10/4/2011 dr. kevin harris & dr. gail deyle....dr. kevin harris & dr. gail deyle. 10/4/2011...

Material presented at AAOMPT 2011 by

Dr. Kevin Harris & Dr. Gail Deyle.

10/4/2011

1

Not Every

Acromioclavicular Joint

Needs Excision

OMPT Interventions for AC

Joint Dysfunction

Kevin D. Harris, PT, DPT, DSc, OCS, FAAOMPT

Gail D. Deyle, PT, DPT, DSc, OCS, FAAOMPT

Consensus opinion

“Physical therapy, unfortunately,

has little to offer because

therapeutic exercise and range of

motion play only a minor

role….Iontophoresis or

phonophoresis may offer some

relief and is relatively benign.”

Buttaci et al 2004

“We may try an injection or

2, but you’ll need to have

surgery sooner or later”

Agenda

• Background & prevalence

• Anatomy & Biomechanics

• Clinical presentation

• Management pathways

– PT

– Injections

– Distal Clavicle Excision

• OMPT Approach

• Our ACJ trial

• Manual Therapy & Clinical Applications

• …here’s what we did and why we did it…

• Hands-on Lab time

• Clinical Reasoning: Case reports

• Conclusion

• Questions



10/4/2011

2

Current Practice

Pattern?

Introduction

• 12 month prevalence of shoulder pain*

– 30.3%

– Second only to low back pain

• Acromioclavicular (AC) joint disease

present in 31% of all shoulder pain

patients**

*Picavet and Schouten 2003; **Ostor, Richards et al. 2005

Natural History

of A-C Separation

Over 48% of patients

sustaining a grade I or II

separation have

symptomatic AC joints 6

years after their injury

Mouhsine, Garofalo et al. 2003

Anatomy & Biomechanics



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3

AC Joint

• Plane synovial

joint

• Joint surfaces

considered

incongruent

– Acromion concave

& distal clavicle

convex

– Can be vice-versa

Renfree et al 2003

Bony Stability of AC

Joint

Passive Stability of

AC Joint

Bontempo et al 2010

Dynamic Stability



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Coronal Image

Simovitch et al 2009

Normal Anatomy Of The

AC Joint On MRI

Alyas et al 2008

Clinical Anatomy

Angle of AC Joint

Simovitch et al 2009



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5

Various AC Joint

Configurations

Bisbinas et al 2006; Pichler et al 2009

Pain Referral

Pattern

Gerber et al 1998

Bone Scan



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6

Pathoanatomy

Osteoarthritis

Etiopathogenesis

• OA is initiated by a mechanical insult to

the joint.

• OA is a manifestation of attempts to

heal the joint and ameliorate the

abnormal biomechanics.

• The osteoarthritis process may cause

joint pain but often is successful,

leading to a stable, painless joint.

Brandt et al 2008

Osteoarthritis

Radiology of OA

• Radiographic changes of OA are

extremely common in the population.

• Many people who have severe

radiographic changes of OA are

asymptomatic.

• Radiographic progression of OA

usually is slow and may cease

completely for many years.

Brandt et al 2008

Common Anatomical

Changes in OA Joints

• Synovitis

• Thickening/fibrosis of joint

capsule

• Degradation of articular

cartilage

• Subchondral sclerosis, cysts

• Osteophytes

• Degradation of disk when

applicable Brandt et al 2008



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7

What Leads To

Pathoanatomy?

Taft et al 1987;

Mouhsine et al 2003

~ ½ have symptomatic

AC joint 6 years later

Altered Mechanics

Chronic grade 1 tear in a 32-year-old male

Old grade 2–3 injury in a 30-year-old male



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Incidentally found chronic grade 3 injury in a 45-year-old male

Degeneration of the ACJ in a 41-year-old female

Spectrum

Normal Mild

Spectrum

Moderate Severe



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? Biomechanics

AC Joint

Biomechanics Basics

• Function of the joint

– To allow the scapula additional

range or rotation on the thorax

– Transmission of forces

• Intra-articular motion not well

understood due to varied joint

morphologies

– Studies inconsistent in identifying

movements and axes of motion



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10

Levangie & Norkin 2005

Posterior tipping Anterior tipping



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11

Literature Update

• Pioneer work done by Inman et al

in 1944

• Data on normal shoulder motion

for both raising and lowering the

arm and for different planes of

elevation are sparse

Literature Update

• Previous studies have primarily relied

on either sensors attached to the skin

or testing in multiple static positions

• Accuracy limited by the use of static

testing or by motion artifact between

the skin and the underlying bones –

particularly for scapular and

clavicular motions, which were

difficult to record with surface

sensors

• 14 shoulders of 7

asymptomatic volunteers

with an average age of 23.6

yrs

• Seated, vertically open MR

• 7 (static) positions of

abduction from 0 to 180

deg.



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12

Internal

Rotation

Posterior

Tipping

Many prior studies have evaluated

shoulder motion, yet no 3-D

analysis comparing the combined

clavicular, scapular, and humeral

motion during arm elevation has

been done

Methods

• 12 a-

symptomatic

• 29.3 yrs +/-

6.8 yrs

Methods

• 3 motions

– Flexion

– Scapular plane abd.

– Humerothoracic abd.

• 2 repetitions each

• Full active ROM

• Measured motion of

the scapula relative

to thorax & scapula

relative to clavicle



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Results

Average of 8 degrees

Results


Results


AC Joint Findings

• Posterior tilting was the

predominant AC joint motion

• Posterior tilting was > 90% AC

joint motion



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Conclusion

Overall shoulder motion

consists of substantial angular

rotations at each of the four

shoulder joints, enabling the

multiple-joint interaction

required to elevate the arm

overhead

Biomechanics

Literature Summary

Author Static

or

Dynami

c

Method Interna

l

Rotatio

n

Upward

Rotatio

n

Posteri

or

Tipping

Sahara Static 3D - Open

MRI

15.6 21.5 22.2

Ludewig Dynamic 3D –

Transcor

tical pin

8 11 19

Pathomechanics

Pathomechanics

• Few high-quality studies exist on normal

biomechanics of shoulder motions

• No pathomechanics data on AC joint

• Methodological flaws in most studies of

biomechanics of shoulder pain patients

– Diagnostic standards

– Lack of agreement in findings

– Small n’s



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Pathomechanics

• Excess clavicular elevation is a

consistent finding in patients with

shoulder pain

• The predominant rotation of the scapula

relative to the clavicle was posterior

tilting

• Reductions in posterior tilting of the

scapula on the thorax have been

associated with shoulder impingement

“When in doubt, examine

the patient…” (Jack McBride, MD)

• We have a rough idea of how the AC

joint should move both theoretically

and clinically (patient’s “good” side)

• Your manual examination will lead you

to the relevant pathomechanics of

your patient

• Degenerated and/or arthritic joints

don’t move well, neither do painful

joints

Anatomy & Biomechanics

Summary

Anatomy Summary

• AC joint morphology is highly

variable

• Synovial joint, susceptible to

osteoarthritis

• Radiologic findings do not

predict pain or function

• Degeneration is expected with age



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Biomechanics

Summary

• Internal/external rotation,

upward/downward rotation, and

anterior/posterior tipping

motions occur at AC joint

• These motions are critical for

overall arm elevation

• Posterior tilting was the

predominant AC joint motion

Management Pathways

Nonoperative

Management

• Rest, activity modification, oral

analgesics, non-steroidal anti-

inflammatory medications, and ice

• Absence of evidence

Rios and Mazzocca 2008; Hossain, Jacobs et al. 2008;

Buttaci, Stitik et al. 2004; Burbank, Stevenson et al. 2008

P T ?

No specific reports in the

literature of physical

rehabilitation or non-invasive

treatment for patients with

primary non-acute AC joint

pathology



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Buttaci et al 2004

“Physical therapy, unfortunately,

has little to offer because

therapeutic exercise and range of

motion play only a minor

role….Iontophoresis or

phonophoresis may offer some

relief and is relatively benign.”

Corticosteroid

Injections

• Relief

– 2 hours to 3

months

• Not definitive

treatment

• 3 Prospective cohorts

• 72 - 81% failed to achieve lasting

benefit

Corticosteroid

Injections

Hossain et al 2008, Jacob & Sallay 1997, van Riet et al 2011



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Distal Clavicle Excision

Evidence

Operative

Management

• Mumford technique reported

prior to World War II

• No trials to ever define the role

of the procedure relative to

other interventions or natural

history

Operative

Management

• 3 Level II or III Trials comparing

surgical approaches

• Complications reported in up to 64%

of cases

– Infection

– H.O.

– Joint instability

– Suprascapular neuropathy

– Distal clavicle fracture

– Anesthesia

• Long-term results of DCE

• 1 in 3 had poor outcome

• Advised against DCE for patients

with higher functional demands



10/4/2011

19

OMPT Approach

…ok, so wiggle the AC

joint & manip the T-spine

right??

Orthopaedic Manual

Physical Therapist (OMPT)

Approach

• Clinical reasoning

• Comprehensive patient examination

– Interview

– Manual examination

• Treatment tailored to the

examination findings for the

individual patient

Deyle, Henderson et al. 2000; Deyle, Allison et al. 2005; Walker,

Boyles et al. 2008; Whitman et al. 2006 Deyle, Henderson et al. 2000; Deyle, Allison et al. 2005;

Walker, Boyles et al. 2008; Whitman et al. 2006



10/4/2011

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OMPT approach trials

• Shoulder Impingement

• Bang & Deyle 2000

• Mechanical Neck Pain

• Walker et al 2009

• Hip Osteoarthritis

• Hoeksma 2004

• Knee Osteoarthritis

• Deyle et al 2000

• Deyle et al 2005

• Lumbar Stenosis

• Whitman et al 2006

Basis for OMPT

Approach

• Chronic AC joint pain may be similar in nature

to other persistent musculoskeletal

conditions

• Other conditions respond well to OMPT

approach in high-quality RCTs

• Supporting evidence at level of systematic

review for impingement syndrome of the

shoulder

Deyle, Henderson et al. 2000; Hoeksma, Dekker et al. 2004; Deyle, Allison et al.

2005; Walker et al 2008; Whitman et al. 2006; Ho 2009

Our Study

Purpose

To observe the short and long term

changes using an OMPT approach for

primary non-acute AC joint pain

In Press, JOSPT, 2012.



10/4/2011

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Study Design

• Prospective single cohort

• Outcomes measured at baseline, 4

weeks & 6 months


Inclusion Criteria

> 50% pain reduction within

10 minutes from an AC joint

injection with anesthetic

only within previous 30 days

In Press, JOSPT,

2012. In Press, JOSPT, 2012.

Exclusion Criteria

• Past history of AC joint

surgery

• AC joint ligamentous

injury (separation) within

last 12 months

• Corticosteroid injection

in this joint in last 6

months

• Neurological deficit

• Fracture or infection of

shoulder girdle bones

• Past history of

neoplastic growth in

shoulder girdle

• Inability to commit for at

least five follow-up

appointments within one

month of initial

evaluation and/or

failure to comply with

prescribed plan of care

• Any standard

contraindications to

manual therapy such as

connective tissue

disorders, rheumatoid

arthritis, osteoporosis

etc.


Intervention

OMPT approach

• Typical 30 minute appointments

• Manual therapy with reinforcing ROM

activities

• Strengthening after 4 weeks

• 6 sessions

– 2x/week

– 3 weeks




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Commonly Used AC Joint

Mobilizations

Anterior to

Posterior

Glide

Superior to

Inferior Glide


Results

Characteristics of the Cohort

Baseline Demographics*

Patients 13

Gender (M/F) 11/2

Mean age in years ± SD 41.1 (± 9.6)

Median symptom duration

(months) 6

Dominant side affected 6

Normal x-rays per radiologist 4

Taking medication for shoulder 5

* Values expressed as frequency count, except

where otherwise indicated


SPADI Scores

• Mean values with error bars representing SD

• Lower values represent less pain and disability

• *p<0.001; Clinically important change = 10


ASES Scores

• Mean values with error bars representing SD

• Higher values represent less pain and disability

• *p<0.001; Clinically important change = 6.4




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Discussion

First trial showing a

potential benefit of non-

invasive treatment of

primary AC joint pain


Discussion

Convincingly positive and clinically

meaningful improvement in shoulder

pain and function:

– SPADI and ASES

– After 6.5 visits utilizing a pragmatic

clinical approach


Clinical Context

Baseline 6 WK *

4 WK**

24 Months*

6 Months**

Optimal

Surgical

Procedure

62 88* 95*

Present

Cohort 59 87** 92**

ASES values

Charron et al 2007


Conclusion

• Statistically significant and clinically

meaningful improvements in shoulder

pain and disability were observed in a

prospective cohort with AC joint pain

following a trial of an OMPT approach

• First reported instance of a

positive outcome with non-invasive

treatment of primary AC joint pain




10/4/2011

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Manual Therapy &

Clinical Applications

When Is The AC Joint

Clinically Relevant?

• Primary AC joint

• Non-specific shoulder pain

– Sub-acromial impingement syndrome

Common AC Joint

Impairments

• Flexion

• Horizontal adduction (flexion)

Flexion Impairments

• Proposed mechanism

– Scapular posterior tipping > upward

rotation occur during flexion

– This requires superior/inferior >

medial/lateral AC joint translation

• Indications

– *AC Joint pain or limitation with

flexion

– Impaired caudal glide



10/4/2011

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Posterior

tipping

Anterior

tipping

>

Intervention for

Flexion Impairment

• Possible mobilizations for AC

joint posterior tipping

Caudal Glide

Progression

Arm at side Arm in

abduction

Prone, arm

flexed

Loaded

position

Impairments

with caudal

glide commonly

found with

difficulty in

elevating arm

Progression of

forces

Caudal Glides

Grades I - V

• Patient position

• Supine, arm at side, minimal GHJ

extension

• Therapist position

• Place the tips of both thumbs on

the superior surface of the

clavicle adjacent to the ACJ;

spread fingers out for stability

• Position forearms in line with the

caudal movement at the ACJ

• Mobilization technique

• Graded oscillatory mobilization is

applied by your arms, acting

through stable thumbs

• May span the joint or be proximal

to joint along distal clavicle

• May alter angle to a more medially

directed force



10/4/2011

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Alternate Technique

for ACJ Caudal Glides

• Lay “dummy

thumb” along

distal clavicle

• Apply caudally-

directed force

through

opposite

pisiform

Caudal Glides in

Abduction


• Supine, arm abducted, minimal

GHJ extension


• Place the tips of both thumbs on

the superior surface of the

clavicle adjacent to the ACJ;

spread fingers out for stability


caudal movement at the ACJ


• Graded oscillatory mobilization

is applied by your arms, acting


• May span the joint or be proximal

to joint along distal clavicle

• May alter angle to a more

medially directed force

Caudal Glides in

Prone Flexion


– Prone; upper extremity

flexed overhead with

forearm resting on chair


– Standing at patient’s head

– Thumbs on distal clavicle,

fingers splayed out for

stability

• Mobilization Technique

– Apply caudally directed

mobilization

Caudal Glides in

Prone Flexion


– Prone; upper extremity

flexed overhead with

forearm resting on chair


– Standing at patient’s head

– Thumbs on distal clavicle,

fingers splayed out for

stability


– Apply caudally directed

mobilization



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Caudal Glides in

Loaded Position


– Prone on elbows


– Standing

– thumbs on distal

clavicle

• Mobilization

Technique

– caudal

Caudal Glides in

Loaded Position


– Prone

– Arm abducted and off

plinth

– Hand in contact with

surface


– Standing

– Thumbs on distal

clavicle

• Mobilization

Technique

– Caudal glide

Horizontal Flexion

Impairments

• Proposed mechanism

– Scapular protraction occurs as the

arm crosses the body

– This requires AC joint internal

rotation

• Indications

– *AC Joint pain or motion impairment

with horizontal flexion

– Impaired A-P movement



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Intervention for

Horizontal Flexion

Impairment

Possible mobilizations for AC joint IR/ER

Anterior to Posterior

Glide Progression

Arm at side Seated

Seated, IR bias

Seated, flexed,

horizontally

adducted

Impairments

with AP glide

commonly

found with

difficulty in

horizontal

adduction or

internal

rotation

Progression of

forces

AP Glides in supine

Grades III/IV

• Patient position: Supine


• Place the tips of both thumbs on the

anterior surface of the clavicle

adjacent to the ACJ; spread fingers

out for stability


posterior movement at the ACJ


• Graded oscillatory mobilization is

applied by your body and arms, acting


• Pad of your outer thumb should feel

the joint motion (feel for the

stationary acromion process)

• Variations: use the pisiform to apply

posterior mobilization or use AC

shear test technique

AP Mobilization in

sitting Grades III/IV



10/4/2011

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AP Mobilization in

sitting Grades III/IV

• Patient position: seated


– Standing perpendicular

to shoulder

– Apply one hand along

distal clavicle

– Apply other hand across

posterior acromion


– Apply graded A-P

mobilization

AP Mobilization Grades

III/IV for IR Rotation Bias

• Same as previous

technique except pre-

position patient in IR

• Progress position,

grade, and/or dosage

as tolerated

AP Mobilization in flexion

Grades III/IV for Horizontal

Adduction Bias


– Seated or standing

– Forearm resting on stable

surface (plinth, cabinet

etc.)


– Perpendicular to shoulder

– A-P hand position


– Apply graded A-P

mobilization

Other Commonly Used ACJ

Mobilizations



10/4/2011

30

P-A Mobilization in

Prone Grades III/IV


– Prone

– Arm off table


– Standing near axilla of

patient

– Contact tips of thumbs on

posterior distal clavicle


– Apply graded P-A

mobilization

– May combine with previous

“loaded” techniques

• Patient position: Supine


• Stand near the patient’s

shoulder, facing towards the

clavicle

• Gently grip the mid clavicle using

your thumbs on the inferior edge

and finger tips superiorly


• Apply a gentle mobilization force

using a rocking or “wiggling”

motion through repetitive wrist

flexion and extension

• Works as a nice easing technique

following direct AC and/or SC

joint mobilizations

Clavicle Rotation

(Wiggle)

Clinical Vignettes

Case #1



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Case #1

Subjective Examination

Case #1

Objective Examination

Case #1

Treatment

Case #1

Follow-up Visit



10/4/2011

32

Case #2 Case #2

Subjective Examination

Case #2

Objective Examination

Case #2

Treatment



10/4/2011

33

Case #2

Follow-up Visit

Summary

• AC Joint is an important, but often

under-appreciated joint

• There’s more movement at the AC

joint than many clinicians

remember

• Role of DCE to be determined

• Evidence for impairment-based

Manual Therapist approach

Conclusion

• AC Joint is a vital link in shoulder

movement

• We have very specific targeted

interventions to treat this joint

• The more precise and direct we

can be, the larger we can expect

our effect size to be

Questions?



10/4/2011

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10/4/2011 dr. kevin harris & dr. gail deyle....dr. kevin harris & dr. gail deyle. 10/4/2011...

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