manual therapy and exercise for subacromial impingement

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 subacromial impingement
• 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
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
Functional Factors that may lead to
Subacromial Impingement
(Adapted from Matsen and Arntz, 1990)
I.
II.
III.
IV.
V.
VI.
Abnormal scapular motion due to limited
motion at the scapulothoracic joint
Functional scapulothoracic instability due to
scapulothoracic muscle weakness or
fatigue (Kibler, 1998, 2002)
Loss of humeral head depression
Posterior capsular tightness (Harryman, 1990)
Glenohumeral joint capsular laxity
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
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
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
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
V. Glenohumeral Joint 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
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
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
• Glenohumeral Joint 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
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
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