1
SHOULDER REHABILITATION – PART II
Ann Cools, PT, PhDGhent University - Belgium
Dept of Rehabilitation Sciences & [email protected]
A Cools 2016
Shoulder rehab course level I
Shoulder pathology andclinical examination
- RC tendinopathy
- Instability
- SLAP lesions
- GIRD
- Scap dyskinesis
Schoulder examination protocol
Shoulder rehabilitationprinciples and techniques
- Eccentric training RC
- Muscle control training in instability
- Thrower’s program & sportspecific exercises
- Stretching GIRD
- Scapular rehab: PM stretching and examples of exercises for control andstrength
A Cools 2016
2
Level II Advanced Course
Day 1: Scapular rehabilitation
1. Scapular biomechanics & kinesiology
2. Advanced evaluation of scapular dyskinesis: measuring scapular position and strength
3. Scapular rehabilitation exercises: from early toadvanced sportspecific rehabilitation
4. Scapular taping techniques
A Cools 2016
Level II Advanced Course
A Cools 2016
Day 2: Capita selecta
1. Rehabilitation of the patient with SLAP lesionsand biceps related pathology : conservative andpost-operative approach
2. Return to sports after shoulder injury: high level performance training and return-to-play criteria
3. Conservative Treatment of (partial and full thickness) rotator cuff tears
4. Rehabilitation of the patient with MDI –Multidirectional Instability of the shoulder
3
Part III Clinical Workshop
8 cases refreshing clinical reasoning andpractical skills
1. Rotator cuff tendinopathy
2. Rotator cuff tear
3. SLAP & tenosynovitis LHB
4. Internal impingement based on instability
5. Multidirectional instability
6. Impingement - Scapular dyskinesis type I
7. Impingement - Scapular dyskinesis type II
8. Impingement - Scapular dyskinesis type IIIA Cools 2016
Scapular biomechanics and kinesiology
Coupled movements scapula and clavicula
A Cools 2016(Ludewig 2009)
4
Coupled movements scapula and clavicula (saddle joint)
- Elevation- Retraction- Posterior axial
rotation
A Cools 2016(Ludewig 2009, Mc Clure 2001, Borstad 2002)
- Upward rotation- Posterior tilting- Internal/external rotation: No consensus, however:‣ Early internal rotation
‣ Late external rotation
A Cools 2016(Ludewig 2009, Mc Clure 2001, Borstad 2002)
Coupled movements scapula and clavicula
5
- Elevation + upward rotation- Retraction + external rotation- Posterior axial rotation* + posterior tilting
A Cools 2016
Coupled movements scapula and clavicula
Scapular upward rotation
A Cools 2016(Ludewig 2009, Mc Clure 2001, Borstad 2002)
6
Scapular upward rotation
A Cools 2016(Ludewig 2009, Mc Clure 2001, Borstad 2002)
Scapular posterior tilting
A Cools 2016(Ludewig 2009, Mc Clure 2001, Borstad 2002)
7
Scapular posterior tilting
A Cools 2016(Ludewig 2009, Mc Clure 2001, Borstad 2002)
Scapular internal/external rotation
A Cools 2016(Ludewig 2009, Mc Clure 2001, Borstad 2002)
8
Scapular internal/external rotation
A Cools 2016(Ludewig 2009, Mc Clure 2001, Borstad 2002)
*Role of the axial rotation of the clavicula
Clavicular Elevation = 40°Scapular Upward Rotation = 60°
P2-P3: upward rotation scapula + axialrotation clavicula (20°)
A Cools 2016
9
Role of lig. Conoideum during this movement
Axial rotation clavicula is the result of tension of this ligament
A Cools 2016
Scapular Muscle Function
Serratus Anterior Trapezius
A Cools 2016
UPPER
MIDDLE
LOWER
10
UT/MT/LT
SALT SAUT SA
A Cools 2016
levator scapulae en rhomboïdeï
-Elevation + retraction + Downward rotation-Probably “postural” muscles-Have to work eccentrically or relax duringelevation….
A Cools 2016
11
m. pectoralis minor
- special scapular muscle: origin and insertionboth anterior side thoracic wall-Performing anterior tilt during isolatedcontraction-Also active performing scapularelevation through level arm
A Cools 2016
Abnormal muscle recruitment patterns in patients with shoulder pain in deepermuscles (Castelein et al Accepted Man Ther 2016)
Muscle Population Scaption Towel wall slide Elevation w ith ER P-value
UT Healthy controls
SIS patients
17,7 ± 5,5
18,7 ± 7,0
14,2 ± 4,6
14,0 ± 6,5
12,3 ± 4,1
12,0 ± 8,6
Exercise X Group NS
Group NS
MT Healthy controls
SIS patients
11,1 ± 4,5
13,9 ± 8,9
7,4 ± 5,7
7,5 ± 4,8
21,0 ± 11,9
24,8 ± 11,5
Exercise X Group NS
Group NS
LT Healthy controls
SIS patients
15,7 ± 5,3
15,6 ± 7,0
9,1 ± 4,4
8,4 ± 4,7
29,3 ± 11,6
27,0 ± 11,3
Exercise X Group NS
Group NS
SA Healthy controls
SIS patients
28,7 ± 14,5
25,7 ± 9,5
26,8 ± 11,9
25,3 ± 11,0
20,8 ± 9,0
19,2 ± 5,2
Exercise X Group NS
Group NS
Pm Healthy controls
SIS patients
9,9 ± 7,6
13,0 ± 8,4
12,3 ± 9,6
17,5 ± 12,0
9,0 ± 7,6
12,8 ± 7,5
Exercise X Group NS
Group P=0,023*
LS Healthy controls
SIS patients
17,1 ± 11,0
18,1 ± 12,0
13,7 ± 9,7
13,3 ± 7,2
22,1 ± 17,4
24,7 ± 17,4
Exercise X Group NS
Group NS
RM Healthy controls
SIS patients
26,0 ± 17,8
25,3 ± 14,6
10,9 ± 4,6
11,0 ± 9,2
31,3 ± 14,0
31,1 ± 18,4
Exercise X Group NS
Group NS
A Cools 2016
12
Type I scapular dyskinesis
A Cools 2016
Lack of Soft-tissue flexibility
Lack of Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
(Cools et al. BJSM 2013)Type I scapular dyskinesis
Pectoralis minor
GIRD Dysfunction lower trap/serrant
A Cools 2016
13
A Cools 2016
Type II scapular dyskinesis
Lack of Soft-tissue flexibility
Lack of Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
(Cools et al. BJSM 2013)Type II scapular dyskinesis
General forward shoulderposture
Dysfunction 3 trap parts/serrant
A Cools 2016
14
A Cools 2016
Type III scapular dyskinesis
Lack of Soft-tissue flexibility
Lack of Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
(Cools et al. BJSM 2013)Type III scapular dyskinesis
A Cools 2016
Tightnesslevator scapulae
DysfunctionUpper trap/serr ant
Upper trap/ lower trap
15
Some examples & practice
• Classify scapular movement as “normal ” or “abnormal ” (Mc Clure 2009, Uhl2009)
‣ Compared to best-knowledge “ideal” (smooth movement)?‣ Asymmetry? Relevant to shoulder pain?‣ Inconsistency?
• Identify predominant type of dyskinesis based on observation (Kibler 2002)
• “observe” muscle performance : muscle volume, fatigue…(Tsai 2003, Mc Quade 1998)
• Observe kinetic chain variables: forward head posture, thoracic kyfosis, rounded shoulders, lumbar spine movement during arm elevation (Lewis 2007, Thygpen 2010)
A Cools 2016
A Cools 2016
16
A Cools 2016
A Cools 2016
17
A Cools 2016
A Cools 2016
18
Some examples & practice
• Classify scapular movement as “normal ” or “abnormal ” (Mc Clure 2009, Uhl2009)
‣ Compared to best-knowledge “ideal” (smooth movement)?‣ Asymmetry? Relevant to shoulder pain?‣ Inconsistency?
• Identify predominant type of dyskinesis based on observation (Kibler 2002)
• “observe” muscle performance : muscle volume, fatigue…(Tsai 2003, Mc Quade 1998)
• Observe kinetic chain variables: forward head posture, thoracic kyfosis, rounded shoulders, lumbar spine movement during arm elevation (Lewis 2007, Thygpen 2010)
A Cools 2016
Advanced assessment of scapular dyskinesis
1. Scapular involvement in shoulder pain: the shoulder symptom modification model (Lewis BJSM 2008)
2. Additional clinical testing/observationand Objective measurements (Cools BJSM 2012, JAT 2013, JSES 2014)
A Cools 2016
19
1. Scapular involvement in shoulder pain
A Cools 2016
ST function and proximal links screening
• Active correction of scapular position• SAT and SRT – modified based on type of
dyskinesis• Thoracic extension • correction head position• Sitting versus standing• …
A Cools 2016
20
2. Additional clinical testing/observation andObjective measurements
1. Scapular upward rotation2. Scapular muscle strength3. Pectoralis Minor Length
A Cools 2016
Practice:
• Inclinometry upward rotation
• Clinical test SA vs TRAP
• HHD scapular muscles
• PM lengthA Cools 2016
1
2
3
4
21
1. SCAPULAR UPWARD ROTATION
A Cools 2016
Pro 3600 inclinometer
First publications on scapular measurements usedpro 3600 (Johnson 2001, Borsa 2003, Su 2004, Laudner 2007….)
A Cools 2016
22
Acumar/similar inclinometer
Easier to use, and high reliability (Watson 2005, Struyff 2011)
A Cools 2016
Reliability and reference data on a normal population of this procedure
A Cools 2016 (Watson BJSM 2005)
23
Results of this procedure on healthyoverhead athletes(Cools et al. JAT 2014)
A Cools 2016
2. SCAPULAR MUSCLE STRENGTH
Clinical test: serr ant versus trapeziusSelected muscles:1. Upper trapezius2. Middle trapezius3. Lower trapezius4. Serratus anterior
A Cools 2016
24
Clinical test: SA vs TRAP
A Cools 2016
(Martin Kelley, scapula meeting 2003)
HDD Measurements: GeneralMANY DIFFERENT PROCEDURES
A Cools 2016
(Michener 2005, Cools 2010, Williams 2009)
25
(HandHeld dynamometer CompuFET, Biometrics)
‣ Upper Trapezius (UT)‣ Serratus Anterior (SA)‣ Middle Trapezius (MT)‣ Lower Trapezius (LT)
A Cools 2016(Mullaney 2005, Michener 2005, Trakis 2008, Cools 2012)
Results from this procedure for overhead athletes(Cools 2010)
ClinicResearch
A Cools 2016
26
A Cools 2016 (Cools et al 2014 JAT)
Clinical relevance of the scapular strengthmeasurements
Scapular muscle strength should be symmetric in non-athletic subjects
Scapular muscles should be stronger in one-handedoverhead athlete on the dominant side
There should be a balance in the force couplesaround the scapula
A Cools 2016
27
3. PECT MINOR LENGTH
Short PM induces changes similar to impingementrelated dyskinesis (Borstad JOSPT 2005)
A Cools 2016
A Cools 2016
PMI - PECTORALIS MINOR INDEX
PMI = (PML/length) x 100
CUT-OFF POINTS
PMI < 7.65: SHORTPMI > 8.61: LONG
3. PECT MINOR LENGTH
28
Cools & Johansson BJSM 2010: significant decrease PM length in elite junior (11-17yr) tennis players dominant versus non-dominant side
A Cools 2016
Scapular rehabilitation exercises: practical workshop
• Scapular rehab algorithm: update• From early rehab exercises to sportspecific
approach• General guidelines scapular correction exercises• Taping techniques• Exercises based on type of scapular dyskinesis
A Cools 2016
29
Scapular Rehabilitation Algorithm (Cools et al. BJSM 2014)
Lack of
Soft-tissue flexibility
Lack of
Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
Pm↑, LS↑, RH↑, UT↑ Posterior shoulder
Anterior shoulder
co-contraction
force couples
LT↓, MT↓, UT↓,
RH↓, SA↓
STRETCHING & MOBILISATIONNEUROMUSCULAR
COORDINATION
STRENGTH
TRAINING
Advanced control
During basic activities
Endurance/strength
Balance -ratio
Advanced control
During sports
Conscious muscle
control
Conscious muscle
controlManual soft tissue techniques
Manual stretching and MWM
Home stretchingA Cools 2016
Scapular Rehabilitation Algorithm (Cools et al. BJSM 2014)
Lack of
Soft-tissue flexibility
Lack of
Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
Pm↑, LS↑, RH↑, UT↑ Posterior shoulder
Anterior shoulder
co-contraction
force couples
LT↓, MT↓, UT↓,
RH↓, SA↓
STRETCHING & MOBILISATIONNEUROMUSCULAR
COORDINATION
STRENGTH
TRAINING
Advanced control
During basic activities
Endurance/strength
Balance -ratio
Advanced control
During sports
Conscious muscle
control
Conscious muscle
controlManual soft tissue techniques
Manual stretching and MWM
Home stretchingA Cools 2016
30
Scapular Rehabilitation Algorithm (Cools et al. BJSM 2014)
Lack of
Soft-tissue flexibility
Lack of
Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
Pm↑, LS↑, RH↑, UT↑ Posterior shoulder
Anterior shoulder
co-contraction
force couples
LT↓, MT↓, UT↓,
RH↓, SA↓
STRETCHING & MOBILISATIONNEUROMUSCULAR
COORDINATION
STRENGTH
TRAINING
Advanced control
During basic activities
Endurance/strength
Balance -ratio
Advanced control
During sports
Conscious muscle
control
Conscious muscle
controlManual soft tissue techniques
Manual stretching and MWM
Home stretchingA Cools 2016
Scapular Rehabilitation Algorithm (Cools et al. BJSM 2014)
Lack of
Soft-tissue flexibility
Lack of
Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
Pm↑, LS↑, RH↑, UT↑ Posterior shoulder
Anterior shoulder
co-contraction
force couples
LT↓, MT↓, UT↓,
RH↓, SA↓
STRETCHING & MOBILISATIONNEUROMUSCULAR
COORDINATION
STRENGTH
TRAINING
Advanced control
During basic activities
Endurance/strength
Balance -ratio
Advanced control
During sports
Conscious muscle
control
Conscious muscle
controlManual soft tissue techniques
Manual stretching and MWM
Home stretchingA Cools 2016
Scapular orientation exercise
31
Scapular orientation exercise
• Palpate base of the spine + acromion• Add tactile feedback to “upward rotation and
posterior tilting”• Adjust body position (gravity) to correct
performance
A Cools 2016
(Mottram 2009)
A Cools 2016
32
A Cools 2016
A Cools 2016(Moser J S&E 2014)
33
Lack of Soft-tissue flexibility
Lack of Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
(Cools et al. BJSM 2013)Type I scapular dyskinesis
Pectoralis minor GIRD Dysfunction lower trap/serr
ant
A Cools 2016
Stretching pectoralis minor
A Cools 2016
34
Lack of Soft-tissue flexibility
Lack of Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
(Cools et al. BJSM 2013)Type I scapular dyskinesis
Pectoralis minor
GIRD Dysfunction lower trap/serrant
A Cools 2016
A Cools 2016
35
Practice and progression
Add thoracic extension and ER component to“inferior glide”
A Cools 2016
Practice and progression
Add KC components, weightsand higher elevation anglesto “lawnmower ”
A Cools 2016A Cools 2015
36
Practice and progression
Add KC components, weightsand higher elevation anglesto “robbery ”
A Cools 2016A Cools 2015
Practice and progression
Other exercises with“external rotationcomponent ”
A Cools 2016A Cools 2015
37
Practice and progression
Other exercises with“external rotationcomponent ”
A Cools 2016A Cools 2015A Cools 2015
A Cools 2016
38
UT/MT/LT/SA
Pect Min
Lev scap
rhomb
1. Elevation scap plane
2. Wall slide
3. Elevation + ER
A Cools 2016
UT ↓SA =MT & LT ↑ RH ↑Pect Min ↓
UT ↓SA =
Lev Scap ↓
Focus on muscle balance rather than muscle strength: UT/SA, Pm/LT, UT/LT, LS/SA… (Castelein et al. JOSPT 2015)
A Cools 2016
39
Focus on muscle balance rather than muscle strength: Pm/SA (Castelein et al. Man Ther 2015)
A Cools 2016
Lack of Soft-tissue flexibility
Lack of Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
(Cools et al. BJSM 2013)Type I scapular dyskinesis
Pectoralis minor
GIRD Dysfunction lower trap/serrant
A Cools 2016
40
A Cools 2016
Exercises with low ratio UT/SA:– Elbow push-up / prone bridging– Serratus punch supine– Serratus punch in CKC (bench slide)
Exercises with low ratio UT/LT– Side-lying forward flexion– Side-lying external rotation– Prone hor abd with ext rot– Prone extension(Ludewig 2004, Decker 1999, Cools 2007, Schory 2016)
(level I shoulder rehab course)
Lack of Soft-tissue flexibility
Lack of Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
(Cools et al. BJSM 2013)Type I scapular dyskinesis
Pectoralis minor
GIRD Dysfunction lower trap/serrant
A Cools 2016
Proprioceptive Taping Techniques
41
GIRD: relaxation of the infraspinatus
A Cools 2016
Scapula: posterior tilt
A Cools 2016(Mc Connell 1999, Cools 2002, Van Herzeele 2013
42
TAPING OF THE SCAPULA: Scientific evidence
Taping improves scapular posterior tilt in all elevationangles, but has no influence on muscle activity or subacromial space width in elite handball players
A Cools 2016(Van Herzeele IJSM 2013; Maenhout CJSM 2012)
Lack of Soft-tissue flexibility
Lack of Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
(Cools et al. BJSM 2013)Type II scapular dyskinesis
A Cools 2016
General forward shoulderposture
Dysfunction 3 trap parts/serrant
A Cools 2015
43
Thoracic and cervical position and ROM exercises
A Cools 2016
Lack of Soft-tissue flexibility
Lack of Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
(Cools et al. BJSM 2013)Type II scapular dyskinesis
A Cools 2016
General forward shoulderposture
Dysfunction 3 trap parts/serrant
A Cools 2015
Exercises increasing strengthin SA and/or trap
44
Exercises for type II scapular dyskinesis
General guideline: focus on retraction /protraction in horizontal plane (90° elevation)
A Cools 2016
A Cools 2016
45
A Cools 2016
Exercises for type II
A Cools 2016
46
Lack of Soft-tissue flexibility
Lack of Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
(Cools et al. BJSM 2013)Type III scapular dyskinesis
A Cools 2016
Tightnesslevator scapulae
DysfunctionUpper trap/serr ant
Upper trap/ lower trap
Exercises: focus on UPWARD ROTATION
• Serr punch >90°• W-V exercise• Wall slide
A Cools 2016
(level I shoulder rehab course)
47
UT ↓SA =MT & LT ↑Pect Min ↓
UT ↓SA =Lev Scap ↓
A Cools 2016
Comparison muscle activity UT, MT, LT, LS, rhomboid
pag. 94A Cools 2016
48
Exercises: focus on UPWARD ROTATION
A Cools 2016
A Cools 2016
Exercises: focus on UPWARD ROTATION
49
A Cools 2016
Exercises: focus on UPWARDROTATION
Scapular Rehabilitation Algorithm (Cools et al. BJSM 2014)
Lack of
Soft-tissue flexibility
Lack of
Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
Pm↑, LS↑, RH↑, UT↑ Posterior shoulder
Anterior shoulder
co-contraction
force couples
LT↓, MT↓, UT↓,
RH↓, SA↓
STRETCHING & MOBILISATIONNEUROMUSCULAR
COORDINATION
STRENGTH
TRAINING
Advanced control
During basic activities
Endurance/strength
Balance -ratio
Advanced control
During sports
Conscious muscle
control
Conscious muscle
controlManual soft tissue techniques
Manual stretching and MWM
Home stretchingA Cools 2016