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Upper Quarter Cervical
Dysfunction Combined
Pathology
Jasmine Chan
Andy Chiu
Brandon Higa
Bryce Keyes
Minsu Kim
Derek Matsui
Adrian Ruiz
Traci Yamashita
www.powerhealths.com/2009/05/shoulder-pain/
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Shoulder Impingement1
• Primary
o
o
o
o
Subacromial crowding
Shape of the Acromion
Superior migration of humeral head
Tight posterior capsule
• Secondary
o
Relative decrease in subacromial
space due to instability of the
glenohumeral or scapulothoracic
joint
Stabilizers of the Shoulder2-4
2 types of shoulder stabilizers
• Static
o Glenohumeral ligaments
o Capsule
o Angle of the Glenoid cavity
• Dynamic
o Rotator cuff musculature
o Scapular stabilizers
o May be affected by cervical pathology
Patient presentation
•
•
•
•
pain, weakness and a loss of movement5
may occur at night if the patient lies on the
affected shoulder.
other symptoms include grinding or popping
during movement6
range of motion may be limited by pain.
o painful arc may be present during elevation
of the arm from 60° to 120°6
Standard Protocol for Shoulder
Impingement7
• Muscle strengthening
o
o
Rotator cuff training
Scapular stabilizers training
• Stretching
o
o
Rotator cuff
PROM
• Pain reduction
o
o
Ice/heat
Anti-inflammatory medication
Shoulder Assessment
• Signs that point to cervical spine
o Posture
 Forward head posture
 Head orientation
 Humeral head location
o AROM/PROM for glenohumeral
joint, and scapulothoracic joint
o Strength
 Myotomal
o Sensory
 Dermatomal
 Peripheral
o Reflex
 Asymmetrical UE reflex
 C4 – C8 diminished or
absent in involved side
Cervical Spine Contribution
• Abnormal movement
o
o
o
•
•
•
•
Facet Hypermobility
Facet Hypomobility
Muscle Imbalance
Whiplash
Cervical Disc Herniation
Cervical Spinal Stenosis
Posture/Resting Alignment
o
o
May alter mechanics of the C-spine
May increase stress on surrounding
Cervical Spine Contribution
• Whiplash8,9
o Secondary shoulder
impingement
associated with
whiplash injury
Cervical Spine Contribution
• Cervical Disc
Herniation4
o Disc degeneration
o Trauma
Cervical Spine Contribution
• Cervical Spine Stenosis4
o Bone spurs around
intervertebral and facet
joints
Cervical Spine &
Shoulder Assessment
• C-spine clearing tests
o VBI, Sharp-Pursar, Sidebend, Traction
• Postural Assessment
• PROM/AROM
• Accessory motion of the C-spine
o upglide, downglide, gapping
• Upper limb tension test
o Ulnar, Median, Radial
• Sensory
• Provocation/Alleviation
o Technique that allows us to identify a specific problematic
segment
o Increases the efficiency of treatment
o Provides the patient with a better prognosis
• Soft tissue accessory assessment
Postural Assessment: Slumped
Sitting4,8
• May effect overall mechanics of the
shoulder and neck
• Upper Crossed Syndrome
o tightness of the anterior musculature of
thorax
o Elongation of the posterior musculature
of thorax
o Weakness of the posterior musculature
of thorax and deep neck stabilizers
o Shortening of suboccipitals
• Ischemia and nerve damage
• Decreased innervation to the rotator cuff
• Indirectly related to posterior capsular
tightness
Postural Assessment: Slumped Sitting8
•
•
•
•
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Proprioceptive changes
Strength deficits
Length Deficits
Nerve Compression
Muscle Fatigue
All can contribute to possible signs of impingement
Scapulohumeral Rhythm
• 4 Joints7
o glenohumeral
o scapulothoracic
o sternoclavicular
o acromioclavicular
• 2 purposes7
o distribute motion between glenohumeral and
scapulothroacic joints
o maintain optimal length/tension relationship of
muscles
Glenohumeral/Scapulothoracic
Contribution
• Shoulder flexion 180°7
o Glenohumeral contribution 120°
o Scapulothoracic contribution 60°
o 2:1 ratio
Postural Intervention
• We look to restore integrity,
length, and strength
• Postural Taping
• Postural Re-education
• Lengthening of the anterior
muscles
• Strengthening of the posterior
muscles
• Strengthening/re-educating the
deep cervical stabilizers
• Strengthen core
Cervical Spine Intervention
• The cervical spine must be treated first.
o A muscle that is neurologically compromised cannot reach full
strength.
• Should focus on joint mobilization
o Upglide, downglide
 Depending on dysfunction
o Gapping
o Traction
• Soft tissue
o Contract/Relax of trapezius, scalenes
o Soft tissue mobilization
• Mobilizations of asymptomatic cervical spines have even been shown to
improve shoulder range of motion and pain.11
Interventions
• Strengthening/ control c-spine muscles
• Shoulder can then be addressed.
o Strengthening of rotator cuff muscles and scapular
stabilizers.
o Scapulo-humeral dissociation
o Inferior glide?
Tracking Down the Problem
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•
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Shoulder impingement
Weak shoulder stabilizers
Cervical radiculopathy
Posture, disc herniation, stenosis,
traumatic, etc.
References
1. Ferdig S. Shoulder Pathology Lecture. Spring 2009. Chapman University, Department of Physical Therapy.
2. Wilson C. Rotator cuff versus cervical spine: making the diagnosis. Nurse Pract. 2005;30(5):44-50.
3. Hess SA. Functional stability of the glenohumeral joint. Man Ther. 2000;5(2):63-71.
4. Magee DJ. Orthopedic Physical Assessment. W.B. Saunders Company; 2002.
5. Fongemie AE, Buss DD & Rolnick SJ. Management of shoulder impingement syndrome and rotator cuff tears. Am Fam
Physician. 1998;57:667–674.
6. Chen AL, Rokito AS & Zuckerman JD. The role of the acromioclavicular joint in impingement syndrome. Clin
Sports Med .
2003;22:343–357.
7. Kamkar A, Irrgang J, Whitney S. Nonoperative management of secondary shoulder impingement syndrome.
JOSPT.
1993;17(5):212-224
8. Chauhan SK, Peckham T, Turner R. Impingement syndrome associated with whiplash injury. J Bone Joint Surg Br. 2003;85B:408-410.
9. Abbassian A, Giddins, GE. Subacromial impingement in patients with whiplash injury to the cervical spine. J
Orthop Surg
Res. 2008;3:25.
10. Langford ML. Poor posture subjects a worker's body to muscle imbalance and nerve compression. Occup Health
Sci.
1994: 63(1); 38-41.
11. McClatchie L, Laprade J, Martin S, Jaglal SB, Richardson D, Agur A. Mobilizations of the asymptomatic cervical
spine can
reduce signs of shoulder dysfunction in adults. Man Ther. 2008;14(4): 369-374.