level 2 shoulder ppt
TRANSCRIPT
![Page 1: Level 2 Shoulder Ppt](https://reader034.vdocument.in/reader034/viewer/2022051012/542ace66219acd87798b4858/html5/thumbnails/1.jpg)
Muscle Assessment of Shoulder
• Global postural assessment• Architecture ie position of thumb / olecranon• Muscle bulk at shoulder and spine
– Lateral deltoid atrophy
• Scapular symmetry• Cervical spine
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Muscle Assessment of Shoulder
• Static scapular position– Normal slight ABD/ER
• Winging– Medial - serratus anterior– Rotatory - rhomboids, levator scapula, trapezius, lat
dorsi– Inferior angle - tight pec minor, LFT weakness
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Muscle Assessment of Shoulder
• Scapulohumeral rhythm in ABD– Scapular and GH force couples
• 0 to 80 ABD– GHJ- deltoid and supraspinatus– Scapular - upper trap and upper SA– ICOR- root scapula– more GH mov’t than scapular
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Muscle Assessment of Shoulder
• 80 to 140 ABD– Continued UFT/ upper serratus and
deltoid/supraspinatus force couples– 90 ABD- additional rotatory force lower trap
and lower Serratus anterior– ICOR moves laterally to ACJ– More scapular mov’t than GHJ– Significance of scapular control in range where
most impingement occurs.
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Muscle Assessment of Shoulder
• 140 to 180 ABD– Less UFT in inner range elevation– Ongoing deltoid/supraspinatus– Increased lower trap and serratus to rotate scapula– mid trap retracts scapula, counteracted by serratus
protraction– More GHJ mov’t than scapular
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Muscle Length Tests
• Scapular quadrants
• Latissimus Dorsi– crk lying, post pelvic tilt, arms OH to bed with
ER.
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• Pec minor– Measure distance post acromion off bed– stabilize ribs 3,4,5 and push coracoid to bed.
• Pec major– Clavicular- horiz ext at 90 ABD, arm flat table– Sternal- ABD 165, arm flat table
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• Levator Scapula– Neck Flexion, SB/Rot away. Stabilize superior
medial scapula
• Upper trapezius– Neck flexion. SB away/Rot towards. Stabilize
superior scapula
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Muscle Length Tests
• Scalenes– Anterior- SB away, slight Rot towards– Mid- SB away.– Posterior- SB away, slight Rot away
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Functional Scapular Tests
• Isometric scapular retraction– trouble holding position and “burning” in less
than 15 seconds + for weakness• Wall push up• Scapular assistance test
– stabilize scapula and provide ER as elevatearm- ?impingement symptoms relieve
– Simulates SA and LFT force couple
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Functional Scapular Tests
• Scapular dyskinesia “hitch or jump”– especially in descending phase of elevation
• 4 point palpation• Kiblers
– Hands side-little muscle activity– Hands on hips-low level LFT and SA– 90 abd- 40% max work of LFT, SA, UFT,
rhomboids
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“Best Exercises” RA Ekstrom et al 2003, Moseley et al 1992
• Upper trap– Shoulder shrug
• Mid trap– Prone horizontal extension (with ER)
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• Low trap– Prone arm raise overhead– Prone horizontal extension with ER– Rowing
• Rhomboids– Prone horizontal extension in neutral
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• Serratus Anterior– Shoulder flexion, horizontal flexion, and ER
• Dynamic hug position– Abduction in scapular plane above 120– Push up with plus– Punch
• Lower Trap and Serratus Anterior– Prone: arm raise overhead– Abduction in scapular plane above 120
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• Supraspinatus– Scaption “thumbs up”, 90 to 125 degrees– Flexion, 90 to 125 degrees
• Empty vs full can position– Empty can- impingement position, superior migration– EMG full can better ( Kelly: AJSM 1996)
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• Infraspinatus/Teres Minor– Sidelying ER– Prone rowing ER– Prone horizontal ABD/ER 90/90 position
• Subscapularis– “lift off” movement– Forehand tennis serve IR at 45 Abduction– IR at 0 Abduction
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Neuromuscular Rehabilitation
• All muscles of RC and deltoid activethroughout full range of ABD and FLEX– RC creates humeral head compression, and
counteracts the vertical force of deltoid.
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• If RC dynamic stabilizers fatigue, getsuperior migration of humeral head leadingto impingement.– Vertical vector deltoid unopposed
• Focus on endurance component of RC withstrength training
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• Contraction posterior RC reduces anteriorcapsule strain by pulling humeral headposterior during ER
• ER should be 65 -70% strength of IR
• If IR’s much stronger contributes to pullinghumeral head anterior.
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• Consider doing IR/ER strength in scapularplane vs coronal– Higher ER torque in scapular plane– Functional plane
• Bias posterior shoulder strengthening– Subscapularis emphasis may promote anterior
HH translation
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• Improve flexibility posterior shoulder– Tight post capsule, or decreased flexibility post
RC will cause anterior migration of HH
• Improve dynamic caudal glide provided byRC muscles/ LH biceps– Prevent superior migration of HH.
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• Importance of trunk stability and LQstrength on shoulder function– Especially for sport
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• Open and closed chain work– Facilitate joint proprioceptors to enhance
stability and dynamic control• Early introduction easy CKC exercises
– Axial loading to increase non contractilestability
– Facilitates co contraction around joint
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Sequence of Strength Exercises
• Scapular stabilization• Humeral head stabilization• Advanced scapular and GH exercises• Return to function/sport specific exercises• Plyometric exercises
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Scapular stabilization• Scapular control neuromuscular drills• Sidelying
– Active scapular PRO/RET/ELEV/DEP• Feldenkrais- hand on table
– Progress manual resistance– Progress to scapular diagonals/circles– Can apply rhythmic stabilization and slow
reversals in various ranges• Sitting- tubing/pulleys
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Scapular stabilization• Isolate specific muscles that tested weak• Serratus anterior
– Sidelying- arm on ball, punching• Progress- remove ball
– Supine- on roll• Punch - bilateral to unilateral - progress circles• Shoulder flexion,horizontal flexion, and ER
– Promotes scapular external rotation– Add tubing
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Scapular stabilization• Serratus anterior
– Sitting- distal arm on ball punching• Manual resist scapular ER• Do circles
– Sitting- bilateral punching with tubing– Sitting- arm abduction in scapular plane on
table above 120 ( force couple with LFT)– Prone: arm raise overhead ( F. couple with
LFT)
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Scapular stabilization
• Mid and lower trap/ Rhomboids– Sidely to sitting- arm on ball, and retract
• Manual resistance, tubing– Stand face wall- horizontal extension (+/- ER)– Stand face wall - karate chop slide/lift– Stand face away wall-push back arms in ER, move
through 60-90 ABD
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Scapular stabilization
• Mid and Low trap/Rhomboids– Prone over roll- arm dangle at 90 flex and
retract– Prone horizontal extension ( + ER)– Prone rowing– Prone arm raise overhead
• 10 mm lift arms from scapula– Sitting- arm abduction in scapular plane on
table above 120
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Humeral head stabilization• Start with isometrics
– sub maximal, through range.– Short lever arm to start
• Include elbow flexion• Emphasis ER/IR 0 degrees• Abduction 0/30/60• Scaption 30/60 thumb up
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Humeral head stabilization
• Start easy CKC exercise as soon as you can– Isometric WB hands on table– Isometric WB hands on wall– With above add:
• wt shift, hand slide, rhythmic stabilization,movement vs resistance
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Humeral head stabilization
• Short arc concentric/eccentric strength• Abduction approaching 90 degrees• Scaption abduction up to 90 degrees, thumb up• Flexion up to 90• IR/ER with rolled towel in scaption• Biceps with shoulder in 35-40 flexion
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Humeral head stabilization
• Specific supraspinatus– Scaption “thumbs up”, 90 to 125 degrees– Flexion, 90 to 125 degrees– Military press
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Humeral head stabilization
• Specific infraspinatus / Teres Minor– Sidelying ER– Prone rowing ER– Prone horizontal ABD 90/elbow 90
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Humeral head stabilization
• Specific subscapularis– IR From 45 ABD scaption plane so less lats and
pec minor contribution.
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Advanced exercises
• D2 PNF pattern– Supine– Sitting/standing
• Manual resistance, rhythmic stabilization, slowreversals, theraband
• Supine- ABD/ER 90– Drop ball in hand
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Advanced exercises
• Closed chain progressions• Standing, use table
– Isometric WB hands on wobble board– Isometric WB hands on ball
• Large to small• Hands move from side to top of ball, then one hand on top of
other
- progress 4 pt to 3 point– Add perturbations
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Advanced exercises
• Progress CKC exercises– Push up with a plus (S. Anterior)
• Start with mini elbow bends– Sitting push up (Lower traps)
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• Walk out feet on ball– Do scapular protraction/retraction bilateral– Lift one hand
• Push ups– Wall--> table--> chair--> floor– large to small ball– Feet on chair– Feet on ball– Feet on ball, and hands on balance board….
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• Walk up stairs on hands• Walk on treadmill on hands• Hands on pro fitter
• Progress sports and work specific activities