presented by: dr. brad m. gilden, dpt, ms pt, cfmt, cscs
DESCRIPTION
Recognition & Prevention of Shoulder Impingement. March 20th, 2013. Presented by: Dr. Brad M. Gilden, DPT, MS PT, CFMT, CSCS. Human Body Built for bi-pedal movement. Problems with prolonged sitting Reinforces poor postural habits Shoulder injuries - PowerPoint PPT PresentationTRANSCRIPT
Presented by:Dr. Brad M. Gilden, DPT, MS PT, CFMT, CSCS
March 20th, 2013
Recognition & Prevention of Shoulder Impingement
1. Human Body Built for bi-pedal movement.
2. Problems with prolonged sitting a. Reinforces poor postural habitsb. Shoulder injuriesc. Epidemiology – 2nd only to LBP
Impingement most commond. 2 Requests
• Functional Shoulder Anatomy• Function of Rotator Cuff• Shoulder Stability• Posture – Normal vs Poor• Shoulder Impingement – What is it and why should I care?• Pain and Inflammation• The Gym can help me injure my shoulder!• Exercise – Compare and Contrast “Good” vs “Bad”• Preventative & Postural Exercises• When to seek Medical Help?• Appendix• A. Sports Specific Exercises B. Muscle List C.& D Nutrition
Agenda
• Full shoulder flexion = 180°• Not accomplished by just GHJ• Full arm elevation involves…• Upper thoracic extension• 1st and 2nd ribs must depress and
move posterior• Scapula needs to rotate upwards• Clavicle needs to elevate and roll
backwards• Glenohumeral joints needs to glide
downward and roll upward• Old Injuries can play a roll – ex. Scar
Tissue from Abdominal surgery
Anatomy/Biomechanics
1. Acromial-Clavicular Joint
2. Sterno-Clavicular Joint
3. Scapulothoracic Joint
4. Gleno-humeral Joint
Shoulder Girdle
Static Stabilization• Increased Mobility = Decreased Stability• Large Humeral Head vs. Small Glenoid Fossa• Labrum - fibrocartilagenous circle attaching glenohumeral
ligaments.
Rotor Cup
• Supraspinatus – Abduction• Infraspinatus – External Rotation• Subscapularis – Internal Rotation• Teres Minor – External Rotation
Rotator Cuff
What’s it called?
Dynamic Stability
• Deltoid “Prime Mover”• Anterior Stability of
GHJ – Subscapularis, supraspinatus
• Posterior Stability of GHJ – Infraspinatus and teres minor
Shoulder Stability Continued• Synergistic action of
Rotator Cuff
Sub
SSTIST
Teres
• Long Head of the Biceps brachii-
• Serratus Anterior – Laterally rotates and protracts scapula
Secondary Stabilizers
• What is good posture?
1. Vertebrae Stack properly2. Joints aligned3. Muscles @ normal
Resting Length4. Reduced tension5. Vertical Compression
Test6. Importance of Good
Posture7. Promotes movement
efficiency8. Good Neuro-muscular
control9. Reduce need for
compensatory movements
• Three natural curves• Muscles – Flexible yet
strong
POSTURE
• We are a product of our
environment• Flexion, flexion and
more flexion• Affect on Vital Organs• Shoulder Flexion Test• Impact Test
Posture
• What causes shoulder impingement?Theory # 1: Mechanical-anatomic
1. Overuse2. Fibrosis forms3. Bony changes, spurs on humeral
tuberosity4. LEADS to RTC tearsTheory #2: Vascular compromise
a. Increased stress to RTCb. Inflammatory responsec. Scar tissue or calcific depositiond. Poor repair secondary to poor vascularitye. Leads to tear of tendon f. Combined effect of poor blood flow and
continued stress does not allow for adequate maturation of healing tissue
Shoulder Impingement
• Theory #3: Kinesiological – poor neuromuscular control and limited scapular movement
• Reflex inhibition and or disuse
• Proper rotator cuff strengthening is essential to prevent disuse/RI
• MEDICAL INTERVENTION
• Implications of steroid injections – Anti-anabolic effect on connective tissue (Not Mark Maquire’s Steroids…)
• Local steroids will relieve pain through inhibiting inflammatory response – may result in weakening of the injected tendon
• Proceed gradually with strengthening
Impingement Continued
INFLAMMATIONPain is an output, not an input.Inflammation is a necessary process for healingChronic inflammation is a problem a. Irritation to nerves and surrounding tissues b. Inhibition of core muscle contractions Instability and compensatory patterns c. Breakdown of healthy tissue
How to deal with Inflammationa. Best anti-inflammatory - good postural alignmentb. Proper Nutrition - Acidic vs. Alkaline (Appendix C
& D)c. Avoidance of irritating movements (no pain no
gain is nonsensical) d. Hydratione. Ice (other modalities)f. NSAIDS (Topical or Oral)g. Steriodal anti-inflammatories (Rx required)h. Minimally Invasive Surgical intervention –
PRP/Regenokine
• Rarely Good the Bad and the Ugly
Gym Woes
• Stretch, don’t overstretch! • Add an Isometric contraction to your stretch.• If radicular signs are present, Do Not Stretch – Good time for PT
consultation• Neck Stretches• General Rule: Stay away from cervical extension
1. Chin Tuck – Axial Extension
Purpose: To achieve neutral position of cervical spine and to strengthen cervical extensor muscles • Remember Axial elongation is necessary for full shoulder
ROM• Shoulders should be relaxed. Chin should tuck down &
back. You can use a finger on the chin as a guide• A verbal cue is to lengthen your neck, crown of head
toward the ceiling
Preventative Exercises
• ELBOW FLEXION TEST• Pivot Prone – Postural ExercisePurpose – Aligns shoulder girdle properly over ribcage, taking tension off of neck.1. Head/Neck neutral, shrug shoulders 1/3 way up, turn palms back while
pinching shoulder blades, then reach fingers toward the floor.2. Hold this position for 10 seconds
• Doorway StretchPurpose – Elongate pec minor muscle1. Place R or L forearm against doorframe, and place opposite hand over
corocoid process (just inside to front shoulder). Abdominals should be tight with head in neutral position (axial elongation)
2. Stagger feet, and slowly lean into wall until stretch is felt. Hand on front of coracoid blocks shoulder from coming forward
3. Press forearm into wall and hold for 3 seconds, slowly release and take up the slack into the new range of motion.
4. Repeat 3-5 times
Postural Exercises
Postural Exercises1. Axial Elongationa. Place fingers along center of neck over spinous processesb. Make fist and place thumb under chin.c. Lightly press tongue to roof of mouth and press spinal
segments back into fingers and tuck chin. Think of elongating the neck.
d. Once in position, apply force with fingers on spine forward and thumb up toward ceiling.
e. Head/Neck should not move.f. Hold 20 seconds and repeat as prescribed by therapist/trainerg. ALTERNATIVE – Repeat as above but use theraband instead
1. Pivot Prone Against Wall2. Stand against wall with knees slightly bend and pillow
behind neck/head. Palms facing the wall.3. Place buttocks against wall and draw stomach in pressing
lumbar spine into wall and progressing upwards until entire spine is touching the wall and neck in axial elongation.
4. Maintain this position of spine, lift shoulders up, turn palms forward (thumbs back) and pinch shoulder blades together, then reach fingers toward floor dropping shoulders into place.
5. Hold this position for 30s/60s/90s or as prescribed by your therapist/trainer
Exercises for Shoulder Pain
1. Glenohumoral Joint Setting – “The Vacuum”
a. Band above door, place high into arm pitb. Using just the RTC muscles (no pecs or lats), suction the shoulder in toward the body against the band and hold for 5 secondsc. Slowly release, then repeat suction motion and hold while providing an isometrically resisted force on the outside of the wrist and hold 5 secd. Repeat as prescribed by your therapist/trainer
1. Pivot Pronea. With palms back, head/neck neutral, elevate shoulders slightlyb. Rotate palms forward/thumbs back and pinch shoulder blades
together.c. Reach hands toward the floor, being sure not to elevate the
sternum.d. Hold 10 seconds, then relaxe. Repeat throughout the day at least once every ½ hour
Exercises for Shoulder Pain
1. Shoulder Clocks – Keep in pain free rangea. Pretend the shoulder is a clock, begin in the center of the clock and move the shoulder up to 12:00 (toward ceiling), then back to center.b. Progress toward 1:00 (toward nose), then return to center and continue around the clock hitting each number.c. Once back to start, repeat in opposite direction
2. Pendulums – Distraction and relaxation for shouldera. Lean over table or counter and let arm completely dangle toward floorb. With legs wide, begin to weight shift into your legs right and left, creating
momentum that lets your arm swing.c. Repeat with legs shifting front to back to have arm swing fwd/back.d. Can also repeat in circles.e. Repeat for 1-3 minutes
** KEY: Must remain relaxed in the shoulder and leg your body do the work
A. Neck Clocks Active figure 8’s1. (If acute) Begin with eye motions into small figure eight
patterns 2. Start with very slow small figure eights or making infinity
sign with nose, and slowly increase range of motion to lubricate neck
3. Repeat for 30 seconds
OUR GIFT TO YOU
C. Arm Circles on side – Improves mobility of entire upper extremity1. Lie on right side with top leg bent and left hand resting on
knee of right leg.2. Reach right hand toward floor keeping head/eyes on
hand throughout exercise3. Bring arm around body in wide circle with head
following4. As arm comes over head inhale, exhale as arm comes
down.5. Repeat 10x’s clockwise & 10x’s counter clockwise
D. Sleeper Stretch – To improve posterior capsule and IR6. Lie on right or left side with arm out at 90°7. Roll onto shoulder until a tightness is felt behind shoulder8. Bend elbow to 90° and place left hand over wrist9. Bring arm slowly toward floor until stretch is felt.10.Perform isometric by pushing right hand into wrist, not
allowing movement to occur – Hold 5 seconds11. Relax, and push further into more internal rotation12.Repeat 5 times13.Do not push through pain
Shoulder Stretching
• Dumbell or Front Squats• Straight arm pull-downs• Standing Rows • RTC strengthening• External Rotation• Internal Rotation
Strengthening
• I’s, Y’s, T’s & Advanced W’s
• Bent Over Rows • Single Arm Rows• Prone T-band ER
Strengthening
What’s more fun than a plank?
• Pain with shoulder movements without resistance
• Pain waking you up at night• Experience numbness or tingling
down arm or scapula• Shoulder Pain with neck movements• Suffered fall or accident and has
persistent shoulder pain > 3 days• Lingering shoulder pain (3 weeks or
more) that seems to be staying the same or getting worse.
How should I know if I need PT?
Sport Specific ExercisesNeed to strengthen muscles responsible for deceleration – eccentric muscle control!!!
ROTATOR CUFF
ACCELERATION DECELERATION CORE ROTATORY BACK MUSCLES
POSTURAL
InternalRotation
Plyometrics RTC work with emphasis on
eccentric
Planks Punch outs Lat Pull downs
Pivot Prone
External Rotation
Chop’s Single Arm Rows with eccentric
focus
PlankAlternative
Russian Twists
Rows Pivot Prone on Wall
I’s, Y’s, T’s & W’s
Lift’s Straight arm pull downs
Side Plank
Isolating trunk/pelvis
rotations
Single ArmRows
Axial Elongation
Setting GHJWith
Isometric holds
BurpiesSquat Thrusts
Shoulder rotation with stable lower
body
Abdominal Series
Eagles Bird Dogs Hip Hinging of bench
Plank on stomach with T-Band
Push Up’s Wrist Curls with focus on eccentric
Dead Bugs
Scorpions Hip extension
Quarterback Squats
Appendix A
• External Rotation – Infraspinatus and Teres minor
• Internal Rotation – Subscapularis & Pectorals• Prone lateral raise with thumb up – Rhomboid• Prone lateral raise thumb down – Mid
trapezius• Prone scaption thumb up – Lower trapezius • Prone scaption thumb down - Supraspinatus• Scaption - Supraspinatus
What am I Training?Appendix B
Appendix C
Appendix D