Using Neutrality To Increase Shoulder

Strength SUSAN M. T. McKAY, OTR/L [email protected]

GOAL

Look at shoulder rehab in a different way. Strength can come from increasing flexibility and placing a joint in proper alignment. Conversely, strengthening a shoulder in improper alignment can cause injury.

WHY PICK ON THE SHOULDER? . Impairs function/limits ADL’s . Pain in shoulder . Compensatory patterns can lead to back pain . Elderly rely on upper body to move/ambulate . The sooner issues are treated, the less physiological damage there is SHOULDER ANATOMY

. Muscles and how they move . A basic review and more . Important to know…

SHOULDER ANATOMY

. Supraspinatus . Initiates and assists deltoid in abduction of arm and acts with other rotator cuff muscles.

SHOULDER ANATOMY

. Infraspinatus . Laterally rotate arm; helps to hold humeral head in glenoid cavity of scapula

SHOULDER ANATOMY

. Subscapularis . Medially rotates arm and adducts it; helps to hold humeral head in glenoid cavity of scapula

SHOULDER ANATOMY

. Teres Minor . Laterally rotate arm; helps to hold humeral head in glenoid cavity of scapula

SHOULDER ANATOMY

. Deltoid . Anterior part: flexes and medially rotates arm; Middle part: abducts arm; Posterior part: extends and laterally rotates arm

SHOULDER ANATOMY

. Latissimus dorsi . Extends, adducts, and medially rotates humerus; raises body toward arms during climbing

SHOULDER ANATOMY

. Teres Major . Adducts and medially rotates arm

SHOULDER ANATOMY

. Pectoralis major . Adducts and medially rotates humerus; draws scapula anteriorly and inferiorly; Acting alone: clavicular head flexes humerus and sternocostal head extends it

SHOULDER ANATOMY

. Pectoralis Minor . Stabilizes scapula by drawing it inferiorly and anteriorly against thoracic wall

SHOULDER ANATOMY

. Coracobrachialis . Helps to flex and adduct arm

SHOULDER ANATOMY

. Rhomboid Major and Minor . Retract scapula and rotate it to depress glenoid cavity; fix scapula to thoracic wall

SHOULDER ANATOMY

. Serratus Anterior . Draws scapula forward and upward; abducts scapula and rotates it; stabilizes vertebral border of scapula

SHOULDER ANATOMY

. Trapezius . Elevates, retracts and rotates scapula; superior fibers elevate, middle fibers retract, and inferior fibers depress scapula; superior and inferior fibers act together in superior rotation of scapula

SHOULDER ANATOMY

. Levator Scapula . Elevates scapula and tilts its glenoid cavity inferiorly by rotating scapula

CLAVICLE AND SCAPULA

. Things you may or may not know . Very important to address when addressing the shoulder . May be the primary reason limiting the shoulder CLAVICLE

. Looking from the front, the medial 2/3 is convex and lateral 1/3 is concave- only long bone that is horizontal in the body . Acts as a “strut” to hold the arm away from the body and allows space for veins and nerves . Muscles/Ligament attached: . Trapezius muscle . Deltoid Muscle . Coracoclavicular ligament . Sternocleidomastoid muscle . Pectoralis major muscle . Subclavius muscle CLAVICLE

. Sternoclavicular (SC) Joint Structure . Articulation of clavicle with the sternum . Only direct attachment of the upper extremity to the skeleton . Clavicle moves in 3 planes (3 degrees of freedom) . Elevation and Depression of SC . Protraction and retraction of SC . Axial Rotation of clavicle . All shoulder girdle movements start at the SC joint, if it is fused not only the clavicle and scapula would be limited but the entire shoulder!

CLAVICLE

. The Acromioclavicular Joint (AC) allows motion in all 3 planes, allowing the scapula to maintain contact with the posterior thorax: . Upward rotation and downward rotation . Rotation in the horizontal plane . Rotation in the sagittal plane . Acromioclavicular Ligament . Joins clavicle to acromion, prevents dislocations of the scapula

CORACOLCLAVICULAR LIGAMENT . Attaches twice on clavicle and the coracoids process of scapula . It is responsible for bearing most of the weight of the hanging arm. Without this ligament, the arm is unable to hang from the body

CORACOCLAVICULAR LIGAMENT SCAPULA

. The scapula is only attached to the thorax by . ligaments at the AC joint . suction mechanism provided by . serratus anterior . subscapualaris . Main stabilizers of the scapula: . Serratus anterior . Rhomboid major and minor . Levator scapulae . Trapezius SCAPULOHUMERAL RHYTHM

. The first 30 degrees of shoulder joint motion is pure glenohumeral joint motion . •After that, for every 2 degrees of shoulder flexion or abduction that occurs, the scapula must upwardly rotate 1 degree . •This 2:1 ratio is known as scapulohumeral rhythm

SCAPULAR DYSKINESIS

. Winging . Posterior movement of the medial border of the scapula, Rotation about a vertical axis . Long Thoracic nerve injury . Weak serratus anterior . Usually from poor posture, especially when stress is carried in their neck- rhomboid and levator scapulae muscles are shortened

SCAPULAR DYSKINESIS

. Tipping . Posterior movement of the inferior angle of the scapula, Rotation about a transverse axis . Pectoralis minor is shortened

RELAX

You made It though The hard Part SHOULDER POSITION

. Different for everyone . Side view, ears should be in alignment with shoulders . Shoulders should be in alignment with hips . May not be able to achieve due to bony/soft tissue changes and congenital deformities

SHOULDER POSITION/PHYSICS

. Levers . The humerus is a complicated class 3 lever when the elbow is straight. (Reminder on a class 3 lever: Effort is in the middle (muscle): the resistance is on one side of the effort (whatever a person is lifting) and the fulcrum is located on the other side (shoulder girdle)) . Fulcrum is set best when the shoulder girdle is at neutral. When shoulder girdle is no longer at neutral, the “lever” loses effectiveness CLASS 3 LEVER

fulcrum effort

resistance

EVALUATION IS IMPORTANT

. This will mostly design how the person is treated . In my experience, most people do not have optimal strength unless they have over 150 degrees of shoulder flexion without compensation . Most people are upwardly rotated and abducted . Pain-where is it specifically? . Additional extension, limited internal and/or external rotation

COMPENSATION

. When a person has lost range of motion, they learn to compensate . The job must be done!!!! . Compensatory patterns will give you clues as to areas that need to be addressed TYPICAL COMPENSATION PATTERNS . Shoulder flexion- abduction of the shoulder, lordosis of cervical/thoracic spine . Shoulder abduction- lateral flexion of torso/spine, shoulder flexion, protraction of scapula

TYPICAL COMPENSATION PATTERNS . Shoulder internal rotation- protraction of scapula, rotation of trunk, kyphosis of thoracic/cervical area . Shoulder external rotation- retraction of scapula, rotation of trunk, lordosis of thoracic/cervical area

ASSESSING RANGE OF MOTION . How is reduced shoulder ROM limiting ADL’s . Limited shoulder flexion: brushing/washing hair, donning/doffing shirt/jacket, reaching into cabinet . Limited horizontal adduction: Donning/doffing clothing, hair care, kitchen tasks, peri care

ASSESSING RANGE OF MOTION . Limited internal rotation: washing back, hooking bra, pulling up pants, peri care, cooking, mowing the lawn/starting mower . Limited external rotation: brushing teeth, brushing/washing hair, using a walker, cooking ASSESSING RANGE OF MOTION . Is functional ROM causing deformity? . Does that person really have functional movement? . Need to look at the entire body . Watch for compensatory movement . Look for pain cues (wincing, grunting, etc.)

ASSESSING RANGE OF MOTION . Where is the block? Eg. Shoulder flexion . Look at straight flexion without allowing any other movement, you will feel a slight “stop” in the movement if there is a restriction . Where is the compensatory movement? . Limited shoulder flexion can cause compensation . Cervical, thoracic, lumbar vertebrae . Spillover into abduction and external rotation ASSESSING RANGE OF MOTION . Long term effects . Pain . Arthritis . Impingement . Decreased strength . Destruction of structures of the shoulder . Biceps . Coracobrachialis . Ultimately loss of function

TREATMENT FOR SCAPULAE . Mostly upwardly rotated and abducted . Mobilizations and soft tissue release . We must… and scapular squeeze . Tell person to try to touch shoulder blades together and towards bottom

AIR SPLINT AIR SPLINT CONTRAINDICATIONS

.ANY ROM RESTRICTIONS .BACK/SHOULDER/CLAVICLE/ARM FRACTURES .DIALYSIS PORTS .PICC LINES .POOR ARTERIAL/VENOUS FLOW TO ARM/DVT AIR SPLINT CONCERNS/ CONSIDERATIONS

. Recent fractures . Vascular issues . Cardiac history . Skin integrity . Osteoporosis . IV’s . Muscle tears . Contractures . Pain tolerance . Mastectomy/ . Recent back Lumpectomy surgeries . Severe arthritis

AIR SPLINT EXERCISES

. Please see additional handout . Works better initially in supine, gravity pulls shoulder into a more neutral position breaking habitual pattern of kyphosis and other compensatory patterns . Can use towel for better positioning or to grade activity . Move into sitting once patient’s shoulder girdle becomes more stable MOBILIZATIONS PRECAUTIONS AND CONTRAINDICATIONS . Any condition that has not been fully evaluated . Joint ankylosis . Joint hypermobility, if techniques that take the joint through its end range are being considered, unless a positional fault is being treated . Joints that are infected . Malignancy in area treated . Fractures . Inflammatory arthritis, especially if it is exacerbated . Metabolic bone diseases (Paget’s, TB, etc) . Debilitating diseases that compromise periarticular tissue (advanced DM) . Long term use of corticosteroids . Swelling- it takes up some of the slack in the capsule making it difficult to evaluate the joint mobility correctly . Excessive joint irritability or pain . Coagulation impairments . Skin rashes or open/healing skin lesions . Protective muscle spasms to the point mobility in the area treated is unable to be evaluated MOBILIZATIONS

. Joint mobilizations are used when ligament or capsule resistance is encountered . Many different ones to use . See sheet for helpful ones Thank you!!!!!

. Many thanks to those . Scott McKay, PAC who helped me: . Chad Randolph, PT . Heather Barnes, . Tim Kisner, PT OTR/L . My model: Beth . Terry Giese, OTR/L Kohler-Rausch, . Nancy Joneth, OTR/L OTR/L . My Photographers: . Howard Whitfield, Diwi Ymson, PT and OTR/L Tanvi Desai, OTR/L