clinical evalua+on of impingement in the overhead athlete · pdf file20.10.2015 ·...

Clinical Evalua+on of Impingement in the Overhead

Athlete Howtonavigatetheexamina/onandwhatworks?

·AndyGlidewell,PT,DPT,ATCJeremyBraziel,LAT,ATC,CSCS

Objec+ves

• Discussvarioustypesofimpingementsmen/onedintheliterature·

• Navigatecommonexamina/onfindings·

•  Iden/fyriskfactorsassociatedwithposteriorinternalimpingement·

• Discussmanagementstrategiesforinternalimpingement

Impingement Syndrome

• Oneofthemostfrequentlydescribedshouldercondi/onsinsportsmedicineandgeneralprac/ce.

•  Irrita/onoftherotatorcuffanatomysomewhereintheshouldergirdlecomplex?

•  Subacromialspace•  Postero-superiorglenoidrim•  Suprascapularnotch

Impingement Syndrome

•  Earlyliteratureconsideredthisapathology,oradiagnosis

•  Nowconsidereda“cluster”ofs/s•  Notconsideredatruepathology

• Commonlyusedalongsidetermssuchas“rotatorcufftendinopathy.”

•  Recommenda/onstoavoidtheuseoftheterm“subacromialimpingementsyndrome.”

Types of Impingement

• PrimaryvssecondaryImpingement

·•  Externalvsinternal

Impingement


•  PrimaryImpingement•  Intrinsicdegenera/venarrowingofthesubacromialspace

•  Ie:ACarthropathy,osteophytes,subacromialswelling

•  Ptstypically>40y/o

•  LimitedIRROM(<50°)comparedtonon-involvedside

•  Generalpictureisoneofhypomobility


•  SecondaryImpingement•  Resultofpreviousunderlyingpathologythatleadstoimpingementsyndrome

•  Nostructuralobstruc/on,ratherafunc/onalproblem

•  Ie:scapulardyskinesia,GHinstability,rotatorcuffweakness,GIRD

•  Botholder&youngerathletes,butusually<35y/o

•  LimitedIR,excessiveER,antero-superiorHHmigra/on


•  ExternalImpingement•  Impingementcommonlyknownas“subacromialimpingement”

•  Encroachmentofsuprahumeralstructuresagainstsubacromialroof(bursa,RTCtendons,LHB)

• ClinicalPredic/onRule•  (+)Hawkins–Kennedytest•  (+)painfularc•  (+)shoulderERpain/weakness


•  InternalImpingement•  “Pathologiccontactbetweenglenoidandthesideoftherotatorcuffthatfacesthear/cularsurfacesoftheshoulder.”

•  Newestofimpingementconcept•  1991paperbyWalchetal.

•  Posteriorshoulderpaininoverheadathletes

Internal Impingement

Examina+on of Internal Impingement

•  Subjec/ve•  MOI->Chronic/micro-trauma/c/cumula/veoverload

•  Insidiousonsetofposteriorshoulderpain

•  Increasingpainasseasonprogresses•  Intensityincreaseseachsuccessiveyear

•  Painisdull,aching,andpoorlylocalized

•  Deniesnumbness,pallor,orparesthesiainthearm

•  Senseof“slipping”oftheshoulder


• Differen/alDiagnosis• Whatcanalsocauseposteriorshoulderpaininoverheadathletes

thatisNOTposteriorinternalimpingement?

• Cervicalradiculopathy• Uppertrapac/vetriggerpoints• Mul/-direc/onalInstability•  Systemicsourcesofshoulderpain•  Suprascapularnerveentrapment*

Suprascapular nerve entrapment

•  OienmistakenasaRTCpathologyorcervicalradiculopathy

•  Twositesofcompression•  Transversescapularligament•  Spinoglenoidnotch

•  Painis“morelocalized4cmMEDIALtoposterolateralcornerofacromion”

•  Painwithpalpa/onatthespinoglenoidnotch.


• Canoccurfromanacutetrauma•  Forcedexternalrota/onofUE•  Stretchonsuprascapularnerve

• Complaintsofmicro-instability

• ROMdoesnotoiendecrease

• Descrip/onofexternalrota/onweakness


•  Fossaatrophy•  canbeeasilyoverlookedinwell-developedindividuals

•  Inchronicsitua/ons,teresminorandserratusanteriorcancompensateforinfrapsinatusweaknesstoobtainnearnormalstrength!

•  Lidocaineanesthe/cinjec/onscanhelpwithdiagnosis


• Objec/ve• Palpa/on/inspec/on

•  (+)Infraspinatusfossa•  (+)Superiorscapularangle

• RangeofMo/on•  TypicallyfullROM•  DominantUE

•  10°-15°moreER@90/90•  10°-15°lessIR@90/90


• Objec/ve• MuscleTes/ng

•  Scapularretractorweakness•  Rhomboids•  Upwardrota/onforcecoupling

•  Test@90/90•  Scapulamustmovetowardsretrac/onwiththrowing

•  Avoidsimpingementofshoulder

• Neurologicalscreen:WNL•  (-)ULTTmediannerve


• Objec/ve•  JointPlay

•  1+to2+anteriorlaxity•  2+posteriorlaxity•  Inferiorlaxitynoted

• AMAlig.laxitygrading*•  1+=0-5mmincreasedtransla/on•  2+=6-10mm•  3+=>10mm


• Wait!•  Remember….a“cluster””ofs/s!!•  NOT1-2specialtests!

•  SpecialTests•  Posteriorimpingementtest•  AKA“Meister”test•  Specificity=85%•  Sensi/vity=94%withnon-contactMOI


• Posteriorimpingementtest

•  Ptsupine

•  UEinscapularplaneat90°ABD

•  PassivelyrotateintomaxER

•  Applyoverpressure

•  (+)ifreproducess/s


•  Clinicalreasoningalgorithm•  Externalimpingement

•  (+)Hawkins-Kennedy,emptycan,Neer’s(ANTpain),apprehension,withanteriorreportedpain

•  Don’tforgetParketalCPR!•  Internalimpingement

•  (+)Neer’s(POSTpain),apprehension,withposteriorreportedpain

•  (-)Hawkins-Kennedy,emptycan

•  PLEASEDON’TFORGETTHERESTOFTHEEXAMINATIONBEFORE

THISALGORITHM!

Risk Factors Associated with Internal Impingement

Risk Factors

• Pathomechanics• AcquiredInstabilityOveruseSyndrome(AIOS)•  InternalRota/onDeficitandtheImplica/ons•  ScapularDyskinesia

Pathomechanics

• ArmAccelera/on7000-7500degrees/sec

• Distrac/veforcesatreleaseare1330NandaveragepitcherBWof940N

• MaxERAnteriorforce=340N•  FleisigetalAmericanJofSportsMed.1999 299lbs

Pathomechanics

E+ology of Internal Impingement

TwoPrimaryCauses1.  ExcessiveHHTransla/ons

a)  Microinstabilityb)  InternalRota/onDeficit(GIRD)Ø  Coolsetal.BrJSportsMed2008

2.  AbnormalScapularPaternsa)  Dyskinesiab)  RetractorDeficiency(Hyperangula/on)Ø  MyersetalAmJSportsMed2006

Scapularposi/oning

IRDeficit

PosteriorInternalImpingement

Func/onalInstability

HHTransla/on

Risk Factors

• Pathomechanics

• AcquiredInstabilityOveruseSyndrome(AIOS)•  InternalRota/onDeficitandtheImplica/ons•  ScapularDyskinesia

Microinstability

•  Func/onalInstabilityorAcquiredInstabilityOveruseSyndrome(AIOS)•  Anteriorcapsulemustbeabletowithstandsignificanttensilestrain•  Stressleadstogradualstretchingofcollagen•  Compromiseofsta/cstability•  Mostcommonlydescribed-anteriorinstability

•  Wilketal.AmJofSportsMed2002

•  Thrower’s-AIOS•  ER=Velo

Risk Factors

• Pathomechanics• AcquiredInstabilityOveruseSyndrome(AIOS)

• InternalRota?onDeficitandtheImplica?ons•  ScapularDyskinesia

Internal Rota+on Deficit •  FactorsImpac/ngIRdeficit

•  OsseousAdapta/on(retarda/onofanteversionbeginningasyoungas8-10yro)

•  PosteriorCapsule•  IGHLlaxity(“hammockFunc/on”)•  IncreasesGHcompression(axialload)@90oABD•  DeAngelisetalOrthoJofSportsMed2015(Cadavericstudy)

•  Increasesantforce@90osuperiortransla/on@100o-PROMstudy

•  SoiTissueAdapta/on-RC•  ScapularAntTilt

IR Deficit-TROM

•  TotalArc(TROM)•  IR+ER=Totalarcofmo/on

•  IRmeasuredbycoracoidstabiliza/on•  ICCWilk.81andLaudner.95

•  Norm180o

•  GIRDclassifiedby>12o-15odifference•  MyersetalAJSM2006.19.7oDifferencewithPII•  >5odifferenceinTROM2.5x’smorelikelytobeinjured

• WilketalAmJSportsMed1998

IR Deficit •  ReinoldetalSportsHealth2009noteda5odecreaseinROMaieronethrowingsession

•  DwellyetalJAT2009monitoredovercourseof1season

•  NosignificantchangeinIRbutincreaseof11oER

•  Suggestthatthosewhodevelop>11oERandlose>1-2oIRmaybe“atypical”

•  Pathologicvs“normal”altera/on

Risk Factors

• Pathomechanics• AcquiredInstabilityOveruseSyndrome(AIOS)•  InternalRota/onDeficitandtheImplica/ons

• ScapularDyskinesia

Scapular Dyskinesia

• Whatisnormalforanoverheadathlete•  2:1?

• Howdoweevaluate???•  Ifyoucanaffectit,suspectit

•  SSMP

•  ScapulaisalinktransferringlargeamountsofEfromLE/Trunktothearm

•  Globaleffect

Ed INVITED REVIEW

Scapular dyskinesia: evolution towardsa systems-based approach

Elaine G Willmore1 and Michael J Smith2

AbstractHistorically, scapular dyskinesia has been used to describe an isolated clinical entity whereby an abnormality in position-ing, movement or function of the scapula is present. Based upon this, treatment approaches have focused on addressinglocal isolated muscle activity. Recently, however, there has been a progressive move towards viewing the scapula as beingpart of a wider system of movement that is regulated and controlled by multiple factors, including the wider kinetic chainand individual patient-centred requirements. We therefore propose a paradigm shift whereby scapular dyskinesia is seennot in isolation but is considered within the broader context of patient-centred care and an entire neuromuscularsystem.

Keywordsscapula, dyskinesis, shoulder, assessment, rehabilitation

Date received: 20th October 2015; accepted: 27th October 2015

Introduction

‘Optimal’ scapular motion is considered to be crucial tothe functioning of the shoulder and, as such, any alter-ation in scapular kinematics is believed to be a contri-buting factor to the development of shoulderpathology.1 In particular, any variation in the amountof scapular upward rotation that occurs is particularlyimplicated as a predisposing factor in the developmentof shoulder symptoms. This is because the scapula mustupwardly and externally rotate and posteriorly tilt ade-quately to prevent the humeral head from compressingand shearing against the under surface of the acromion:one of the proposed mechanisms for producing the syn-drome commonly referred to as subacromial impinge-ment. Based on this widely held view, the aim of manyshoulder rehabilitation programmes is to correct aber-rant, local scapula mechanics.

The notion of scapular dyskinesis for the purposes ofthe present review does not include presentations wherethere is a defined abnormality of the neuromuscularsystem; for example, neuritis, neuropathy, neuropraxiaor other forms of peripheral nerve injury.

The purpose of the present review is to summarizecurrent concepts and provide the clinician with not onlya foundation of reasoning on which to base clinicaldecision-making, but also some practical suggestions

as to how these could be incorporated and utilized indaily practice.

What is normal and does it matter?

Scapulohumeral rhythm (SHR) is the co-ordinationbetween humeral and scapular movements and wasfirst described by Codman2 and subsequently popular-ized by Inman.3 X-rays were used to calculate scapulamovement of seemingly one subject and the conclusionreached that there was an overall constant scapulohum-eral rhythm of 2 : 1 during shoulder flexion and abduc-tion. Considering that a full arc of shoulder movementis 180!, this is a result of 120! of glenohumeral move-ment and 60! of upward rotation.

With the benefit of time and technology, it is clearthat SHR is much more complex than the reported 2 : 1

1Gloucestershire Hospitals NHS Foundation Trust, PhysiotherapyDepartment, Cheltenham General Hospital, Cheltenham, UK2College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK

Corresponding author:Elaine Willmore, Physiotherapy Department, Cheltenham GeneralHospital, Sandford Road, Cheltenham, GL53 7AN, UK.Tel: þ0300 422 3040.Email: [email protected]

Shoulder & Elbow

2016, Vol. 8(1) 61–70

! The Author(s) 2016

Reprints and permissions:

sagepub.co.uk/journalsPermissions.nav

DOI: 10.1177/1758573215618857

sel.sagepub.com

easier to integrate than others. For example, if dynamicexternal rotation or tip toe/single leg standing reducesthe symptoms or the appearance of dyskinesis, then thiscan easily be used as a foundation on which any numberof other exercises functionally relevant to the patient canbe built. If, however, humeral facilitation or scapularupward rotation improves the patients symptoms, thenthis is less straightforward. Scapular upward rotation isnot a movement that exists in isolation and the transla-tional anterior posterior glide movement of humeralhead facilitation requires an externally applied pressure.

The challenge then becomes finding an exercise thatcapitalizes on the symptom reduction achieved duringsymptom modification. For this, clinical reasoningneeds to take one step further and this is significantlyaided by understanding the roles and function of thescapula and rotator cuff.

Understanding the functional anatomy

When glenohumeral movement occurs, the scapulamust also move to allow the repositioning of the glen-oid fossa thus increasing the available range of move-ment. During this movement, the scapulohumeral andaxioscapular muscles must collectively function tomaintain optimal mechanical alignment. Rotator cuffactivity prevents unwanted humeral head translationbut, when left unchecked, would pull the scapula lat-erally, essentially creating a destabilizing force. Theaxioscapular muscles respond by preventing the scapu-lohumeral muscles from destabilizing the scapula and

produce the upward rotation, posterior tilting and exter-nally rotate necessary for optimal movement and func-tion.30 A high correlation therefore exists between theaction of scapulohumeral and axioscapular musclesand activity in one group does not exist without corres-ponding activity in the other.

Just like the rotator cuff, scapula muscles have mul-tiple roles which vary, dependent on the task, the load,the speed or the range in which the movement is occur-ring.30 At any time, dependent on these factors, anypart of the rotator cuff, other scapulohumeral or axios-capular muscles could be acting in an agonist, antag-onist, stabilizing (static or dynamic) or synergisticfunction (Table 2). Glenohumeral external rotationexercises, for example, are classically regarded as work-ing the rotator cuff in its agonist role. This is true, but itis also true of all shoulder rotator torque generatorsand is therefore not specific to the rotator cuff.Glenohumeral external rotation however also requiresthe scapular muscles to function in their stabilizing role,explaining why either static or dynamic rotation uti-lized through symptom modification procedures canchange apparent scapula dyskinesis.

In addition to their agonistic role specific shouldermuscles also stabilize against destabilizing forces cre-ated by other shoulder muscles but this is far fromstatic. Rotator cuff muscles prevent unwanted transla-tion of the humeral head caused by other humeral mus-cles (e.g. deltoid and pectoralis major). Axioscapularmuscles work against the destabilizing force of the sca-pulohumeral muscles to prevent the scapulohumeral

Clinical Applica!ons of a Symptoms and Systems based assessment

Apparent Scapula Dyskinesis observed

Humeral Head Facilita!on

Poten!al interven!ons

Scapula Facilita!on External Rota!on (sta!c)

Tip toe standing Gym ball si"ng External Rota!on (dynamic)

Single leg standing

Reduc!on in symptoms

Incorporate into treatment plan

Figure 1. Potential symptom modification procedures.

64 Ed Shoulder & Elbow 8(1)

Scapular Retrac+on

•  Scapularmusculaturebalance•  OHathletes-protrac/on>retrac/on•  Non-athle/cpopula/onshavean=protrac/on:retrac/on

•  CoolsetalBrJSportsMed2008

• Retrac/onnecessarytoavoidhyperangula/on• AxioscapularmusculatureprovidesbaseforER

•  RhomboidMajor/minor•  MiddleTrapezius•  LevatorScapulae•  SerratusAnterior

Hyperangula+on

Treatment Selec+on and Concepts

Treatment-AIOS • Goals:

•  EmphasizeDynamicStabiliza/onandNMControl•  AnteriorLaxityhasbeenassociatedwithdecreaseinPropriocep/on

•  Laudneretal.ClinJofSportsMed2012

•  IntegrateLocalandGlobalStabiliza/on•  RestoreMuscularImbalance•  RestoreMuscularEndurance•  Ins/tutePlyometricProgram

Treatment-IR Deficit

• Goals:•  TissuePliability•  NormalHHTransla/on

• Methods:•  ScapularFacilita/on•  IASTM/Cupping•  Mobiliza/onwithMovement•  PostCapsuleStretching

•  ”Sleeper/ModifiedSleeper”,CrossBodystretch The International Journal of Sports Physical Therapy | Volume 9, Number 1 | February 2014 | Page 1

ABSTRACTBackground: Due to the repetitive rotational and distractive forces exerted onto the posterior shoulder during the deceleration phase of the overhead throwing motion, limited glenohumeral (GH) range of motion (ROM) is a common trait found among baseball players, making them prone to a wide variety of shoulder injuries. Although utilization of instrument-assisted soft tissue mobilization (IASTM), such as the Graston® Technique, has proven effective for various injuries and disorders, there is currently no empirical data regarding the effectiveness of this treatment on posterior shoulder tightness.

Purpose: To determine the effectiveness of IASTM in improving acute passive GH horizontal adduction and internal rotation ROM in collegiate baseball players.

Methods: Thirty-five asymptomatic collegiate baseball players were randomly assigned to one of two groups. Seventeen participants received one application of IASTM to the posterior shoulder in between pretest and posttest measurements of passive GH horizontal adduction and internal rotation ROM. The remaining 18 participants did not receive a treatment intervention between tests, serving as the controls. Data were analyzed using separate 2×2 mixed-model analysis of variance, with treatment group as the between-subjects variable and time as the within-subjects variable.

Results: A significant group-by-time interaction was present for GH horizontal adduction ROM with the IASTM group showing greater improvements in ROM (11.1°) compared to the control group (-0.12°) (p<0.001). A significant group-by-time interaction was also present for GH internal rotation ROM with the IASTM group having greater improvements (4.8°) compared to the control group (-0.14°) (p<0.001).

Conclusions: The results of this study indicate that an application of IASTM to the posterior shoulder pro-vides acute improvements in both GH horizontal adduction ROM and internal rotation ROM among base-ball players.

Level of Evidence: 2b

Keywords: Manual therapy, rehabilitation, shoulder, throwing athlete

IJSP

T ORIGINAL RESEARCHACUTE EFFECTS OF INSTRUMENT ASSISTED SOFT TISSUE MOBILIZATION FOR IMPROVING POSTERIOR SHOULDER RANGE OF MOTION IN COLLEGIATE BASEBALL PLAYERSKevin Laudner, PhD, ATC1

Bryce D. Compton, MS, LAT, ATC2

Todd A. McLoda, PhD, ATC3

Chris M. Walters, MS, ATC4

1 Illinois State University, Normal, IL, USA2 Provena Covenant Medical Center, Urbana, IL, USA3 Illinois State University, College of Applied Science and

Technology, Normal, IL, USA4 Glenbard North High School, Carol Stream, IL, USAThe institutional review board at Illinois State University

approved this study protocol.

CORRESPONDING AUTHORKevin G. Laudner, PhD, [email protected]: 1-309-438-5197fax: 1-309-438-5559

The Acute Effects of Sleeper Stretches on ShoulderRange of MotionKevin G. Laudner, PhD, ATC*; Robert C. Sipes, ATC, CSCS!;James T. Wilson, ATC, CSCS*

*Illinois State University, Normal, IL; 3Eastern Illinois University, Charleston, IL

Context: The deceleration phase of the throwing motioncreates large distraction forces at the shoulder, which mayresult in posterior shoulder tightness and ensuing alterations inshoulder range of motion (ROM) and may result in an increasedrisk of shoulder injury. Researchers have hypothesized thatvarious stretching options increase this motion, but few data onthe effectiveness of treating such tightness are available.

Objective: To evaluate the acute effects of ‘‘sleeper stretch-es’’ on shoulder ROM.

Design: Descriptive with repeated measures.Setting: Biomechanics laboratory and 2 separate collegiate

athletic training facilities.Patients or Other Participants: Thirty-three National Colle-

giate Athletic Association Division I baseball players (15 pitchers,18 position players; age 5 19.8 6 1.3 years, height 5 184.7 66.4 cm, mass 5 84.8 6 7.7 kg) and 33 physically active malecollege students (age 5 20.1 6 0.6 years, height 5 179.6 66.6 cm, mass 5 83.4 6 11.3 kg) who reported no recentparticipation (within 5 years) in overhead athletic activities.

Intervention(s): Range-of-motion measurements of thedominant shoulder were assessed before and after completionof 3 sets of 30-second passive sleeper stretches among the

baseball players. The ROM measurements in the nonthrowergroup were taken using identical methods as those in thebaseball group, but this group did not perform any stretch ormovement between measurements.

Main Outcome Measure(s): Internal and external glenohu-meral rotation ROM and posterior shoulder motion (glenohu-meral horizontal adduction).

Results: In the baseball group, posterior shoulder tightness,internal rotation ROM, and external rotation ROM were 23.56 67.76, 43.86 6 9.56, and 118.66 6 10.96, respectively, before thestretches and were 21.26 6 8.86, 46.96 6 9.86, and 119.26 611.06, respectively, after the stretches. These data revealedincreases in posterior shoulder motion (P 5 .01, effect size 50.30) and in internal shoulder rotation (P 5 .003, effect size 50.32) after application of the stretches. No other differenceswere observed in the baseball group, and no differences werenoted in the nonthrower group.

Conclusions: Based on our results, the sleeper stretchesproduced a statistically significant acute increase in posteriorshoulder flexibility. However, this change in motion may not beclinically significant.

Key Words: flexibility, soft tissue, throwing athletes

Key Points

N Sleeper stretches acutely increased posterior shoulder motion and internal shoulder rotation in the dominant arm ofbaseball players.

N External shoulder rotation was not different after the stretches.N The statistically significant acute increases in shoulder range of motion may be clinically insignificant.

Researchers1–7 have extensively examined alterationsin the range of motion (ROM) of the dominantshoulder of throwing athletes, such as decreased

internal rotation, increased external rotation, and increasedposterior shoulder tightness (limited glenohumeral [GH]horizontal adduction). Such alterations have been linkedempirically to bony8–12 and soft tissue13,14 adaptations thatresult from the large rotational and distractive forces actingon the GH joint during the throwing motion.15–18

Bony adaptations among throwing athletes often appearas increased humeral retroversion. This increase has beenreported to decrease shoulder internal rotation11,12 andincrease external rotation,9–12 leaving the total arc ofmotion (sum of total internal and external rotation)19

relatively unchanged.8,12 Furthermore, investigators20,21

have hypothesized that the deceleration phase of thethrowing motion is a major contributor to the developmentof posterior shoulder soft tissue tightness, resulting in

alterations of shoulder ROM similar to those of bonyadaptations. As the humerus internally rotates during thefollow-through phase of the throwing motion, the posteriorinferior capsule may be placed in a primary location toresist the deceleration forces, becoming a direct restraintagainst these loads.20 Accumulation of such forces mayresult in tightness of the posterior capsule and otherdynamic restraints (posterior deltoid, infraspinatus, teresminor, and latissimus dorsi), which causes alteredROM.20,21

Because throwing athletes often endure large forces andlarge numbers of repetitions, such athletes routinelyparticipate in a variety of shoulder stretching exercisesbefore and after a bout of throwing. They use thesestretches to attempt to lengthen soft tissue restraints so thatthey can increase throwing velocity and control and canlimit the incidence of injury and muscle soreness. Tech-niques typically involve both passive and ballistic stretches

Journal of Athletic Training 2008;43(4):359–363g by the National Athletic Trainers’ Association, Incwww.nata.org/jat

original research

Journal of Athletic Training 359

SleeperStretch—Toperformornot?Literatureandclinicalapplica/onisconflic/ng

PreTx PostTxCupping Change55 58 348 60 1255 63 855 72 1757 75 1853 67 1460 68 855 63 860 70 1050 55 548 62 1455 68 1355 65 1053 70 1760 68 865 65 055 70 1555 78 2365 75 1065 68 360 73 1347 55 853 60 757 62 5

55.875 66.25 10.375

Treatment-Scapular Dyskinesia

•  SystemBasedApproach• Understandingdeficiencyandtreataccordingly•  SSMP•  EmphasizeDynamicStabiliza/onandNMControl•  IntegrateLocalandGlobalStabiliza/on• RestoreMuscularImbalance• RestoreMuscularEndurance•  Ins/tutePlyometricProgram

www.201trm.com

ThankYou

@201trm

clinical evalua+on of impingement in the overhead athlete · pdf file20.10.2015 ·...

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