Robertson EBP Shoulder Update

Shoulder Update!
2014 University of Texas at El Paso
Centennial Lecture Series
Evidence-based Management
Speaker:
Eric Robertson, PT, DPT, OCS, FAAOMPT

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.

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

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…

Impingement Syndrome Concept
Neer, 1972
• Altered cuff mechanics
• Compromised or constricted
• coracoacromial arch
• Stage I, II, III

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

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)

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

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

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

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

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.

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

• 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

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

Treatment: Non-surgical vs Surgical
• Emphasize prevention
• Current Best Evidence Summary:

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

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

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

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

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?

Musculoskeleta
l
Somatovisceral
Biopsychosoci
l
Neurophysiologi
cal

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

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

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

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

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

Kelley MJ, et al, JOSPT, 39 (2), 2009

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

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

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‟

Long Term Effects
• Summary: Full PLOF is not a given.

Treatment Options
• Wait and see
• PT directed rehab
• MD directed rehab
• Oral corticosteroids
• Steroid injections
• Capsular distension
• Long lever MUA
• Arthroscopic release
• Translational MUA

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.

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.

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.

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

• 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

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)

0
100
200
300
400
500
600
Patient 1 Patient 2 Patient 3 Patient 4
DegreesofPROM
Pre-Rx
Immediate
Final
Total Passive ROM

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)

Results
Post ER
Post AbdPre Abd
Pre ER

Video Fluoroscopy
6 wk Post-
ManipulationPre-Manipulation

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.

Patient #1
Diabetic male, AC x 7 months
Humera
l head
Torn Scar tissue
Glenoid

Patient #1:
Diabetic male, AC x 7 months
Humeral
head
Scar Tissue
Labrum

Patient #2:
Secondary AC x 14 months.
Humeral head
„Veil‟ of scar tissue

Patient #2:
Secondary AC x 14 months.
Humeral head
Scar tissue
Glenoid

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.

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

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

• 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

MANUAL THERAPY FOR
THE SHOULDER

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

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

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

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

5 Variables in the CPR
• Painfree shoulder flexion < 1270
• Shoulder IR < 530 at 900 abduction
• Negative Neer test
• Not taking medications
• Symptoms < 90 days

Prognostic Factors for MT
Mintken et al, Physical Therapy, Jan, 2010

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

Prognostic Factors: Risk of Persistent Pain
Kuijpers et al, Pain, J2006

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

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

SHOULDER INSTABILITY
Things that move too much…

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

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

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.

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

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

Labrum Anatomy
Putz, et al Ascopy 1999

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

Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose

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

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

Physical Examination
Special tests
Apprehension test Relocation test
Load & Shift test Sulcus test

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

• 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

• 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

Exercise for Selected
Shoulder Disorders

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

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

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.

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)

Baechle TR. Essentials of Strength and Conditioning. Human Kinetics. 2008.
Strength Continuum

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

Evidence Based Scapular Interventions
• Serratus anterior
strengthening or
retraining
• Upper trapezius
activation reduction
• Pectoralis minor
stretching
• Thoracic extension
posture and exercise
• Posterior shoulder
stretching

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

What are the best exercises for
Muscles around the shoulder ?

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

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

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

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

Recommended Exercises for Serratus
Serratus anterior
• 1. Push-up with plus
• 2. Dynamic hug
• 3. Serratus punch 120°

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
• Upper trapezius
• 1. Shrug
• 2. Prone row

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

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

Recommended Exercises for
Rhomboids and Levator
• Rhomboids and levator scapulae
• 1. Prone row
• 3. Prone extension with ER
Escamilla et al. Sports Med 2009; 39 (8): 663-685

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

• 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

Program Summary
and Outcomes
Tate et al. JOSPT 2010. 40(8)

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

Phase I

Phase II

Phase III

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

Exercise for Rotator Cuff Tears

• 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.

• 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

• 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

• 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

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)

• 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

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)

• 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.

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

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

• Integrate LE/trunk w/loads
• Push-press to single-arm squat
• Lunge and Reach Progression
Integrating the Shoulder:
Return to Function Phase

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

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

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

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.

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

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: http://www.ncbi.nlm.nih.gov/pubmed/18703377 [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: http://www.ncbi.nlm.nih.gov/pubmed/18752983 [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.

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

Robertson EBP Shoulder Update

More Related Content

What's hot

Viewers also liked

Similar to Robertson EBP Shoulder Update

More from Eric Robertson

Recently uploaded

Robertson EBP Shoulder Update

Editor's Notes