Osteopatia do ombro

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  • Osteopathic Medicine for the Osteopathic Medicine for the ShoulderShoulder

    Michael Ladewski, DOMichael Ladewski, DOResurrection Medical CenterResurrection Medical Center

    Sports Medicine FellowSports Medicine Fellow

  • Anatomy and BiomechanicsAnatomy and Biomechanics

    Functional Anatomy Functional Anatomy Great motion = Great motion = great instabilitygreat instability

  • Anatomy and BiomechanicsAnatomy and Biomechanics

    Mechanics Mechanics Ball in SocketBall in Socket i.e. not constrained by bonei.e. not constrained by bone Relies on soft tissue for stabilityRelies on soft tissue for stability Normal shoulder abduction requires normal Normal shoulder abduction requires normal

    scapulothoracic motionscapulothoracic motion 1 degree of scapular rotation for every 3 degree of 1 degree of scapular rotation for every 3 degree of

    shoulder abductionshoulder abduction

  • Anatomy and BiomechanicsAnatomy and Biomechanics

    Shoulder stabilityShoulder stability Static FactorsStatic Factors Dynamic FactorsDynamic Factors

  • Static StabilizersStatic Stabilizers

    Bony AnatomyBony Anatomy LabrumLabrum CapsuleCapsule LigamentsLigaments

  • Static StabilizersStatic Stabilizers

    Bony AnatomyBony Anatomy Cupped socketCupped socket

  • Static StabilizersStatic Stabilizers LabrumLabrum Firbocartilaginous Firbocartilaginous

    structurestructure Surrounds glenoidSurrounds glenoid Increases Increases

    diameter /depth / diameter /depth / contact surface contact surface area of glenoidarea of glenoid

    Anchor for Anchor for capsule / capsule / ligamentsligaments

  • Static StabilizersStatic Stabilizers

    CapsuleCapsule Fibrous tissue Fibrous tissue

    surrounding surrounding humerus and humerus and glenoidglenoid

    Thickenings Thickenings comprise comprise ligamentsligaments

  • Static StabilizersStatic Stabilizers LigamentsLigaments

    Prevent excessive Prevent excessive endend--range motionrange motion

    Superior Superior glenohumeral (SGHL)glenohumeral (SGHL)

    Middle glenohumeral Middle glenohumeral (MGHL)(MGHL)

    Inferior glenohumeral Inferior glenohumeral (IGHL)(IGHL)

  • Dynamic StabilizersDynamic Stabilizers

    Adhesion Adhesion CohesionCohesion Negative Intraarticular Pressure (suction Negative Intraarticular Pressure (suction

    cup effect)cup effect) Muscular ComponentMuscular Component

  • Dynamic StabilizersDynamic Stabilizers

    Muscular Muscular ComponentComponent Rotator CuffRotator Cuff Scapular StabilizersScapular Stabilizers Biceps?Biceps?

  • Dynamic StabilizersDynamic Stabilizers

    Rotator Cuff Rotator Cuff maintains humeral maintains humeral head concentrically head concentrically within glenoidwithin glenoid SubscapularisSubscapularis SupraspinatousSupraspinatous InfraspinatousInfraspinatous Teres MinorTeres Minor

  • Dynamic StabilizersDynamic Stabilizers

    SubscapularisSubscapularis Internally rotatesInternally rotates Passive restraint to Passive restraint to

    anterior subluxationanterior subluxation Dynamic restraint to Dynamic restraint to

    anterior subluxationanterior subluxation

  • Dynamic StabilizersDynamic Stabilizers

    SupraspinatousSupraspinatous Depresses humeral Depresses humeral

    headhead Initiates AbductionInitiates Abduction

  • Dynamic StabilizersDynamic Stabilizers

    Infraspinatous and Infraspinatous and Terres MinorTerres Minor External RotationExternal Rotation Resists posterior Resists posterior

    subluxationsubluxation

  • Dynamic StabilizersDynamic Stabilizers

    Scapular StabilizersScapular Stabilizers Serratus Anterior Serratus Anterior moves scapula on chest moves scapula on chest

    wall, rotates coracoacromial arch, allows wall, rotates coracoacromial arch, allows stable base for shoulder motionstable base for shoulder motion

    TrapeziusTrapezius Levator ScapulaeLevator Scapulae RhomboidsRhomboids

  • Dynamic StabilizersDynamic Stabilizers

    Serratus AnteriorSerratus Anterior moves scapula on chest wallmoves scapula on chest wall rotates coracoacromial archrotates coracoacromial arch allows stable base for shoulder motionallows stable base for shoulder motion

  • Osteopathic Manipulative Osteopathic Manipulative TechniquesTechniques

    Help maintain efficient muscle balance, Help maintain efficient muscle balance, neuromuscular firing patterns, flexibility in neuromuscular firing patterns, flexibility in shoulder complexshoulder complex

  • Spencer TechniqueSpencer Technique

    Developed by Spencer, D.O. in 1916Developed by Spencer, D.O. in 1916 Articulatory technique used at shoulder to Articulatory technique used at shoulder to

    increase ROMincrease ROM Spencer used technique to increase Spencer used technique to increase

    painfree ROM via stretching tissues and painfree ROM via stretching tissues and lymphatic flow from injured arealymphatic flow from injured area

    Some modifications made over timeSome modifications made over time

  • Spencer TechniqueSpencer Technique Useful when restriction or fibrosis has Useful when restriction or fibrosis has

    developed in soft tissue during period of developed in soft tissue during period of inactivity after injuryinactivity after injury

    Treat: early adhesive capsulitis, healed Treat: early adhesive capsulitis, healed fractures, subacute dislocations, any other fractures, subacute dislocations, any other degenerative or traumatic condition with degenerative or traumatic condition with restrictions in glenohumeral motionrestrictions in glenohumeral motion

    Decreases muscle spasms in shoulder Decreases muscle spasms in shoulder stabilizing musclesstabilizing muscles

  • Spencer TechniqueSpencer Technique Can be used for both evaluation and treatment Can be used for both evaluation and treatment

    of shoulderof shoulder Can be modified into a muscle energy techniqueCan be modified into a muscle energy technique 7 motions or stages in total7 motions or stages in total Physician stands at head of table along side Physician stands at head of table along side

    patient, facing the patientpatient, facing the patient Physician uses cephalad hand to stabilize clavicle Physician uses cephalad hand to stabilize clavicle

    and scapula against thorax while using caudal and scapula against thorax while using caudal hand to introduce the motionshand to introduce the motions

    Patient lies on unaffected side with affected Patient lies on unaffected side with affected shoulder facing upshoulder facing up

  • Spencer TechniqueSpencer Technique

    Motion 1: ExtensionMotion 1: Extension Flex patientFlex patients elbow and s elbow and

    EXTEND shoulder joint in EXTEND shoulder joint in horizontal plane until end horizontal plane until end ROM feltROM felt

    Return to neutralReturn to neutral Repeat 6 to 8 timesRepeat 6 to 8 times Can modify into muscle Can modify into muscle

    energy techniqueenergy technique

  • Spencer TechniqueSpencer Technique

    Motion 2: FlexionMotion 2: Flexion Extend elbow, FLEX Extend elbow, FLEX

    shoulder until end ROM shoulder until end ROM feltfelt

    Return to neutralReturn to neutral Repeat 6 to 8 timesRepeat 6 to 8 times Can modify into muscle Can modify into muscle

    energy techniqueenergy technique

  • Spencer TechniqueSpencer Technique

    Motion 3: Motion 3: Circumduction / Circumduction / CompressionCompression Flex elbow and abduct to 90 Flex elbow and abduct to 90

    degreesdegrees Use patientUse patients elbow as a s elbow as a

    pivot to ROTATE humerus pivot to ROTATE humerus clockwise and clockwise and counterclockwise in circlescounterclockwise in circles

    Apply slight COMPRESSION Apply slight COMPRESSION on the glenohumeral jointon the glenohumeral joint

    Gradually increase circle sizeGradually increase circle size

  • Spencer TechniqueSpencer Technique

    Motion 4: Motion 4: Circumduction / Circumduction / TractionTraction Maintain arm in abducted Maintain arm in abducted

    position with elbow flexedposition with elbow flexed Apply TRACTION force on Apply TRACTION force on

    glenohumeral joint while glenohumeral joint while rotating humerus in clockwise rotating humerus in clockwise and counterclockwise circlesand counterclockwise circles

    Gradually increase circle sizeGradually increase circle size

  • Spencer TechniqueSpencer Technique

    Motion 5: AbductionMotion 5: Abduction Flex patientFlex patients elbows elbow Abduct arm to 90 degreesAbduct arm to 90 degrees Exert upward (cephalad) Exert upward (cephalad)

    pressure at elbow to pressure at elbow to increase ABDUCTION until increase ABDUCTION until end ROM feltend ROM felt

    Return to starting pointReturn to starting point Repeat 6 to 8 timesRepeat 6 to 8 times Can modify into muscle Can modify into muscle

    energy techniqueenergy technique

  • Spencer TechniqueSpencer Technique Motion 6: Motion 6: Internal RotationInternal Rotation

    Flex patientFlex patients elbow and s elbow and position patientposition patients hand s hand behind lower backbehind lower back

    Exert forward (anterior) Exert forward (anterior) pressure at elbow to pressure at elbow to INTERNALLY ROTATE until INTERNALLY ROTATE until end ROM feltend ROM felt

    Return to starting pointReturn to starting point Repeat 6 to 8 timesRepeat 6 to 8 times Can modify into muscle Can modify into muscle

    energy techniqueenergy technique

  • Spencer TechniqueSpencer Technique Motion 7:Motion 7:

    Extend patientExtend patients elbow, place s