posterior shoulder impingement rehab

Figure 12 Rhythmic stabilization performed with scapular protraction. Among several other pathologies, calcific tendinopathy of the rotator cuff tendons is frequently observed during the ultrasound examination of patients with painful shoulder. Clinical features. The examiner then feels for translation of the humeral head along the glenoid face. Poppen and Walker6 calculated this force at 0.42 times body weight. How do you repair it? Dull ache in the front or side of the shoulder. Use of examination procedures to assess the accessory mobility of the glenohumeral joint is of critical importance in guiding this portion of the treatment. The range of motion is small. Step 2. fraying of posterior rotator cuff (supraspinatus-infraspinatus interval) posterior and superior labral lesions. You may also view our shoulder fitness and rehab videos with over 20 different exercises to strengthen your shoulder. Recent research has compared the effects of the cross-arm stretch to the sleeper stretch in a population of recreational athletes, some with significant glenohumeral IR range of motion deficiency.56 Four weeks of stretching produced significantly greater IR gains in the group performing the cross-body stretch as compared with the sleeper stretch. Several proposed mechanisms have been discussed attempting to explain this glenohumeral ROM relationship of increased ER and limited IR.33,45,46The tightness of the posterior capsule as well as the muscle tendon unit of the posterior rotator cuff has been believed to limit internal glenohumeral joint rotation. Primary impingement, also known as compressive disease or outlet impingement, is a direct result of compression of the rotator cuff tendons between the humeral head and the overlying anterior third of the acromion, cora-coacromial ligament, coracoid, or acromial-clavicular joint.1,2 The physiologic space between the inferior acromion and superior surface of the rotator cuff tendons is termed the subacromial space. Figure 11(A, B) Manual scapular stabilization in sidelying position for scapular retraction (A), and protraction (B). Bilateral comparison of IR ROM is taken with careful interpretation of isolated glenohumeral motion. The examiner is careful to utilize a posterolaterally directed force (in the direction of the arrow) along the line of the glenohumeral joint. Each utilizes an inherent anterior hand placement; this gives varying degrees of posterior pressure to minimize scapular compensation and to provide a check against anterior humeral head translation during the IR stretch. Recently, my colleagues and I measured the bilateral total rotation ROM in both professional baseball pitchers and elite junior tennis players.33 Our findings showed the professional baseball pitchers to have greater dominant arm ER and significantly less dominant arm IR when compared with the contralateral nondominant side. Explore all your options. Observed in younger, more athletic patients, it is a reversible condition with conservative physical therapy. 572 0 obj <> endobj Internal (posterosuperior) impingement syndrome is typified by a painful shoulder due to impingement of the soft tissue, including the RC, joint capsule and the posterosuperior part of The second important test to determine the presence of IR ROM limitation is the assessment of physiological ROM. Described by Dr. Stone as a "gift to his patients," this short, weekly blog focuses on sports, performance, & orthopaedic care. xmp.id:7fce4b75-b173-4b39-b5eb-6a3a0a8d4c3c With more-extensive amounts of posterior capsular tightness, the humeral head was found to shift posterosuperiorly. Solem-Bertoft et al28 has shown the importance of scapular retraction posturing by reporting a reduction in the width of the subacromial space when comparing scapular protraction posturing to scapular retraction. Dr. Sameer Nagda, MD is an Orthopedic Surgery Specialist in Alexandria, VA. Call for information or to book an appointment to see us in person. The primary symptoms and physical signs of this stage of impingement or compressive disease are similar to the other two stages and consist of a positive impingement sign, painful arc of movement, and varying degrees of muscular weakness.2. %PDF-1.5 % It is important to use consistent measurement techniques when documenting ROM of glenohumeral joint rotation. If, during the initial evaluation of a high-level baseball pitcher, the clinician finds a ROM pattern of 120 degrees of ER and only 30 degrees of IR, some uncertainty may exist as to whether that represents a range of motion deficit in IR that requires rehabilitative intervention via stretching and specific mobilization. Treatments for impingement syndrome include rest, ice, over-the-counter 7,10-13 Subacromial impingement syndrome is the most commonly diagnosed shoulder pathology within the general population 14-16 and is also a frequent pathology seen in baseball pitchers. In these professional throwing athletes, 93% had undersurface fraying of the rotator cuff tendons and 88% showed fraying of the posterosuperior glenoid. Clinical application of the total rotation ROM concept is best demonstrated by a case presentation of a unilaterally dominant upper-extremity sports athlete. Stage : consists of stiffness and difficulty in warming up, but no complaints of pain. Additionally, with this technique a protracted scapular position can be utilized to increase the activation of the serratus anterior muscle30,31; several studies have identified decreased muscular activation of this muscle in patients diagnosed with glenohumeral impingement and instability.25,32 Results showed even submaximal contractions increased perfusion during all 1-minute contractions; but they also produced a postcon-traction latent hyperemia following the muscular contraction. Lucas7 estimated this force at 10.2 times the weight of the arm. The typical age range for this stage of injury is 25 to 40 years. This more-posterior orientation of the tendons aligns them such that the undersurface of the tendons rubs on the posterior-superior glenoid lip and becomes pinched or compressed between the humeral head and the posterosuperior glenoid rim.19 In contrast to patients with traditional outlet impingement (either primary or secondary), the area of the rotator cuff tendon that is involved in posterior or undersurface impingement is the articular side of the rotator cuff tendon. 3 Rehabilitation of Macro-Instability In a series of 10 patients with traditional impingement signs and anterior-based pain presentations, Struhl23 arthroscopically confirmed contact between the fragmented undersurface of the rotator cuff tendons and the anterosuperior labrum during the Hawkins impingement test, viewed from a posterior arthroscopic portal. 388 0 obj <>stream Attenuation of the static stabilizers of the glenohumeral joint, such as the capsular ligaments and labrum from the excessive demands incurred in throwing or overhead activities, can lead to anterior instability of the glenohumeral joint. An additional type of impingement more recently discussed as an etiology for rotator cuff pathology that can often progress to an undersurface tear of the rotator cuff in the shoulder of a young athletic patient is termed posterior, internal or inside, or undersurface impingement.18,19 This phenomenon was originally identified by Walch et al19 upon performing shoulder arthroscopy with the shoulder placed in the 90 degrees of abduction and 90 degrees of external rotation (ER) (90/90) position. Placement of the shoulder in the 90/90 position causes the supraspinatus and infraspinatus tendons to rotate posteriorly. nonsurgical treatment for shoulder impingement. While shoulder impingement can be painful and affect your daily activities, most people make a full recovery within a few months. In many cases, youll just need some rest and physical therapy. If those dont provide relief, you may need surgery, which can add a few months to your recovery time. Biomechanics and theories of pathology. A common error in this exam technique is the use either of the coronal plane for testing or of a straight posteriorly directed force by the examiners hand rather than the recommended posterolateral force. If you would like help relieving your shoulder pain, our team of highly-trained therapists can alleviate the pain with personalized 1:1 physical therapy sessions. Modalities such as electrical stimulation, ultrasound, and iontophoresis can be applied to promote improved blood supply and decrease pain levels; however, a clearly superior modality or sequence of modalities for the early management of tendon pathology in the human shoulder is lacking. Perform 15 - 20 reps, Stand with a towel rolled underarm, your elbow bent 90, and the Theraband across the front of you and attached to a door. Observed in younger, more athletic patients, it is a reversible condition with conservative physical therapy. Figure 14 Technique used to measure more isolated glenohumeral joint internal rotation with the shoulder in 90 degrees of abduction in the coronal plane. Burkhart et al34 have termed this IR loss GIRD-glenohumeral internal rotation deficitand define it as a loss of internal rotation of 20 degrees or more compared with the contralateral side. Orthopaedic surgeon, clinician, scientist, inventor, and founder of multiple companies. The game that everyone can play, and all can get hurt. The loss of IR ROM is significant for several reasons. Posterior, Internal, or Undersurface Impingement In contrast, we tested 117 elite male junior tennis players.33 In these tennis players, significantly less IR ROM was found on the dominant arm (45 degrees versus 56 degrees), as well as significantly less total rotation ROM on the dominant arm (149 degrees versus 158 degrees). Adobe InDesign CC 13.0 (Macintosh) Total Rotation Range-of-Motion Concept The total rotation ROM, however, was not significantly different between extremities in the professional baseball pitchers (145 degrees dominant arm, 146 degrees nondominant arm). This technique is most often referred to as the posterior load and shift or posterior drawer test.35,36 Figure 1-3 shows the recommended technique for this examination maneuver whereby the glenohumeral joint is abducted 90 degrees in the scapular plane (note the position of the humerus 30 degrees anterior the coronal plane). Range-of-Motion Exercises. top. Manual techniques allow the clinician to interface directly with the patients scapula to bypass the glenohumeral joint and permit repetitive scapular exercise without inducing undue stress to the rotator cuff in the early phase. Due to the increased humeral head translation, the biceps tendon and rotator cuff can become impinged secondary to the ensuing instability.13,14 A progressive loss of glenohumeral joint stability is created when the dynamic stabilizing functions of the rotator cuff are diminished from fatigue and tendon injury.14,17 The effects of secondary impingement can lead to rotator cuff tears as the instability and impingement continue.3,14. When this occurs, the bones in the shoulder pinch down on the tendons and cause shoulder impingement. With the arthroscope inserted in the glenohumeral joint, they found that 41 out of 41 dominant shoulders evaluated had posterior undersurface impingement between the rotator cuff and posterior superior glenoid. To further illustrate the role of ROM and passive stretching during this phase of the rehabilitation, Figures 15 and 16 show versions of clinical IR stretching positions that utilize the scapular plane and can be performed in multiple and varied positions of glenohumeral abduction. False Research by Kibler et al47 and Roetert et al48 has identified decreases in the total rotation ROM arc in the dominant extremity of elite tennis players correlated with increasing age and number of competitive years of play. Phase I - Maximal Protection Acute Phase Goals: Relieve pain and inflammation Normalize range of motion . endstream endobj 3 0 obj <> endobj 5 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 6 0 obj <>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 7 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 8 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]>>/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 9 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]>>/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 10 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]>>/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 11 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 41 0 obj <>stream Ischiofemoral impingement has also been proposed as an etiology in sciatic nerve compression and proximal hamstring tendinopathy. 588 0 obj <>/Filter/FlateDecode/ID[<0D5C6F65DB095E47A75EF0C0584F80E7><19BF309E71A0A646A90004519F36AC6B>]/Index[572 27]/Info 571 0 R/Length 91/Prev 219929/Root 573 0 R/Size 599/Type/XRef/W[1 3 1]>>stream Modalities such as electrical stimulation, ultrasound, and iontophoresis can be applied to promote improved blood supply and decrease pain levels; however, a clearly superior modality or sequence of modalities for the early management of tendon pathology in the human shoulder is lacking. The typical age range for this stage of injury is 25 to 40 years. Rehabilitation ofSpecific Shoulder Pathologies / Table 11 contains the descriptive data from the professional baseball pitchers and elite junior tennis players.33 More research including additional subject populations is needed to outline the total rotation ROM concept further. To have a numerical representation of the total rotation range of motion available at the glenohumeral joint, the glenohumeral joint IR, and ER ROM measure are added together. Measured using anteroposterior radiographs, it was 7 to 13 mm in size in patients with shoulder pain3 and 6 to 14 mm in normal shoulders.4 Flatow et al5 have shown that elevation of the humerus leads to predictable and reproducible patterns of subacromial impingement of the rotator cuff tendons against the overlying acromion and coracoacromial ligament. 365 0 obj <>/Filter/FlateDecode/ID[<4A4E3F3BA7CB234F94F7D87A37576B23><7ABB4B68D9A2F54499B0AE6B22F14F8A>]/Index[343 46]/Info 342 0 R/Length 104/Prev 66714/Root 344 0 R/Size 389/Type/XRef/W[1 2 1]>>stream hbbd```b``n+-XDsA$G'd:"A3{ >k``bd`, # A- Step 3. The examiner is careful to utilize a posterolaterally directed force (in the direction of the arrow) along the line of the glenohumeral joint. To have a numerical representation of the total rotation range of motion available at the glenohumeral joint, the glenohumeral joint IR, and ER ROM measure are added together. %PDF-1.6 % Todd S. Ellenbecker Halbrecht et al21 has confirmed via magnetic resonance imaging (MRI) that physical contact of the undersurface of the supraspinatus tendon against the posterior-superior glenoid was found in 10 collegiate baseball pitchers when their pitching arm was placed in the position of 90 degrees of ER and 90 degrees of abduction. The presence of anterior translation of the humeral head with maximal ER and 90 degrees of abduction, which has been confirmed arthroscopically during the subluxation-relocation test, can produce mechanical rubbing and fraying on the undersurface of the rotator cuff tendons. One area that has received a great deal of attention in the scientific literature is the presence of an IR ROM limitation, particularly in the overhead athlete with rotator cuff dysfunction.33,34 To determine the course of treatment for the patient with limited IR ROM, clinical assessment strategies must be employed to determine whether the limitation and subsequent treatment strategy to address the limitation in glenohumeral joint IR should be targeted for the muscletendon unit or the posterior capsule. San Francisco, CA 94123, United States. Your rotator cuff may be injured if you feel pain when you extend your arm Additionally, Crockett et al45 have shown unilateral increases in humeral retroversion in throwing athletes, which would explain the increase in ER with accompanying IR loss. The deposition of hydroxyapatite calcium crystals should not be considered as a static process but rather a dynamic pathological process Why? To determine the tightness of the posterior glenohumeral joint capsule, an accessory mobility technique to assess the mobility of the humeral head relative to the glenoid is recommended. This total rotation ROM concept can be used to guide the clinician during rehabilitation, specifically in the application of stretching and mobilization exercises, to best determine what glenohumeral joint requires additional mobility. Shoulder impingement usually takes about three to six months to heal completely. More severe cases can take up to a year to heal. However, you can usually start returning to your normal activities Protocol R1 Non-Operative Rehabilitation Program for Acute Glenohumeral Joint Dislocation. Full-thickness tears of the rotator cuff, partial-thickness tears of the rotator cuff, biceps tendon lesions, and bony alteration of the acromion and acromioclavicular joint may be associated with this stage.12 In addition to bony alterations that are acquired with repetitive stress to the shoulder, the native shape of the acromion is of relevance. However, patients with primary impingement often present with underlying capsular hypo-mobility and are definite candidates for specific mobilization techniques to improve glenohumeral joint arthrokinematics. The position of the shoulder in forward flexion, horizontal adduction, and internal rotation (IR) during the acceleration and follow-through phases of the throwing motion is likely to produce subacromial impingement due to abrasion of the supraspinatus, infraspinatus, or biceps tendon against the overlying structures.9 These data provide scientific rationale for the concept of primary impingement or compressive disease as an etiology of rotator cuff pathology. One rather consistent finding present during the examination of the overhead athlete is increased dominant arm ER as well as reduced dominant arm glenohumeral joint IR.33,4143 I have found that this relationship is only identified under conditions where the glenohumeral joint rotation was measured with the scapula stabilized.44 Failure to stabilize the scapula may not produce glenohumeral joint IR ROM limitations even though they are present, possibly due to scapular compensation. 1 Rehabilitation of Shoulder Impingement: Primary, Secondary, and Internal, 5 Rehabilitation of Acromioclavicular Joint Injuries, 6 Classification and Treatment of Scapular Pathology. If you would like help relieving your shoulder pain, our team of highly-trained therapists can alleviate the pain with personalized 1:1 physical therapy sessions. Contact us at (415) 563-3110 for an appointment. Impingement of the undersurface of the rotator cuff on the posterosuperior glenoid labrum may be a cause of painful structural disease in the athlete practicing sports with overhead movement. Camp C, Dines D, et al. Placement of the shoulder in the 90/90 position causes the supraspinatus and infraspinatus tendons to rotate posteriorly. Hold 5 seconds and repeat 10 times, Sitting or standing up straight, arms down at sides, rotate arms outward while trying to extend downward at the same time. Approximately 10 degrees less total rotation ROM can be expected in the dominant arm of the uninjured elite junior tennis player as compared with the nondominant extremity. With a regular routine of these three stretches (#24), you can improve your thoracic mobility and promote better posturecrucial for combating the pain of shoulder impingement. Note the inherent means of scapular stabilization in both methods that are necessary to optimize the value of the stretching procedure. Stage Iedema and hemorrhageresults from the mechanical irritation of the tendon; this is caused by impingement incurred from overhead activity. endstream endobj 488 0 obj <. Stage Iedema and hemorrhageresults from the mechanical irritation of the tendon; this is caused by impingement incurred from overhead activity. Peak forces against the acromion were measured in a range of motion (ROM) between 85 degrees and 136 degrees of elevation.8 This position is a functionally important one for daily activities, sport-specific movements,9,10 and situations commonly encountered on a job as well. 487 0 obj <> endobj %%EOF Several proposed mechanisms have been discussed attempting to explain this glenohumeral ROM relationship of increased ER and limited IR.33,45,46The tightness of the posterior capsule as well as the muscle tendon unit of the posterior rotator cuff has been believed to limit internal glenohumeral joint rotation. Rehabilitation of Rotator Cuff Impingement Poppen and Walker6 calculated this force at 0.42 times body weight. There can be additional harm caused by the posterior deltoid if the rotator cuff is not functioning properly. These findings have provided the rationale for the early use of internal and ER isometrics or submaximal manual resistance in the scapular plane with low levels of elevation to prevent any subacromial contact early in the rehabilitation process. PJT,*$(dsJE5N i> *A%QL&1+ul|n0\IpLxm! Hold this for 2030 seconds 23 times a day. Your physical therapist may use manual techniques, such as gentle joint movements, soft-tissue massage, and shoulder stretches to get your shoulder moving properly, so that the tendons and bursa avoid impingement. If, during the initial evaluation of a high-level baseball pitcher, the clinician finds a ROM pattern of 120 degrees of ER and only 30 degrees of IR, some uncertainty may exist as to whether that represents a range of motion deficit in IR that requires rehabilitative intervention via stretching and specific mobilization. %%EOF Jensen etal27 studied the effects of submaximal [5 to 50% maximum voluntary contraction (MVC)] contractions in the supraspinatus tendon measured with laser Doppler flowmetry. A large spectrum of mobility can be encountered when treating the patient with glenohumeral impingement. In the grading technique designed by Altchek,37 grade I is considered normal motion within the glenoid (typically 8 to 10 mm38), and a grade II translation is when the clinician-guided stress produces movement of the humeral head over the glenoid rim posteriorly with relocation of the humeral head into the glenoid when stress is removed. If you've dislocated your shoulder, it means it Collarbone (clavicle) fractures are painful and personalized 1:1 physical therapy sessions, The Changing Approach to Rotator Cuff Repair. 2017-11-09T08:49:39-06:00 Significant advances in basic research in the anatomy and biomechanics of the human shoulder have led to the identification of multiple types of impingement, each with underlying pathomechanical causes. If measurement of that patients nondominant extremity rotation, however, reveals 90 degrees of ER and 60 degrees of internal rotation, the current recommendation based on the total rotation ROM concept would be to avoid extensive mobilization and passive stretching of the dominant extremity because the total rotation ROM in both extremities is 150 degrees (120 ER + 30 IR = 150 dominant arm/90 ER and 60 IR = 150 total rotation non-dominant arm). Stage: hallmarked by the complaint of pain during the late cocking phase of the throwing cycle. hbbd```b`` "WI[ fH` R1DJ?LAdd\bHYLLA"@$o` - Research by Kibler et al47 and Roetert et al48 has identified decreases in the total rotation ROM arc in the dominant extremity of elite tennis players correlated with increasing age and number of competitive years of play. Figure 13 Posterior glenohumeral joint translation test at 90 degrees of abduction in the scapular plane. endstream endobj 344 0 obj <. In addition to the early scapular stabilization and submaximal rotator cuff exercise, ROM and mobilization may be indicated based on the underlying mobility status of the patient. 2017-11-09T08:49:39-06:00 So its on the undersurface of the rotator cuff now. Unidirectional posterior shoulder instability is much less common than anterior instability, however it should be strongly suspected in those high risk group of athletes with posteroir shoulder pain and/or clicking. Specific changes in the program will be made by the physician as appropriate for the individual patient. Hold 5 seconds and repeat 10 times, Standing in a doorway with hand holding onto doorframe just below shoulder height, turn body away from your arm until a stretch is felt in the chest. Rehabilitation ofShoulder Impingement:Primary, Secondary,and Internal The straight posterior force compresses the humeral head into the glenoid because of the anteverted position of the glenoid; this would inaccurately lead to the assumption by the examining clinician that limited posterior capsular mobility is present. If measurement of that patients nondominant extremity rotation, however, reveals 90 degrees of ER and 60 degrees of internal rotation, the current recommendation based on the total rotation ROM concept would be to avoid extensive mobilization and passive stretching of the dominant extremity because the total rotation ROM in both extremities is 150 degrees (120 ER + 30 IR = 150 dominant arm/90 ER and 60 IR = 150 total rotation non-dominant arm). The total rotation ROM did differ between extremities. One study highlights the importance of early submaximal exercise to increase local blood flow. Results showed even submaximal contractions increased perfusion during all 1-minute contractions; but they also produced a postcon-traction latent hyperemia following the muscular contraction. Neers Stages of Impingement In these professional throwing athletes, 93% had undersurface fraying of the rotator cuff tendons and 88% showed fraying of the posterosuperior glenoid. First, non-operative interventions are recommended such as: Cessation from throwing and resting your shoulder until the pain is controlled. Initial Phase It should be pointed out that incorrect use of this posterior glide assessment technique may lead to the false identification of posterior capsular tightness. reversing GIRD in those with posterior shoulder tightness, creating improved dynamic stabilization of the glenohumeral Rehabilitation Guidelines for Posterior Shoulder Reconstruction with or without Labral Repair PHASE III (begin after meeting Phase II criteria, usually 8 weeks after surgery) Appointments Y]n^fGjgYKQg$->W&{gWS4Mzk> xm91lm}{I[ 27?qy~2\ue5g. Neutral position of the back, shoulders, and spine should be maintained during standing, sitting, and lifting activities. Painful to lie on the shoulder. Anterior internal impingement has recently been described as a source of pain in patients with a stable shoulder and positive traditional impingement signs.23 Struhl23 reported this phenomenon during arthroscopic evaluation of patients who had clinical signs of traditional outlet impingement and anterior-based pain presentations. Anterior Internal Impingement Remember this number: 25%. Jensen etal27 studied the effects of submaximal [5 to 50% maximum voluntary contraction (MVC)] contractions in the supraspinatus tendon measured with laser Doppler flowmetry. If, like many of our patients, you don't live in the Bay Area, we offer a complimentaryphone consultation service. Outcomes 2016;7(12):776. Wall Slides. World J Orthop. application/pdf Sitting or standing up straight, pinch shoulder blades together as if pinching a peanut between them. Types of Rotator Cuff ImpingementPrimary Impingement or Compressive DiseaseSecondary ImpingementPosterior, Internal, or Undersurface ImpingementAnterior Internal Impingement Indications for Treatment: Subacromial impingement with rotator cuff tendinopathy is a very common condition xmp.did:048011740720681188C6C22164859945 Progression will be based on individual patient presentation, which is assessed throughout the treatment process. Phase I Protection Phase (weeks 0-4): Review videos for shoulder immobilizer and passive ROM (Codmans pendulum, passive flexion). Approximately 10 degrees less total rotation ROM can be expected in the dominant arm of the uninjured elite junior tennis player as compared with the nondominant extremity. Traditional impingement involves the superior or bursal surface of the rotator cuff tendon or tendons and typically produces anterior and anterolateral pain distributions.20 Conversely, individuals presenting with posterior shoulder pain brought on by positioning of the arm in 90 degrees of abduction and 90 degrees or more of ER, typically from overhead positions in sport or work activities, may be considered as potential candidates for undersurface impingement. Rotator cuff injury A more severe cause of posterior shoulder pain could be a rotator cuff injury. The rotator cuff must be protected against mechanical compression by the overlying coracoacromial arch or posterior glenoid; this can be done by modifying ergonomic, sport-specific postures and movement patterns as well as those related to activities of daily living (ADL). Note: All progressions are approximations and should be used as a guideline only. Biomechanical analysis of the shoulder has produced theoretical estimates of the compressive forces against the acromion with elevation of the shoulder. Elbow Flares Lie on your back in a comfortable position and put both hands behind your head Stretch the front of your shoulder by letting your elbows drop out to the side, down as close to Several authors recommend measurement of glenohumeral IR with the joint in 90 degrees of abduction in the coronal plane.3941 During IR ROM measurement (Fig. A common error in this exam technique is the use either of the coronal plane for testing or of a straight posteriorly directed force by the examiners hand rather than the recommended posterolateral force. Hold 15 seconds and repeat 5 times, Holding onto a table with fingertips and arm relaxed, stand up and away from arm to distract arm from shoulder. For this exercise, all you need is a blank wall and a towel. shoulder internal impingement non-operative guidelines The following internal impingement guidelines were developed by HSS Rehabilitation and are categorized into five phases with the hypertrophy and Figure 11A shows the specific technique I use with my patients to resist scapular retraction manually. adobe:docid:indd:d426ab4c-3564-11de-9476-80770b4263da How do you repair it? The goal of treatment for shoulder impingement syndrome is to reduce your pain and restore shoulder function. Rehabilitation of Rotator Cuff ImpingementInitial PhaseTotal Rotation Range-of-Motion ConceptTotal Arm Strength PhaseDischarge Considerations proof:pdf Phase II Motion Phase (weeks 5-8): Review videos for active ROM,overhead pulley and isometric strengthening (flexion, extension,abduction, external I Activation of the serratus anterior and lower trapezius force couple is imperative to enable scapular upward rotation and stabilization during arm elevation.29 Rhythmic stabilization applied to the proximal aspect of the extremity progressing to distal with the glenohumeral joint in 80 to 90 degrees of elevation in the scapular plane (Fig. Patients presenting with a limitation in IR ROM who have grade II translation should not have posterior glide accessory techniques applied to increase IR ROM due to the hyper-mobility of the posterior capsule made evident during this important passive clinical test. Your doctor may recommend non-operative or operative treatments to treat internal impingement of the shoulder. First, non-operative interventions are recommended such as: Cessation from throwing and resting your shoulder until the pain is controlled. 14), care must be taken to stabilize the scapula, with the patient supine so that the patients body weight can minimize scapular motion as the examiner uses a posteriorly directed force on the anterior aspect of the coracoid and shoulder. Bilateral comparison of IR ROM is taken with careful interpretation of isolated glenohumeral motion. 503 0 obj <>/Filter/FlateDecode/ID[<134431657913AA4EB46C7748850DE83C>]/Index[487 27]/Info 486 0 R/Length 91/Prev 266624/Root 488 0 R/Size 514/Type/XRef/W[1 3 1]>>stream Recently, my colleagues and I measured the bilateral total rotation ROM in both professional baseball pitchers and elite junior tennis players.33 Our findings showed the professional baseball pitchers to have greater dominant arm ER and significantly less dominant arm IR when compared with the contralateral nondominant side. In a series of 10 patients with traditional impingement signs and anterior-based pain presentations, Struhl23 arthroscopically confirmed contact between the fragmented undersurface of the rotator cuff tendons and the anterosuperior labrum during the Hawkins impingement test, viewed from a posterior arthroscopic portal. A very common pathology in overhead-throwing athletes is posterior shoulder pain resulting from internal impingement. Secondary Impingement 513 0 obj <>stream Impingement or compressive symptoms may be secondary to underlying instability of the glenohumeral joint.13,14 Though relatively common knowledge today, this concept was not well understood or recognized in the medical community even through the mid- to late 1980s. Dr. Stone was trained at Harvard University in internal medicine and orthopaedic surgery and at Stanford University in general surgery. The total rotation ROM, however, was not significantly different between extremities in the professional baseball pitchers (145 degrees dominant arm, 146 degrees nondominant arm). The straight posterior force compresses the humeral head into the glenoid because of the anteverted position of the glenoid; this would inaccurately lead to the assumption by the examining clinician that limited posterior capsular mobility is present. The posterior deltoids angle of pull compresses the humeral head against the glenoid, accentuating the skeletal, tendinous, and labral lesions.18 Walch et al19 arthroscopically evaluated 17 throwing athletes with shoulder pain during throwing and found undersurface impingement that resulted in eight partial-thickness rotator cuff tears and 12 lesions in the posterosuperior labrum. If you think about the rotator cuff, its classic impingement with a rotator cuff pathologies is technically external, which means its on the outside or the top layer of the rotator cuff. Go until tension and hold for 3 seconds and repeat 5 times, Holding the band with both hands and with it wrapped around a doorknob, pinch shoulder blades and pull back towards you as if rowing a boat. In this chapter, the main types of rotator cuff impingement are discussed together with both general and specific rehabilitation principles and strategies based on the available evidence. Pathologies such as internal impingement, SLAP lesions, UCL elbow sprains, and subacromial impingement syndrome have been associated with PST. It has been hypothesized that shoulder pain seen in swimmers may be the result of anterior internal impingement; the pain is frequently reported at hand entry into the waterin this position, the humeral position is similar to that of the Neer and Hawkins test.23 %PDF-1.6 % A number of different theories have been proposed to explain internal impingement. The presence of anterior translation of the humeral head with maximal ER and 90 degrees of abduction, which has been confirmed arthroscopically during the subluxation-relocation test, can produce mechanical rubbing and fraying on the undersurface of the rotator cuff tendons. This technique is most often referred to as the, Classification and Treatment of Scapular Pathology, Rehabilitation of Acromioclavicular Joint Injuries, Use of Interval Return Programs for Shoulder Rehabilitation, Use of Taping and External Devices in Shoulder Rehabilitation, Modification of Traditional Exercises for Shoulder Rehabilitation and a Return-to-Lifting Program. Additionally, Burkhart et al34 have clinically demonstrated the concept of posterior-superior humeral head shear in the abducted externally rotated position with tightness of the posterior band of the inferior glenohumeral ligament. Rotate arm outwards away from band, making sure to keep shoulders back and do not hike shoulder. In contrast, we tested 117 elite male junior tennis players.33 In these tennis players, significantly less IR ROM was found on the dominant arm (45 degrees versus 56 degrees), as well as significantly less total rotation ROM on the dominant arm (149 degrees versus 158 degrees). #5. xmp.iid:72d4091a-11ea-4bc0-aa63-76ef9431a5ea It is beyond the scope of this chapter to discuss the complex and comprehensive evaluation methods specifically; however, a detailed and systematic approach to shoulder and upper-extremity evaluation must be undertaken both to identify the specific type of rotator cuff impingement as well as to determine the often-subtle underlying causes. 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