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SHOULDER REHABILITATION – PART II

Ann Cools, PT, PhDGhent University - Belgium

Dept of Rehabilitation Sciences & PhysiotherapyAnn.Cools@UGent.be

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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

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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

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Level II Advanced Course

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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

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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

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Coupled movements scapula and clavicula (saddle joint)

- Elevation- Retraction- Posterior axial

rotation

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- Upward rotation- Posterior tilting- Internal/external rotation: No consensus, however:‣ Early internal rotation

‣ Late external rotation

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Coupled movements scapula and clavicula

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- Elevation + upward rotation- Retraction + external rotation- Posterior axial rotation* + posterior tilting

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Coupled movements scapula and clavicula

Scapular upward rotation

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Scapular upward rotation

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Scapular posterior tilting

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Scapular posterior tilting

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Scapular internal/external rotation

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Scapular internal/external rotation

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*Role of the axial rotation of the clavicula

Clavicular Elevation = 40°Scapular Upward Rotation = 60°

P2-P3: upward rotation scapula + axialrotation clavicula (20°)

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Role of lig. Conoideum during this movement

Axial rotation clavicula is the result of tension of this ligament

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Scapular Muscle Function

Serratus Anterior Trapezius

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UPPER

MIDDLE

LOWER

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UT/MT/LT

SALT SAUT SA

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levator scapulae en rhomboïdeï

-Elevation + retraction + Downward rotation-Probably “postural” muscles-Have to work eccentrically or relax duringelevation….

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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

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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

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Type I scapular dyskinesis

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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

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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

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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

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Tightnesslevator scapulae

DysfunctionUpper trap/serr ant

Upper trap/ lower trap

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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)

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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)

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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)

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1. Scapular involvement in shoulder pain

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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• …

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2. Additional clinical testing/observation andObjective measurements

1. Scapular upward rotation2. Scapular muscle strength3. Pectoralis Minor Length

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Practice:

• Inclinometry upward rotation

• Clinical test SA vs TRAP

• HHD scapular muscles

• PM lengthA Cools 2016

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1. SCAPULAR UPWARD ROTATION

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Pro 3600 inclinometer

First publications on scapular measurements usedpro 3600 (Johnson 2001, Borsa 2003, Su 2004, Laudner 2007….)

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Acumar/similar inclinometer

Easier to use, and high reliability (Watson 2005, Struyff 2011)

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Reliability and reference data on a normal population of this procedure

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Results of this procedure on healthyoverhead athletes(Cools et al. JAT 2014)

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2. SCAPULAR MUSCLE STRENGTH

Clinical test: serr ant versus trapeziusSelected muscles:1. Upper trapezius2. Middle trapezius3. Lower trapezius4. Serratus anterior

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Clinical test: SA vs TRAP

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(Martin Kelley, scapula meeting 2003)

HDD Measurements: GeneralMANY DIFFERENT PROCEDURES

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(Michener 2005, Cools 2010, Williams 2009)

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(HandHeld dynamometer CompuFET, Biometrics)

‣ Upper Trapezius (UT)‣ Serratus Anterior (SA)‣ Middle Trapezius (MT)‣ Lower Trapezius (LT)

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Results from this procedure for overhead athletes(Cools 2010)

ClinicResearch

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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

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3. PECT MINOR LENGTH

Short PM induces changes similar to impingementrelated dyskinesis (Borstad JOSPT 2005)

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PMI - PECTORALIS MINOR INDEX

PMI = (PML/length) x 100

CUT-OFF POINTS

PMI < 7.65: SHORTPMI > 8.61: LONG

3. PECT MINOR LENGTH

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Cools & Johansson BJSM 2010: significant decrease PM length in elite junior (11-17yr) tennis players dominant versus non-dominant side

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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

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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

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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

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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

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(Mottram 2009)

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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

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Stretching pectoralis minor

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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

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Practice and progression

Add thoracic extension and ER component to“inferior glide”

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Practice and progression

Add KC components, weightsand higher elevation anglesto “lawnmower ”

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Practice and progression

Add KC components, weightsand higher elevation anglesto “robbery ”

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Practice and progression

Other exercises with“external rotationcomponent ”

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Practice and progression

Other exercises with“external rotationcomponent ”

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UT/MT/LT/SA

Pect Min

Lev scap

rhomb

1. Elevation scap plane

2. Wall slide

3. Elevation + ER

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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)

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Focus on muscle balance rather than muscle strength: Pm/SA (Castelein et al. Man Ther 2015)

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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

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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

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Proprioceptive Taping Techniques

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GIRD: relaxation of the infraspinatus

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Scapula: posterior tilt

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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

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General forward shoulderposture

Dysfunction 3 trap parts/serrant

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Thoracic and cervical position and ROM exercises

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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

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General forward shoulderposture

Dysfunction 3 trap parts/serrant

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Exercises increasing strengthin SA and/or trap

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Exercises for type II scapular dyskinesis

General guideline: focus on retraction /protraction in horizontal plane (90° elevation)

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Exercises for type II

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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

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Tightnesslevator scapulae

DysfunctionUpper trap/serr ant

Upper trap/ lower trap

Exercises: focus on UPWARD ROTATION

• Serr punch >90°• W-V exercise• Wall slide

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(level I shoulder rehab course)

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UT ↓SA =MT & LT ↑Pect Min ↓

UT ↓SA =Lev Scap ↓

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Comparison muscle activity UT, MT, LT, LS, rhomboid

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Exercises: focus on UPWARD ROTATION

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Exercises: focus on UPWARD ROTATION

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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