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Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
Ann cools 2 internal impingement [compatibiliteitsmodus]
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Ann cools 2 internal impingement [compatibiliteitsmodus]

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  • 1. Internal impingement in theoverhead athlete: GUIDELINES FORREHABILITATION Prof dr Ann Cools, PT, PhD Dept Rehab. Sciences & Physiotherapy Ghent University, Belgium
  • 2. Impingement symptoms External Internal Subacromial (posterior) impingement impingement Primary SecundaryImpingement Impingement Rotator cuff Biceps Scapular dyskinesis instability G.I.R.D. pathology SLAP Ann Cools Wrightington nov 2012 (Cools et al. BJSM 2008)
  • 3. “HYPER-ANGULATION” 1. Anterior instability Excessive humeral head translations 2. Posterior shoulder stiffness Alterations of glenohumeral kinematics 3. Scapular dyskinesis: Insufficient scapular retraction during cocking Ann Cools Wrightington nov 2012(Wilk et al. AJSM 2002, Cools et al. BJSM 2008, Castagna et al. BJSM 2010, Ludewig et al. Man Ther 2011)
  • 4. Patient presentation Female volleyball player (attacker) 27 years old Chronic shoulder pain (6 months) During serve and smash, pain at the back of the shoulder G.I.R.D. Pain in ABER – positive Relocation test – positive Release test Ann Cools Wrightington nov 2012
  • 5. Patient presentation Anterior tilt scapula during rest and arm movements Positive tests scapular involvement in shoulder pain (scapular assistance & scapular retraction test) Pectoralis minor short & tight Ann Cools Wrightington nov 2012
  • 6. “HYPER-ANGULATION” 1. Anterior instability Excessive humeral head translations 2. Posterior shoulder stiffness Alterations of glenohumeral kinematics 3. Scapular dyskinesis: Insufficient scapular retraction during cocking Ann Cools Wrightington nov 2012(Wilk et al. AJSM 2002, Cools et al. BJSM 2008, Castagna et al. BJSM 2010, Ludewig et al. Man Ther 2011)
  • 7. Stretching posteriorshoulder: clinical experience Ann Cools Wrightington nov 2012
  • 8. POSTERIOR SHOULDERSTRETCHING Sleeper’s stretch & cross body stretch improve ROM (Mc Clure 2005) Additional manual mobilisations improve ROM (Manske 2010, Cools 2011) Improvement ROM is related to reduction of symptoms (Tyler 2010) Ann Cools Wrightington nov 2012
  • 9. STRETCHING G.I.R.D.:influence on the subacromial space? Measurements: - Acromiohumeral distance (Echoblaster 128; Telemed, Vilnius, Lithuania) - Glehonumeral ROM (Acumar inclinometer) Quantifying acromiohumeral distance in overhead athletes with glenohumeral internal rotation loss and the Ann Cools Wrightington nov 2012 influence of a stretching program. Maenhout A, Van Eessel V, Vanraes A, Van Dyck L, Cools A. (AJSM May 2012)
  • 10. STRETCHING G.I.R.D.:influence on the subacromial space? Intervention: - 6 weeks stretching - Sleeper’s stretch Quantifying acromiohumeral distance in overhead athletes with glenohumeral internal rotation loss and the Ann Cools Wrightington nov 2012 influence of a stretching program. Maenhout A, Van Eessel V, Vanraes A, Van Dyck L, Cools A. (Accepted AJSM May 2012)
  • 11. STRETCHING G.I.R.D.: 120 influence on the subacromial space? * 100Range of motion (°) 80 * * D 60 ND 40 * 10 20 9 0 * 8 Internal rotation External rotation * Horizontal 7 adduction 6 AHD (mm) 5 D 4 ND 3 2 1 0 Quantifying acromiohumeral distance in overhead athletes with glenohumeral 0° internal rotation loss and60° Ann Cools Wrightington nov 2012 45° Degree of abduction the influence of a stretching program. Maenhout A, Van Eessel V, Vanraes A, Van Dyck L, Cools A. (AJSM May 2012)
  • 12. STRETCHING G.I.R.D.:influence on the subacromial space?Stretching improves ROM , and increases the subacromial space in overhead athletes with GIRD Quantifying acromiohumeral distance in overhead athletes with glenohumeral internal rotation loss and the Ann Cools Wrightington nov 2012 influence of a stretching program. Maenhout A, Van Eessel V, Vanraes A, Van Dyck L, Cools A. (AJSM May 2012)
  • 13. “HYPER-ANGULATION” 1. Anterior instability Excessive humeral head translations 2. Posterior shoulder stiffness Alterations of glenohumeral kinematics 3. Scapular dyskinesis: Insufficient scapular retraction during cocking Ann Cools Wrightington nov 2012(Wilk et al. AJSM 2002, Cools et al. BJSM 2008, Castagna et al. BJSM 2010, Ludewig et al. Man Ther 2011)
  • 14. (Ellenbecker & Cools, BJSM 2010) Scapular Rehab Algorithm Lack of Lack of Soft-tissue flexibility Muscle performance Scapular muscles GH muscles/capsule Muscle Control Muscle Strength- Levator scapulae - infraspinatus - co-contraction - lower/middle trap- pectoralis minor - posterior capsule - force couples - serratus anterior
  • 15. Stretching pectoralis minor: literature Borstad et al. JOSPT 2005: short PM influences scapular kinematics and induces changes similar to impingement related dyskinesis Cools & Johansson BJSM 2010: significant decrease PM length in elite junior (11-17yr) tennis players Reeser PM&R 2010: tight PM is associated with history of shoulder pain in volleyball players Borstad et al. JSES 2006: unilateral self stretch (in 90° ABER) best results, Ann Cools Wrightington nov 2012 however…
  • 16. Stretching pectoralisminor: clinical experience Ann Cools Wrightington nov 2012
  • 17. (Ellenbecker & Cools, BJSM 2010) Scapular Rehab Algorithm Lack of Lack of Soft-tissue flexibility Muscle performance Scapular muscles GH muscles/capsule Muscle Control Muscle Strength- Levator scapulae - infraspinatus - co-contraction - lower/middle trap- pectoralis minor - posterior capsule - force couples - serratus anterior (SAT+) (SRT+)
  • 18. Ann Cools Wrightington nov 2012
  • 19. Scapular muscle balance during RCexercises - progression Ann Cools Wrightington nov 2012
  • 20. Scapular muscle control during basic dailyactivities: external rotation component! Ann Cools Wrightington nov 2012 (Kibler 1998, Vanderhoeven 2006, Kibler 2006, Cools & Walravens 2005, Cools 2008)
  • 21. Results 5 weekstreatment Basic clinical exam is (-) Scapular control increased, however not sufficient No pain during (beach) volleyball, however no full return to sport (season) Working on other links of the kinetic chain (very poor pelvic stability, contol during squat...) Continue self-stretching Ann Cools Wrightington nov 2012
  • 22. Thank youwww.eusser.org 22

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