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Page 1: Osteopatia do ombro

Osteopathic Medicine for the Osteopathic Medicine for the ShoulderShoulder

Michael Ladewski, DOMichael Ladewski, DOResurrection Medical CenterResurrection Medical Center

Sports Medicine FellowSports Medicine Fellow

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Anatomy and BiomechanicsAnatomy and Biomechanics

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

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Anatomy and BiomechanicsAnatomy and Biomechanics

Mechanics Mechanics –– Ball in SocketBall in Socketi.e. not constrained by bonei.e. not constrained by boneRelies on soft tissue for stabilityRelies on soft tissue for stabilityNormal 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

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Anatomy and BiomechanicsAnatomy and Biomechanics

Shoulder stabilityShoulder stabilityStatic FactorsStatic FactorsDynamic FactorsDynamic Factors

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Static StabilizersStatic Stabilizers

Bony AnatomyBony AnatomyLabrumLabrumCapsuleCapsuleLigamentsLigaments

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Static StabilizersStatic Stabilizers

Bony AnatomyBony AnatomyCupped socketCupped socket

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Static StabilizersStatic StabilizersLabrumLabrum

Firbocartilaginous Firbocartilaginous structurestructureSurrounds glenoidSurrounds glenoidIncreases Increases diameter /depth / diameter /depth / contact surface contact surface area of glenoidarea of glenoidAnchor for Anchor for capsule / capsule / ligamentsligaments

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Static StabilizersStatic Stabilizers

CapsuleCapsuleFibrous tissue Fibrous tissue surrounding surrounding humerus and humerus and glenoidglenoidThickenings Thickenings comprise comprise ligamentsligaments

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Static StabilizersStatic StabilizersLigamentsLigaments

Prevent excessive Prevent excessive endend--range motionrange motionSuperior Superior glenohumeral (SGHL)glenohumeral (SGHL)Middle glenohumeral Middle glenohumeral (MGHL)(MGHL)Inferior glenohumeral Inferior glenohumeral (IGHL)(IGHL)

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Dynamic StabilizersDynamic Stabilizers

Adhesion Adhesion –– CohesionCohesionNegative Intraarticular Pressure (suction Negative Intraarticular Pressure (suction cup effect)cup effect)Muscular ComponentMuscular Component

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Dynamic StabilizersDynamic Stabilizers

Muscular Muscular ComponentComponent

Rotator CuffRotator CuffScapular StabilizersScapular StabilizersBiceps?Biceps?

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Dynamic StabilizersDynamic Stabilizers

Rotator Cuff Rotator Cuff ––maintains humeral maintains humeral head concentrically head concentrically within glenoidwithin glenoid

SubscapularisSubscapularisSupraspinatousSupraspinatousInfraspinatousInfraspinatousTeres MinorTeres Minor

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Dynamic StabilizersDynamic Stabilizers

SubscapularisSubscapularisInternally rotatesInternally rotatesPassive restraint to Passive restraint to anterior subluxationanterior subluxationDynamic restraint to Dynamic restraint to anterior subluxationanterior subluxation

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Dynamic StabilizersDynamic Stabilizers

SupraspinatousSupraspinatousDepresses humeral Depresses humeral headheadInitiates AbductionInitiates Abduction

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Dynamic StabilizersDynamic Stabilizers

Infraspinatous and Infraspinatous and Terres MinorTerres Minor

External RotationExternal RotationResists posterior Resists posterior subluxationsubluxation

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Dynamic StabilizersDynamic Stabilizers

Scapular StabilizersScapular StabilizersSerratus 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 motionTrapeziusTrapeziusLevator ScapulaeLevator ScapulaeRhomboidsRhomboids

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Dynamic StabilizersDynamic Stabilizers

Serratus AnteriorSerratus Anteriormoves scapula on chest wallmoves scapula on chest wallrotates coracoacromial archrotates coracoacromial archallows stable base for shoulder motionallows stable base for shoulder motion

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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

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Spencer TechniqueSpencer Technique

Developed by Spencer, D.O. in 1916Developed by Spencer, D.O. in 1916Articulatory technique used at shoulder to Articulatory technique used at shoulder to increase ROMincrease ROMSpencer 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 areaSome modifications made over timeSome modifications made over time

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Spencer TechniqueSpencer TechniqueUseful 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 injuryTreat: 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 motionDecreases muscle spasms in shoulder Decreases muscle spasms in shoulder stabilizing musclesstabilizing muscles

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Spencer TechniqueSpencer TechniqueCan be used for both evaluation and treatment Can be used for both evaluation and treatment of shoulderof shoulderCan be modified into a muscle energy techniqueCan be modified into a muscle energy technique7 motions or stages in total7 motions or stages in totalPhysician stands at head of table along side Physician stands at head of table along side patient, facing the patientpatient, facing the patientPhysician 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 motionsPatient lies on unaffected side with affected Patient lies on unaffected side with affected shoulder facing upshoulder facing up

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Spencer TechniqueSpencer Technique

Motion 1: ExtensionMotion 1: ExtensionFlex patientFlex patient’’s elbow and s elbow and EXTEND shoulder joint in EXTEND shoulder joint in horizontal plane until end horizontal plane until end ROM feltROM feltReturn to neutralReturn to neutralRepeat 6 to 8 timesRepeat 6 to 8 timesCan modify into muscle Can modify into muscle energy techniqueenergy technique

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Spencer TechniqueSpencer Technique

Motion 2: FlexionMotion 2: FlexionExtend elbow, FLEX Extend elbow, FLEX shoulder until end ROM shoulder until end ROM feltfeltReturn to neutralReturn to neutralRepeat 6 to 8 timesRepeat 6 to 8 timesCan modify into muscle Can modify into muscle energy techniqueenergy technique

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Spencer TechniqueSpencer Technique

Motion 3: Motion 3: Circumduction / Circumduction / CompressionCompression

Flex elbow and abduct to 90 Flex elbow and abduct to 90 degreesdegreesUse patientUse patient’’s elbow as a s elbow as a pivot to ROTATE humerus pivot to ROTATE humerus clockwise and clockwise and counterclockwise in circlescounterclockwise in circlesApply slight COMPRESSION Apply slight COMPRESSION on the glenohumeral jointon the glenohumeral jointGradually increase circle sizeGradually increase circle size

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Spencer TechniqueSpencer Technique

Motion 4: Motion 4: Circumduction / Circumduction / TractionTraction

Maintain arm in abducted Maintain arm in abducted position with elbow flexedposition with elbow flexedApply 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 circlesGradually increase circle sizeGradually increase circle size

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Spencer TechniqueSpencer Technique

Motion 5: AbductionMotion 5: AbductionFlex patientFlex patient’’s elbows elbowAbduct arm to 90 degreesAbduct arm to 90 degreesExert upward (cephalad) Exert upward (cephalad) pressure at elbow to pressure at elbow to increase ABDUCTION until increase ABDUCTION until end ROM feltend ROM feltReturn to starting pointReturn to starting pointRepeat 6 to 8 timesRepeat 6 to 8 timesCan modify into muscle Can modify into muscle energy techniqueenergy technique

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Spencer TechniqueSpencer TechniqueMotion 6: Motion 6: Internal RotationInternal Rotation

Flex patientFlex patient’’s elbow and s elbow and position patientposition patient’’s hand s hand behind lower backbehind lower backExert forward (anterior) Exert forward (anterior) pressure at elbow to pressure at elbow to INTERNALLY ROTATE until INTERNALLY ROTATE until end ROM feltend ROM feltReturn to starting pointReturn to starting pointRepeat 6 to 8 timesRepeat 6 to 8 timesCan modify into muscle Can modify into muscle energy techniqueenergy technique

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Spencer TechniqueSpencer TechniqueMotion 7:Motion 7:

Extend patientExtend patient’’s elbow, place s elbow, place their hand on physiciantheir hand on physician’’s s shouldershoulderPhysician clasps his hands around Physician clasps his hands around patientpatient’’s shoulders shoulderProvide slow, gentle traction Provide slow, gentle traction stretch by pulling humeral head stretch by pulling humeral head toward physician holding tensiontoward physician holding tensionReturn to neutral then add Return to neutral then add compression force into glenoid compression force into glenoid fossafossaRepeat 6 to 8 timesRepeat 6 to 8 times

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Spencer TechniqueSpencer TechniqueOriginal Spencer technique started and Original Spencer technique started and ended with Motion 7 described previouslyended with Motion 7 described previouslyAdditional articulatory motion:Additional articulatory motion:

Flex patientFlex patient’’s elbow, rest patients elbow, rest patient’’s hand on s hand on physicianphysician’’s cephalad wrist stabilizing shoulder s cephalad wrist stabilizing shoulder girdlegirdleMove patientMove patient’’s elbow in arc toward his face s elbow in arc toward his face and then feet producing EXTERNAL and then feet producing EXTERNAL ROTATION and ADDUCTIONROTATION and ADDUCTIONReturn to starting pointReturn to starting pointRepeat 6 to 8 timesRepeat 6 to 8 times

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Myofascial Release: Scapular Lift Myofascial Release: Scapular Lift / Rotation/ Rotation

Targets the rhomboids and associated Targets the rhomboids and associated scapular restrictionsscapular restrictionsIncrease in scapular motion increases Increase in scapular motion increases glenohumeral motionglenohumeral motion

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Myofascial Release: Scapular LiftMyofascial Release: Scapular Lift

Patient lies on side Patient lies on side opposite the dysfunctional opposite the dysfunctional scapulascapulaClinician places finger Clinician places finger pads under medial border pads under medial border of affected scapulaof affected scapulaApply gentle superior Apply gentle superior traction to medial scapula traction to medial scapula along entire medial borderalong entire medial border

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Myofascial Release: Scapular Myofascial Release: Scapular RotationRotation

Same position for patient / Same position for patient / clinicianclinicianClinicians cephalad hand cups Clinicians cephalad hand cups shoulder over anterior aspectshoulder over anterior aspectOther hand cups fingers around Other hand cups fingers around inferior scapular angleinferior scapular angleIntroduce steady and deliberate Introduce steady and deliberate rotational force to scapula, rotational force to scapula, alternating internal and external alternating internal and external rotationrotation

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Osteopathic Medicine for the Osteopathic Medicine for the ShoulderShoulder

References:References:Foundations for Osteopathic Medicine, 2Foundations for Osteopathic Medicine, 2ndnd

EditionEditionPrinciples of Manual Sports Medicine, Principles of Manual Sports Medicine, KarageanesKarageanesFunctional Anatomy of the Shoulder, ACSM Functional Anatomy of the Shoulder, ACSM Team Physician CourseTeam Physician Course