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Shoulder Complex
The McConnell Treatment Approach
Alfio Albasini, Switzerland,
PT, PostGradManipTherap
Adjunct Fellow, Università Svizzera Italiana (USI)
Member of CEC, Otto Bock Healthcare
International Presenter
[email protected]
www.endura-europe.com
www.albasinimueller.ch
A.Albasini Grad Dip Adv Man Ther
Jaweler/ Pitcher : Mobile / Stabile
“loose enough to throw but stable enough to
prevent symptoms”
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The Thrower’s paradox
The thrower’s shoulder must be lax enough
to allow excessive external rotation but stable
enough to prevent symptomatic humeral head
subluxations, thus requiring a delicate balance
between mobility and functional stability.
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Stability of the glenohumeral joint
• Passive limited
• Only 25-35% of the humeral head is in
contact with the glenoid at any time
• Activ stabilizer allow only a few
millimeters of translation in any plane
during motion (Bowen and Warren 1991)
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Labrum’s contributions to
stability:
• Increased surface of area of glenoid
• Increases depth and concavity of glenoid
• Provides concave space necessary to
maintain negative pressure, acting as a seal
against HOH
• Prevents distraction and decreases
translation
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Glenoid Labrum
• Forms a ring around periphery of glenoid,
provides anchorage for capsule & ligaments
• Superior aspect meniscal:
- attachment for LHB, SGHL, MGHL
- loosely attached to glenoid
- flexible, adapts to changing aspects of articular surfaces during movement
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SLAP: superior labrum anterior posterior
• The name SLAP is derived from- Superior Labrum Anterior-Posterior • The feature that makes SLAP possible is the way
the upper biceps tendon hooks over the head of the
humerus. If the arm is forcefully bent inward and
twists at the shoulder, the humeral head acts as a
lever and tears the biceps tendon and labrum
cartilage from the glenoid bone in a front-to-back
(anterior-posterior) direction.
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SLAP: superior labrum anterior posterior
What exactly causes of a SLAP lesions ??
- acute traumatic events ?
- chronic repetitive injuries that lead to failure ?
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SLAP: superior labrum anterior posterior
O’Brien Test
sensitivity 100%
Specificity 97-98%
for Labral as
ACJ abnormality
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SLAP lesion Type IV
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Glenoid Labrum
• Inferior aspect inelastic, fibrous extension of
glenoid articular cartilage:
- firmly attached to glenoid
- attachment for IGHLC, LH triceps
- mobility indicates patholoy
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The Inferior Glenohumeral Ligament
Complex consists of three parts :
• Anterior band: primary stabilizer at 30° of
horizontal extension and at neutral extension
• Posterior band: primary stabilizer at 30° of
horizontal
flexion
• Axillary pouch:
between anterior and posterior bands
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The Inferior Glenohumeral Ligament
Complex (IGHLC)
Anterior
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Posterior
The inferior Glenohumeral Ligament
Complex (IGHLC) in IR
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The inferior Glenohumeral Ligament
Complex (IGHLC) in ER
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TheMiddle Glenohumeral Ligament (MGHL)
• Absent in 30% of the population
• Origin: from labrum or bony neck of glenoid below the superior
• Insertion:medial to lesser tuberosity
• With subscapularis tendon contributes to
anterior stability at 45° of abduction
• limits external rotation in lower range of abduction
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TheMiddle Glenohumeral
Ligament (MGHL)
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The Superior Glenohumeral Ligament
(SGHL)
• Origin: from labrum anterior to the biceps tendon • Insertion:superior to the lesser tuberossity near the bicipital groove
• In conjunction with the coracohumeral ligament
provides a passive restraint to inferior subluxation of
the humerus in the resting position of the arm
• Secondary function:
limits posteriore dislocation when the shoulder is in ADD/F/IR
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The Superior Glenohumeral
Ligament (SGHL)
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The Coracohumeral Ligament (CHL)
• Origin: lateral aspect of the base of the coracoid process
• Insertion: greater tuberosity on the lateral of the bicipital groove
• Function: suspensory nature when
(debatable) the arm is dependent
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The Coracohumeral Ligament
(CHL)
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Dependent arm and gravity at rest
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POSTURE
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Posture and Alignment
• Vertebral margin of the scapula has to be
parallel to the vertebral column, approx. 7.62 cm to mid line of the thorax
• Scapula sits approx. betw. T2 e T7
(S.Sahrmann, Diagnosis & Treatment of Movement Impairment Syndromes,
2004)
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Position of the Scapula
• Protraction/retraction
– Scapula 15-30˚ forward of
coronal plane
– Medial border 6cm to spine
• Forward tilt/pseudo winging
– 8˚ anterior tile, if excessive
pseudo winging
• Medial rotation/winging
– Medial scapular border lifted off
thoracic cage
Scapula Position and Control
• Abduction /Adduction
• Elevation / Depression
• Rotation up-/ downward
• Rotation in/out
• Tilt/Winging
• Scapula alata
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Scapula Position and Control
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How to measure: Inclinometer ?
ÜResearch (Watson, Balster 2004
BJSM)
ÜClinical method for measuring
Scapula
ÜUpward/Downward Rotation
Ü Medial/Lateral shift • Elevation/
Depression
Ü Method is reliable, valid and
easy to use
Ü © LynWatson August 2004
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Validity and reliability of smartphone magnetometer-based
goniometer evaluation of shoulder abduction e A pilot study
Linda B. Johnson et al 2015
Manual Therapy 20 (2015) 777-782
Conclusion: Our results
show that the smartphone
MG has equivalent reliability
compared to the
traditional UG when
measuring passive shoulder
abduction
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Posture and Alignment
Ü Vertebral margin of the scapula has to be parallel to the
vertebral column, approx. 7.62 cm to mid line of the thorax
ÜScapula sits approx. betw. T2 e T7
(S.Sahrmann, Diagnosis & Treatment of Movement
Impairment Syndromes, 2004)
ÜInferior angle T7 or 21.3 cm down from C7 spine process
8.1 cm out from the spine
Ü Upward Rotation (2°-18°), with inclinometer 10°
ÜInternal Rotation (33°-35°)
ÜAnt tilt 8° (Lyn Watson 2011)
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Posture and Alignment
Palpate with the four
fingers method and compare one side to the
other
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Scapula Elevation/Depression
Scapula Elevation
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Scapula Depression; Anterior Glide HOH
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Scapula Upward Rotation
•
•
•
Ludewig PM et al , JOSPT 1996
Lukasiewicz et al, JOSTP 1999
McClure PW et al, J Shoulder Elbow
Surg 2001
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Optimal scapulohumeral rhythm
Ideal
scapulohumeral
rhythm
- 1: 2
- Scapula
stabilised first 60°
70 Upward
Upward Rotation˚
60
50
40
30
20
Karduna, 2001
10
Downward
0
30
60
90
120
Shoulder - Elevation
• Basic function of the shoulder
• Rhytmical combination of glenohumeral and scapular
rotation:
- first 30° ratio 2:1 glenohum jt : scapula
- at first 60° ratio 4:1
- then continues at 5:4 (Poppen & Walker 1976)
• Normal range is
168° men
175° women
• At the beginning of arm elevation there is a slight upward
displacement of 1-3mm ot the HOH (Graichen et al 2000; Liu e al
1997) where the force are balanced (< 6mm rotator cuff’s
pathology)
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150
Scapular Dyskinesia /Dyskinesis:
Altered scapular motion and position have been
termed scapular dyskinesis.
The definition of dyskinesis is the alteration of
normal scapular kinematics.
‘Dys’ (alteration of) ‘kinesis’ (motion) is a
general term that reflects the loss of normal control of
scapular motion. An alternative term that is often
used interchangeably is ‘dyskinesia’.
Kibler WB, et al. Br J Sports Med 2013;47:877–885. doi:10.1136/bjsports-2013-092425
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Causes of Scapular Dyskinesis:
Multiple factors may cause dyskinesis:
•Bony causes include thoracic kyphosis or clavicle fracture nonunion
or shortened mal-union.
•Joint causes include high grade AC instability, AC arthrosis and
instability and GH joint internal derangement.
•Neurological causes include cervical radiculopathy, long thoracic or
spinal accessory nerve palsy.
•Soft tissue mechanisms for scapular dyskinesis involve inflexibility
(tightness) or intrinsic muscle problems.
•Inflexibility and stiffness of the pectoralis minor and biceps short
head can create anterior tilt and protraction due to their pull on the
coracoid.
Kibler WB, et al. Br J Sports Med 2013;47:877–885. doi:10.1136/bjsports-2013-092425
A.Albasini Grad Dip Adv Man Ther
Causes of Scapular Dyskinesis2 :
• Soft tissue posterior shoulder inflexibility can lead to GH internal
rotation deficit (GIRD), which creates a ‘wind-up’ of the scapula on
the thorax with reduced humeral internal rotation and horizontal
abduction.
• Alterations in periscapular muscle activation are related to scapular
dyskinesis. Serratus anterior activation and strength is decreased in
patients with impingement and shoulder pain, contributing to the loss
of posterior tilt and upward rotation causing dyskinesis.
• In addition, the upper trapezius/lower trapezius force couple may be
altered, with delayed onset of activation in the lower trapezius, which
alters scapular upward rotation and posterior tilt. Altered scapular
motion or position both decrease linear measures of the subacromial
space, increase impingement symptoms, decrease rotator cuff strength,
increase strain on the anterior GH ligaments and increase the risk of
internal impingement.
Kibler WB, et al. Br J Sports Med 2013;47:877–885.
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Causes of Scapular Dyskinesis 3 :
•
Scapular dyskinesis may be found in association with many
types of shoulder pathologies, although the exact relationship
between dyskinesis and clinical pathology is not clear.
•
Scapular dyskinesis may be the cause or the result of a shoulder
injury, exacerbate shoulder symptoms or adversely affect treatment or outcomes
•
In cases of nerve injury, fracture, AC separation or muscle detachment, the injury
creates the dyskinesis which affects shoulder function.
•
In other cases, such as rotator cuff disease, labral injury and multidirectional instability
(MDI), it may be that dyskinesis is the causative, creating pathomechanicsthat
predispose the arm to injury, or it may be response to the injury, creating
pathomechanics that increase the dysfunction
Kibler WB, et al. Br J Sports Med 2013;47:877–885. doi:10.1136/bjsports-2013-092425
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Scapula Downward Rotation
Scapular Dyskinesis:
Ü Rotator Cuff tears on scapular kinematics ?
- increased upward rotation ??
- Compensation ?
Ü Nerve block on healthy subjects in order to
produce experimental dysfunction of supra &
infraspinatus muscles:
subjects demonstrated significant increase in
scapular upward rotation & ER during arm
elevation (McCully et al 2006)
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Scapula Downward Rotation
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Scapular Kinematic
ÜWhen fatiguing the shoulder through repetitive
overhead activities:
significant increase in upward rotation
( Dvir et al 1978)
ÜTightness of posterior capsule:
pull scapula laterally (Borich et al 2002)
ÜThoracic posture:
increased scapular ant tilt and IR
( Kebaetse et al 1999)
ÜInfluence of P: injection of NaCl into the all trapezius
in healthy subjects.
Reorganization of coordination among trapezius.
UT involved side, decrease, LT increase
UT non involved side increase during Flexion
(Falla et al 2007)
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Postural Considerations
• Faulty position of the scapula compromise
movement’s pattern
• During ABD scapula rotate downward due to
the pull of the tight rhomboids over the
lengthened lower trapezius (1st part of mvt) bad position of glenoid
• Reduced bone stability of glenohumeral jt.
• Increase activ’s control demand
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Stretching Activ/Passiv pectoral minor
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Scapular Dyskinesis:
ÜSerratus Anterior & LT susceptible to inhibition in
painful shoulders
ÜSeen as non-specific response to any painful condition
ÜDisorganization of normal firing pattern
ÜDecreased ability to produce torque & stabilize
scapula
(Kibler Br J Sports Med 2010;44:300–305. )
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Scapula Anterior/Posterior Tilt
Scapula Anterior Tilt
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Long Thx nerve paulsy
Scapula Internal/External Rotation
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• A Rot int/ext
• B upward
downard rot.
• C ant/post tilt
• D clavicola
protract/retract
• E clavicola
elevat./depress.
D. Ebaugh et al, J Orthop Sports PhysTher 2006;36(8):557-571.
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Scapula Medial/Lateral Slide, Adduction / Abduction
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Common Patterns of Dynamic Scapula
Control Dysfunction
•
•
•
•
Dominance of scapula downward rotation
Scapula elevation: excessive or early initiation
“True winging” (medial rotation)
“Pseudo winging” (reduced posterior tilt)
Alfio Albasini Adv Manip Therap
Possible causes for poor scapular
control
• Motor Control: serratus ant/LT/ middle Trap / Rhomboid
• Muscle shortness
post rot cuff/ biceps /pectoralis minor / lat dorsi/levat scap
• Soft tissue tightness / Shortness
posterior capsule
• Thoracic spine position: kyphosis
• Cervical spine position: forward head posture
• Shoulder dysfunction: impingement syndrome / RC tear / GH
instability / Labral Tear
Alfio Albasini Adv Manip Therap
Postural Considerations
• Forward sitting shoulder is particularly
susceptible to various impingement syndromes
• Depressed shoulder is particularly susceptible to
various impingement syndromes
• Increased thoracic kyphosis may limit shoulder
flexion and predispose an individual to an
impingement problem
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Scapula Depression; Anterior Glide HOH
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Position of the Head of the Humerus
(HOH)
Anterior Glide
Superior Glide
Medial Rotation
Gleno-Humeral Hypomobility
•
•
•
•
“The head of the humerus should not be more
protracted than 1/3 in relation to the acromion”
S.Sahrmann, Diagnosis & Treatment of Movement Impairment Syndromes,
2004
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Position of the Head of the Humerus (HOH)
Anterior
● Mid glenoid to
anterior and posterior
humeral head is
equidistant
x
Glenoid
Humerus
y
Posterior
– Distance x = y
1/3
● 1/3 humeral head lies
anterior to acromion
Acromion
2/3
Acromiohumeral distance measurement in rotator cuff tendinopathy:
is there a reliable, clinically applicable method ? A systematic review
McCreesh KM, et al. Br J Sports Med 2015;49:298–305
Conclusions • The results support the reliability of ultrasound and CT
or MRI for the measurement of AHD;
• The reliability of AHD measurement using radiographs
has not been supported by the studies reviewed.
Normal mvt.
during elevation: • upward rotation
• posterior tilt
• slight IR, at the EoR ER • Clavicle
elevation/retraction
Reprinted with permission from Borich et al. 2002. JOSPT
2009; 39 (2);90-104
(Ludewic Pm et al 1996; Lukasierwicz AC et al 1999; McClure PW et al 2001)
Scapular motions from (A) posterior (upward/downward rotation), (B)
superior (internal/external rotation), and (C) lateral (anterior/posterior
tilting) views. Axes of rotation are indicated as black dots.
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Effects of altered
posture on the shoulder
• Increase forward head posture
– Reduced scapula upward rotation & posterior tilt
Mitchener, 2004
• Increased thoracic flexion (12˚)
– Altered scapula & GHJ dynamic control
• Kaebeatse, 1999; Borstad,2005
• Slouched posture vs. upright
– ↓ humeral elevation, ↓ scapula post tilt, ↓ upward rotation
• Finley, 2003; Lewis, 2005; Bullock, 2005
– SAS (acromiohumeral distance) increased with upright
posture compared to normal posture
• Kalra, 2010
Thoracic Spine Mobility
•
In a RCT, the addition of manual therapy to supervised exercise program for shoulder
impingement demonstrated significantly greater improvement than supervised exercises alone.
( Bang et al 2000)
•
Shoulder pain in individuals with shoulder impingement immediately decreased after a TSM
(thoracic spine manipulation). The observed changes in scapular kinematics following TSM
were not considered clinically important.
(Haik et al JOSPT 2014)
•
No meaningful immediate changes in thoracic or scapular motion were seen in participants with
shoulder pain who received either thoracic SMT or sham thoracic SMT
Immediate changes in them symptoms of subacromial impingement syndrome following
thoracic SMT may not be due to biomechanical changes at the thoracic spine or scapula.
Because thoracic SMT led to improved outcomes that were not different from those of a sham
manipulation, it is possible that benefits from manual therapy may be derived from aspects of
treatment other than manipulative thrust.
(Kardouni et al JOSPT 2015)
•
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Impingement
Occurs when the space is functionally narrowed between:
• Acromion & coracoacromial arch
• AC joint above & glenohumeral jt below
Causes mechanical irritation of the rotator
cuff tendons resulting in hemorrhage and
swelling
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Impingement
• Subacromial or external impingement is the mechanical
encroachment of the soft tissue (bursa, rotator cuff tendons) in the
subacromial space between the humeral head and the acromial arch.4
This encroachment particularly takes place in the midrange of
motion, often causing a ‘‘painful arc’’ during active abduction
• Internal impingement comprises encroachment of the rotator cuff
tendons between the humeral head and the glenoid rim. Based on the
location of the impingement, anterosuperior and posterosuperior
glenoid impingement have been described
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Impingement
Diagnoses associated with rotator cuff
impingement
•
•
•
•
•
•
•
•
•
Subacromial bone spurs and/or bursal hypertrophy
AC joint arthrosis and /or bone spurs
Rotator cuff disease
Superior labral injury
Glenohumeral internal rotation deficit (GIRD)
Glenohumeral instability
Biceps tendinopathy
Scapular dyskinesis
Cervical radiculopathy
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External Impingement
• Compression Acromion & C/A Arch Supraspinatus
• Contacts supraspinatus
• Creates spurring & thickened sub-acromial bursa
• Creates impingement pain
• Partial thickness tears rotator cuff (bursal surface)
• May lead to full thickness tears
• May require injection or sub-acromial decompression +/- cuff tear
• Supraspinatus - compression
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Impingement
Internal or Glenoid Impingement
• Occurs mainly in overhead sportspeople during the late
cocking stage of throwing (Ext/Abd/ER) when
impingement of the undersurface of the RC (particularaly
the tendon of supraspinatus and infraspinatus) occurs
against the posterosuperior surface of the glenoid (between
the greater tubercle of the humerus and the posterosuperior
rim of the glenoid).
• This is normally a physiological occurence, but it may
become pathologic in the overhaed sporsperson due to
repetitive trauma/oveuse, and injury to the superior
labrum.
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Internal Impingement
• Contact Zones
• Abd / ER = contact posterosuperior
labrum & supraspinatus
• Flex / IR = contact anterosuperior labrum
& biceps
• Articular Surface Tears
• Combination compression & torsion
articular surface of the tendon
• More likely to progress
• Associated instability & SLAP lesions
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Impingement
• External impingement:
- primary - secondary
• Internal impingement
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