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Shoulder RehabShoulder Rehab
Martin A. Scott MSc MCSPMartin A. Scott MSc MCSP
Nottingham Shoulder & Elbow UnitNottingham Shoulder & Elbow Unit
[email protected]@nuh.nhs.uk
Meister, 2000a
2
© Bodies
The The ““hypermobilehypermobile”” shouldershoulder
�� Stability is lost to increase the Stability is lost to increase the range of motion (range of motion (TennentTennent, , Beach & Meyers (2003))Beach & Meyers (2003))
�� Dynamic control is a major Dynamic control is a major issueissue
Factors affecting glenohumeral Factors affecting glenohumeral
joint stabilityjoint stability�� LabrumLabrum
�� Joint capsuleJoint capsule
�� LigamentsLigaments
�� Internal pressure Internal pressure gradientgradient
�� Bony camBony cam
�� Dynamic muscle Dynamic muscle contractioncontraction
XX
XX
XX
??
??
√√√√√√√√
3
DislocationDislocation
TraumaticTraumatic
�� End of rangeEnd of range
�� Ligament/labral damageLigament/labral damage
AtraumaticAtraumatic
�� Mid rangeMid range
�� Not constrained by Not constrained by ligamentsligaments
Lippitt S & Matsen F (1993) CORR 291
Lee SB et al (2000) JBJS 82A(6)
DislocationDislocation
TraumaticTraumatic
�� End of rangeEnd of range
�� Ligament/labral damageLigament/labral damage
AtraumaticAtraumatic
�� Mid rangeMid range
�� Not constrained by Not constrained by ligamentsligaments
�� Controlled by Controlled by
musclesmuscles
Lippitt S & Matsen F (1993) CORR 291
Lee SB et al (2000) JBJS 82A(6)
InstabilityInstability
�� High risk sportsHigh risk sports
�� Contact +/Contact +/-- throwing (throwing (BoileauBoileau et al., 2006et al., 2006 ))
�� Return to sport (mean 36 months postReturn to sport (mean 36 months post--op)op)
�� 14/91 failures (further instability)14/91 failures (further instability)
�� 58/91 at same level58/91 at same level
�� 13/91 at a lower level13/91 at a lower level
�� 6/91 stopped participation (6/91 stopped participation (BoileauBoileau et al., 2006)et al., 2006)
InstabilityInstability
�� TUBSTUBS
�� Can be hyper lax (Can be hyper lax (egeg26/91, 26/91, BoileauBoileau et al., et al., 2006)2006)
�� Conservative treatment Conservative treatment gives 17gives 17--96% recurrence 96% recurrence in patients <30 (in patients <30 (BottoniBottoni
et al., 2002)et al., 2002)
�� At 4 year mean follow up, At 4 year mean follow up, subscapularis function subscapularis function correlates with outcome correlates with outcome from surgery (Sachs et al., from surgery (Sachs et al.,
20052005))
InstabilityInstability
Sachs et al., 2005Sachs et al., 2005
ImpingementImpingement
Harryman et al., 1990
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ImpingementImpingement
�� PrimaryPrimary
�� SecondarySecondary
�� Internal (Internal (BudoffBudoff et al., et al., 2003;2003; Belling Sorensen Belling Sorensen and Jorgensen, 2000; van and Jorgensen, 2000; van derder HoevenHoeven and and KiblerKibler, , 2006)2006)
�� Observed in arthroscopy Observed in arthroscopy ((YonedaYoneda et al., 2006et al., 2006 ))
ImpingementImpingement
Harryman et al., 1990
ImpingementImpingement
�� PrimaryPrimary
�� SecondarySecondary
�� Internal (Internal (BudoffBudoff et al., et al., 2003;2003; Belling Sorensen Belling Sorensen and Jorgensen, 2000; van and Jorgensen, 2000; van derder HoevenHoeven and and KiblerKibler, , 2006)2006)
ImpingementImpingement
�� PrimaryPrimary
�� SecondarySecondary
�� Internal (Internal (BudoffBudoff et al., et al., 2003;2003; Belling Sorensen Belling Sorensen and Jorgensen, 2000; van and Jorgensen, 2000; van derder HoevenHoeven and and KiblerKibler, , 2006)2006)
�� Observed in arthroscopy Observed in arthroscopy ((YonedaYoneda et al., 2006et al., 2006 ))
ImpingementImpingement ImpingementImpingement
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ImpingementImpingement
�� PrimaryPrimary
�� SecondarySecondary
�� Internal (Internal (BudoffBudoff et al., et al., 2003;2003; Belling Sorensen Belling Sorensen and Jorgensen, 2000; van and Jorgensen, 2000; van derder HoevenHoeven and and KiblerKibler, , 2006)2006)
ImpingementImpingement
Neer, 1972; Yanai and Hay, 2000; Wilk et al., 2002
ImpingementImpingement
Labriola et al., 2005
ImpingementImpingement
Elliott, 2006
InstabilityInstability AssessmentAssessment
�� Muscle patterningMuscle patterning
�� Under/over recruitmentUnder/over recruitment
�� Low/high toneLow/high tone
�� Movement patternsMovement patterns
�� ObservationObservation
�� Relative Relative alignmentalignment of of bony landmarksbony landmarks
�� Relative Relative timingtiming of of
movements of body movements of body segmentssegments
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Range of motionRange of motion
�� Tightness/stiffnessTightness/stiffness
•• Latissimus DorsiLatissimus Dorsi
•• Pectoralis MinorPectoralis Minor
•• Posterior structuresPosterior structures
�� Allow free movement of Allow free movement of the scapula around the the scapula around the
thorax, and external thorax, and external rotation of the humerus rotation of the humerus throughout rangethroughout range
Silliman JF & Hawkins RJ (1993) CORR 291
Borstad JD & Ludewig PM (2005) JOSPT 35(4)
Gain appropriate ROMGain appropriate ROM
�� Tight posterior inferior Tight posterior inferior glenohumeral joint capsule glenohumeral joint capsule can pull the scapula away can pull the scapula away from the chest wall (Burkhart from the chest wall (Burkhart et alet al 2003)2003)
�� Stiff latissimus dorsi impedes Stiff latissimus dorsi impedes full scapulothoracic motionfull scapulothoracic motion
�� Stiff pectoralis minor is Stiff pectoralis minor is associated with Type I associated with Type I dyskinesia (dyskinesia (BorstadBorstad & & LudewigLudewig 2005)2005)
StrengthenStrengthen
�� Rotator cuffRotator cuff�� Allows control of the Allows control of the humeral head in the humeral head in the glenoidglenoid
�� Scapulothoracic Scapulothoracic musclesmuscles�� Allows the glenoid to Allows the glenoid to be positioned relative to be positioned relative to the humeral headthe humeral head
Hawkins RJ & Saddemi SR (1990) Cur Orth 4
Kibler, W. B. (1998). Medicine & Science in Sports &
Exercise 30(4 Suppl): S40-50.
Strengthen scapulothoracic Strengthen scapulothoracic
musculaturemusculature
�� Serratus anteriorSerratus anterior
�� Lower fibres of trapeziusLower fibres of trapezius
�� External rotatorsExternal rotators
Strengthen scapulothoracic Strengthen scapulothoracic
musculaturemusculature
�� Serratus anteriorSerratus anterior
�� Lower fibres of trapeziusLower fibres of trapezius
�� Closed chain exercises Closed chain exercises ((KiblerKibler 1998)1998)
Strengthen scapulothoracic Strengthen scapulothoracic
musculaturemusculature
�� Serratus anteriorSerratus anterior
�� Lower fibres of trapezius Lower fibres of trapezius ((EkstromEkstrom et alet al 2003, Decker 2003, Decker et alet al 2003, Michener 2003, Michener et alet al
2005)2005)
7
Gain scapular dynamic controlGain scapular dynamic controlMaintain scapular dynamic Maintain scapular dynamic
controlcontrol
�� Scapulothoracic Scapulothoracic movement movement
�� Glenohumeral rhythmGlenohumeral rhythm
�� MultiplanarMultiplanar exercisesexercises
�� Visual feedbackVisual feedback
Maintain scapular dynamic Maintain scapular dynamic
controlcontrol
�� Scapulothoracic Scapulothoracic movement movement
�� Glenohumeral rhythmGlenohumeral rhythm
�� MultiplanarMultiplanar exercisesexercises
Maintain scapular dynamic Maintain scapular dynamic
controlcontrol
�� Scapulothoracic Scapulothoracic movement movement
�� Glenohumeral rhythmGlenohumeral rhythm
�� MultiplanarMultiplanar exercisesexercises
�� Visual feedbackVisual feedback
Maintain scapular dynamic Maintain scapular dynamic
controlcontrol
�� Scapulothoracic Scapulothoracic movement movement
�� Glenohumeral rhythmGlenohumeral rhythm
�� MultiplanarMultiplanar exercisesexercises
�� Visual feedbackVisual feedback
�� Function!Function!
From the feet up!From the feet up!
Limpisvasti et al., 2007
8
Harmonious Harmonious rotation(srotation(s))
Limpisvasti et al., 2007
Good alignmentGood alignment
Good alignmentGood alignmentExactly what are effective throwing Exactly what are effective throwing
mechanics?mechanics?
by Paul Nyman by Paul Nyman
May 02, 2008 May 02, 2008
Maintain scapular dynamic Maintain scapular dynamic
control control –– and take it into sport!and take it into sport!Maintain dynamic control Maintain dynamic control –– and and
take it into sport!take it into sport!
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Maintain dynamic control Maintain dynamic control –– and and
take it into sport!take it into sport!Maintain dynamic control Maintain dynamic control –– and and
take it into sport!take it into sport!
Thank youThank you
Martin A. Scott MSc MCSPMartin A. Scott MSc MCSP
Nottingham Shoulder & Elbow UnitNottingham Shoulder & Elbow Unit
[email protected]@nuh.nhs.uk
Stretch before StrengthenStretch before Strengthen
●● Establish tissue mobility to allow normal Establish tissue mobility to allow normal kinematicskinematics
●● Allows greater muscle volume to contract and Allows greater muscle volume to contract and releaserelease
●● Reduces risk of secondary compensationReduces risk of secondary compensation
RugbyRugby
●●ScrumScrum
●●RookRook
●●LineoutLineout
●●Tackle(pileTackle(pile on,collision,shirton,collision,shirt pull,anklepull,ankle tap)tap)
●●PassPass
●●HandoffHandoff
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FootballFootball
●● Collision(withCollision(with other player or ground)other player or ground)
●● Throw inThrow in
●● Goalkeeping divesGoalkeeping dives
Basketball/handball/volleyballBasketball/handball/volleyball
●● BlockshotBlockshot//
●● HookpassHookpass/shot/shot
●● Ball dribblingBall dribbling
CricketCricket
●● Outfield throwsOutfield throws
●● BowlingBowling
●● WicketkeepingWicketkeeping/slip dives/slip dives
●● Crease slidesCrease slides
BoxingBoxing
●● ImpactImpact
●● Missed punchMissed punch
●● FatigueFatigue
●● Poor defensive posturePoor defensive posture