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Corrective Ex for the Shoulder

1

Agenda

• Anatomy

• Positioning/Dysfunction

• Assessments

• Mobility

• Stability

• Strength


Skeletal Anatomy


2

Skeletal Anatomy


Muscular Anatomy


Pectorals


3

Levator scapula


Latissimus dorsi


Posterior oblique subsystem


4

Rotator cuff


Rotator cuff


Neural Anatomy


5

Brachial Plexus



Kinetic Chain

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Shoulder Impingement

Nordt, W.W., Garrelston, R.B., & Plotkin, R. (1999). The measurement of subacromial contact pressure in

patients with impingement syndrome. Journal of Arthroscopic Surgery, 15, 121-125

Braman, J., et al. (2013). Shoulder impingement revisited: Evolution of diagnostic understanding in

orthopedic and physical therapy. Med Biology Eng Comput. [Epub]


Scapula Position

Associated with impingement

syndrome: • Internal rotation

• Anterior tilt

• Downward rotation

Struyf, F., Nijs, J., Baevens, J.P., Mottram, S., & Meeusen, R. (2011). Scapular positioning and movement in

unimpaired shoulders, shoulder impingement syndrome, and glenohumeral instability. Scandinavian Journal

of Medicine & Science in Sports, 21, 352-358


Scapulohumeral Rhythm

Norkin, C.C., & Levangie, P.K. (1992). The shoulder complex. In: Joint structure and function: A

comprehensive analysis (2nd ed.). 240-261. Philadelphia, PA: FA Davis

Inman, V.T., Saunders, S.J., & Abbott, L.C. (1996). Observations on the function of the shoulder joint.

Clinical orthopedics, 330, 3-12

Neumann, D.A. (2002). Shoulder complex. In: Kinesiology of the musculoskeletal system: Foundations for

physical rehabilitation. 189-248. St. Louis, MO: Mosby


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Posture

Forward head posture

• 1”=10lbs

• Loads exceed tissue

tolerance

• Decreased lung

capacity

• Increased stress

Kapandji, I.A. (2007). The physiology of the joints (6th ed.). Philadelphia, PA: Elsevier Health Sciences


What “allows” forward head?

Nuchal Ligament


What “allows” forward head?


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Shoulder Assessments


Assessing the Shoulder

Riddle, D.L., Rothstein, J.M., & Lamb, R.L. (1987). Goniometric reliability in a clinical setting: Shoulder

assessments. Physical Therapy, 67, 668-673


Subacromial Impingement

Silva, L., Andreu, J.L., & Munoz, P. (2008). Accuracy of physical examination in subacromial impingement

syndrome. Rheumatology, 47, 679-683



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Supine Flexion

Riddle, D.L., Rothstein, J.M., & Lamb, R.L. (1987). Goniometric reliability in a clinical setting: Shoulder assessments. Physical Therapy, 67, 668-673


GH Internal Rotation

Borstad, J.D., Mathiowetz, K.M., & Minday, L.W. (2007). Clinical measurement of posterior shoulder

flexibility. Manual Therapy, 12, 386-389


Thoracic Rotation

Johnson, K.D., Kim, K.M., Yu, B.K., Saliba, S.A., & Grindstaff, T.L. (2012). Reliability of thoracic spine range

of motion measurement in healthy adults. Journal of Athletic Training, 46(1), 52-60




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Thoracic Rotation

Johnson, K.D., Kim, K.M., Yu, B.K., Saliba, S.A., & Grindstaff, T.L. (2012). Reliability of thoracic spine range

of motion measurement in healthy adults. Journal of Athletic Training, 46(1), 52-60




Breathing

Gulick, D. (2009). Ortho notes clinical examination pocket guide (2nd ed.). Philadelphia, PA: FA Davis


Practical Application—SMR

1. Thoracic Spine

2. Pectorals

3. Latissimus dorsi

4. Posterior deltoid

5. Levator scapulae

6. Biceps


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Thoracic Spine


Pecs


Latissimus Dorsi


12

Posterior Deltoid


Levator Scapula


Biceps


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Practical Application—Lengthening

1. Pectoral stretch

2. Latissimus dorsi stretch

3. Thoracic extension

4. Thoracic rotation


Pec Stretch


Lat Stretch


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Thoracic Extension


Thoracic Rotation


Stabilize or Strengthen?

“Compression structures fall due to a lack

of stability, not strength” James Edward Gordon, Structures or Why Things

Don’t Fall Down


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Stabilize or Strengthen?

Tissue mobility or lengthening is only as good

as the exercise that comes after it

Progressions

1. Scapular stabilizers

2. Internal rotators

3. External rotators

4. Complex movement

Progressions

1. Non-weight bearing

2. Weight bearing

3. Upright

4. Endurance and

proprioception

Senbursa, G., et al. (2007). Comparison of conservative treatment with and without manual physical therapy

for patients with shoulder impingement syndrome: A prospective, randomized clinical trial. Knee Surgery

Sports Traumatology Athroscopy, 15, 915-921

Lombardi, I. et al. (2008). Progressive resistance training in patients with shoulder impingement syndrome: A

randomized controlled trial. Arthritis & Rheumatism, 59(5), 615-622

Cools, A.M., et al. (2008). Internal impingement in the tennis player: Rehabilitation guidelines. British Journal

of Sports Medicine, 42, 165-171


RC Exercise Review

1. Exercise has statistically and clinically significant

effects on pain reduction and improving function

2. Manual therapy augments the effects of exercise

3. Scapular plane before sagittal, sagittal before

frontal

Kuhn, J.E. (2009). Exercise in the treatment of rotator cuff impingement: A systematic review and

synthesized evidence-based rehabilitation protocol. Journal of Shoulder and Elbow Surgery, 18(4), e33-e36


Progression Matrix

Progressions

1. Scapular stabilizers

2. Internal rotators

3. External rotators

4. Complex movement

Progressions

1. Non-weight bearing

2. Weight bearing

3. Upright

4. Endurance and

proprioception


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Scapula—non-weight bearing

Cools, A.M., et al. (2007). Rehabilitation of scapular muscle balance: Which exercises to prescribe? The

American Journal of Sports Medicine, 35(10), 1744-1751.


Scapula—weight bearing

Lister, J.L., et al. (2007). Scapular stabilizer activity during bodyblade, cuff weights, and thera-band use.

Journal of Sports Rehabilitation, 16, 50-67.


Scapula—weight bearing


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Internal rotators—weight bearing


Sakita, K., Seeley, M.K., Myrer, J.W., & Hopkins, J.T. (2015). Shoulder-muscle electromyography during

shoulder external rotation exercises with and without slight abduction. Journal of Sport Rehabilitation, 24,

109-115

Internal rotators—non-weight bearing

External rotators—non-weight bearing


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External rotators—weight bearing


Complex Stability


Complex Movement


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Total Body Integration


Reactive


Example Template

Exercise Time/Reps Sets

SMR T-spine, pecs, lats, levator, post. delt

30-60 seconds 1

Stretch Pecs, lats, extension, rotation

30-45 seconds 1

Stabilization/Ac

tivation

Retraction, depress,

eccentric scaption,

plank, IR, ER,

12 repetitions 2-3

Complex Bear crawl, Crab walk, Modified down dog

12 repetitions 2-3

Total Body Squat w/shoulder RNT

12 repetitions 2-3

Reactive Side plank ball throw 8 each side 2-3

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