Upper Quarter Cervical Dysfunction Combined

PathologyJasmine Chan

Andy ChiuBrandon HigaBryce KeyesMinsu Kim

Derek MatsuiAdrian Ruiz

Traci Yamashita

www.powerhealths.com/2009/05/shoulder-pain/

askdrkit.com/neck-pain

askdrkit.com/neck-pain

Shoulder Impingement1 • Primary

o Subacromial crowding o Shape of the Acromion o Superior migration of humeral heado Tight posterior capsule

• Secondaryo Relative decrease in subacromial

space due to instability of the glenohumeral or scapulothoracic joint

2 types of shoulder stabilizers• Static

o Glenohumeral ligaments o Capsule o Angle of the Glenoid cavity

• Dynamic o Rotator cuff musculature o Scapular stabilizers o May be affected by cervical pathology

Stabilizers of the Shoulder2-4

Patient presentation• pain, weakness and a loss of movement5• may occur at night if the patient lies on the

affected shoulder. • other symptoms include grinding or popping

during movement6 • range of motion may be limited by pain. 

o painful arc may be present during elevation of the arm from 60° to 120°6

Standard Protocol for Shoulder Impingement7

• Muscle strengtheningo Rotator cuff trainingo Scapular stabilizers training

• Stretchingo Rotator cuff o PROM

• Pain reductiono Ice/heato Anti-inflammatory medication

Shoulder Assessment• Signs that point to cervical spine

o Posture Forward head posture Head orientation Humeral head location

o AROM/PROM for glenohumeral joint, and scapulothoracic joint

o Strength Myotomal

o Sensory Dermatomal Peripheral

o Reflex Asymmetrical UE reflex

C4 – C8 diminished or absent in involved side

Cervical Spine Contribution• Abnormal movement

o Facet Hypermobility o Facet Hypomobility o Muscle Imbalance

• Whiplash• Cervical Disc Herniation• Cervical Spinal Stenosis• Posture/Resting Alignment

o May alter mechanics of the C-spineo May increase stress on surrounding 

 

Cervical Spine Contribution

• Whiplash8,9o Secondary shoulder

impingement associated with whiplash injury

 

Cervical Spine Contribution

• Cervical Disc Herniation4o Disc degenerationo Trauma

Cervical Spine Contribution

• Cervical Spine Stenosis4o Bone spurs around

intervertebral and facet joints

Cervical Spine & Shoulder  Assessment

• C-spine clearing testso VBI, Sharp-Pursar, Sidebend, Traction

• Postural Assessment • PROM/AROM• Accessory motion of the C-spine

o upglide, downglide, gapping • Upper limb tension test

o Ulnar, Median, Radial• Sensory• Provocation/Alleviation

o Technique that allows us to identify a specific problematic segment

o Increases the efficiency of treatment o Provides the patient with a better prognosis

• Soft tissue accessory assessment

Postural Assessment: Slumped Sitting4,8 • May effect overall mechanics of the

shoulder and neck• Upper Crossed Syndrome 

o tightness of the anterior musculature of thorax

o Elongation of the posterior musculature of thorax

o  Weakness of the posterior musculature of thorax and deep neck stabilizers 

o Shortening of suboccipitals• Ischemia and nerve damage • Decreased innervation to the rotator cuff• Indirectly related to posterior capsular

tightness 

Postural Assessment: Slumped Sitting8

• Proprioceptive changes• Strength deficits• Length Deficits• Nerve Compression• Muscle Fatigue• All can contribute to possible signs of impingement

Scapulohumeral Rhythm

• 4 Joints7o glenohumeralo scapulothoracico sternoclavicularo acromioclavicular

• 2 purposes7o distribute motion between glenohumeral and

scapulothroacic jointso maintain optimal length/tension relationship of

muscles

Glenohumeral/Scapulothoracic Contribution

• Shoulder flexion 180°7o Glenohumeral contribution 120°o Scapulothoracic contribution 60°o 2:1 ratio

Postural Intervention • We look to restore integrity,

length, and strength • Postural Taping• Postural Re-education• Lengthening of the anterior

muscles • Strengthening of the posterior

muscles• Strengthening/re-educating the

deep cervical stabilizers• Strengthen core

 

Cervical Spine Intervention• The cervical spine must be treated first.

o A muscle that is neurologically compromised cannot reach full strength.

• Should focus on joint mobilization o Upglide, downglide

Depending on dysfunction o Gappingo Traction

• Soft tissueo Contract/Relax of trapezius, scaleneso Soft tissue mobilization 

• Mobilizations of asymptomatic cervical spines have even been shown to improve shoulder range of motion and pain.11

Interventions

• Strengthening/ control c-spine muscles• Shoulder can then be addressed.

o Strengthening of rotator cuff muscles and scapular stabilizers.

o Scapulo-humeral dissociation o Inferior glide?

Tracking Down the Problem

• Shoulder impingement • Weak shoulder stabilizers• Cervical radiculopathy• Posture, disc herniation, stenosis,

traumatic, etc.

                      References   1. Ferdig S. Shoulder Pathology Lecture.  Spring 2009. Chapman University, Department of Physical Therapy. 2. Wilson C. Rotator cuff versus cervical spine: making the diagnosis. Nurse Pract. 2005;30(5):44-50. 3. Hess SA.  Functional stability of the glenohumeral joint.  Man Ther. 2000;5(2):63-71.4. Magee DJ. Orthopedic Physical Assessment. W.B. Saunders Company; 2002.5. Fongemie AE, Buss DD & Rolnick SJ.  Management of shoulder impingement syndrome and rotator cuff tears. Am     Fam Physician. 1998;57:667–674. 6. Chen AL, Rokito AS & Zuckerman JD. The role of the acromioclavicular joint in impingement syndrome. Clin             Sports Med . 2003;22:343–357. 7. Kamkar A, Irrgang J, Whitney S. Nonoperative management of secondary shoulder impingement syndrome.                 JOSPT. 1993;17(5):212-2248. Chauhan SK, Peckham T, Turner R. Impingement syndrome associated with whiplash injury. J Bone Joint Surg Br.     2003;85-B:408-410. 9. Abbassian A, Giddins, GE. Subacromial impingement in patients with whiplash injury to the cervical spine. J             Orthop Surg Res. 2008;3:25. 10. Langford ML.  Poor posture subjects a worker's body to muscle imbalance and nerve compression.  Occup Health         Sci. 1994: 63(1); 38-41.  11. McClatchie L, Laprade J, Martin S, Jaglal SB, Richardson D, Agur A. Mobilizations of the asymptomatic cervical         spine can reduce signs of shoulder dysfunction in adults. Man Ther. 2008;14(4): 369-374.