Symposium of Sport Medicine, 11 13 January 2013

Introduction

Rehabilitation of overhead shoulder injuries

Robert van Cingel,

The throwing motion Pathology:

Rotator cuff Biceps SLAP Instability GIRD Impingement and the role of the scapula

PT, OMT, PhD

Sport Medisch Centrum Papendal, Arnhem, The Netherlands HAN University of Applied Sciences, Nijmegen, The Netherlands

Clinical diagnosis Rehabilitation

The throwing motion

Tremendous forces are placed on the shoulder joint at extremely high angular velocities It is estimated that anterior translations forces generated are equal to 1.5 body weight during the late cocking phase and there is a distraction force equal to BW during acceleration
(Fleisig Fleisig 99)

The throwing motion

Throwing and other overhead sports requires an optimal balance between mobility and stability of the shoulder The chronic repetitive stress can strain the delicate balance and place the shoulder at risk for a variety of disorders Treatment starts with an accurate diagnosis

Pathology

Impingement

Impingement
Is one of the most frequently described pathological shoulder conditions in sports medicine Early literature described impingement as a pathology or diagnosis (Neer 72) but today impingement is considered to be a cluster of symptoms, rather than a pathology itself There is a association between impingement and a variety of underlying pathological mechanisms (Cools 08,
10, 12)

Definition based on the side of encroachment

2 types: subacromial and internal Subacromial (external or outlet): mechanical encroachment of the soft tissues (bursa, rotator cuff) in the subacromial space between the humeral head and the acromial arch with an painful arc during active abduction

Impingement

Impingement

Definition based on the side of encroachment

2 types: subacromial and internal Internal impingement comprises the encroachment of the RC tendons between the humeral head and the glenoid rim and can be anterosuperior or posterosuperior (PS is most frequent: SST and IST between greater tubercle and the posterosuperior rim of the glenoid). This friction occurs during the late cocking position

Definition based on the cause of encroachment

2 types: primary and secondary Primary: a structural narrowing of the subacromial space causes pain and dysfunction (e.g. arthrosis AC joint, swelling soft tissues) Secondary: there are no structural obstructions, but functional problems occurring only in a specific position. This may occur in the subacromial space as well as in the GH joint / scapula

Clinical diagnosis

Clinical diagnosis

There is a great need for large, prospective studies that examine the diagnostic accuracy of many aspects of clinical examination in diagnosing shoulder pathologies (10, 12)

Rehabilitation scapula dyskinesis

Rehabilitation scapula dyskinesis

Scapula thoracic dysfunction

Analysis of scapular muscles / force couples UT + SA and LT for stability / movement control

Abnormal scapular muscle function

Dyskinesis type I (prominent inferior angle, tipping tipping Dyskinesis type II (prominent medial border, winging winging Dyskinesis type III (prominent superior / medial border, shrug shrug with elevation)

UPPER MIDDLE

LOWER

Rehabilitation scapula dyskinesis

Rehabilitation scapula dyskinesis

Abnormal scapular muscle function

Decrease SA strength Muscle imbalance UT versus LT Timing disorders LT

Strengthening SA
Push up with plus Serratus punch Dynamic hug

Type 1

Type 2

Rehabilitation scapula dyskinesis

Rehabilitation scapula dyskinesis

Strengthening LT & Rhomboid

Low rowing Horizontal abduction / ext rotation Elbow in the back pocket pocket

Balance UT/LT & UT/MT

Side lying forward flexion Side lying external rotation Horizontal abduction & ext rotation Prone extension

Thank you for your attention!