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The Sporting Shoulder With Andrea Mosler

B. App. Sc (Physiotherapy) M. App. Sc (Sports Physiotherapy)

Andrea Mosler

- Specialist sports physiotherapist

- Australian Institute of Sport

- Sports medicine coordinator for National women’s Water Polo

- Olympic Water Polo Physiotherapist

since 2000, 2004 and 2008

- Professional interests include management of disorders of the shoulder

complex and hip and groin injuries.

Introduction

four articulations

all move together to provide

synchronous motion

Examine all components of shoulder

complex

Glenohumeral Joint

Ligaments

considerable variation in all studies

primary restraint at EOR

tightening of the capsule results in

coupled translations and rotations

capsular and tonal imbalance can

interfere with these coupled motions

Inferior glenohumeral ligament complex

O’Brien et al 1990

Static stability

ligaments act as static passive restraints at EOR

anterior support shifts from superior to inferior structures with elevation

HOH should remain centred in glenoid except in cocking position (Howell et al 1988, Bowen et al 1992, Shiffern et al

2002)

HOH relocated to the centre of glenoid with horizontal flexion

potential shearing stress on the artic cartilage and labrum

Static stability of HOH


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von Eisenhart-Rothe


Jobe and Pink 1991

Dynamic stability

• primary stabilising mechanism in mid-range

• resting muscle tone (Shiffern et al 2002)

ROTATOR CUFF

• maintain HOH in glenoid cavity, and ↑capsular stiffness

• large collagen component to subscap tendon

• feedback loop between ligaments and RC

• LHB contributes to anterior stability through ↑ torsional tension

• Emerging evidence!

Rodosky et al 1994

Long head of biceps complex PREVIEW ONLY


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Long head of biceps

Pagnani et al 1996

Anatomical Connections

Scapular rotators

• scapula supported by muscles and ligaments

• full elevation requires adequate stability and

rotation of the scapula

• position the scapula and stabilise it against the

thoracic cage

• place the scapula under the HOH so

movements occur with the maximum stability

Must have effective and balanced function of

all these muscles for normal scapular

motion and scapulothoracic/glenohumeral

synchrony

Scapular Rotators PREVIEW ONLY


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Biomechanics of arm elevation

• Large variation

between and

within individuals

• Overall ratio of 2:1

• 3 phases of rotation

• Axis of scapular rotation moves from

RSS→ACjt

Scapular Mechanics

Kinetic chain

allows generation, summation, transfer and

regulation of forces from legs to the hand and thus to

the object

sequential involvement of each link required to create

the energy, produce the force and stabilise the joints

for optimum performance without injury

shoulder is often the link that breaks

FAILURE IN ONE LINK FAILURE IN ANOTHER

Contributions of the force and

kinetic energy of the chain

Link Acc (m/s) %kinetic

energy

%force

Hip/trunk 13.5 51 54

Shoulder 33 13 21

Elbow 53 21 15

Wrist 65 15 10

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Six stages of throwing

Kvitne et al 1995 Shortcut to VTS_13_1.VOB.lnk

Rizzo 2006.m4v

Martial Arts/Wrestling PREVIEW ONLY


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Sporting Shoulder Injuries

• Acute injuries/contact

• Overuse injuries

• Mixed

• Degenerative conditions

• Arthropathies

Sporting Shoulder Injuries

• Acjt, Scjt injuries

• Snapping scapula

• Rotator cuff/LHB tendinopathy

• Impingement- internal vs SAS;1° and 2°

• Labral Injuries

• Nerve Injuries

• Instability

AC jt injuries

• Mechanism- usually

(70%) from a direct

blow to point of

shoulder, but also

indirect mechanism

from FOOSH

• Injuries classified as

Type 1-6 (Rockwood

1996)

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AC jt injury classification Type I: partial tear AC ligt but no change

in position of the distal clavicle wrt acromion.

Type II: Rupture AC ligt with partial tear of

C-C ligts. Distal end clavicle displaced wrt acromion but < full width of the clavicle

Type III: Rupture AC ligt with partial tear of C-C ligts. Distal end clavicle displaced wrt acromion but >full width of the clavicle

Type IV: Rupture all ligts with post displacement distal clavicle through aponeuroses of trapezius.

Type V: Distal clavicle severely displaced superiorly toward base of the neck, covered only by skin and subcutaneous tissue, complete rupture of the deltoid- trapezius musculature

Type VI: Inferior dislocation of clavicle under either acromion or coracoid process

AC jt injuries

Most studies demonstrate favourable results with

conservative management for all but really

severe injuries (Type 4-6)

Distal clavicle osteolysis (DCO) and

OA can also be cause of

symptoms, especially in

athletes

Beware of stress #

(Constantinou and Kastanos 2008)

Scjt Injuries

• Acute injuries

• Rare, but can be

life threatening!

• Overuse instability

Hoekzema et al 2008

Specific pathomechanics thrower’s

shoulder

• Scarring/tightening posterior shoulder

(?structures) + bony changes →→↓GH internal

rotation range (GIRD)

• Abnormality in coupled movements, migration of

glenoid contact point

• ↑Load dynamic stabilisers

• Dysfunctional sensorimotor acuity

• Damage to labrum

• ?? Stretching of anterior capsule

• ??Uncontrolled translation HOH

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Rotator cuff/LHB pathology

• ??Inflammation (bursa)

• Impingement- cause or effect???

• Degenerative process

• Partial→full thickness tears

• Most tears on articular surface, near

insertion (??critical zone, also area of

↑load) ?poor vascularisation a factor

• trauma can also occur

Rotator Cuff pathological process

• Similar deg process to other tendons

• Large compressive component to load and

?progression of pathology

• Neer- 3 Stages of impinge/RC disease; is

not supported with current literature

• Deg changes ↓ tendon capacity to cope

with tensile and compressive loads

Rotator Cuff tendinopathy

• Need to understand and embrace current

concepts of tendon pathology and

management and apply it to the shoulder

Specifically;

• Mechanotransduction

• Pathological process/staging

• Pain mechanisms

• Adapt current management methods for

tendinopathy in other parts of the body

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AC

SST

HOH

Supraspinatus tendinopathy SAS Impingement PRIMARY- is this a clinical entity?

• Os acromiale

• Variation in acromion shape/size, deg

• CAL thickening

• Acjt degenerative changes

• Swelling, fibrosis and/or thickening of subacromial bursa

SECONDARY

• Xs superior migration of the HOH due to muscle imbalance or structural changes

• Rotator cuff tendinopathy continuum

bony spur on the inferior

surface of the acromion Superior migration of HOH

Congenital or acquired?

Achilles Enthesis organ (Shaw and Benjamin 2007)

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Internal Impingement

Elevation/ER

Pinching between HOH and post-sup edge glenoid rim

Undersurface fraying RC

Labral,?osteochondal changes

Flexion

Sup-ant glenoid and sup translated HOH with type II SLAP

http://2.bp.blogspot.com/_BBt5FH3wT9o/SdXNtJcmGtI/AAAAAAAAAlc/jE6QyLyAGS4/s1600-h/Haglund

Internal Impingement Labral pathology

• Detachment/Bankart

• Degeneration/splits/tears

• Internal Impingement

• Bennett’s lesion

• SLAP lesions- peel back sign

Bankart lesion Bankart with Hill Sachs lesion PREVIEW ONLY


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Bennett’s lesion

Four

types of

SLAP

lesions

Rodosky et al 1994

Type

II

Further subdivision Type II PREVIEW ONLY


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Peel back mechanism Nerve injuries

• Suprascapular neuropathy- Volleyball

• Quadrilateral space syndrome

• Long thoracic neuropathy

• Brachial plexus injuries/thoracic outlet

(Safran 2004 pt s1 & 2)

Ringel et al 1990

Suprascapular

Nerve Entrapment

• Up to 1/3

volleyballers

• Symptoms variable

• Can lead to a

dangerous

sequelae

• ?subclinical

neuropraxia

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Quadrilateral space

McClelland and Hoy 2008

Quadrilateral space syndrome

• compression of the axillary nerve within

the quadrilateral space- fibrous bands

• Differentiate other causes of axillary nerve

injury

• Pain vague, dull aching or burning over t

lateral and posterior shoulder

• Insidious onset and agg by activity,

• ?weakness with overhead activity,

paraesthesia, wasting deltoid

Instabilities

• Definition- variable

• Classification important as affects management choices!!! (MacFarland et al 2003)

1. Severity –dislocation, subluxation, translational instability

2. Aetiology- Traumatic vs atraumatic, acute vs recurrent

3. Voluntary vs involuntary

4. Direction (ant, post, multi)

5. Structural- mechanical vs functional

Mechanisms of instability

laxity ≠ instability

Three separate categories;

1. Laxity- hypermobility without signs or symptoms

2. Translational instability- loss of centering of HOH

3. True instability- subluxation and dislocation with signs and symptoms of instability

• not all lax shoulders become unstable

• unstable shoulders are not always symptomatic

• ?what causes this progression

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Mechanisms of instability

• IGHLC stretches before tearing, acute pulls on

shoulder (Bigliani et al 1992)

• Pathology doesn’t always match symptoms

• Proprioception is disturbed in unstable

shoulders

• Proprioception controls muscle recruitment

• Synchronisation of muscle activity necessary

for maintenance of stability at the shoulder joint

SENSORIMOTOR ACUITY IS THE KEY!!

Management-

Pathology and symptoms • Traditionally diagnosis-based assessment and management

• Elite athletes don’t fit the mould

• Significant pathology has been demonstrated in asymptomatic shoulders (Jerosch , Miniaci and Connor studies)

• ? Precursor to symptoms or not correlated with symptoms at all

• Pathological shoulders can become asymptomatic WITHOUT correction to pathology (Murrell series)

Articular sided SST tear

Connor et al 2003

Capsuloligamentous Injury

(dislocation or subluxation)

Mechanical

Instability

Glenohumeral

Instability

Repetitive

Injury

Proprioceptive

Deficits

Neuromuscular

Alterations

Surgery

Lephart et al, 1996

Rehabilitation

Pain

Physiotherapy management of

the sporting shoulder BASIC PRINCIPLES

• determine underlying pathology

• determine the effect of associated structures/joints

• examine range and quality of glenohumeral physiological motion

• determine severity and direction(s) of instability (if present)

• examine relevant soft tissue

• Determine deficits of muscle strength, endurance, recruitment, timing and proprioception

• Examine kinetic chain and biomechanical dysfunction

• Determine predisposing factors to injury

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Predisposing factors to injury

• Change in a component of kinetic chain

• Change in technique

• Change in training load

• Fatigue

• Change to weight program

• Age

• Acute injuries

• Cross training/unaccustomed activity

• Change in neural input

Management principles

Place factors in order of importance

Treat ALL positive findings

Assessment findings will often form treatment

techniques

Respect the pathology-many

shoulder problems cannot be “fixed”

by conservative management!!


Need to

• get rid of the pain! (Hodges, Crossley, Hess, David)

• restore normal joint kinematics

• restore normal muscle function

How?????

• many ways to skin a cat!


Many tools

• Soft tissue techniques

• Acupuncture

• Stretching

• Taping

• Exercise/rehab

• Load management

• Electrotherapy

Rehabilitation program

Must be specific to the;

• pathology

• biomechanical demands of the activity

• demands of the athlete

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Rehabilitation aims

Restore/improve

• Scapular stability and movement with stability

• Normal intra-articular mechanics and physiological joint range

• Mechanics of the kinetic chain

• Rotator cuff and LHB function

• Proprioception and recruitment in response to dynamic stimuli

• Muscle strength and endurance

Normalise muscle function

• Waking up sleeping muscles

• Enhance activation of specific muscles

• True weakness

• Scapular stability and kinesis

Normalise muscle function Proprioception- “..encompasses sensations about body position

and movement that provide information necessary

for optimal control of posture and locomotion” (Edmonds et al 2003)

= limb movement (kinaesthesia)

+ limb position (joint position sense)

Is impaired with shoulder dysfunction but CAN be enhanced!

Sensorimotor acuity = proprioception +

central processing + motor output

Rehabilitation exercises

• HOH centering (isolate RC function)

• Scapular stability and movement with stability

• Sensorimotor acuity

• Closed kinetic chain

• Closed open kinetic chain

• Incorporation of kinetic chain principles

Enhancing sensorimotor acuity

• Getting rid of pain

• Trigger point therapy/acupuncture

• Mobilisation (Vicenzino)

• Taping

• Specific exercises

• Normalise muscle recruitment

• Increase resistance to fatigue

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Exercises to enhance

sensorimotor acuity

• Body blade

• Ball rolling

• Wobble board push ups

• Rhythmic stabilizations

• Plyometric exercises

•Controlled concentrated exercise

Athletes need muscles!!

• Need to work closely with strength and

conditioning coach

• Deltoid like quads of the shoulder

• Ensure that rehab program does not

replace a loaded gym program

• Keep athlete training as functionally as

possible to avoid disuse/loss fitness

Summary

• Complicated joint

• Mechanisms of injury are complex and

multifactorial

• Pathology and symptoms do not always

correlate

• Can change pain and sensorimotor

dysfunction

• Aim to permanently change motor patterns

• Respect the pathology!

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Join us next time:

Physiotherapy Update on Burns

Management Presenter: Dr. Dale Edgar

Thank you

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