s EDUCATION WORKSHOPS Shoulder Injury Prevention and Rehabilitation for Health & Fitness Professionals with B.App.Sc (Physio), Dip.Ed (P.E.)
CONTENTS Topic Page 1. Functional Anatomy 3 2. Scapulohumeral Rhythm / Causes of Shoulder Pain 4 3. Screening of Patients with Shoulder Pain 5 4. Impingement and Instability 6 5. Typical Presentations 7 6. Acromion (the Roof of the Shoulder) 9 7. Scapula Control / Variation of Acromion Shapes 10 8. Rotator Cuff Tear Due To Impingement 11 9. Rotator Cuff Repair and Acromioplasty 11 10. Shoulder Injury Prevention and Rehabilitation Practical 12 11. Commonly Used Rehabilitation Exercises 13 12. Useful References and Texts 16 IMPORTANT NOTE The aim of this workshop is to increase the knowledge of fitness leaders, personal trainers and instructors in the area of injury prevention and safe exercise prescription. An awareness of common injuries and their physiotherapy and medical rehabilitation programs will assist the fitness leader in providing correct supervision of their clients whilst in the fitness centre or personal training studio. At no stage should fitness leaders assume the role of diagnostic practitioners or primary rehabilitation consultants without direction and assistance from the treating medical professional or physiotherapist. To do so will place the fitness leaders in danger of litigation and intense scrutiny by their peers as well as by the legal and medical community. The information presented in this workshop is to be used as a guide only and should never be used as a replacement for medical or physiotherapy intervention. We hope you enjoy the workshop. 2
FUNCTIONAL ANATOMY The glenohumeral joint is a ball and socket joint which, unlike the hip, only has a shallow socket and requires additional stability. Static Stabilisers Joint capsule Glenohumeral ligaments Glenoid Labrum Dynamic Stabilisers Inner sleeve (rotator cuffs - S.I.T.S) Outer sleeve (delts, lats, teres major, biceps) Scapular controllers (traps, serratus, rhomboids) Fig 1: Ligaments of the Glenohumeral Joint Fig 2: Muscles of the Rotator Cuff 3
SCAPULOHUMERAL RHYTHM Glenohumeral movements involve associated motion at the scapulothoracic, acromioclavicular (AC) and sternoclavicular joints. This integrated motion is called scapulohumeral rhythm. Correct scapulohumeral rhythm ensures that: Upward rotation of the scapular with abduction prevents impingement The joint is stable at greater than 90 degrees of adduction (places glenoid under humeral head) A stable base is provided for muscles originating on the scapula and allows them to function at their optimal length-tension relationship. CAUSES OF SHOULDER PAIN The common causes of shoulder pain include: Rotator cuff strain Rotator cuff tendinosis Glenohumeral dislocation Clavicle fracture Referred pain Glenohumeral instability Other less common causes of shoulder pain are: Calcific tendinitis Bicep tendinosis Muscle tears (bicep, pec major) Adhesive capsulitis Nerve entrapment Neural tension 4
SCREENING OF PATIENTS WITH SHOULDER PAIN A well taken client history can give you up to 85% of the information needed to decide if the person is able to commence weight training. THE FOLLOWING POINTS CAN BE USED AS AN APPROXIMATE GUIDE: a) Night pain (i.e. worse or wakes at night): Indicates active inflammation No training allowed + medical referral b) Nature of pain: Constant = inflammatory condition (no training + medical referral) Only on some movements = can train in pain free ranges Only on weight training = can train in pain free ranges (can help diagnosis) c) Is the pain localised to the shoulder? If neck or arm pain as well (No training + medical referral) d) Is there altered sensation (i.e. pins & needles or numbness) No training + medical referral 5
IMPINGMENT AND INSTABILITY Anatomical abnormalities (e.g. beaked acromion, osteophytes) Poor scapular control Anterior instability Excessive load on rotator cuff muscles Encroachment from above Inferior movement of acromion Anterosuperior translation of humeral head Rotator cuff weakness Narrowing of subacromial space Imbalance between humeral head elevators and depressors Impingement with exercise Swelling of rotator cuff tendon Elevation of humeral head Posterior capsule tightness Rotator Cuff tendinosis Overuse Instability Abnormal biomechanics 6
TYPICAL PRESENTATIONS Rotator Cuff Tendinosis or Tendinopathy May be primary (overuse) or secondary (instability). Can be associated with sub acromial bursitis. Pain with overhead activities with possible history of instability. Painful arc between 70 and 120 of abduction. Treatment will initially involve a reduction of the inflammation process via avoiding aggravating activities, ice, NSAIDS, physiotherapy, taping and possibly injection. Stage two will be correction of causative factors. These are (see chart): 1. Anatomical abnormalities (i.e. sloped acromion, anterior osteophytes) 2. Poor scapular control. 3. Anterior instability. 4. Rotator cuff weakness (especially ER) 5. Imbalance between humeral head depressors and elevators. 6. Posterior capsule tightness. 7. Poor biomechanics (e.g. thoracic kyphosis) Rotator Cuff Tears/ Strains Present as a sudden inset of pain or a "twinge" in the shoulder. Common in the older athletic population due to tendon degeneration. Often night pain and unable to sleep on the problem shoulder. Treatment will involve rest, stretching, soft tissue therapy and possible surgery. Instability May be either post traumatic or atraumatic (due to repeated stress of static restraints) The instability may be anterior, posterior, inferior or a combination (multidirectional) Problems with overhead tricep, rear pull down, press behind neck, side raise, seated row at full shoulder flexion, and bottom of incline press. Often pain after 1 hour of exercise due to fatigue of stabilizing muscles. Treatment will involve rotator cuff strengthening, scapular stabilizing exercises and modification of sporting activities. 7
Acromioclavicular Joint Injuries Pain due to repeated minor injuries from excessive bench press and dips. Treatment involved physiotherapy, scapular control exercises with possible injection. Pectoralis Major Strains/ Tendinitis Pain anterior shoulder due to hands too wide on bench press. Treatment as for other rotator cuff tendinosis conditions. 8
ACROMION (the "roof" of the shoulder) Fig 3: Sub-acromial Impingement When deltoid contracts, its vertical fibres pull the head of the humerus straight up towards the acromion. In the healthy shoulder the infraspinatus, teres minor and subscapularis (seen in fig 4) pull down on the humerus to counteract this upward pull of the deltoid. This prevents the head of the humerus from crushing into the acromion and impinging the supraspinatis tendon and the subacromial bursa. Following repeated impingement the structures that occupy the subacromial space become inflamed and thus further reducing the subacromial space and increasing the likelihood of further impingement. Fig 3. shows an inflamed tendon following repeated impingement. Fig 4: Rotator Cuff Muscles 9
SCAPULA CONTROL Fig 5: Lack of scapula stabilisation results in excessive rotation and protraction of the scapula with glenohumeral movement thus causing inferior movement of the acromion. This inferior movement of the acromion increases the likelihood of impingement. Lower trapezius, rhomboids and serratus anterior must Variation of Acromion Shapes Fig 6: Normal anatomic variants can cause compression. Three distinct types of acromion can readily be seen on radiographs, especially on the angled outlet Y view. The type I acromion, which is flat, is the "normal" acromion. The type II acromion is more curved and downward dipping, and the type III acromion is hooked and downward dipping, obstructing the outlet for the supraspinatus tendon. Cadaveric studies have shown an increased incidence of rotator cuff tears in persons with type II and type III acromions. 11 10
ROTATOR CUFF TEAR DUE TO IMPINGMENT Fig 7: shows the progressive degeneration following repeated impingement of the subacromial bursa (blue), resultant inflammation (red) and tearing of the supraspinatis muscle (white) Torn Supraspinatis Tendon ROTATOR CUFF REPAIR AND ACROMIOPLASTY Fig 8A: Torn supraspinatis tendon Fig 8 Fig 8B: Arthroscopically repaired supraspinatis tendon. Tendon is trimmed and reattached to humerus. Fig 8C: If on x-ray or arthroscope a type II or type III acromion is found to be encroaching into the subacromial space and thus contributing to impingement, part of the acromion may be removed arthroscopically in a surgery known as an acromioplasty. NB: rotator cuff repairs or acromioplasties may be performed in isolation or these procedures may be done concurrently. 11
SHOULDER INJURY PREVENTION AND REHABILITATION PRACTICAL Prehab Examination 1) Thoracic Extension 2) Muscle Wasting 3) Scapulohumeral rhythm (incl. winging) 4) Posture Problem Exercises, Techniques & Equipment a) Press Behind Neck b) Rear Pulldown c) Deep Dumbell Bench Press d) Bench Press (especially to the neck) e) Dips f) Pec Dec g) Upright Rows h) Pullovers i) Seated Rows (with no lordosis) j) Supraspinatus FlyEs k) Shrugs Notes: 12
COMMONLY USED REHABILTATION EXERCISES To Improve Scapula Control a) Towel Squeeze b) Cable Extension / c) Theraband ER & Ext Adduction d) Isometric Rotator Cuff e) Push-up Plus f) Reverse Dips g) Wide Rows h) Swiss Ball Push-up i) 1 Arm Prone Bridge j) Prone Ball Supermans ` 13
To Improve Thoracic Spine Extension and Poor Biomechanics a) Towel Pullovers b) Ball Roll-outs c) Ball Pullovers Notes: d) Standing One Arm e) DB Rows Rows Notes: 14
To Improve Rotator Cuff Strength a) Cable ER and IR b) Cable ER with PNF c) Strap Stop Sign d) Lying L Flyes e) Lying Flyes f) Standing L Flyes g) T Bench Rotator Cuff h) Cuban Press j) Prone Ball Supermans ` 15
USEFUL REFERENCES AND TEXTS 1) Clinical Sports Medicine, Brukner and Khan, McGraw Hill Publishers 2) Primary Anatomy, Basmajian, Williams and Wilkins Publishers. 3) Sports Injuries- Their Prevention and Treatment, Peterson and Renstrom, Law Book Company. 4) Back Care, Oliver, Butterworth-Heineman Publishers. 5) Practical Orthopaedic Medicine, Corrigan and Maitland, Butterworths Publishers. 6) Back Pain - Recognition and Management, Hutson, Butterworth-Heineman Publishers. 7) Serious Strength Training, Bompa and Cornacchia, Human Kinetics Publishers. 8) Essentials of Strength Training, Baechle (editor), Human Kinetics Publishers. 9) Vertebral Manipulation, Maitland, Butterworth Publishers. 10) Therapeutic Exercises using the Swiss Ball, Creager, Executive Physical Therapy. 11) Bigliani LU, Morrison DS, April EW. The morphology of the acromion and its relationship to rotator cuff tears. Orthop Trans 1986;10:228. 16