Shoulder pathology

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Evidence-Based Exercise Prescription for Clients with Shoulder Disorders

Morey J. Kolber, PT, PhD, OCS, CSCS

Vitae Nova Southeastern University

Associate Professor Orthopaedics

Boca Raton Orthopaedic Group Director of Physical Therapy

Research Agenda/Clinical Interest Shoulder Complex

Weight-training/weight-lifting population

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Outline Introduction Epidemiology of shoulder disorders Shoulder complex: joints

Common disorders & relevant anatomyOverarching rehabilitation principles Impairments Condition specific precautions/contraindications

DischargePost-RehabilitationCommunication Exercise-based interventions Return to sport/gym

Epidemiology: Shoulder Disorders General population lifetime prevalence up to 67%

Belle, Baillieres Clin Rheumatol, 1989 Luime et al, Scand J Rheumatol, 2004

General population 1-year prevalence up to 47% Weight-training participants up to 59% Kolber et al, J Strength Cond Res, ePub 2012 Luime et al, Scand J Rheumatol, 2004

After 1 year: 40-50% of new episodes persistvan der Heijden, Baillieres Clin Rheumatol, 1999; Sobel et al, Huisarts Wet, 1995

3rd most common region: musculoskeletal disordersDi Fabio & Boissonault, J Orthop Sports Phys Ther, 1998

Shoulder ComplexComprised of: Three (3) jointsGlenohumeral jointAcromioclavicular joint Sternoclavicular joint

One (1) articulation Scapulothoracic articulation

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Common Disorders

*Impingement syndrome

*Rotator cuff pathology

Anterior instability Acromioclavicular disorders

Kolber et al, J Strength Cond Res, 2010; van der Wall, Clin Nucl Med, 1998; Yu, Semin MusculoskeletRadiol, 2005 ; Kolber et al, J Strength Cond Res, e-pub; Gross et al, Am J Sports Med,1993

Rotator Cuff Pathology Primary etiology: Subacromial Impingement

Park et al, J Bone Joint Surg Am, 2005; Hirano et al, J Shoulder Elbow Surg, 2002

Subacromial Impingement Primary etiology Microtrauma:

Repetitive overhead elevation with..

Perpetuating variables:Structural: type 3 acromion processRotator cuff weaknessMuscle performance imbalancesScapular dyskinesiaPosterior shoulder tightness & capsular tightnessRepetitive overhead activity with improper biomechanics

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Anterior Instability

Gross et al Am J Sports Med, 1993; Kolber et al, J Strength Cond Res, e-pub 2012

Anterior Instability Primary etiology Microtrauma:

Repetitive 90/90 position & beyondMacrotrauma:

Dislocation/subluxation

Perpetuating variables: Insufficiency of anterior ligaments & capsule

Arthrokinematic hypermobility Posterior shoulder tightness Rotator cuff weakness

Overarching Rehabilitation Principles Identify & treat key impairments

Return to function Address perpetuating/associated factors

Identify diagnosis specific precautions/contraindicationsProgress safely through healing stages

Acute Sub-acute

Return patient to pre-morbid sport/exercise as applicableEncourage patient to continue & advance exercise routineGuide patient in their pursuit of fitness

Remodeling

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Post- Rehabilitation Considerations

Patient vs. Client

Communication

Key impairments

Precautions

Key Impairments Key impairment-based findings: Postural kyphosis (RTC) Posterior shoulder tightness (RTC & AI) Pectoral minor tightness (RTC) Hyperlaxity anterior capsule/ligaments (AI) Scapular muscle imbalance (RTC & AI)

Upper trapezius vs. lower trapeziusUpper trapezius vs. serratus anterior

Rotator cuff weakness & imbalance (RTC & AI)Weak external rotators (RTC & AI)Imbalance external vs. internal rotators (RTC)Imbalance ext. rotators vs. anterior/lateral deltoids (RTC)

RTC = Rotator cuff AI = Anterior instability

Rotator Cuff PathologyPost-rehabilitation needs

Continue to address clients impairmentsADVANCE program volume & load as appropriatePursue higher level function:

Return to gym-sport-recreationPost-rehabilitation precautions

Overhead activity with improper biomechanicsRepetitiveoverhead activityOverzealous upper trapezius & ant/lat deltoid training

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Anterior InstabilityPost-rehabilitation needs

Continue to address clients impairmentsADVANCE program volume & load as appropriatePursue higher level function:

Return to gym-sport-recreationPost-rehabilitation precautions

Avoid 90-90 High-Five positionAvoid unnecessary stretching of pec MAJORAvoid horizontal abduction past neutral*

*Especially when in external rotation

Exercise-Based Interventions

Impairments Gym-specific considerations

Rotator cuff pathologyAnterior instability

Impairment: Postural Kyphosis

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Impairment: Posterior Shoulder TightnessAnatomical Involvement

Impairment: Posterior Shoulder TightnessPosterior shoulder tightness: assessment

Video content available on-line: Strength & Conditioning Journal April 2012

Impairment: Posterior Shoulder TightnessPosterior shoulder tightness: intervention #1

Sleeper Stretch

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Impairment: Posterior Shoulder TightnessPosterior shoulder tightness: intervention #2

Cross-Arm Stretch with Scapular Stabilization

Impairment: Pec Minor Tightness


30

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Muscle Performance ImpairmentsIdeal goals:Maximal activationMaximal isolationReality: Exercises that maximally activate: perpetuate imbalancesEarly post-rehabilitation needs: Exercises that activate key muscles Minimize undesirable recruitmentLate post-rehabilitation: Maximal activation

Impairment: Muscle performance Weakness/Impairment

External rotators Serratus anterior Lower trapezius

Imbalances Internal/External rotation Abduction/External Rotation Upper/Lower trapezius Upper trapezius/Serratus anterior

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Impairment: External Rotator Weakness


External rotator muscle performance - conservative


Teres minor 84% MVIC Infraspinatus 46-70% MVICSupraspinatus 20-51% MVICLower trapezius 48% MVICLateral deltoid 8% MVIC

Myers et, J Athl Train, 2005; Hintermeister, Am J Sports Med, 1998; Dark, Phys Ther, 2007

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External rotator muscle performance - advanced

Impairment: External Rotator WeaknessExternal rotator muscle performance - advanced

Impairment: External Rotator WeaknessMuscle % MVIC

Infra 50-130Supra 68Low Trap 79Up Trap 20Serratus Ant 57Post Delt 79Lat Delt 49

Reinold, J Orthop Sports Phys Ther, 2009; Ekstrom et al, J Orthop Sports Phys Ther, 2003

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Impairment: Lower Trapezius Weakness


Impairment: Lower Trapezius Weakness Lower trapezius muscle performance - advanced

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Muscle % MVICLower trap 97Middle trap 100+Upper trap 79Serratus ant 43

Lat delt 90Post delt 88-100+

Infraspinatus 39-85Supraspinatus 65-82

Boettcher et al, Med Sci Sports Exerc, 2009; Ekstrom et al, J Orthop Sports Phys Ther, 2003Reinold et al, J Orthop Sports Phys Ther, 2004; Blackburn et al, Athl Train, 1990

Impairment: Serratus Anterior Weakness

Impairment: Serratus Anterior WeaknessSerratus anterior muscle performance - conservativePunches: 50-80% MVIC*UT activation 7% MVIC

Decker et al, Am J Sports Med, 2003Myers et al, J Athl Train, 2005Ekstrom et al, J Orthop Sports Phys Ther, 2003

Push up plus:73-80% MVIC* UT activation 8-19% MVIC

Ludewig et al, Am J Sports Med, 2004 Moseley et al, Am J Sports Med, 1992

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Impairment: Serratus Anterior Weakness

Scaption above 120

Serratus ant. MVIC 96%Upper trap MVIC 79%

Upper Cut

Serratus ant. MVIC 100%Upper trap MVIC 66%

Ludewig et al, Am J Sports Med, 2004; Moseley et al, Am J Sports Med, 1992 Ekstrom et al, J Orthop Sports Phys Ther, 2003

Eccentric Training: External RotatorsIndication: mechanotransduction

Video content available on-line: Strength & Conditioning Journal February 2013

Eccentric Training: External Rotators

Advanced: overhead athlete

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Return to Gym and/or Sport Considerations: Gym

Adjustment/advancement of volume & load Atrophy is common..consider Rehabilitation vs. Post rehabilitation volume & load Rest between sets?

Gym/exercises: require consideration of biomechanicsRotator cuff disordersAnterior instability

Rotator Cuff Pathology: Gym Considerations

Key points: biomechanics when elevating arm >90Need to externally rotate just prior to 60-140 Impingement risk greatest at 90

Solution:Limit exercise to below 90Externally rotate just prior to 90Alternate angle of elevation: scapular planeWhy low weight & higher reps?

Lateral Raises-Lateral Deltoids


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Rotator Cuff Pathology: Gym Considerations Scapular plane:


Front Raises-Anterior Deltoids


Upright Rows -Lateral Deltoids & Upper Trapezius

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Anterior Instability: Gym ConsiderationsKey points:

Avoid the 90/90 High-Five position Behind the neck military press & lat pull-downs Pectoral chest machines - 90/90 pectoral stretching

Avoid horizontal abduction > 0 (especially if in ER) Bench press or dumbbells & associated exercise

O.K. to strengthen supportive muscle in positions* * Proceed with caution

Anterior Instability: Gym Considerations

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Machine Chest Press


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Exercise Prescription Summary Rotator cuff strength & BALANCEFocus: External rotators (ER) Eccentric to promote healing

Scapulothoracic stability & rhythm Focus: Lower trapezius & serratus anterior

Joint mobility & flexibility Focus: Posterior shoulder tightness (internal rotation) Focus: Pectoral minor stretching

PrecautionsAnterior instability: 90/90 & horizontal abduction > 0 with ER

Rotator cuff: avoid abduction past 90 unless thumb upAvoid repetitive arm elevation > 90 unless in scapular plane

Recommended Reading

Strength Cond J, 2011;33:42-55

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References Pabian P, Kolber MJ, McCarthy J. Post-rehabilitation strength and conditioning of the shoulder: An interdisciplinary approach. Strength Cond J. 2011;33:42-55.

Brumitt J, Meira E. Rehab Exercise Prescription Sequencing for Shoulder External Rotators. Strength Cond J. 2005; 27:39-41.

Corrao M, Kolber MJ, Wilson SH. Addressing Posterior Shoulder Tightness in the Athletic Population. Strength Cond J. 2009;31:61-65

Kolber MJ, Beekhuizen K, Cheng MS, Hellman MA. Shoulder Injuries and Disorders Attributed to Resistance Training: A Brief Review. J Strength Cond Res. 2010;24:1696-1704

Corrao M, Pizzini G, Palo D, Hanney WJ, Kolber MJ. Weight-Training Modifications for the Individual with Anterior Shoulder Instability. Strength Cond J. 2010;32:52-55

Kolber MJ, Hanney WJ, Benevento JD. Quantifying Posterior Shoulder Tightness in the Athletic Population. Strength Cond J. 2012;34:18-21.

ReferencesKolber MJ, Beekhuizen KS, Santore T, Fiers H. Implications for Shoulder Positioning During Strengthening of the Shoulder External Rotators. Strength Cond J. 2008;30:12-16.

Lantz J, McCrain M. Modifying Chest Press Exercises for Athletes with Shoulder Pathology. Strength Cond J. 2005;27:69-72.

Lorenz D. The Importance of the Posterior Capsule of the Shoulder in Overhead Athletes. Strength Cond J. 2005;27:60-62.

Mulligan IJ, Bidington WB, Barnhart BD, Ellenbecker TS. Isokinetic Profile of Shoulder Internal and External Rotators of High School Aged Baseball pitchers. J Strength Cond Res. 2004;18:861-866.

Schoenfeld B, Kolber MJ, Haimes JE. The Upright Row: Implications for Preventing Subacromial Impingement. Strength Cond J. 2011;33:25-28

Luime JJ, Koes BW, Hendriksen IJ, Burdorf A, Verhagen AP, Miedema HS, Verhaar JA. Prevalence and incidence of shoulder pain in the general population; a systematic review. Scand J Rheumatol. 2004;33:73-81.

Referencesvan der Heijden GJ. Shoulder disorders: state-of-the-art review. Baillieres Clin Rheumatol. 1999;13:287-309.

Chaconas EJ, Kolber MJ. Eccentric Training for the Shoulder External Rotators Part 1: Efficacy and Biophysiological Evidence. Strength Cond J. 2013;35:48-50.

Chaconas EJ, Kolber MJ. Eccentric Training for the Shoulder External Rotators Part 2: Practical Applications. Strength Cond J. 2013;35:8-10.

Kolber MJ, Corrao M, Hanney WJ. Characteristics of Anterior Shoulder Instability and Hyperlaxity in the Weight-Training Population. J Strength Cond Res. ePub 2012.

Goertzen M, Schppe K, Lange G, Schulitz KP. Injuries and damage caused by excess stress in body building and power lifting. Sportverletz Sportschaden. 1989;3:32-6.

McFarland EG, Wasik M. Epidemiology of collegiate baseball injuries. Clin J Sport Med. 1998;8:10-3.

Di Fabio RP, Boissonnault W. Physical therapy and health-related outcomes for patients with common orthopaedic diagnoses. J Orthop Sports Phys Ther. 1998; 27:219-30.

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Shoulder pathology