Differentiating Anterior Shoulder Pain In The Overhead Athlete

Angela T. Gordon PT, DSc, MPT, COMT, OCS, ATC

Stacy Soapmann PT, DSc, FAAOMPT

Objectives Identify the possible causes of

anterior shoulder pain: Scapular dyskinesis Posture Spinal facilitation Muscular trigger points Lower kinetic chain

dysfunction

Case studies from major league players

Define regional interdependence as it relates to the overhead athlete Cervical Thoracic Scapula SC joint AC joint

Evaluation of the kinetic chain in overhead athletes

Scapula Dynamic Scapula

Dynamic Scapula: Kinematics 3 rotations, 2

translations Translations superior and

inferior protraction and

retraction

Rotations upward and

downward rotation internal and

external rotation anterior and

posterior tipping

Dynamic Scapula

•Muscular and Neural Control Systems

•Muscular Activation System

•Boney and Ligamentous Restraints

Stability dependent on 3 major factors

Scapular Dyskinesis

Kibler defines scapular dyskinesis as:

A loss in scapular retraction and ER with altered timing and magnitude of upward scapular rotation. This leads to an anterior tilt of the glenoid and subsequent reduction in RTC force.

SICK Scapular

Scapular Malposition

Inferior medial border prominence

Coracoid pain and malposition

Dyskinesis of scapular movement

Scapular Dyskinesis Clinical Features

Overuse muscular fatigue syndrome

Pectoralis tightness, LT/SA force couple weakness

Inferior and or medial border prominence

Anterior tilting of the scapula

Decrease in shoulder internal rotation

Kibler Classification of Scapular Dysfunction

Inferior angle dysfunction

Medial border dysfunction

Superior scapular dysfunction

How do we classify this scapular dysfunction

What Causes Scapular Dyskinesis

Spine All muscles

innervated by cervical nerve roots

Thoracic mobility

Underlying GH pathology

Muscle imbalance Posture Overuse of sport

demands

Previous injury Instability Loss of proprioception

Trivia: How many muscles attach to the Scapula

Glenoid Labrum

Functions: Deepen the GH socket to

aide in shoulder stability? Or Sensitive proprioception

organ for the shoulder girdle providing feedback for movement in all 3 degrees of freedom

Described in a clock like fashion Bankart Lesion – 3/6 position SLAP: superior Posterior Reverse Bankart 6/9

Glenoid Labrum

Signs and symptoms of a glenoid labrum: Pain accompanying

overhead arm motion Instability with or without

clickingDecreased range of motion Loss of strength Pain Anteriorly or posterior Internal Impingement signs

Posture

Janda’s Upper Crossed Syndrome

Case Study One Olympic potential Swimmer Diagnosis Biceps tendonitis Evaluation Findings: Forward head posture Weak scapular force couples: SA LT Scapular dyskinesis Protracted Ant Tilted scapula Weak Core Hypermobile in all planes

Treatment Scapular stabilization Proprioceptive training Neuro reeducation in the unstable overhead position

What about the Biceps?

Muscular Trigger points

What is a Trigger point?

Symptoms: local tenderness referred pain local twitch response

Shoulder: Infraspinatus: muscular

overload, eccentric forces during follow through

TrP Shoulder Region

Other muscles that refer to the anterior shoulder

Deltoid

Pectoralis major/minor

Scalenes

Case Study Two

MLB pitcher complains of pain duration 5 months Improves with rest Aggravated by pitching Points to local spot in anterior shoulder All labral tests negative No signs of impingement Strength: scapular retraction test positive, infraspinatus 4+/5,

Serratus 4+/5, Lower trap 4+/5 TrP: infraspinatus, deltoid, Teres Major/Minor

Treatment: TDN to infraspinatus and Deltoid 90% resolution of pain in 1 session Return to painfree Pitching 1 week later.

Squirrel

Regional Interdependence

Cervical facilitation

C2/3 Hypomobility

Biceps Tendonitis

Thoracic/Rib dysfunctions

Cervical Facilitation Elevation/Protraction Latissimus Dorsi (C5/)6

Elevation/Retraction Serratus Anterior (C5/6, C6/7)

Depression/Protraction Levator Scapulae (C2/3,

C3/4, C4/5) Rhomboid

Depression/Retraction Pectoralis Minor (C6/7,

C7/T1) Serratus Upper Fibers

C2-3 Hypomobility

Clinically a very common injury we see is a post-traumatic arthritis of the C2-3 region. Following a MVA if the R C2-3 gets “stuck” or becomes

hypomobile and the L side becomes hypermobile this can causing increased tone in the L levator scaplae What does this do to the scapula positioning?

Biceps Tendonitis

Innervated by C6

When you look at the anatomy the C6 nerve root exits between the C5-6 segment

The C5-6 segment has the smallest foramen hole and the C5-6 nerve root is the largest

If stenosis or osteophytes occur then it can affect the innervation of the bicep

Thoracic/Rib dysfunctions

No agreed upon consensus about the combined movements of the thoracic spine

Some authors state that if you elevate your R arm you will get extension and ipsilateral rotation/SB of the R side of the thoracic spine

What would hypomobility of the thoracic spine do to the mechanics/timing of the shoulder girdle movement?

Case Study Three

MLB Pitcher Biceps Pain ongoing Evaluation: Scapular Dyskinesis UT/LS hypertonicity Csp/Tsp scan: Right C2/3 hypomobility T1-3 rotation limited C5/6 hypermobile

Tender Biceps tendon –resisted MMT improves with repetition

Treatment: 3 sessions Csp manipulation Tsp manipulation TFM to Biceps Scapular/Cervical

stabilization program

The Thrower's Paradox:

The thrower's shoulder must be lax enough to allow maximal external rotation but stable enough to prevent symptomatic humeral head subluxations, thus requiring a delicate balance between mobility and stability functionally.

The Kinetic Chain of Throwers

It is important to understand that while these athletes are throwing with their arms, they gain a large amount of momentum and force through the use of their legs and torso.

Kinetic Chain Dysfunction

Lower Extremity Hip IR/ER ROM Weakness

Core: TA must be first muscle

activated prior to UE movement

Scapula: Funnels the energy from LE to

UE

Evaluation of Kinetic Chain

No Gold standard

Difficult to evaluate

Time constraints

Evidence limited

Evaluation of Kinetic Chain

What we do know:All the links in the chain are important

Timing is everything

Scapula is the key component

Core – is the proximal STABILITY to allow for all extremity MOBILITY

Evaluation of Kinetic Chain

Upper Extremity: Scapular: Kibler scapular retraction

test Kibler lateral scapular

slide test Flip sign Strength: prone LT

seated SA Length tests

Shoulder ROM: IR/ER supine at 90

degrees abduction – 2 person measurement

Posture

Lower Extremity: SFMA – general screen

used to identify areas of dysfunction

Hip ROM prone with knee

at 90 degrees IR/ER – 2 person measurement

Strength: Hip Abd, ER, Extension

Core Strength: DKLT or

abdominal brace test

What can lead to Anterior Shoulder Pain in the Overhead Athlete?

Scapular dyskinesis

Glenoid Labrum

Postural adaptations

Muscular Trigger points

Regional interdependence from spinal segments Biceps Tendonitis

Kinetic Chain Breakdown

Differential Diagnosis of the Overhead Athlete

Labrum vs TrP

Weakness

Use of TDN to reproduce pain Treatment at same time

Stability Tests O’Brien Sulcus Relocation Clunk

Regional Interdependence vsBiceps tendonitis

Any history of cervical dysfunction

Referred pain vs local pain

Histological changes from changes in axonal transport

Use of dry needling for differential diagnosis? What leads to TrP in the

shoulder girdle?

Proper use of special tests clusters for better specificity?

Evaluating the kinetic chain? Identify breakdown

point Throwing all arm? Previous history of

injury anywhere in kinetic chain

Differential Diagnosis of the Overhead Athlete

Principles of Integrated Functional Kinetic Chain Rehab

Establish proper postural alignment

Achieve motion in all involved segments Total arc of motion

Facilitate scapular motion

Achieve proper scapular stabilization Endurance strength vs power strength

Utilize closed kinetic chain exercises Integrate core into upper extremity dynamic exercises

Work in multiple planes

References

Seroyer SH, Nho SJ et al. The Kinetic Chain in Overhead Pitching: Its Potential Role for Performance Enhancement and Injury Prevention. Ath Train. 2010;2(2): 135-146.

Sciascia A, Cromwell R. Kinetic Chain Rehabilitation: A Theoretical Framework. Rehab Research and Practice. 2012;1-9.

Burkhart SS et al. The Disabled Throwing Shoulder: Spectrum of Pathology Part III: The Sick Scapula, Scapular Dyskinesis, The Kinetic Chain, And Rehabilitation. J of Arthroscopy and related Surgery. 2003; 19(6): 641-661.

Reinhold MM et al. Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature. J Ortho Sports Phys Ther. 2009; 39(2):105-117.

Davis, JT, Fluhme, D et al. The Effect of Pitching Biomechanics on the Upper Extremity in Youth and Adolescent Baseball Pitchers. Am J Sports Med. 2009:37;1484-1491.

Kibler BW, Ludewig PM, et al. Clinical Implications of Scapular Dyskinesis in Shoulder Injury: the 2013 consensus statement from the scapular summit.Br J Sports Med. 2013;47:877-885.

Hayes K, Callanan M et al. Shoulder Instability: Management and Rehabilitation. J Ortho & Sports Phy Ther. 2002;32(10):497-509.

References

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Cools AM, Dewitte V, Lanszweert F et al. Rehabilitation of Scapular Muscle Balance: Which Exercises to Prescribe? Am Ortho Society for Sports Med. 2007;35(10): 1744-1751.

Reinhold MM et al. Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature. J Ortho Sports Phys Ther. 2009; 39(2):105-117.

Voight ML et al. The Role of The Scapula in the Rehabilitation of Shoulder Injuries. J of Athletic Training. 2000;35(3):364-372

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