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Differentiating Anterior Shoulder Pain In The Overhead Athlete Angela T. Gordon PT, DSc, MPT, COMT, OCS, ATC Stacy Soapmann PT, DSc, FAAOMPT Objectives Identify the possible causes of anterior shoulder pain: Scapular dyskinesis Posture Spinal facilitation Define regional interdependence as it relates to the overhead athlete Cervical Thoracic Muscular trigger points Scapula Lower kinetic chain dysfunction AC joint Case studies from major league players SC joint Evaluation of the kinetic chain in overhead athletes Scapula Dynamic Scapula Dynamic Scapula: Kinematics 3 rotations, 2 translations Translations superior and inferior protraction and retraction Rotations upward and downward rotation internal and external rotation anterior and posterior tipping Dynamic Scapula Stability dependent on 3 major factors •Muscular and Neural Control Systems •Muscular Activation System •Boney and Ligamentous Restraints Scapular Dyskinesis Kibler defines scapular dyskinesis as: A loss in scapular retraction and ER with altered timing and magnitude of upward scapular rotation. This leads to an anterior tilt of the glenoid and subsequent reduction in RTC force. SICK Scapular Scapular Malposition Inferior medial border prominence Coracoid pain and malposition Dyskinesis of scapular movement Scapular Dyskinesis Clinical Features Overuse muscular fatigue syndrome Pectoralis tightness, LT/SA force couple weakness Inferior and or medial border prominence Anterior tilting of the scapula Decrease in shoulder internal rotation Kibler Classification of Scapular Dysfunction Inferior angle dysfunction Medial border dysfunction Superior scapular dysfunction How do we classify this scapular dysfunction What Causes Scapular Dyskinesis Spine All muscles innervated by cervical nerve roots Thoracic mobility Underlying GH pathology Muscle imbalance Posture Overuse of sport demands Previous injury Instability Loss of proprioception Trivia: How many muscles attach to the Scapula Glenoid Labrum Functions: Deepen the GH socket to aide in shoulder stability? Or Sensitive proprioception organ for the shoulder girdle providing feedback for movement in all 3 degrees of freedom Described in a clock like fashion Bankart Lesion – 3/6 position SLAP: superior Posterior Reverse Bankart 6/9 Glenoid Labrum Signs and symptoms of a glenoid labrum: Pain accompanying overhead arm motion Instability with or without clicking Decreased range of motion Loss of strength Pain Anteriorly or posterior Internal Impingement signs Posture Janda’s Upper Crossed Syndrome Case Study One Olympic potential Swimmer Diagnosis Biceps tendonitis Evaluation Findings: Forward head posture Weak scapular force couples: SA LT Scapular dyskinesis Protracted Ant Tilted scapula Weak Core Hypermobile in all planes Treatment Scapular stabilization Proprioceptive training Neuro reeducation in the unstable overhead position What about the Biceps? Muscular Trigger points What is a Trigger point? Symptoms: local tenderness referred pain local twitch response Shoulder: Infraspinatus: muscular overload, eccentric forces during follow through TrP Shoulder Region Other muscles that refer to the anterior shoulder Deltoid Pectoralis major/minor Scalenes Case Study Two MLB pitcher complains of pain duration 5 months Improves with rest Aggravated by pitching Points to local spot in anterior shoulder All labral tests negative No signs of impingement Strength: scapular retraction test positive, infraspinatus 4+/5, Serratus 4+/5, Lower trap 4+/5 TrP: infraspinatus, deltoid, Teres Major/Minor Treatment: TDN to infraspinatus and Deltoid 90% resolution of pain in 1 session Return to painfree Pitching 1 week later. Squirrel Regional Interdependence Cervical facilitation C2/3 Hypomobility Biceps Tendonitis Thoracic/Rib dysfunctions Cervical Facilitation Elevation/Protraction Latissimus Dorsi (C5/)6 Elevation/Retraction Serratus Anterior (C5/6, C6/7) Depression/Protraction Levator Scapulae (C2/3, C3/4, C4/5) Rhomboid Depression/Retraction Pectoralis Minor (C6/7, C7/T1) Serratus Upper Fibers C2-3 Hypomobility Clinically a very common injury we see is a posttraumatic arthritis of the C2-3 region. Following a MVA if the R C2-3 gets “stuck” or becomes hypomobile and the L side becomes hypermobile this can causing increased tone in the L levator scaplae What does this do to the scapula positioning? Biceps Tendonitis Innervated by C6 When you look at the anatomy the C6 nerve root exits between the C5-6 segment The C5-6 segment has the smallest foramen hole and the C5-6 nerve root is the largest If stenosis or osteophytes occur then it can affect the innervation of the bicep Thoracic/Rib dysfunctions No agreed upon consensus about the combined movements of the thoracic spine Some authors state that if you elevate your R arm you will get extension and ipsilateral rotation/SB of the R side of the thoracic spine What would hypomobility of the thoracic spine do to the mechanics/timing of the shoulder girdle movement? Case Study Three MLB Pitcher Biceps Pain ongoing Evaluation: Scapular Dyskinesis Tender Biceps tendon – resisted MMT improves with repetition Treatment: UT/LS hypertonicity 3 sessions Csp/Tsp scan: Right Csp manipulation C2/3 hypomobility Tsp manipulation T1-3 rotation limited TFM to Biceps C5/6 hypermobile Scapular/Cervical stabilization program The Thrower's Paradox: The thrower's shoulder must be lax enough to allow maximal external rotation but stable enough to prevent symptomatic humeral head subluxations, thus requiring a delicate balance between mobility and stability functionally. The Kinetic Chain of Throwers It is important to understand that while these athletes are throwing with their arms, they gain a large amount of momentum and force through the use of their legs and torso. Kinetic Chain Dysfunction Lower Extremity Hip IR/ER ROM Weakness Core: TA must be first muscle activated prior to UE movement Scapula: Funnels the energy from LE to UE Evaluation of Kinetic Chain No Gold standard Difficult to evaluate Time constraints Evidence limited Evaluation of Kinetic Chain What we do know: All the links in the chain are important Timing is everything Scapula is the key component Core – is the proximal STABILITY to allow for all extremity MOBILITY Evaluation of Kinetic Chain Upper Extremity: Scapular: Kibler scapular retraction test Kibler lateral scapular slide test Flip sign Strength: prone LT seated SA Length tests Shoulder ROM: IR/ER supine at 90 degrees abduction – 2 person measurement Posture Lower Extremity: SFMA – general screen used to identify areas of dysfunction Hip ROM prone with knee at 90 degrees IR/ER – 2 person measurement Strength: Hip Abd, ER, Extension Core Strength: DKLT or abdominal brace test What can lead to Anterior Shoulder Pain in the Overhead Athlete? Scapular dyskinesis Postural adaptations Regional interdependence from spinal segments Biceps Tendonitis Muscular Trigger points Kinetic Chain Breakdown Glenoid Labrum Differential Diagnosis of the Overhead Athlete Labrum vs TrP Weakness Use of TDN to reproduce pain Treatment at same time Stability Tests O’Brien Sulcus Relocation Clunk Regional Interdependence vs Biceps tendonitis Any history of cervical dysfunction Referred pain vs local pain Histological changes from changes in axonal transport Differential Diagnosis of the Overhead Athlete Use of dry needling for differential diagnosis? What leads to TrP in the shoulder girdle? Proper use of special tests clusters for better specificity? Evaluating the kinetic chain? Identify breakdown point Throwing all arm? Previous history of injury anywhere in kinetic chain Principles of Integrated Functional Kinetic Chain Rehab Establish proper postural alignment Achieve motion in all involved segments Total arc of motion Facilitate scapular motion Achieve proper scapular stabilization Endurance strength vs power strength Utilize closed kinetic chain exercises Integrate core into upper extremity dynamic exercises Work in multiple planes References Seroyer SH, Nho SJ et al. The Kinetic Chain in Overhead Pitching: Its Potential Role for Performance Enhancement and Injury Prevention. Ath Train. 2010;2(2): 135-146. Sciascia A, Cromwell R. Kinetic Chain Rehabilitation: A Theoretical Framework. Rehab Research and Practice. 2012;1-9. Burkhart SS et al. The Disabled Throwing Shoulder: Spectrum of Pathology Part III: The Sick Scapula, Scapular Dyskinesis, The Kinetic Chain, And Rehabilitation. J of Arthroscopy and related Surgery. 2003; 19(6): 641-661. Reinhold MM et al. Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature. J Ortho Sports Phys Ther. 2009; 39(2):105-117. Davis, JT, Fluhme, D et al. The Effect of Pitching Biomechanics on the Upper Extremity in Youth and Adolescent Baseball Pitchers. Am J Sports Med. 2009:37;1484-1491. Kibler BW, Ludewig PM, et al. Clinical Implications of Scapular Dyskinesis in Shoulder Injury: the 2013 consensus statement from the scapular summit.Br J Sports Med. 2013;47:877-885. Hayes K, Callanan M et al. Shoulder Instability: Management and Rehabilitation. J Ortho & Sports Phy Ther. 2002;32(10):497-509. References De Mey K, Danneels L, Cagnie B, Cools, AM. Scapular Muscle Rehabilitation Exercises in Overhead Athletes With Impingement Symptoms: Effect of a 6 week Training Program on Muscle Recruitment and Functional Outcome. Am J Sports Med. 2012;40:1906-1915. Fleisig G. Biomechanics of Baseball Pitching: Implications for Injury and Performance. Inter Sumposium of Bio in Sports. 2010:46-50. Myers JB, Laudner KG, Pasquale MR et al. Scapular Position and Orientation in Throwing Athletes. Am J Sports Med. 2005;33(2):263-271. Cools AM, Dewitte V, Lanszweert F et al. Rehabilitation of Scapular Muscle Balance: Which Exercises to Prescribe? Am Ortho Society for Sports Med. 2007;35(10): 17441751. Reinhold MM et al. Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature. J Ortho Sports Phys Ther. 2009; 39(2):105-117. Voight ML et al. The Role of The Scapula in the Rehabilitation of Shoulder Injuries. J of Athletic Training. 2000;35(3):364-372 Hodges PW, Richardson CA. Contraction of the abdominal muscles associated with movement of the lower limb. Phys Ther. 1997;77(2):132-141.
