6- SWIMMERS SHOULDER.pdf

http://news.bbc.co.uk/sport2/hi/photo_galleries/photos_of_the_day/5112544.stm  Repetitive nature of swimming. 8000- 12000 practice m/training 2x/day...

http://news.bbc.co.uk/sport2/hi/photo_galleries/photos_of_the_day/5112544.stm  Repetitive nature of swimming. 8000- 12000 practice m/training 2x/day 5-7 days/week 9,900 strokes/week/shoulder for males 16,500 strokes/week/shoulder for females adduction and internal rotation Impingement syndrome: It is compression of - rotator cuff - subacromial bursae - biceps tendon against under surface of the acromoin and coracoacromial ligament,during arm elevation  critical zone of Codman head of humerus compresses the vessels in this area Vascular cell death theory Increased stress concentration at the point of insertion of the tendon Mechanical Tendons with degenerative changes rupture at much lower loads theory degeneration of the nerve fibrils Loss of proprioceptive feed back Neurological little protection against sudden adduction forces considerations  Stage I Stage II: Stage III Edema and Fibrosis and Bone spurs and inflammation. tendinitis tendon ruptures Typical age: < 25 25- 40 > 40 Clinical Reversible lesion reversible by Not reversible course modification of activity. Physical 1. Tenderness over 1. Soft tissue 1. Limitation of signs greater crepitus. active ROM. tuberosity & 2. Limitation of 2. Atrophy of the anterior ridge of active and passive infraspinatus. acromion. ROM 3. Weakness of 2. painful arc of shoulder abduction abduction between and external 60 and 120 degrees. rotation. 3. Shoulder ROM. may be restricted A) Structural 1- shape of the acromion type I—flat (17%) type II—curved (43%) type III—hooked (39%) Type IV—convex (upturned) (1%) A) Structural 2- Bone spurs on the acromion 3- Os acromiale: pre-acromion meso-acromion meta-acromion 4- Coracoacromial ligament B) Mechanical 5-Rotator cuff overuse 6- Posterior internal impingement: B) Mechanical 7- muscle imbalance  supraspinatous Deltoid line line of action : of action : Scapular movement resulting in scapular winging caused by (A) trapezius palsy (B).serratus anterior palsy B) Mechanical 8- Posterior capsule contracture 9- Posture 10- Scapular dyskinesis SUMMARY of SC Joint AC Joint Scapulo- GH Joint MAJOR thoracic Joint KINEMATICS DURING ABDUCTION Early Phase 25 degrees of 5 degrees of 30 degrees of 60 degrees of 0-90 elevation upward upward abduction rotation rotation Late Phase 5 Degrees of 25 degrees of 30 degrees of 60 degrees of 90-180 elevation and upward upward abduction 35 degrees of rotation rotation posterior rotation of the clavicle TOTAL 30 degrees of 30 degrees of 60 degrees of 120 degrees 0-180 elevation and upward upward of abduction 35 degrees of rotation rotation posterior rotation  Accessory movement Internal rotation (protraction) then External rotation (retraction) Secondary movement Posterior tilt Primary movement Upward rotation  ↓Scapular upward rotation and posterior tilt  Scapular Dyskinesis: visible alterations in scapular position and 1. ↓ Inferior glenohumeral motion patterns joint stability 2. ↓ Subacromial space IMPINGEMENT ↑Scapular internal rotation (protraction) ↑Glenohumeral joint external rotation ↓ Anterior bony stability Posterior cuff internal impingement.  Soft tissue Muscle tightness imbalance Muscle Shoulder fatigue instability Muscle SCAPULAR Thoracic weakness DYSKINESIS posture Lower trapezius Upper trapezius Middle trapezius Levator scapulae Tonic system Phasic system -Phylogenetically older Phylogenetically younger Generally flexor or postural muscles Generally extensor muscles Tendency toward tightness, Tendency toward weakness, hypotonia, hypertonia, shortening, and and lengthening contractures Readily activated in movement, Less readily activated in most especially with fatigue or novel or movement patterns (delayed activation) complex movement patterns. Less likely to atrophy More likely to atrophy Less fragile More fragile Typically one-joint muscles Typically two-joint muscles Tonic system muscles Phasic system muscles prone to tightness prone to weakness  Suboccipitals  Middle and lower trapezius  Pectorals (major and minor)  Rhomboids  Upper trapezius  Serratus anterior  Levatorscaplua  Deep cervical flexors (longus  SCM colli and capitis)  Scalenes*  Scalenes*  Upper-extremity extensors  Latissimus dorsi and supinators  Upper-extremity flexors and  Digastricus pronators  Masticators  Resist normal upward scapular rotatoin, Pectoralis minor Resist posteror tilting Resist external rotation (retraction) posterior shoulder capsule pulling the scapula laterally over the thorax indicated by limited anterior tilting internal rotation and increase the anterior and superior horizontal adduction translation of the humeral head  Weakness of serratus anterior, rhomboids or trapezius Tightness of pectoralis minor  Normal < 25.4 mm (1inch) Acromion  Neer’s  Hawkins Kennedy impingement test test &Yocum test  Supraspinatus test (Empty- Drop-arm (Codman’s test) can test)  Lift-off sign  Abdominal (subscapularis) compression (Belly- press) test Two Inclinometers The purpose of this presentation is to HIGHLIGHT most current evidence on management of patients following ACL reconstruction. improvement in internal rotation from the cross- body stretch was greater than from the sleeper stretch. ( RCT: 1b).  (Izumi et al., 2008) 8 fresh-frozen cadaver shoulders were used to assess 8 stretching positions internal rotation + 0°, 30°, 60°, and 90° elevation in the scapular plane; 60° flexion;60° abduction; 30° extension; and 60º flexion and horizontal adduction Strain was measured in the upper,middle, and lower parts of the capsule. 30° scaption + int. rot. Stretch upper & middle parts of posterior capsule 30° extension + int. rot. Stretching upper and lower parts of posterior capsule  A, B, and C are optimal for restoration of UT/LT muscle imbalances  A, B, and D are optimal for restoration of UT/MT muscle imbalances. Voluntary contraction of the middle (a) and lower (b) trapezius muscle (grade of recommendation : B) Eccentric rotator cuff training (Evidence Level: B) Standing external rotation at 90° abduction Standing internal rotation at 90° abduction (grade of recommendation : B) Row at 90° abduction (grade of recommendation : B)  Manual therapy thecniques (DTFM)  An electromyographic study found scapula taping to significantly reduce upper trapezius fiber muscle activity  Kinesio Taping was no better than other interventions (Parreira et al., 2014) (level I evidence) Mulligan technique THANK YOU Questions?