principles of shoulder rehabilitation and return …...principles of shoulder rehabilitation and...

6/06/2013

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PRINCIPLES OF SHOULDER REHABILITATION AND RETURN TO SPORT

Presented by: Joel Werman B.App.Sc. (Physio), Grad.Dip.Sc. (Sports Physio)

Specialist Sports Physiotherapist

Will commence LIVE from Sydney, Australia at 7:30pm AEST

Andrew Ellis BSc (Ex. Sci), M. Phty

World Health Webinars CEO

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Joel Werman

• Specialist Sports Physiotherapist and Fellow of the

Australian College of Physiotherapy.

• Specialized in the treatment of shoulders for over 23 years

• Founding member of the Shoulder and Elbow

Physiotherapists of Australia group

• Lectured extensively on the subject of the shoulder covering

a wide range of subjects

• Through extensive clinical experience has devised own

approach to assessment and treatment of the shoulder

which is based on a structured clinical reasoning model.

Specialist Sports

Physiotherapist

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PRINCIPLES OF SHOULDER REHABILITATION AND RETURN TO SPORT

Joel Werman

APA Specialist Sports Physiotherapist Fellow of The Australian College of Physiotherapists

THREE CATAGORIES OF SHOULDER

PROBLEMS:

1. Structural

2. Functional

3. Combination

It is imperative to determine which category

the patient falls into so as to establish

appropriate goals, expectations and

management outcomes.


PROBLEMS:

1. Structural


PROBLEMS:

1.Structural

Should you proceed

immediately to radiological

investigations and/or

specialist referral?

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PROBLEMS:

LISTEN to the history…

was there a significant trauma or

incident?

has this built up over many years?

unable to sleep at night due to the

pain

• LOOK at the patient…

Severe pain and disability


PROBLEMS:

‘You can’t make a silk purse

out of a sow’s ear’

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PROBLEMS:

2. Functional

Timing and tuning.

The objective of the shoulder is

for the ball to stay centered in

the middle of the socket

throughout a full range of

movement.


PROBLEMS:

3. Combination (structural and functional):

• The existence of some structural issues combined with (often)

secondary/ compensatory functional deficits.

• You must understand the extent of the structural concerns

together with the needs and expectations of the patient to

determine the management options.

ASSESSMENT

The objective examination will directly dictate the rehabilitation

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ASSESSMENT

Posture, symmetry, general

muscle tone,

Signs of hyper-mobility

ASSESSMENT

Active range of motion- assess quality of movement with respect to

scapular dyskinesia , pain and end range.

ASSESSMENT

Passive range of motion.

Is the restriction of active range the same passively?

Can the arm go further when performed passively?

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ASSESSMENT

• Re-assess restricted or painful active movement with techniques

to manually reposition the scapular, or the head of the

humerus in the glenoid

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ASSESSMENT

Scapular ‘dumping’ : support under the inferior angle of

the scapular and reassess active forward elevation &/or

active range of external rotation in neutral

ASSESSMENT

Strength testing :

manually

Hand held dynamometer

Re-test with active scapular

retraction

“Where it’s tight you stretch it,

where it’s weak you strengthen it”

( Ian Collier - 1988 )

Clinical reasoning : Identify the

deficient component parts of

the shoulder in your objective

examination

Justify your intervention and

prioritize your objectives

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WHAT DOESN’T WORK:

Electrotherapy:

interferential

ultrasound

laser

short wave

RESEARCH / EVIDENCE :

The Cochrane Collaboration - Cochrane Reviews 2003

Physiotherapy interventions for shoulder pain

Green S, Buchbinder R, Hetrick SE

Main results Twenty six trials met inclusion criteria. Methodological quality was variable and trial populations were generally small (median sample size = 48, range 14 to 180). Exercise was demonstrated to be effective in terms of short term recovery in rotator cuff disease (RR 7.74 (1.97, 30.32), and longer term benefit with respect to function (RR 2.45 (1.24, 4.86). Combining mobilisation with exercise resulted in additional benefit when compared to exercise alone for rotator cuff disease. Laser therapy was demonstrated to be more effective than placebo (RR 3.71 (1.89, 7.28) for adhesive capsulitis but not for rotator cuff tendinitis. Both ultrasound and pulsed electromagnetic field therapy resulted in improvement compared to placebo in pain in calcific tendinitis (RR 1.81 (1.26, 2.60) and RR 19 (1.16, 12.43)

respectively). There is no evidence of the effect of ultrasound in shoulder pain (mixed diagnosis), adhesive capsulitis or rotator cuff tendinitis. When compared to exercises, ultrasound is of no additional benefit over and above exercise alone. There is some evidence that for rotator cuff disease, corticosteroid injections are superior to physiotherapy and no evidence that physiotherapy alone is of benefit for adhesive capsulitis

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Passive joint mobilization

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Does Passive Mobilization of Shoulder Region Joints Provide

Additional Benefit Over Advice and Exercise Alone for

People Who Have Shoulder Pain and Minimal Movement

Restriction? A Randomized Controlled Trial

Ross Yiasemides, Mark Halaki, Ian Cathers and Karen A. Ginn

Physical Therapy February 2011 vol. 91 no. 2 178-189

Conclusion This randomized controlled clinical trial does not

provide evidence that the addition of passive mobilization,

applied to shoulder region joints, to exercise and advice is more

effective than exercise and advice alone in the treatment of people

with shoulder pain and minimal movement restriction.


Most other passive interventions, particularly in isolation

WHAT DOES WORK:

Exercise therapy


Physiotherapy interventions for shoulder pain

Green S, Buchbinder R, Hetrick SE

Main results Twenty six trials met inclusion criteria. Methodological quality was variable and trial

populations were generally small (median sample size = 48, range 14 to 180).

Exercise was demonstrated to be effective in

terms of short term recovery in rotator cuff

disease (RR 7.74 (1.97, 30.32), and longer term

benefit with respect to function (RR 2.45 (1.24, 4.86). Combining mobilisation with exercise resulted in additional benefit when compared to

exercise alone for rotator cuff disease. Laser therapy was demonstrated to be more

effective than placebo (RR 3.71 (1.89, 7.28) for adhesive capsulitis but not for rotator

cuff tendinitis. Both ultrasound and pulsed electromagnetic field therapy resulted in

improvement compared to placebo in pain in calcific tendinitis (RR 1.81 (1.26, 2.60)

and RR 19 (1.16, 12.43) respectively).

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EXERCISE THERAPY:

Addresses:

a. Flexibility

b. Strength

- neuromuscular control

- muscle hypertrophy

The relevance of an exercise is how it relates to the patient’s

problem. Clinical reasoning requires the physio to justify the

choice of intervention as dictated by the initial examination.

http://ptjournal.apta.org/search?author1=Ross+Yiasemides&sortspec=date&submit=Submit

http://ptjournal.apta.org/search?author1=Ross+Yiasemides&sortspec=date&submit=Submit

http://ptjournal.apta.org/search?author1=Mark+Halaki&sortspec=date&submit=Submit

http://ptjournal.apta.org/search?author1=Mark+Halaki&sortspec=date&submit=Submit

http://ptjournal.apta.org/search?author1=Ian+Cathers&sortspec=date&submit=Submit

http://ptjournal.apta.org/search?author1=Ian+Cathers&sortspec=date&submit=Submit

http://ptjournal.apta.org/search?author1=Karen+A.+Ginn&sortspec=date&submit=Submit



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Goal of Physiotherapy:

OBJECTIVES:

to ‘normalize’ the shoulder girdle

mechanics to allow the humeral

head to stay centered in the

glenoid fossa through a full range

of movement

EXERCISE THERAPY:

a. Flexibility:

→ a home program of

appropriate stretches done

gently but regularly

throughout the day. Do one

minute of stretching

4 to 6 times a day

→ soft tissue massage as an

adjunct

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ABNORMAL BIOMECHANICS

PAIN AND NEUROMUSCULAR CONTROL:

• Neuromuscular control of scapular musculature is diminished in the presence of pathology (Ludewig, 2000).

Pain inhibits muscle activation at a central level.

Tissue damage

Altered mechanics

(scapula dyskinesia) Inflammation

Muscle

Imbalance

PAIN!

EXERCISE THERAPY:

b. Strength :

The scapular provides a

dynamic platform for the arm.

Alteration of the normal

anchoring function of the

scapular stabilizers results in

compromise to the

subacromial space

EXERCISE THERAPY:

Incidence of scapular dyskinesia:

Studies have shown dysfunction in scapula

position and mechanics in 68% of cases

with abnormalities of the rotator cuff and

100% of those with glenohumeral instability

(Kibler & McMullen, 2003)

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EXERCISE THERAPY:

Crane analogy:

If the base is not anchored

securely, the crane is unable

to lift the load.

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4 PHASES OF REHABILITATION

Crawl walk run sprint !

‘Would you ask your limping patient to go for a run?’

‘Would you expect a crane to lift a load if the base was not

securely anchored?’

Phase 1: Reactivate the scapular stabilizers

Phase 2: Add light resistance

Phase 3: Muscle hypertrophy

Phase 4: Sport specific rehabilitation

THEORY:

How do you reactivate the scapular stabilizers?

Analysis study of a scapular orientation exercise and

subjects’ ability to learn the exercise. Manual Therapy. 14

(13-18). 2009.

Mottram, S.L., Woledge, R.C., Morrisse, D. Motion

“Examples of cues included passive/assisted movements into the SOE

position, tactile feedback with gentle pressure on the acromion to

encourage upward rotation, recognition of a feeling of widening

the chest to encourage posterior tilt, demonstration of common

wrongly directed movements, demonstration and verbal feedback”

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THEORY:

The subacromial impingement syndrome of the shoulder treated by

conventional physiotherapy, self-training, and a shoulder brace:

Results of a prospective, randomized study

Markus Walther, MD, PhDa, Andreas Werner, MD, PhDb,

Theresa Stahlschmidt, MDc, Rainer Woelfel, MD,

2004 Journal of Shoulder and Elbow Surgery

‘Pull the shoulder blades back and push the sternum forward’

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THEORY:

Journal of Bodywork and Movement Therapies (2006) 10, 71–76

Self-management of shoulder disorders—Part 3:

Craig Liebenson, DC

‘Starting with light resistance perform scapular setting (pulling your

shoulder back and down).’

PHASE 1

Scapular setting:

Early rehabilitation focuses on re-establishing normal scapular control. Setting the scapular back and level ( NOT DOWN ! ) while raising the arm away from the body.

The ability to dissociate movement of the arm from the scapular is the essential building block of restoring normal biomechanics.

Unilateral control initially.

PHASE 1

• The objective is to normalize the

mechanics of the scapular at the

neuromuscular level by initially ‘over-

activating’ the retractors as static

stabilizers (not as prime movers).

• Through conscious over-activation,

subconscious control is restored.

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PHASE 2

Begin adding external loads to

the arm while performing

exercises in an inner range of

movement.

All exercises must be

performed with the scapular

anchored in it’s retracted

(back & level ) position.

All exercises must be

performed without symptoms!

PHASE 3 (early)

Increase loads and begin

training in outer ranges,

working to include

aspects of endurance,

speed and sport

specificity…

All with an emphasis on

control

PHASE 3 (late)

After the initial phase of

scapular retraining,

progression of the

rehabilitation should allow

for more advanced upper

body strengthening while the

scapular is allowed to

naturally adopt it’s

appropriate position.

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PHASE 4

Return to sport:

• How do you know when the athlete is ready to return to sport?

When the objective findings have normalized to the extent that

they are compatible with the demands of the individual’s sport

Must be able to understand the biomechanical requirements of

the sport

PHASE 4

Return to sport:

Must be graduated with

consideration to the variables of

intensity, frequency, duration,

environment, equipment and

technique

TREATMENT

Establish realistic and explicit goals with the patient in terms of:

time frames

outcomes (measureable)

patient involvement

therapist’s role

determination of success or failure

alternative options and when to instigate these

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EXPECTATIONS / OUTCOMES:

Rule of thumb: Initial improvement generally takes as many

weeks as it has been months, that the problem has existed.

By 12 weeks you will have 80% of your potential

improvement behind you.

Average patient requires about 4–6 visits over a two to

three month period.

PATIENT COMPLIANCE:

“ How do you get your patients to do their exercises ?”

Appropriate education

Goal setting – written out in the form of a contract

Make the exercises achievable – set the patient up for

success, not for failure

Write everything down- clear diagrams, instructions re

repetitions/ frequency

PATIENT COMPLIANCE:

Suitable scheduling of follow up appointments

Feed-back: positive and negative as required. ‘Call it as it

is’

Constant reassessment and comparisons with the

established goals

The young athlete: reassure them that the exercises will

(hopefully) fix their pain, but also improve their

performance

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EXERCISE THERAPY:

Exercise prescription:

Which exercise ?

How many ?

How often ?

What force / resistance ?

Pain ?

Technique

THE THROWING SHOULDER THE THROWING SHOULDER

http://www.writemarketdesign.com/About/About.htm

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THE THROWING SHOULDER

Sports Participation and Humeral Torsion

RJ Whitely,KA Ginn, LL Nicholson… - J Orthop Sports Phys …, 2009 -

ukpmc.ac.uk

STUDY DESIGN: Cross-sectional study.

OBJECTIVE: To examine differences between arms in humeral

torsion in adult and adolescent throwing and nonthrowing

athletes, and nonathletic adults.

BACKGROUND: It is hypothesized that humeral retrotorsion

develops ...

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Retroversion of the humerus in throwing athletes is a

developmental consequence of participation from a young age


Glenohumeral internal rotation

deficiency (GIRD):

When the amount of IR or total arc of

motion difference reaches a certain

threshold (typically 20 or more

degrees of IR or 8 degrees total arc

difference), it is known as glenohumeral

internal rotation deficit or total arc of

motion deficit.


• Other pathology of the throwing shoulder includes:

Internal impingement

Anterior instability

SLAP lesions

Rotator cuff and bicipital tendinopathy

Bennett lesion

A/C joint pathology

Suprascapular nerve entrapment

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A detailed consideration must be given to the entire kinetic

chain when assessing the shoulder of the throwing athlete.


Kinetic chain assessment:

Foot and ankle range of movement. Previous ankle sprain and loss of dorsiflexion

Hip/knee control. Single leg quarter squat

Glute/ hamstring eccentric control

Core strength. Eccentric control of trunk flexion on the follow through

Adequate flexibility at each segment

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Treatment:

As previously discussed, the objective of rehabilitation of the

throwing shoulder is to identify the deficient biomechanical

components and set about strategies to correct them

Assess issues of flexibility, neuromuscular control and strength as

relevant to the thrower

Establish an appropriate plan of action with the patient

CONCLUSION

Physiotherapy rehabilitation for shoulder

pathology aims to normalize deficient

shoulder mechanics

A targeted, clinically reasoned approach,

determined from the initial objective

examination, addressing issues of

flexibility and/or muscle control and

strength, is essential

CONCLUSION

• Rehabilitation programs must be suitably structured to

work in a graduated manner from least to more demanding

exercises

• Use this logical approach to help make treating shoulders easy!

THANK YOU

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Live Q & A With Joel Werman

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Coming up next week

Live Q & A With Joel Werman

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From Joel Werman

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principles of shoulder rehabilitation and return …...principles of shoulder rehabilitation and...

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