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Chapter 26 The Shoulder Girdle Copyright 2005 Lippincott Williams & Wilkins Anatomy and Kinesiology Composed of four distinct articulations. Each joint works interdependently and in concert. 1. 2. 3. 4. Sternoclavicular (SC) Acromioclavicular (AC) Scapulothoracic (ST) Glenohumeral (GH Copyright 2005 Lippincott Williams & Wilkins Sternoclavicular Joint Synovial joint that articulates with 1st rib and sternal notch. Movements Elevation (4–60°) Depression (5–15°) Protraction/retraction (15°) from resting position Rotation (30–50° posteriorly about horizontal axis) Copyright 2005 Lippincott Williams & Wilkins SC Articulation Copyright 2005 Lippincott Williams & Wilkins Acromioclavicular Joint Formed by articulation of acromion process of scapula with acriomial end of clavicle Joint Motions Upward/downward rotation Medial (winging)/ lateral rotation) Anterior/posterior tilting (tipping) Copyright 2005 Lippincott Williams & Wilkins Axes of Motion – AC Joint Copyright 2005 Lippincott Williams & Wilkins Scapulothoracic Joint Functional, not “true” joint. Articulates with convex rib cage. Motions of Scapula Elevation/depression Abduction/adduction Medial/lateral rotation Upward/downward rotation Copyright 2005 Lippincott Williams & Wilkins Glenohumeral Joint Synovial joint Head of humerus articulates with glenoid fossa of scapula Copyright 2005 Lippincott Williams & Wilkins AC/GH Ligaments Copyright 2005 Lippincott Williams & Wilkins Scapulohumeral Rhythm Initially believed to be 2:1. More recent proposal of three distinct patterns (each with different ratio). Middle phase (80–140 degrees abduction) – Scapular rotation provides greater contribution to arm elevation than GH motion. Copyright 2005 Lippincott Williams & Wilkins Myology Scapulohumeral Group Supraspinatus Infraspinatus Teres minor Subscapularis Deltoid (anterior fibers) Deltoid (middle fibers) Deltoid (posterior fibers) Teres major Coracobrachialis Function Humeral abduction Lateral rotation (LR) LR Medial rotation (MR) Flexion and MR Abduction Extension and LR MR Flexion and MR Copyright 2005 Lippincott Williams & Wilkins Myology (cont.) Axioscapular Group Upper trapezius Middle trapezius Lower trapezius Serratus anterior Rhomboid major/minor Levator scapula Pectoralis minor anterior Scapular Function Elevation Elevation/adduction Depression/adduction Abduction Elevation/adduction Elevation Depression and tilting Copyright 2005 Lippincott Williams & Wilkins Myology (cont.) Axiohumeral Group Function Pectoralis major MR extension and adduction, clavicular fibers flex to 90 degrees. Latissimus dorsi MR and extension Copyright 2005 Lippincott Williams & Wilkins Rotator Cuff – Deltoid Force Couple Deltoid functions to elevate the arm and produces superior translation of humeral head. Inferior and medial forces of rotator cuff (RC) offset superior translation of deltoid (specifically the INF, TM, subscap). RC also assists in limiting anterior/posterior translation of humeral head. Copyright 2005 Lippincott Williams & Wilkins Scapular Force Couple Rotation of scapula is provided by trapezius force couple (upper, mid, lower) and and serratus anterior. PICR migrates from root of scapula toward AC joint. Copyright 2005 Lippincott Williams & Wilkins EMG and Scapular Force Couple Copyright 2005 Lippincott Williams & Wilkins Integrated RC – Deltoid and Scapular Force Couples Scapular rotation during arm elevation adds to total ROM. Lack of scapular rotation = impingement. Scapular rotation is necessary to keep acromion moving away from deltoid insertion. Lack of scapular rotation – Head of humerus translates superiorly. Failure of scapular adduction – Head of humerus translates anteriorly. Copyright 2005 Lippincott Williams & Wilkins Lack of Scapular Rotation During Arm Elevation Copyright 2005 Lippincott Williams & Wilkins Examination and Evaluation “Includes, but not limited to…..” Patient/client history Clearing examinations Motor function (motor control and learning) Muscle performance Pain Peripheral nerve injury Posture ROM, muscle length, joint mobility/integrity Work, community, and leisure integration or reintegration (including ADLs) Copyright 2005 Lippincott Williams & Wilkins Patient Client/History General patient data + functional limitation related to shoulder dysfunction. Clearing Exams Routine cervicothoracic spine screening. Though rare, elbow-wrist-hand – as a “source.” Visceral referral of symptoms. Copyright 2005 Lippincott Williams & Wilkins Motor Function (Motor Control and Learning) Visual observation, palpation of PICR of ST and GH joints. Observation can be augmented by SEMG. SEMG assesses timing, magnitude, and patterns of recruitment. SEMG can be useful in determining faulty motor control patterns. Copyright 2005 Lippincott Williams & Wilkins Muscle Performance Specific MMTs Can be done in conjunction with SEMG or dynamometer Positional strength testing Selective tension tests Copyright 2005 Lippincott Williams & Wilkins Pain Choose tests that will determine pathomechanical cause of pain Palpation of selected tissues to evaluate tissue tension, temperature, swelling, and provocation of pain Subjective report of pain (VAS, etc.) Peripheral Nerve Integrity Thoracic outlet and neural tissue provocation testing Patterns of weakness indicate peripheral nerve, nerve root involvement, or forms of myopathy Copyright 2005 Lippincott Williams & Wilkins Posture Total body alignment (related to symmetry in limb length) Head, thoracic, and lumbar spine alignment. Pelvic position (all three planes) Analysis of alignment of scapula, clavicle, and humerus (all three planes) Do not underestimate the role of the lower quadrant on function of the shoulder girdle Copyright 2005 Lippincott Williams & Wilkins ROM, Muscle Length, Joint Mobility/Integrity – Tests A/PROM ST, GH, CSP, TSP Passive arthrokinematic mobility of SC, AC, GH, ST, and cervicothoracic joints Capsuloligamentous integrity Glenoid labrum integrity tests Rotator cuff integrity Copyright 2005 Lippincott Williams & Wilkins ROM, Muscle Length, Joint Mobility/Integrity – Tests (cont.) Subacromial impingement tests Muscle length testing for SH, axioscapular, and axiohumeral muscle groups Functional movements including reaching behind the back, touching back of the head and neck, and reaching across to the opposite shoulder Copyright 2005 Lippincott Williams & Wilkins Work, Community, and Leisure Integration or Reintegration (including ADLs) Functional testing in the form of performance testing or subjective grading For example, shoulder pain and disability index (SPADI) Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Intervention for Common Physiologic Impairments – Pain Differential diagnosis of pain in the shoulder girdle is difficult due to interdependence of anatomy of shoulder, elbow, wrist, hand, and cervicothoracic spine. Treatment can be directed toward the source of the pain (i.e., rotator cuff tendinopathy) Treatment must be directed toward the cause of the pain (i.e., scapula downward syndrome) Copyright 2005 Lippincott Williams & Wilkins ROM and Joint Mobility Impairments Hypomobility Often coexists with hypermobility Treatment Manual stretching with concurrent strengthening of weakened antagonist. For example, stretch rhomboids while strengthening scapular upward rotators. Copyright 2005 Lippincott Williams & Wilkins Stretching of Rhomboids/Upward Rotator Strengthening FIGURE 26-11. Transitional rotator cuff exercises. (A) The patient places the ulnar aspects of the hands on the wall and slides the hands up the wall in the sagittal or scapular plane, depending on whether the focus is on the serratus anterior or lower trapezius, respectively. Copyright 2005 Lippincott Williams & Wilkins Hypermobility To treat effectively – Hypomobile segment(s) must be identified. Improve muscle performance, length-tension relationships, motor control of dynamic stabilizers For example, anterior GH hypermobility due to inefficient properties of medial rotators (subscapularis) Goal – Train subscapularis to limit anterior GH movement Include functional activities Copyright 2005 Lippincott Williams & Wilkins Subscapularis Isometric Exercise Strengthen in Shortened Range Copyright 2005 Lippincott Williams & Wilkins Impaired Muscle Performance Neurologic pathology Muscle strain Disuse, deconditioning, and reduced conditioning Copyright 2005 Lippincott Williams & Wilkins Neurologic Pathology Supraspinatus, axillary, long thoracic, spinal accessory, and brachial plexus nerves are vulnerable to injury. Resolve pathomechanics relating to injury (postures and body mechanics). Early stages – NMES and level I exercises can be used to prevent atrophy. PROM and joint mobility exercises to prevent loss of mobility. Progress exercise positions from gravity-assisted to gravity-lessened to against gravity. Copyright 2005 Lippincott Williams & Wilkins Muscle Strain Can result from sudden and excessive tension or from gradual and continuous tension imposed on muscle. Initially – Isometric contractions in pain-free shortened range Concentric-eccentric dynamic exercise can be slowly introduced Low-load muscle contractions in regeneration phase Final phase of healing should include activity-specific exercises Copyright 2005 Lippincott Williams & Wilkins Disuse, Deconditioning, and Reduced Conditioning Combined program aimed at restoring muscle force, endurance, and coordination. Conditioning program should include exercises for all major muscle groups. Posture and movement technique should be closely monitored. Training depends on performance level (e.g., high-level athletes, strenuous workers). Copyright 2005 Lippincott Williams & Wilkins Shoulder Girdle Conditioning Program Bench press (flat, incline, decline) Prone middle and lower trapezius Latissimus pulldown Lateral deltoid raise – Frontal or scapular plane (through full ROM) or military press Front deltoid raise (through full ROM) Biceps curl Triceps extension Copyright 2005 Lippincott Williams & Wilkins Posture and Movement Impairment Posture Treatment Education of habitual postures (cervical, thoracic, lumbar, and pelvic) standing, sitting, and sleeping. Ergonomic/workstation education and modification. Support via bracing, taping, etc. to reduce strain on lengthened muscles. Movement Restore optimal PICR during active motion. Use of SEMG and cinematography can be helpful Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Interventions for Common Diagnoses Rotator cuff disorders include medical diagnsoses such as: Impingement syndrome Rotator cuff/glenoid labral tears Posterior shoulder pain GH hypermobility/instability Copyright 2005 Lippincott Williams & Wilkins Stages of Pathology Stage I – Edema and hemorrage Stage II – Fibrosis and tendonitis Stage III – Tendon degeneration and rupture May involve: Supraspinatus Biceps tendon Subacromial bursa AC joint Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Intervention of Rotator Cuff Disorders Secondary disorders should consider impairments related to hypermobility and instability related to impingement. Serratus anterior and trapezius (all portions) strengthening is essential while monitoring GH movement! Attention to “level” (difficulty) of intervention is important for dosage and success. Copyright 2005 Lippincott Williams & Wilkins Treatment for Primary Rotator Cuff Disorders Early stages – Medications, rest, resting position, ice Physical agents (IFC, etc.) for pain and inflammation ROM, muscle length, joint mobility exercises, and joint mobilization Muscle performance exercises Posture and movement training Surgery – If conservative treatment fails Prevention – Educate early recognition Copyright 2005 Lippincott Williams & Wilkins Specific Therapeutic Exercise Intervention for Rotator Cuff Disorder Pain and inflammation – Provide exercise for impairments contributing to cause of symptoms. Muscle length – Passive manual stretch of rhomboids. Self-stretch to GH lateral rotators. Muscle performance – Strengthen middle/lower trapezius, serratus anterior in short range. Strengthen rotator cuff. Posture and movement – Ergonomic modifications. SEMG training for temporal relationships in scapular rotators. Functional training. Copyright 2005 Lippincott Williams & Wilkins Scapular Upward Rotator Exercises Upper Trapezius Shoulder shrug from armelevated postion Middle Trapezius Prone arm lift with arm overhead Prone horizontal extension with lateral rotation Lower Trapezius Prone arm lift with arm overhead Prone lateral rotation at 90° abduction Prone horizontal extension with lateral rotation Copyright 2005 Lippincott Williams & Wilkins Middle and Lower Trapezius Strengthening – Levels I/II/III Copyright 2005 Lippincott Williams & Wilkins Serratus Anterior Progressions – Levels I/II/III Copyright 2005 Lippincott Williams & Wilkins Hypermobility/Instability of GH Joint GH stability involves articular geometry, the static capsuloligamentous complex, dynamic muscular stabilizers, and NM control. Most common abnormal GH Motions Excessive anterior translation during lateral rotation and abduction Excessive anterior translation during medial rotation Copyright 2005 Lippincott Williams & Wilkins Continuum of Shoulder Stability Copyright 2005 Lippincott Williams & Wilkins Contribution of Shoulder Musculature to Joint Stability Passive muscle tension from bulk effect of rotator cuff. Rotator cuff contraction – Compression of articular surfaces. Joint motion that secondarily tightens passive ligamentous restraints. Barrier or restrain effect of contracted rotator cuff muscle. Redirection of joint force to center of glenoid surface by coordination of forces from GH and ST joints. Copyright 2005 Lippincott Williams & Wilkins Scapulothoracic Muscle Balance Efficient forces depend on stability of origins on scapula. Scapular position affects length-tension properties of rotator cuff. Scapular upward rotation, posterior tilt, lateral rotation – necessary to maximize subacromial space. Copyright 2005 Lippincott Williams & Wilkins Treatment for GH Instability/Hypermobility Specific joint mobilization (posterior capsule). Immobilization (max. 3 weeks) IF subluxation is diagnosed. AROM against gravity as patient regains strength and motor control. Main target muscle tends to be subscapularis as well as gradually resisted exercises for pectoralis major, latissimus, teres major. Infraspinatous and teres minor are also often targeted. Must have stable scapula for rotator cuff function to be effective! Copyright 2005 Lippincott Williams & Wilkins Treatment Principles for Postoperative Rotator Cuff Disorders – Four Phases Educate patient – Tendinous repair may take 12 months. Protective (1–6 wks) – Sling protection/pendulum exercise, selfassisted ROM. Early intermediate (6wks–3 mos) – Additional self assisted ROM, PROM. Late intermediate (3–5 mos) – Isometrics and progress to dynamics if possible. Swimming at 5 mos. Advanced rehabilitation (5 mos–1 year) – Submaximal activityspecific training. Progress to maximal training by end of year one. Copyright 2005 Lippincott Williams & Wilkins Adhesive Capsulitis Characterized by a gradual loss of active and passive ROM. Primary adhesive capsulitis Secondary adhesive capsulitis 1. 2. 3. 4. 4 Stages Stage 1 – Acute (0–3 months) Stage 2 – Freezing stage (3–9 months) Stage 3 – Frozen stage (15–24 months) Stage 4 – Thawing stage Copyright 2005 Lippincott Williams & Wilkins Treatment of Adhesive Capsulitis Type and intensity of exercise depends on patient’s specific strength, ROM, joint mobility, motor control, and level of irritability. Stage 1 NSAIDs, steroid, and local analgesics can be helpful. Postural training to discourage FHP and kyphosis. Therapeutic modalities to control pain, inflammation, and promote relaxation. Copyright 2005 Lippincott Williams & Wilkins Treatment of Adhesive Capsulitis Stage 1 (cont.) Grade I and II joint mobilizations and movements within pain-free range. Closed chain exercises to promote GH stabilization. Scapular exercises in pain-free positions. Taping can be used to augment stability. Copyright 2005 Lippincott Williams & Wilkins Treatment of Adhesive Capsulitis Stage 2 Continue to decrease pain and inflammation. Passive stretching of posterior capsule (in pain-free range). Active exercises against gravity MAY be introduced. Careful isolated strengthening of rotator cuff, serratus anterior, middle and lower trapezius. Taping of ST joint for stabilization. Copyright 2005 Lippincott Williams & Wilkins Treatment of Adhesive Capsulitis Stages 3 and 4 Improve GH mobility. Restore SH rhythm. Aggressive stretching and joint mobilization. Heat may be used for relaxation of tissues. Strengthening of rotator cuff and SH muscles. Copyright 2005 Lippincott Williams & Wilkins Adjunctive Interventions: Taping Scapular taping can improve the resting alignment of the scapula on the thorax Goals and Benefits of Taping Improve initial alignment. Alter length-tension properties. Provide support and reduce stress to myofascial tissues. Provides kinesthetic awareness of scapular position during rest and movement. Guide PICR during movement. Copyright 2005 Lippincott Williams & Wilkins Scapular Correction Possibilities with Tape Correction of scapular depression and improving scapular elevation. Correction of scapular downward rotation and improving scapular upward rotation. Correction of scapular abduction and improving scapular adduction. Correction of scapular winging. Correction of scapular anterior tilt. Correction of scapular elevation. Copyright 2005 Lippincott Williams & Wilkins Taping Scapula into Upward Rotation C Copyright 2005 Lippincott Williams & Wilkins Taping Scapula into Elevation Copyright 2005 Lippincott Williams & Wilkins Summary Management of the shoulder complex requires an understanding of the anatomy and kinesiology of the four articulations that make up the complex. Precise PICRs at each articulation and integration of each with respect to joint function, force couples, precise motor control are required for optimal function of the shoulder complex. Function of shoulder girdle affects and is affected by other regions of upper and lower quadrant. Copyright 2005 Lippincott Williams & Wilkins Summary (cont.) Treatment of impairments should be complemented by functional retraining modified to the level of ability at a given time in the rehab process. Ideal total body posture is a prerequisite for optimal movement in shoulder girdle complex. Understanding the integrated approach to therapeutic exercise in the shoulder girdle is key to successful outcomes of shoulder girdle conditions. Copyright 2005 Lippincott Williams & Wilkins Summary (cont.) Rotator cuff disorders include impingement syndrome, rotator cuff/glenoid labral tears, posterior shoulder pain, GH hypermobility, and instability. Treatment of adhesive capsulitis is individually based on the stage of disease. Early intervention is key to successful outcomes of adhesive capsulitis. Scapular taping can improve resting posture and thereby affect movement of the shoulder girdle complex. Copyright 2005 Lippincott Williams & Wilkins