Shoulder Impingement Mechanisms PDF

Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, 9/28/2024 1 M.Sc, PhD, PCT Biomechanics 2 Dr. Ibrahim Tobba Mohamed, PT, B.Sc., M.Sc., PhD, PCT. Lecturer of orthopedic P.T - MSA Le...

Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, 9/28/2024 1 M.Sc, PhD, PCT Biomechanics 2 Dr. Ibrahim Tobba Mohamed, PT, B.Sc., M.Sc., PhD, PCT. Lecturer of orthopedic P.T - MSA Lecturer of musculoskeletal & general biomechanics - MSA Professional Certified Trainer from AUC Graduate of the presidential leadership program  Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, 9/28/2024 3 PhD, PCT move to achieve full shoulder elevation? body parts need to What motions &  Safe learning environment 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 4  Code of conduct Don’t disturb others (Side talk) Ask questions with permissions U r free to eat & drink as long as u don’t break the 1st rule (no crunchy sounds) Phones r a big NO Respect others 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 5  What motions & parts need to move to achieve full shoulder elevation? Unjustly simplified info !!! 1. All of the range Sh. Jt. Abd. + scapular upward rotation 2. First 30 degree mainly sh. Jt 3. Most agreed upon rhythm is 2:1 sh. jt to sh. Girdle 4. Sh. Jt = 120 degree & Sh. Girdle = 60 degree 5. It’s not only Abd. & upward rotation 6. There’s a 3rd motion 7. Put your Arm in full int. Rot & try to ABD. Your Sh. fully 8. Sh. Jt. Ext. rot. From 90 degree – infraspinatus & teres minor. Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, 9/28/2024 M.Sc, PhD, PCT 6 Full motions to achieve maximum humeral elevation Shoulder jt. Abducts Ext. rot. At 90 degree Upwardly rotates 45 to 55 degrees Shoulder girdle Posterior tilts 20 to 40 degrees Externally rotates 15 to 35 degrees Extend Thoracic spine Side bend Rotate Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, 9/28/2024 7 M.Sc, PhD, PCT  Charles Neer, 1972 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 8 Subacromial (Coraco-acromial) space & its content 1. Supraspinatus tendon 2. Tendon of the long head of the Biceps Muscle 3. Subacromial Bursa 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9 Shoulder impingement syndrome is a painful condition of the upper extremity resulting from a structural narrowing of the subacromial space & compression of subacromial space content 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 10 Charles Neer, 1972 Impingement on the tendinous portion of the rotator cuff by the coraco-acromial ligament and the anterior third of the acromion is responsible for a characteristic syndrome of disability of the shoulder. The treatment of the impingement is to remove the anterior edge and undersurface of the anterior part of the acromion with the attached coraco-acromial ligament. Most patients improved Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, 9/28/2024 PhD, PCT 11  3 forms of acromion. 9/28/2024 Hooked is the devil Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 12  Hooked acromion is the devil 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 13  WHY? Not all patients improve!!! Is acromial shape (hooked) new!!! 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 14  Logic (philosophy) Science Experimentation (Evidence) 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 15 Can Hooked acromion exist in asymptomatic 4%have it. individuals? 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 16 Does acromion shape change with age? No 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 17  Conclusion Hooked acromion is not the cause Why did pts recover after acromioplasty!!! If hooked acromion is not the cause, then what causes it!!!!!!!!!!!!! 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 18  Biomechanics gave the answer 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 19  The humerus goes up not the acromion that comes down 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 20  1ST NORMAL MECHANICS OF SH. IMPINGEMENT Rotator cuff muscles 1. Supraspinatus. 2. Infraspinatus. 3. Teres minor. 4. Subscapularis. 9/28/2024 21 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT  FUNCTION OF THE ROTATOR CUFF 1. Joint compression. 2. Neutralizing the mover muscles gliding/shearing force. Stabilization (Inman and Abbott, 1944) Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 22  FORCE RESOLUTION OF THE DELTOID Contraction of the deltoid during abduction causes superior shift of the humeral head Into the subacromion space Do we feel pain every time we abduct our shoulders Does the body allow it ? Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 23  FORCE RESOLUTION OF THE INFRASPINATUS, TERES MINOR AND SUBSCAPULARIS Produces downward shear/glide Courtesy Intellectual of joint property structure of Dr. Ibrahim& Tobba function Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 24  GLIDING CANCELATION ACTION (CENTRALIZATION) Infraspinatus, teres minor and subscapularis Deltoid Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 25  SH. ABD. MECHANISM 9/28/2024 26 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT  1ST PATHOMECHANICS OF SH. IMPINGEMENT Weakness of the (depressor) rotator cuff muscles infraspinatus, teres minor and subscapularis Abnormal unneutralized superior glide of the deltoid. Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 27  TREATMENT OF THE 1ST PATHOMECHANICS IS Strengthening of the glenohumeral depressor rotator cuff muscles. Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 28  Logical Framework for musculoskeletal (MSK) clinical practice Normal mechanics Pathomechanics Clinical intervention to restore normal Clinical mechanics Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 29  2ND NORMAL MECHANICS OF SH. IMPINGEMENT Mechanism of Ms contraction Ms contraction approximates both attachments to the center For a effective motion to result, one of the two attachment need to be fixed & the second is allowed to move. E.g: biceps brachii If fixation of an attachment is impaired, functional effectiveness will be reduced Same goes for the rotator cuff Fixed base of action is required for an effective humeral head depression by the rotator cuff MS. (Muscolino, 2011) Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 30  2ND PATHOMECHANICS OF SH. IMPINGEMENT Weakness of the scapular stabilizer & change of scapular static & dynamic position will lead to loss of force production ability of the rotator cuff Scapular dyskinesis Def - is an alteration in the normal position or motion of the scapula during coupled scapulohumeral movements Can result from muscle imbalance Weakness or shortening Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 31  TREATMENT OF THE 2ND PATHOMECHANICS IS Strengthening of the scapular stabilizer muscles. Stretch short scapular muscles Restoration of scapular muscle balance Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 32  3RD NORMAL MECHANICS OF SH. IMPINGEMENT Glenohumeral capsule Is redundant with inferior folds in adduction Straightening of the folds happens during abduction, allowing minimal resistance to motion (downward glide). 9/28/2024 33  3RD PATHOMECHANICS OF SH. IMPINGEMENT Tightness of inferior & posterior Sh. Capsule Will cause superior or superioanterior translation of the humeral head leading to impingement. Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 34  GIRD – GLENOHUMERAL INTERNAL ROTATION DEFICIT Posteroinferior capsular tightness is known – common in over head athletes. 9/28/2024 35 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT  TREATMENT OF THE 3RD PATHOMECHANICS Returning normal capsular elasticity & motion through mobilization & capsular stretching Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 36  4TH NORMAL MECHANICS OF SH. IMPINGEMENT Thoracic spine extension, side bending & rotation is associated with shoulder motion & relevant for normal full ROM Thoracic extension is a component motion that is needed for full overhead reaching. 9/28/2024 37  4TH PATHOMECHANICS OF SH. IMPINGEMENT Thoracic hypomobility will effect scapular mobility (kinematics) causing scapular dyskinesia Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 38  TREATMENT OF THE 4TH PATHOMECHANICS Returning normal spinal mobility, utilizing mob, manip, fascial & muscular techniques. Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 39 5THNORMAL MECHANICS OF SH. IMPINGEMENT Good alignment & posture is necessary for normal scapulothoracic & full upper limb motion 9/28/2024 40 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT  5TH PATHOMECHANICS OF SH. IMPINGEMENT Postural deviation is associated with alternation of shoulder mechanics Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 41  TREATMENT OF THE 5TH PATHOMECHANICS Correcting postural deviations & emphasizing patient self postural orientation Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 42  BASIC SIS PATHOMECHANICS 1. Weakness of the glenohumeral depressor rotator cuff muscles. 2. Weakness of the scapular stabilizer muscles (scapular dyskinesis). 3. Tight inferior or posterior capsule (GIRD). 4. Hypomobility of the thoracic spine 5. Postural deviations Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 43  Logic & experimentation Are the two components of science 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 44 Components of science LOGIC EXPERIMENTATION (EVIDENCE) Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 45  Biomechanics is the logic Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 46 P.T from zero to hero Started as more as a believe than science Biomechanics became the science of orthopedic P.T – creating a logical framework of P.T Clinical research – measuring outcomes: Combined with Biomechanics transformed P.T from a believe to a science. 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 47 Cause effect relationship Rain - Umbrella Possibility of multiple causes 1. Raining 2. Sun 3. Selling 4. For later The cause always exist Causal / causative treatment Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, 9/28/2024 48 M.Sc, PhD, PCT  Surgery or PT for SIS 9/28/2024 Intellectual property of Dr. Ibrahim tobba ibrahim, PT, B.Sc, M.Sc, PhD, PCT 49 2020 Conclusion: There were no clinically important or statistically significant differences in outcomes between conservative versus sur-gical interventions among patients with subacromial impingement syndrome 9/28/2024 Intellectual property of Dr. Ibrahim tobba ibrahim, PT, B.Sc, M.Sc, PhD, PCT 50  Arthrokinematics’ value The roll-and-slide arthrokinematics are essential to the completion of full-range abduction. The longitudinal diameter of the articular surface of the humeral head is almost twice the size of the longitudinal diameter on the glenoid fossa. The arthrokinematics of abduction demonstrate how a simultaneous roll and off setting slide allow a larger convex surface to roll over a much smaller concave surface without running out of articular surface. Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, 9/28/2024 51 M.Sc, PhD, PCT  Pathomechanics of roll & slide If roll-and-slide arthrokinematics does not occur. for example, excessive thickening or stiffness in the inferior capsular ligament of the GH joint associated with adhesive capsulitis. Such stiffness could limit the inferior slide of the humeral head during abduction. Without a sufficient concurrent inferior slide during abduction, the superior roll of the humeral head would ultimately lead to a jamming of the head against the coracoacromial arch. An adult-sized humeral head that is rolling up a glenoid fossa without a concurrent inferior slide would translate through the 10-mm subacromial space after only 22 degrees of GH joint abduction. Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, 9/28/2024 52 M.Sc, PhD, PCT Clinical mechanics of roll & slide The resulting excessive superior migration of the humeral head would likely lead to excessive stress placed on the articular cartilage of the humeral head or tissues located within the subacromial space, such as the supraspinatus tendon and associated bursa Such abnormal arthrokinematics may also physically block further abduction Explanation of Adhesive capsulitis & 3rd dysfunction SIS What’s ur proposed treatment??? Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, 9/28/2024 53 M.Sc, PhD, PCT Acromiohumeral distance with abduction The acromiohumeral distance (i.E., The distance between the undersurface of the acromion and proximal humerus). During shoulder abduction, the acromiohumeral distance naturally fluctuates from about 7.5 mm at 20 degrees of abduction to its smallest distance of 2.6 mm near 85 degrees of abduction. The acromiohumeral distance then increases to about 5 mm at 150 degrees of abduction. Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, 9/28/2024 54 M.Sc, PhD, PCT GHJ painful ARC (clinical mechanics application) Pain felt during the 60- 120 abduction degree is indicative of shoulder disorder 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 55 Dynamic stability As abduction reaches about 90 degrees, the prominent humeral head gradually unfolds and stretches the axillary pouch of the inferior capsular ligament of the GH joint. The resulting tension within the inferior capsule acts as a hammock or sling, which supports the head of the humerus. Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, 9/28/2024 B.Sc, M.Sc, PhD, PCT 56 Dynamic Centralization” of the Humeral Head is an interaction between the Joint Capsule (passive) and the Rotator Cuff (active) Activated muscle forces combined with the passive forces from stretched capsular ligaments maintains the humeral head in proper position on the glenoid fossa. During active external rotation. The infraspinatus contracts to produce active external rotation torque at the GH joint. Because the infraspinatus attaches partially to the posterior capsule, its active contraction limits the amount of slack produced in this structure. Maintenance of even relatively low-level tension in the posterior capsule, combined with the natural rigidity from the activated muscle, helps stabilize the posterior side of the joint during active external rotation. the anterior side of the joint is also stabilized during active external rotation. Passive tension in the stretched subscapularis muscle, middle glenohumeral capsular ligament, and coracohumeral ligament all add rigidity to the anterior capsule. Forces therefore are generated on both sides of the joint during active external rotation, serving to stabilize and centralize the humeral head against the glenoid fossa. Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, 9/28/2024 57 M.Sc, PhD, PCT Pathomechancs of joint capsule Excessively tight GH joint capsule may interfere with the effectiveness of the centralization During active external rotation an overly tight anterior capsule could create a large, passive force that positions the humeral head too far posteriorly. This mechanism could decentralize the humeral head relative to the glenoid producing posterior instability / joint pain During active internal rotation, an overly tight posterior capsule can displace the humeral head too far anteriorly. This situation is a possible factor associated with GH joint instability and subacromial impingement syndrome Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, 9/28/2024 58 M.Sc, PhD, PCT  Recap/ILOs 5 dysfunctions of SIS Biomechanics as logic of musculoskeletal clinical practice PT from zero to hero Arms of science Dynamic stabilization of the shoulder joint This was our 1st lecture Introduction to kinetics, pathomechanics & shoulder biomechanics part 1 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 59 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 60 Practical section Feel arthrokinematics of shoulder with osteokinematics Experience Sh. Abduction with maximum int. rot. Palpate thoracic mobility with end-range Sh. abduction Demonstrate the roll & slide rule using a ball on a limited surface Draw by hand force resolution of the normal mechanics of deltoid rotator cuff relationship including (force resolution) Discuss examples when one arms of science are wrong, so an accepted scientific knowledge became invalid Explore research process 9/28/2024 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 61 Intellectual property of Dr. Ibrahim Tobba Ibrahim, PT, B.Sc, M.Sc, PhD, PCT 9/28/2024 62