Presented by:Dr. Brad M. Gilden, DPT, MS PT, CFMT, CSCS

March 20th, 2013

Recognition & Prevention of Shoulder Impingement

1. Human Body Built for bi-pedal movement.

2. Problems with prolonged sitting a. Reinforces poor postural habitsb. Shoulder injuriesc. Epidemiology – 2nd only to LBP

Impingement most commond. 2 Requests

• Functional Shoulder Anatomy• Function of Rotator Cuff• Shoulder Stability• Posture – Normal vs Poor• Shoulder Impingement – What is it and why should I care?• Pain and Inflammation• The Gym can help me injure my shoulder!• Exercise – Compare and Contrast “Good” vs “Bad”• Preventative & Postural Exercises• When to seek Medical Help?• Appendix• A. Sports Specific Exercises B. Muscle List C.& D Nutrition

Agenda

• Full shoulder flexion = 180°• Not accomplished by just GHJ• Full arm elevation involves…• Upper thoracic extension• 1st and 2nd ribs must depress and

move posterior• Scapula needs to rotate upwards• Clavicle needs to elevate and roll

backwards• Glenohumeral joints needs to glide

downward and roll upward• Old Injuries can play a roll – ex. Scar

Tissue from Abdominal surgery

Anatomy/Biomechanics

1. Acromial-Clavicular Joint

2. Sterno-Clavicular Joint

3. Scapulothoracic Joint

4. Gleno-humeral Joint

Shoulder Girdle

Static Stabilization• Increased Mobility = Decreased Stability• Large Humeral Head vs. Small Glenoid Fossa• Labrum - fibrocartilagenous circle attaching glenohumeral

ligaments.

Rotor Cup

• Supraspinatus – Abduction• Infraspinatus – External Rotation• Subscapularis – Internal Rotation• Teres Minor – External Rotation

Rotator Cuff

What’s it called?

Dynamic Stability

• Deltoid “Prime Mover”• Anterior Stability of

GHJ – Subscapularis, supraspinatus

• Posterior Stability of GHJ – Infraspinatus and teres minor

Shoulder Stability Continued• Synergistic action of

Rotator Cuff

Sub

SSTIST

Teres

• Long Head of the Biceps brachii-

• Serratus Anterior – Laterally rotates and protracts scapula

Secondary Stabilizers

• What is good posture?

1. Vertebrae Stack properly2. Joints aligned3. Muscles @ normal

Resting Length4. Reduced tension5. Vertical Compression

Test6. Importance of Good

Posture7. Promotes movement

efficiency8. Good Neuro-muscular

control9. Reduce need for

compensatory movements

• Three natural curves• Muscles – Flexible yet

strong

POSTURE

• We are a product of our

environment• Flexion, flexion and

more flexion• Affect on Vital Organs• Shoulder Flexion Test• Impact Test

Posture

• What causes shoulder impingement?Theory # 1: Mechanical-anatomic

1. Overuse2. Fibrosis forms3. Bony changes, spurs on humeral

tuberosity4. LEADS to RTC tearsTheory #2: Vascular compromise

a. Increased stress to RTCb. Inflammatory responsec. Scar tissue or calcific depositiond. Poor repair secondary to poor vascularitye. Leads to tear of tendon f. Combined effect of poor blood flow and

continued stress does not allow for adequate maturation of healing tissue

Shoulder Impingement

• Theory #3: Kinesiological – poor neuromuscular control and limited scapular movement

• Reflex inhibition and or disuse

• Proper rotator cuff strengthening is essential to prevent disuse/RI

• MEDICAL INTERVENTION

• Implications of steroid injections – Anti-anabolic effect on connective tissue (Not Mark Maquire’s Steroids…)

• Local steroids will relieve pain through inhibiting inflammatory response – may result in weakening of the injected tendon

• Proceed gradually with strengthening

Impingement Continued

INFLAMMATIONPain is an output, not an input.Inflammation is a necessary process for healingChronic inflammation is a problem a. Irritation to nerves and surrounding tissues b. Inhibition of core muscle contractions Instability and compensatory patterns c. Breakdown of healthy tissue

How to deal with Inflammationa. Best anti-inflammatory - good postural alignmentb. Proper Nutrition - Acidic vs. Alkaline (Appendix C

& D)c. Avoidance of irritating movements (no pain no

gain is nonsensical) d. Hydratione. Ice (other modalities)f. NSAIDS (Topical or Oral)g. Steriodal anti-inflammatories (Rx required)h. Minimally Invasive Surgical intervention –

PRP/Regenokine

• Rarely Good the Bad and the Ugly

Gym Woes

• Stretch, don’t overstretch! • Add an Isometric contraction to your stretch.• If radicular signs are present, Do Not Stretch – Good time for PT

consultation• Neck Stretches• General Rule: Stay away from cervical extension

1. Chin Tuck – Axial Extension

Purpose: To achieve neutral position of cervical spine and to strengthen cervical extensor muscles • Remember Axial elongation is necessary for full shoulder

ROM• Shoulders should be relaxed. Chin should tuck down &

back. You can use a finger on the chin as a guide• A verbal cue is to lengthen your neck, crown of head

toward the ceiling

Preventative Exercises

• ELBOW FLEXION TEST• Pivot Prone – Postural ExercisePurpose – Aligns shoulder girdle properly over ribcage, taking tension off of neck.1. Head/Neck neutral, shrug shoulders 1/3 way up, turn palms back while

pinching shoulder blades, then reach fingers toward the floor.2. Hold this position for 10 seconds

• Doorway StretchPurpose – Elongate pec minor muscle1. Place R or L forearm against doorframe, and place opposite hand over

corocoid process (just inside to front shoulder). Abdominals should be tight with head in neutral position (axial elongation)

2. Stagger feet, and slowly lean into wall until stretch is felt. Hand on front of coracoid blocks shoulder from coming forward

3. Press forearm into wall and hold for 3 seconds, slowly release and take up the slack into the new range of motion.

4. Repeat 3-5 times

Postural Exercises

Postural Exercises1. Axial Elongationa. Place fingers along center of neck over spinous processesb. Make fist and place thumb under chin.c. Lightly press tongue to roof of mouth and press spinal

segments back into fingers and tuck chin. Think of elongating the neck.

d. Once in position, apply force with fingers on spine forward and thumb up toward ceiling.

e. Head/Neck should not move.f. Hold 20 seconds and repeat as prescribed by therapist/trainerg. ALTERNATIVE – Repeat as above but use theraband instead

1. Pivot Prone Against Wall2. Stand against wall with knees slightly bend and pillow

behind neck/head. Palms facing the wall.3. Place buttocks against wall and draw stomach in pressing

lumbar spine into wall and progressing upwards until entire spine is touching the wall and neck in axial elongation.

4. Maintain this position of spine, lift shoulders up, turn palms forward (thumbs back) and pinch shoulder blades together, then reach fingers toward floor dropping shoulders into place.

5. Hold this position for 30s/60s/90s or as prescribed by your therapist/trainer

Exercises for Shoulder Pain

1. Glenohumoral Joint Setting – “The Vacuum”

a. Band above door, place high into arm pitb. Using just the RTC muscles (no pecs or lats), suction the shoulder in toward the body against the band and hold for 5 secondsc. Slowly release, then repeat suction motion and hold while providing an isometrically resisted force on the outside of the wrist and hold 5 secd. Repeat as prescribed by your therapist/trainer

1. Pivot Pronea. With palms back, head/neck neutral, elevate shoulders slightlyb. Rotate palms forward/thumbs back and pinch shoulder blades

together.c. Reach hands toward the floor, being sure not to elevate the

sternum.d. Hold 10 seconds, then relaxe. Repeat throughout the day at least once every ½ hour

Exercises for Shoulder Pain

1. Shoulder Clocks – Keep in pain free rangea. Pretend the shoulder is a clock, begin in the center of the clock and move the shoulder up to 12:00 (toward ceiling), then back to center.b. Progress toward 1:00 (toward nose), then return to center and continue around the clock hitting each number.c. Once back to start, repeat in opposite direction

2. Pendulums – Distraction and relaxation for shouldera. Lean over table or counter and let arm completely dangle toward floorb. With legs wide, begin to weight shift into your legs right and left, creating

momentum that lets your arm swing.c. Repeat with legs shifting front to back to have arm swing fwd/back.d. Can also repeat in circles.e. Repeat for 1-3 minutes

** KEY: Must remain relaxed in the shoulder and leg your body do the work

A. Neck Clocks Active figure 8’s1. (If acute) Begin with eye motions into small figure eight

patterns 2. Start with very slow small figure eights or making infinity

sign with nose, and slowly increase range of motion to lubricate neck

3. Repeat for 30 seconds

OUR GIFT TO YOU

C. Arm Circles on side – Improves mobility of entire upper extremity1. Lie on right side with top leg bent and left hand resting on

knee of right leg.2. Reach right hand toward floor keeping head/eyes on

hand throughout exercise3. Bring arm around body in wide circle with head

following4. As arm comes over head inhale, exhale as arm comes

down.5. Repeat 10x’s clockwise & 10x’s counter clockwise

D. Sleeper Stretch – To improve posterior capsule and IR6. Lie on right or left side with arm out at 90°7. Roll onto shoulder until a tightness is felt behind shoulder8. Bend elbow to 90° and place left hand over wrist9. Bring arm slowly toward floor until stretch is felt.10.Perform isometric by pushing right hand into wrist, not

allowing movement to occur – Hold 5 seconds11. Relax, and push further into more internal rotation12.Repeat 5 times13.Do not push through pain

Shoulder Stretching

• Dumbell or Front Squats• Straight arm pull-downs• Standing Rows • RTC strengthening• External Rotation• Internal Rotation

Strengthening

• I’s, Y’s, T’s & Advanced W’s

• Bent Over Rows • Single Arm Rows• Prone T-band ER

Strengthening

What’s more fun than a plank?

• Pain with shoulder movements without resistance

• Pain waking you up at night• Experience numbness or tingling

down arm or scapula• Shoulder Pain with neck movements• Suffered fall or accident and has

persistent shoulder pain > 3 days• Lingering shoulder pain (3 weeks or

more) that seems to be staying the same or getting worse.

How should I know if I need PT?

Sport Specific ExercisesNeed to strengthen muscles responsible for deceleration – eccentric muscle control!!!

ROTATOR CUFF

ACCELERATION DECELERATION CORE ROTATORY BACK MUSCLES

POSTURAL

InternalRotation

Plyometrics RTC work with emphasis on

eccentric

Planks Punch outs Lat Pull downs

Pivot Prone

External Rotation

Chop’s Single Arm Rows with eccentric

focus

PlankAlternative

Russian Twists

Rows Pivot Prone on Wall

I’s, Y’s, T’s & W’s

Lift’s Straight arm pull downs

Side Plank

Isolating trunk/pelvis

rotations

Single ArmRows

Axial Elongation

Setting GHJWith

Isometric holds

BurpiesSquat Thrusts

Shoulder rotation with stable lower

body

Abdominal Series

Eagles Bird Dogs Hip Hinging of bench

Plank on stomach with T-Band

Push Up’s Wrist Curls with focus on eccentric

Dead Bugs

Scorpions Hip extension

Quarterback Squats

Appendix A

• External Rotation – Infraspinatus and Teres minor

• Internal Rotation – Subscapularis & Pectorals• Prone lateral raise with thumb up – Rhomboid• Prone lateral raise thumb down – Mid

trapezius• Prone scaption thumb up – Lower trapezius • Prone scaption thumb down - Supraspinatus• Scaption - Supraspinatus

What am I Training?Appendix B

Appendix C

Appendix D