Robertson EBP Shoulder Update


Published on

Published in: Health & Medicine
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide
  • Welcome to the Diagnosis and Treatment of Anterior Knee Pain. My name is Eric Robertson from Texas State University. I invited you to Sit back, relax, and enjoy the lecture.
  • In this lecture, we will review background information about SIS, including classification of different types of SIS, staging of the disorder, and specifics related to diagnosing SIS. We will then move on to look at a variety of studies which can help guide us as we seek to develop an evidence-supported approach to SIS. By the end of this lecture, you should feel confident that you have an up-to-date awareness of the best evidence approach to managing patients with SIS.
  • Shoulder pain is the second most commonly seen diagnosis in physical therapy clinics in the United States, second only to that monster known as low back pain. It’s been estimated that direct costs related to shoulder pain have approached $7Billion annually and can affect upwards of 20-30% of adults. If this wide range and scope of shoulder pain wasn’t enough of a concern, the statistics related to recovery might really get you interested. For shoulder pain in general, it’s estimated that only 50% of patients will report a self-perceived recovery after one year and that recurrent shoulder pain, and chronic shoulder pain are likely outcomes. There is only a fair to poor prognosis for patients with shoulder pain. You can see from the chart here as well, that those with persistant shoulder pain, like many chronic conditions tend to do, exhibit a much greater cost on the health system. Note that these statistics are talking about shoulder pain in general, from a non-specific standpoint, rather than dealing with a specific diagnosis. However, It’s likely that the vast majority of patients with shoulder pain will present with some form of shoulder impingement and so it’s not a stretch to extrapolate this information about incidence and prognosis to our topic of interest today.
  • Dr. Charles Neer, famously known among physical therapists for the Neer shoulder impingement test, first described the concept of mechanical shoulder impingement back in 1972. In that description, Neer outlined a theory that shoulder impingement consisted of some disruption to the mechanics of the rotator cuff, most likely having to do with the coracoacromial arch height, and the subacromial space. He described 3 forms of acromial morphology, and designated them Type I, II, or III. The Type I acromion was described as a flat acromion, which resulted in a suitable subacromial space and was correlated to a low incidence of impingement. This was present in about 17% of the population. The Type II acromion was a different story. This morphology was described as curved and resulted in a reduced subacromial space. Accordingly, this was correlated to a higher incidence of SIS. Type II acromion was thought by Neer to be the most commonly seen variant, present in about 43% of the population. The type III acromion, thought at the time to be a genetic anatomic variant or the result of severe degenerative changes, was described as a “beaked” acromion. This morphology was distinctive as the anterior tip of the acromion curved sharply downward serving to drastically reduce the subacromial space and was correlated with a very high incidence of SIS and quite often with tears of the rotator cuff.Neer’s description of shoulder impingement was taken to heart by health professionals and served as the basis for learning and managing this condition up until about 1994, when, among others, Dr. James Andrews offered a more detailed description of subacromial impingement syndrome, including classifying impingement into primary and secondary forms.
  • Before we look at classification of shoulder impingement, let’s take a look at the concept of disease progression as proposed by Neer. This has been described as a continuum of shoulder impingement. Patients in stage 1 of the disease are likely to be under the age of 25, and the impingment upon the tissues of the rotator cuff mild. As such, at this stage SIS is a reversible condition and is very responsive to conservative treatment. The name given to this group, edema and hemorrhage indicates the acute inflammatory nature of this stage. Patients in stage II are likely to be a bit older, presenting with shoulders that have undergone some more wear and tear. The tissue of the rotator cuff in this stage present with more fibrotic changes, and re-organization of collagen tissues, resulting in more persistent tendonopathy. These patients often have a history of recurrent shoulder pain over time and were considered by neer to be less responsive to conservative treatment. If a trial of conservative treatment was not effective, a subacromialdescompression could be considered as an effective management strategy for patients in stage II.Patients in stage III tended to be older and presented with significant anatomic changes, including osteophystes or bone spurs and not uncommonly, tendon rupture. This stage was the end of a progressive cascade of shoulder disability and surgical repair of the rotator cuff and acrompioplasty was suggested as the primary intervention strategy. Even though these stages of shoulder impingement were described a relatively long time ago, they still very accurately describe the possible disease progression and patient presentation one is likely to encounter when managing patients with dysfunctional shoulders. SIS truly occurs along a continuum and preventign the progression of disability is a primary goal of managing patients with shoulder pain.
  • As I mentioned, Andrews described two forms of subacromial impingement in the early 1990’s: primary and secondary. Primary shoulder impingement is the form that Neer was really talking about. This is a mechanical impingement of the glenohumeral joint under the subacromial arch. Patients with primary shoulder impingement have a reduced subacromial space and often related problems with the AC joint as well. When conceptualizing primary shoulder impingement, you can think of it as a mechanical block, or something in the way. Secondary shoulder impingement is one of uncertain glenohumeral positioning. This is usually associated with an unstable shoulder, especially in patients who present with multi-directional instability. This can be the result of either mechanical or functional instability of the shoulder. When conceptualizing secondary shoulder impingement, its often helpful to relate this with instability of the shoulder. I’ve added some imaged here to help you remember, primary shoulder impingement is quite often related to anatomical causes, while secondary shoulder impingement is quite often related to difficulty stabilizing the shoulder, such as in this patient with gross scapular winging.
  • Looking more closely at primary shoulder impingement, we can break down the structures that are involved as well as the presumed causes of the disorder. You can see that any structure which runs under or near the subacromial arch is potentially vulnerable to mechanical impingement, especially the long head of the biceps and the supraspinatus and infraspinatus muscle tendons. RC weakness can lead to inflammation and reduced space, especially as fibrotic changes occur within those tissues. Patients with primary shoulder impingement also very frequently present with tightness of the posterior capsule of the shoulder in addition to morphologic changes of the acromion. Finally, postures like increased thoracic kyphosis and forward heard posture can serve to effectively reduce the subacromial space and impinge the structures of the shoulder.
  • Next we can see a more detailed breakdown of secondary shoulder impingement. As you can see, the structures involved aren’t going to change, we’re still dealing with the shoulder. However, the causes of secondary shoulder impingement are more related to muscle function and neuromotor control. RC weakness or tears can compromise the stability of the humeral head during motion as well as more structural factors like capsular laxity. Often, patients with secondary shoulder impingement present with multidirectional shoulder instability. This instability can be a functional instability, or one that’s present during motions and affected by muscle activation rather than purely a mechanical instability. Scapular dyskinesia is not uncommon, and in some patients, it may be this abnormality of postural control which is the main contributor to the inconsistent and improper positioning of the humerus under the coracoacromial arch.
  • Patients with Primary SIS often present with very characteristic historical factors, which is useful as you begin to generate your initial hypothesis. Pain at night, pain with overhead activities, and complaints of shoulder stiffness are common reports. Remember too, that considering Neer's descriptions of staging, especially with respect to age and recurrent pain can be useful components of a patient historical report as you begin to consider SIS. Impairment findings with shoulder impingement are likely to include decreased AROM for shoulder flexion, abduction and External Rotation, along with decreased passive PROM and accessory mobility of the shoulder, especially in directions limited by the posterior capsule. Muscle weakness becomes more and more common as the disease severity progresses and patients often have poor posture. Two test-item clusters exist that can help make sense of the many available special tests at the shoulder. These are potentially very useful as many studies have reported variable diagnostic values for certain special tests like the Neer and Hawkins-Kennedy tests. The first Test-item cluster we will look at, presented by Park et al, identified the H-K test, the presence of a painful arc sign and a positive infraspinatus muscle test as indicative of primary SIS. If all three items are present, a positive LR of 10.56 was reported, which affords a very strong shift in probability that the patient has the disorder. If only two items are present, the +LR is still 5, which is also quite strong. Conversely, if a patient tests negative on all three items, the –LR was reported to be 0.17, which is equally helpful to rule out the disorder. Also useful information is the fact that Park also reported that if you substitute the presence of a painful arc for a positive drop arm sign in this test-item cluster, you are more than likely observing a rotator cuff tear versus simple shoulder impingement.
  • Another study, this one performed by Michener et al in a 2009 issue of Archives of Physical Medicine and Rehabilitation found 5 tests with utility to help rule in or out SIS. These authors reported that the Neer test was sensitive, and it’s absence could assist in ruling out SIS, while the empty can test was specific, and could moderately help rule in SIS. The painful arc test, H-K test and ext rotation resistance test, which was performed similarly to the infraspinatus muscle test, were both sensitive and specific. Perhaps more useful was the established cutoff value of 3 positive special tests. 3 or more positive tests out of these 5 could help you to rule in SIS, while less than 3 could help you to rule out the disorder. Looking at both of these TIC’s together, it’s probably useful to include each of these items in the Michener study, as they can be performed quickly and are repeated across both the Park and Michener TIC. Along with pertinent historical features and these useful clusters, once a physical therapist has ruled out cervical origin, systemic origin and has not identified profound weakness which could indicate a rotator cuff tendon rupture, the diagnosis of SIS doesn’t need to be complicated.
  • Diagnosing secondary shoulder impingement is a little less clear, partly because you are observing the secondary effects of what might be a primary weakness or deficiency in the shoulder capsule. Historically, these patients present as young patients, often overhead athletes with a history of shoulder instability. They might report that they can pop their shoulder or even a history of dislocation of subluxation, but that’s not necessary for this diagnosis. Pain again occurs with overhead activities and from an impairment standpoint, we’d expect to find weakness of the rotator cuff and scapular stabilizers coupled with increased accessory joint mobility. The classic impingement special tests may or may not be positive, depending on the patient and level of irritability, so relying on them is less clear for patients with secondary shoulder instability. However, tests like the Jobe’s relocation or other assessments of instability may indeed be positive. Some authors have reported observation of scapular dyskinesia as an important factor, but, while reported to be a reliable measure, one validation study found the presence of scapular dyskinesis was not strongly related to the presence of shoulder symptoms in a group of overhead athletes. You can see from the image on the right that it can be fairly easy to detect abnormal scapular patterns, but the complex nature of the shoulder and scapulo-humeral rhythm make extrapolating this finding as a purported cause of pain weak.
  • Another idea we could consider when evaluating patients with secondary shoulder impingement it to look at their performance during an upper extremity functional task designed to assess stability of the upper quarter. The Upper Extremity Y-balance test, as described by Phil Plisky is one option. This test is designed to maximally challenge both mobility and stability of the upper quarter, as well as assess the mobility and stability of the thoracic spine and core musculature. To perform this test, a patient assumes a one are push up position and standardized language is used to request the patient to perform a reaching task in the Medial, Inferiolater and Superiolater directions, performed without a rest. This test hasn’t been validated specifically in a population of patients with shoulder instability, but considering the structural and functional requirements of this task, its makes a lot of sense to consider.
  • Outcome measures are helpful tools to evaluate patient baseline functional status, disease severity, and to monitor the progress of an intervention. Here you can see 3 objective measures likely to be utilized with shoulder patients. The numeric pain rating scale is employed for all types of patients, obviously, but for shoulder patients, some clinicians and some researchers have used this scale while specifically asking about painful activities. To do this, 3 items are often used from the Penn Shoulder Scale, a comprehensive battery assessing shoulder function. This items ask patients to rate pain related to pain while at rest, pain during normal activities of daily living, and finally pain experienced during strenuous activities. By delineating pain in this fashion, you may be able to get a more insightful look into how the shoulder dysfunction is affecting the patient. The Disability of Arm, Shoulder, and Hand scale or DASH is a nice scale for use with shoulder patients, although it has been designed an an upper extremity index, not one specifically related to the shoulder. There is a shorter, quick version of the DASH, which has also been validated and is quite useful. The SPADI, or shoulder pain and disability index, is a shoulder-specific measure of function and is often used in research and clinical settings. The MCID of both the DASH and SPADI has been determined, with an MCID of 10-15 for the DASH and 8-13 for the SPADI. Remember, when you seen changes equal to or greater than the MCID, you know that your patient has experienced real, clinically meaningful changes, surpassing measurement error inherent in the tool.
  • Before we look deep into the evidence for intervention, let’s first consider some general overriding treatment principles for patients with various forms of shoulder impingement. We know that for patients with all stages of primary shoulder impingement, we need to work on increasing mobility. Of course, as the stage of the illness progresses, we need to be more and more aware that surgical repair might be indicated. For secondary shoulder impingement, we need to stabilize the shoulder, including some neuromuscular re-education to the upper quarter. We won’t delve into the specifics of internal shoulder impingement in this lecture, but it’s worth mentioning. Internal shoulder impingement designates an impingement of internal structures within the GH joint, especially the posterior superior labrum. Patients with internal impingement often present with pain in a specific range and is common in overhead athletes and weightlifters. For these patients, a program designed to strengthen the RC and stabilize the shoulder can be attempted, with labral repair or surgical correction an option for non-successful candidates. Figure out internal impingement stat
  • First, we have a landmark study by Bang and Deyle published in 2000 in JOSPT. This was a multi-center randomized controlled trial evaluating the effectiveness of manual therapy added to an exercise program for patients with SIS. 52 subjects with SIS were dividing into an exercise group and a manual therapy + exercise group. They were assessed at baseline, 1 and 2 months for measures of strength, pain, and an author-developed functional assessment questionnaire. The approach Bang and Deyle used was very much a Maitland derived impairment-based approach. Both groups received a supervised exercise program including strengthening and a home exercise program which included the use of an exercise log.  The results demonstrated improvement for pain and function in both groups, but greater improvements in the MT+Ex group. Interestingly, significant strength gains were only observed by the manual therapy + exercise group. This is a well-designed study which does a good job representing the impairment-based approach to OMPT. The use of strict inclusion criteria and such items as the exercise log help contribute to the strength of the results. The functional assessment used was not independently validated which is a weakness. The take home message from this study has to be that we can achieve gains using exercise only, but the addition of OMPT is going to advance those gains and may also be important for realizing strength improvements in this population of patients that traditionally has a difficult time tolerating much strength training work.--Results:Pain & FunctionMT+Ex with significantly more improvement StrengthOnly MT+Ex group with significant improvementBang and Deyle performed a Multi-Center RCT. Subjects were Pts referred to PT for shoulder impingement (more strict inclusion criteria for DX of SIS than previous study), utilized Maitland, impairment based approach to patient. Pain was measured on a VAS, and the function measure was not validated (questionnaire developed by authors).Both groupsstrengthening x 3 weeklystretching dailycontinued for 30 daysexercise logExercise & manual therapy grouptreatment reinforcing home exercisesIn-Clinic – Both groups with supervised strengthening in clinic, Ex group had supervised stretching also. 2 X 2 MANOVA Mixed DesignIndVar – Group and Time (pre and post rx)Dep Variables – Collapsed info for VAS, Pain, FunctionPOST-HOC ANALYSISUnivariate ANOVAsEach DVAdjusted Alpha =0.017
  • The Bergman study is also one we like to hang out hats on as manual physical therapists. Subjects were recruited from general practices in the Netherlands and the research question looked at the effects of adding manipulative therapy to the shoulder girdle. In this study, the shoulder girdle and the cervico-thoracic spine received HVLAT manipulation or HALVT mobilization. For inclusion, subject must have presented with shoulder symptoms, which were defined as pain between the neck and the elbows as shown in the image here. As you can see, this wasn’t a strict inclusion of SIS patients specifically. The authors cited Cyriax, Greenman, and Lewitt as inspiration for their “style” of manipulative treatment. One weakness in this design was the use of patient perceived improvement as “full recovery”, a somewhat subjective measure for a primary outcome measure.No limits were placed on duration of symptoms before the first consultation and there was no exclusion for symptoms to neck or lower arm.As you look at the results listed here on the slide, the percentages are representing the % of patients who reported “full recovery” from their limiting shoulder pain. At 6 weeks, there were no between group differences, but at 12 weeks, a significantly higher percentage of the MT+UMC group reported recovery. Usual medical care, cortico-steroid injections, and non-OMPT physical therapy all produced consistently less patient reported recovery.The inclusion of spinal manipulative therapy into the intervention plan for patients with SIS is an important take-home message of this high quality study.--Design: Multi-site RCTPop: N=150, painful shoulder girdle Outcomes:Baseline, 6 ,12 , 26 , 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint, shoulder disability, additional care receivedInterventions:Usual Medical Care (UMC)Advice/information, therapy NSAIDS/analgesics & CSIsManipulative Therapy (MT) + UMCMT to neck, tx-spine & ribs, shoulder girdle< 6 sessions (in 12 wks)Results:At: 12, 26, 52 Wks:“Full Recovery” : MT >UMCSeverity of main complaint & disability – MT> UMC
  • This article was published in 2008, entitled, “Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults.” The placebo controlled, randomized, blinded cross-over trial looked at pain and the presence of a painful arc in 21 subjects with unilateral shoulder pain and no prior history of neck pain. The intervention included 1 session of a cervical lateral glide performed as shown here in the seated position for 2 minutes, or a placebo mobilization. The glide was described as a Mulligan grade IV. For the experimental group, this resulted in immediate reduction in pain and painful arc. It’s important to note that this was not an impairment-based approach, rather a predetermined intervention performed on the cervical spine for patients who presented with shoulder dysfunction. These results are strongly suggestive of a neurophysiologic effect for mobilization in the cervical spine, as well as supportive of the regional interdependence concept.Design: Randomized, blinded, placebo controlled, cross over trialPopulation: N=21, generalized unilateral shoulder pain with painful arc and no Hx of neck painOutcomes:Pain (VAS)Painful ArcInterventions: 1 session2 min of seated cervical lateral glide at C5,6,7. (Mulligan Grade IV+) or placebo mobilizationResults:Immediate Painful Arc and VAS significantly decreased in cervical mobilization condition.
  • We’ve seen quite a bit of variation in the investigations on the effectiveness of manual PT and exercise for patients with shoulder dysfunction. Common issues across many of the studies have been related to the use of inconsistent outcome measures, lack of functional outcomes, and poor descriptions of the actual manual therapy intervention. This much needed case series by Tate et al was recently published in JOSPT. It described the best evidence-based intervention for patiients with SIS using standard functional report measures like the DASH and GROC. The key to this series was that the authors attempted to standardize a treatment program and describe it in detail, in possible hope or in anticipation of a follow-up RCT on the topic. In this case series, patients all tended to demonstrate recovery, however, due to the research design, no cause and effect can be inferred.
  • So far, we have seen several high quality trials supporting the inclusion of OMPT as part of a comprehensive intervention for patients with SIS. In order to accurately gauge how strong this collection of evidence is, it’s important to look quickly at other interventions in this same population. As you can see here, passive modalities, NSAIDS, CSI, and even arthroscopic debridement are not often associated with the type of strong improvements seen in the several preceding trials. In essence, they are not better than the status quo, and we might be throwing our money down the toilet! The one caveat there may be corticosteroid injections, and we’ll look at that a little bit more closely in a minute.
  • I inserted this slide from Dr. Wainner’s regional interdepence lecture, as it’s a good reminder and a nice segue to some trials that studied a more regional approach to shoulder impingement.
  • We should also make sure to consider assessing for impairments from a more regional perspective. Shoulder function can be affected by structures in the cervical and thoracic spine, and even the ribs. Sometimes a patient can experience dramatic improvement when the first rib is treated or when the thoracic spine is mobilized. Likewise, we should also appreciate the fact that pain is sometime modulated by higher central neural processes. This is especially important considering many patients we see with shoulder pain might have a chronic form of pain, or recurrent pain. For these individuals, we do need to keep an eye on the fact that their pain might not be unlike the chronic pain someone might present with persistent or recurrent low back pain, and many of the same pain management strategies can be utilized.
  • As we begin to conclude this lecture, I’d like to bring up a new trend I’ve spotted in the literature concerning interventions for SIS. Eccentric strength training. Since most Type 1 SIS involves a certain degree of chronicity, it makes sense that we would see chronic tissue changes in the tissues involved: things like reduced inflammatory response and disorganization of collagen fibers. As such, we can extrapolate findings from other regions were eccentric training has been used effectively to treat tendonosis issues. And indeed, in a recently published study in BMJ by Holmgren et al, a specific exercise training program reduced the need for surgery in their cohort. The intervention in this trial included eccentric RC training, concentric and eccentric exercises for scapular stabilizers and a regional manual mobilization approach. Patients in the treatment group reports overall improvement at about 70% vs. 23% those in the general exercise of the neck and shoulder group. Further, only 20% of the treatment group required subsequent sub acromial decompression, while 63% of the control group underwent surgery. Consider adding eccentric training prinicples to your shoulder patients, but like always, take care that you load these patients Spark plugs + coils: factory: Thermostat:Air filter:Ac condensor fan: 195 + 110Total: $649 +tax
  • In conclusion, subacromial impingement is a common and easily diagnosed musculoskeletal disorder of the shoulder, however, it’s correlated, like much shoulder pain, with a questionable prognosis. Manual therapy combined with exercise, including those techniques directed regionally at the cervical, thoracic spine and ribs seems to be more effective than exercise alone or usual medical care. There is no apparent benefit to surgical decmpression according to a systemicatic review. More research is still needed to determine which interventions are the most effective, evaluate long term outcomes for physical therapy interventions and assess the cost/benefit ratio of this approach. Overall, there’s a good body of evidence, that continues to grow supporting best evidence management for this population of patients. Keep on the lookout for more on subgrouping and more comprehensive approaches included in RCT trial, perhaps building on the Tate Case series we looked at. This concludes the presentation and thank you again for joining me! This is Eric Robertson signing off.
  • Greetings, I’m Bob Boyles, from the University of Puget Sound, and I’d like to welcome you to the start of another block of instruction: The Upper Quarter.Notice I used the term “Upper Quarter” and not UE. As you will see in this series of lectures, function of the joints of the upper extremity are dependent of the upper quarter as a unit, and vice versa. So when we talk about upper quarter, think UE and include the biomechanics, articulations and musculature of the thoracic and cervical spines. So, don’t forget what you learned from the CT lectures and labs.
  • We have seen with quite a bit of evidence, that manual therapy and exercise is particularly effective for patients with SIS. Earlier this year, Mintken et al developed a prognostic clinical prediction rule to help clinicians identify those patients with shoulder pain likely to respond to manual therapy interventions. The factors in their rule consisted of painfree shoulder flexion of less than 127 degrees, shoulder IR motion of less than 53 degrees at 90 degrees of abduction, a negative Neer test, not taking medication for their shoulder pain, and symptoms less than 90 days. Yes, the negative Neer test included in this rule was a surprise to the ressearchers, however, they cited the work of Winters and Sobel, which remind us that not all patients with shoulder pain, even those diagnosied with SIS will have a mechanical, pathoanatomical problem at the glenohumeral joint. Some patients will have dysfunction of the cervical and thoracic spine, and perhaps the negative neer test is directing us to those patients preferentially. Only follow-up validation will be able to say for sure! Until then, we have a cluster of items which can help fortify our prognosis for improvement with manual therapy interventions.
  • On the other end of the spectrum, we see some work by Kuijpers et al, which looked at prognosis for shoulder pain in general and factors that might pre-dispose someone to experience persistent shoulder pain. This study did not result in a rule, but instead a risk score, whereby important factors earned points and clinicians could calculate total estimated risk for pain. Long duration of complaints, gradual onset of pain, and high intensity of shoulder pain were all factors contributing to a poor prognosis and so you should be on the lookout for these factors when you’re examining patients. I think these criteria fit nicely in opposition with the criteria set forth by Mintken et al for a good prognosis for improvement with manual therapy techniques. It seems lower pain and recent onset are factors which are important to consider in the management of patients with shoulder pain.
  • Hi, this is Eric Robertson and today we’ll be discussing shoulder instabilities. Go ahead and sit back, relax, and enjoy the lecture!
  • Instability is a relatively common issue with shoulders, and this shouldn’t be any surprise, given the large freedom of motion available at the joint. The small amount of bony congruency also contributes to this. Before we look into some epidemiology of instability, let’s define it. Let’s use the term for any clinical syndrome that is a result of laxity in the shoulder. This can be anything from secnodary shoulder impingment, rotoator cuff or labral issues, or ligamentous structural laxity. The most obvious form of instability is the shoulder dislocation, but it’s not the only form.
  • If we look specifically at the epidemiology of shoulder dislocation, we can see that dislocation occurs most commonly in the 2nd and 6th decades of life, and the vast majority of them are anterior dislocations. Many occur primarily due to trauma, especially in younger patients. The overall prognosis for dislocation of the glenohumeral joint is not very good, in that up to 70% will likely experience a second dislocation event within the next two years.
  • Frodo Sandven is a comedian that specializes in the genre of gross out comedy. I’m not so sure that’s actually funny, but perhaps he can be useful to us as he voluntarily takes advantage of his tremendous shoulder laxity to pass his body through a tennis racket. The gentleman, if you can call him that, is demonstrating laxity, but we wouldn’t diagnosis him with instability until the next morning when he had pain resulting from his laxity. This is an important concept when discussing shoulder instability, as many people have a decent amount of laxity in the shoulder, but the term instability is reserved for those with clinical symptoms as a result of the laxity.
  • To fully understand shoulder instability, we should begin by exploring the various components of shoulder stability. Stability at the glenohumeral joint is derived from a combination of factors, and this graph makes a strong attempt at demonstrating this visually. Bony congruency and a negative intrcapsular pressure gradient is formed in part by the glenoid labrum. Postural factors help position the glenoid on a slight incline, which also contributes to stability while the arm is at rest. You can also see how as we elevate the arm, the contributors of stability change, with more ligamentous and muscle stability taking place further through the range. Of real importance here, is that at no point in time are any of these contributors to stability at a true zero mark, reinforcing the fact that optimal shoulder function is derrived from the complex interplay of postural support, bony congruency, labral function, and optimal ligamentous and neuromuscular stabilization. While this seems perhaps annoyingly complex, I’d like to look at it from a different perspective: with so many contributors to overall stability, it’s highlly likely that we as physical therapists can find some area ammenable to improvement!
  • Here you can see a cut away anatomy image of the glenoid labrum. The cup-like shape of the labrun helps enhance the amount of bony congruencey as it wraps around the humeral head. Addittionally, you can see the close interplay of the labrum to the glenohumeral ligaments and the biceps tendon. All important factors when considerign a differential diganosis of the hsoulder.
  • Example Title slide
  • No common scapular dysfunction with people of shoulder pathology!Many different scapular adaptations!
  • Maximal RTC activation requires a stable scapular base, since all RTC muscles have their proximal attachment on the scapula.
  • SPP had highest activation of the SA SPP also had low UT/SA ratios EPP and KPP exercises also had high SA activity with low UT/SA ratios. The WPP demonstrated higher UT/SA ratios.In clinical cases of scapular winging the SPP is an optimal exercise.
  • In view of the intermuscular and intramuscular imbalances often established in these patients,
  • An exercise found to be clinically effective for aiding proprioception is the side lying plank: the affected arm points towards the ceiling at 90° to the body, and the patient is encouraged to balance a ball or place and hold the hand in space with the eyes closed, thus helping to retrain joint position sense (figure 12). Activities should now be more sportspecific with goal-orientated tasks, as these have been shown to be effective in cognitive motor retraining.45 Examples can be throwing at a specific target, bouncing a ball around an obstacle course or shooting into a basketball/netball hoop. It is vital that the patient regains five key components prior to returning to their sport; flexibility, strength, balance, proprioception and of course confidence. If confidence is still lacking, the athlete is at risk of compensating with abnormal movement faults, increasing their risk of reinjury and instability.
  • Another idea we could consider when evaluating patients with secondary shoulder impingement it to look at their performance during an upper extremity functional task designed to assess stability of the upper quarter. The Upper Extremity Y-balance test, as described by Phil Plisky is one option. This test is designed to maximally challenge both mobility and stability of the upper quarter, as well as assess the mobility and stability of the thoracic spine and core musculature. To perform this test, a patient assumes a one are push up position and standardized language is used to request the patient to perform a reaching task in the Medial, Inferiolater and Superiolater directions, performed without a rest. This test hasn’t been validated specifically in a population of patients with shoulder instability, but considering the structural and functional requirements of this task, its makes a lot of sense to consider.
  • Robertson EBP Shoulder Update

    1. 1. Shoulder Update! 2014 University of Texas at El Paso Centennial Lecture Series Evidence-based Management Speaker: Eric Robertson, PT, DPT, OCS, FAAOMPT
    2. 2. Objectives • Attendees will accurately describe diagnostic and prognostic criteria for patients with various should conditions. • Attendees will integrate predictors of response into examination of patients with shoulder pain. • Attendees will review evidence supporting manual therapy interventions for patients with shoulder pain. • Attendees will integrate information about psychologically informed practice into their management of patients with shoulder pain. • Attendees will review best-evidence interventions for patients with shoulder pain.
    3. 3. Shoulder Pain: Incidence and Costs • $7 Billion annually in U.S. (2000) • 20-30% of the population • Poor perceived recovery rate: <50% • Prognosis is Fair to Poor for incidence of non-specific shoulder pain
    4. 4. Our Path Things that don‟t move enough • Subacromial Impingement • Adhesive Capsulitis • Evidence for Manual Therapy Things that move too much • Shoulder Instability • Evidence-supported exercise I‟m getting Emotional…
    5. 5. Impingement Syndrome Concept Neer, 1972 • Altered cuff mechanics • Compromised or constricted • coracoacromial arch • Stage I, II, III
    6. 6. The SIS Continuum: Neer Classification Stage I: Edema & Hemorrhage < 25, reversible, conservative treatment Stage II: Fibrosis & Tendinopathy 25-40, recurrent pain, consider SAD Stage III: Bone Spurs & Tendon Rupture >40, progressive disability, sx repair
    7. 7. Impingement Classification • Mechanical glenohumeral impingement • Altered/reduced sub-acromial space • Associated AC joint problems • Think: “block” Primary • Uncertain glenohumeral positioning • Inherently unstable shoulder • Mechanically • Functional • Think: Instability Secondary (Andrews, 1993, Kamkar, A. et al. JOSPT Vol.17, No.5, p.212-224 May 1993)
    8. 8. Primary Impingement • RC tendons • Long head of biceps • GH joint capsule • Subacromial bursa • Subacromial arch/space Structures • RC weakness or inflammation (also of bursa) • RC tendinopathy • Posterior capsule tightness • Morphology of acromion • Postural dysfunction Causes (Andrews, 1993, Kamkar, A. et al. JOSPT Vol.17, No.5, p.212-224 May 1993)
    9. 9. Secondary Impingement • RC tendons • Long head of biceps • GH joint capsule • Subacromial bursa • Subacromial arch/space Structures • RC weakness • RC tear • Capsular laxity • Multidirectional instability • Functional instability or neuromuscular inhibition • Scapular dyskinesia Causes (Andrews, 1993, Kamkar, A. et al. JOSPT Vol.17, No.5, p.212-224 May 1993)
    10. 10. Diagnosis of Primary SIS • Historical Factors: • Pain at night, pain with overhead activities, complaints of stiffness • Test-item Cluster for SIS • +LR=10.56, -LR=0.17 (all 3) • Hawkins-Kennedy Test • Painful Arc Sign • Infraspinatus Muscle Test Park, et al, 2005
    11. 11. Diagnosis of Primary SIS • Another Perspective: • A larger test-item cluster  3 or more / 5 tests rules in SIS  3 or less /5 rules out SIS Test Sens/Spec t +LR/-LR Neer Sens -0.35 Painful Arc Both +2.25 / -0.38 Ext Rot Resistance Both +4.39 Hawkins-Kennedy Both ~1 Empty Can Spec +3.90 Michener et al, APMR, 2009
    12. 12. Diagnosis of Secondary SIS • Historical Factors: • Young, history of instability, pain with overhead activities, hypermobility, overhead athlete • Objective Findings: • Observation of scapular dyskinesis • Weakness of scapular stabilizers • + Instability tests (Jobes Relocation, lateral scapular slide test, for example) McClure P, Tate AR, Kareha S, Irwin D, Zlupko E. A clinical method for identifying scapular dyskinesis, part 1: reliability. J Athl Train. 2009;44(2):160-164.
    13. 13. Upper Extremity Y-Balance Test • A measure of UE stability • “is a body relative quantitative analysis of a person‟s ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limb.” P. Plisky
    14. 14. • Numeric Pain Rating Scale • And/or 3 pain items from the Penn Shoulder Scale: pain at rest, normal & strenuous activities NPRS • Disability of Arm, Shoulder, and Hand • Quick DASH also good. DASH • Shoulder Pain and Disability IndexSPADI MCID: 10-15 points Outcome Measures for SIS MCID: 8-13 points
    15. 15. General Treatment Principles Type of SIS Presentation Guiding Principle Management Primary Stage I Stage II Stage III Young, pain with activity Rest, restore mechanics MT and Exercise 26-40, pain at night, prolonged symptoms Restore sub- acromial space MT and Exercise, possible surgery Older, chronic, associated with RC tears Manage conservatively unless sx indicated RC strengthening, Jt mob, surgical Secondary Multi-directional instability Stabilize Proprioceptive, neuromuscular strengthening Internal Young, impingement in specific range Strengthen cuff muscles Rehab or labral repair
    16. 16. Treatment: Non-surgical vs Surgical • Emphasize prevention • Current Best Evidence Summary:
    17. 17. Bang & Deyle JOSPT, 2000 Bottom Line:  While both groups improved, the MT+Ex group had greater improvements, including strength gains. Considerations:  MT + Ex group received treatment reinforcing HEP Design: RCT Pop: N=52, impingement syndrome Outcomes: Baseline, 1 & 2 mo Strength, Pain , Functional Assessment Questionnaire (FAQ) Interventions: 6 sessions, 3-4 wks •Exercise Group (Ex) •Stretching & Cuff Ex •Manual Therapy & Exercise Group (MT+Ex) •Ex as above •Man Ther Upper Quarter Results: •Pain & Function MT+Ex with significantly more improvement •Strength Only MT+Ex group with significant improvement Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement
    18. 18. Bergman et al, Annals of Internal Medicine, 2004 Bottom Line:  MT + UMC was the winner for achieving “full recovery” at 12 wks (43% vs. 21%)  Same difference in recovery rate (17%) observed at 52wks Considerations:  Perceived recovery: 6 & 26 Wks – CIs included 0  Other interventions  UMC: 28% CSI; 27% PT  MT+UMC: 25% CSI; 23% PT; 3.8 MT visits Design: Multi-site RCT Pop: N=150, painful shoulder girdle Outcomes: Baseline, 6 ,12 , 26 , 52 wks Primary - patient perceived recovery Secondary - severity of main complaint, shoulder disability, additional care received Interventions: •Usual Medical Care (UMC) Advice/information, therapy NSAIDS/analgesics & CSIs •Manipulative Therapy (MT) + UMC MT to neck, tx-spine & ribs, shoulder girdle ≤ 6 sessions (in 12 wks) Results: •At: 12, 26, 52 Wks: “Full Recovery” : MT >UMC Severity of main complaint & disability – MT> UMC Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder Dysfunction and Pain
    19. 19. McClatchie et al. Manual Therapy,2008 Bottom Line: • Changes in shoulder from treating the asymptomatic C-spine beyond placebo Considerations:  Suggestive of a neurophysiologic effect, that treatment of this area may facilitate recovery in distant regions.  Not an impairment-based approach Design: RCT, cross-over design Pop: N=21 pts with shoulder pain, painful arc, and no Hx of neck pain Outcomes: Pain (VAS), Painful Arc Interventions: •1 session: 2 min of seated cervical lateral glide at C5,6,7. (Mulligan Grade IV+) or placebo mobilization Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
    20. 20. Tate et al. JOSPT, 2010 Bottom Line: • Strong study describing treatment approach. Considerations:  No cause and effect! Design: Case Series Pop: N=10 pts with SIS Outcomes: DASH (50% improvement), GROC Interventions: •Standardized treatment program including exercise and manual techniques Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
    21. 21. Other Interventions? Bottom Line: • Usual Medical Care, Arthroscopy, Passive Interventions, Pharmaceutical Management, even usual PT all seem to be ineffective! 1. PT = Arthroscopic debridement + PT (Brox, 1993) 2. CSI may only be beneficial for a sub-group. (Bergman et al., 2004) 3. Passive Interventions and Modalities not effective (Leduc et al., 2003) 4. NSAIDs: no meaningful changes (Green at al., 2003; Petri et al., 2004) 5. CSI only short term effect, and only prior to 12 weeks. (Crashaw, 2010) How does the evidence look for other interventions for SIS?
    22. 22. Musculoskeleta l Somatovisceral Biopsychosoci l Neurophysiologi cal
    23. 23. SIS: A Regional Perspective Cervical Spine: forward head, muscle tightness Ribs: first and second rib dysfunction Thoracic Spine: attachment for many scapula stabilizers CNS: neuromotor control, pain processing, core synergies and stabilization
    24. 24. Eccentric Exercise? • Degenerative Process = Chronic Changes • Tendonosis? • Eccentric strength training to the rotator cuff • Holmgren et al, 2012: Reduced need for surgery with ecc. 0 20 40 60 80 Subsequent Surgery
    25. 25. More research is needed to determine which interventions are the most effective, long term outcomes, and economic benefit of physical therapy programs for SIS Manual therapy in addition to exercise, including those techniques directed regionally is more effective than exercise along or usual care. SIS is prevalent, easily diagnosed, yet correlated with a questionable prognosis SIS Conclusions
    26. 26. Adhesive Capsulitis
    27. 27. What is it? • Effects 2-5% of the general population and 10-38% of the population with diabetes or thyroid disease • Primarily effects those 40-65 yrs • Females > Males • Primary (idiopathic) • Secondary • Intrinsic vs extrinsic
    28. 28. Differential Diagnosis • May present similarly to other common shoulder conditions seen in PT -Rotator cuff tears -tendonitis -osteoarthritis -labral tear -subacromial bursitis **Diagnostic imaging usually unnecessary, but may be used to rule out other conditions
    29. 29. Kelley MJ, et al, JOSPT, 39 (2), 2009
    30. 30. Kelley MJ, et al, JOSPT, 39 (2), 2009
    31. 31. Kelley MJ, et al, JOSPT, 39 (2), 2009
    32. 32. Natural History • Little agreement in the literature • “even the most severe cases recover with or without treatment in about 2 years,” Codman – 1934 • “20-40 % of cases do not respond to conservative treatment” Castellarin – 2004
    33. 33. Duration of the Disease (with conservative treatment) • Reeves – 1975 • Prospective study, n = 41 • Average duration; 30.1 months • Shaffer et al. – 1992 • Retrospective study, n = 62 • Average duration; 12 months • Miller et al. – 1996 • Retrospective study, n = 50 • Average duration; 14 months
    34. 34. Long Term Effects • Reeves – 1975 • At 5 yr. f/u: 54% with limited ROM • 7% with functional limitation • Shaffer et al. – 1992 • At 7 year f/u: 43% with limited ROM • 11% had functional limitation • Miller et al. – 1996 • At 10 year f/u: 100% regained „functional ROM‟
    35. 35. Long Term Effects • Summary: Full PLOF is not a given.
    36. 36. Treatment Options • Wait and see • PT directed rehab • MD directed rehab • Oral corticosteroids • Steroid injections • Capsular distension • Long lever MUA • Arthroscopic release • Translational MUA
    37. 37. Oral steroids Cochrane Review : Buchbinder, 2009 • One trial reported significant short-term benefits of oral steroids versus placebo: 48% reported success; overall improvement in pain 2.7 on a 0 to 10 point scale; total shoulder abduction increased by 23.3 degrees; Shoulder Pain and Disability Index (SPADI) score improved by 18.1. But benefits were not maintained at 6 weeks. • A second trial reported no significant differences between oral steroid and placebo in pain or range of movement. • A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months. • Conclusion: oral steroids provides significant short-term benefits in pain, range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks.
    38. 38. Steroid Injections Cochrane Review : Buchbinder, 2009 • For adhesive capsulitis, two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling. One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term. • Conclusion: Despite many RCTs of corticosteroid injections for shoulder pain, their small sample sizes, variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment. Subacromial corticosteroid injection for rotator cuff disease and intra- articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well- maintained.
    39. 39. Capsular Distension Cochrane: Buchbinder 2009 • Distension methods: air, air w steroid injection, saline, and saline w steroid injection • Undergoing distension with steroid and saline solution compared to placebo (fake distension); - May improve pain at three weeks. - May improve disability at three, six and 12 weeks. • Undergoing distension with steroid and saline solution compared to ordinary injection with steroid; - May not lead to any difference in pain and disability. • Conclusion: arthrographic distension with saline and steroid provides short-term benefits in pain, range of movement and function in adhesive capsulitis. It is uncertain whether this is better than alternative interventions.
    40. 40. Traditional Manipulation long-lever techniques • Common practice in some centers for patients who have failed conservative Rx. • Sandor – 2000. • M.U.A. is a useful way to treat frozen shoulder. • Kivimaki et al. – 2001. • Traditional manipulation risks fracture, especially in osteoporotic patients. • Hannifan - 2000
    41. 41. • Markus et al. – 2005 • 30 consecutive cases of recalcitrant AC received MUA • “unequivocal acute intrarticular lesions were found in 12 joints” • 4 Ant. labrum detachments- with 1 osteochondral fragment • 3 SLAP tears • 2 Partial ruptures of GH ligaments • 2 Partial tears of subscapularis tendons • “the joint should not be mobilized by force. In resistant shoulders, controlled endoscopic release is preferable.” Traditional Manipulation long-lever techniques
    42. 42. Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis: A Case Series • Subjects (N= 4) • Average Symptom Duration = 7.5 mo • Treatment • Interscalene block followed by impairment-based mobilizations/manipulations • Post manipulation Rx: mobilization, ROM, strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits) • Outcome Measures • PROM and SPADI • Video fluoroscopy recordings for 2 patients • Taken pre-rx, immediately post-rx, 6- and 12-week (Boyles et al, Manual Therapy, 2005)
    43. 43. 0 100 200 300 400 500 600 Patient 1 Patient 2 Patient 3 Patient 4 DegreesofPROM Pre-Rx Immediate Final Total Passive ROM
    44. 44. 0 10 20 30 40 50 60 70 Patient 1 Patient 2 Patient 3 Patient 4 SPADIscore(0-100) Pre-RX Final SPADI Scores (Pre-manipulation to final)
    45. 45. Results Post ER Post AbdPre Abd Pre ER
    46. 46. Video Fluoroscopy 6 wk Post- ManipulationPre-Manipulation
    47. 47. Case Studies: Arthroscopic findings following translational MUA. Hando B., article in write up • Arthroscopy performed immediately following translational manipulations • Patient #1: 42 y.o. diabetic male. 14 month history of labral tear, impingement. AC x 7 months. • Patient #2: 42 y.o.f., secondary AC s/p humeral neck fracture. AC x 14 months.
    48. 48. Patient #1 Diabetic male, AC x 7 months Humera l head Torn Scar tissue Glenoid
    49. 49. Patient #1: Diabetic male, AC x 7 months Humeral head Scar Tissue Labrum
    50. 50. Patient #2: Secondary AC x 14 months. Humeral head „Veil‟ of scar tissue
    51. 51. Patient #2: Secondary AC x 14 months. Humeral head Scar tissue Glenoid
    52. 52. Intra-articular Findings • In both shoulders: • No acute intra-articular lesions were found. Rotator cuff, biceps tendon, subscapularis tendon, glenoid, labru m and humeral surfaces were found in perfect condition.
    53. 53. Translational Manipulation Theory • “Translational manipulation attempts to restore the normal movements associated with angular GH motion.” • “…the applied force moves the humeral head in a linear direction, parallel to the glenoid fossa.” • Advantages over long-lever M.U.A include: • Minimizing GH joint compression • Improved operator control • Increased subacromial space • Isolates manipulative force to GH joint • Minimizes stress to brachial plexus Placzek, et al, Amer J of Ortho– 2004
    54. 54. Prognosis • In most cases conservative treatment is successful in relieving pain and restoring pre- condition motion. • Some patients may never regain full motion • Estimated 10% of patients unsuccessful with conservative treatment and require more aggressive management • Spontaneous recovery may occur up to 2 years post-onset
    55. 55. • Little evidence to support modalities, oral or injectable steroids or capsular distension. All may have some short term relief but none reported for the long term. • Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis. • Perhaps, patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard, less effective programs. Clinical Bottom Line
    57. 57. Green et al, Cochrane Database of Systematic Reviews, 2003 Physiotherapy Interventions for Shoulder Pain • Two broad categories of shoulder pain: • Rotator cuff tendonitis disease • Adhesive capsulitis • Results • Exercise is effective for short- and long-term recovery in rotator cuff disease • Manual therapy provides added benefit to exercise • No evidence of US effectiveness in shoulder pain • No evidence that physiotherapy alone is of benefit for adhesive capsulitis
    58. 58. Green et al, Cochrane Database of Systematic Reviews, 2010 Physiotherapy Interventions for Shoulder Pain • Two broad categories of shoulder pain: • Rotator cuff tendonitis disease • Adhesive capsulitis • Results • Exercise is effective for short- and long-term recovery in rotator cuff disease • Manual therapy provides added benefit to exercise • No evidence of US effectiveness in shoulder pain, AC, rotator cuff disease • No evidence that physiotherapy alone is of benefit for adhesive capsulitis
    59. 59. Effectiveness of Rehabilitation for Patients with Impingement Syndrome: A Systematic Review • Systematic review of 12 RCTs • Results: • Therex more effective in reducing pain and increasing function than placebo. Mixed results when compared to surgery • Adding MT to therex provides favorable outcomes compared to therex alone • Does not support the use of US as a beneficial treatment • Conflicting results in use of acupuncture Michener LA et al, J Hand Ther, 2004
    60. 60. Paul Mintken, Josh Cleland, Kristin Carpenter, Mel Bieniek, Mike Keirns, Julie Whitman Physical Therapy January 2010 Identifying Prognostic Factors for Successful Short-Term Outcomes in Individuals with Shoulder Pain Receiving Cervicothoracic Manipulation
    61. 61. 5 Variables in the CPR • Painfree shoulder flexion < 1270 • Shoulder IR < 530 at 900 abduction • Negative Neer test • Not taking medications • Symptoms < 90 days
    62. 62. Prognostic Factors for MT Mintken et al, Physical Therapy, Jan, 2010
    63. 63. The Rule Pre-test Probability of Dramatic Success with Manipulation 61% 3 or more present: •Painfree shoulder flexion < 1270 •Shoulder IR < 530 •Negative Neer test •Not taking medications •Symptoms < 90 days 89% Post-test Probability of Dramatic Success with Manipulation +LR = 5.3
    64. 64. Prognostic Factors: Risk of Persistent Pain Kuijpers et al, Pain, J2006
    65. 65. In the works…. Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation: A randomized clinical trial. Mintken P, Boyles R, Cleland J, Michener L, Strunce J, Burns S, Carpenter K, McDevitt A
    66. 66. In the works….. In data collection phase Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome: a randomized clinical trial. Rhon, Boyles & Cleland VS
    67. 67. SHOULDER INSTABILITY Things that move too much…
    68. 68. Epidemiology 66%-100% of individuals < 20 years of age 13%-63% of individuals between 20 and 40 years age 0%-16% of individuals older than 40 years of age Instability is defined as a clinical syndrome that occurs when shoulder laxity produces symptoms
    69. 69. Epidemiology • Primary Dislocations: • Most common in 2nd & 6th decades • ~92-98% are anterior dislocations (remainder are posterior) • 95% of first-time dislocations result from traumatic force • 5% are atraumatic (sleep, minor movements) • Recurrent Dislocations: • 70% of first-time dislocations dislocate again within 2 years • Younger patients more likely to have recurrence Shoulder Dislocation
    70. 70. Laxity vs. Instability • Laxity – the extent to which the humeral head can be translated on the glenoid • Instability – an abnormal increase in GH translation that causes symptoms (subluxation or dislocation) Schenk, J Am Acad Orthop Surg, 1998.
    71. 71. Shoulder Stability: A Result of Multiple Components • Bony Congruency • Enhanced by labrum • Negative pressure • at side & at rest • Muscles & tendons • static and dynamic • Ligaments & capsule Glenohumeral Elevation
    72. 72. Shoulder Function • G-H joint has ↑ mobility, but at loss of stability • 25% of humeral head contacts glenoid fossa • Static, Soft tissue constraints: • Capsule, G-H ligaments, labrum • Dynamic constraints consist of: • Neuromuscular system (proprioceptive mechanisms and scapular/humeral muscles
    73. 73. Labrum Anatomy Putz, et al Ascopy 1999
    74. 74. Neuromuscular Stabilization • The glenoid moves like a seal‟s nose to remain in the right spot to control the ball (head) The Shoulder: A Balance of Mobility and Stability
    75. 75. Classifying Instability
    76. 76. Classifying Instability
    77. 77. Classifying Instability
    78. 78. Instability Spectrum TUBS AMBRI Born LooseTorn Loose
    79. 79. Clinical Presentation Traumatic Injury • Position of dislocation • Anterior/posterior shoulder pain • Apprehensive to moving arm out from body Nontraumatic Injury • General multi-joint hypermobility • Anterior/posterior shoulder pain • Loose inferior capsule
    80. 80. Clinical Presentation Traumatic Injury • Position of dislocation • Anterior/posterior shoulder pain • Apprehensive to moving arm out from body Nontraumatic Injury • General multi-joint hypermobility • Anterior/posterior shoulder pain • Loose inferior capsule
    81. 81. Physical Examination • Observation: • “protective” posture • Anterior tipping of scapulae • Pain/palpation • Diffuse pain over anterior and posterior shoulder • Humeral head position at rest • Motion • Unable/unwilling to move into endranges of ABD & ER • Strength • Limited by pain, weak ABD & ER • Ability to co-activate dynamic stabilizers likely diminished • Check RC and scapular muscles • Sensation/Proprioception • Sensation generally intact, check Axillary n. • Proprioception/Kinesthetic deficits may be noticeable
    82. 82. Physical Examination Special tests Apprehension test Relocation test Load & Shift test Sulcus test
    83. 83. Non-surgical Management • Older patients have lower recurrence therefore better candidates vs younger patients • Immobilization has been standard component • Traditionally 6 weeks in ADD/IR (sling) position • More recently, immobilize in AB/ER • Neither approach give optimal outcomes; recurrence rates of ~ 30% Traumatic Instability
    84. 84. Non-surgical Management • Role of Exercise • Few studies investigating outcomes • Aronen et al (1984) advocated strengthening program emphasizing adductor and internal rotation motions • Yoneda et al (1982) used similar approach but included strengthening in higher positions of abduction • Both studies had re-dislocation rates in the 15-25% range • Gibson et al, 2004. Cochrane Review: Low evidence, 6 weeks of immobilization and 12 weeks of structured rehab, including scap stability. Surgical approach may be superior. Traumatic Instability
    85. 85. Non-surgical Management • Role of Exercise • Again, few studies investigating outcomes • Progressive strengthening of rotator cuff, deltoid and scapular stabilizers • Functional coordination exercise • Lifestyle modification General Instability Rehabilitation Principles
    86. 86. Exercise for Selected Shoulder Disorders
    87. 87. Essential Elements for Dynamic Stability of the Shoulder Complex • Adequate compressive forces • RC doing its job • Scapular base • Mobility/stability • Proprioception and NM control of the entire kinetic chain • Muscular endurance • Train to job/sport specificity
    88. 88. Shoulder Flexibility Requirements • Pectoralis Muscles: • Associated with excessive scapular protraction and downward rotation, both disturbing optimal glenohumeral mechanics. • Posterior-Inferior G-H Capsule: • Associated with SLAP tears & internal impingement syndrome in throwing athletes • Latissimus Dorsi and Teres Major: • Associated with resistance to UE elevation
    89. 89. Andersen et al. Phys Ther. 2010 Apr;90(4):538-49. • RESULTS: Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance. • CONCLUSIONS: • Therapists can choose either resistance method in clinical practice.
    90. 90. How do we load the shoulder? Myth • We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles. Evidence* • EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight • Larger muscle groups do not overpower smaller groups, such as the rotator cuff. • Load should be based on the individual goals requirements. Alpert et al (J Shoulder Elbow Surg. 2000;9:47-58) Dark et al (Phys Ther. 2007;87:1039-1046)
    91. 91. Baechle TR. Essentials of Strength and Conditioning. Human Kinetics. 2008. Strength Continuum
    92. 92. SCAPULA‟S ROLE IN SHOULDER STABILITY • Dynamic positioning of the glenoid fossa relative to the humeral axis (~300) • Minimizes GH shear & maximizes GH compression • Optimal muscle activation (minimized RTC activation requirements) • Stable base of origin for muscles • Responsible for function and stability • Length dependent activation patterns • Deltoid, biceps, triceps, and RTC
    93. 93. Evidence Based Scapular Interventions • Serratus anterior strengthening or retraining • Upper trapezius activation reduction • Pectoralis minor stretching • Thoracic extension posture and exercise • Posterior shoulder stretching
    94. 94. Scapular Retraining Exercises • Scapular Punches • Isometric Scapular Retractions • Scapular Clocks • Rotations on a ball • Prone Y‟s, T‟s, W‟s • Seated push-ups • Rows • Integrate hip/trunk strengthening and stretching throughout rehab
    95. 95. What are the best exercises for Muscles around the shoulder ?
    96. 96. Recommended Exercises for Rotator Cuff • Supraspinatus • 1. Full can • 2. Prone full can • Infraspinatus and teres minor • 1. Side-lying ER • 2. Prone ER at 90° abduction • 3. ER with towel roll • Subscapularis • 1. IR at 0° abduction • 2. IR at 90° abduction (less pec) • 3. IR diagonal exercise
    97. 97. 20 participants performed full can and empty can exercises and 3D scapula kinematics were captured Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN exercise. When maintenance of the subacromial space is important, use of the FULL CAN exercise seems most appropriate for selective strengthening of the supraspinatus
    98. 98. Infraspinatus and subscapularis activity…. • Infraspinatus and subscapularis activity have generally been reported to be higher in the „full can‟ compared with the „empty can‟, • Posterior deltoid activity is higher in „empty can‟ ex. Escamilla et al. Sports Med 2009; 39 (8): 663-685
    99. 99. Best Exercise for the Serratus? Ludewig et al. Am J Sports Med 2004 32: 484-93. SUGGESTED SEQUENCE • Plus phase: Wall Pushup Plus • Elbow Pushup Plus • Knee Pushup Plus • Standard Pushup Plus In clinical cases of scapular winging the Standard Pushup Plus is an optimal exercise
    100. 100. Recommended Exercises for Serratus Serratus anterior • 1. Push-up with plus • 2. Dynamic hug • 3. Serratus punch 120°
    101. 101. Recommended Exercises for Trapezii • Lower trapezius • 1. Prone full can • 2. Prone ER at 90° abduction • 3. Prone horiz abd at 90° with ER • 4. Bilateral ER (best LT/UT ratio) • Middle trapezius • 1. Prone row • 2. Prone horiz abd at 90° with ER • Upper trapezius • 1. Shrug • 2. Prone row • 3. Prone horiz abd at 90° with ER
    102. 102. Best Exercises to Minimize Upper Trap? • Exercises promoting lower trapezius (LT), middle trapezius (MT), and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended. • Examined 12 commonly used trapezius exercises and looked for low ratios of UT/LT, UT/MT, or UT/SA • No exercise optimized UT/SA ratio. • This is the first study calculating balance ratios of trapezius activity during these exercises. Cools et al. Am J Sportsmedicine.2007;35(10):1744-51
    103. 103. Conclusions: THESE are good trapezius exercises , but they are NOT good Serratus Anterior Ex • sidelying external rotation, • side-lying forward flexion, • prone horiz. abduction with external rotation, and • prone extension exercises ….to promote LT and MT activity with minimal activation of the UT part. • Based on our results, we suggest the use of: Cools et al. Am J Sportsmedicine.2007;35(10):1744-51
    104. 104. Recommended Exercises for Rhomboids and Levator • Rhomboids and levator scapulae • 1. Prone row • 2. Prone horiz abd at 90° with ER • 3. Prone extension with ER Escamilla et al. Sports Med 2009; 39 (8): 663-685
    105. 105. General thoughts on therex for shoulder • Initial phase • Pain control, edema reduction, gentle PROM, address functional problems • Sub-acute • Progress PROM as tolerated, possibly add in AAROM, address functional problems • Progress to AROM followed by strengthening • Return to functional state • Progress strengthening, agility, dynamic stabilization, sport- specific exercises
    106. 106. • 10 Patients with Impingement received • Manual Therapy (Using a regional interdependence approach) • 3 Phase Exercise Protocol by Tate et al JOSPT 2008 • Motor control/strengthening (phases I-III) • Stretching • Patient Education
    107. 107. Program Summary and Outcomes Tate et al. JOSPT 2010. 40(8)
    108. 108. Instructions • Begin with band under very mild tension • Progress to next strongest elastic band when able to do 3 sets of 10 reps without substantial pain or fatigue • T-band standard: 3.5ft long • Longer for taller people doing scaption • Avoid or modify position of any exercise producing significant symptoms Tate et al. JOSPT 2010. 40(8)
    109. 109. Tateetal.JOSPT2010.40(8)
    110. 110. Tate et al. JOSPT 2010. 40(8) Phase I
    111. 111. Tate et al. JOSPT 2010. 40(8) Phase II
    112. 112. Tate et al. JOSPT 2010. 40(8) Phase III
    113. 113. Clinical Bottom Line: Exercise for SIS • Conservative treatment is recommended over surgery • Exercise is effective at improving pain and function • Improve scapular motion and clear subacromial space • Correct posture • Strengthen shoulder stabilizers • Rhomboids • Serratus anterior • Mid and Lower trapezius • Strengthen rotator cuff • Stretch tight structures • Pec major and minor • Upper trapezius • Posterior capsule
    114. 114. Exercise for Rotator Cuff Tears
    115. 115. • Results: • 4 studies were specific to massive rotator cuff tears. • 1 study had a sub-group with massive cuff tears • 5 studies were not specific on size of the full thickness tear. • Due to the heterogeneity of outcome measures used, it was not possible to combine results. • In all studies an improvement in outcome scores was reported • The findings suggest that some evidence exists to support the use of exercise in the management of full thickness rotator cuff tears. Ainsworth & Lewis. Br J Sports Med 2007;41:200–210.
    116. 116. • 20 patients with full-thickness rotator cuff tears [RCTs] • Treatment: activity modification, NSAIDs, physical modalities, and a specific exercise program • Statistically significant improvements were obtained in • ROM • Pain • Function scores according to ASES, Constant score, SF-36 scores, and isokinetic strength (P < 0.05). At the 6-month evaluation, • 11 patients (55%) reported that they were “much better” • 9 patients (45%) “better”. • Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively. Baydar et al. Rheumatol Int (2009) 29:623–628
    117. 117. • Conclusion: Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive. Seida et al. Ann Intern Med. 2010 Aug 17;153(4):246-55. Epub 2010 Jul 5
    118. 118. Exercise for Instability
    119. 119. • Functional rehab following shoulder dislocation • Increase proprioceptive awareness • Increase dynamic stabilization • Elicit preparatory and reactive muscle activation • Restoration of functional movement patterns • (Lephart and Henry, 1996) • Open and closed chain exercises improve proprioception • (Rogol et al, 1998). • Closed chain activities increase functional joint stability • (Ubinger et al, 1999; Henry et al, 2001) • Exercises that enhance coactivation improve recovery • (Ginn and Cohen, 2005) • Shoulder plyometric training increases proprioception • (Swanik et al, 2002) Shoulder Instability Rehab
    120. 120. Motor Control Alterations with GH Instabity • Decreased supraspinatus- subscapularis coactivation • Slower biceps brachii activation • Decreased pectoralis major & biceps brachii recruitment • Suppressed scapular stabilization by Trapezius and Serratus • (Glousman et al., 1988; Kelly et al 2005; Kronberg et al., 1991; McMahonet al., 1996; Myers et al., 2004)
    121. 121. • 6 Subjects with GH Instability • Significant increases scapular protraction and anterior tilt. • Activity of the lower trap and serratus delayed during first part of elevation • Altered humeral head and glenoid alignment predispose shoulder instability • Scapular changes are perhaps due to an inadequate scapular muscular activity. • Evidence to suggest that the sensorimotor contributors to joint stability can be restored. The unstable shoulder in arm elevation: A three- dimensional and electromyographic study in subjects with glenohumeral instability. Matias R, Pascoal AG Clinical Biomechanics 21 (2006) S52–S58
    122. 122. Naughton J et al. Upper-body wobbleboard training effects on the post- dislocation shoulder. Phys Ther In Sport. 2005; 6:31–37. • 15 uninjured control • 15 dislocated/subluxed within 1 year • Assessed movement discrimination • 4 wk training period Trunk Lying on Swiss ball balancing UE on wobbleboard 10 min daily Significant improvement movement discrimination with dislocators ( p<0.001)
    123. 123. • Rehab success for shoulder instability • Requires cuff recruitment • Facilitate glenohumeral approximation • Concavity-Compression Retraining • (Similar to Dynamic Relocation Test) Neuromuscular retraining for multidirectional instability of the shoulder -- a case study. Darlow B NZ J Physiother. 2006;34(2):60-65.
    124. 124. Instability Rehabilitation Implications • Restore normal function of rotator cuff musculature • Strengthen infraspinatus and teres minor (ERs) to avoid anterio- inferior instability • Avoid rehabilitation exercises combining abduction and external rotation • Serratus anterior and trapezius strengthening exercises can begin early in rehab process • Begin with isometric exercises with manual resistance, progress to dynamic strengthening • Eventually plyometric exercises for highly active populations • Include proprioceptive exercises to combat loss due to tissue damage
    125. 125. Advanced phase: functional rehabilitation • Focus on continued strength and endurance • Retraining patterns of movement biased towards functional tasks • Repetition, speed and load may be varied facilitating feedforward processing • Dynamic stabilization challenged by pushups on a ball or throwing and catching a ball • Plyometric drills such as two-hand chest passes, overhead soccer throw and side-to- side throws • Bouncing balls off trampoline • Global upper-limb strengthening • Kibler et al. Clin Sports Med 2008 Jaggi and Lambert Br J Sports Med 2010;44:5 333-340
    126. 126. • Integrate LE/trunk w/loads • Push-press to single-arm squat • Lunge and Reach Progression Integrating the Shoulder: Return to Function Phase
    127. 127. Return to sport • Sport specific goal-orientated tasks • Throwing at a specific target • Bouncing a ball around an obstacle course • Shooting into a basketball/netball hoop • Patient should regain 5 key components prior to return to sport 1. Flexibility 2. Strength 3. Balance 4. Proprioception 5. CONFIDENCE! • If confidence is lacking, patient at risk of compensation, reinjury and recurrence of instability. Jaggi and Lambert Br J Sports Med 2010;44:5 333-340
    128. 128. Upper Extremity Y-Balance Test • “Y Balance test is a body relative quantitative analysis of a person‟s ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limb.” • Test-retest reliability 0.80 to 0.99 • Interrater reliability 1.00 • Average composite scores right/left (%Limb Length) • Men 81.7%/82.3% • Women 80.7% /80.7%. Gorman, Butler Plisky and Kiesel. J Strength Cond Res. 2012 Jan 5. Epub
    129. 129. Our Path Things that don‟t move enough • Subacromial Impingement • Adhesive Capsulitis • Evidence for Manual Therapy Things that move too much • Shoulder Instability • Evidence-supported exercise I‟m getting Emotional…
    130. 130. I‟m getting Emotional… Evidence for risk factors for chronic pain • Catastrophizing, fear avoidance, self-efficacy, all important for shoulder dysfunction, like so many MSK conditions • COMT phenotypes? Kinesiophobia • Measure these fine things! • TSK, FDAQ, FABQ Remember to acknowledge and treat chronic conditions as chronic pain • Graded Exposure/Graded Exercise • Pain Science Education • Fewer manual technqiues • Focus on function
    131. 131. Pain Phenotypes, you say? • Genetic expressions for inflammation (IL1B, TNF/LTA region, IL6 single nucleotide polymorphisms, SNPs) • and, Psychological factors… • Combine to predict shoulder pain phenotypes: specifically, pain level, duration, and disability George et al, 3/2014 Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype.
    132. 132. Genetically Predisposed? • Strong associations between type of COMT (catechol-o-methyl- transferase) phenotype and catastrophizing! • Are predictive of upper extremity disability and depressive symptoms related to pain Biopsychosocial influence on exercise-induced injury: genetic and psychological combinations are predictive of shoulder pain phenotypes. George et al, 1/2014
    133. 133. References 1. Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;30(3):126-137. 2. Boyles RE, Ritland BM, Miracle BM, et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther. 2009;14(4):375-380. 3. Kuijpers T, van Tulder MW, van der Heijden GJMG, Bouter LM, van der Windt DAWM. Costs of shoulder pain in primary care consulters: a prospective cohort study in The Netherlands. BMC Musculoskelet Disord. 2006;7:83. 4. McClure P, Tate AR, Kareha S, Irwin D, Zlupko E. A clinical method for identifying scapular dyskinesis, part 1: reliability. J Athl Train. 2009;44(2):160-164. 5. Mintken PE, Cleland JA, Carpenter KJ, et al. Some factors predict successful short-term outcomes in individuals with shoulder pain receiving cervicothoracic manipulation: a single-arm trial. Phys Ther. 2010;90(1):26-42. 6. Morse K, Davis AD, Afra R, et al. Arthroscopic versus mini-open rotator cuff repair: a comprehensive review and meta-analysis. Am J Sports Med. 2008;36(9):1824- 1828. 7. Norlander S, Nordgren B. Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine. Scand J Rehabil Med. 1998;30(4):243-251. 8. Tate AR, McClure PW, Kareha S, Irwin D. Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in overhead athletes. J Orthop Sports Phys Ther. 2008;38(1):4-11. 9. Tate AR, McClure P, Kareha S, Irwin D, Barbe MF. A clinical method for identifying scapular dyskinesis, part 2: validity. J Athl Train. 2009;44(2):165-173. 10. Winters JC, Jorritsma W, Groenier KH, et al. Treatment of shoulder complaints in general practice: long term results of a randomised, single blind study comparing physiotherapy, manipulation, and corticosteroid injection. BMJ. 1999;318(7195):1395-1396. 11. Crawshaw DP, Helliwell PS, Hensor EMA, et al. Exercise therapy after corticosteroid injection for moderate to severe shoulder pain: large pragmatic randomised trial. BMJ. 2010;340:c3037. 12. Conroy DE, Hayes KW. The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome. J Orthop Sports Phys Ther. 1998;28(1):3-14. 13. Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;30(3):126-37. 14. Bergman GJD, Winters JC, Groenier KH, et al. Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain: a randomized, controlled trial. Ann Intern Med. 2004;141(6):432-9. 15. Winters JC, Sobel JS, Groenier KH, Arendzen HJ, Meyboom-de Jong B. Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice: randomised, single blind study. BMJ. 1997;314(7090):1320-5. 16. Senbursa G, Baltaci G, Atay A. Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: a prospective, randomized clinical trial. Knee Surg Sports Traumatol Arthrosc. 2007;15(7):915-21. 17. Boyles RE, Ritland BM, Miracle BM, et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther. 2008. Available at: [Accessed September 7, 2008]. 18. Arslan S, Celiker R. Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis. Rheumatol Int. 2001;21(1):20-3. 19. Vermeulen HM, Rozing PM, Obermann WR, le Cessie S, Vliet Vlieland TPM. Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: randomized controlled trial. Phys Ther. 2006;86(3):355-68. 20. McClatchie L, Laprade J, Martin S, et al. Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults. Man Ther. 2008. Available at: [Accessed September 7, 2008]. Holmgren, Theresa, Hanna Björnsson Hallgren, Birgitta Öberg, Lars Adolfsson, and Kajsa Johansson. “Effect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome: Randomised Controlled Study.” BMJ (Clinical Research Ed.) 344 (2012): e787.
    134. 134. References: • Brotzman SC, Manske RC: Clinical Orthopedic Rehabilitation. Elsevier, 2011 • Carter T, Hall H, McIntosh G, et al. Intertester reliability of a classification system for shoulder pain. Physiotherapy. 2012; 98:40-6 • Hayes K, Callanan M, Walton J, et al: Shoulder instability: management and rehabilitation. JOSPT, 2002; 32:497-509 • Hegedus EJ, Goode AP, Cook CE, et al: Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012; DOI: 10.1136/bjsports-2012-091066 • Jaggi A, Lambert S: Rehabilitation for shoulder instability. Br J Sports Med. 2010; 44:333– 340 • May S, Chance-Larsen K, et al: Reliability of physical examination tests used in the assessment of patients with shoulder problems: a systematic review. 2010;90:179-190 • Robinson CM, Howes J, Murdoch H, Will E, Graham C: Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients. J Bone Joint Surg Am, 2006; 88:2326-36 • Wilk KE, Reinold MM, Dugas JR, Arrigo CA, Moser MW, Andrews JR. Current concepts in the recognition and treatment of superior labral (SLAP) lesions. J Orthop Sports Phys Ther. 2005;35:273-91