercise
• Slide 25
• Adhesive Capsulitis
• What is it
• Differential Diagnosis
• Kelley MJ et al JOSPT 39 (2) 2009
• Slide 30
• Slide 31
• Natural History
• Duration of the Disease (with conservative treatment)
• Long Term Effects
• Long Term Effects (2)
• Treatment Options
• Oral steroids Cochrane Review Buchbinder 2009
• Steroid Injections Cochrane Review Buchbinder 2009
• Capsular Distension Cochrane Buchbinder 2009
• Traditional Manipulation long-lever techniques
• Traditional Manipulation long-lever techniques (2)
• Manipulation Following Interscalene Block for Shoulder Adhesive
• Total Passive ROM
• SPADI Scores (Pre-manipulation to final)
• Results
• Video Fluoroscopy
• Case Studies Arthroscopic findings following translational
• Patient 1 Diabetic male AC x 7 months
• Patient 1 Diabetic male AC x 7 months
• Patient 2 Secondary AC x 14 months
• Patient 2 Secondary AC x 14 months (2)
• Intra-articular Findings
• Translational Manipulation Theory
• Prognosis
• Clinical Bottom Line
• Slide 56
• manual Therapy for the Shoulder
• Physiotherapy Interventions for Shoulder Pain
• Physiotherapy Interventions for Shoulder Pain (2)
• Effectiveness of Rehabilitation for Patients with Impingement S
• Slide 61
• 5 Variables in the CPR
• Prognostic Factors for MT
• The Rule
• Prognostic Factors Risk of Persistent Pain
• In the workshellip
• In the workshellip In data collection phase
• Shoulder Instability
• Epidemiology
• Epidemiology (2)
• Laxity vs Instability
• Shoulder Stability A Result of Multiple Components
• Shoulder Function
• Labrum Anatomy
• Neuromuscular Stabilization
• Classifying Instability
• Classifying Instability (2)
• Classifying Instability (3)
• Instability Spectrum
• Clinical Presentation
• Clinical Presentation (2)
• Physical Examination
• Physical Examination (2)
• Non-surgical Management
• Non-surgical Management (2)
• Non-surgical Management (3)
• Exercise for Selected Shoulder Disorders
• Essential Elements for Dynamic Stability of the Shoulder Comple
• Shoulder Flexibility Requirements
• Slide 91
• How do we load the shoulder
• Slide 93
• SCAPULArsquoS ROLE IN SHOULDER STABILITY
• Slide 95
• Evidence Based Scapular Interventions
• Scapular Retraining Exercises
• What are the best exercises for Muscles around the shoulder
• Recommended Exercises for Rotator Cuff
• Slide 100
• Infraspinatus and subscapularis activityhellip
• Best Exercise for the Serratus
• Recommended Exercises for Serratus
• Recommended Exercises for Trapezii
• Best Exercises to Minimize Upper Trap
• Conclusions THESE are good trapezius exercises but they are
• Recommended Exercises for Rhomboids and Levator
• General thoughts on therex for shoulder
• Slide 110
• Program Summary and Outcomes
• Instructions
• Slide 113
• Slide 114
• Slide 115
• Slide 116
• Clinical Bottom Line Exercise for SIS
• Exercise for Rotator Cuff Tears
• Slide 119
• Slide 120
• Slide 121
• Exercise for Instability
• Shoulder Instability Rehab
• Motor Control Alterations with GH Instabity
• Slide 125
• Naughton J et al Upper-body wobbleboard training effects on t
• Slide 127
• Instability Rehabilitation Implications
• Advanced phase functional rehabilitation
• Slide 130
• Return to sport
• Slide 132
• Our Path (2)
• Slide 134
• Pain Phenotypes you say
• Genetically Predisposed
• Slide 137
• References

Pain Phenotypes you say

bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)

bull and Psychological factorshellip

bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability

George et al 32014

Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype

Genetically Predisposed

bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing

bull Are predictive of upper extremity disability and depressive symptoms related to pain

Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014

References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement

syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement

syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a

prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train

200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving

cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med

200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J

Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in

overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-

173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind

study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large

pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome

J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement

syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and

pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for

treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder

impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement

syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis

Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in

the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man

Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]

Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787

Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for

shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation

JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide

clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066

bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340

bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190

bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36

bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91

• Shoulder Update 2014 University of Texas at El Paso Centennia
• Objectives
• Shoulder Pain Incidence and Costs
• Our Path
• Impingement Syndrome Concept
• The SIS Continuum Neer Classification
• Impingement Classification
• Primary Impingement
• Secondary Impingement
• Diagnosis of Primary SIS
• Diagnosis of Primary SIS (2)
• Diagnosis of Secondary SIS
• Slide 13
• Outcome Measures for SIS
• General Treatment Principles
• Treatment Non-surgical vs Surgical
• Bang amp Deyle JOSPT 2000
• Bergman et al Annals of Internal Medicine 2004
• McClatchie et al Manual Therapy2008
• Tate et al JOSPT 2010
• Other Interventions
• Slide 22
• SIS A Regional Perspective
• Eccentric Exercise
• Slide 25
• Adhesive Capsulitis
• What is it
• Differential Diagnosis
• Kelley MJ et al JOSPT 39 (2) 2009
• Slide 30
• Slide 31
• Natural History
• Duration of the Disease (with conservative treatment)
• Long Term Effects
• Long Term Effects (2)
• Treatment Options
• Oral steroids Cochrane Review Buchbinder 2009
• Steroid Injections Cochrane Review Buchbinder 2009
• Capsular Distension Cochrane Buchbinder 2009
• Traditional Manipulation long-lever techniques
• Traditional Manipulation long-lever techniques (2)
• Manipulation Following Interscalene Block for Shoulder Adhesive
• Total Passive ROM
• SPADI Scores (Pre-manipulation to final)
• Results
• Video Fluoroscopy
• Case Studies Arthroscopic findings following translational
• Patient 1 Diabetic male AC x 7 months
• Patient 1 Diabetic male AC x 7 months
• Patient 2 Secondary AC x 14 months
• Patient 2 Secondary AC x 14 months (2)
• Intra-articular Findings
• Translational Manipulation Theory
• Prognosis
• Clinical Bottom Line
• Slide 56
• manual Therapy for the Shoulder
• Physiotherapy Interventions for Shoulder Pain
• Physiotherapy Interventions for Shoulder Pain (2)
• Effectiveness of Rehabilitation for Patients with Impingement S
• Slide 61
• 5 Variables in the CPR
• Prognostic Factors for MT
• The Rule
• Prognostic Factors Risk of Persistent Pain
• In the workshellip
• In the workshellip In data collection phase
• Shoulder Instability
• Epidemiology
• Epidemiology (2)
• Laxity vs Instability
• Shoulder Stability A Result of Multiple Components
• Shoulder Function
• Labrum Anatomy
• Neuromuscular Stabilization
• Classifying Instability
• Classifying Instability (2)
• Classifying Instability (3)
• Instability Spectrum
• Clinical Presentation
• Clinical Presentation (2)
• Physical Examination
• Physical Examination (2)
• Non-surgical Management
• Non-surgical Management (2)
• Non-surgical Management (3)
• Exercise for Selected Shoulder Disorders
• Essential Elements for Dynamic Stability of the Shoulder Comple
• Shoulder Flexibility Requirements
• Slide 91
• How do we load the shoulder
• Slide 93
• SCAPULArsquoS ROLE IN SHOULDER STABILITY
• Slide 95
• Evidence Based Scapular Interventions
• Scapular Retraining Exercises
• What are the best exercises for Muscles around the shoulder
• Recommended Exercises for Rotator Cuff
• Slide 100
• Infraspinatus and subscapularis activityhellip
• Best Exercise for the Serratus
• Recommended Exercises for Serratus
• Recommended Exercises for Trapezii
• Best Exercises to Minimize Upper Trap
• Conclusions THESE are good trapezius exercises but they are
• Recommended Exercises for Rhomboids and Levator
• General thoughts on therex for shoulder
• Slide 110
• Program Summary and Outcomes
• Instructions
• Slide 113
• Slide 114
• Slide 115
• Slide 116
• Clinical Bottom Line Exercise for SIS
• Exercise for Rotator Cuff Tears
• Slide 119
• Slide 120
• Slide 121
• Exercise for Instability
• Shoulder Instability Rehab
• Motor Control Alterations with GH Instabity
• Slide 125
• Naughton J et al Upper-body wobbleboard training effects on t
• Slide 127
• Instability Rehabilitation Implications
• Advanced phase functional rehabilitation
• Slide 130
• Return to sport
• Slide 132
• Our Path (2)
• Slide 134
• Pain Phenotypes you say
• Genetically Predisposed
• Slide 137
• References

Genetically Predisposed

bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing

bull Are predictive of upper extremity disability and depressive symptoms related to pain

Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014

References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement

syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement

syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a

prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train

200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving

cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med

200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J

Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in

overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-

173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind

study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large

pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome

J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement

syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and

pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for

treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder

impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement

syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis

Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in

the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man

Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]

Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787

Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for

shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation

JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide

clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066

bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340

bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190

bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36

bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91

• Shoulder Update 2014 University of Texas at El Paso Centennia
• Objectives
• Shoulder Pain Incidence and Costs
• Our Path
• Impingement Syndrome Concept
• The SIS Continuum Neer Classification
• Impingement Classification
• Primary Impingement
• Secondary Impingement
• Diagnosis of Primary SIS
• Diagnosis of Primary SIS (2)
• Diagnosis of Secondary SIS
• Slide 13
• Outcome Measures for SIS
• General Treatment Principles
• Treatment Non-surgical vs Surgical
• Bang amp Deyle JOSPT 2000
• Bergman et al Annals of Internal Medicine 2004
• McClatchie et al Manual Therapy2008
• Tate et al JOSPT 2010
• Other Interventions
• Slide 22
• SIS A Regional Perspective
• Eccentric Exercise
• Slide 25
• Adhesive Capsulitis
• What is it
• Differential Diagnosis
• Kelley MJ et al JOSPT 39 (2) 2009
• Slide 30
• Slide 31
• Natural History
• Duration of the Disease (with conservative treatment)
• Long Term Effects
• Long Term Effects (2)
• Treatment Options
• Oral steroids Cochrane Review Buchbinder 2009
• Steroid Injections Cochrane Review Buchbinder 2009
• Capsular Distension Cochrane Buchbinder 2009
• Traditional Manipulation long-lever techniques
• Traditional Manipulation long-lever techniques (2)
• Manipulation Following Interscalene Block for Shoulder Adhesive
• Total Passive ROM
• SPADI Scores (Pre-manipulation to final)
• Results
• Video Fluoroscopy
• Case Studies Arthroscopic findings following translational
• Patient 1 Diabetic male AC x 7 months
• Patient 1 Diabetic male AC x 7 months
• Patient 2 Secondary AC x 14 months
• Patient 2 Secondary AC x 14 months (2)
• Intra-articular Findings
• Translational Manipulation Theory
• Prognosis
• Clinical Bottom Line
• Slide 56
• manual Therapy for the Shoulder
• Physiotherapy Interventions for Shoulder Pain
• Physiotherapy Interventions for Shoulder Pain (2)
• Effectiveness of Rehabilitation for Patients with Impingement S
• Slide 61
• 5 Variables in the CPR
• Prognostic Factors for MT
• The Rule
• Prognostic Factors Risk of Persistent Pain
• In the workshellip
• In the workshellip In data collection phase
• Shoulder Instability
• Epidemiology
• Epidemiology (2)
• Laxity vs Instability
• Shoulder Stability A Result of Multiple Components
• Shoulder Function
• Labrum Anatomy
• Neuromuscular Stabilization
• Classifying Instability
• Classifying Instability (2)
• Classifying Instability (3)
• Instability Spectrum
• Clinical Presentation
• Clinical Presentation (2)
• Physical Examination
• Physical Examination (2)
• Non-surgical Management
• Non-surgical Management (2)
• Non-surgical Management (3)
• Exercise for Selected Shoulder Disorders
• Essential Elements for Dynamic Stability of the Shoulder Comple
• Shoulder Flexibility Requirements
• Slide 91
• How do we load the shoulder
• Slide 93
• SCAPULArsquoS ROLE IN SHOULDER STABILITY
• Slide 95
• Evidence Based Scapular Interventions
• Scapular Retraining Exercises
• What are the best exercises for Muscles around the shoulder
• Recommended Exercises for Rotator Cuff
• Slide 100
• Infraspinatus and subscapularis activityhellip
• Best Exercise for the Serratus
• Recommended Exercises for Serratus
• Recommended Exercises for Trapezii
• Best Exercises to Minimize Upper Trap
• Conclusions THESE are good trapezius exercises but they are
• Recommended Exercises for Rhomboids and Levator
• General thoughts on therex for shoulder
• Slide 110
• Program Summary and Outcomes
• Instructions
• Slide 113
• Slide 114
• Slide 115
• Slide 116
• Clinical Bottom Line Exercise for SIS
• Exercise for Rotator Cuff Tears
• Slide 119
• Slide 120
• Slide 121
• Exercise for Instability
• Shoulder Instability Rehab
• Motor Control Alterations with GH Instabity
• Slide 125
• Naughton J et al Upper-body wobbleboard training effects on t
• Slide 127
• Instability Rehabilitation Implications
• Advanced phase functional rehabilitation
• Slide 130
• Return to sport
• Slide 132
• Our Path (2)
• Slide 134
• Pain Phenotypes you say
• Genetically Predisposed
• Slide 137
• References

References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement

syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement

syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a

prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train

200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving

cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med

200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J

Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in

overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-

173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind

study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large

pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome

J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement

syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and

pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for

treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder

impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement

syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis

Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in

the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man

Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]

Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787

Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for

shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation

JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide

clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066

bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340

bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190

bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36

bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91

• Shoulder Update 2014 University of Texas at El Paso Centennia
• Objectives
• Shoulder Pain Incidence and Costs
• Our Path
• Impingement Syndrome Concept
• The SIS Continuum Neer Classification
• Impingement Classification
• Primary Impingement
• Secondary Impingement
• Diagnosis of Primary SIS
• Diagnosis of Primary SIS (2)
• Diagnosis of Secondary SIS
• Slide 13
• Outcome Measures for SIS
• General Treatment Principles
• Treatment Non-surgical vs Surgical
• Bang amp Deyle JOSPT 2000
• Bergman et al Annals of Internal Medicine 2004
• McClatchie et al Manual Therapy2008
• Tate et al JOSPT 2010
• Other Interventions
• Slide 22
• SIS A Regional Perspective
• Eccentric Exercise
• Slide 25
• Adhesive Capsulitis
• What is it
• Differential Diagnosis
• Kelley MJ et al JOSPT 39 (2) 2009
• Slide 30
• Slide 31
• Natural History
• Duration of the Disease (with conservative treatment)
• Long Term Effects
• Long Term Effects (2)
• Treatment Options
• Oral steroids Cochrane Review Buchbinder 2009
• Steroid Injections Cochrane Review Buchbinder 2009
• Capsular Distension Cochrane Buchbinder 2009
• Traditional Manipulation long-lever techniques
• Traditional Manipulation long-lever techniques (2)
• Manipulation Following Interscalene Block for Shoulder Adhesive
• Total Passive ROM
• SPADI Scores (Pre-manipulation to final)
• Results
• Video Fluoroscopy
• Case Studies Arthroscopic findings following translational
• Patient 1 Diabetic male AC x 7 months
• Patient 1 Diabetic male AC x 7 months
• Patient 2 Secondary AC x 14 months
• Patient 2 Secondary AC x 14 months (2)
• Intra-articular Findings
• Translational Manipulation Theory
• Prognosis
• Clinical Bottom Line
• Slide 56
• manual Therapy for the Shoulder
• Physiotherapy Interventions for Shoulder Pain
• Physiotherapy Interventions for Shoulder Pain (2)
• Effectiveness of Rehabilitation for Patients with Impingement S
• Slide 61
• 5 Variables in the CPR
• Prognostic Factors for MT
• The Rule
• Prognostic Factors Risk of Persistent Pain
• In the workshellip
• In the workshellip In data collection phase
• Shoulder Instability
• Epidemiology
• Epidemiology (2)
• Laxity vs Instability
• Shoulder Stability A Result of Multiple Components
• Shoulder Function
• Labrum Anatomy
• Neuromuscular Stabilization
• Classifying Instability
• Classifying Instability (2)
• Classifying Instability (3)
• Instability Spectrum
• Clinical Presentation
• Clinical Presentation (2)
• Physical Examination
• Physical Examination (2)
• Non-surgical Management
• Non-surgical Management (2)
• Non-surgical Management (3)
• Exercise for Selected Shoulder Disorders
• Essential Elements for Dynamic Stability of the Shoulder Comple
• Shoulder Flexibility Requirements
• Slide 91
• How do we load the shoulder
• Slide 93
• SCAPULArsquoS ROLE IN SHOULDER STABILITY
• Slide 95
• Evidence Based Scapular Interventions
• Scapular Retraining Exercises
• What are the best exercises for Muscles around the shoulder
• Recommended Exercises for Rotator Cuff
• Slide 100
• Infraspinatus and subscapularis activityhellip
• Best Exercise for the Serratus
• Recommended Exercises for Serratus
• Recommended Exercises for Trapezii
• Best Exercises to Minimize Upper Trap
• Conclusions THESE are good trapezius exercises but they are
• Recommended Exercises for Rhomboids and Levator
• General thoughts on therex for shoulder
• Slide 110
• Program Summary and Outcomes
• Instructions
• Slide 113
• Slide 114
• Slide 115
• Slide 116
• Clinical Bottom Line Exercise for SIS
• Exercise for Rotator Cuff Tears
• Slide 119
• Slide 120
• Slide 121
• Exercise for Instability
• Shoulder Instability Rehab
• Motor Control Alterations with GH Instabity
• Slide 125
• Naughton J et al Upper-body wobbleboard training effects on t
• Slide 127
• Instability Rehabilitation Implications
• Advanced phase functional rehabilitation
• Slide 130
• Return to sport
• Slide 132
• Our Path (2)
• Slide 134
• Pain Phenotypes you say
• Genetically Predisposed
• Slide 137
• References

Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for

shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation

JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide

clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066

bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340

bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190

bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36

bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91

• Shoulder Update 2014 University of Texas at El Paso Centennia
• Objectives
• Shoulder Pain Incidence and Costs
• Our Path
• Impingement Syndrome Concept
• The SIS Continuum Neer Classification
• Impingement Classification
• Primary Impingement
• Secondary Impingement
• Diagnosis of Primary SIS
• Diagnosis of Primary SIS (2)
• Diagnosis of Secondary SIS
• Slide 13
• Outcome Measures for SIS
• General Treatment Principles
• Treatment Non-surgical vs Surgical
• Bang amp Deyle JOSPT 2000
• Bergman et al Annals of Internal Medicine 2004
• McClatchie et al Manual Therapy2008
• Tate et al JOSPT 2010
• Other Interventions
• Slide 22
• SIS A Regional Perspective
• Eccentric Exercise
• Slide 25
• Adhesive Capsulitis
• What is it
• Differential Diagnosis
• Kelley MJ et al JOSPT 39 (2) 2009
• Slide 30
• Slide 31
• Natural History
• Duration of the Disease (with conservative treatment)
• Long Term Effects
• Long Term Effects (2)
• Treatment Options
• Oral steroids Cochrane Review Buchbinder 2009
• Steroid Injections Cochrane Review Buchbinder 2009
• Capsular Distension Cochrane Buchbinder 2009
• Traditional Manipulation long-lever techniques
• Traditional Manipulation long-lever techniques (2)
• Manipulation Following Interscalene Block for Shoulder Adhesive
• Total Passive ROM
• SPADI Scores (Pre-manipulation to final)
• Results
• Video Fluoroscopy
• Case Studies Arthroscopic findings following translational
• Patient 1 Diabetic male AC x 7 months
• Patient 1 Diabetic male AC x 7 months
• Patient 2 Secondary AC x 14 months
• Patient 2 Secondary AC x 14 months (2)
• Intra-articular Findings
• Translational Manipulation Theory
• Prognosis
• Clinical Bottom Line
• Slide 56
• manual Therapy for the Shoulder
• Physiotherapy Interventions for Shoulder Pain
• Physiotherapy Interventions for Shoulder Pain (2)
• Effectiveness of Rehabilitation for Patients with Impingement S
• Slide 61
• 5 Variables in the CPR
• Prognostic Factors for MT
• The Rule
• Prognostic Factors Risk of Persistent Pain
• In the workshellip
• In the workshellip In data collection phase
• Shoulder Instability
• Epidemiology
• Epidemiology (2)
• Laxity vs Instability
• Shoulder Stability A Result of Multiple Components
• Shoulder Function
• Labrum Anatomy
• Neuromuscular Stabilization
• Classifying Instability
• Classifying Instability (2)
• Classifying Instability (3)
• Instability Spectrum
• Clinical Presentation
• Clinical Presentation (2)
• Physical Examination
• Physical Examination (2)
• Non-surgical Management
• Non-surgical Management (2)
• Non-surgical Management (3)
• Exercise for Selected Shoulder Disorders
• Essential Elements for Dynamic Stability of the Shoulder Comple
• Shoulder Flexibility Requirements
• Slide 91
• How do we load the shoulder
• Slide 93
• SCAPULArsquoS ROLE IN SHOULDER STABILITY
• Slide 95
• Evidence Based Scapular Interventions
• Scapular Retraining Exercises
• What are the best exercises for Muscles around the shoulder
• Recommended Exercises for Rotator Cuff
• Slide 100
• Infraspinatus and subscapularis activityhellip
• Best Exercise for the Serratus
• Recommended Exercises for Serratus
• Recommended Exercises for Trapezii
• Best Exercises to Minimize Upper Trap
• Conclusions THESE are good trapezius exercises but they are
• Recommended Exercises for Rhomboids and Levator
• General thoughts on therex for shoulder
• Slide 110
• Program Summary and Outcomes
• Instructions
• Slide 113
• Slide 114
• Slide 115
• Slide 116
• Clinical Bottom Line Exercise for SIS
• Exercise for Rotator Cuff Tears
• Slide 119
• Slide 120
• Slide 121
• Exercise for Instability
• Shoulder Instability Rehab
• Motor Control Alterations with GH Instabity
• Slide 125
• Naughton J et al Upper-body wobbleboard training effects on t
• Slide 127
• Instability Rehabilitation Implications
• Advanced phase functional rehabilitation
• Slide 130
• Return to sport
• Slide 132
• Our Path (2)
• Slide 134
• Pain Phenotypes you say
• Genetically Predisposed
• Slide 137
• References