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PRINCIPLES OF SHOULDER REHABILITATION AND RETURN TO SPORT
Presented by: Joel Werman B.App.Sc. (Physio), Grad.Dip.Sc. (Sports Physio)
Specialist Sports Physiotherapist
Will commence LIVE from Sydney, Australia at 7:30pm AEST
Andrew Ellis BSc (Ex. Sci), M. Phty
World Health Webinars CEO
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Joel Werman
• Specialist Sports Physiotherapist and Fellow of the
Australian College of Physiotherapy.
• Specialized in the treatment of shoulders for over 23 years
• Founding member of the Shoulder and Elbow
Physiotherapists of Australia group
• Lectured extensively on the subject of the shoulder covering
a wide range of subjects
• Through extensive clinical experience has devised own
approach to assessment and treatment of the shoulder
which is based on a structured clinical reasoning model.
Specialist Sports
Physiotherapist
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PRINCIPLES OF SHOULDER REHABILITATION AND RETURN TO SPORT
Joel Werman
APA Specialist Sports Physiotherapist Fellow of The Australian College of Physiotherapists
THREE CATAGORIES OF SHOULDER
PROBLEMS:
1. Structural
2. Functional
3. Combination
It is imperative to determine which category
the patient falls into so as to establish
appropriate goals, expectations and
management outcomes.
THREE CATAGORIES OF SHOULDER
PROBLEMS:
1. Structural
THREE CATAGORIES OF SHOULDER
PROBLEMS:
1.Structural
Should you proceed
immediately to radiological
investigations and/or
specialist referral?
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THREE CATAGORIES OF SHOULDER
PROBLEMS:
LISTEN to the history…
was there a significant trauma or
incident?
has this built up over many years?
unable to sleep at night due to the
pain
• LOOK at the patient…
Severe pain and disability
THREE CATAGORIES OF SHOULDER
PROBLEMS:
‘You can’t make a silk purse
out of a sow’s ear’
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THREE CATAGORIES OF SHOULDER
PROBLEMS:
2. Functional
Timing and tuning.
The objective of the shoulder is
for the ball to stay centered in
the middle of the socket
throughout a full range of
movement.
THREE CATAGORIES OF SHOULDER
PROBLEMS:
3. Combination (structural and functional):
• The existence of some structural issues combined with (often)
secondary/ compensatory functional deficits.
• You must understand the extent of the structural concerns
together with the needs and expectations of the patient to
determine the management options.
ASSESSMENT
The objective examination will directly dictate the rehabilitation
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ASSESSMENT
Posture, symmetry, general
muscle tone,
Signs of hyper-mobility
ASSESSMENT
Active range of motion- assess quality of movement with respect to
scapular dyskinesia , pain and end range.
ASSESSMENT
Passive range of motion.
Is the restriction of active range the same passively?
Can the arm go further when performed passively?
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ASSESSMENT
• Re-assess restricted or painful active movement with techniques
to manually reposition the scapular, or the head of the
humerus in the glenoid
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ASSESSMENT
Scapular ‘dumping’ : support under the inferior angle of
the scapular and reassess active forward elevation &/or
active range of external rotation in neutral
ASSESSMENT
Strength testing :
manually
Hand held dynamometer
Re-test with active scapular
retraction
“Where it’s tight you stretch it,
where it’s weak you strengthen it”
( Ian Collier - 1988 )
Clinical reasoning : Identify the
deficient component parts of
the shoulder in your objective
examination
Justify your intervention and
prioritize your objectives
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WHAT DOESN’T WORK:
Electrotherapy:
interferential
ultrasound
laser
short wave
RESEARCH / EVIDENCE :
The Cochrane Collaboration - Cochrane Reviews 2003
Physiotherapy interventions for shoulder pain
Green S, Buchbinder R, Hetrick SE
Main results Twenty six trials met inclusion criteria. Methodological quality was variable and trial populations were generally small (median sample size = 48, range 14 to 180). Exercise was demonstrated to be effective in terms of short term recovery in rotator cuff disease (RR 7.74 (1.97, 30.32), and longer term benefit with respect to function (RR 2.45 (1.24, 4.86). Combining mobilisation with exercise resulted in additional benefit when compared to exercise alone for rotator cuff disease. Laser therapy was demonstrated to be more effective than placebo (RR 3.71 (1.89, 7.28) for adhesive capsulitis but not for rotator cuff tendinitis. Both ultrasound and pulsed electromagnetic field therapy resulted in improvement compared to placebo in pain in calcific tendinitis (RR 1.81 (1.26, 2.60) and RR 19 (1.16, 12.43)
respectively). There is no evidence of the effect of ultrasound in shoulder pain (mixed diagnosis), adhesive capsulitis or rotator cuff tendinitis. When compared to exercises, ultrasound is of no additional benefit over and above exercise alone. There is some evidence that for rotator cuff disease, corticosteroid injections are superior to physiotherapy and no evidence that physiotherapy alone is of benefit for adhesive capsulitis
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WHAT DOESN’T WORK:
Passive joint mobilization
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RESEARCH / EVIDENCE :
Does Passive Mobilization of Shoulder Region Joints Provide
Additional Benefit Over Advice and Exercise Alone for
People Who Have Shoulder Pain and Minimal Movement
Restriction? A Randomized Controlled Trial
Ross Yiasemides, Mark Halaki, Ian Cathers and Karen A. Ginn
Physical Therapy February 2011 vol. 91 no. 2 178-189
Conclusion This randomized controlled clinical trial does not
provide evidence that the addition of passive mobilization,
applied to shoulder region joints, to exercise and advice is more
effective than exercise and advice alone in the treatment of people
with shoulder pain and minimal movement restriction.
WHAT DOESN’T WORK:
Most other passive interventions, particularly in isolation
WHAT DOES WORK:
Exercise therapy
RESEARCH / EVIDENCE :
Physiotherapy interventions for shoulder pain
Green S, Buchbinder R, Hetrick SE
Main results Twenty six trials met inclusion criteria. Methodological quality was variable and trial
populations were generally small (median sample size = 48, range 14 to 180).
Exercise was demonstrated to be effective in
terms of short term recovery in rotator cuff
disease (RR 7.74 (1.97, 30.32), and longer term
benefit with respect to function (RR 2.45 (1.24, 4.86). Combining mobilisation with exercise resulted in additional benefit when compared to
exercise alone for rotator cuff disease. Laser therapy was demonstrated to be more
effective than placebo (RR 3.71 (1.89, 7.28) for adhesive capsulitis but not for rotator
cuff tendinitis. Both ultrasound and pulsed electromagnetic field therapy resulted in
improvement compared to placebo in pain in calcific tendinitis (RR 1.81 (1.26, 2.60)
and RR 19 (1.16, 12.43) respectively).
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EXERCISE THERAPY:
Addresses:
a. Flexibility
b. Strength
- neuromuscular control
- muscle hypertrophy
The relevance of an exercise is how it relates to the patient’s
problem. Clinical reasoning requires the physio to justify the
choice of intervention as dictated by the initial examination.
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Goal of Physiotherapy:
OBJECTIVES:
to ‘normalize’ the shoulder girdle
mechanics to allow the humeral
head to stay centered in the
glenoid fossa through a full range
of movement
EXERCISE THERAPY:
a. Flexibility:
→ a home program of
appropriate stretches done
gently but regularly
throughout the day. Do one
minute of stretching
4 to 6 times a day
→ soft tissue massage as an
adjunct
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ABNORMAL BIOMECHANICS
PAIN AND NEUROMUSCULAR CONTROL:
• Neuromuscular control of scapular musculature is diminished in the presence of pathology (Ludewig, 2000).
Pain inhibits muscle activation at a central level.
Tissue damage
Altered mechanics
(scapula dyskinesia) Inflammation
Muscle
Imbalance
PAIN!
EXERCISE THERAPY:
b. Strength :
The scapular provides a
dynamic platform for the arm.
Alteration of the normal
anchoring function of the
scapular stabilizers results in
compromise to the
subacromial space
EXERCISE THERAPY:
Incidence of scapular dyskinesia:
Studies have shown dysfunction in scapula
position and mechanics in 68% of cases
with abnormalities of the rotator cuff and
100% of those with glenohumeral instability
(Kibler & McMullen, 2003)
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EXERCISE THERAPY:
Crane analogy:
If the base is not anchored
securely, the crane is unable
to lift the load.
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4 PHASES OF REHABILITATION
Crawl walk run sprint !
‘Would you ask your limping patient to go for a run?’
‘Would you expect a crane to lift a load if the base was not
securely anchored?’
Phase 1: Reactivate the scapular stabilizers
Phase 2: Add light resistance
Phase 3: Muscle hypertrophy
Phase 4: Sport specific rehabilitation
THEORY:
How do you reactivate the scapular stabilizers?
Analysis study of a scapular orientation exercise and
subjects’ ability to learn the exercise. Manual Therapy. 14
(13-18). 2009.
Mottram, S.L., Woledge, R.C., Morrisse, D. Motion
“Examples of cues included passive/assisted movements into the SOE
position, tactile feedback with gentle pressure on the acromion to
encourage upward rotation, recognition of a feeling of widening
the chest to encourage posterior tilt, demonstration of common
wrongly directed movements, demonstration and verbal feedback”
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THEORY:
The subacromial impingement syndrome of the shoulder treated by
conventional physiotherapy, self-training, and a shoulder brace:
Results of a prospective, randomized study
Markus Walther, MD, PhDa, Andreas Werner, MD, PhDb,
Theresa Stahlschmidt, MDc, Rainer Woelfel, MD,
2004 Journal of Shoulder and Elbow Surgery
‘Pull the shoulder blades back and push the sternum forward’
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THEORY:
Journal of Bodywork and Movement Therapies (2006) 10, 71–76
Self-management of shoulder disorders—Part 3:
Craig Liebenson, DC
‘Starting with light resistance perform scapular setting (pulling your
shoulder back and down).’
PHASE 1
Scapular setting:
Early rehabilitation focuses on re-establishing normal scapular control. Setting the scapular back and level ( NOT DOWN ! ) while raising the arm away from the body.
The ability to dissociate movement of the arm from the scapular is the essential building block of restoring normal biomechanics.
Unilateral control initially.
PHASE 1
• The objective is to normalize the
mechanics of the scapular at the
neuromuscular level by initially ‘over-
activating’ the retractors as static
stabilizers (not as prime movers).
• Through conscious over-activation,
subconscious control is restored.
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PHASE 2
Begin adding external loads to
the arm while performing
exercises in an inner range of
movement.
All exercises must be
performed with the scapular
anchored in it’s retracted
(back & level ) position.
All exercises must be
performed without symptoms!
PHASE 3 (early)
Increase loads and begin
training in outer ranges,
working to include
aspects of endurance,
speed and sport
specificity…
All with an emphasis on
control
PHASE 3 (late)
After the initial phase of
scapular retraining,
progression of the
rehabilitation should allow
for more advanced upper
body strengthening while the
scapular is allowed to
naturally adopt it’s
appropriate position.
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PHASE 4
Return to sport:
• How do you know when the athlete is ready to return to sport?
When the objective findings have normalized to the extent that
they are compatible with the demands of the individual’s sport
Must be able to understand the biomechanical requirements of
the sport
PHASE 4
Return to sport:
Must be graduated with
consideration to the variables of
intensity, frequency, duration,
environment, equipment and
technique
TREATMENT
Establish realistic and explicit goals with the patient in terms of:
time frames
outcomes (measureable)
patient involvement
therapist’s role
determination of success or failure
alternative options and when to instigate these
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EXPECTATIONS / OUTCOMES:
Rule of thumb: Initial improvement generally takes as many
weeks as it has been months, that the problem has existed.
By 12 weeks you will have 80% of your potential
improvement behind you.
Average patient requires about 4–6 visits over a two to
three month period.
PATIENT COMPLIANCE:
“ How do you get your patients to do their exercises ?”
Appropriate education
Goal setting – written out in the form of a contract
Make the exercises achievable – set the patient up for
success, not for failure
Write everything down- clear diagrams, instructions re
repetitions/ frequency
PATIENT COMPLIANCE:
Suitable scheduling of follow up appointments
Feed-back: positive and negative as required. ‘Call it as it
is’
Constant reassessment and comparisons with the
established goals
The young athlete: reassure them that the exercises will
(hopefully) fix their pain, but also improve their
performance
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EXERCISE THERAPY:
Exercise prescription:
Which exercise ?
How many ?
How often ?
What force / resistance ?
Pain ?
Technique
THE THROWING SHOULDER THE THROWING SHOULDER
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THE THROWING SHOULDER
Sports Participation and Humeral Torsion
RJ Whitely,KA Ginn, LL Nicholson… - J Orthop Sports Phys …, 2009 -
ukpmc.ac.uk
STUDY DESIGN: Cross-sectional study.
OBJECTIVE: To examine differences between arms in humeral
torsion in adult and adolescent throwing and nonthrowing
athletes, and nonathletic adults.
BACKGROUND: It is hypothesized that humeral retrotorsion
develops ...
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THE THROWING SHOULDER
Retroversion of the humerus in throwing athletes is a
developmental consequence of participation from a young age
THE THROWING SHOULDER
Glenohumeral internal rotation
deficiency (GIRD):
When the amount of IR or total arc of
motion difference reaches a certain
threshold (typically 20 or more
degrees of IR or 8 degrees total arc
difference), it is known as glenohumeral
internal rotation deficit or total arc of
motion deficit.
THE THROWING SHOULDER
• Other pathology of the throwing shoulder includes:
Internal impingement
Anterior instability
SLAP lesions
Rotator cuff and bicipital tendinopathy
Bennett lesion
A/C joint pathology
Suprascapular nerve entrapment
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THE THROWING SHOULDER
A detailed consideration must be given to the entire kinetic
chain when assessing the shoulder of the throwing athlete.
THE THROWING SHOULDER
Kinetic chain assessment:
Foot and ankle range of movement. Previous ankle sprain and loss of dorsiflexion
Hip/knee control. Single leg quarter squat
Glute/ hamstring eccentric control
Core strength. Eccentric control of trunk flexion on the follow through
Adequate flexibility at each segment
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THE THROWING SHOULDER
Treatment:
As previously discussed, the objective of rehabilitation of the
throwing shoulder is to identify the deficient biomechanical
components and set about strategies to correct them
Assess issues of flexibility, neuromuscular control and strength as
relevant to the thrower
Establish an appropriate plan of action with the patient
CONCLUSION
Physiotherapy rehabilitation for shoulder
pathology aims to normalize deficient
shoulder mechanics
A targeted, clinically reasoned approach,
determined from the initial objective
examination, addressing issues of
flexibility and/or muscle control and
strength, is essential
CONCLUSION
• Rehabilitation programs must be suitably structured to
work in a graduated manner from least to more demanding
exercises
• Use this logical approach to help make treating shoulders easy!
THANK YOU
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