Sydney Physiotherapy Solutions Matt Crawshaw Blair Chapman Chantal Wingfield

Today’s Topic is The Scapular Shoulder pathology Measuring static and dynamic scapular stabilisation Using measurements to screen for prevention of shoulder injuries and to identify scapular dysfunction due to injury. Using measurements to progress rehabilitation. Shoulder is most mobile in the body = complex and prone to injury Fundamental for our upper limb function as prox stability is paramount for distal control as we know with the core and trunk My role today is to provide you with some food for thought regarding some of the potential pathologies your client’s may be experiencing and aiding you decision making regarding when you should refer on and who to. In the following few slides we will go through each of these in more detail

Today’s Goal Interact and Share 2. Develop trust with you discuss shoulder injuries from the Personal Trainers perspective discuss shoulder injuries from the physiotherapist perspective suggest a framework where the Personal Trainers and the Physiotherapists can be a team for the client with a focus on keeping them training with the Personal Trainer through their injury. 2. Develop trust with you

Framework for Physio’s and PT’s to work within When we receive a patient from a PT with a Shoulder problem   Our responsibility lies equally between the patient and the PT. We need to establish a diagnosis and prognosis and communicate that to the patient and the PT.

Framework for Physio’s and PT’s to work within To reduce Symptoms and address the likely poor scapular stabilising strategy that is present as a reaction to the injury. To give patient back to PT with minimal Sx and a good scap stabilising strategy for the PT to load that strategy to regain full strength .

Framework for Physio’s and PT’s to work within Important for the PT to understand how to identify good and bad scap stabilising strategies and to be able to monitor this during strength training. We need to do this as soon as possible to maintain the relationship between patient and PT. If there is a longer period of rest required for the shoulder we need to provide the PT with safe strengthening exercises to do during the rehab process.

More detail of this Framework Chantal is going to present the pathologies we are thinking of when a shoulder injury is referred to us from a PT and how we diagnose this. Blair will describe the current understanding of scap stabilisation and how it is affected by injury. He will run a small practical session on how to measure and identify this for screening your clients before strength training and rehabilitating your clients back into strength training post injury.

Shoulder Pathologies Fracture Alternative considerations Dislocation Cervical spine Muscle tear Thoracic ring dysfunction Labral tear Thoracic outlet syndrom / Brachial plexus ACJ injuries Peripheral neuropathies Frozen shoulder Tumors / lung Ca / heart Arthritis Subacromial impingement – including tendinitis, bursitis and postural dysfunctions Shoulder is most mobile in the body = complex and prone to injury Fundamental for our upper limb function as prox stability is paramount for distal control as we know with the core and trunk My role today is to provide you with some food for thought regarding some of the potential pathologies your client’s may be experiencing and aiding you decision making regarding when you should refer on and who to. In the following few slides we will go through each of these in more detail

Dislocation Usually traumatic Anterior most common Be aware of the chronically unstable shoulder Physiotherapy input recommended and usually imagery required as recurrence is highly likely Surgical stabilisations occasionally required in presence of structural defect EG Bankart, unstable SLAP or Hill Sachs Chronic instabilities minor injury or repetitive micro-trauma or as a result of some action such as throwing a ball Idiopathic connective tissue disorders – EG elhos danlos etc….

Muscle tear E.g. Rotator cuff but not exclusive Can be traumatic or degenerative Usually causes pain upper arm Often but not always complain of weakness Needs physio input +/- orthopaedic input depending on extent of tear/dysfunction & duration of symptoms Diagnosed clinically with use of US or MRI as required If traumatic, timing is key as better surgical outcomes within 3 months of injury May require some rest from loaded upper limb work

Labral Tear Can be traumatic or degenerative Can be asymptomatic Can cause clicking, feelings of instability or deep shoulder ache Physio input recommended with ongoing PT. Physio to guide re ex precautions & rehabilitate shoulder stability whilst training So if you have a client with persistent clicking during overhead presses or ache post upper limb work outs etc – refer for an assessment. Not definitively labral tear can be purely poor motor control / altered biomechanics (possible as a result of an alternative pathology) but if in doubt we can refer for an MRI with contrast 95% sensitivity whereas no contrast = 75% Our aim will never be to stop their training with you but we may be able to suggest some ex options in early phases and will aim to get them back to you asap to continue full training and prevent further degeneration, reinforcement of poor motor control and ultimately limiting their long term training program Occasionally surgical input required if unstable or fail conservative input Caution with shoulder weight bearing and overhead loading during initial rehab phase

ACJ Usually managed conservatively We will grade the injury and guide regarding their rehab and ongoing training Avoid distraction / loading / weight bearing for ~ 2–6 weeks depending on grade of injury Important to ensure normal mechanics post injury as can lead to secondary problems such as impingement Can involve fractured clavical / collar bone or ACJ lig injuries resulting in step deformity and instability of ACJ as per picture Lig strains usually managed conservatively No loading / distraction / weightbearing for 6/52 Can help with some taping techniques

Frozen Shoulder AKA ‘Adhesive Capsulitis’ Inflammation and scarring of your joint capsule Starts as a painful shoulder and develops into a stiff shoulder More common in diabetics Needs range maintenance exercises and occasionally onward referral for a corticosteriod injection or capsular release

Arthritis Osteoarthritis is also known as joint ‘wear and tear’ Older population Stiffness and pain Need careful grading of exercises, not too high loads as indicative that their cuff and labrum are severely degenerative Very occasionally referred for shoulder replacement but outcomes currently limited. Good pain responses but ROM and strength outcomes poor so last resort.

Subacromial Impingement – Bursitis / tendinitis Can occur post trauma, with overuse, sudden increase in training or gradual insidious onset as a result of poor biomechanics Often occurs due to poor biomechanics this may be post RC, Lhbicep or labral tear, ACJ sprain or just as a result of poor posture and natural biomechanics eg depressed / protracted shoulder girdle ** discuss this in more detail Head of hum pos Posture*** RC function Often present with am pain, pain post ex Need physiotherapy input If left untreated will worsen and reoccur. Risk of leading to degenerative tear. May require US Ix, MRI to rule out underlying structural pathology eg labral or RC tear and corticosteroid injections can help Surgical input controversial must exhaust conservative options before considering Present with pain during arm elevation at end of range or often a painful arc and usually HBB also sore

Additional Potential Differentials Cervical spine Upper lung lobe Cervical arteries Heart Thoracic outlet / brachial plexus Peripheral neuropathy Thoracic ring dysfunction If unsure, refer to us and we will happily assess and give feedback We utilise a series of clinical tests, questions and real time ultrasound to establish our diagnosis and then will develop a collaborative management plan with both you and the client peripheral neuropathy can present with pain, weakness, loss of sensation or paraesthesia of the shoulder into the arm Some of these include: subjective clinical tests Real time US Trial treatment options Onward referral for MRI, US, Xray, etc… Onward referral to an sports doc or othropod via GP if required

Scapular Mechanics

Scapular Movement

Muscle Actions Upward Rotation Serratus anterior, UFT,LFT Downward Rotation Levator scapula, Rhomboids, Pec minor Anterior/Posterior Tilting Anterior: Pec minor Posterior: LFT Protraction/ Retraction Protraction: Pec minor, serratus anterior Retraction: Rhomboids, Trapezius as a whole (latissimus dorsi if humerus fixed) External Rotation Serratus anterior Internal Rotation

Common Presentation As a result of injury or trauma Downward rotation Anterior tilt Medial rotation Which muscles are overactive? Secondary Issues? Talk about the cue back and down Talk about the impingement that occurs due to poor position if doing overhead

Visual Assessment Kibler Classification of Scapular Dysfunction Type 1 or inferior Dysfunction Main feature is inferior angle prominence as a result of anterior tilting. Best seen with hands on hips or eccentric lowering of arms from overhead ( most common in rotator cuff dysfunction) Type 2 or medial Dysfunction Prominence of entire medial border of scapula due to internal rotation of scapula. Best seen with hands on hips, eccentric lowering from overhead Common in shoulder joint instability Type 3 or Superior Dysfunction Excessive and early elevation of the scapula during elevation. Ie. Shoulder Shrugging. Often seen in rotator cuff dysfunction and deltoid rotator cuff force coupling imbalances Studies support validity of visual observation of scapular dyskinesis

Rotator Cuff Function What is the function of the rotator Cuff? Relationship with scapula Arm abduction (Lateral raises, military press) Horizontal adduction (chest press, fly’s) Shoulder flexion (front raises, boxing)

Observation Examples

Summary Any questions ?