treatment and management of shoulder pain · •biceps tendinitis/osis •capsule tear...

TREATMENT AND MANAGEMENT OF SHOULDER PAIN

JUSTIN HILDEBRAND DC

WHO AM I?

• DR. JUSTIN HILDEBRAND

• CLINICIAN AT KC NORTH SPINE & JOINT CENTER

• ADJUNCT FACULTY CLEVELAND UNIVERSITY

• BOARD CERTIFIED ACUPUNCTURE

• CERTIFIED DRY NEEDLING

• NATIONAL ACADEMY OF SPORTS MEDICINE

• HIGHLAND COMMUNITY COLLEGE FACULTY

• PARK UNIVERSITY ONLINE FACULTY

SHOULDER ANATOMY• ROTATOR CUFF

• SUPRA-SUPRA FOSSA TO THE GREATER TUBERCLE*, ABDUCTS THE HUMERUS

• INFRA-INFRA FOSSA TO POST GREATER TUBERCLE*, EXTERNALLY ROTATES

• TERES MINOR-LATERAL BORDER OF SCAPULA TO INFERIOR GREATER TUBERCLE,

EXTERNALLY ROTATES

• SUBSCAPULARIS-SUBSCAP FOSSA TO LESSER TUBERCLE/NECK, INTERNALLY

ROTATES

• BICEP?- RADIAL TUB TO CORACOID (SHORT) AND GLENOID TUBERCLE (LONG),

FLEXES HUMERUS

• POSTERIOR CAPSULE-POSTERIOR LIGAMENTS AN INFRA TENDON

ROTATOR CUFF

SCAPULAR MOVERS

ELEVATORS

• UPPER TRAP-NUCHAL

LINE/EOP/LIGAMENTS TO

LATERAL CLAVICLE

• LEVATOR SCAPULAE-TVP C3-4

TO MEDIAL SCAPULA

• ALSO SCAPULA DOWNWARD

ROTATOR AND ABDUCTOR

• SERRATUS ANTERIOR- RIBS TO

MEDIAL BORDER

DEPRESSORS

• PEC MINOR-RIBS 3-5 TO

CORACOID PROCESS

• PEC MAJOR-STERNUM/RIBS TO

INTERTUBERCULAR GROOVE

• LOWER TRAP-SP OF T4-12 TO

INFERIOR MED SCAPULA

• LAT-PELVIS, SACRUM, T7-5, RIBS

TO INTERTUBERCULAR

GROOVE

PROTRACTORS

• SERRATUS ANTERIOR

• PEC MINOR

• PEC MAJOR- ALSO SHOULDER

ADDUCTION/INT

ROT/EXTENSOR

• LEVATOR-ALSO C/S IPSI

LATERAL FLEXION AND IPSI

ROTATION

RETRACTORS

• MIDDLE TRAP-C7-T3 SP TO

ACROMION & SCAPULAR SPINE

• LOWER TRAP

• RHOMBOIDS-C7 THRU T5 TO

MEDIAL BORDER

• LAT-ALSO SHOULDER

ADDUCTOR/EXTENSOR/INT

ROT

UPWARD ROTATION

• MIDDLE & LOWER TRAP

• SERRATUS ANTERIOR

DOWNWARD ROTATION

• LEVATOR

• RHOMBOIDS

• PEC MINOR/MAJOR

• LAT DORSI

BIOMECHANICS

• SCAPULAR PLANE – SCAPULAR REST 35 DEGREES FROM THE FRONTAL

PLANE

• SCAPULAR MOTION DEPENDENT ON THE MOTION OF SC AND AC JOINT

• AFTER 30 DEGREES OF HUMERUS ABDUCTION → SCAPULA MOVES 2:1

• GH JOINT IS ROLL AND SLIDE MEANING AS HUMERUS ROLLS SUPERIORLY

IT SLIDES INFERIOR DURING ABDUCTION

• FLEXION/EXT SPINS

• EXTERNAL ROTATION ROLLS POSTERIOR AND SLIDES ANTERIOR

COMMON SHOULDER CONDITIONS

• ROTATOR CUFF TEAR/INJURY

• ANTERIOR IMPINGEMENT *MC SPORTS DIAGNOSIS*

• POSTERIOR IMPINGEMENT

• SLAP

• POSTERIOR LABRUM

• BICEPS TENDINITIS/OSIS

• CAPSULE TEAR

• DISLOCATIONS

• BONE PATH, CYST, AND VASCULAR CONDITIONS

ORTHOPEDIC TEST

• RULE OUT NECK AND NERVE

• DOORBELL

• LOAD SHIFT

• HK

• OBRIEN’S

• APLY’S

• SUPRASPINATUS

• BICEP

• LABRAL TEARS

• ANDREWS

• GRIND

FUNCTIONAL TESTS

• T4

• SHOULDER ABDUCTION

• QUAD ROCK

• SUPINE PASSIVE ROM

T4 EXTENSION

WHY T4

• INDICATION

• SUBACUTE OR MUSCULOSKELETAL

PAIN (UPPER OR LOWER)

• POOR POSTURE

• OVER-HEAD ATHLETE

• SCREENS FOR:

• T/S EXTENSION

• OVERACTIVE LATISIMUS DORSI,

PECTORALIS, SUBOCCITALS

FINDINGS

• LACK OF THORACIC EXTENSION

AND…

• CERVICAL EXTENSION SUGGEST

OVERACTIVE SUBOCCIPITALS

• LUMBAR EXTENSION SUGGEST

CORE INSTABILITY AND

OVERACTIVE LATS (OVERACTIVE HIP

FLEXORS?)

• KNUCKLES CAN NOT TOUCH THE

WALL SUGGEST OVERACTIVE PECS

(SHOULDER DYSFUNCTION?)

QUADRUPED ROCK

WHY

• INDICATIONS

• UPPER QUARTER DYSFUNCTION

• NECK PAIN

• SCAPULOTHORACIC DYSFUNCTION

• SCREENS FOR:

• SCAPULAR STABILIZER WEAKNESS

• DNF WEAKNESS

• OVERACTIVE PECS, LEVATOR SCAPS, AND

TRAPS

FINDINGS

• SCAPULAR WINGING = SERRATUS

ANTERIOR UNDER ACTIVITY/INHIBITION

• SCAPULAR FLARING = MID-LOWER TRAP

UNDER ACTIVITY/INHIBITION

• SHOULDER SHRUG = UPPER

TRAP/LEVATOR SCAPULAR OVER

ACTIVITY

• CHIN PROTRUSION=DEEP NECK FLEXOR

UNDER ACTIVITY/INHIBITION

• PATIENTS WEIGHT ON OUTSIDE OF

HANDS = SCAPULAR INSTABILITY

ARM ABDUCTION

WHY ABD

• INDICATIONS

• SHOULDER OR UPPER QUARTER

PAIN

• ADHESIVE CAPSULITIS (FROZEN

SHOULDER)

• NECK PAIN, WHIPLASH, OR

HEADACHE

• SCREENS FOR:

• SCAPULOTHORACIC RHYTHM

• OVERACTIVE UPPER TRAP AND

LEVATOR SCAPULAR

FINDINGS

• SHOULDER ELEVATION IN FIRST

60 DEGREES

• HYPERTONIC LEVATORS AND

TRAPS

• HEAD MOVEMENT

• LACK OF OR EXCESSIVE

SCAPULAR MOVEMENT

ROM

SUPINE

• INTERNAL/EXTERNAL

ROTATION SHOULD = 180O

• FLEXION WITH THUMBS UP

SHOULD COMPLETE WITHOUT

RIB FLARE = LATS?

• SHOULDERS SHOULD BE 1IN

OFF TABLE = PEC MINOR?

• PEC MAJOR CHECK

SEATED

• ARM RESTING ON LEG

• CHECK INTERNAL AND

EXTERNAL ROTATION

• FEEL TENSION AND TIGHTNESS

IN RESTRICTED MOTIONS

• INFRA/TERES

• PEC

• CAPSULE

• LAT

TREATMENTS• MANIPULATION

• SOFT TISSUE TECHNIQUES

• TRIGGER POINT

• PIR

• INSTRUMENT ASSISTED SOFT

TISSUE MANIPULATION

• CUPPING

• DRY NEEDLING

• REHABILITATION

• TAPING

• PROGRESSION

• STATIC – STATIC

• STATIC – DYNAMIC

• DYNAMIC – STATIC

• DYNAMIC – DYNAMIC

• PATIENT STATIC – CUP STATIC

• PT STATIC – IASTM/CUP

DYNAMIC

• PT DYNAMIC – CUP STATIC

• PT DYNAMIC – IASTM/CUP

DYNAMIC

PALPATION & MANIPULATION

Sternoclavicular Joint

AC Joint

Glenohumeral Joint

Proximal Radio-ulnar joint/Supination

Proximal & Distal Carpal Joint

Carpal Tunnel Mobilization

SC JOINT

PALPATION

• PLACE 2 FINGERS OVER THE

SC JOINT

• PASSIVELY RAISE THE ARM,

ROTATE THE ARM, CIRCLE

THE ARM

• FEEL FOR MOVEMENT

ADJUSTMENT

• PT SUPINE

• DISTRACT ARM

• PLACE PALM/PISIFORM

OVER SC JOINT

• THRUST INTO DROP PIECE

OR TOGGLE BOARD

SC JOINT

PALPATION MANIPULATION

AC JOINT

• NO ADJUSTMENT SHOWN

• WHY?

• GLIDING OF PLANE JOINT

• THE JOINT SURFACES ARE MOSTLY FLAT TO SLIGHTLY CONCAVE OR

CONVEX

• DUE TO FLATNESS OF THE JOINT, ROLL AND SLIDE ARTHROKINEMATICS

DO NOT OCCUR

• JOINT MOTION CONSIST OF UPWARD/DOWNWARD ROTATION AND

ROTATIONAL ADJUSTMENTS

SCAPULOTHORACIC JOINT

Not a true joint

Scapula should rest in about 35 degrees of internal rotation = scapular plane

Scap-thoracic motion occurs do to shared motion of AC & SC

Restricted motion of either joint can decrease scapular motion

Upward rotation of the scapula is essential for optimal function (painfree and full) shoulder abduction

GLENOHUMERALJOINT

Highly mobile joint, but directional restrictions will occur.

Palpation is often enough to free the joint.

Accessory motions (arthokinematics) are important to assess as this is where the restrictions will be (i.e. posterior glide, inferior glide, etc.).

“A key to optimal glenohumeral joint motion is that the head of the humerus remains centered in relationship to the glenoid as motion occurs at the shoulder joint” (Sahrmann, 2002)

The shoulder gives up stability for a great deal of mobility but can give up ROM when scapula and/or core are not stabilized properly.

GH JOINT POST SHEAR

• BRING ARM TO 90 DEGREES

• SUPPORT POST SHOULDER/CAPSULE

• CHALLENGE IN POST SHEAR

• POST SHEAR WITH ADDUCTION

• ADJUSTMENT

• DROP ON TOGGLE IN RESTRICTED MOTION

SHOULDER MOBILIZATION

SUPINE SHOULDER MOB

Grasp pt’s humerus and distract laterally in repetition

1

Grasp humerus and rotate while pulling

2

Grasp humerus and scoop through posterior capsule

3

SEATED SHOULDER MOB

EXTERNAL ROTATION

• PT SEATED WITH ARM RESTING

ON YOUR KNEE 90O AND IN

EXTERAL ROTATION

• HOLD HUMERUS DOWN WHILE

YOU PULL ARM AWAY FROM

BODY AND EXERALT ROT

• DO NOT ALLOW HUMERUS TO

GLIDE SUPERIOR BUT DO NOT

PUSH INFERIOR

INTERNAL ROTATION

• PT SEATED WITH ARM RESTING

ON YOUR KNEE 90O AND IN

INTERNAL ROTATION

• HOLD HUMERUS DOWN WHILE

YOU PULL ARM AWAY FROM

BODY AND INTERNALLY ROT

• DO NOT ALLOW HUMERUS TO

GLIDE SUPERIOR BUT DO NOT

PUSH INFERIOR

ELBOW SUPINATION

Supinate forearm and extend arm

Place on toggle board

Thrust

WRIST

1

Check

•Check proximal & distal rows by shearing

2

Shear

•Shear proximal carpels off radius

3

Shear

•Shear distal carpals off proximal

4

Drop on

•Drop on toggle to free up motion

TRIGGER POINTS• ACTIVE TRPS ARE HARD

SPOTS/POINTS IN

MUSCLES THAT PRODUCE

REFERRED PAIN

• PASSIVE TRIGGER POINTS

ARE HARD SPOTS/POINTS

IN MUSCLES THAT ONLY

PRODUCE LOCAL PAIN

• YOU PALPATE TRP BY

ROLLING OVER POINT

AND A TWITCH RESPONSE

APPEARS

TRIGGER POINTS

TRAP LEVATOR

TRP

INFRASPINATUS TERES MINOR

TRP

PEC MINOR SUPRASPINATUS

PEC RELEASE• PT SEATED WITH ARM SUPPORTED

ABOVE HEAD

• REACH AROUND PT AND PALPATE

PEC WHILE SLOWLY MOVING

ARM TO FIND TENSION

• COMPRESS POINT AND HAVE

THEM PUSH FORWARD

• HAVE THEM RELAX AND GO LIMB

• SNAP SHOULDER

• REPEAT

TRAP WITH REFLEX• PATIENT PRONE WITH

ARM UP AT 135 DEGREES

• INSTRUCT THEM TO LOOK

SLIGHT TOWARD UP ARM

AND GENTLE PUSH

ELBOW DOWN AND

BACK

• WITH PROPER

ACTIVATION PALPATE TRP

• COMPRESS

PIR (HAMMER)

• 1. BRING THE MUSCLE TO ITS MAXIMUM LENGTH WITHOUT STRETCHING,

TAKING UP THE SLACK. THERE SHOULD BE ONLY MINIMAL OR NO PAIN.

• 2. THE PATIENT IS ASKED TO RESIST WITH ONLY MINIMAL FORCE

(ISOMETRICALLY) AND TO BREATHE IN FOR 10 SECONDS.

• 3. THE PATIENT IS THEN TOLD TO “LET GO” (RELAX) AND EXHALE SLOWLY.

IT IS IMPORTANT FOR THE DOCTOR TO WAIT AND FEEL THE RELAXATION.

THE DOCTOR COULD WAIT 10 TO 20 SECONDS OR LONGER AS LONG

AS RELAXATION IS TAKING PLACE. DUE TO PURE RELAXATION THERE

SHOULD BE AN INCREASE IN THE RANGE OF MOTION.

PROCEDURE CONT

• 4. IF THE PATIENT HAS DIFFICULTY RELAXING, HOLD THE ISOMETRIC

PHASE FOR 30 SECONDS BEFORE HAVING THE PATIENT “LET GO.”

• 5. USUALLY THREE TO FIVE TIMES IS ALL THAT IS NECESSARY TO

OBTAIN SPONTANEOUS STRETCH EACH SESSION.

• 6. ALONG WITH THE BREATHING, HAVING THE PATIENT LOOK UP

(EYES ONLY). THIS HELPS FACILITATE THE INSPIRATION, WHICH

FACILITATES THE MUSCLE. HAVE THE PATIENT LOOK DOWN DURING

EXPIRATION TO AID IN RELAXATION.

LEVATOR SCAPULAE

• REFERRED PAIN

• VERTEBRAL BORDER OF THE SCAPULA

• NAPE OF THE NECK

• EFFECTS OF SHORTENED MUSCLE

• PAIN ON SAME SIDE AS PATIENT TURNS HEAD

• TORTICOLLIS

• EVALUATION

• LATERALLY BEND AND ROTATE HEAD AWAY FROM TESTED SIDE, APPLY

PRESSURE TO SHOULDER

LEVATOR SCAP PIR

• SUPINE WITH AFFECTED SIDE ARM LAYING NEXT

TO HIS/HER SIDE. THE PATIENTS/CLIENTS HEAD IS

LATERALLY FLEXED AWAY, CONTRALATERALLY

ROTATED, AND PLACED INTO FLEXION.

• YOU ARE SEATED AT HEAD OF TABLE. ONE HAND

IS PLACED ON THE SPINE OF THE AFFECTED

SCAPULA AND THE OTHER HOLDS THE HEAD IN

THE CORRECT POSITION. APPLY PRESSURE ON

THE PATIENT/CLIENTS SCAPULA BY PRESSING IN

A INFERIOR DIRECTION FINDING THE BARRIER. IT

IS IMPORTANT TO STAY LIGHT AT ALL TIMES.

• THE PATIENT/CLIENT IS ASKED TO RAISE THE

SCAPULA SUPERIORLY AGAINST PRESSURE WITH

MINIMUM EFFORT AND BREATHE IN FOR 10 SECS.

• PATIENT IS INSTRUCTED TO HOLD THEIR BREATH,

LET GO, AND BREATHE OUT. IT IS IMPORTANT TO

WAIT AND FEEL THE RELAXATION. WAIT 10 TO

20 SECONDS OR LONGER AS LONG AS

RELAXATION IS TAKING PLACE.

• AFTER RELAXATION FIND THE NEXT BARRIER AND

REPEAT THE PROCEDURE UNTIL RELAXATION

CEASES TO OCCUR.

UPPER TRAP

• REFERRED PAIN

• ALONG BACK OF NECK TO BEHIND EAR AND TEMPLE


• HA

• NECK PAIN

• FORWARD HEAD POSTURE

• EVALUATION

• EARLY ELEVATION OF SHOULDER

UPPER TRAP PIR

• SUPINE WITH AFFECTED SIDE ARM LAYING NEXT

TO HIS/HER SIDE. THE HEAD IS LATERALLY FLEXED

AWAY, IPSILATERALLY ROTATED, AND PLACED

INTO FLEXION.

• YOU ARE SEATED AT HEAD OF TABLE. ONE HAND

IS PLACED ON THE AFFECTED SCAPULA AND

SHOULDER AND THE OTHER HOLDS THE HEAD IN

THE CORRECT POSITION. THE DOCTOR EXERTS

PRESSURE ON THE PATIENT’S SHOULDER BY

PRESSING IN A CAUDAL DIRECTION FINDING THE

BARRIER. IT IS IMPORTANT TO STAY LIGHT AT ALL

TIMES.

• THE PATIENT/CLIENT IS ASKED TO RAISE THE

SHOULDER SUPERIORLY AGAINST PRESSURE WITH

MINIMUM EFFORT AND BREATHE IN FOR 10 SECS.

• PATIENT/CLIENT IS INSTRUCTED TO HOLD THEIR

BREATH, LET GO, AND BREATHE OUT. IT IS

IMPORTANT FOR TO WAIT AND FEEL THE

RELAXATION. YOU COULD WAIT 10 TO 20

SECONDS OR LONGER AS LONG AS RELAXATION

IS TAKING PLACE.

• AFTER RELAXATION FIND THE NEXT BARRIER AND

REPEATS THE PROCEDURE UNTIL RELAXATION

CEASES TO OCCUR.

POST CAPSULE/INFRASPINATUS

• REFERRED PAIN

• ANTERIOR DELTOID, SHOULDER, LATERAL FOREARM, AND HAND


• PAIN WHEN SLEEPING ON SIDE

• DIFFICULTY REACHING BEHIND BACK

• ROTATOR CUFF ISSUES

• EVAL

• DECREASED INTERNAL ROTATION SUPINE

POST CAPSULE/INFRASPINATUS

PIR

• SUPINE WITH ARM IN 90O ABDUCTION AND FLEXION AT THE ELBOW

• YOU ARE SEATED AT THE HEAD OF THE TABLE WITH THE PATIENT/CLIENT’S

ELBOW RESTING ON YOUR KNEE.

• YOUR OUTSIDE HAND HOLDS THE PATIENT’S WRIST AND THE OTHER HAND

STABILIZES THE SCAPULA TO PREVENT IT FROM ELEVATING

• INTERNALLY ROTATES THE ABDUCTED SHOULDER TAKING UP THE SLACK AND

FINDING THE BARRIER

• THE PATIENT/CLIENT IS ASKED TO RESIST WITH ONLY MINIMAL FORCE

(ISOMETRICALLY) AGAINST YOUR HAND AND TO BREATHE IN FOR 10

SECONDS. IT IS IMPORTANT FOR TO STAY LIGHT AT ALL TIMES.

• THE PATIENT/CLIENT IS THEN TOLD TO ’LET GO’ (RELAX) AND EXHALE

SLOWLY. IT IS IMPORTANT TO WAIT AND FEEL THE RELAXATION. YOU COULD

WAIT 10 TO 20 SECONDS OR LONGER AS LONG AS RELAXATION IS TAKING

PLACE. DUE TO PURE RELAXATION THERE SHOULD BE AN INCREASE IN THE

RANGE OF MOTION.

• AFTER RELAXATION FIND THE NEXT BARRIER AND REPEAT THE PROCEDURE

UNTIL RELAXATION CEASES TO OCCUR.

SUBSCAPULARIS

• REFERRED PAIN

• POSTERIOR DELTOID AND BACK OF ARM


• DIFFICULTY REACHING BACK AS IN THROWING

• FROZEN SHOULDER

• ROTATOR CUFF ISSUES

• EVAL

• DECREASED EXTERNAL ROTATION SUPINE

SUBSCAP PIR

• SUPINE WITH ARM IN 90O ABDUCTION AND FLEXION AT THE ELBOW

• YOU ARE SEATED AT THE HEAD OF THE TABLE WITH THE PATIENT/CLIENTS’S ELBOW RESTING

ON YOUR KNEE.

• YOUR OUTSIDE HAND HOLDS THE PATIENT’S WRIST AND THE OTHER HAND STABILIZES THE

ANTERIOR SHOULDER TO PREVENT IT FROM ELEVATING

• EXTERNALLY ROTATES THE ABDUCTED SHOULDER TAKING UP THE SLACK AND FINDING THE

BARRIER

• THE PATIENT/CLIENT IS ASKED TO RESIST WITH ONLY MINIMAL FORCE (ISOMETRICALLY)

AGAINST THE YOUR HAND AND TO BREATHE IN FOR 10 SECONDS. IT IS IMPORTANT FOR TO

STAY LIGHT AT ALL TIMES.

• THE PATIENT/CLIENT IS THEN TOLD TO ’LET GO’ (RELAX) AND EXHALE SLOWLY. IT IS

IMPORTANT TO WAIT AND FEEL THE RELAXATION. YOU COULD WAIT 10 TO 20 SECONDS OR

LONGER AS LONG AS RELAXATION IS TAKING PLACE. DUE TO PURE RELAXATION THERE

SHOULD BE AN INCREASE IN THE RANGE OF MOTION.

• AFTER RELAXATION FIND THE NEXT BARRIER AND REPEAT THE PROCEDURE UNTIL RELAXATION

CEASES TO OCCUR.

PEC MINOR/MAJOR

• REFERRED PAIN

• ANTERIOR CHEST, BREAST, INNER ARM, AND FOREARM


• BREAST HYPERSENSITIVITY

• SHOULDER IMPINGEMENT

• RIB PAIN

• THORACIC OUTLET

• EVAL

• ROLLED SHOULDERS

• ELEVATION OF THE RIBS WITH ARM ABDUCTION AND ELEVATION

PEC PIR

• SUPINE AND YOU ARE STANDING ON THE AFFECTED SIDE.

• WITH INFERIOR HAND, DEPRESS THE RIB CAGE AND WITH SUPERIOR HAND THE

TAKE UP THE SLACK BY ROLLING THE PATIENTS SHOULDER POSTERIORLY AND

FINDS A BARRIER (YOU CAN USE THE ARM TO ROLL SHOULDER). IT IS

IMPORTANT TO STAY LIGHT AT ALL TIMES.

• THE PATIENT/CLIENT IS INSTRUCTED TO RESIST PRESSURE WITH MINIMUM

EFFORT AND BREATHE IN FOR 10 SECS.

• THE PATIENT/CLIENT IS ASKED TO HOLD THEIR BREATH, LET GO, AND BREATHE

OUT. IT IS IMPORTANT TO WAIT AND FEEL THE RELAXATION. YOU COULD WAIT

10 TO 20 SECONDS OR LONGER AS LONG AS RELAXATION IS TAKING PLACE.

• AFTER RELAXATION FIND THE NEXT BARRIER AND REPEAT THE PROCEDURE UNTIL

RELAXATION CEASES TO OCCUR.

THORACIC SPINE

• REFERRED PAIN

• THORACIC SPINE, NECK, SHOULDERS, RIBS

• EFFECTS OF ROUNDED BACK

• LOSS OF SHOULDER MOVEMENT

• EXCESSIVE NECK MOVEMENT

• PAIN

• EVAL

• VISUALIZATION OF ROUNDED BACK

• LACK OF MOBILITY IN THORACIC SPINE

THORACIC SPINE PIR

• SEATED WITH FINGERS INTERLOCKED BEHIND HEAD

• ONE ARM SUPPORTED PATIENT ELBOWS AND THE OTHER IS

PLACED ON THORACIC SPINE

• FIND BARRIER. PATIENT PUSHES ELBOWS DOWN GENTLY INTO

YOUR ARM WITH BREATHING IN.

• THE PATIENT/CLIENT IS ASKED TO HOLD THEIR BREATH, LET GO,

AND BREATHE OUT. IT IS IMPORTANT TO WAIT AND FEEL THE

RELAXATION. YOU COULD WAIT 10 TO 20 SECONDS OR LONGER

AS LONG AS RELAXATION IS TAKING PLACE.

• AFTER RELAXATION FIND THE NEXT BARRIER BY RASING THE

ELBOWS AND REPEAT THE PROCEDURE UNTIL RELAXATION CEASES

TO OCCUR.

INSTRUMENT ASSISTED

• INSTRUMENT ASSISTED SOFT TISSUE MANIPULATION IS A FORM OF MYOFASCIAL

RELEASE WHERE A TOOL IS USED TO HELP DIAGNOSE AND TREAT SOFT TISSUE

RESTRICTIONS.

• THE INSTRUMENT IS GLIDED OVER THE SKIN TO DETECT IRREGULARITIES AND SOFT

TISSUE ADHESIONS LOCATED IN FASCIA AND MUSCLES.

• INCREASED FRICTION FROM SOFT TISSUE RESTRICTIONS OR ADHESIONS CREATES A RED

RESPONSE WHICH SERVES TO AID IN DIAGNOSIS.

• AS THE INSTRUMENT IS RAN OVER THE SKIN AND A RED RESPONSE IS PRODUCED

CONTINUED STIMULATION OVER THE AREA IS WARRANTED.

• TREATMENT OVER THE ADHESION CONTINUES UNTIL A RED RESPONSE IS PRODUCED

OVER THE ENTIRE SURROUNDING AREA.

SUPRA TENDON/AC

• START WITH THE PATIENT SEATED WITH THE

ARM IN SLIGHT FLEXION AND ABDUCTION

AND EXPOSED.

• PROPERLY LUBRICATE THE PATIENT’S

SHOULDER.

• INSTRUCT THEM TO SLOWLY INTERNALLY

ROTATE AND PLACE THEIR HAND IN THEIR

OPPOSITE SIDE BACK POCKET.

• GENTLY GLIDE THE SCALER OVER THE

SUPRASPINATUS TENDON AND THE MUSCLE

BELLY.

• SLOWLY REPEAT THE MOTION UNTIL

TREATMENT IS COMPLETE.

• MAKING SURE TO TREAT ANY ADHESIONS

AND/OR SCAR TISSUE LOCATED BY THE

TOOL OR RED RESPONSE.

• THE ENTIRE SUPRASPINATUS CAN BE

TREATED WITH THIS PROCEDURE.

LAT

• START WITH THE PATIENT PRONE WITH THEIR SHOULDER

EXPOSED AND HAND PLACED NEXT TO THEIR EAR.

• PROPERLY LUBRICATE THE PATIENT’S SHOULDER.

• INSTRUCT THEM TO SLOWLY RAISE THEIR ARM ABOVE

THEIR HEAD.

• FIRST HAVE THEM TURN THEIR THUMB TOWARDS THE

FLOOR AND THEN ROTATE THEIR PALM TOWARDS THE

CEILING.

• GENTLY GLIDE THE SCALER OVER THE POSTERIOR ROTATOR

CUFF (INFRASPINATUS, TERES MINOR/MAJOR) AND

LATISSIMUS DORSI STARTING AT THE SUPERIOR SCAPULAR

SPINE AND MOVE INFERIOR.

• SLOWLY REPEAT THE MOTION UNTIL TREATMENT IS

COMPLETE.

• MAKING SURE TO TREAT ANY ADHESIONS AND/OR SCAR

TISSUE LOCATED BY THE TOOL OR RED RESPONSE.

• THE ENTIRE POSTERIOR, INFERIOR AND LATERAL SHOULDER

CAN BE TREATED WITH THIS PROCEDURE.

BICEP

• START WITH THE PATIENT SEATED WITH THE

ARM IN ANATOMICAL POSITION AND

EXPOSED.


• INSTRUCT THEM SLOWLY EXTEND THEIR ARM.

• GENTLY GLIDE THE SCALER OVER THE A\C

LIGAMENT AND LONG HEAD OF THE BICEPS

FEMORIS.

• SLOWLY REPEAT THE MOTION UNTIL

TREATMENT IS COMPLETE.

• MAKING SURE TO TREAT ANY ADHESIONS

AND/OR SCAR TISSUE LOCATED BY THE TOOL

OR RED RESPONSE.

• THE ANTERIOR SHOULDER AND BICEPS MUSCLE

CAN BE TREATED WITH THIS PROCEDURE.

RHOMBOID

• START WITH THE PATIENT SEATED AND BACK

EXPOSED.

• PROPERLY LUBRICATE THE PATIENT’S BACK.

• HAVE THEM TO RAISE THEIR ARM TO 90O AND

HOLD.

• INSTRUCT THEM TO SLOWLY HORIZONTALLY

ADDUCT AND SLIGHTLY FLEX THEIR ARM.

• GENTLY GLIDE THE SCALER OVER THE RHOMBOID

STARTING AT THE MEDIAL BORDER OF THE SCAPULA.


COMPLETE.

• MAKING SURE TO TREAT ANY ADHESIONS AND/OR

SCAR TISSUE LOCATED BY THE TOOL OR RED

RESPONSE.

• THE ENTIRE RHOMBOID MAJOR AND MINOR CAN BE

TREATED WITH THIS PROCEDURE.

POST CAP

• START WITH THE PATIENT SEATED AND SHOULDER

EXPOSED.


• HAVE THE PATIENT ABDUCT THEIR ARM TO 90O WITH THE

ELBOW FLEXED.

• INSTRUCT THEM TO SLOWLY INTERNALLY ROTATE AND

HORIZONTALLY ADDUCT THE SHOULDER ACROSS THEIR

BODY.

• GENTLY GLIDE THE SCALER OVER THE POSTERIOR DELTOID,

SUPRASPINATUS AND CAPSULE.


COMPLETE.

• MAKING SURE TO TREAT ANY ADHESIONS AND/OR SCAR

TISSUE LOCATED BY THE TOOL OR RED RESPONSE.

• THE ENTIRE POSTERIOR SHOULDER CAN BE TREATED WITH

THIS PROCEDURE.

WHY DRY NEEDLE? – STRUCTURE & FUNCTION

• NEEDLING…

• INCREASES BETA-ENDORPHIN RELEASE → INHIBIT PAIN

• ACTIVATE A-BETA, DELTA, AND C FIBERS → INHIBIT PAIN

• INCREASES NO → INCREASED BLOOD FLOW

• PERIPHERAL & SPINAL MECHANISMS. BUTS 2016

• CGRP PRODUCES SKELETAL MUSCLE VASODILATION. SATO 2000

• DN MORE EFFECTIVE THAN STRETCHING & PENS

• EFFECTIVENESS OF TRIGGER POINT DRY NEEDING, BOYLES 2015

CUPPING

• THE ONLY DECOMPRESSIVE THERAPY I CAN THINK OF

• UTILIZES NEGATIVE PRESSURE TO LIFT TISSUE

• DRY VS WET

• THOUSANDS OF YEARS OLD

• MARKOWSKI 2014 STUDY SHOWS STATIC/STATIC CUPPING FOR 10 MINUTES IMPROVED VAS, SLR, TRUCK

FLEXION

• TENSION SHOWED TO BE MAX UNDER MOST BULBOUS PORTION OF SKIN

• AS WIDE AS .4 TIMES THE DIAMETER OF THE CUP

• SMALLER CUP DIRECT TO DEEPER TISSUE

• LARGER CUP LARGER SURFACE AREA

• ****SUMMARIZED FROM SUE FALSONE SFDN1 COURSE****

REHABILITATION

• KISS APPROACH

• KEEP IS SIMPLE

• LOW TECH

• RULE OUT NECK FIRST

• DIRECTIONAL PREFERENCE

• STABILIZE

DIRECTIONAL PREFERENCE

LOW ROBBER

• PLACE AN EXERCISE BAND

AROUND YOUR WRIST.

LOWER YOUR SHOULDER

BLADES INTO YOUR BACK

POCKETS.

• ROTATE YOUR ARMS

OUTWARD; YOU SHOULD

FEEL CONTRACTION

BETWEEN YOUR

SHOULDER BLADES.

• RETURN TO THE START

POSITION AND REPEAT 10

TIMES

QUADAPED LOWER TRAP

• START ON YOUR KNEES AND SIT YOUR GLUTES

DOWN ONTO YOUR ANKLES.

• PLACE YOUR ELBOWS IN FRONT OF YOUR

KNEES (TOUCHING YOUR ELBOWS TO YOUR

KNEES) WITH THE ARMS PARALLEL TO EACH

OTHER.

• KEEP YOUR BACK AND NECK AS NEUTRAL AS

POSSIBLE AND TRY TO LOWER YOUR

SHOULDER BLADES LIKE YOU ARE TRYING TO

PLACE THEM IN YOUR BACK POCKET.

• THEN TURN YOUR PALMS UP TO THE CEILING

AND MOVE YOUR WRISTS AWAY FROM EACH

OTHER, KEEPING THEM ON THE GROUND.

• REPEAT THIS 10 TIMES. REPEAT 3-4 TIMES A

DAY.

REFLEX TURNING 2

• LAY ON YOUR SIDE.

• BRING YOUR TOP LEG UP TO 90

DEGREES AND SLIGHTLY BEND

YOUR BOTTOM LEG.

• YOU SHOULD BE LYING DIRECTLY

ONTO YOUR SHOULDER WITH

YOUR ELBOW BENT AT 90 DEGREES.

(SEE 1ST PIC ABOVE)

• TURN YOUR HAND SO YOU CAN

SEE THE BACK OF IT.

• PLACE YOUR UPSIDE HAND ONTO

YOUR ELBOW AND PUSH DOWN.

• TRY AND RAISE YOUR SHOULDER

OFF THE GROUND.

• HOLD FOR A 10 SEC COUNT AND

REPEAT 10 TIMES.

PRONE DNF

• LAY ON YOUR STOMACH WITH

YOUR ARMS ABOVE YOUR HEAD

AND ELBOWS BENT AT 90O

• PLACE YOUR FOREHEAD ON THE

TABLE.

• SLIGHTLY TUCK YOUR CHIN AND

GENTLY PRESS YOUR ELBOWS INTO

THE TABLE WHILE LOWERING YOUR

SHOULDER BLADES DOWNWARD.

• RAISE YOUR ENTIRE HEAD OFF THE

TABLE FOCUSING TO MAKE THE

MAJORITY OF THE MOVEMENT

COME FROM YOUR UPPER BACK.

• HOLD FOR 2 SECS, AND RETURN

YOUR FOREHEAD TO THE TABLE.

• REPEAT 3 TIMES FOR 10 REPS EACH.

TAPING

• BETTER DEFINED AS PROPRIOCEPTIVE TAPING

• USED TO DECREASE PAIN, DECREASE EDEMA,

ASSIST MUSCLE FUNCTION, AND IMPROVE

JOINT FUNCTION

• DESIGNED TO SIMULATE HUMAN SKIN IN

THICKNESS AND WEIGHT

• THE ONLY THERAPEUTIC TAPE THAT ALLOWS

FOR FULL RANGE OF MOVEMENT WHILE

PROVIDING SUPPORT TO THE MUSCLE

• ADHESIVE IS HEAT ACTIVATED, SO IT CAN

WORN FOR 3-5 DAYS INCLUDING IN THE

SHOWER AND POOL

• IN RELATING TO PAIN AND IMPROVING

FUNCTION:

• KINESIOLOGY TAPING FACILITATES THE

PROPRIOCEPTIVE SYSTEM OF THE

NERVOUS SYSTEM

• IMAGINE THAT SOMEONE'S BICEP HURTS,

TO STOP THE PAIN THEY CONTINUOUSLY

RUB IT.

• TAPING ACTS THE SAME WAY TO

DECREASE THE PAIN BUT ALSO HELPS THE

MUSCLE CONTRACT CORRECTLY DUE TO

ITS ELASTIC PROPERTIES

• THE SKIN IS STIMULATED, WHICH

STIMULATES THE RECEPTORS, WHICH

CHANGES MUSCLE FUNCTION

DELTOID & UPPER TRAP

BICEP & ROLLED SHOULDER

REFERENCES• MAGEE, DAVID J. ORTHOPEDIC PHYSICAL ASSESSMENT. N.P.: N.P., N.D.

PRINT.

• NEUMANN, DONALD A. KINESIOLOGY OF THE MUSCULOSKELETAL

SYSTEM: FOUNDATIONS FOR REHABILITATION. ST. LOUIS, MO:

MOSBY/ELSEVIER, 2010. PRINT

• TRAVELL, JANET G., AND LOIS S. SIMONS. MYOFASCIAL PAIN AND

DYSFUNCTION: THE TRIGGER POINT MANUAL. N.P.: WILLIAMS & WILKINS,

1999. PRINT.

• HAMMER, WARREN. FUNCTIONAL SOFT TISSUE EXAMINATION AND

TREATMENT BY MANUAL METHODS. N.P.: JONES & BARTLETT PUB, 2006.

PRINT.

• LEWIT, KAREL. MANIPULATIVE THERAPY: MUSCULOSKELETAL MEDICINE.

EDINBURGH: CHURCHILL LIVINGSTONE/ELSEVIER, 2010. PRINT.

• KASE, KENZO. ELASTIC THERAPEUTIC TAPING: LET'S TALK TREATMENT.

DYNAMIC CHIROPRACTIC – JULY 29, 2011, VOL. 29, ISSUE 16.

• LIEBENSON C, ED. REHABILITATION OF THE SPINE: A PRACTITIONER'S

MANUAL, 2ND ED. BALTIMORE: LIPPINCOTT/WILLIAMS & WILKINS, 2007

• FALSONE, SUE. SFDN1 COURSE. PRESENTED ARIZONA 2018.

• HILDEBRAND, JUSTIN. SOFT TISSUE PROTOCOLS. KC, MO: HCR, 2014.

• HILDEBRAND, JUSTIN. REHAB MANUAL. KC, MO: HCR, 2014.

treatment and management of shoulder pain · •biceps tendinitis/osis •capsule tear...

Documents