Shoulder Sjsu Rehab

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Lecture May 2008 at San Jose State University Athletic Training

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Shoulder Sjsu Rehab

  1. 1. SHOULDER REHABILITATION: Evaluation and Treatment of Impingement and Instability Syndromes <ul><li>Ross M. Nakaji, PT, OCS, SCS, ATC, CSCS </li></ul>
  2. 2. ABOUT THE SPEAKER <ul><li>West Valley College, Saratoga, CA 1988-1990: GE Transfer </li></ul><ul><li>University of the Pacific, Stockton, CA in 1993: BA in Sports Medicine, Athletic Training </li></ul><ul><li>Graduate Assistant Trainer (ATC) at Stanford University 1993-1995 </li></ul><ul><li>University of the Pacific in 1997: MS in Physical Therapy </li></ul><ul><li>Board Certification in Orthopedics (OCS, 2002) </li></ul><ul><li>Board Certification in Sports (SCS, 2006) </li></ul><ul><li>Teaching experience: </li></ul><ul><ul><li>O’Connor-Stanford Hospital Sports Medicine/Family Practice Residency and Fellowship </li></ul></ul><ul><ul><ul><li>Clinical/Adjunct Faculty </li></ul></ul></ul><ul><ul><li>SOAR-Stanford Hospital Orthopedic Surgery-Sports Medicine Fellowship </li></ul></ul><ul><ul><ul><li>Guest Lecturer </li></ul></ul></ul><ul><ul><li>West Valley College Sports Medicine Program </li></ul></ul><ul><ul><ul><li>Guest Lecturer </li></ul></ul></ul><ul><ul><li>San Jose State University Sports Medicine </li></ul></ul><ul><ul><ul><li>Guest Lecturer </li></ul></ul></ul><ul><ul><li>Richard Jackson Seminars </li></ul></ul><ul><ul><ul><li>Lab Assistant </li></ul></ul></ul>
  3. 3. ABOUT THE SPEAKER <ul><li>Second Generation PT, father Bob Nakaji, PT </li></ul><ul><li>Wife-Kris Nakaji, PT </li></ul><ul><ul><li>Pediatric PT and Co-Owner of “Kids Perspective PT” </li></ul></ul><ul><li>2 children, Garrison (5), Kimiko (3) </li></ul>
  4. 4. Pop Quiz <ul><li>Ross M. Nakaji, PT, OCS, SCS, ATC, CSCS= </li></ul><ul><li>Small Man’s Syndrome </li></ul><ul><li>Another credential: ADD/ADHD </li></ul><ul><li>Has made numerous mistakes in clinical practice </li></ul><ul><li>All of the above </li></ul><ul><li>Answer: d </li></ul>
  5. 5. OVERVIEW <ul><li>“ The more you know, the less you know” </li></ul><ul><li>Black or White…..shades of Gray </li></ul><ul><li>Rough guideline to assist thought processes </li></ul>
  6. 6. BACKGROUND <ul><li>Common area of complaint in the athlete. </li></ul><ul><li>Not specific to throwing </li></ul><ul><li>Need to make an accurate diagnosis prior to treatment </li></ul><ul><li>Requires an understanding of the anatomy, biomechanics, and common pathology </li></ul>
  7. 7. THE SHOULDER <ul><li>A balance between motion and stability </li></ul><ul><li>Static and dynamic stabilizers </li></ul><ul><ul><li>Static: Bones and ligaments </li></ul></ul><ul><ul><li>Dynamic: Motor groups </li></ul></ul>
  8. 8. SHOULDER ANATOMY <ul><li>The shoulder consists of three bones, three joints, and one non-synovial articulation </li></ul><ul><li>Motor groups: scapular, RTC, & power </li></ul><ul><li>All areas can cause pathology </li></ul><ul><li>Important to be familiar with surface anatomy and radiological anatomy </li></ul>
  9. 9. ARTICULATIONS <ul><li>Glenohumeral joint </li></ul><ul><li>Acromioclavicular joint </li></ul><ul><li>Sternoclavicular </li></ul><ul><li>Scapulothoracic articulation </li></ul>
  10. 10. GLENOHUMERAL JOINT <ul><li>Shallow ball & socket joint </li></ul><ul><ul><li>“ Golf ball on a tee” </li></ul></ul><ul><li>Stabilized by bony contour, labrum, ligaments, and motor groups </li></ul>
  11. 11. LABRUM <ul><li>Deepens glenoid depth </li></ul><ul><li>Chock block function </li></ul><ul><li>Major contributor to stability </li></ul><ul><li>Also allows for attachment of ligaments and biceps </li></ul>
  12. 12. LIGAMENTS <ul><li>Glenohumeral </li></ul><ul><ul><li>Superior </li></ul></ul><ul><ul><li>Middle </li></ul></ul><ul><ul><li>Inferior </li></ul></ul><ul><li>Coraco-clavicular </li></ul><ul><li>Coracoacromial </li></ul>
  13. 13. BONES <ul><li>Humerus </li></ul><ul><li>Scapula </li></ul><ul><li>Clavicle </li></ul>
  14. 14. HUMERUS <ul><li>Articular surface </li></ul><ul><li>Greater tuberosity </li></ul><ul><li>Lesser tuberosity </li></ul><ul><li>Bicipital groove </li></ul>
  15. 15. SCAPULA <ul><li>Glenoid articular surface </li></ul><ul><li>Acromion </li></ul><ul><li>Coracoid process </li></ul><ul><li>Scapular body </li></ul>
  16. 16. ACROMION MORPHOLOGY <ul><li>Type I = flat </li></ul><ul><li>Type II = mild curve </li></ul><ul><li>Type III = sharp hook </li></ul>
  17. 17. CLAVICLE <ul><li>Articular surfaces </li></ul><ul><li>Coracoclavicular and </li></ul><ul><li>coraco-acromial Ligaments </li></ul><ul><li>Shaft </li></ul>
  18. 18. MOTOR FUNCTION <ul><ul><li>Balance between motor groups </li></ul></ul><ul><ul><li>Synchrony for good function </li></ul></ul><ul><ul><li>Force couples for motion </li></ul></ul>
  19. 19. SYNCHRONY/FORCE COUPLES <ul><li>Multiple muscles firing together to impart a specific function. </li></ul><ul><li>Usually pairs of muscles </li></ul><ul><li>Often RTC muscle and power muscle </li></ul><ul><li>Disruption leads to compensation and breakdown </li></ul>
  20. 20. MOTOR FUNCTION <ul><li>Shoulder stabilizers </li></ul><ul><ul><li>(usually weak) </li></ul></ul><ul><li>Scapular stabilizers </li></ul><ul><ul><li>(usually tight, weak) </li></ul></ul><ul><li>Power muscles </li></ul><ul><ul><li>(usually tight, too strong) </li></ul></ul><ul><li>Focus of rehab </li></ul>
  21. 21. SHOULDER STABILIZERS <ul><li>Rotator cuff </li></ul><ul><ul><li>Supraspinatus </li></ul></ul><ul><ul><li>Subscapularis </li></ul></ul><ul><ul><li>Infraspinatus </li></ul></ul><ul><ul><li>Teres minor </li></ul></ul><ul><li>Biceps long head </li></ul>
  22. 22. SCAPULAR STABILIZERS <ul><li>Serratus anterior* </li></ul><ul><li>Rhomboids </li></ul><ul><li>Levator scapulae </li></ul><ul><li>Trapezius (upper, mid, lower*) </li></ul><ul><ul><li>*Key mm in rehab </li></ul></ul>
  23. 23. POWER MUSCLES <ul><li>Deltoid </li></ul><ul><li>Pectoralis major </li></ul><ul><li>Latissimus dorsi </li></ul>
  24. 24. EVALUATING SHOULDER PROBLEMS
  25. 25. PROBLEM AREAS <ul><li>Rotator cuff </li></ul><ul><li>Capsulolabral </li></ul><ul><li>Joint issues </li></ul><ul><li>Miscellaneous issues </li></ul>
  26. 26. EPIDEMIOLOGY <ul><li>Why should we be concerned with Shoulder Pain? </li></ul><ul><ul><li>2 nd leading cause of musculoskeletal primary care visits </li></ul></ul><ul><ul><ul><li>Green S, et. al. Cochrane Database Systematic Review, 2005 </li></ul></ul></ul><ul><ul><li>7.5 million PT visits in 2000 & $39 Billion in direct care costs for shoulder exam and treatments </li></ul></ul><ul><ul><ul><li>Johnson MP, et. al Estimates of direct health care expenditures among individuals with shoulder dysfunction in US. JOSPT 35: A4,2005 </li></ul></ul></ul><ul><ul><li>RTC tendinopathies affect 20-30% of general population and becomes more prevalent and disabling with age . </li></ul></ul><ul><ul><ul><li>Weis JT, et. al. A randomized placebo-controlled trial of PT for RTC tendinopathies. JOSPT (abstract) 35:A5, 2005 </li></ul></ul></ul>
  27. 27. EPIDEMIOLOGY <ul><li>Retrospective descriptive study: </li></ul><ul><ul><li>Impingements: 55% </li></ul></ul><ul><ul><li>Post Op Repairs: 18% </li></ul></ul><ul><ul><li>Frozen Shoulders: 9% </li></ul></ul><ul><ul><li>RTC Tear: 8% </li></ul></ul><ul><ul><li>Shoulder Instability: 3% </li></ul></ul><ul><ul><li>S/P Fx: 2% </li></ul></ul><ul><ul><li>Misc Dx: 5% </li></ul></ul><ul><ul><ul><li>Millar AL, et. al. JOSPT, 36:403-414, 2006 </li></ul></ul></ul>
  28. 28. EPIDEMIOLOGY <ul><li>Retrospective descriptive study: </li></ul><ul><ul><li>Pts improved in both clinical and functional measures </li></ul></ul><ul><ul><li>Type of shoulder dysfunction affects prognosis </li></ul></ul><ul><ul><li>Expected outcomes should be based on the initial diagnosis and specific measures </li></ul></ul><ul><ul><ul><li>Millar AL, et. al. JOSPT, 36:403-414, 2006 </li></ul></ul></ul>
  29. 29. Subjective & History Examination <ul><li>Subjective Functional Assessment </li></ul><ul><ul><li>DASH, Quick Dash </li></ul></ul><ul><ul><ul><li>Denotes Severity of problem </li></ul></ul></ul><ul><li>Visual analog scale 10 cm (VAS) </li></ul><ul><ul><li>Quantifies Irritability and behavior of pain </li></ul></ul><ul><li>Mechanism on Injury (MOI): </li></ul><ul><ul><li>MacroTrauma: Distinct mechanism of injury; </li></ul></ul><ul><ul><li>- Primarily Strengthen and Stabilize </li></ul></ul><ul><ul><li>MicroTrauma: No mechanism, overuse or chronic; </li></ul></ul><ul><ul><ul><li>-C heck and treat biomechanics first </li></ul></ul></ul>
  30. 30. Subjective & History Examination <ul><li>“ Your patient will tell you how to treat them-Listen…” </li></ul><ul><li>Darcy Umphred, PhD, PT </li></ul><ul><li>Retired Professor, University of the Pacific Dept. of Physical Therapy </li></ul>
  31. 31. Subjective & History Examination <ul><li>Location of symptoms: </li></ul><ul><ul><li>Subacromial space  lateral shoulder/deltoid </li></ul></ul><ul><ul><ul><li>Diff. Dx: Young thrower  Little league shoulder/Fx </li></ul></ul></ul><ul><ul><li>AC joint  Superficial to AC joint </li></ul></ul><ul><ul><li>Biceps tendon/Subscapularis  Ant. Shoulder </li></ul></ul><ul><ul><li>Posterior capsule/infraspinatus/Teres minor  </li></ul></ul><ul><ul><li>posterior deltoid region </li></ul></ul><ul><ul><li>Gerber, C. et. al. The pattern of pain produced by irritation of the acromioclavicular joint and subacromial space. JSES, 1998 </li></ul></ul>
  32. 32. Posture <ul><li>Lacks evidence of direct positive effect on shoulder, hypothetical </li></ul><ul><ul><li>Empirically, Sit up, increases Elevation </li></ul></ul><ul><li>Night pain </li></ul><ul><ul><li>Contributing factors: </li></ul></ul><ul><ul><ul><li>Compression of nerves </li></ul></ul></ul><ul><ul><ul><li>Ischemia of tissues </li></ul></ul></ul><ul><li>Normal subacromial space=11 mm </li></ul><ul><ul><li>Salem-Bertoft, E., Thomas, L., Westerberg, C. The influence of retraction and protraction on the width of the subacromial space: an MRI study. CORR, 296:99-103, 1993 </li></ul></ul>
  33. 33. Neurological Scan Exam <ul><li>Dermatomes </li></ul><ul><li>DTRs </li></ul><ul><li>Myotomes </li></ul><ul><li>Peripheral nerve entrapment </li></ul><ul><ul><li>Suprascapular nerve palsy: overhead athlete, pain in posterior shoulder, weakness and atrophy of infraspinous fossa mm </li></ul></ul><ul><li>Clear Cervical Spine </li></ul>
  34. 34. ROM & Posture <ul><li>Adaptive vs. Maladaptive Phenomenon </li></ul><ul><li>Baseball pitchers </li></ul><ul><ul><li>Posterior shift in ROM </li></ul></ul><ul><ul><li>Osseous and non-osseous contractile tissue changes between Dominant and Non Dominant arm </li></ul></ul><ul><ul><li>Total ROM is same </li></ul></ul>
  35. 35. Total Arc of Motion <ul><li>Goniometric Measurements: </li></ul><ul><li>External rotation(ER)=90 deg </li></ul><ul><li>Internal rotation(IR) isolated=45 deg </li></ul><ul><li>Internal rotation Composite (IR +ST)= 70 deg </li></ul><ul><li>Total Arc of Motion=90+70=160 deg </li></ul>
  36. 36. Tennis vs. Baseball players <ul><li>Posterior shift in the ROM and assymetry </li></ul><ul><li>Ellenbecker, TS, Davies, GJ et. al. Med Sci Sports Exer. 34:2052-2056, 2002 </li></ul>
  37. 37. Total Arc of Motion-GIRD <ul><li>NL Total Arc of Motion= </li></ul><ul><li>ER 90 + IR 70= 160 degrees </li></ul><ul><li>Overhead throwing athlete= </li></ul><ul><li>ER 130 + IR 30= 160 degrees </li></ul><ul><li>“Posterior Shift” in Total Arc of Motion </li></ul>
  38. 38. Total Arc of Motion <ul><li>GIRD-ERG </li></ul><ul><ul><li>Glenohumeral internal rotation deficits </li></ul></ul><ul><ul><li>External rotation gain </li></ul></ul><ul><li>Recognition is KEY for treatment: </li></ul>
  39. 39. Shoulder Rotation Motion <ul><li>“ To Stretch or not to Stretch?” </li></ul>
  40. 40. GIRD-ERG Example <ul><li>Uninvolved Side: </li></ul><ul><ul><li>ER 90 + IR 70= Total Arc=160 degrees </li></ul></ul><ul><li>Involved Side: </li></ul><ul><ul><li>ER 130 + IR 30=Total Arc=160 degrees </li></ul></ul><ul><li>Therefore, Leave Motion alone, no need to mobilize or stretch </li></ul>
  41. 41. GIRD-ERG Example <ul><li>U Side: ER 90 + IR 70 = </li></ul><ul><li>Total arc=160 degrees </li></ul><ul><li>I Side: ER 130 + IR 10 = </li></ul><ul><li>Total arc=140 degrees </li></ul><ul><li>Treatment required for limitation in IR motion </li></ul><ul><ul><li>IE Sleeper stretch, GH post mobs </li></ul></ul>
  42. 42. GIRD-ERG references <ul><li>Adaptive Changes in Humeral Retroversion in Throwers </li></ul><ul><ul><li>Several articles AJSM 2002 </li></ul></ul><ul><ul><li>Wolff’s law of Boney Remodeling </li></ul></ul><ul><li>Meister, K et. al. Rotational motion changes in the GH joint of the adolescent/Little league baseball player. Am J Sports Med. 33:693-698, 2005 </li></ul><ul><ul><li>Elevation & total ROM decreased as age increased </li></ul></ul><ul><ul><li>Changes due to both bony and soft tissue adaptation </li></ul></ul><ul><ul><li>Most dramatic decline in total ROM 13-14 y.o. (peak age: 15) </li></ul></ul><ul><ul><li>Decrease in rotational motion increased stress at physis during throwing </li></ul></ul>
  43. 43. Evaluation of Specific Structures <ul><li>Algorithm Based exam </li></ul><ul><ul><li>Algorithm Defined: A process consisting of steps, each depending on the outcome of the previous one </li></ul></ul><ul><ul><ul><li>Stedman’s Medical Dictionary, 2002 </li></ul></ul></ul><ul><ul><li>At least 2 tests for most structures to rule in or out specific structures </li></ul></ul><ul><ul><li>Corroborate results for completeness </li></ul></ul><ul><li>Alleviation-Provocation </li></ul><ul><ul><li>Kaltenborn-Evjenth system </li></ul></ul><ul><li>Clustering of signs & symptoms facilitates clinical decision making </li></ul>
  44. 44. Objective Exam <ul><li>Cyriax’s Sequence of Pain & Limitation with end feels </li></ul><ul><li>Pain before Resistance=Red light condition (hands off) </li></ul><ul><li>Pain at beginning of Resistance=Yellow light condition (treat with caution) </li></ul><ul><li>Pain after Resistance=Green light (treat directly) </li></ul>
  45. 45. Objective Exam <ul><li>Contractile lesion (muscle, tendon, MT junction, tendo-periosteal junction) is painful with AROM or resisted motion in same direction and with PROM in opposite direction </li></ul><ul><li>Non Contractile lesion is painful with AROM and PROM in same direction and with negative isometric testing </li></ul>
  46. 46. Objective Exam <ul><li>Grade: </li></ul><ul><li>NL: Pain-free & strong </li></ul><ul><li>I: Painful & strong </li></ul><ul><li>II: Painful & weak </li></ul><ul><ul><li>False (+) = fracture </li></ul></ul><ul><li>III: Pain-free & weak </li></ul><ul><ul><li>False (+) = Neuro deficit </li></ul></ul>
  47. 47. Objective Exam <ul><li>Isometric testing: </li></ul><ul><li>Cyriax’s Selective tissue testing </li></ul><ul><li>Pain-free Strong </li></ul><ul><li>Painful Weak </li></ul><ul><li>Tensiometer testing </li></ul>
  48. 48. Corroborative Testing for Completeness <ul><li>Instabilities: </li></ul><ul><ul><li>Sup capsule + RTC interval: 1 </li></ul></ul><ul><ul><li>Inf capsule, labrum and IGHL: 4 </li></ul></ul><ul><ul><li>Ant GH capsule, labrum and lig: 3 </li></ul></ul><ul><ul><li>Post capsule+ labrum: 4 </li></ul></ul><ul><li>SLAP lesions: 6 </li></ul><ul><li>Bankhart lesions: 4 </li></ul><ul><li>Long head of Biceps: 6 </li></ul><ul><li>RTC Impingement: 4 </li></ul>
  49. 49. Special Tests <ul><li>Instability (Global) </li></ul><ul><ul><li>MDI at 0: Sulcus sign (Sup capsule, RTC interval) </li></ul></ul><ul><ul><li>MDI at 90: Sulcus at 90 (inf capsule, IGHL) </li></ul></ul><ul><ul><li>Load & Shift: Anterior instability (Ant capsule and lig) </li></ul></ul><ul><ul><li>Posterior Load & Shift: Posterior instability (Post capsule) </li></ul></ul>
  50. 50. Special Tests <ul><li>SLAP and Long Head of Biceps </li></ul><ul><ul><li>Compression Rotation (SLAP) </li></ul></ul><ul><ul><li>Anterior Slide (Ant/Sup-deceleration) </li></ul></ul><ul><ul><li>Posterior Slide (Post/Sup-Peel Back) </li></ul></ul><ul><ul><li>Speed’s Test (LHBT * in front OR SLAP * deep in shoulder) </li></ul></ul><ul><ul><li>O’Brien’s (SLAP (+) on part 1, (-) on part 2 OR superior pain AC joint) </li></ul></ul>
  51. 51. Special Tests <ul><li>IMPINGEMENT TESTS </li></ul><ul><li>Neer: (Supra, LHBT) </li></ul><ul><li>Hawkins-Kennedy: (Supra) </li></ul><ul><li>Coracoid Impingement: (*Medial=LHBT, subscap; *Laterally=Supra) </li></ul><ul><li>Cross Over test: (*Medial=LHBT, subscapularis; *Superior=AC jt.; *Posterior=Infra/Teres minor or posterior capsule or Internal impingement) </li></ul>
  52. 52. Special Tests <ul><li>INSTABILITY TESTS </li></ul><ul><li>Apprehension Test: </li></ul><ul><ul><li>Macrotrauma/Ant dislocation </li></ul></ul><ul><ul><ul><li>Classic ABD/ER 90/90 position </li></ul></ul></ul><ul><li>Jobe Subluxation Relocation: </li></ul><ul><ul><li>Microtrauma/Ant instability: </li></ul></ul><ul><ul><ul><li>Posterior compression reduces symptoms </li></ul></ul></ul><ul><ul><li>Internal impingement: </li></ul></ul><ul><ul><ul><li>Pain in post shoulder with ABD/ER position </li></ul></ul></ul><ul><li>Posterior Glide: </li></ul><ul><ul><li>Macrotrauma.post instability </li></ul></ul>
  53. 53. CAPSULOLABRAL ISSUES <ul><li>Instability </li></ul><ul><li>SLAP tear </li></ul>
  54. 54. ROTATOR CUFF ISSUES <ul><li>Impingement Syndrome </li></ul><ul><ul><li>Painful structures in Subacromial Space w/largest # of pain fibers: </li></ul></ul><ul><ul><ul><li>1. Bursa, 2. RTC tendon, 3. LHBT </li></ul></ul></ul><ul><ul><ul><li>Soifer, TB et. al. Arthroscopy, 1996 </li></ul></ul></ul><ul><ul><ul><li>Periosteum of inf acromion, Inf capsule of AC jt, Fascia, Fat, NV Triad, Bursa, RTC tendons, Sup capsule, Synovial lining, LHBT </li></ul></ul></ul><ul><li>Partial and complete tears </li></ul><ul><li>Biceps pathology </li></ul>
  55. 55. Stages of ROTATOR CUFF Impingement <ul><li>“ The GOOD, the BAD, The UGLY…” </li></ul><ul><li>Stage I: Hemorhage & edema </li></ul><ul><ul><ul><ul><ul><li>Under 25 y.o., subluxor or AC jt arthritis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Reversible and conservative Rx helpful </li></ul></ul></ul></ul></ul><ul><li>Stage II: Fibrosis & Tendinosis </li></ul><ul><ul><ul><ul><ul><li>25-45 y.o., CA tendinitis, Frozen shoulders </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Recurrent with activity </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Treated with bursectomy, SAD, CA lig resection </li></ul></ul></ul></ul></ul><ul><li>Stage III: Bone Spurs & Tendon Rupture </li></ul><ul><ul><ul><ul><ul><li>40 y.o.+ </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Diff Dx: Cervical spine radiculopathy </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Progressive disability leading to SAD or RTC repair </li></ul></ul></ul></ul></ul>
  56. 56. Subacromial Space <ul><li>GH Jt: 0 degrees: Acromiohumeral interval= 11 mm </li></ul><ul><li>GH Jt @ 90 deg Elevation: Acromiohumeral interval= 5.7 mm </li></ul><ul><li>Acromial undersurface & RTC tendons are in closest proximity ~60-120 deg elevation </li></ul><ul><li>Flatow, EL, et al. Excursion of the rotator cuff under the acromion. AM J Sports Med 22 (6): 779-788, 1994 </li></ul>
  57. 57. INSTABILITY
  58. 58. SHOULDER INSTABILITY DEFINITION <ul><li>Abnormal translation of humeral head on glenoid </li></ul><ul><li>Joint is minimally constrained designed </li></ul><ul><ul><li>Shallow glenoid vault </li></ul></ul><ul><ul><li>Small glenoid articular surface </li></ul></ul><ul><li>Requires symptoms, laxity, and pathology </li></ul><ul><li>Laxity does not equal instability </li></ul>
  59. 59. SHOULDER INSTABILITY <ul><li>LAXITY DOES NOT EQUAL INSTABILITY </li></ul><ul><li>TUBS/”Torn Loose”: </li></ul><ul><ul><li>Traumatic </li></ul></ul><ul><ul><li>Unilateral </li></ul></ul><ul><ul><li>Bankhart lesion </li></ul></ul><ul><ul><li>Surgery often indicated </li></ul></ul><ul><li>AMBRI/”Born Loose”: </li></ul><ul><ul><li>Atraumatic </li></ul></ul><ul><ul><li>Multidirectional </li></ul></ul><ul><ul><li>Bilateral </li></ul></ul><ul><ul><li>Rehab candidate (Non risk taker and non athletic) </li></ul></ul><ul><ul><li>Inferior capsular shift if surgical </li></ul></ul>
  60. 60. PHASES OF PITCHING <ul><li>Windup </li></ul><ul><li>Early cocking </li></ul><ul><li>Late cocking </li></ul><ul><li>Acceleration </li></ul><ul><li>Deceleration </li></ul><ul><li>Follow-through </li></ul>
  61. 61. JOBE RELATIONSHIP BETWEEN IMPINGEMENT AND INSTABILITY <ul><li>Type I – Pure instability </li></ul><ul><li>Type II – Impingement with traumatic Instability </li></ul><ul><li>Type III – Impingement with generalized laxity </li></ul><ul><li>Type IV – Pure impingement </li></ul>
  62. 62. ANTERIOR SHOULDER DISLOCATIONS <ul><li>Macro Instabilty usually in ABD/ER </li></ul><ul><li>Anterior > Posterior dislocations </li></ul><ul><ul><ul><li>MacKroner K, Lind T, Jensen J. The epidemiology of shoulder dislocations. Arch Orthop Trauma Surg 1989; 10:258-99. </li></ul></ul></ul><ul><li>Age related recurrence: </li></ul><ul><ul><li><20 yrs=90% </li></ul></ul><ul><ul><li>20-40 yrs=60% </li></ul></ul><ul><ul><li>>40 yrs=10% </li></ul></ul><ul><ul><ul><li>Simonet WT, Cofield RH. Prognosis in anterior shoulder dislocation. Am Sports Med 1984; 12:19-24. </li></ul></ul></ul><ul><ul><ul><li>Rowe, JBJS, 1956 </li></ul></ul></ul><ul><ul><ul><li>Rowe CR, Zarins BZ. Recurrent transient subluxation of the shoulder. J Bone Joint Surg 1981; 63A:863-71. </li></ul></ul></ul><ul><li>Usual immobilization in ADD/IR </li></ul>
  63. 63. INSTABILITY <ul><li>Unclear if immobilization duration or securely is helpful </li></ul><ul><ul><li>Rowe, JBJS, 1956 </li></ul></ul><ul><li>Recently, bracing in slight external rotation to reduce torn labrum felt to be helpful </li></ul><ul><ul><li>Coaptation/Contact healing of Bankart lesion in slight ER position of immobilization </li></ul></ul><ul><ul><ul><li>Miller et. al. JSES, 2004 </li></ul></ul></ul><ul><ul><ul><li>Itoi et. al. JBJS, 1999 and 2001 </li></ul></ul></ul><ul><ul><li>Pilot study Immobilized in 30 deg ER x 3 weeks </li></ul></ul><ul><ul><ul><li>Itoi et. al. JSES, 2003 </li></ul></ul></ul><ul><li>If recurrence is problematic or patient wishes to minimize recurrence then surgical reconstruction open or arthroscopic is 85-90% successful. </li></ul>
  64. 64. SURGICAL TREATMENT
  65. 65. ANTERIOR APPROACH SUBSCAPULARIS SPLITTING
  66. 66. ANTERIOR APPROACH SUBSCAPULARIS SPLITTING
  67. 67. ARTHROSCOPIC BANKART REPAIR
  68. 68. KEY TO SUCCESS <ul><li>Stable front wall </li></ul><ul><ul><li>Strong subscapularis and scapular stabilizers </li></ul></ul><ul><ul><li>Functional IGHL </li></ul></ul><ul><li>Adequate room posteriorly </li></ul><ul><ul><li>Adequately stretch posterior capsule </li></ul></ul><ul><li>Sound mechanics </li></ul><ul><li>No excessive tightening </li></ul>
  69. 69. SLAP TEARS
  70. 70. SLAP TEARS <ul><li>Occurs from fall on outstretched hand, traction, or throwing </li></ul><ul><li>C/o pain in varying positions and not instability </li></ul><ul><li>Pain is deep in shoulder joint </li></ul><ul><li>Symptoms can relate to level of activity </li></ul><ul><li>Often confused with impingement syndrome </li></ul>
  71. 71. SLAP TYPES
  72. 72. SLAP TEARS <ul><li>Diagnose on exam with O’Brien test or Crank test </li></ul><ul><li>Confirm with MRI. Gadolinium enhances results although plain MRI is often adequate. </li></ul><ul><li>Not usually amenable to conservative treatment. </li></ul><ul><li>Requires arthroscopic repair or debridement </li></ul>
  73. 73. ARTHROSCOPIC SLAP REPAIR
  74. 74. ROTATOR CUFF DISORDERS
  75. 75. IMPINGEMENT SYNDROMES <ul><li>CLASSIFICATIONS: </li></ul><ul><li>Primary </li></ul><ul><ul><li>Hypomobile </li></ul></ul><ul><li>Secondary </li></ul><ul><ul><li>Hypermobile </li></ul></ul><ul><li>Internal </li></ul>
  76. 76. IMPINGEMENT SYNDROME <ul><li>Includes: </li></ul><ul><ul><li>subacromial bursitis </li></ul></ul><ul><ul><li>rotator cuff tendinitis </li></ul></ul><ul><ul><li>biceps tendinitis </li></ul></ul><ul><li>May occur from acute trauma or chronic overuse. </li></ul><ul><li>Pain with overhead activity or sleeping on shoulder </li></ul><ul><li>NSAIDs may help </li></ul>
  77. 77. IMPINGEMENT SYNDROME <ul><li>Primary (Hypomobile) </li></ul><ul><ul><ul><li>Classic described by Dr. Neer 1970’s </li></ul></ul></ul><ul><ul><ul><ul><li>Stage I: Edema & Hemmorrhage </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Stage II: Fibrosis & Tendinitis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Stage III: Bone Spurs & Rupture </li></ul></ul></ul></ul><ul><ul><ul><li>Due to hypomobility & compression to RTC </li></ul></ul></ul><ul><ul><ul><li>Bursal side involvement </li></ul></ul></ul><ul><ul><ul><li>Over 40 y.o. </li></ul></ul></ul>
  78. 78. ACROMION’S ROLE IN PRIMARY IMPINGEMENT <ul><li>Type I = flat </li></ul><ul><li>Type II = mild curve </li></ul><ul><li>Type III = sharp hook </li></ul><ul><ul><li>Via Outlet View XRay </li></ul></ul><ul><li>Biglani, LU et.al. Ortho Trans, 1986 </li></ul><ul><li>Morrison DS, et.al. Ortho Trans, 1987 </li></ul>
  79. 79. PRIMARY IMPINGEMENT SYNDROME <ul><li>Treatment is initially conservative </li></ul><ul><ul><li>PT or RTC program </li></ul></ul><ul><ul><ul><li>Type I Acromion: 91% success rate in PT </li></ul></ul></ul><ul><ul><ul><li>Type II/III: 66% success in PT </li></ul></ul></ul><ul><ul><ul><li>Symptoms usually decrease in 1 st 4 weeks, discharge if no improvement by 6 weeks </li></ul></ul></ul><ul><li>Morrison D et. al. Conservative management for Subacromial Impingement of the shoulder JBJS-A, 79:732-737, 1997 </li></ul>
  80. 80. PRIMARY IMPINGEMENT SYNDROME <ul><li>Treat hypomobility: </li></ul><ul><ul><li>Joint mobilization, LLLD stretch </li></ul></ul><ul><li>Cross Friction techniques </li></ul><ul><li>Pect/lat stretching </li></ul><ul><li>Proximal to distal exercise: Scapula->RTC </li></ul><ul><li>NSAIDS </li></ul><ul><li>Subacromial steroid injection </li></ul><ul><li>Arthroscopic Subacromial Decompression (SAD) is often successful in partially or completely alleviating symptoms </li></ul>
  81. 81. SECONDARY IMPINGEMENT SYNDROME <ul><li>Due to hypermobility and inflammatory reaction to microtrauma </li></ul><ul><li>Age 15-40 </li></ul><ul><li>Articular/Bursal side involvement </li></ul><ul><li>Normal physiological laxity </li></ul><ul><ul><li>No instability on exam </li></ul></ul><ul><ul><li>Microsubluxation: increased translation of GH head </li></ul></ul><ul><ul><li>RTC fatigues to dynamically control and stabilize joint </li></ul></ul><ul><li>Treatment: </li></ul><ul><li>DO NOT STRETCH THIS PATIENT!!! </li></ul><ul><ul><li>Cross friction to tendon at fault/painful </li></ul></ul><ul><ul><li>Dynamically stabilize, proprioceptive/kinesthetic training, NM reactive training </li></ul></ul><ul><ul><li>Functional rehab of Core->scapula->RTC->arm->forearm </li></ul></ul>
  82. 82. INTERNAL IMPINGEMENT <ul><li>Undersurface RTC tendinitis/partial tearing from abnormal contact against supero-posterior glenoid </li></ul><ul><li>Pain with excessive ER at 90 deg ABD </li></ul><ul><li>Cause is from excessive anterior translation, posterior capsular hypomobility, increase horizontal extension (Excessive ER, limited IR) </li></ul>
  83. 83. INTERNAL IMPINGEMENT <ul><li>Cause is from excessive anterior translation, posterior capsular hypomobility, increase horizontal extension (Excessive ER, limited IR) </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>ID cause: Hyper or Hypo? </li></ul></ul><ul><ul><ul><li>Hyper treat like secondary impingement </li></ul></ul></ul><ul><ul><ul><li>Hypo treat like primary impingement </li></ul></ul></ul><ul><ul><li>Change causative factor (see above) </li></ul></ul><ul><ul><li>Dynamically stabilize, proprioceptive/kinesthetic training, NM reactive training, functional rehab </li></ul></ul>
  84. 84. BICEPS PATHOLOGY <ul><li>Pain in front of shoulder/often differential dx for SLAP lesion </li></ul><ul><li>Instability (uncommon) usually occurs with subscapularis rupture </li></ul><ul><li>Tendinitis treated with injection/exercise focusing on serratus, lower trap and RTC </li></ul><ul><li>Tear can be treated conservatively if only involves long head. If under 50 and heavy laborer consider tenodesis </li></ul>
  85. 85. ACROMIOCLAVICULAR SEPARATION <ul><li>Mechanism is falling onto shoulder </li></ul><ul><li>Local tenderness </li></ul><ul><li>Aggravated with cross chest </li></ul><ul><li>Treatment is sling for comfort </li></ul><ul><li>Grade degree of separation </li></ul>
  86. 86. CALCIFIC TENDINITIS <ul><li>May present like impingement syndrome </li></ul><ul><li>Can be mistaken for Acute subdeltoid bursitis </li></ul><ul><li>May be chronic insidious onset </li></ul><ul><li>Responds well to Pulsed US </li></ul><ul><ul><li>Cochrane Database of Systematic Reviews. Physiotherapy intervations for shoulder pain. Green et.al. 2005 </li></ul></ul><ul><li>Avoid Cross Friction techniques </li></ul><ul><li>Surgical debridement of calcium deposit </li></ul>
  87. 87. CALCIFIC TENDINITIS
  88. 88. ROTATOR CUFF TEARS <ul><li>May present like impingement syndrome </li></ul><ul><li>Weakness can be none to profound </li></ul><ul><li>External rotation weakness suggests large tear </li></ul><ul><li>Observe for atrophy </li></ul><ul><li>May be acute injury or chronic insidious onset </li></ul>
  89. 89. ROTATOR CUFF TEAR <ul><li>Confirm diagnosis with MRI </li></ul><ul><li>Tears have increasing incidence with age </li></ul><ul><li>MRI to be done when exam highly suggestive of tear or failed conservative effort </li></ul>
  90. 90. WHAT NEEDS TO BE REPAIRED? <ul><li>Debate over what needs to be repaired </li></ul><ul><li>Numerous studies show that asymptomatic RTC tears are a natural part of aging </li></ul><ul><li>Debate over whether partial tears require repair </li></ul><ul><li>Bottom line: Strengthen RTC & scapular mm </li></ul>
  91. 91. ROTATOR CUFF TEARS <ul><li>Treatment involves surgical repair </li></ul><ul><li>Partial tears greater than 50% require repair </li></ul><ul><li>Tears are graded from small to massive </li></ul><ul><li>Repairs can be done arthroscopically, mini-open, and classic open approach. </li></ul>
  92. 92. REPAIR TECHNIQUES <ul><li>Classic open technique with deltoid takedown </li></ul><ul><li>Mini-open technique with arthroscopic SAD </li></ul><ul><li>Arthroscopic repair </li></ul>
  93. 93. ARTHROSCOPIC RTC SURGERY <ul><li>Goals: identical repair, less deltoid violation, cosmetically appealing </li></ul><ul><li>Need proficiency in SAD, knot tying, RTC mobilization </li></ul><ul><li>Be willing to abort to open technique </li></ul>
  94. 94. ARTHROSCOPIC RTC REPAIR
  95. 95. ARTHROSCOPIC RTC REPAIR
  96. 96. REHABILITATION <ul><li>Goals are to regain motion, strength, and endurance in that order </li></ul><ul><li>Timing is predicated on surgical treatment </li></ul><ul><li>Need to obtain motion within two months or complete motion may be difficult </li></ul><ul><li>Need to determine the philosophy of the surgeon </li></ul>
  97. 97. INSTABILITY REHABILITATION <ul><li>Immediate active range-of-motion in “safe zone” </li></ul><ul><li>Focus on scapular stabilizers and stretching 180 degrees away </li></ul><ul><li>Anterior repair allows ER to 0 degrees for first 4 wks, followed by 20 degrees until 6 wks, then as tolerated </li></ul><ul><li>No elbow-behind-torso exercise for 4-6 mos. </li></ul>
  98. 98. ROTATOR CUFF REHAB <ul><li>Can begin PROM once pain under control </li></ul><ul><li>Often Codman exercises well tolerated </li></ul><ul><li>Active IR/ER at the side is allowed immediately for most tears </li></ul><ul><li>Sling for first 3-4 wks </li></ul><ul><li>AAROM to start at 4-6 wks </li></ul><ul><li>AROM to start at 6-8 wks </li></ul><ul><li>PRE’s to start at 8-12 wks </li></ul>
  99. 99. SLAP REPAIR REHAB <ul><li>Early PROM allowed </li></ul><ul><li>Avoid biceps tension/stretching </li></ul><ul><li>Sling for 3-6 wks </li></ul><ul><li>AAROM at 3 wks </li></ul><ul><li>AROM at 4-6 wks </li></ul><ul><li>PRE’s at 8 wks except for bicep strengthening </li></ul><ul><li>Biceps PRE’s at 12 wks </li></ul>
  100. 100. THERAPEUTIC EXERCISE 101 <ul><li>Shoulder Rehab Exercises are similar for all injuries, pathologies and Surgeries </li></ul><ul><li>RESPECT: </li></ul><ul><ul><li>Acuteness or phase of rehab </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>ROM limitations </li></ul></ul><ul><ul><li>Soft tissue healing </li></ul></ul>
  101. 101. EXERCISE PROGRESSION/CONTINUUM <ul><li>Multiple angle isometrics </li></ul><ul><ul><li>Sub-max pain free </li></ul></ul><ul><li>Multiple angle isometrics </li></ul><ul><ul><li>Max, pain free </li></ul></ul><ul><li>Short arc ex, sub-max, pain free </li></ul><ul><li>Short arc ex, max, pain free </li></ul><ul><li>Full arc ex, sub-max, pain free </li></ul><ul><li>Full arc, max, pain free </li></ul><ul><li>Plyometrics </li></ul><ul><li>Functional specific exercises </li></ul><ul><li>Davies, GJ. A Compendium of Isokinetics in Clinical Usage, 1984 </li></ul>
  102. 102. EXERCISE GUIDELINES <ul><li>Based on evaluation (SINS) </li></ul><ul><li>(-) Neurological symptoms </li></ul><ul><li>If NO pain at start of ex, then develops, STOP </li></ul><ul><li>If pain is present at start of ex, then increases, STOP </li></ul><ul><li>In pain is present at start of ex, then plateaus, CONTINUE </li></ul>
  103. 103. MUSCLE FUNCTIONS <ul><li>ISOMETRIC  STABILIZER </li></ul><ul><li>CONCENTRIC  MOTOR </li></ul><ul><li>ECCENTRIC  SHOCK ABSORBER </li></ul>
  104. 104. ISOMETRICS <ul><li>“ Rule of 10s” </li></ul><ul><ul><li>10 sec contraction </li></ul></ul><ul><ul><ul><li>(2 sec ramp up, 6 sec contraction and 2 sec down) </li></ul></ul></ul><ul><ul><ul><li>Due to “Rebound phenomenon” of pain if contraction or release contraction quickly </li></ul></ul></ul><ul><ul><li>10 sec rest </li></ul></ul><ul><ul><li>10 reps </li></ul></ul><ul><ul><li>10 sets </li></ul></ul><ul><ul><li>10 positions </li></ul></ul><ul><ul><li>In clinic: Should be held for 6 seconds early stages of rehab </li></ul></ul>
  105. 105. ISOTONICS <ul><li>Contractions: </li></ul><ul><ul><li>Shortening (Concentric) </li></ul></ul><ul><ul><li>Lengthening (Eccentric) </li></ul></ul><ul><li>Resistance: </li></ul><ul><ul><li>Constant or fixed </li></ul></ul><ul><li>Velocity: </li></ul><ul><ul><li>Variable (most at 50-60 deg/sec.) </li></ul></ul><ul><li>In clinic: Use short arc isotonics in newly gained ROM in 30 deg increments due to physiological overflow </li></ul>
  106. 106. ECCENTRICS <ul><li>Lengthening “Negative” work </li></ul><ul><li>Increased physiological work and force </li></ul><ul><li>Shock absorber </li></ul><ul><li>Joint reaction  deceleration </li></ul><ul><li>Short Electromechanical delay </li></ul><ul><li>Albert, MA et. al. Eccentric Muscle Training in Sports and Orthopedics 2 nd Edition. Churchill Livingstone . 1991 </li></ul>
  107. 107. MUSCLE FORCE <ul><li>Elftman Proposal </li></ul><ul><ul><li>States optimal force production of different modes of contraction is arranged in a predictable Heirarchy as follows: </li></ul></ul><ul><ul><li>ECCENTRIC  ISOMETRIC  CONCENTRIC </li></ul></ul><ul><ul><li>Elftman, H. Biomechanics of muscle. JBJS 48:363, 1966 </li></ul></ul>
  108. 108. Delayed Onset Muscle Soreness (DOMS) <ul><li>Eccentric > Concentric force by 10-40% </li></ul><ul><li>Defined: Sensation of discomfort or pain in the skeletal muscles that occurs following an unaccustomed muscular exerction </li></ul><ul><li>Lasts 7-10 days </li></ul><ul><li>Best treated with CV exercise or NSAIDS </li></ul><ul><li>Albert, MA et. al. Eccentric Muscle Training in Sports and Orthopedics 2 nd Edition. Churchill Livingstone . 1991 </li></ul>
  109. 109. TRAINING METHODS <ul><li>OPTIMAL SETS: </li></ul><ul><ul><li>Untrained: 1 set </li></ul></ul><ul><ul><li>Trained: 3 sets </li></ul></ul><ul><ul><li>Wolfe, BL et. al. Qualitative analysis of single vs multiple set programs in resistance training. JSCR. 18:35-47, 2004 </li></ul></ul><ul><li>OPTIMAL REPS: </li></ul><ul><ul><li>10 reps </li></ul></ul><ul><ul><li>Davies GJ et. al. The optimum repetitions to increase total work in the quadriceps and hamstrings. Physical Therapy, 66 (5) 1986 </li></ul></ul><ul><ul><li>Davies GJ et. al. The optimum repetitions to increase peak torque to body weight in the quadriceps to hamstrings. Medicine and Science in Sports and Exercise, 18 (2), 1986 </li></ul></ul>
  110. 110. TRAINING METHODS <ul><li>OPTIMAL REST INTERVALS: </li></ul><ul><ul><li>90 seconds to 3 minutes </li></ul></ul><ul><ul><li>Isometrics: 1 min recovery </li></ul></ul><ul><ul><li>Isotonics: ½ to 1 min recovery </li></ul></ul><ul><ul><li>Isokinetics: 2-4 min recovery </li></ul></ul><ul><ul><li>Ariki, PK, Davies GJ et. al. Optimum rest interval between isokinetic velocity spectrum rehabilitation sets. Physical Therapy, 65 (5): 733-734, 1985 </li></ul></ul><ul><li>OPTIMAL FREQUENCY PER WEEK: </li></ul><ul><ul><li>2-3 X/WEEK </li></ul></ul><ul><ul><li>NO statistical difference </li></ul></ul><ul><li>OPTIMAL TRAINING DURATION: </li></ul><ul><ul><li>6 weeks to create training response </li></ul></ul><ul><ul><li>Moritani, T, Devries, HA. Neural factors vs hypertophy in the time course of muscle strength gain. Am J Phys Med. 58:115-130, 1979 </li></ul></ul>
  111. 111. Application to Specific Tissues <ul><li>“Optimal Loading Zone” allows body to hypertrophy and grow. </li></ul><ul><li>SAID=Specific Adaptation to Imposed Demands </li></ul>
  112. 112. Shoulder Rehab Exercises <ul><li>UBE (retro) for warm ups </li></ul><ul><li>Scaption </li></ul><ul><li>Press up </li></ul><ul><li>Row </li></ul><ul><li>Push up plus </li></ul><ul><ul><ul><li>Moseley et.al. AJSM, 1992 </li></ul></ul></ul><ul><li>Flexion </li></ul><ul><li>Hz ABD with ER </li></ul><ul><ul><ul><li>Townsend et.al. AJSM, 1991 </li></ul></ul></ul><ul><li>Full can/Scaption </li></ul><ul><ul><ul><li>Itoi, et.al. AJSM, 1999 & Takeda et.al. AJSM, 2002 </li></ul></ul></ul><ul><li>External rotation & Internal rotation </li></ul><ul><ul><ul><li>Inman et. al. JBJS 26:1-30, 1944 </li></ul></ul></ul><ul><ul><ul><li>Sharkey, NA et.al. AJSM, 23 (3): 270-275, 1995 </li></ul></ul></ul><ul><ul><ul><li>Reinold, MM, et. al. JOSPT. 34: 385-394, 2004 (ADD towel roll) </li></ul></ul></ul><ul><li>Bicep-Triceps </li></ul>
  113. 113. Manually Resisted Exercises <ul><li>Rhythmic Stabilization at 90 degrees (Perterbations) </li></ul><ul><li>AKA “Balanced Position”: per Kevin Wilk at ~100 deg Flexion & 20 deg Hz Abduction </li></ul><ul><li>Wilk Rhythmic Stabilization in Scapular plane with Med Ball </li></ul>
  114. 114. Advanced Resistance Exercises <ul><li>Body Blade </li></ul><ul><li>Band Wall Walk </li></ul><ul><li>CoreBoard Rotation </li></ul>
  115. 115. Advanced Resistance Exercises <ul><li>IMPULSE-Inertial Exercise Trainer </li></ul><ul><ul><li>Albert’s Rule of 3’s: </li></ul></ul><ul><ul><ul><li>3 reps per second </li></ul></ul></ul><ul><ul><ul><li>3 bouts x 30 sec, followed by 30 sec rest periods </li></ul></ul></ul><ul><ul><ul><li>3 x week </li></ul></ul></ul><ul><ul><ul><li>3 patterns </li></ul></ul></ul>
  116. 116. Clinical Pearls <ul><li>Listen to where patient/athlete says their pain is…. </li></ul><ul><li>When gaining ROM, use Traffic light analogy. </li></ul><ul><ul><li>Good/Bad pain </li></ul></ul><ul><li>Always keep thumb “Up” </li></ul><ul><ul><li>Neutral Sup-Pro position with exercises </li></ul></ul><ul><li>Strengthen ER/IR RTC mm in 30/30/30 </li></ul><ul><ul><li>30 deg flexion, 30 deg ABD, 30 deg of ER. Reinhold et. al. </li></ul></ul><ul><ul><li>Loose packed position and position of comfort </li></ul></ul><ul><ul><li>“ Critical Blood Flow zone” </li></ul></ul><ul><li>Open lines of communication with MD </li></ul><ul><ul><li>Problems, compliance, etc. </li></ul></ul>
  117. 117. <ul><li>QUESTIONS ? </li></ul>
  118. 118. Special Thanks/Acknowledgements <ul><li>Scott Shaw, MS, ATC </li></ul><ul><li>John T. Kao, MD </li></ul><ul><li>Michael F. Dillingham, MD </li></ul><ul><li>Rob Naber, PT, OCS, ATC </li></ul><ul><li>Mark Albert, MEd, PT, SCS, ATC </li></ul><ul><li>George J. Davies, DPT, SCS, ATC, LAT, CSCS </li></ul><ul><li>Rob Manske, DPT, SCS, ATC, CSCS </li></ul><ul><li>Don V. Torrey, PT, ATC </li></ul><ul><li>My Patients and Staff </li></ul>
  119. 119. <ul><li>THANK YOU! </li></ul>

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