Internal impingement in the overhead athlete: GUIDELINES FOR REHABILITATION

Prof dr Ann Cools, PT, PhDDept Rehab. Sciences & PhysiotherapyGhent University, Belgium

Ann Cools Wrightington nov 2012

Impingement symptoms

ExternalSubacromial impingement

Internal(posterior)

impingement

PrimaryImpingement

Secundary Impingement

BicepsSLAP

Rotator cuffpathology

Scapular dyskinesis instability G.I.R.D.

(Cools et al. BJSM 2008)

“HYPER-ANGULATION”

1. Anterior instability

Excessive humeral headtranslations

2. Posterior shoulder stiffness

Alterations of glenohumeralkinematics

3. Scapular dyskinesis:

Insufficient scapular retractionduring cocking

(Wilk et al. AJSM 2002, Cools et al. BJSM 2008, Castagna et al. BJSM 2010, Ludewig et al. Man Ther 2011)

Ann Cools Wrightington nov 2012

Ann Cools Wrightington nov 2012

Patient presentation

� Female volleyball player (attacker)

� 27 years old

� Chronic shoulder pain (6 months)

� During serve and smash, pain at the back of the shoulder

� G.I.R.D.

� Pain in ABER – positive Relocation test – positive Release test

Ann Cools Wrightington nov 2012

Patient presentation

� Anterior tilt scapula during rest and arm movements

� Positive tests scapular involvement in shoulder pain (scapular assistance & scapular retraction test)

� Pectoralis minor short & tight

“HYPER-ANGULATION”

1. Anterior instability

Excessive humeral headtranslations

2. Posterior shoulder stiffness

Alterations of glenohumeralkinematics

3. Scapular dyskinesis:

Insufficient scapular retractionduring cocking

(Wilk et al. AJSM 2002, Cools et al. BJSM 2008, Castagna et al. BJSM 2010, Ludewig et al. Man Ther 2011)

Ann Cools Wrightington nov 2012

Ann Cools Wrightington nov 2012

Stretching posterior shoulder: clinical experience

� Sleeper’s stretch & cross body stretch improve ROM (Mc Clure2005)

� Additional manual mobilisationsimprove ROM (Manske 2010, Cools 2011)

� Improvement ROM is related to reduction of symptoms (Tyler 2010)

Ann Cools Wrightington nov 2012

POSTERIOR SHOULDER STRETCHING

STRETCHING G.I.R.D.:influence on the subacromial space?

Measurements:

- Acromiohumeral distance (Echoblaster 128; Telemed, Vilnius, Lithuania)

- Glehonumeral ROM (Acumar inclinometer)

Ann Cools Wrightington nov 2012

Quantifying acromiohumeral distance in overhead athletes with glenohumeral

internal rotation loss and the influence of a stretching program. Maenhout A,

Van Eessel V, Vanraes A, Van Dyck L, Cools A. (AJSM May 2012)

STRETCHING G.I.R.D.:influence on the subacromial space?

Intervention:

- 6 weeks stretching

- Sleeper’s stretch

Ann Cools Wrightington nov 2012

Quantifying acromiohumeral distance in overhead athletes with glenohumeral

internal rotation loss and the influence of a stretching program. Maenhout A,

Van Eessel V, Vanraes A, Van Dyck L, Cools A. (Accepted AJSM May 2012)

STRETCHING G.I.R.D.:influence on the subacromial space?

Ann Cools Wrightington nov 2012

0

20

40

60

80

100

120

Internal rotation External rotation Horizontal

adduction

Ra

ng

e o

f m

oti

on

(°)

D

ND

**

*

0

1

2

3

4

5

6

7

8

9

10

0° 45° 60°

AH

D (

mm

)

Degree of abduction

D

ND

*

**

Quantifying acromiohumeral distance in overhead athletes with glenohumeral

internal rotation loss and the influence of a stretching program. Maenhout A,

Van Eessel V, Vanraes A, Van Dyck L, Cools A. (AJSM May 2012)

STRETCHING G.I.R.D.:influence on the subacromial space?

Stretching improves ROM , and increases the subacromial space in overhead athletes with GIRD

Ann Cools Wrightington nov 2012

Quantifying acromiohumeral distance in overhead athletes with glenohumeral

internal rotation loss and the influence of a stretching program. Maenhout A,

Van Eessel V, Vanraes A, Van Dyck L, Cools A. (AJSM May 2012)

“HYPER-ANGULATION”

1. Anterior instability

Excessive humeral headtranslations

2. Posterior shoulder stiffness

Alterations of glenohumeralkinematics

3. Scapular dyskinesis:

Insufficient scapular retractionduring cocking

(Wilk et al. AJSM 2002, Cools et al. BJSM 2008, Castagna et al. BJSM 2010, Ludewig et al. Man Ther 2011)

Ann Cools Wrightington nov 2012

Scapular Rehab AlgorithmLack of

Soft-tissue flexibilityLack of

Muscle performance

Scapular muscles GH muscles/capsule Muscle Control Muscle Strength

- Levator scapulae- pectoralis minor

- infraspinatus- posterior capsule

- co-contraction- force couples

- lower/middle trap- serratus anterior

(Ellenbecker & Cools, BJSM 2010)

Stretching pectoralis minor: literature

� Borstad et al. JOSPT 2005: short PM influences scapular kinematics and induceschanges similar to impingement relateddyskinesis

� Cools & Johansson BJSM 2010: significant decrease PM length in elite junior (11-17yr) tennis players

� Reeser PM&R 2010: tight PM is associatedwith history of shoulder pain in volleyballplayers

� Borstad et al. JSES 2006: unilateral selfstretch (in 90° ABER) best results, however…

Ann Cools Wrightington nov 2012

Ann Cools Wrightington nov 2012

Stretching pectoralis minor: clinical experience

Scapular Rehab AlgorithmLack of

Soft-tissue flexibilityLack of

Muscle performance

Scapular muscles GH muscles/capsule Muscle Control Muscle Strength

- Levator scapulae- pectoralis minor

- infraspinatus- posterior capsule

- co-contraction- force couples

- lower/middle trap- serratus anterior

(Ellenbecker & Cools, BJSM 2010)

(SAT+) (SRT+)

Ann Cools Wrightington nov 2012

Ann Cools Wrightington nov 2012

Scapular muscle balance during RC exercises - progression

Ann Cools Wrightington nov 2012

Scapular muscle control during basic dailyactivities: external rotation component!

(Kibler 1998, Vanderhoeven 2006, Kibler 2006, Cools & Walravens 2005, Cools 2008)

Ann Cools Wrightington nov 2012

Results 5 weeks treatment

� Basic clinical exam is (-)

� Scapular control increased, however notsufficient

� No pain during (beach) volleyball, howeverno full return to sport (season)

� Working on other links of the kinetic chain (very poor pelvic stability, contol duringsquat...)

� Continue self-stretching

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Thank you