Clinical pearls for the shoulder/arm exam and the treatment

What is seeing you-are you seeing it

W. Ben Kibler, MD

Medical director

Case 1• 18 y/o R hand dominant high school

pitcher, with 6 week hx gradual onset of anterior shoulder pain while pitching in season. Sore in cocking to acceleration and at ball release, no click or pop. Decreased velocity and endurance. No pain at night or in other activities. PT- no relief. Dx- impingement> surgery

Case 2• 19 y/o R tennis player- chronic

pain in shoulder during, after play. Pain localized to posterior joint line and lateral acromion, worse in cocking and ball impact. Also mild episodic back pain, does not keep him from playing. PT including modalities, rubber tubing, and massage gives no relief. Injection of unknown type gave no relief

Case 3• 45 y.o. worker, chronic (L)

shoulder pain, worse with overhead motion, decreased use over last 6 mos, painful arc, weakness. PT- no relief, injection- short term benefit. Dx- impingement- surgery

Case 4• 20 y.o college pitcher, 2 mo

pain (L) elbow, no acute injury, decreased velocity/ location, pain @ ball release, no swelling, no neuro sx, elbow exercises, modalities- no relief

BODY ASA SYSTEM OF LINKS

(SEGMENTS)

HANAVAN MODEL

Adapted from Hanavan, EP. Mathematical Model of the Human Body. Wright-Patterson Air Force

Base, Ohio, 1964, AMRL-TR, 64-102.

3

1

2 76

9

5

8

4 1110

1312

14 15

Kinetic chain• Sequenced coordination of

activation- body segments• Kinematic- body motions• Kinetic- force development• Kinetic- general term for

both activation chains

Kinetic chain• Purposes- efficient:

– Force development– Sequenced motions– Force transfer– Joint protection

• Prox stability >distal mobility

THE KINETIC CHAIN

Legs

Trunk and Back

Shoulder

ElbowWrist

0

F

O

R

C

E

TIMEAdapted From Groppel

Kinetic Chain• Body as a multi-segmented

mechanism• 244 possible DOF – multiple

possible pathways• Task specific requirements• “Bernstein’s problem”

Kinetic Chain• Dec. DOF to efficiently

accomplish tasks– Develop motions– Apply loads– Muscle activations: force generation, joint stability

Kinetic Chain• Closed system for force

production/transfer• Alterations in one area

require compensations from other areas to maintain same output/progression

What is seeing you• Leg/hip- flexibility/strength/

injury- 50%• Core stability/strength- 65%• Scapular dyskinesis- 90%• GIRD, GERD, TROMD- 90%• Altered anatomy- 100%

What is seeing you• Standardized approach- rule

in/rule out all factors• Screening exam tests• Detailed evaluation- (+) tests• Comprehensive information

Shoulder rotation, flexibility, strengthInternal

derangement

Scapular dyskinesisevaluation

Leg stability series

Hip rotationPlank

Knee stabilityAnkle ROM

Hip, leg, core• Ankle ROM• Knee ROM, P-F, meniscus• 1 leg stability- stance/squat• HIP ROM- ER, IR• 3 way core stability

Scapular dyskinesis• Position at rest• Motion- flexion/extension• Low row strength• Flexibility- pec minor, lat• Corrective tests- SAT, SRT

Shoulder joint• IR- scapula stable• ER- arm neutral, pronated• Rotator cuff- scapula stable• AC joint stability• Joint- labrum, rot cuff,

biceps, instability

Conclusions• Kinetic chain- mechanism

by which coordination of the multiple segments for specific tasks is achieved

• Body works as a unit • Kinetic chain framework

Conclusions• Body fails as a unit• Patterns of failure• Catch up, compensations• Victims and culprits• Overview, screening,

detailed exam

Case 1• 18 y/o R hand dominant high school pitcher, with 6

week hx gradual onset of anterior shoulder pain while pitching in season. Sore in cocking to acceleration and at ball release, no click or pop. Decreased velocity and endurance. No pain at night or in other activities.

• (+) Neer, Hawkins sign• Weak supraspinatus in forward flexion, empty can• GIRD – 35 degrees, (-) labral testing, (-) instability,

sulcus• (+) SAT, SRT• X-ray (-)

Case 2• 19 y/o R hand dominant college tennis player with season

long pain in shoulder and back. Worse while playing also hurts after play. Pain localized to posterior joint line and lateral acromion, worse in cocking and ball impact. Also noted some mild back pain which seems to come and go, does not keep him from playing. PT including modalities, rubber tubing, and massage gives no relief. Injection of unknown type gave no relief

• (+) Neer, Hawkins sign, (+) painful arc• Weak supraspinatus/infraspinatus• (+) M-DLS with (+) SRT, (-) anterior instability• GIRD 45 deg. With scapular wind-up, Type I/III scapular

dyskinesis• Lumbar lordosis, (+) single leg stability w/ Trendelenburg• Non-contrast MRI (-)

Case 3• 45 y.o. worker, chronic (L) shoulder pain,

worse with overhead motion, decreased use over last 6 mos, painful arc, weakness. PT- no relief, injection- short term benefit. Dx-impingement- surgery

• (+) Neer, Hawkins, painful arc, (+) SAT• Decreased rot cuff strength, (+) SRT• Taping, massage, dry needling- no benefit• X-ray- Type 2 acromion, MRI- “tendinopathy”

Case 4• 20 y.o college pitcher, 2 mo pain (L) elbow,

no acute injury, decreased velocity/ location, pain @ ball release, no swelling, no neuro sx, elbow exercises, modalities- no relief

• Pain medial elbow- epicondyle, ulna• (+) valgus stress, (-) post med stress• (-) neuro- ulnar nerve• Tight GH ROM, scapula • Kinetic chain deficit

THANK YOU