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  1. MANUAL THERAPY AND EXERCISE FOR SUBACROMIAL IMPINGEMENT OF THE SHOULDER Combined Sections Meeting 2006 San Diego, CA February 1-5 2006 Mark R. Bookhout, PT, MS, FAAOMPT President, Physical Therapy Orthopedic Specialists, Inc. Minneapolis, MN Course Description: This three hour presentation will present six functional factors that may cause subacromial impingement of the shoulder. Tests and measures used in the examination process for each of these functional factors will be discussed. The speaker will then present the use of manual therapy and exercise as procedural interventions in an eclectic approach to treatment and management of these patients. Level 3 - Advanced Course Objectives • The therapist will become familiar with six functional factors that may lead to subacromial impingement • The therapist will understand the biomechanics of each of these factors as they relate to the development of subacromialimpingement • The therapist will understand the role of manual therapy in the examination of each of these six functional factors • The therapist will learn an innovative and eclectic approach to the overall examination and intervention of patients diagnosed with subacromial impingement 1

  2. Subacromial Impingement • Definition – Impingement of the rotator cuff beneath the coracoacromial arch (Neer, 1972) – Primary Impingement vs. Secondary Impingement Primary Impingement ? Definition – occurs as a result of subacromial crowding, posterior capsule tightness, or excessive superior migration of the humeral head due to weakness of the humeral head depressors (Harryman et al, 1990; Matsen and Arntz, 1990; Neer, 1972) Secondary Impingement • Definition – thought to occur due to a relative decrease in the subacromial space because of instability of the glenohumeral joint (Harner et al, 1990; Jobe and Kivitne, 1989) or functional scapulothracic instability (Kibler, 1989) 2

  3. Functional Factors that may lead to SubacromialImpingement (Adapted from Matsen and Arntz, 1990) I. Abnormal scapular motion due to limited motion at the scapulothoracic joint II. Functional scapulothoracic instability due to scapulothoracic muscle weakness or fatigue (Kibler, 1998, 2002) III. Loss of humeral head depression IV. Posterior capsular tightness (Harryman, 1990) V. Glenohumeral joint capsular laxity VI. Abnormal scapular position due to thoracic kyphosis A Biomechanical Approach to Examination, Intervention and Exercise Instruction • Sternoclavicular Joint • Acromioclavicular Joint • Scapulothoracic Joint • Glenohumeral joint • Cervico-Thoracic Spine and Rib Cage I. Abnormal Scapular Motion due to Limited Motion at the Scapulothoracic Joint • Movements of the scapula are associated with movements of the Sternoclavicular and Acromioclavicular Joints (Inman, 1944) • Scapula rotates 60 degrees during full shoulder elevation dependent upon the ability of the clavicle to elevate and rotate at the SC and AC joints • Evaluation of the Scapulothoracic Joint must therefore include evaluation of the SC and AC joints 3

  4. Scapular Movement Scapular movement occurs in three planes (Lukasiewicz et al.,1999 and Ludewig et al., 1996) Upward/downward rotation around an AP axis Anterior/posterior tipping around an axis along the spine of the scapula Internal/external rotation around a vertical axis II. Functional Scapulothoracic Instability due to Scapulothoracic Muscle Weakness/Inhibition • Postural observation • Stability tests • Functional muscle tests Kibler Scapular Dysfunctions (Kibler et al 2002) • Inferior Angle Dysfunction – anterior tilting – Most commonly found in patients with rotator cuff dysfunction • Medial Border Dysfunction – internal rotation – Most often occurs in patients with glenohumeral joint instability • Superior Dysfunction - scapular elevation – Most often occurs with rotator cuff dysfunction – Deltoid-rotator cuff force couple imbalances (Inman,1944) 4

  5. Stability Tests for the Scapulothoracic Joint • Kibler Lateral Scapular Slide Test • Kibler Scapular Assistance Test • Kibler Scapular Retraction Test • Posterior Tilt Test III. Loss of Humeral Head Depression due to: • C5-6 radiculopathy • Suprascapular nerve palsy • Partial/full thickness rotator cuff tears • Rupture of long head of the biceps Matzen and Arntz, 1990 Rotator Cuff Assessment for Partial or Full Thickness Tears • Empty and full can tests – integrity of the supraspinatus – Accuracy of the test is greater when muscular weakness rather than pain is the determining factor (Itoi et al, 1999) • Gerber Lift-Off Test – integrity of subscapularis – Accuracy of this test requires the patient to have normal internal rotation ROM (Gerber and Krushell, 1991) • Dropping Sign Test – integrity of infraspinatus – A positive test has been correlated with a complete tear of the infraspinatus (Walch et al, 1998) 5

  6. Rotator Cuff Impingement Tests • Used to determine the integrity of the rotator cuff and the long head of the biceps • Impingement of these muscles may result in pain and/or weakness resulting in a loss of their ability to depress the humeral head • An impairment of balance between the deltoid and supraspinatus ultimately leads to superior migration of the humeral head (Weiner and Macnab, 1970) Rotator Cuff Impingement Tests • Neer Impingement Test • Hawkins-Kennedy Impingement Test • Coracoid Impingement Test • Cross-Arm Adduction Test • Yocum Impingement Test Significance of Posterior Capsule Tightness • Tightness correlates to a loss of internal rotation and increased anterior humeral head translation (Tyler et al, 1999;Gerber et al,2003) • Tightness of the posterior capsule linked to increased superior migration of the humeral head (Matsen and Arntz, 1990) • Positive Tyler posterior shoulder tightness test found in patients with subacromial impingement (Tyler et al, 2000) 6

  7. V. GlenohumeralJoint Stability Tests Assessment for Capsular Laxity • Multidirectional Instability Sulcus Sign • Load and Shift Test • Anterior and Posterior Drawer Tests • Apprehension Test • Subluxation/Relocation Test • Dynamic Rotary Stability Test VI. Abnormal Scapular Position due to Thoracic Kyphosis • Fu et al, 1991 noted weakened scapular muscles in association with thoracic kyphosis as companions of rotator cuff tendonitis • Solem-Bertofft et al, 1993 using MRI found that protraction of the scapula decreases the subacromial space, hypothetically related to the degree of thoracic kyphosis • Greenfield et al, 1995 however found no difference in thoracic kyphosis (posture) in shoulder patients vs. normals Additional Tests for the Manual Therapist to Consider: • Side lying shoulder circles • Apley’s scratch tests (Hoppenfeld, 1976; Magee, 1997) • Passive mobility testing of the cervical spine • Passive mobility testing of the thoracic spine and ribs • Combined mobility testing of the shoulder and thoracic spine 7

  8. Comparative Combined Shoulder Rotation Assessment • Apley’s scratch tests (Hoppenfeld,1976) with adduction,IR and slight extension right arm and flexion abduction and ER of left arm (top) • Compare top with bottom picture • Illustration of restricted thoracic rotation to the left? Manual Therapy Treatment Manual Therapy combined with supervised exercise is better than exercise alone for increasing strength, decreasing pain and improving function in patients with shoulder impingement (Bang & Deyle, 2000) Manual Therapy Treatment for Joint Dysfunction • Address mobility restrictions in the cervical spine and thoracic spine • Address mobility restrictions in the rib cage especially restricted torsional (rotational) movement of the ribs • Mobilize the SC, AC and Scapulothoracic Joints as indicated 8

  9. Is this a Shoulder or a Thoracic Spine Problem? Does restricted thoracic rotation to the left result in a loss of IR of the right shoulder and/or a loss of ER of the left shoulder? (observed in this model) Manual Therapy Treatment for the Shoulder • Sternoclavicular Joint – Restrictions for anterior/posterior glide, abduction or IR/ER • Acromioclavicular Joint – Restrictions for anterior/posterior glide, abduction or IR/ER • Scapulothoracic Mobility – Restrictions for upward rotation, ER and especially for posterior tilt • GlenohumeralJoint Retraining Manual Therapy Treatment for Muscle Imbalances • Stretch/lengthen the muscles that interfere with normal 3-D scapulothoracic mobility – Levator scapulae – Pectoralis minor – Latissimus dorsi 9

  10. Manual Therapy Treatment for Muscle Imbalances • Facilitate and strengthen muscles that tend to be inhibited and weak – Serratus anterior – Lower trapezius – Supraspinatus – Infrspinatus – Teres Minor – Subscapularis Home Exercises • Self mobilization exercises • Stretching exercises • Neuromotor retraining • Strengthening exercises Bibliography for Manual Therapy and Exercise for Subacromial Impingement of the Shoulder • Bang MD, Deyle GD: Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;30(3):126-137. • Cleland J, Selleck B, Stowell T, et al: Short-term effects of thoracic manipulation on lower trapezius muscle strength. J Manual Manipulative Ther. 2004;12(2):82-90. • Culham E: The relationship of age and thoracic posture to the resting position and mobility of the shoulder complex. PhD Thesis. 1992; Queen’s University, Kingston, Ontario, Canada. • Culham E, Peat M: Functional anatomy of the shoulder complex. J Orthop Sports Phys Ther. 1993;18(1):342- 350. 10

  11. • David G, Jones MA, Magarey ME, Sharpe MH, Dvir Z: Rotator cuff muscle performance during glenohumeral joint rotations: an isokinetic, electromyographic and ultrasonographic study. Tenth Biennial Conference, Manipulative Physiotherapists Association of Australia, Melbourne. 1997. • David G, Magarey ME, Jones MA, Dvir Z, Turker KS, Sharpe M: EMG and strength correlates of selected shoulder muscles during rotations of the glenohumeral joint. Journal of Clinical Biomechanics. 2000;15:95-102. • Davies GJ, DeCarlo MS: Examination of the shoulder complex: current concepts in rehabilitation of the shoulder. Sports Physical Therapy Association Home Study Course. LaCrosse, WI, 1993. • Ekstrom RA, Donatelli RA, Soderberg GL: Surface electromyographic analysis of exercises for the trapezius and serratus anterior muscles. J Orthop Sports Phys Ther. 2003;33(5):247-258. • Ellenbecker TS: Clinical Examination of the Shoulder. St Louis, Elsevier Saunders; 2004. • Fu F, Freddie H, Harner CH, Klein AH: Shoulder impingement syndrome. A critical review. Clin Orthop. 1991;269: 162-173. • Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: clinical features in 16 cases. J Bone Joint Surg. 1991;73B:389-394. • Gerber C, Werner CML, MacyJC, et al: Effect of selective capsulorrhaphy on the passive range of motion of the glenohumeral joint. J Bone Joint Surg. 2003;85A:(1):48-55. • Greenfield B, Catlin PA, Coats PW et al: Posture in patients with shoulder overuse injuries and healthy individuals. J Orthop Sports Phys Ther. 1995; 21:287- 295. • Harner CD, FU FH, Klein AH: Shoulder Impingement Syndrome: New Concepts. Presented at the Fourth Annual Panther Sports Medicine Symposium (Current Concepts of the Shoulder in Throwing and Racquet Sports), Pittsburgh,PA, November 29-December 1, 1990. • Harryman DT, Sidles JA, Clark JM et al: Translation of the humeral head on the glenoid with passive glenohumeral motion. J Bone Joint Surg. 1990; 72 A: (9):1334-1343. • Hawkins RJ, Kennedy JC: Impingement syndrome in athletes. Am J Sport Med. 1980;8:151-158. • Hess SA: Functional stability of the glenohumeral joint. Manual Therapy. 2000;5(2):63-71. • Hoppenfeld S: Physical Examination of the Spine and Extremities. Norwalk, CT: Appleton-Century-Crofts; 1976. • Howell SM, Galinat BJ: The containment mechanism: The primary stabilizer of the glenohumeral joint. Annual Meeting of American Academy of Orthopedic Surgeons. San Francisco, 1987. • Inman VT, Saunders JB, Abbott LC: Observations on the function of the shoulder joint. J Bone joint Surg. 1944;26(1):1-30. 11

  12. • Itoi E, Kido T, Sano A et al: Which is more useful the “full can test” or the “empty can test” in detecting the torn supraspinatus tendon? Am J Sports Med. 1999;27(1):65- 68. • Jobe FW, Kivitne RS: Shoulder pain in the overhand or throwing athlete. Orthop Rev. 1989;18:963-975. • Jobe FW, Moynes DR: Delineation and diagnostic criteria and a rehabilitation program for rotator cuff injuries. Am J Sports Med. 1982;10:336-339. • Jobe FW, Bradley JP: The diagnosis and nonoperative treatment of shoulder injuries in athletes. Clin Sports Med. 1989;8:419-437. • Kebaetse M, McClure P, Pratt NA: Thoracic position effect on shoulder range of motion, strength, and three- dimensional scapular kinematics. Arch Phys Med Rehabil. 1999;80:945-950. • Kendall FD, McCreary EK: Muscle Testing and Function, ed 3, Baltimore, MD: Williams and Wilkins; 1983. • Kibler WB, Chandler TJ: Functional scapular instability in throwing athletes. Presented at the American Orthopaedic Society for Sports Medicine’s 15thAnnual Meeting, Traverse City, MI, June 19-22, 1989. • Kibler WB: The role of the scapula in athletic shoulder function. Am J Sports Med. 1998;26(2):325-337. • Kibler WB, Uhl TL, Maddux JWQ et al: Qualitative clinical evaluation of scapular dysfunction: a reliability study. J Shoulder Elbow Surg. 2002;11: 550-556. • Koslow PA, Prosser LA, Strony GA et al: Specificity of the lateral scapular slide test in asymptomatic competitive athletes. J Orthop Sports Phys Ther. 2003;33(6):331-336. • Liebler EJ, Tufano-Coors L, Douris P et al: The effect of thoracic spine mobilization on lower trapezius strength testing. J Manual Manipulative Ther. 2001;9(4):207-212. • Lippitt S, Matsen F: Mechanisms of glenohumeral joint stability. Clin Orthop Rel Res. 1993;291:20-28. • Ludewig PM, Cook TM, Nawoczenski DA: Three- dimensional scapular orientation and muscle activity at selected positions of humeral elevation. J Orthop Sports Phys Ther. 1996;24(2):57-65. • Lukasiewicz AC, McClure P, Michener L et al: Comparison of 3-dimensional scapular position and orientation between subjects with and without shoulder impingement. J Orthop Sports Phys Ther. 1999;29(10): 574-586. • Magee DJ: Orthopaedic Physical Assessment, ed 3, Philadelphia, PA: WB Saunders; 1997. • Matsen FA III, Artnz CT: Subacromial impingement. In Rockwood CA, Jr, Matsen FA III, eds: The Shoulder, Philadelphia, WB Saunders; 1990. • Meurer A, Grober J, Betz U et al: Thoracic spine mobility in patients with an impingement syndrome compared to healthy subjects – an inclinometric study. Z Orthop. 2004;142:415 420. 12

  13. • Neer CS: Anterior acromioplasty for the chronic impingement syndrome in the shoulder. J Bone Joint Surg. 1972;54A(1):41-50. • Neer CS: Cuff tears, biceps lesions, and impingement. In Neer CS, ed: Shoulder Reconstruction. Philadelphia, PA: WB Saunders; 1990. • Neer CS, Welsh RP: The shoulder in sports. Clin Orthop Rel Res. 1977;8:583. • Pagnani MJ, Warren RF: Stabilizers of the glenohumeral joint. J Shoulder Elbow Surg. 1994;3:73-90. • Solem-Bertoft E, Thuomas K, Westerberg C: The influence of scapula retraction and protraction on the width of the subacromial space. Clin Orthop. 1993;266:99-103. • Stefko JM, Jobe FW, Vanderwilde RS, et al: Electromyographic and nerve block analysis of the subscapularis liftoff test. J Shoulder Elbow Surg. 1997;6:347-355. • Tyler TF, Roy T, Nicholas SJ, et al: Reliability and validity of a new method of measuring posterior shoulder tightness. J Orthop Sports Phys Ther. 1999;29(5):262- 274. • Tyler TF, Nicholas SJ, Roy T, et al: Quantification of posterior capsular tightness and motion loss in patients with shoulder impingement. Am J Sports Med. 2000;28(5):668-673. • Valadie AL, Jobe CM, Pink MM, et al: Anatomy of provocative tests for impingement syndrome of the shoulder. J Shoulder Elbow Surg. 2000; 9(1):36-46. • Walch F, Boulahia A, Calderone S, et al: The “dropping” and Hornblower’s signs in evaluationof rotator cuff tears. J Bone joint Surg. 1998;80B:(4): 624-628. • Weiner DS, MacNab I: Superior migration of the humeral head. A radiological aid in the diagnosis of tears of the rotator cuff. J Bone Joint Surg. 1970;52B:(3):524-527. 13