2012 rehab

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2012 rehab

  1. 1. Shoulder Rehab Martin A. Scott MSc MCSPNottingham Shoulder & Elbow Unit martin.scott@nuh.nhs.uk Meister, 2000a 1
  2. 2. © Bodies Factors affecting glenohumeral The “hypermobile” shoulder hypermobile” joint stability Labrum X Joint capsule XStability is lost to increase therange of motion (Tennent, (Tennent, Ligaments XBeach & Meyers (2003)) Internal pressure ? gradientDynamic control is a major Bony cam ?issue Dynamic muscle √ contraction 2
  3. 3. Dislocation Dislocation Traumatic Atraumatic Traumatic AtraumaticEnd of range Mid range End of range Mid rangeLigament/labral damage Not constrained by Ligament/labral damage Not constrained by ligaments ligaments Controlled by muscles Lippitt S & Matsen F (1993) CORR 291 Lippitt S & Matsen F (1993) CORR 291 Lee SB et al (2000) JBJS 82A(6) Lee SB et al (2000) JBJS 82A(6) Instability InstabilityHigh risk sports TUBS Contact +/- throwing (Boileau et al., 2006 ) +/- (Boileau Can be hyper lax (eg (eg At 4 year mean follow up, 26/91, Boileau et al., subscapularis functionReturn to sport (mean 36 months post-op) post- 2006) correlates with outcome 14/91 failures (further instability) Conservative treatment from surgery (Sachs et al., gives 17-96% recurrence 17- 2005) 2005 ) 58/91 at same level in patients <30 (Bottoni (Bottoni 13/91 at a lower level et al., 2002) 6/91 stopped participation (Boileau et al., 2006) (Boileau Instability Impingement Harryman et al., 1990 Sachs et al., 2005 3
  4. 4. Impingement ImpingementPrimarySecondary Internal (Budoff et al., (Budoff 2003; Belling Sorensen and Jorgensen, 2000; van der Hoeven and Kibler, Kibler, 2006) Observed in arthroscopy (Yoneda et al., 2006 ) Harryman et al., 1990 Impingement ImpingementPrimary PrimarySecondary Secondary Internal (Budoff et al., (Budoff Internal (Budoff et al., (Budoff 2003; Belling Sorensen 2003; Belling Sorensen and Jorgensen, 2000; van and Jorgensen, 2000; van der Hoeven and Kibler, Kibler, der Hoeven and Kibler, Kibler, 2006) 2006) Observed in arthroscopy (Yoneda et al., 2006 ) Impingement Impingement 4
  5. 5. Impingement ImpingementPrimarySecondary Internal (Budoff et al., (Budoff 2003; Belling Sorensen and Jorgensen, 2000; van der Hoeven and Kibler, Kibler, 2006) Neer, 1972; Yanai and Hay, 2000; Wilk et al., 2002 Impingement Impingement Labriola et al., 2005 Elliott, 2006 Instability Assessment Muscle patterning Observation Under/over recruitment Relative alignment of Low/high tone bony landmarks Movement patterns Relative timing of movements of body segments 5
  6. 6. Range of motion Gain appropriate ROM Tight posterior inferior glenohumeral joint capsule Tightness/stiffness Allow free movement of can pull the scapula away • Latissimus Dorsi the scapula around the from the chest wall (Burkhart thorax, and external et al 2003) • Pectoralis Minor Stiff latissimus dorsi impedes rotation of the humerus full scapulothoracic motion • Posterior structures throughout range Stiff pectoralis minor is associated with Type I dyskinesia (Borstad & (Borstad Ludewig 2005)Silliman JF & Hawkins RJ (1993) CORR 291Borstad JD & Ludewig PM (2005) JOSPT 35(4) Strengthen scapulothoracic Strengthen musculature Rotator cuff Allows control of the Scapulothoracic Serratus anterior humeral head in the muscles Lower fibres of trapezius glenoid Allows the glenoid to be positioned relative to External rotators the humeral head Hawkins RJ & Saddemi SR (1990) Cur Orth 4 Kibler, W. B. (1998). Medicine & Science in Sports & Exercise 30(4 Suppl): S40-50. Strengthen scapulothoracic Strengthen scapulothoracic musculature musculature Serratus anterior Serratus anterior Lower fibres of trapezius Lower fibres of trapezius (Ekstrom et al 2003, Decker Closed chain exercises et al 2003, Michener et al (Kibler 1998) 2005) 6
  7. 7. Maintain scapular dynamicGain scapular dynamic control control Scapulothoracic movement Glenohumeral rhythm Multiplanar exercises Visual feedback Maintain scapular dynamic Maintain scapular dynamic control control ScapulothoracicScapulothoracic movementmovement Glenohumeral rhythmGlenohumeral rhythm Multiplanar exercisesMultiplanar exercises Visual feedback Maintain scapular dynamic From the feet up! control Scapulothoracic movement Glenohumeral rhythm Multiplanar exercises Visual feedback Function! Limpisvasti et al., 2007 7
  8. 8. Harmonious rotation(s) rotation(s) Good alignment Limpisvasti et al., 2007 Good alignment Exactly what are effective throwing mechanics? by Paul Nyman May 02, 2008 Maintain scapular dynamic Maintain dynamic control – andcontrol – and take it into sport! take it into sport! 8
  9. 9. Maintain dynamic control – and Maintain dynamic control – and take it into sport! take it into sport! Thank you Martin A. Scott MSc MCSP Nottingham Shoulder & Elbow Unit martin.scott@nuh.nhs.uk Stretch before Strengthen Rugby● Establish tissue mobility to allow normal kinematics ● Scrum● Allows greater muscle volume to contract and ● Rook release ● Lineout● Reduces risk of secondary compensation ● Tackle(pile on,collision,shirt pull,ankle tap) ● Pass ● Handoff 9
  10. 10. Football Basketball/handball/volleyball● Collision(with other player or ground) ● Blockshot/ Blockshot/● Throw in ● Hookpass/shot Hookpass/shot● Goalkeeping dives ● Ball dribbling Boxing Cricket● Outfield throws ● Impact● Bowling ● Missed punch● Wicketkeeping/slip Wicketkeeping/slip dives ● Fatigue● Crease slides ● Poor defensive posture 10

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