2012 rehab

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1 Shoulder Rehab Shoulder Rehab Martin A. Scott MSc MCSP Martin A. Scott MSc MCSP Nottingham Shoulder & Elbow Unit Nottingham Shoulder & Elbow Unit [email protected] [email protected] Meister, 2000a

Transcript of 2012 rehab

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Shoulder RehabShoulder Rehab

Martin A. Scott MSc MCSPMartin A. Scott MSc MCSP

Nottingham Shoulder & Elbow UnitNottingham Shoulder & Elbow Unit

[email protected]@nuh.nhs.uk

Meister, 2000a

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© Bodies

The The ““hypermobilehypermobile”” shouldershoulder

�� Stability is lost to increase the Stability is lost to increase the range of motion (range of motion (TennentTennent, , Beach & Meyers (2003))Beach & Meyers (2003))

�� Dynamic control is a major Dynamic control is a major issueissue

Factors affecting glenohumeral Factors affecting glenohumeral

joint stabilityjoint stability�� LabrumLabrum

�� Joint capsuleJoint capsule

�� LigamentsLigaments

�� Internal pressure Internal pressure gradientgradient

�� Bony camBony cam

�� Dynamic muscle Dynamic muscle contractioncontraction

XX

XX

XX

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√√√√√√√√

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DislocationDislocation

TraumaticTraumatic

�� End of rangeEnd of range

�� Ligament/labral damageLigament/labral damage

AtraumaticAtraumatic

�� Mid rangeMid range

�� Not constrained by Not constrained by ligamentsligaments

Lippitt S & Matsen F (1993) CORR 291

Lee SB et al (2000) JBJS 82A(6)

DislocationDislocation

TraumaticTraumatic

�� End of rangeEnd of range

�� Ligament/labral damageLigament/labral damage

AtraumaticAtraumatic

�� Mid rangeMid range

�� Not constrained by Not constrained by ligamentsligaments

�� Controlled by Controlled by

musclesmuscles

Lippitt S & Matsen F (1993) CORR 291

Lee SB et al (2000) JBJS 82A(6)

InstabilityInstability

�� High risk sportsHigh risk sports

�� Contact +/Contact +/-- throwing (throwing (BoileauBoileau et al., 2006et al., 2006 ))

�� Return to sport (mean 36 months postReturn to sport (mean 36 months post--op)op)

�� 14/91 failures (further instability)14/91 failures (further instability)

�� 58/91 at same level58/91 at same level

�� 13/91 at a lower level13/91 at a lower level

�� 6/91 stopped participation (6/91 stopped participation (BoileauBoileau et al., 2006)et al., 2006)

InstabilityInstability

�� TUBSTUBS

�� Can be hyper lax (Can be hyper lax (egeg26/91, 26/91, BoileauBoileau et al., et al., 2006)2006)

�� Conservative treatment Conservative treatment gives 17gives 17--96% recurrence 96% recurrence in patients <30 (in patients <30 (BottoniBottoni

et al., 2002)et al., 2002)

�� At 4 year mean follow up, At 4 year mean follow up, subscapularis function subscapularis function correlates with outcome correlates with outcome from surgery (Sachs et al., from surgery (Sachs et al.,

20052005))

InstabilityInstability

Sachs et al., 2005Sachs et al., 2005

ImpingementImpingement

Harryman et al., 1990

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ImpingementImpingement

�� PrimaryPrimary

�� SecondarySecondary

�� Internal (Internal (BudoffBudoff et al., et al., 2003;2003; Belling Sorensen Belling Sorensen and Jorgensen, 2000; van and Jorgensen, 2000; van derder HoevenHoeven and and KiblerKibler, , 2006)2006)

�� Observed in arthroscopy Observed in arthroscopy ((YonedaYoneda et al., 2006et al., 2006 ))

ImpingementImpingement

Harryman et al., 1990

ImpingementImpingement

�� PrimaryPrimary

�� SecondarySecondary

�� Internal (Internal (BudoffBudoff et al., et al., 2003;2003; Belling Sorensen Belling Sorensen and Jorgensen, 2000; van and Jorgensen, 2000; van derder HoevenHoeven and and KiblerKibler, , 2006)2006)

ImpingementImpingement

�� PrimaryPrimary

�� SecondarySecondary

�� Internal (Internal (BudoffBudoff et al., et al., 2003;2003; Belling Sorensen Belling Sorensen and Jorgensen, 2000; van and Jorgensen, 2000; van derder HoevenHoeven and and KiblerKibler, , 2006)2006)

�� Observed in arthroscopy Observed in arthroscopy ((YonedaYoneda et al., 2006et al., 2006 ))

ImpingementImpingement ImpingementImpingement

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ImpingementImpingement

�� PrimaryPrimary

�� SecondarySecondary

�� Internal (Internal (BudoffBudoff et al., et al., 2003;2003; Belling Sorensen Belling Sorensen and Jorgensen, 2000; van and Jorgensen, 2000; van derder HoevenHoeven and and KiblerKibler, , 2006)2006)

ImpingementImpingement

Neer, 1972; Yanai and Hay, 2000; Wilk et al., 2002

ImpingementImpingement

Labriola et al., 2005

ImpingementImpingement

Elliott, 2006

InstabilityInstability AssessmentAssessment

�� Muscle patterningMuscle patterning

�� Under/over recruitmentUnder/over recruitment

�� Low/high toneLow/high tone

�� Movement patternsMovement patterns

�� ObservationObservation

�� Relative Relative alignmentalignment of of bony landmarksbony landmarks

�� Relative Relative timingtiming of of

movements of body movements of body segmentssegments

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Range of motionRange of motion

�� Tightness/stiffnessTightness/stiffness

•• Latissimus DorsiLatissimus Dorsi

•• Pectoralis MinorPectoralis Minor

•• Posterior structuresPosterior structures

�� Allow free movement of Allow free movement of the scapula around the the scapula around the

thorax, and external thorax, and external rotation of the humerus rotation of the humerus throughout rangethroughout range

Silliman JF & Hawkins RJ (1993) CORR 291

Borstad JD & Ludewig PM (2005) JOSPT 35(4)

Gain appropriate ROMGain appropriate ROM

�� Tight posterior inferior Tight posterior inferior glenohumeral joint capsule glenohumeral joint capsule can pull the scapula away can pull the scapula away from the chest wall (Burkhart from the chest wall (Burkhart et alet al 2003)2003)

�� Stiff latissimus dorsi impedes Stiff latissimus dorsi impedes full scapulothoracic motionfull scapulothoracic motion

�� Stiff pectoralis minor is Stiff pectoralis minor is associated with Type I associated with Type I dyskinesia (dyskinesia (BorstadBorstad & & LudewigLudewig 2005)2005)

StrengthenStrengthen

�� Rotator cuffRotator cuff�� Allows control of the Allows control of the humeral head in the humeral head in the glenoidglenoid

�� Scapulothoracic Scapulothoracic musclesmuscles�� Allows the glenoid to Allows the glenoid to be positioned relative to be positioned relative to the humeral headthe humeral head

Hawkins RJ & Saddemi SR (1990) Cur Orth 4

Kibler, W. B. (1998). Medicine & Science in Sports &

Exercise 30(4 Suppl): S40-50.

Strengthen scapulothoracic Strengthen scapulothoracic

musculaturemusculature

�� Serratus anteriorSerratus anterior

�� Lower fibres of trapeziusLower fibres of trapezius

�� External rotatorsExternal rotators

Strengthen scapulothoracic Strengthen scapulothoracic

musculaturemusculature

�� Serratus anteriorSerratus anterior

�� Lower fibres of trapeziusLower fibres of trapezius

�� Closed chain exercises Closed chain exercises ((KiblerKibler 1998)1998)

Strengthen scapulothoracic Strengthen scapulothoracic

musculaturemusculature

�� Serratus anteriorSerratus anterior

�� Lower fibres of trapezius Lower fibres of trapezius ((EkstromEkstrom et alet al 2003, Decker 2003, Decker et alet al 2003, Michener 2003, Michener et alet al

2005)2005)

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Gain scapular dynamic controlGain scapular dynamic controlMaintain scapular dynamic Maintain scapular dynamic

controlcontrol

�� Scapulothoracic Scapulothoracic movement movement

�� Glenohumeral rhythmGlenohumeral rhythm

�� MultiplanarMultiplanar exercisesexercises

�� Visual feedbackVisual feedback

Maintain scapular dynamic Maintain scapular dynamic

controlcontrol

�� Scapulothoracic Scapulothoracic movement movement

�� Glenohumeral rhythmGlenohumeral rhythm

�� MultiplanarMultiplanar exercisesexercises

Maintain scapular dynamic Maintain scapular dynamic

controlcontrol

�� Scapulothoracic Scapulothoracic movement movement

�� Glenohumeral rhythmGlenohumeral rhythm

�� MultiplanarMultiplanar exercisesexercises

�� Visual feedbackVisual feedback

Maintain scapular dynamic Maintain scapular dynamic

controlcontrol

�� Scapulothoracic Scapulothoracic movement movement

�� Glenohumeral rhythmGlenohumeral rhythm

�� MultiplanarMultiplanar exercisesexercises

�� Visual feedbackVisual feedback

�� Function!Function!

From the feet up!From the feet up!

Limpisvasti et al., 2007

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Harmonious Harmonious rotation(srotation(s))

Limpisvasti et al., 2007

Good alignmentGood alignment

Good alignmentGood alignmentExactly what are effective throwing Exactly what are effective throwing

mechanics?mechanics?

by Paul Nyman by Paul Nyman

May 02, 2008 May 02, 2008

Maintain scapular dynamic Maintain scapular dynamic

control control –– and take it into sport!and take it into sport!Maintain dynamic control Maintain dynamic control –– and and

take it into sport!take it into sport!

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Maintain dynamic control Maintain dynamic control –– and and

take it into sport!take it into sport!Maintain dynamic control Maintain dynamic control –– and and

take it into sport!take it into sport!

Thank youThank you

Martin A. Scott MSc MCSPMartin A. Scott MSc MCSP

Nottingham Shoulder & Elbow UnitNottingham Shoulder & Elbow Unit

[email protected]@nuh.nhs.uk

Stretch before StrengthenStretch before Strengthen

●● Establish tissue mobility to allow normal Establish tissue mobility to allow normal kinematicskinematics

●● Allows greater muscle volume to contract and Allows greater muscle volume to contract and releaserelease

●● Reduces risk of secondary compensationReduces risk of secondary compensation

RugbyRugby

●●ScrumScrum

●●RookRook

●●LineoutLineout

●●Tackle(pileTackle(pile on,collision,shirton,collision,shirt pull,anklepull,ankle tap)tap)

●●PassPass

●●HandoffHandoff

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FootballFootball

●● Collision(withCollision(with other player or ground)other player or ground)

●● Throw inThrow in

●● Goalkeeping divesGoalkeeping dives

Basketball/handball/volleyballBasketball/handball/volleyball

●● BlockshotBlockshot//

●● HookpassHookpass/shot/shot

●● Ball dribblingBall dribbling

CricketCricket

●● Outfield throwsOutfield throws

●● BowlingBowling

●● WicketkeepingWicketkeeping/slip dives/slip dives

●● Crease slidesCrease slides

BoxingBoxing

●● ImpactImpact

●● Missed punchMissed punch

●● FatigueFatigue

●● Poor defensive posturePoor defensive posture