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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” A.Albasini Grad Dip Adv Man Ther 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. A.Albasini Grad Dip Adv Man Ther 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) A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther 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. A.Albasini Grad Dip Adv Man Ther SLAP: superior labrum anterior posterior What exactly causes of a SLAP lesions ?? - acute traumatic events ? - chronic repetitive injuries that lead to failure ? A.Albasini Grad Dip Adv Man Ther SLAP: superior labrum anterior posterior O’Brien Test sensitivity 100% Specificity 97-98% for Labral as ACJ abnormality A.Albasini Grad Dip Adv Man Ther SLAP lesion Type IV A.Albasini Grad Dip Adv Man Ther A.Albasini Grad Dip Adv Man Ther Glenoid Labrum • Inferior aspect inelastic, fibrous extension of glenoid articular cartilage: - firmly attached to glenoid - attachment for IGHLC, LH triceps - mobility indicates patholoy A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther The Inferior Glenohumeral Ligament Complex (IGHLC) Anterior A.Albasini Grad Dip Adv Man Ther Posterior The inferior Glenohumeral Ligament Complex (IGHLC) in IR A.Albasini Grad Dip Adv Man Ther The inferior Glenohumeral Ligament Complex (IGHLC) in ER A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther TheMiddle Glenohumeral Ligament (MGHL) A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther The Superior Glenohumeral Ligament (SGHL) A.Albasini Grad Dip Adv Man Ther A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther The Coracohumeral Ligament (CHL) A.Albasini Grad Dip Adv Man Ther Dependent arm and gravity at rest A.Albasini Grad Dip Adv Man Ther POSTURE A.Albasini Grad Dip Adv Man Ther 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) A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther Scapula Position and Control A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther 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) A.Albasini Grad Dip Adv Man Ther Posture and Alignment Palpate with the four fingers method and compare one side to the other A.Albasini Grad Dip Adv Man Ther Scapula Elevation/Depression Scapula Elevation A.Albasini Grad Dip Adv Man Ther Scapula Depression; Anterior Glide HOH A.Albasini Grad Dip Adv Man Ther A.Albasini Grad Dip Adv Man Ther Scapula Upward Rotation • • • Ludewig PM et al , JOSPT 1996 Lukasiewicz et al, JOSTP 1999 McClure PW et al, J Shoulder Elbow Surg 2001 A.Albasini Grad Dip Adv Man Ther A.Albasini Grad Dip Adv Man Ther A.Albasini Grad Dip Adv Man Ther 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) A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther 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. A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther 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) A.Albasini Grad Dip Adv Man Ther Scapula Downward Rotation A.Albasini Grad Dip Adv Man Ther 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) A.Albasini Grad Dip Adv Man Ther A.Albasini Grad Dip Adv Man Ther A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther Stretching Activ/Passiv pectoral minor A.Albasini Grad Dip Adv Man Ther 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. ) A.Albasini Grad Dip Adv Man Ther A.Albasini Grad Dip Adv Man Ther Scapula Anterior/Posterior Tilt Scapula Anterior Tilt A.Albasini Grad Dip Adv Man Ther Long Thx nerve paulsy Scapula Internal/External Rotation A.Albasini Grad Dip Adv Man Ther • 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. A.Albasini Grad Dip Adv Man Ther Scapula Medial/Lateral Slide, Adduction / Abduction A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther Scapula Depression; Anterior Glide HOH A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther 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. A.Albasini Grad Dip Adv Man Ther 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) • A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther 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. A.Albasini Grad Dip Adv Man Ther 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 A.Albasini Grad Dip Adv Man Ther Impingement • External impingement: - primary - secondary • Internal impingement A.Albasini Grad Dip Adv Man Ther