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Robertson EBP Shoulder Update
1. Shoulder Update!
2014 University of Texas at El Paso
Centennial Lecture Series
Evidence-based Management
Speaker:
Eric Robertson, PT, DPT, OCS, FAAOMPT
2. Objectives
• Attendees will accurately describe diagnostic and prognostic
criteria for patients with various should conditions.
• Attendees will integrate predictors of response into
examination of patients with shoulder pain.
• Attendees will review evidence supporting manual therapy
interventions for patients with shoulder pain.
• Attendees will integrate information about psychologically
informed practice into their management of patients with
shoulder pain.
• Attendees will review best-evidence interventions for patients
with shoulder pain.
3. Shoulder Pain: Incidence and Costs
• $7 Billion annually in U.S. (2000)
• 20-30% of the population
• Poor perceived recovery rate: <50%
• Prognosis is Fair to Poor for incidence of non-specific
shoulder pain
4. Our Path
Things that don‟t move enough
• Subacromial Impingement
• Adhesive Capsulitis
• Evidence for Manual Therapy
Things that move too much
• Shoulder Instability
• Evidence-supported exercise
I‟m getting Emotional…
7. Impingement Classification
• Mechanical glenohumeral
impingement
• Altered/reduced
sub-acromial space
• Associated AC joint
problems
• Think: “block”
Primary
• Uncertain glenohumeral
positioning
• Inherently unstable
shoulder
• Mechanically
• Functional
• Think: Instability
Secondary
(Andrews, 1993, Kamkar, A. et al. JOSPT Vol.17, No.5, p.212-224 May 1993)
8. Primary Impingement
• RC tendons
• Long head of biceps
• GH joint capsule
• Subacromial bursa
• Subacromial arch/space
Structures
• RC weakness or
inflammation (also of bursa)
• RC tendinopathy
• Posterior capsule tightness
• Morphology of acromion
• Postural dysfunction
Causes
(Andrews, 1993, Kamkar, A. et al. JOSPT Vol.17, No.5, p.212-224 May 1993)
9. Secondary Impingement
• RC tendons
• Long head of biceps
• GH joint capsule
• Subacromial bursa
• Subacromial arch/space
Structures
• RC weakness
• RC tear
• Capsular laxity
• Multidirectional instability
• Functional instability or
neuromuscular inhibition
• Scapular dyskinesia
Causes
(Andrews, 1993, Kamkar, A. et al. JOSPT Vol.17, No.5, p.212-224 May 1993)
10. Diagnosis of Primary SIS
• Historical Factors:
• Pain at night, pain with overhead activities,
complaints of stiffness
• Test-item Cluster for SIS
• +LR=10.56, -LR=0.17 (all 3)
• Hawkins-Kennedy Test
• Painful Arc Sign
• Infraspinatus Muscle Test
Park, et al, 2005
11. Diagnosis of Primary SIS
• Another Perspective:
• A larger test-item cluster
3 or more / 5 tests rules in SIS
3 or less /5 rules out SIS
Test Sens/Spec
t
+LR/-LR
Neer Sens -0.35
Painful Arc Both +2.25 / -0.38
Ext Rot Resistance Both +4.39
Hawkins-Kennedy Both ~1
Empty Can Spec +3.90
Michener et al, APMR, 2009
12. Diagnosis of Secondary SIS
• Historical Factors:
• Young, history of instability, pain with overhead
activities, hypermobility, overhead athlete
• Objective Findings:
• Observation of scapular dyskinesis
• Weakness of scapular stabilizers
• + Instability tests (Jobes Relocation, lateral
scapular slide test, for example)
McClure P, Tate AR, Kareha S, Irwin D, Zlupko E. A clinical method for identifying scapular
dyskinesis, part 1: reliability. J Athl Train. 2009;44(2):160-164.
13. Upper Extremity Y-Balance Test
• A measure of UE stability
• “is a body relative quantitative analysis of a person‟s ability to reach with the
free upper limb while maintaining single-limb weight-bearing on the
contralateral upper limb.”
P. Plisky
14. • Numeric Pain Rating Scale
• And/or 3 pain items from the Penn
Shoulder Scale: pain at rest, normal &
strenuous activities
NPRS
• Disability of Arm, Shoulder, and
Hand
• Quick DASH also good.
DASH
• Shoulder Pain and Disability IndexSPADI
MCID: 10-15
points
Outcome Measures for SIS
MCID: 8-13 points
15. General Treatment Principles
Type of SIS Presentation Guiding Principle Management
Primary
Stage I
Stage II
Stage III
Young, pain with activity Rest, restore
mechanics
MT and Exercise
26-40, pain at night,
prolonged symptoms
Restore sub-
acromial space
MT and Exercise,
possible surgery
Older, chronic,
associated with RC tears
Manage
conservatively
unless sx indicated
RC strengthening, Jt
mob, surgical
Secondary Multi-directional
instability
Stabilize Proprioceptive,
neuromuscular
strengthening
Internal Young, impingement in
specific range
Strengthen cuff
muscles
Rehab or labral
repair
17. Bang & Deyle
JOSPT, 2000
Bottom Line:
While both groups improved, the MT+Ex
group had greater improvements, including
strength gains.
Considerations:
MT + Ex group received treatment reinforcing HEP
Design: RCT
Pop: N=52, impingement
syndrome
Outcomes:
Baseline, 1 & 2 mo
Strength, Pain , Functional
Assessment Questionnaire
(FAQ)
Interventions: 6 sessions, 3-4
wks
•Exercise Group (Ex)
•Stretching & Cuff Ex
•Manual Therapy & Exercise
Group (MT+Ex)
•Ex as above
•Man Ther Upper
Quarter
Results:
•Pain & Function
MT+Ex with significantly
more improvement
•Strength
Only MT+Ex group with
significant improvement
Comparison of Supervised Exercise With and Without Manual
Physical Therapy for Patients With Shoulder Impingement
18. Bergman et al, Annals of
Internal Medicine, 2004
Bottom Line:
MT + UMC was the winner for achieving “full
recovery” at 12 wks (43% vs. 21%)
Same difference in recovery rate (17%) observed at
52wks
Considerations:
Perceived recovery: 6 & 26 Wks – CIs included 0
Other interventions
UMC: 28% CSI; 27% PT
MT+UMC: 25% CSI; 23% PT; 3.8 MT visits
Design: Multi-site RCT
Pop: N=150, painful shoulder girdle
Outcomes:
Baseline, 6 ,12 , 26 , 52 wks
Primary - patient perceived recovery
Secondary - severity of main
complaint, shoulder disability,
additional care received
Interventions:
•Usual Medical Care (UMC)
Advice/information, therapy
NSAIDS/analgesics & CSIs
•Manipulative Therapy (MT) + UMC
MT to neck, tx-spine & ribs, shoulder
girdle
≤ 6 sessions (in 12 wks)
Results:
•At: 12, 26, 52 Wks:
“Full Recovery” : MT >UMC
Severity of main complaint &
disability – MT> UMC
Manipulative Therapy in Addition to Usual
Medical Care for Patients with Shoulder
Dysfunction and Pain
19. McClatchie et al.
Manual Therapy,2008
Bottom Line:
• Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations:
Suggestive of a neurophysiologic effect, that treatment
of this area may facilitate recovery in distant regions.
Not an impairment-based approach
Design: RCT, cross-over
design
Pop: N=21 pts with shoulder pain,
painful arc, and no Hx of neck pain
Outcomes:
Pain (VAS), Painful Arc
Interventions:
•1 session: 2 min of seated cervical
lateral glide at C5,6,7. (Mulligan Grade
IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can
reduce signs of shoulder dysfunction in adults
20. Tate et al.
JOSPT, 2010
Bottom Line:
• Strong study describing treatment approach.
Considerations:
No cause and effect!
Design: Case Series
Pop: N=10 pts with SIS
Outcomes:
DASH (50%
improvement), GROC
Interventions:
•Standardized treatment
program including exercise and
manual techniques
Comprehensive Impairment-Based Exercise and Manual
Therapy Intervention for Patients With Subacromial
21. Other Interventions?
Bottom Line:
• Usual Medical Care, Arthroscopy, Passive Interventions,
Pharmaceutical Management, even usual PT all seem to be
ineffective!
1. PT = Arthroscopic debridement + PT (Brox, 1993)
2. CSI may only be beneficial for a sub-group. (Bergman et al., 2004)
3. Passive Interventions and Modalities not effective (Leduc et al., 2003)
4. NSAIDs: no meaningful changes (Green at al., 2003; Petri et al., 2004)
5. CSI only short term effect, and only prior to 12 weeks. (Crashaw, 2010)
How does the evidence look for other interventions for SIS?
23. SIS: A Regional Perspective
Cervical Spine: forward head, muscle
tightness
Ribs: first and second rib dysfunction
Thoracic Spine: attachment for many scapula
stabilizers
CNS: neuromotor control, pain processing,
core synergies and stabilization
24. Eccentric Exercise?
• Degenerative Process = Chronic Changes
• Tendonosis?
• Eccentric strength training to the rotator cuff
• Holmgren et al, 2012: Reduced need for surgery with ecc.
0
20
40
60
80
Subsequent Surgery
25. More research is needed to determine which interventions are the most
effective, long term outcomes, and economic benefit of physical
therapy programs for SIS
Manual therapy in addition to exercise, including those techniques
directed regionally is more effective than exercise along or usual care.
SIS is prevalent, easily diagnosed, yet correlated with a questionable
prognosis
SIS Conclusions
27. What is it?
• Effects 2-5% of the general population and 10-38% of the
population with diabetes or thyroid disease
• Primarily effects those 40-65 yrs
• Females > Males
• Primary (idiopathic)
• Secondary
• Intrinsic vs extrinsic
28. Differential Diagnosis
• May present similarly to other common shoulder conditions
seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
**Diagnostic imaging usually unnecessary, but may be
used to rule out other conditions
32. Natural History
• Little agreement in the literature
• “even the most severe cases recover with
or without treatment in about 2 years,”
Codman – 1934
• “20-40 % of cases do not respond to
conservative treatment”
Castellarin – 2004
33. Duration of the Disease
(with conservative treatment)
• Reeves – 1975
• Prospective study, n = 41
• Average duration; 30.1 months
• Shaffer et al. – 1992
• Retrospective study, n = 62
• Average duration; 12 months
• Miller et al. – 1996
• Retrospective study, n = 50
• Average duration; 14 months
34. Long Term Effects
• Reeves – 1975
• At 5 yr. f/u: 54% with limited ROM
• 7% with functional limitation
• Shaffer et al. – 1992
• At 7 year f/u: 43% with limited ROM
• 11% had functional limitation
• Miller et al. – 1996
• At 10 year f/u: 100% regained „functional
ROM‟
36. Treatment Options
• Wait and see
• PT directed rehab
• MD directed rehab
• Oral corticosteroids
• Steroid injections
• Capsular distension
• Long lever MUA
• Arthroscopic release
• Translational MUA
37. Oral steroids
Cochrane Review : Buchbinder, 2009
• One trial reported significant short-term benefits of oral steroids
versus placebo: 48% reported success; overall improvement in pain
2.7 on a 0 to 10 point scale; total shoulder abduction increased by
23.3 degrees; Shoulder Pain and Disability Index (SPADI) score
improved by 18.1. But benefits were not maintained at 6 weeks.
• A second trial reported no significant differences between oral steroid
and placebo in pain or range of movement.
• A third trial reported that oral steroids provided a more rapid initial
improvement in pain compared to no treatment but negligible
differences by five months.
• Conclusion: oral steroids provides significant short-term benefits in
pain, range of movement of the shoulder and function in adhesive
capsulitis but the effect may not be maintained beyond six weeks.
38. Steroid Injections
Cochrane Review : Buchbinder, 2009
• For adhesive capsulitis, two trials suggested a possible early benefit of
intra-articular steroid injection over placebo but there was insufficient data
for pooling. One trial suggested short-term benefit of intra-articular
corticosteroid injection over physiotherapy in the short-term.
• Conclusion: Despite many RCTs of corticosteroid injections
for shoulder pain, their small sample sizes, variable
methodological quality and heterogeneity means that there is
little overall evidence to guide treatment. Subacromial
corticosteroid injection for rotator cuff disease and intra-
articular injection for adhesive capsulitis may be beneficial
although their effect may be small and not well-
maintained.
39. Capsular Distension
Cochrane: Buchbinder 2009
• Distension methods: air, air w steroid injection, saline, and saline w
steroid injection
• Undergoing distension with steroid and saline solution compared to
placebo (fake distension);
- May improve pain at three weeks.
- May improve disability at three, six and 12 weeks.
• Undergoing distension with steroid and saline solution compared to
ordinary injection with steroid;
- May not lead to any difference in pain and disability.
• Conclusion: arthrographic distension with saline and steroid provides
short-term benefits in pain, range of movement and function in
adhesive capsulitis. It is uncertain whether this is better than
alternative interventions.
40. Traditional Manipulation
long-lever techniques
• Common practice in some centers for patients
who have failed conservative Rx.
• Sandor – 2000.
• M.U.A. is a useful way to treat frozen shoulder.
• Kivimaki et al. – 2001.
• Traditional manipulation risks fracture, especially
in osteoporotic patients.
• Hannifan - 2000
41. • Markus et al. – 2005
• 30 consecutive cases of recalcitrant AC received MUA
• “unequivocal acute intrarticular lesions were found in 12 joints”
• 4 Ant. labrum detachments- with 1 osteochondral fragment
• 3 SLAP tears
• 2 Partial ruptures of GH ligaments
• 2 Partial tears of subscapularis tendons
• “the joint should not be mobilized by force. In
resistant shoulders, controlled endoscopic release
is preferable.”
Traditional Manipulation
long-lever techniques
42. Manipulation Following Interscalene Block for
Shoulder Adhesive Capsulitis: A Case Series
• Subjects (N= 4)
• Average Symptom Duration = 7.5 mo
• Treatment
• Interscalene block followed by impairment-based
mobilizations/manipulations
• Post manipulation Rx: mobilization, ROM, strengthening
exercises and ice (qd for one week then tiw for 2 weeks
~ 10 visits)
• Outcome Measures
• PROM and SPADI
• Video fluoroscopy recordings for 2 patients
• Taken pre-rx, immediately post-rx, 6- and 12-week
(Boyles et al, Manual Therapy, 2005)
47. Case Studies:
Arthroscopic findings following translational MUA.
Hando B., article in write up
• Arthroscopy performed immediately following
translational manipulations
• Patient #1: 42 y.o. diabetic male. 14 month
history of labral tear, impingement. AC x 7
months.
• Patient #2: 42 y.o.f., secondary AC s/p humeral
neck fracture. AC x 14 months.
52. Intra-articular Findings
• In both shoulders:
• No acute intra-articular
lesions were found.
Rotator cuff, biceps
tendon, subscapularis
tendon, glenoid, labru
m and humeral
surfaces were found in
perfect condition.
53. Translational Manipulation Theory
• “Translational manipulation attempts to restore the
normal movements associated with angular GH motion.”
• “…the applied force moves the humeral head in a linear
direction, parallel to the glenoid fossa.”
• Advantages over long-lever M.U.A include:
• Minimizing GH joint compression
• Improved operator control
• Increased subacromial space
• Isolates manipulative force to GH joint
• Minimizes stress to brachial plexus
Placzek, et al, Amer J of Ortho– 2004
54. Prognosis
• In most cases conservative treatment is
successful in relieving pain and restoring pre-
condition motion.
• Some patients may never regain full motion
• Estimated 10% of patients unsuccessful with
conservative treatment and require more
aggressive management
• Spontaneous recovery may occur up to 2 years
post-onset
55. • Little evidence to support modalities, oral or injectable steroids or
capsular distension. All may have some short term relief but none
reported for the long term.
• Mounting and compelling evidence exists that translational
manipulation following interscalene block is safe and effective
treatment for the management of shoulder adhesive capsulitis.
• Perhaps, patients should be offered this option early in the course of
care rather than waiting out the pain and added expense of
standard, less effective programs.
Clinical Bottom Line
58. Green et al, Cochrane Database of Systematic Reviews, 2003
Physiotherapy Interventions for
Shoulder Pain
• Two broad categories of shoulder pain:
• Rotator cuff tendonitis disease
• Adhesive capsulitis
• Results
• Exercise is effective for short- and long-term recovery in
rotator cuff disease
• Manual therapy provides added benefit to exercise
• No evidence of US effectiveness in shoulder pain
• No evidence that physiotherapy alone is of benefit for
adhesive capsulitis
59. Green et al, Cochrane Database of Systematic Reviews, 2010
Physiotherapy Interventions for
Shoulder Pain
• Two broad categories of shoulder pain:
• Rotator cuff tendonitis disease
• Adhesive capsulitis
• Results
• Exercise is effective for short- and long-term recovery in
rotator cuff disease
• Manual therapy provides added benefit to exercise
• No evidence of US effectiveness in shoulder
pain, AC, rotator cuff disease
• No evidence that physiotherapy alone is of benefit for
adhesive capsulitis
60. Effectiveness of Rehabilitation for Patients
with Impingement Syndrome: A Systematic
Review
• Systematic review of 12 RCTs
• Results:
• Therex more effective in reducing pain and increasing
function than placebo. Mixed results when compared
to surgery
• Adding MT to therex provides favorable outcomes
compared to therex alone
• Does not support the use of US as a beneficial
treatment
• Conflicting results in use of acupuncture
Michener LA et al, J Hand Ther, 2004
61. Paul Mintken, Josh Cleland, Kristin Carpenter, Mel
Bieniek, Mike Keirns, Julie Whitman
Physical Therapy January 2010
Identifying Prognostic Factors for
Successful Short-Term Outcomes in
Individuals with Shoulder Pain Receiving
Cervicothoracic Manipulation
62. 5 Variables in the CPR
• Painfree shoulder flexion < 1270
• Shoulder IR < 530 at 900 abduction
• Negative Neer test
• Not taking medications
• Symptoms < 90 days
64. The Rule
Pre-test Probability
of Dramatic Success
with Manipulation
61%
3 or more present:
•Painfree shoulder flexion < 1270
•Shoulder IR < 530
•Negative Neer test
•Not taking medications
•Symptoms < 90 days
89%
Post-test Probability
of Dramatic Success
with Manipulation
+LR = 5.3
66. In the works….
Validation of a clinical prediction rule to
identify patients with shoulder pain likely to
benefit from cervicothoracic manipulation: A
randomized clinical trial.
Mintken P, Boyles R, Cleland J, Michener L, Strunce J, Burns
S, Carpenter K, McDevitt A
67. In the works…..
In data collection phase
Manual physical therapy versus
subacromial corticosteroid injection for
the treatment of shoulder impingement
syndrome: a randomized clinical trial.
Rhon, Boyles & Cleland
VS
69. Epidemiology
66%-100% of individuals < 20 years
of age
13%-63% of individuals between 20
and 40 years age
0%-16% of individuals older than
40 years of age
Instability is defined as a clinical syndrome
that occurs when shoulder laxity produces symptoms
70. Epidemiology
• Primary Dislocations:
• Most common in 2nd & 6th decades
• ~92-98% are anterior dislocations (remainder are posterior)
• 95% of first-time dislocations result from traumatic force
• 5% are atraumatic (sleep, minor movements)
• Recurrent Dislocations:
• 70% of first-time dislocations dislocate again within 2 years
• Younger patients more likely to have recurrence
Shoulder Dislocation
71. Laxity vs. Instability
• Laxity – the extent
to which the
humeral head can
be translated on the
glenoid
• Instability – an
abnormal increase
in GH translation
that causes
symptoms
(subluxation or
dislocation)
Schenk, J Am Acad Orthop Surg, 1998.
72. Shoulder Stability:
A Result of Multiple Components
• Bony Congruency
• Enhanced by labrum
• Negative pressure
• at side & at rest
• Muscles & tendons
• static and dynamic
• Ligaments & capsule
Glenohumeral Elevation
73. Shoulder Function
• G-H joint has ↑ mobility, but at loss of
stability
• 25% of humeral head contacts glenoid
fossa
• Static, Soft tissue constraints:
• Capsule, G-H ligaments, labrum
• Dynamic constraints consist of:
• Neuromuscular system (proprioceptive
mechanisms and scapular/humeral
muscles
75. Neuromuscular Stabilization
• The glenoid moves like
a seal‟s nose to remain
in the right spot to
control the ball (head)
The Shoulder: A Balance of
Mobility and Stability
80. Clinical Presentation
Traumatic Injury
• Position of dislocation
• Anterior/posterior shoulder
pain
• Apprehensive to moving
arm out from body
Nontraumatic Injury
• General multi-joint
hypermobility
• Anterior/posterior shoulder
pain
• Loose inferior capsule
81. Clinical Presentation
Traumatic Injury
• Position of dislocation
• Anterior/posterior shoulder
pain
• Apprehensive to moving
arm out from body
Nontraumatic Injury
• General multi-joint
hypermobility
• Anterior/posterior shoulder
pain
• Loose inferior capsule
82. Physical Examination
• Observation:
• “protective” posture
• Anterior tipping of scapulae
• Pain/palpation
• Diffuse pain over anterior and posterior shoulder
• Humeral head position at rest
• Motion
• Unable/unwilling to move into endranges of ABD & ER
• Strength
• Limited by pain, weak ABD & ER
• Ability to co-activate dynamic stabilizers likely diminished
• Check RC and scapular muscles
• Sensation/Proprioception
• Sensation generally intact, check Axillary n.
• Proprioception/Kinesthetic deficits may be noticeable
84. Non-surgical Management
• Older patients have lower recurrence therefore better candidates
vs younger patients
• Immobilization has been standard component
• Traditionally 6 weeks in ADD/IR (sling) position
• More recently, immobilize in AB/ER
• Neither approach give optimal outcomes; recurrence rates of ~ 30%
Traumatic Instability
85. Non-surgical Management
• Role of Exercise
• Few studies investigating outcomes
• Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motions
• Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abduction
• Both studies had re-dislocation rates in the 15-25% range
• Gibson et al, 2004. Cochrane Review: Low evidence, 6 weeks of
immobilization and 12 weeks of structured rehab, including scap
stability. Surgical approach may be superior.
Traumatic Instability
86. Non-surgical Management
• Role of Exercise
• Again, few studies investigating outcomes
• Progressive strengthening of rotator cuff, deltoid and scapular
stabilizers
• Functional coordination exercise
• Lifestyle modification
General Instability Rehabilitation Principles
88. Essential Elements for Dynamic
Stability of the Shoulder Complex
• Adequate compressive forces
• RC doing its job
• Scapular base
• Mobility/stability
• Proprioception and NM
control of the entire kinetic
chain
• Muscular endurance
• Train to job/sport specificity
89. Shoulder
Flexibility Requirements
• Pectoralis Muscles:
• Associated with excessive scapular protraction
and downward rotation, both disturbing optimal
glenohumeral mechanics.
• Posterior-Inferior G-H Capsule:
• Associated with SLAP tears & internal
impingement syndrome in throwing athletes
• Latissimus Dorsi and Teres Major:
• Associated with resistance to UE elevation
90. Andersen et al. Phys Ther. 2010 Apr;90(4):538-49.
• RESULTS: Resistance exercise with
dumbbells as well as elastic tubing
showed increasing EMG amplitude
with increasing resistance.
• CONCLUSIONS:
• Therapists can choose either
resistance method in clinical
practice.
91. How do we load the shoulder?
Myth
• We must limit the amount of
weight used during
glenohumeral and
scapulothoracic exercises to
assure that the appropriate
muscles are being utilized
and not larger compensatory
muscles.
Evidence*
• EMG signal amplitude of the
smaller RC muscles and
larger deltoid muscles
increased linearly in relation
to the amount of weight
• Larger muscle groups do not
overpower smaller
groups, such as the rotator
cuff.
• Load should be based on the
individual goals
requirements.
Alpert et al (J Shoulder Elbow Surg. 2000;9:47-58)
Dark et al (Phys Ther. 2007;87:1039-1046)
92. Baechle TR. Essentials of Strength and Conditioning. Human Kinetics. 2008.
Strength Continuum
93. SCAPULA‟S ROLE IN SHOULDER STABILITY
• Dynamic positioning of the glenoid fossa relative to the
humeral axis (~300)
• Minimizes GH shear & maximizes GH compression
• Optimal muscle activation (minimized RTC activation
requirements)
• Stable base of origin for muscles
• Responsible for function and stability
• Length dependent activation patterns
• Deltoid, biceps, triceps, and RTC
94.
95. Evidence Based Scapular Interventions
• Serratus anterior
strengthening or
retraining
• Upper trapezius
activation reduction
• Pectoralis minor
stretching
• Thoracic extension
posture and exercise
• Posterior shoulder
stretching
96. Scapular Retraining Exercises
• Scapular Punches
• Isometric Scapular Retractions
• Scapular Clocks
• Rotations on a ball
• Prone Y‟s, T‟s, W‟s
• Seated push-ups
• Rows
• Integrate hip/trunk
strengthening and stretching throughout rehab
97. What are the best exercises for
Muscles around the shoulder ?
98. Recommended Exercises for Rotator Cuff
• Supraspinatus
• 1. Full can
• 2. Prone full can
• Infraspinatus and teres minor
• 1. Side-lying ER
• 2. Prone ER at 90° abduction
• 3. ER with towel roll
• Subscapularis
• 1. IR at 0° abduction
• 2. IR at 90° abduction (less pec)
• 3. IR diagonal exercise
99. 20 participants performed full can and empty can exercises and
3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the
volume of the supraspinatus outlet during the EMPTY CAN exercise.
When maintenance of the subacromial space is important, use of the FULL CAN exercise
seems most appropriate for selective strengthening of the supraspinatus
100. Infraspinatus and subscapularis
activity….
• Infraspinatus and
subscapularis activity
have generally been
reported to be higher in
the „full can‟ compared
with the „empty can‟,
• Posterior deltoid activity
is higher in „empty can‟
ex.
Escamilla et al. Sports Med 2009; 39 (8): 663-685
101. Best Exercise for the Serratus?
Ludewig et al. Am J Sports Med 2004 32: 484-93.
SUGGESTED SEQUENCE
• Plus phase: Wall Pushup Plus
• Elbow Pushup Plus
• Knee Pushup Plus
• Standard Pushup Plus
In clinical cases of
scapular winging the
Standard Pushup
Plus is an optimal
exercise
102. Recommended Exercises for Serratus
Serratus anterior
• 1. Push-up with plus
• 2. Dynamic hug
• 3. Serratus punch 120°
103. Recommended Exercises for Trapezii
• Lower trapezius
• 1. Prone full can
• 2. Prone ER at 90° abduction
• 3. Prone horiz abd at 90° with ER
• 4. Bilateral ER (best LT/UT ratio)
• Middle trapezius
• 1. Prone row
• 2. Prone horiz abd at 90° with ER
• Upper trapezius
• 1. Shrug
• 2. Prone row
• 3. Prone horiz abd at 90° with ER
104. Best Exercises to Minimize Upper Trap?
• Exercises promoting lower trapezius (LT), middle
trapezius (MT), and serratus anterior (SA)
activation with minimal activity in the upper
trapezius (UT) are recommended.
• Examined 12 commonly used trapezius exercises and looked for
low ratios of UT/LT, UT/MT, or UT/SA
• No exercise optimized UT/SA ratio.
• This is the first study calculating balance ratios of
trapezius activity during these exercises.
Cools et al. Am J Sportsmedicine.2007;35(10):1744-51
105. Conclusions: THESE are good trapezius exercises , but
they are NOT good Serratus Anterior Ex
• sidelying external rotation,
• side-lying forward flexion,
• prone horiz. abduction with
external rotation, and
• prone extension exercises
….to promote LT and MT activity
with minimal activation of the UT
part.
• Based on our results, we
suggest the use of:
Cools et al. Am J Sportsmedicine.2007;35(10):1744-51
106. Recommended Exercises for
Rhomboids and Levator
• Rhomboids and levator scapulae
• 1. Prone row
• 2. Prone horiz abd at 90° with ER
• 3. Prone extension with ER
Escamilla et al. Sports Med 2009; 39 (8): 663-685
107. General thoughts on therex for shoulder
• Initial phase
• Pain control, edema reduction, gentle PROM, address
functional problems
• Sub-acute
• Progress PROM as tolerated, possibly add in
AAROM, address functional problems
• Progress to AROM followed by strengthening
• Return to functional state
• Progress strengthening, agility, dynamic stabilization, sport-
specific exercises
108. • 10 Patients with Impingement received
• Manual Therapy (Using a regional interdependence approach)
• 3 Phase Exercise Protocol by Tate et al JOSPT 2008
• Motor control/strengthening (phases I-III)
• Stretching
• Patient Education
110. Instructions
• Begin with band under very mild tension
• Progress to next strongest elastic band when able to do 3 sets of
10 reps without substantial pain or fatigue
• T-band standard: 3.5ft long
• Longer for taller people doing scaption
• Avoid or modify position of any exercise producing significant
symptoms
Tate et al. JOSPT 2010. 40(8)
115. Clinical Bottom Line: Exercise for SIS
• Conservative treatment is recommended over surgery
• Exercise is effective at improving pain and function
• Improve scapular motion and clear subacromial space
• Correct posture
• Strengthen shoulder stabilizers
• Rhomboids
• Serratus anterior
• Mid and Lower trapezius
• Strengthen rotator cuff
• Stretch tight structures
• Pec major and minor
• Upper trapezius
• Posterior capsule
117. • Results:
• 4 studies were specific to massive rotator cuff tears.
• 1 study had a sub-group with massive cuff tears
• 5 studies were not specific on size of the full thickness tear.
• Due to the heterogeneity of outcome measures used, it was
not possible to combine results.
• In all studies an improvement in outcome scores was
reported
• The findings suggest that some evidence exists to support
the use of exercise in the management of full thickness
rotator cuff tears.
Ainsworth & Lewis. Br J Sports Med 2007;41:200–210.
118. • 20 patients with full-thickness rotator cuff tears [RCTs]
• Treatment: activity modification, NSAIDs, physical modalities, and a
specific exercise program
• Statistically significant improvements were obtained in
• ROM
• Pain
• Function scores according to ASES, Constant score, SF-36 scores, and
isokinetic strength (P < 0.05).
At the 6-month evaluation,
• 11 patients (55%) reported that they were “much better”
• 9 patients (45%) “better”.
• Conservative treatment of full-thickness RCTs yields satisfactory
results both subjectively and objectively.
Baydar et al. Rheumatol Int (2009) 29:623–628
119. • Conclusion: Evidence on the
comparative effectiveness and
harms of various operative and
nonoperative treatments for
rotator cuff tears is limited
and inconclusive.
Seida et al. Ann Intern Med. 2010 Aug 17;153(4):246-55. Epub 2010 Jul
5
121. • Functional rehab following shoulder dislocation
• Increase proprioceptive awareness
• Increase dynamic stabilization
• Elicit preparatory and reactive muscle activation
• Restoration of functional movement patterns
• (Lephart and Henry, 1996)
• Open and closed chain exercises improve proprioception
• (Rogol et al, 1998).
• Closed chain activities increase functional joint stability
• (Ubinger et al, 1999; Henry et al, 2001)
• Exercises that enhance coactivation improve recovery
• (Ginn and Cohen, 2005)
• Shoulder plyometric training increases proprioception
• (Swanik et al, 2002)
Shoulder Instability Rehab
122. Motor Control Alterations with GH Instabity
• Decreased supraspinatus-
subscapularis coactivation
• Slower biceps brachii activation
• Decreased pectoralis major &
biceps brachii recruitment
• Suppressed scapular stabilization
by Trapezius and Serratus
• (Glousman et al., 1988; Kelly et al 2005; Kronberg et
al., 1991; McMahonet al., 1996; Myers et al., 2004)
123. • 6 Subjects with GH Instability
• Significant increases scapular protraction
and anterior tilt.
• Activity of the lower trap and serratus
delayed during first part of elevation
• Altered humeral head and glenoid alignment
predispose shoulder instability
• Scapular changes are perhaps due to an
inadequate scapular muscular activity.
• Evidence to suggest that the sensorimotor
contributors to joint stability can be
restored.
The unstable shoulder in arm elevation: A three-
dimensional and electromyographic study in
subjects with glenohumeral instability.
Matias R, Pascoal AG
Clinical Biomechanics 21 (2006) S52–S58
124. Naughton J et al. Upper-body wobbleboard training effects on the post-
dislocation shoulder. Phys Ther In Sport. 2005; 6:31–37.
• 15 uninjured control
• 15 dislocated/subluxed within 1 year
• Assessed movement discrimination
• 4 wk training period Trunk Lying on
Swiss ball balancing UE on
wobbleboard 10 min daily
Significant improvement
movement discrimination with
dislocators ( p<0.001)
125. • Rehab success for shoulder instability
• Requires cuff recruitment
• Facilitate glenohumeral approximation
• Concavity-Compression Retraining
• (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional
instability of the shoulder -- a case study.
Darlow B
NZ J Physiother. 2006;34(2):60-65.
126. Instability Rehabilitation Implications
• Restore normal function of rotator cuff musculature
• Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
• Avoid rehabilitation exercises combining abduction and
external rotation
• Serratus anterior and trapezius strengthening exercises can
begin early in rehab process
• Begin with isometric exercises with manual resistance, progress
to dynamic strengthening
• Eventually plyometric exercises for highly active populations
• Include proprioceptive exercises to combat loss due to tissue
damage
127. Advanced phase: functional rehabilitation
• Focus on continued strength and endurance
• Retraining patterns of movement biased
towards functional tasks
• Repetition, speed and load may be varied
facilitating feedforward processing
• Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ball
• Plyometric drills such as two-hand chest
passes, overhead soccer throw and side-to-
side throws
• Bouncing balls off trampoline
• Global upper-limb strengthening
• Kibler et al. Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010;44:5 333-340
128. • Integrate LE/trunk w/loads
• Push-press to single-arm squat
• Lunge and Reach Progression
Integrating the Shoulder:
Return to Function Phase
129. Return to sport
• Sport specific goal-orientated tasks
• Throwing at a specific target
• Bouncing a ball around an obstacle course
• Shooting into a basketball/netball hoop
• Patient should regain 5 key components
prior to return to sport
1. Flexibility
2. Strength
3. Balance
4. Proprioception
5. CONFIDENCE!
• If confidence is lacking, patient at risk of
compensation, reinjury and recurrence of instability.
Jaggi and Lambert Br J Sports Med 2010;44:5 333-340
130. Upper Extremity Y-Balance Test
• “Y Balance test is a body relative quantitative analysis of a person‟s ability to reach
with the free upper limb while maintaining single-limb weight-bearing on the
contralateral upper limb.”
• Test-retest reliability 0.80 to 0.99
• Interrater reliability 1.00
• Average composite scores right/left (%Limb Length)
• Men 81.7%/82.3%
• Women 80.7% /80.7%.
Gorman, Butler Plisky and Kiesel. J Strength Cond Res. 2012 Jan 5. Epub
131. Our Path
Things that don‟t move enough
• Subacromial Impingement
• Adhesive Capsulitis
• Evidence for Manual Therapy
Things that move too much
• Shoulder Instability
• Evidence-supported exercise
I‟m getting Emotional…
132. I‟m getting Emotional…
Evidence for risk factors for chronic pain
• Catastrophizing, fear avoidance, self-efficacy, all important for shoulder dysfunction, like
so many MSK conditions
• COMT phenotypes?
Kinesiophobia
• Measure these fine things!
• TSK, FDAQ, FABQ
Remember to acknowledge and treat chronic conditions as chronic pain
• Graded Exposure/Graded Exercise
• Pain Science Education
• Fewer manual technqiues
• Focus on function
133. Pain Phenotypes, you say?
• Genetic expressions for inflammation (IL1B, TNF/LTA
region, IL6 single nucleotide polymorphisms, SNPs)
• and, Psychological factors…
• Combine to predict shoulder pain phenotypes: specifically, pain
level, duration, and disability
George et al, 3/2014
Inflammatory Genes and Psychological Factors Predict
Induced Shoulder Pain Phenotype.
134. Genetically Predisposed?
• Strong associations between type of COMT (catechol-o-methyl-
transferase) phenotype and catastrophizing!
• Are predictive of upper extremity disability and depressive
symptoms related to pain
Biopsychosocial influence on exercise-induced injury: genetic and
psychological combinations are predictive of shoulder pain
phenotypes. George et al, 1/2014
135. References
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2. Boyles RE, Ritland BM, Miracle BM, et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther.
2009;14(4):375-380.
3. Kuijpers T, van Tulder MW, van der Heijden GJMG, Bouter LM, van der Windt DAWM. Costs of shoulder pain in primary care consulters: a prospective cohort study in
The Netherlands. BMC Musculoskelet Disord. 2006;7:83.
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5. Mintken PE, Cleland JA, Carpenter KJ, et al. Some factors predict successful short-term outcomes in individuals with shoulder pain receiving cervicothoracic
manipulation: a single-arm trial. Phys Ther. 2010;90(1):26-42.
6. Morse K, Davis AD, Afra R, et al. Arthroscopic versus mini-open rotator cuff repair: a comprehensive review and meta-analysis. Am J Sports Med. 2008;36(9):1824-
1828.
7. Norlander S, Nordgren B. Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine. Scand J Rehabil Med.
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8. Tate AR, McClure PW, Kareha S, Irwin D. Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in overhead athletes. J
Orthop Sports Phys Ther. 2008;38(1):4-11.
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10. Winters JC, Jorritsma W, Groenier KH, et al. Treatment of shoulder complaints in general practice: long term results of a randomised, single blind study comparing
physiotherapy, manipulation, and corticosteroid injection. BMJ. 1999;318(7195):1395-1396.
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BMJ. 2010;340:c3037.
12. Conroy DE, Hayes KW. The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome. J Orthop Sports
Phys Ther. 1998;28(1):3-14.
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Sports Phys Ther. 2000;30(3):126-37.
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randomized, controlled trial. Ann Intern Med. 2004;141(6):432-9.
15. Winters JC, Sobel JS, Groenier KH, Arendzen HJ, Meyboom-de Jong B. Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder
complaints in general practice: randomised, single blind study. BMJ. 1997;314(7090):1320-5.
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prospective, randomized clinical trial. Knee Surg Sports Traumatol Arthrosc. 2007;15(7):915-21.
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18. Arslan S, Celiker R. Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis. Rheumatol Int.
2001;21(1):20-3.
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adhesive capsulitis of the shoulder: randomized controlled trial. Phys Ther. 2006;86(3):355-68.
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Editor's Notes
Welcome to the Diagnosis and Treatment of Anterior Knee Pain. My name is Eric Robertson from Texas State University. I invited you to Sit back, relax, and enjoy the lecture.
In this lecture, we will review background information about SIS, including classification of different types of SIS, staging of the disorder, and specifics related to diagnosing SIS. We will then move on to look at a variety of studies which can help guide us as we seek to develop an evidence-supported approach to SIS. By the end of this lecture, you should feel confident that you have an up-to-date awareness of the best evidence approach to managing patients with SIS.
Shoulder pain is the second most commonly seen diagnosis in physical therapy clinics in the United States, second only to that monster known as low back pain. It’s been estimated that direct costs related to shoulder pain have approached $7Billion annually and can affect upwards of 20-30% of adults. If this wide range and scope of shoulder pain wasn’t enough of a concern, the statistics related to recovery might really get you interested. For shoulder pain in general, it’s estimated that only 50% of patients will report a self-perceived recovery after one year and that recurrent shoulder pain, and chronic shoulder pain are likely outcomes. There is only a fair to poor prognosis for patients with shoulder pain. You can see from the chart here as well, that those with persistant shoulder pain, like many chronic conditions tend to do, exhibit a much greater cost on the health system. Note that these statistics are talking about shoulder pain in general, from a non-specific standpoint, rather than dealing with a specific diagnosis. However, It’s likely that the vast majority of patients with shoulder pain will present with some form of shoulder impingement and so it’s not a stretch to extrapolate this information about incidence and prognosis to our topic of interest today.
Dr. Charles Neer, famously known among physical therapists for the Neer shoulder impingement test, first described the concept of mechanical shoulder impingement back in 1972. In that description, Neer outlined a theory that shoulder impingement consisted of some disruption to the mechanics of the rotator cuff, most likely having to do with the coracoacromial arch height, and the subacromial space. He described 3 forms of acromial morphology, and designated them Type I, II, or III. The Type I acromion was described as a flat acromion, which resulted in a suitable subacromial space and was correlated to a low incidence of impingement. This was present in about 17% of the population. The Type II acromion was a different story. This morphology was described as curved and resulted in a reduced subacromial space. Accordingly, this was correlated to a higher incidence of SIS. Type II acromion was thought by Neer to be the most commonly seen variant, present in about 43% of the population. The type III acromion, thought at the time to be a genetic anatomic variant or the result of severe degenerative changes, was described as a “beaked” acromion. This morphology was distinctive as the anterior tip of the acromion curved sharply downward serving to drastically reduce the subacromial space and was correlated with a very high incidence of SIS and quite often with tears of the rotator cuff.Neer’s description of shoulder impingement was taken to heart by health professionals and served as the basis for learning and managing this condition up until about 1994, when, among others, Dr. James Andrews offered a more detailed description of subacromial impingement syndrome, including classifying impingement into primary and secondary forms.
Before we look at classification of shoulder impingement, let’s take a look at the concept of disease progression as proposed by Neer. This has been described as a continuum of shoulder impingement. Patients in stage 1 of the disease are likely to be under the age of 25, and the impingment upon the tissues of the rotator cuff mild. As such, at this stage SIS is a reversible condition and is very responsive to conservative treatment. The name given to this group, edema and hemorrhage indicates the acute inflammatory nature of this stage. Patients in stage II are likely to be a bit older, presenting with shoulders that have undergone some more wear and tear. The tissue of the rotator cuff in this stage present with more fibrotic changes, and re-organization of collagen tissues, resulting in more persistent tendonopathy. These patients often have a history of recurrent shoulder pain over time and were considered by neer to be less responsive to conservative treatment. If a trial of conservative treatment was not effective, a subacromialdescompression could be considered as an effective management strategy for patients in stage II.Patients in stage III tended to be older and presented with significant anatomic changes, including osteophystes or bone spurs and not uncommonly, tendon rupture. This stage was the end of a progressive cascade of shoulder disability and surgical repair of the rotator cuff and acrompioplasty was suggested as the primary intervention strategy. Even though these stages of shoulder impingement were described a relatively long time ago, they still very accurately describe the possible disease progression and patient presentation one is likely to encounter when managing patients with dysfunctional shoulders. SIS truly occurs along a continuum and preventign the progression of disability is a primary goal of managing patients with shoulder pain.
As I mentioned, Andrews described two forms of subacromial impingement in the early 1990’s: primary and secondary. Primary shoulder impingement is the form that Neer was really talking about. This is a mechanical impingement of the glenohumeral joint under the subacromial arch. Patients with primary shoulder impingement have a reduced subacromial space and often related problems with the AC joint as well. When conceptualizing primary shoulder impingement, you can think of it as a mechanical block, or something in the way. Secondary shoulder impingement is one of uncertain glenohumeral positioning. This is usually associated with an unstable shoulder, especially in patients who present with multi-directional instability. This can be the result of either mechanical or functional instability of the shoulder. When conceptualizing secondary shoulder impingement, its often helpful to relate this with instability of the shoulder. I’ve added some imaged here to help you remember, primary shoulder impingement is quite often related to anatomical causes, while secondary shoulder impingement is quite often related to difficulty stabilizing the shoulder, such as in this patient with gross scapular winging.
Looking more closely at primary shoulder impingement, we can break down the structures that are involved as well as the presumed causes of the disorder. You can see that any structure which runs under or near the subacromial arch is potentially vulnerable to mechanical impingement, especially the long head of the biceps and the supraspinatus and infraspinatus muscle tendons. RC weakness can lead to inflammation and reduced space, especially as fibrotic changes occur within those tissues. Patients with primary shoulder impingement also very frequently present with tightness of the posterior capsule of the shoulder in addition to morphologic changes of the acromion. Finally, postures like increased thoracic kyphosis and forward heard posture can serve to effectively reduce the subacromial space and impinge the structures of the shoulder.
Next we can see a more detailed breakdown of secondary shoulder impingement. As you can see, the structures involved aren’t going to change, we’re still dealing with the shoulder. However, the causes of secondary shoulder impingement are more related to muscle function and neuromotor control. RC weakness or tears can compromise the stability of the humeral head during motion as well as more structural factors like capsular laxity. Often, patients with secondary shoulder impingement present with multidirectional shoulder instability. This instability can be a functional instability, or one that’s present during motions and affected by muscle activation rather than purely a mechanical instability. Scapular dyskinesia is not uncommon, and in some patients, it may be this abnormality of postural control which is the main contributor to the inconsistent and improper positioning of the humerus under the coracoacromial arch.
Patients with Primary SIS often present with very characteristic historical factors, which is useful as you begin to generate your initial hypothesis. Pain at night, pain with overhead activities, and complaints of shoulder stiffness are common reports. Remember too, that considering Neer's descriptions of staging, especially with respect to age and recurrent pain can be useful components of a patient historical report as you begin to consider SIS. Impairment findings with shoulder impingement are likely to include decreased AROM for shoulder flexion, abduction and External Rotation, along with decreased passive PROM and accessory mobility of the shoulder, especially in directions limited by the posterior capsule. Muscle weakness becomes more and more common as the disease severity progresses and patients often have poor posture. Two test-item clusters exist that can help make sense of the many available special tests at the shoulder. These are potentially very useful as many studies have reported variable diagnostic values for certain special tests like the Neer and Hawkins-Kennedy tests. The first Test-item cluster we will look at, presented by Park et al, identified the H-K test, the presence of a painful arc sign and a positive infraspinatus muscle test as indicative of primary SIS. If all three items are present, a positive LR of 10.56 was reported, which affords a very strong shift in probability that the patient has the disorder. If only two items are present, the +LR is still 5, which is also quite strong. Conversely, if a patient tests negative on all three items, the –LR was reported to be 0.17, which is equally helpful to rule out the disorder. Also useful information is the fact that Park also reported that if you substitute the presence of a painful arc for a positive drop arm sign in this test-item cluster, you are more than likely observing a rotator cuff tear versus simple shoulder impingement.
Another study, this one performed by Michener et al in a 2009 issue of Archives of Physical Medicine and Rehabilitation found 5 tests with utility to help rule in or out SIS. These authors reported that the Neer test was sensitive, and it’s absence could assist in ruling out SIS, while the empty can test was specific, and could moderately help rule in SIS. The painful arc test, H-K test and ext rotation resistance test, which was performed similarly to the infraspinatus muscle test, were both sensitive and specific. Perhaps more useful was the established cutoff value of 3 positive special tests. 3 or more positive tests out of these 5 could help you to rule in SIS, while less than 3 could help you to rule out the disorder. Looking at both of these TIC’s together, it’s probably useful to include each of these items in the Michener study, as they can be performed quickly and are repeated across both the Park and Michener TIC. Along with pertinent historical features and these useful clusters, once a physical therapist has ruled out cervical origin, systemic origin and has not identified profound weakness which could indicate a rotator cuff tendon rupture, the diagnosis of SIS doesn’t need to be complicated.
Diagnosing secondary shoulder impingement is a little less clear, partly because you are observing the secondary effects of what might be a primary weakness or deficiency in the shoulder capsule. Historically, these patients present as young patients, often overhead athletes with a history of shoulder instability. They might report that they can pop their shoulder or even a history of dislocation of subluxation, but that’s not necessary for this diagnosis. Pain again occurs with overhead activities and from an impairment standpoint, we’d expect to find weakness of the rotator cuff and scapular stabilizers coupled with increased accessory joint mobility. The classic impingement special tests may or may not be positive, depending on the patient and level of irritability, so relying on them is less clear for patients with secondary shoulder instability. However, tests like the Jobe’s relocation or other assessments of instability may indeed be positive. Some authors have reported observation of scapular dyskinesia as an important factor, but, while reported to be a reliable measure, one validation study found the presence of scapular dyskinesis was not strongly related to the presence of shoulder symptoms in a group of overhead athletes. You can see from the image on the right that it can be fairly easy to detect abnormal scapular patterns, but the complex nature of the shoulder and scapulo-humeral rhythm make extrapolating this finding as a purported cause of pain weak.
Another idea we could consider when evaluating patients with secondary shoulder impingement it to look at their performance during an upper extremity functional task designed to assess stability of the upper quarter. The Upper Extremity Y-balance test, as described by Phil Plisky is one option. This test is designed to maximally challenge both mobility and stability of the upper quarter, as well as assess the mobility and stability of the thoracic spine and core musculature. To perform this test, a patient assumes a one are push up position and standardized language is used to request the patient to perform a reaching task in the Medial, Inferiolater and Superiolater directions, performed without a rest. This test hasn’t been validated specifically in a population of patients with shoulder instability, but considering the structural and functional requirements of this task, its makes a lot of sense to consider.
Outcome measures are helpful tools to evaluate patient baseline functional status, disease severity, and to monitor the progress of an intervention. Here you can see 3 objective measures likely to be utilized with shoulder patients. The numeric pain rating scale is employed for all types of patients, obviously, but for shoulder patients, some clinicians and some researchers have used this scale while specifically asking about painful activities. To do this, 3 items are often used from the Penn Shoulder Scale, a comprehensive battery assessing shoulder function. This items ask patients to rate pain related to pain while at rest, pain during normal activities of daily living, and finally pain experienced during strenuous activities. By delineating pain in this fashion, you may be able to get a more insightful look into how the shoulder dysfunction is affecting the patient. The Disability of Arm, Shoulder, and Hand scale or DASH is a nice scale for use with shoulder patients, although it has been designed an an upper extremity index, not one specifically related to the shoulder. There is a shorter, quick version of the DASH, which has also been validated and is quite useful. The SPADI, or shoulder pain and disability index, is a shoulder-specific measure of function and is often used in research and clinical settings. The MCID of both the DASH and SPADI has been determined, with an MCID of 10-15 for the DASH and 8-13 for the SPADI. Remember, when you seen changes equal to or greater than the MCID, you know that your patient has experienced real, clinically meaningful changes, surpassing measurement error inherent in the tool.http://www.ncbi.nlm.nih.gov/pubmed/19405008http://www.ncbi.nlm.nih.gov/pubmed/20044703
Before we look deep into the evidence for intervention, let’s first consider some general overriding treatment principles for patients with various forms of shoulder impingement. We know that for patients with all stages of primary shoulder impingement, we need to work on increasing mobility. Of course, as the stage of the illness progresses, we need to be more and more aware that surgical repair might be indicated. For secondary shoulder impingement, we need to stabilize the shoulder, including some neuromuscular re-education to the upper quarter. We won’t delve into the specifics of internal shoulder impingement in this lecture, but it’s worth mentioning. Internal shoulder impingement designates an impingement of internal structures within the GH joint, especially the posterior superior labrum. Patients with internal impingement often present with pain in a specific range and is common in overhead athletes and weightlifters. For these patients, a program designed to strengthen the RC and stabilize the shoulder can be attempted, with labral repair or surgical correction an option for non-successful candidates. Figure out internal impingement stat
First, we have a landmark study by Bang and Deyle published in 2000 in JOSPT. This was a multi-center randomized controlled trial evaluating the effectiveness of manual therapy added to an exercise program for patients with SIS. 52 subjects with SIS were dividing into an exercise group and a manual therapy + exercise group. They were assessed at baseline, 1 and 2 months for measures of strength, pain, and an author-developed functional assessment questionnaire. The approach Bang and Deyle used was very much a Maitland derived impairment-based approach. Both groups received a supervised exercise program including strengthening and a home exercise program which included the use of an exercise log. The results demonstrated improvement for pain and function in both groups, but greater improvements in the MT+Ex group. Interestingly, significant strength gains were only observed by the manual therapy + exercise group. This is a well-designed study which does a good job representing the impairment-based approach to OMPT. The use of strict inclusion criteria and such items as the exercise log help contribute to the strength of the results. The functional assessment used was not independently validated which is a weakness. The take home message from this study has to be that we can achieve gains using exercise only, but the addition of OMPT is going to advance those gains and may also be important for realizing strength improvements in this population of patients that traditionally has a difficult time tolerating much strength training work.--Results:Pain & FunctionMT+Ex with significantly more improvement StrengthOnly MT+Ex group with significant improvementBang and Deyle performed a Multi-Center RCT. Subjects were Pts referred to PT for shoulder impingement (more strict inclusion criteria for DX of SIS than previous study), utilized Maitland, impairment based approach to patient. Pain was measured on a VAS, and the function measure was not validated (questionnaire developed by authors).Both groupsstrengthening x 3 weeklystretching dailycontinued for 30 daysexercise logExercise & manual therapy grouptreatment reinforcing home exercisesIn-Clinic – Both groups with supervised strengthening in clinic, Ex group had supervised stretching also. 2 X 2 MANOVA Mixed DesignIndVar – Group and Time (pre and post rx)Dep Variables – Collapsed info for VAS, Pain, FunctionPOST-HOC ANALYSISUnivariate ANOVAsEach DVAdjusted Alpha =0.017
The Bergman study is also one we like to hang out hats on as manual physical therapists. Subjects were recruited from general practices in the Netherlands and the research question looked at the effects of adding manipulative therapy to the shoulder girdle. In this study, the shoulder girdle and the cervico-thoracic spine received HVLAT manipulation or HALVT mobilization. For inclusion, subject must have presented with shoulder symptoms, which were defined as pain between the neck and the elbows as shown in the image here. As you can see, this wasn’t a strict inclusion of SIS patients specifically. The authors cited Cyriax, Greenman, and Lewitt as inspiration for their “style” of manipulative treatment. One weakness in this design was the use of patient perceived improvement as “full recovery”, a somewhat subjective measure for a primary outcome measure.No limits were placed on duration of symptoms before the first consultation and there was no exclusion for symptoms to neck or lower arm.As you look at the results listed here on the slide, the percentages are representing the % of patients who reported “full recovery” from their limiting shoulder pain. At 6 weeks, there were no between group differences, but at 12 weeks, a significantly higher percentage of the MT+UMC group reported recovery. Usual medical care, cortico-steroid injections, and non-OMPT physical therapy all produced consistently less patient reported recovery.The inclusion of spinal manipulative therapy into the intervention plan for patients with SIS is an important take-home message of this high quality study.--Design: Multi-site RCTPop: N=150, painful shoulder girdle Outcomes:Baseline, 6 ,12 , 26 , 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint, shoulder disability, additional care receivedInterventions:Usual Medical Care (UMC)Advice/information, therapy NSAIDS/analgesics & CSIsManipulative Therapy (MT) + UMCMT to neck, tx-spine & ribs, shoulder girdle< 6 sessions (in 12 wks)Results:At: 12, 26, 52 Wks:“Full Recovery” : MT >UMCSeverity of main complaint & disability – MT> UMC
This article was published in 2008, entitled, “Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults.” The placebo controlled, randomized, blinded cross-over trial looked at pain and the presence of a painful arc in 21 subjects with unilateral shoulder pain and no prior history of neck pain. The intervention included 1 session of a cervical lateral glide performed as shown here in the seated position for 2 minutes, or a placebo mobilization. The glide was described as a Mulligan grade IV. For the experimental group, this resulted in immediate reduction in pain and painful arc. It’s important to note that this was not an impairment-based approach, rather a predetermined intervention performed on the cervical spine for patients who presented with shoulder dysfunction. These results are strongly suggestive of a neurophysiologic effect for mobilization in the cervical spine, as well as supportive of the regional interdependence concept.Design: Randomized, blinded, placebo controlled, cross over trialPopulation: N=21, generalized unilateral shoulder pain with painful arc and no Hx of neck painOutcomes:Pain (VAS)Painful ArcInterventions: 1 session2 min of seated cervical lateral glide at C5,6,7. (Mulligan Grade IV+) or placebo mobilizationResults:Immediate Painful Arc and VAS significantly decreased in cervical mobilization condition.
We’ve seen quite a bit of variation in the investigations on the effectiveness of manual PT and exercise for patients with shoulder dysfunction. Common issues across many of the studies have been related to the use of inconsistent outcome measures, lack of functional outcomes, and poor descriptions of the actual manual therapy intervention. This much needed case series by Tate et al was recently published in JOSPT. It described the best evidence-based intervention for patiients with SIS using standard functional report measures like the DASH and GROC. The key to this series was that the authors attempted to standardize a treatment program and describe it in detail, in possible hope or in anticipation of a follow-up RCT on the topic. In this case series, patients all tended to demonstrate recovery, however, due to the research design, no cause and effect can be inferred.
So far, we have seen several high quality trials supporting the inclusion of OMPT as part of a comprehensive intervention for patients with SIS. In order to accurately gauge how strong this collection of evidence is, it’s important to look quickly at other interventions in this same population. As you can see here, passive modalities, NSAIDS, CSI, and even arthroscopic debridement are not often associated with the type of strong improvements seen in the several preceding trials. In essence, they are not better than the status quo, and we might be throwing our money down the toilet! The one caveat there may be corticosteroid injections, and we’ll look at that a little bit more closely in a minute.
I inserted this slide from Dr. Wainner’s regional interdepence lecture, as it’s a good reminder and a nice segue to some trials that studied a more regional approach to shoulder impingement.
We should also make sure to consider assessing for impairments from a more regional perspective. Shoulder function can be affected by structures in the cervical and thoracic spine, and even the ribs. Sometimes a patient can experience dramatic improvement when the first rib is treated or when the thoracic spine is mobilized. Likewise, we should also appreciate the fact that pain is sometime modulated by higher central neural processes. This is especially important considering many patients we see with shoulder pain might have a chronic form of pain, or recurrent pain. For these individuals, we do need to keep an eye on the fact that their pain might not be unlike the chronic pain someone might present with persistent or recurrent low back pain, and many of the same pain management strategies can be utilized.
As we begin to conclude this lecture, I’d like to bring up a new trend I’ve spotted in the literature concerning interventions for SIS. Eccentric strength training. Since most Type 1 SIS involves a certain degree of chronicity, it makes sense that we would see chronic tissue changes in the tissues involved: things like reduced inflammatory response and disorganization of collagen fibers. As such, we can extrapolate findings from other regions were eccentric training has been used effectively to treat tendonosis issues. And indeed, in a recently published study in BMJ by Holmgren et al, a specific exercise training program reduced the need for surgery in their cohort. The intervention in this trial included eccentric RC training, concentric and eccentric exercises for scapular stabilizers and a regional manual mobilization approach. Patients in the treatment group reports overall improvement at about 70% vs. 23% those in the general exercise of the neck and shoulder group. Further, only 20% of the treatment group required subsequent sub acromial decompression, while 63% of the control group underwent surgery. Consider adding eccentric training prinicples to your shoulder patients, but like always, take care that you load these patients Spark plugs + coils: factory: Thermostat:Air filter:Ac condensor fan: 195 + 110Total: $649 +tax
In conclusion, subacromial impingement is a common and easily diagnosed musculoskeletal disorder of the shoulder, however, it’s correlated, like much shoulder pain, with a questionable prognosis. Manual therapy combined with exercise, including those techniques directed regionally at the cervical, thoracic spine and ribs seems to be more effective than exercise alone or usual medical care. There is no apparent benefit to surgical decmpression according to a systemicatic review. More research is still needed to determine which interventions are the most effective, evaluate long term outcomes for physical therapy interventions and assess the cost/benefit ratio of this approach. Overall, there’s a good body of evidence, that continues to grow supporting best evidence management for this population of patients. Keep on the lookout for more on subgrouping and more comprehensive approaches included in RCT trial, perhaps building on the Tate Case series we looked at. This concludes the presentation and thank you again for joining me! This is Eric Robertson signing off.
Greetings, I’m Bob Boyles, from the University of Puget Sound, and I’d like to welcome you to the start of another block of instruction: The Upper Quarter.Notice I used the term “Upper Quarter” and not UE. As you will see in this series of lectures, function of the joints of the upper extremity are dependent of the upper quarter as a unit, and vice versa. So when we talk about upper quarter, think UE and include the biomechanics, articulations and musculature of the thoracic and cervical spines. So, don’t forget what you learned from the CT lectures and labs.
We have seen with quite a bit of evidence, that manual therapy and exercise is particularly effective for patients with SIS. Earlier this year, Mintken et al developed a prognostic clinical prediction rule to help clinicians identify those patients with shoulder pain likely to respond to manual therapy interventions. The factors in their rule consisted of painfree shoulder flexion of less than 127 degrees, shoulder IR motion of less than 53 degrees at 90 degrees of abduction, a negative Neer test, not taking medication for their shoulder pain, and symptoms less than 90 days. Yes, the negative Neer test included in this rule was a surprise to the ressearchers, however, they cited the work of Winters and Sobel, which remind us that not all patients with shoulder pain, even those diagnosied with SIS will have a mechanical, pathoanatomical problem at the glenohumeral joint. Some patients will have dysfunction of the cervical and thoracic spine, and perhaps the negative neer test is directing us to those patients preferentially. Only follow-up validation will be able to say for sure! Until then, we have a cluster of items which can help fortify our prognosis for improvement with manual therapy interventions.
On the other end of the spectrum, we see some work by Kuijpers et al, which looked at prognosis for shoulder pain in general and factors that might pre-dispose someone to experience persistent shoulder pain. This study did not result in a rule, but instead a risk score, whereby important factors earned points and clinicians could calculate total estimated risk for pain. Long duration of complaints, gradual onset of pain, and high intensity of shoulder pain were all factors contributing to a poor prognosis and so you should be on the lookout for these factors when you’re examining patients. I think these criteria fit nicely in opposition with the criteria set forth by Mintken et al for a good prognosis for improvement with manual therapy techniques. It seems lower pain and recent onset are factors which are important to consider in the management of patients with shoulder pain.
Hi, this is Eric Robertson and today we’ll be discussing shoulder instabilities. Go ahead and sit back, relax, and enjoy the lecture!
Instability is a relatively common issue with shoulders, and this shouldn’t be any surprise, given the large freedom of motion available at the joint. The small amount of bony congruency also contributes to this. Before we look into some epidemiology of instability, let’s define it. Let’s use the term for any clinical syndrome that is a result of laxity in the shoulder. This can be anything from secnodary shoulder impingment, rotoator cuff or labral issues, or ligamentous structural laxity. The most obvious form of instability is the shoulder dislocation, but it’s not the only form.
If we look specifically at the epidemiology of shoulder dislocation, we can see that dislocation occurs most commonly in the 2nd and 6th decades of life, and the vast majority of them are anterior dislocations. Many occur primarily due to trauma, especially in younger patients. The overall prognosis for dislocation of the glenohumeral joint is not very good, in that up to 70% will likely experience a second dislocation event within the next two years.
Frodo Sandven is a comedian that specializes in the genre of gross out comedy. I’m not so sure that’s actually funny, but perhaps he can be useful to us as he voluntarily takes advantage of his tremendous shoulder laxity to pass his body through a tennis racket. The gentleman, if you can call him that, is demonstrating laxity, but we wouldn’t diagnosis him with instability until the next morning when he had pain resulting from his laxity. This is an important concept when discussing shoulder instability, as many people have a decent amount of laxity in the shoulder, but the term instability is reserved for those with clinical symptoms as a result of the laxity.
To fully understand shoulder instability, we should begin by exploring the various components of shoulder stability. Stability at the glenohumeral joint is derived from a combination of factors, and this graph makes a strong attempt at demonstrating this visually. Bony congruency and a negative intrcapsular pressure gradient is formed in part by the glenoid labrum. Postural factors help position the glenoid on a slight incline, which also contributes to stability while the arm is at rest. You can also see how as we elevate the arm, the contributors of stability change, with more ligamentous and muscle stability taking place further through the range. Of real importance here, is that at no point in time are any of these contributors to stability at a true zero mark, reinforcing the fact that optimal shoulder function is derrived from the complex interplay of postural support, bony congruency, labral function, and optimal ligamentous and neuromuscular stabilization. While this seems perhaps annoyingly complex, I’d like to look at it from a different perspective: with so many contributors to overall stability, it’s highlly likely that we as physical therapists can find some area ammenable to improvement!
Here you can see a cut away anatomy image of the glenoid labrum. The cup-like shape of the labrun helps enhance the amount of bony congruencey as it wraps around the humeral head. Addittionally, you can see the close interplay of the labrum to the glenohumeral ligaments and the biceps tendon. All important factors when considerign a differential diganosis of the hsoulder.
Example Title slide
No common scapular dysfunction with people of shoulder pathology!Many different scapular adaptations!
Maximal RTC activation requires a stable scapular base, since all RTC muscles have their proximal attachment on the scapula.
SPP had highest activation of the SA SPP also had low UT/SA ratios EPP and KPP exercises also had high SA activity with low UT/SA ratios. The WPP demonstrated higher UT/SA ratios.In clinical cases of scapular winging the SPP is an optimal exercise.
In view of the intermuscular and intramuscular imbalances often established in these patients,
An exercise found to be clinically effective for aiding proprioception is the side lying plank: the affected arm points towards the ceiling at 90° to the body, and the patient is encouraged to balance a ball or place and hold the hand in space with the eyes closed, thus helping to retrain joint position sense (figure 12). Activities should now be more sportspecific with goal-orientated tasks, as these have been shown to be effective in cognitive motor retraining.45 Examples can be throwing at a specific target, bouncing a ball around an obstacle course or shooting into a basketball/netball hoop. It is vital that the patient regains five key components prior to returning to their sport; flexibility, strength, balance, proprioception and of course confidence. If confidence is still lacking, the athlete is at risk of compensating with abnormal movement faults, increasing their risk of reinjury and instability.
Another idea we could consider when evaluating patients with secondary shoulder impingement it to look at their performance during an upper extremity functional task designed to assess stability of the upper quarter. The Upper Extremity Y-balance test, as described by Phil Plisky is one option. This test is designed to maximally challenge both mobility and stability of the upper quarter, as well as assess the mobility and stability of the thoracic spine and core musculature. To perform this test, a patient assumes a one are push up position and standardized language is used to request the patient to perform a reaching task in the Medial, Inferiolater and Superiolater directions, performed without a rest. This test hasn’t been validated specifically in a population of patients with shoulder instability, but considering the structural and functional requirements of this task, its makes a lot of sense to consider.
