Advanced Shoulder Update

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Advanced Shoulder Update

  1. 1. Advanced Shoulder Update January 16-17, 2010 Material Presented by Ryan Perry Condensed by Christopher Keating
  2. 2. Anatomy Highlights <ul><li>GH,AC,SC,ST,T/S </li></ul><ul><li>Upper Subscap – Mover </li></ul><ul><li>Lower Subscap – Stabilizer </li></ul><ul><li>Supraspinatus – Most prone to degeneration </li></ul><ul><li>8 Bursae in Shoulder </li></ul><ul><li>2 Bursae at Scapula ~ Scapular crepitus </li></ul>
  3. 3. Biomechanics <ul><li>Treat the Glide not the Roll </li></ul><ul><li>GH </li></ul><ul><ul><li>OPP~ 55-70 Abd, 60 E’ Flex, 30 Hoz Add </li></ul></ul><ul><ul><li>CPP~ Max Abd, ER, Ext </li></ul></ul><ul><ul><li>CPP~ IR, Ext, Add </li></ul></ul><ul><li>AC </li></ul><ul><ul><li>CPP~ 90 Abd (Isolates the SC joint) </li></ul></ul><ul><li>SC </li></ul><ul><ul><li>CPP~ Full Elevation </li></ul></ul>
  4. 4. Special Tests Impingement <ul><li>Hawkins-Kennedy </li></ul><ul><ul><li>Patient seated with arm and elbow flexed to 90. The examiner IR the GH compressing subacromial tunnel against the coracoacromial arch </li></ul></ul><ul><ul><li>+ Pain at anterior shoulder </li></ul></ul><ul><ul><li>Sn 92% Sp 25% (Calis 2000) </li></ul></ul><ul><li>Neer </li></ul><ul><ul><li>Patient is seated and examiner forcefully flexes the arm with overpressue with scapular stabilization </li></ul></ul><ul><ul><li>+ Pain at the anterior/lateral/superior </li></ul></ul><ul><ul><li>Sn 88% Sp 30% (Calis 2000) </li></ul></ul>
  5. 5. Special Tests Impingement <ul><li>Cross-Body Adduction </li></ul><ul><ul><li>Positioned as in HK but in place or IR pt is forced into Horizontal Adduction </li></ul></ul><ul><ul><li>+ Pain at Anterior/Lateral Shoulder </li></ul></ul><ul><ul><li>Sp 82% Sn 27% (Calis 2000) </li></ul></ul><ul><li>Cluster Testing </li></ul><ul><ul><li>Park 2005 </li></ul></ul><ul><li>If all 3 tests positive a Likelihood Ratio of 10.56 </li></ul><ul><ul><li>Strong conclusive evidence for impingement </li></ul></ul>
  6. 6. Special Tests RTC Tear (Full) <ul><li>Infraspinatus MMT </li></ul><ul><li>Painful Arc </li></ul><ul><li>Drop-Arm </li></ul><ul><li>Cluster Testing </li></ul><ul><ul><li>Park 2005 </li></ul></ul><ul><ul><li>All 3 + </li></ul></ul><ul><ul><li>Likelihood Ratio of 15 </li></ul></ul><ul><ul><li>If over 70 than 1 + test will be 76% chance of RTC tear </li></ul></ul>
  7. 7. Special Tests Labral Tear <ul><li>O’Brien </li></ul><ul><li>Crank </li></ul><ul><li>Clunk </li></ul><ul><li>Modified Dynamic Labral Shear* </li></ul><ul><li>Anterior Slide </li></ul><ul><li>Anterior Load Shift 0-45-90 * </li></ul>
  8. 8. Scapular Research <ul><li>Scapular weakness and abnormal position have been associated with RTC pathlogy </li></ul><ul><li>Lateral position of scapula increases pressure on anterior structures </li></ul><ul><li>May not correct tear or fix impingement, but can correct malalignment </li></ul><ul><li>Serratus Anterior and Lower Trap are first to be inhibited in scap mechanics </li></ul><ul><li>Upper trap over activation common is patients with scapula malalignment </li></ul>
  9. 9. Manual Therapy Principles <ul><li>Effects of MT </li></ul><ul><ul><li>Reduced Muscle Guarding </li></ul></ul><ul><ul><li>Improved Joint Mobility </li></ul></ul><ul><ul><li>Increased ROM </li></ul></ul><ul><ul><li>Normalized Muscle Tone </li></ul></ul><ul><ul><li>Psychosocial </li></ul></ul>
  10. 10. MTP <ul><li>Fix the Hinge Don’t Crank the Handle </li></ul><ul><li>Avoid osteokinematic motions </li></ul><ul><li>Shortened muscles should not be stretched in the presence of pain </li></ul><ul><ul><li>Inhibit tone </li></ul></ul><ul><ul><ul><li>Mobs, STM, Exercise Dose </li></ul></ul></ul>
  11. 11. Manual Therapy Principles <ul><li>Assess – Rx – Reassess </li></ul><ul><li>Hypomobile joint treatment begins with the exam of adjacent joints </li></ul><ul><li>Begin and End with Distraction </li></ul><ul><li>Treat the Glide of Limitation then Range Joint </li></ul><ul><li>Start at resting position and progress to end range </li></ul>
  12. 12. Techniques <ul><li>GH </li></ul><ul><ul><li>Distraction </li></ul></ul><ul><ul><li>Anterior </li></ul></ul><ul><ul><li>Posterior I, II </li></ul></ul><ul><ul><li>Inferior </li></ul></ul><ul><li>Thoracic </li></ul><ul><ul><li>Mob and Manip </li></ul></ul><ul><li>AC </li></ul><ul><ul><li>Distraction I,II,III </li></ul></ul>
  13. 13. Exercises <ul><li>Best ER </li></ul><ul><ul><li>1) Sidelying ER without Towel </li></ul></ul><ul><ul><li>2) Prone Horizontal abd at 100 full ER </li></ul></ul><ul><ul><li>To progress consider flex in place of Abduction secondary to increases tone and ant instability </li></ul></ul>
  14. 14. Exercises <ul><li>Best Lower Trap </li></ul><ul><ul><li>1) Prone Scaption </li></ul></ul><ul><ul><li>2) Shoulder ER at 90 Abd </li></ul></ul><ul><ul><li>Also the same for middle trap </li></ul></ul>
  15. 15. Exercises <ul><li>Best for Serratus Anterior </li></ul><ul><ul><li>1) D1 Flexion </li></ul></ul><ul><ul><li>2) Scaption > 120 </li></ul></ul><ul><ul><li>3) Scaption < 80 </li></ul></ul><ul><ul><li>Upper SA </li></ul></ul><ul><ul><ul><li>Push-up with a plus </li></ul></ul></ul><ul><ul><ul><li>Bear Hug </li></ul></ul></ul><ul><ul><ul><li>SA Punch </li></ul></ul></ul>
  16. 16. Progressions…

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