Shoulder Assessment and Rehabilitation

- new ideas?

by

Andrew Walker

Senior II Physiotherapist

Objectives

• Give a brief reminder of shoulder anatomy and relevant biomechanics

• Discuss principles of assessment and rehabilitation in this topic area

• Present a brief case study.

Functional Anatomy of the shoulder complex:

• It is a highly mobile set of joints dependent on muscle control for stability.

• Shoulder Girdle consists of:– Steronoclavicular (SCjt)– Acromioclavicular (ACjt)– Glenohumeral (GH jt)– Scapulothoracic (ST jt)

SC jt

• Complex saddle shaped articulation• Enclosed by capsule

– reinforced by anterior and posterior sternoclavicular ligaments.

• Stabilised– anteriorly by sternal head of sternocleidomastoid– posteriorly bysternothyroid and sternohyoid muscles.

• Interclavicular ligaments connects right and left clavicles.

• SC jt has tremendous stability.

• Movements: Protract/Retract, Elevate/Depress (hinge) and posterior rotation.

• Large medial forces likely to cause # rather than dislocation.

• SC jt rarely injured – mainly traumatically through RTA or contact sport.

ACjt

• Gliding/Plane joint.• Enclosed by capsule

– reinforced by superior and inferior acromioclavicular ligaments.

• Stabilised– Coracoclavicular ligament (trapezoid and conoid parts)

• Articular disc is variably complete/incomplete.– Suggested that incomplete disc is not an abnormality,

but infact an indication of degeneration.

• Movement: Upward/downward rotation, horizontal plane rotation, sagittal plane rotation.

• AC jt inherently unstable and susceptible to dislocation.– This occurs if a medial force is applied and

exceeds the tensile strength of the coracoclavicular ligament.

AC vs SC jt…..

• Functional differences:– SC jt permits relative motion of the clavicle

guiding the general path of the scapula.– AC jt permits slight/subtle movements of the

scapula. These movements provide the maximum extent of mobility at the ST jt.

ST jt

• Not a true joint – a contact between the posterior-lateral surface of the thorax and the anterior surface of the scapula.

• Very important though- Our wide ROM is due to this joint!

• Movements:– elevation/depression– Protraction/Retraction– Upward (lateral)/downward (medial)

• Elevation/Depression– composite of SC and AC rotations.– Adjustments at AC help keep scapula flush

• Protraction/Retraction– Composite of SC and AC horizontal

rotations.– Main amount from SC articulation.

Adjustments come from AC.

• Upward/downward rotation– Complete upward rotation (approx 60º)

needs rotation of both AC and SC

GH jt

• Ball and Socket– Large head, shallow glenoid, deepened by

labrum.– Glenoid angled medially and superiorly.– Humeral head retroverted.

• Works in conjunction with the scapula, and hence the AC and SC.

• Stability: GH surrounded by a fibrous capsule, into which the rotator cuff, capsular and coracohumeral ligaments blend. Long head of biceps.

• Coracohumeral ligament– Constraints external rotation, flexion and

extension.• Capsular (glenohumeral) ligaments:

– Superior – constraint of adduction– Middle – constraint of anterior translation, external

rotation.– Inferior – constraint of external/internal rotation.

Force Couples at the GH

• “Neutral zone” concept (Panjabi, 1992) applied to GH.– Passive restraint by capsulolabral structures– Active restraint by muscles leading to optimal

positioning of the humeral head in the glenoid.– Isolated strength is not important!

• A muscle may function well isometrically, but poorly functionally.

• Kibler (1998) description of force couples as a “length dependent pattern”– That is the co-contraction of muscles

controlled by feedback from muscle spindles to maintain a joint neutral.

Coronal Force Couple

• Force couple of deltoid and supraspinatus during abduction, compressing the humeral head into the glenoid.

Transverse Force Couple

• What happens when the force couple fails?– Creation of an abnormal axis of rotation– Abnormal translation of the head of

humerus.

Force Couple at the ST

• These vary depending on the degree of elevation.

• However, primary contributions are:– Serratus anterior – always active to a degree– Trapezius – upper, mid, lower at different phases

• During the movement the axis of rotation moves.

a) Primarily LSA ,and UT.• MT and LT control

b) ↑ LT, with continued LSA and UT.

c) LT and LSAd) LT and LSA are the

primary rotators of the scapula.• UT rotates the

clavicle.• MT controls

upward rotation.

• Present research suggests that pain affects the timing of muscles– e.g. TrA + multifidus, in Lsp and VMO in the

knee (Jull, Richardson, McConnell and others!)

• Research by Magarey and Jones (2003) and Kibler (1998) suggests that in the shoulder pain:– RC and biceps fail to activate prior to

deltopectorals– Serratus and lower traps are susceptible to

inhibition.

Dynamic Assessment of the Rotator cuff and the scapula

• Observation of posture:– Assessment of posture as a whole– Cervicothoracic posture has considerable

influence on scapula position and motion.– Improved posture was found to increase ROM of

shoulder elevation in subjects with impingement (Baker et al 2005)

• Analysis of movement patterns– Detailed visual analysis – note any substitution

patterns.– Ability to dissociate movements – i.e scapula

from trunk.– Control of concentric and eccentric movement

should be evaluated.– If symptoms are reproduced by the addition of

load, this should be assessed.

How to evaluate force couples of RC?

• Magarey and Jones (2003) have suggested a two part assessment:– Dynamic rotatory stability test (DRST)– Dynamic Relocation test (DRT)

DRST

• Tests the ability to maintain GH neutral during rotatory movements.

• Tested in different positions of flexion and abduction - from neutral towards the problematic functional position.

• Test Performed isotonically, eccentrically and concentrically and at varied speed and loading.

DRT

• Tests the ability of the transverse force couple to hold humeral head in glenoid against a destabilising load.

• Patients with pain may find it hard to isolate this force couple/co-contraction– Patient sits with arm 60º elevation in scapula plane, neutral

rotation and 90º elbow flexion.

– Patient is asked to draw humeral head into the glenoid.

– To best assess the therapist needs to attempt to palpate at least one part of this force couple. (subscap easiest to palp in floor of axilla,tested with resisted med rotn)

• If patient can co-contraction, needs to be assessed in the position of functional difficulty, or positions of difficulty indicated in DRST.

Scapula Stability and Control

• Magarey (2003) suggest 2 methods to investigate scapula stability– Weightbearing Assessment– Scapula Diagonal Patterns

• Weightbearing Assessment– Standard position is 4 pt kneeling. Although try

others such as leaning against wall.• Can the patient dissociate spinal movements• Can patient protract and retract scapula without

spinal movement• Then scapula holding/stability is assessed through

different varieties of loading. - conversely, if pt has poor control, need to work in reduced loading.

• Scapula Diagonals– Utilises scapula PNF patterns

• D1– Depression/retraction component– Elevation/protraction component

• D2– Depression/retraction component– Elevation/protraction component

D1 D2

Case Study – very brief!

History:• 14 year old boy.• hx of sh pain following playing a 2 ½ hour game in

tournament 1 year ago.• Was painful with all movements and couldn't play tennis.• Had PT – PUS and min exs. Able to do forehand and

backhand.• Not resolved- Presents with pain on serving and smashing

in tennis.• Saw Ortho Consult – MRI and XR - NAD

Assessment:• Posture is poor slouched with obvious winging of

scapula.• Difficulty in correcting posture.• Hawkins +ve• Active ROM is a little sore with EOR OP.• No capsular restriction.• DRST reveals poor GH/RC control in 120+ elevation.

Poor control in DRT.• Difficulty dissociating scapula from trunk• Difficulty with PNF diagonals.

Treatment: • Rotation with theraband in assessed positions

with transverse force couple contraction to improve control.

• Scapula stability/posture.– Postural education in sitting inc TrA and mult.– Work on serratus – wall press– Work on PNF diagonals – taught mum to assist to

give feedback.– Scapula/thorax dissociation in 4pt kneel.

Outcome:• No pain EOR OP, but still pain on serve.• In reviewing serve, ? Thoracic rotation restriction. Does

have some stiffness in left rotation.• DRST improving up to 140, but still poor at 160+.• Progression – As improving, needs to continue

developing cuff and scapula control/proprioception in higher elevation. Starting thoracic rotation stretches. R/v serve again after a few further sessions.

Conclusion

• The rest of the shoulder assessment (I.e. acc mvts, special tests) are still important.

• DRST and DRT are dynamic, using biomechanic principles to assess and treat shoulder dysfunction.

• Hence a good understanding of the complex mechanics of this set of joints is required.

• These methods require further research other than expert opinion and biomechanical logic.

References

• M Bullock et al., (2005) Shoulder impingement: the effect of sitting posture on shoulder pain and range of motion, Manual Therapy, 10 (2005) 28–37

• M.E. Magarey, M.A. Jones (2003) Specific evaluation of the function of force couples relevant for stabilization of the glenohumeral joint, Manual Therapy, 8(4), 247–253

• M.E. Magarey, M.A. Jones (2003) Dynamic evaluation and early management of altered motor control around the shoulder complex, Manual Therapy, 8(4), 195–206

• M.E. Magarey, M.A. Jones (2004) Clinical evaluation, diagnosis and passive management of the shoulder complex, NZ Journal of Physiotherapy, 32 (2), 55-66