Differentiating Anterior Shoulder Pain In The Overhead Athlete
Angela T. Gordon PT, DSc, MPT, COMT, OCS, ATC
Stacy Soapmann PT, DSc, FAAOMPT
Objectives Identify the possible causes of
anterior shoulder pain: Scapular dyskinesis Posture Spinal facilitation Muscular trigger points Lower kinetic chain
dysfunction
Case studies from major league players
Define regional interdependence as it relates to the overhead athlete Cervical Thoracic Scapula SC joint AC joint
Evaluation of the kinetic chain in overhead athletes
Scapula Dynamic Scapula
Dynamic Scapula: Kinematics 3 rotations, 2
translations Translations superior and
inferior protraction and
retraction
Rotations upward and
downward rotation internal and
external rotation anterior and
posterior tipping
Dynamic Scapula
•Muscular and Neural Control Systems
•Muscular Activation System
•Boney and Ligamentous Restraints
Stability dependent on 3 major factors
Scapular Dyskinesis
Kibler defines scapular dyskinesis as:
A loss in scapular retraction and ER with altered timing and magnitude of upward scapular rotation. This leads to an anterior tilt of the glenoid and subsequent reduction in RTC force.
SICK Scapular
Scapular Malposition
Inferior medial border prominence
Coracoid pain and malposition
Dyskinesis of scapular movement
Scapular Dyskinesis Clinical Features
Overuse muscular fatigue syndrome
Pectoralis tightness, LT/SA force couple weakness
Inferior and or medial border prominence
Anterior tilting of the scapula
Decrease in shoulder internal rotation
Kibler Classification of Scapular Dysfunction
Inferior angle dysfunction
Medial border dysfunction
Superior scapular dysfunction
How do we classify this scapular dysfunction
What Causes Scapular Dyskinesis
Spine All muscles
innervated by cervical nerve roots
Thoracic mobility
Underlying GH pathology
Muscle imbalance Posture Overuse of sport
demands
Previous injury Instability Loss of proprioception
Trivia: How many muscles attach to the Scapula
Glenoid Labrum
Functions: Deepen the GH socket to
aide in shoulder stability? Or Sensitive proprioception
organ for the shoulder girdle providing feedback for movement in all 3 degrees of freedom
Described in a clock like fashion Bankart Lesion – 3/6 position SLAP: superior Posterior Reverse Bankart 6/9
Glenoid Labrum
Signs and symptoms of a glenoid labrum: Pain accompanying
overhead arm motion Instability with or without
clickingDecreased range of motion Loss of strength Pain Anteriorly or posterior Internal Impingement signs
Posture
Janda’s Upper Crossed Syndrome
Case Study One Olympic potential Swimmer Diagnosis Biceps tendonitis Evaluation Findings: Forward head posture Weak scapular force couples: SA LT Scapular dyskinesis Protracted Ant Tilted scapula Weak Core Hypermobile in all planes
Treatment Scapular stabilization Proprioceptive training Neuro reeducation in the unstable overhead position
What about the Biceps?
Muscular Trigger points
What is a Trigger point?
Symptoms: local tenderness referred pain local twitch response
Shoulder: Infraspinatus: muscular
overload, eccentric forces during follow through
TrP Shoulder Region
Other muscles that refer to the anterior shoulder
Deltoid
Pectoralis major/minor
Scalenes
Case Study Two
MLB pitcher complains of pain duration 5 months Improves with rest Aggravated by pitching Points to local spot in anterior shoulder All labral tests negative No signs of impingement Strength: scapular retraction test positive, infraspinatus 4+/5,
Serratus 4+/5, Lower trap 4+/5 TrP: infraspinatus, deltoid, Teres Major/Minor
Treatment: TDN to infraspinatus and Deltoid 90% resolution of pain in 1 session Return to painfree Pitching 1 week later.
Squirrel
Regional Interdependence
Cervical facilitation
C2/3 Hypomobility
Biceps Tendonitis
Thoracic/Rib dysfunctions
Cervical Facilitation Elevation/Protraction Latissimus Dorsi (C5/)6
Elevation/Retraction Serratus Anterior (C5/6, C6/7)
Depression/Protraction Levator Scapulae (C2/3,
C3/4, C4/5) Rhomboid
Depression/Retraction Pectoralis Minor (C6/7,
C7/T1) Serratus Upper Fibers
C2-3 Hypomobility
Clinically a very common injury we see is a post-traumatic arthritis of the C2-3 region. Following a MVA if the R C2-3 gets “stuck” or becomes
hypomobile and the L side becomes hypermobile this can causing increased tone in the L levator scaplae What does this do to the scapula positioning?
Biceps Tendonitis
Innervated by C6
When you look at the anatomy the C6 nerve root exits between the C5-6 segment
The C5-6 segment has the smallest foramen hole and the C5-6 nerve root is the largest
If stenosis or osteophytes occur then it can affect the innervation of the bicep
Thoracic/Rib dysfunctions
No agreed upon consensus about the combined movements of the thoracic spine
Some authors state that if you elevate your R arm you will get extension and ipsilateral rotation/SB of the R side of the thoracic spine
What would hypomobility of the thoracic spine do to the mechanics/timing of the shoulder girdle movement?
Case Study Three
MLB Pitcher Biceps Pain ongoing Evaluation: Scapular Dyskinesis UT/LS hypertonicity Csp/Tsp scan: Right C2/3 hypomobility T1-3 rotation limited C5/6 hypermobile
Tender Biceps tendon –resisted MMT improves with repetition
Treatment: 3 sessions Csp manipulation Tsp manipulation TFM to Biceps Scapular/Cervical
stabilization program
The Thrower's Paradox:
The thrower's shoulder must be lax enough to allow maximal external rotation but stable enough to prevent symptomatic humeral head subluxations, thus requiring a delicate balance between mobility and stability functionally.
The Kinetic Chain of Throwers
It is important to understand that while these athletes are throwing with their arms, they gain a large amount of momentum and force through the use of their legs and torso.
Kinetic Chain Dysfunction
Lower Extremity Hip IR/ER ROM Weakness
Core: TA must be first muscle
activated prior to UE movement
Scapula: Funnels the energy from LE to
UE
Evaluation of Kinetic Chain
No Gold standard
Difficult to evaluate
Time constraints
Evidence limited
Evaluation of Kinetic Chain
What we do know:All the links in the chain are important
Timing is everything
Scapula is the key component
Core – is the proximal STABILITY to allow for all extremity MOBILITY
Evaluation of Kinetic Chain
Upper Extremity: Scapular: Kibler scapular retraction
test Kibler lateral scapular
slide test Flip sign Strength: prone LT
seated SA Length tests
Shoulder ROM: IR/ER supine at 90
degrees abduction – 2 person measurement
Posture
Lower Extremity: SFMA – general screen
used to identify areas of dysfunction
Hip ROM prone with knee
at 90 degrees IR/ER – 2 person measurement
Strength: Hip Abd, ER, Extension
Core Strength: DKLT or
abdominal brace test
What can lead to Anterior Shoulder Pain in the Overhead Athlete?
Scapular dyskinesis
Glenoid Labrum
Postural adaptations
Muscular Trigger points
Regional interdependence from spinal segments Biceps Tendonitis
Kinetic Chain Breakdown
Differential Diagnosis of the Overhead Athlete
Labrum vs TrP
Weakness
Use of TDN to reproduce pain Treatment at same time
Stability Tests O’Brien Sulcus Relocation Clunk
Regional Interdependence vsBiceps tendonitis
Any history of cervical dysfunction
Referred pain vs local pain
Histological changes from changes in axonal transport
Use of dry needling for differential diagnosis? What leads to TrP in the
shoulder girdle?
Proper use of special tests clusters for better specificity?
Evaluating the kinetic chain? Identify breakdown
point Throwing all arm? Previous history of
injury anywhere in kinetic chain
Differential Diagnosis of the Overhead Athlete
Principles of Integrated Functional Kinetic Chain Rehab
Establish proper postural alignment
Achieve motion in all involved segments Total arc of motion
Facilitate scapular motion
Achieve proper scapular stabilization Endurance strength vs power strength
Utilize closed kinetic chain exercises Integrate core into upper extremity dynamic exercises
Work in multiple planes
References
Seroyer SH, Nho SJ et al. The Kinetic Chain in Overhead Pitching: Its Potential Role for Performance Enhancement and Injury Prevention. Ath Train. 2010;2(2): 135-146.
Sciascia A, Cromwell R. Kinetic Chain Rehabilitation: A Theoretical Framework. Rehab Research and Practice. 2012;1-9.
Burkhart SS et al. The Disabled Throwing Shoulder: Spectrum of Pathology Part III: The Sick Scapula, Scapular Dyskinesis, The Kinetic Chain, And Rehabilitation. J of Arthroscopy and related Surgery. 2003; 19(6): 641-661.
Reinhold MM et al. Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature. J Ortho Sports Phys Ther. 2009; 39(2):105-117.
Davis, JT, Fluhme, D et al. The Effect of Pitching Biomechanics on the Upper Extremity in Youth and Adolescent Baseball Pitchers. Am J Sports Med. 2009:37;1484-1491.
Kibler BW, Ludewig PM, et al. Clinical Implications of Scapular Dyskinesis in Shoulder Injury: the 2013 consensus statement from the scapular summit.Br J Sports Med. 2013;47:877-885.
Hayes K, Callanan M et al. Shoulder Instability: Management and Rehabilitation. J Ortho & Sports Phy Ther. 2002;32(10):497-509.
References
De Mey K, Danneels L, Cagnie B, Cools, AM. Scapular Muscle Rehabilitation Exercises in Overhead Athletes With Impingement Symptoms: Effect of a 6 week Training Program on Muscle Recruitment and Functional Outcome. Am J Sports Med. 2012;40:1906-1915.
Fleisig G. Biomechanics of Baseball Pitching: Implications for Injury and Performance. Inter Sumposium of Bio in Sports. 2010:46-50.
Myers JB, Laudner KG, Pasquale MR et al. Scapular Position and Orientation in Throwing Athletes. Am J Sports Med. 2005;33(2):263-271.
Cools AM, Dewitte V, Lanszweert F et al. Rehabilitation of Scapular Muscle Balance: Which Exercises to Prescribe? Am Ortho Society for Sports Med. 2007;35(10): 1744-1751.
Reinhold MM et al. Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature. J Ortho Sports Phys Ther. 2009; 39(2):105-117.
Voight ML et al. The Role of The Scapula in the Rehabilitation of Shoulder Injuries. J of Athletic Training. 2000;35(3):364-372
Hodges PW, Richardson CA. Contraction of the abdominal muscles associated with movement of the lower limb. Phys Ther. 1997;77(2):132-141.
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