Week 11 - Functional Anatomy and Rehabilitation of the Shoulder(2).pdf

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WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice  EHR520 – Week 11 Functional Anatomy and Rehabilitation of the Shoulder Tim Miller (ESSAM AES AEP) E: [email protected] Ph: (02) 6338 4442 Functional Anatomy and Rehabilitation of the Shoulder FUNCTIONAL ANATOMY OF THE SHOULDER Introduction Shoulder Complex structure Purpose is to position the hand for function Extensive mobility (greater instability) Used for expansive motion and speed Pitching: 7500°/s Tennis: 1500°/s Injury risk occurs during deceleration in throwing, club, and racquet sports Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 4 Influencing Factors Stability: Static and dynamic Scapula muscles Force couples Trunk and hip strength Posture Cervical and thoracic spines Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 5 Shoulder Joints Sternoclavicular Saddle joint Acromioclavicular Synovial plane joint (gliding) Scapulothoracic Anterior surface of scapula & posterior rib cage (gliding) Glenohumeral Glenoid cavity & head of humerus Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 6 Shoulder Ligaments Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 7 Shoulder Ligaments Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 8 Rotator Cuff Rotator Cuff Maintains GH alignment during all movements – Supraspinatus (ADB/ER) – Infraspinatus (ER) – Teres minor (ER) – Subscapularis (IR) Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 9 Scapular Stabilisers Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 10 Scapular Movements Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 11 Scapular Movements Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 12 Scapular Plane 30° forward from frontal plane (i.e. 30° horizontal shoulder flexion) Functional plane of motion Scaption – Elevation in scapular plane Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 13 Shoulder Rehabilitation Sequence Find cause (for chronic problems) Relieve pain, promote healing Restore ROM/flexibility Regain strength/endurance (scapula muscles first) Achieve ABCs Functional activities Performance‐specific exercises Return to optimal function Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 14 Functional Anatomy and Rehabilitation of the Shoulder PATHOLOGY OF THE SHOULDER Scapular Dyskinesis Abnormal position/movement of scapula Risk for: Instability, impingement, rotator cuff tendinopathy, glenoid labrum tears, adhesive capsulitis (frozen shoulder), AC joint sprains and biceps tendon injuries Prominent posterior inferior scapular angle at rest Caused by: Restricted soft‐tissue structures, poor posture, muscle strength imbalances and hyperactivity of the upper trapezius Rehab: Posture correction, reducing hypertonicity, flexibility, strength & endurance, educating on proper muscle recruitment Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 16 Glenohumeral Instability Damage to either static/passive or active/dynamic structures can lead to cycle of instability Instability may be anterior, posterior, inferior or multidirectional Mechanisms: Traumatic injuries (e.g. shoulder dislocation) Atraumatic injuries (e.g. repeated overhead activities) Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 17 Glenohumeral Instability Signs & Symptoms: Recurrent dislocation or subluxation Shoulder pain & episodes of “dead arm” syndrome Pain is usually the result of impingement of the rotator cuff tendons due to recurrent translation of the humeral head Eventual weakening of the rotator cuff muscles which leads to failure of humeral head depression Recurrent episodes result in rotator cuff tendinopathy Treatment: Conservative care first Decrease inflammation and pain Restore full ROM Progressive strengthening of RC Scapular stability Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 18 Shoulder Dislocation Almost always traumatic (unless there is an underlying joint laxity or connective tissue disorder) Can be anterior (most common) or posterior Anterior (97%) – Usually a blow to the arm in an abducted, externally rotated and horizontally extended GHJ Posterior (3%) – Usually a fall on an outstretched arm Complications can include Rotator cuff tear GHJ ligament tears Bankart lesion (damage to the joint’s labrum) Hill-Sach’s fracture (fracture to the humeral head) Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 19 Shoulder Dislocation Treatment should begin conservatively Work away from the position of dislocation to start with Progressively move towards the less stable position of dislocation Avoid having the patient become apprehensive See Apprehension Test Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 20 Shoulder Impingement Can be either: Primary (structural) Secondary (biomechanical – posture and movement) Four acromial types: Type 1 – Flat (12%) Type 2 – Curved (56%) Type 3 – Hooked (29%) Type 4 – Convex (3%) Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 21 Shoulder Impingement (Secondary) Mechanism: Decrease in the sub‐acromial space Can affect supraspinatus, infraspinatus, subscapularis, biceps tendon (long head) and sub‐acromial bursa Repetitive overhead actions, postural mal-alignments, dynamic & static stabilisers fail to maintain an adequate sub-acromial joint space Impingement causes mechanical irritation of the tendons and / or sub- acromial bursa, leading to inflammation & further impingement Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 22 Shoulder Impingement (Secondary) Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 23 Shoulder Impingement (Secondary) Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 24 Shoulder Impingement (Secondary) Signs & symptoms: Pain during / after activity usually felt at the tip of the shoulder. Can also refer down the deltoid and into the upper arm during overhead activities Pain with abduction suggests supraspinatus tendon Pain with flexion suggests long head biceps tendon or subscapularis tendon (sub‐coracoid impingement) Inflammation of sub‐acromial bursa / thickening of tendon(s) Restriction of movement Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 25 Shoulder Impingement - Rehabilitation Restoration of normal shoulder biomechanics in effort to maintain sub- acromial joint space during dynamic movements (particularly overhead) Strengthen dynamic stabilisers, rotator cuff muscles that act to both compress & depress the humeral head relative to the glenoid ER’s (infraspinatus & teres minor) usually weaker concentrically than IR’s & need strengthening Posterior joint capsule usually tight, limiting IR & need stretching Strengthening of muscles that abduct, elevate & upward rotate the scapula (serratus anterior, upper trapezius & levator scapulae) should be incorporated (GHJ rhythm) Middle trapezius & rhomboids should be strengthened eccentrically in particular, to help decelerate scapula during throwing activities Inferior trapezius should be strengthened to recreate a balance in the force couple with the upper traps, facilitating scapular stability Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 26 Shoulder Impingement - Rehabilitation Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 27 Rotator Cuff Tears Can be traumatic or atraumatic (more common with advancing age and shoulder impingement) Usually involves supraspinatus only (sometimes infraspinatus as well) Tear in the tendon is usually at the insertion point Can be partial or full thickness Partial thickness tears are often rehabilitated conservatively Avoid significantly loaded abduction to begin with Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 28 Rotator Cuff Tears Full thickness tears are often repaired surgically Very long and painful recovery 6 weeks in a sling initially Usually a 6 – 12 months rehabilitation process The procedure is usually performed arthroscopically https://www.youtube.com/watch?v=0065OKVAwdg https://www.youtube.com/watch?v=M5fUXA_qgYo Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 29 AC Joint Sprain Signs and symptoms: Pain at the end of the clavicle, that may spread Often swelling Deformity can be apparent in more severe injury Pain with GHJ movement, particularly flexion and adduction The most common mechanism of injury is a direct blow to the shoulder with the shoulder in adduction (against the body) Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 30 AC Joint Sprain Treatment depends upon the severity of the injury. Rockwood Classification below Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 31 Adhesive Capsulitis (Frozen Shoulder) Mechanism: Commonly referred to as “frozen shoulder” – shoulder stiffness Shoulder capsule becomes inflamed and stiff, developing adhesions which greatly restrict movement and cause pain – External rotation, abduction and flexion, in that order Can occur following significant trauma (e.g. a fracture or surgery); may develop following injury to the cervical spine; commonly associated with endocrine disorders (e.g. diabetes, thyroid disorders) Can also occur spontaneously (idiopathic frozen shoulder): typically in 40‐60 year olds; females > males; non‐dominant shoulder Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 32 Adhesive Capsulitis (Frozen Shoulder) Treatment: Inflammatory condition therefore don’t overstretch Focus on improving posture, scapular stability and rotator cuff strength within pain-free ROM Massage/trigger point of surrounding muscles (e.g. pecs, infraspinatus, trapezius) Can progress to surgery (capsular release) Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 33 Adhesive Capsulitis (Frozen Shoulder) Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 34 Shoulder – Special Tests Neer’s Test – Shoulder impingement https://www.youtube.com/watch?v=bXA8cblZUok Hawkins-Kennedy Test – Shoulder impingement https://www.youtube.com/watch?v=6GkKB2oXi3o Painful Arc – Shoulder impingement https://www.youtube.com/watch?v=engHP9OA92U Speed’s Test – Biceps tendinopathy or labral tear https://www.youtube.com/watch?v=gbG_O9Gv8aQ Drop Arm Sign – Full thickness rotator cuff tear https://www.youtube.com/watch?v=JXgRBeqToik Sulcus Sign – Shoulder instability https://www.youtube.com/watch?v=vV7u2JtdYWI Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 35 Shoulder – Special Tests Load and Shift Test – Shoulder instability https://www.youtube.com/watch?v=txARar71h5E Apprehension Test – Shoulder instability post-anterior GHJ dislocation https://www.youtube.com/watch?v=jZ29dAXKA5M Full Can Test – Rotator cuff pathology (supraspinatus) https://www.youtube.com/watch?v=NuBOHdm20cc Week 11 - Functional Anatomy and Rehabilitation of the Shoulder 36