adobe:docid:indd:d426ab4c-3564-11de-9476-80770b4263da %%EOF The size of the humeral (arm bone) head in comparison to the glenoid (the socket on the Stage II compressive disease outlined by Neer is termed fibrosis and tendonitis. Your physical therapist may use manual techniques, such as gentle joint movements, soft-tissue massage, and shoulder stretches to get your shoulder moving properly, so that the tendons and bursa avoid impingement. In the grading technique designed by Altchek,37 grade I is considered normal motion within the glenoid (typically 8 to 10 mm38), and a grade II translation is when the clinician-guided stress produces movement of the humeral head over the glenoid rim posteriorly with relocation of the humeral head into the glenoid when stress is removed. Jensen etal27 studied the effects of submaximal [5 to 50% maximum voluntary contraction (MVC)] contractions in the supraspinatus tendon measured with laser Doppler flowmetry. Questions regarding the progress of Types of Rotator Cuff Impingement The second important test to determine the presence of IR ROM limitation is the assessment of physiological ROM. In these professional throwing athletes, 93% had undersurface fraying of the rotator cuff tendons and 88% showed fraying of the posterosuperior glenoid. However, patients with primary impingement often present with underlying capsular hypo-mobility and are definite candidates for specific mobilization techniques to improve glenohumeral joint arthrokinematics. Bennett described a posterior shoulder pain syndrome in baseball pitchers related to the repetitive traction of the posterior capsule and triceps tendon.7 Walch et al described the posterosuperior impingement (PSI) for the first time in 19928 and emphasised Manual techniques allow the clinician to interface directly with the patients scapula to bypass the glenohumeral joint and permit repetitive scapular exercise without inducing undue stress to the rotator cuff in the early phase. A large spectrum of mobility can be encountered when treating the patient with glenohumeral impingement. 513 0 obj <>stream Burkhart et al34 have termed this IR loss GIRD-glenohumeral internal rotation deficitand define it as a loss of internal rotation of 20 degrees or more compared with the contralateral side. Posterior Impingement Test | Internal Impingement. To have a numerical representation of the total rotation range of motion available at the glenohumeral joint, the glenohumeral joint IR, and ER ROM measure are added together. Step 2. Note: All progressions are approximations and should be used as a guideline only. Phase II Motion Phase (weeks 5-8): Review videos for active ROM,overhead pulley and isometric strengthening (flexion, extension,abduction, external nonsurgical treatment for shoulder impingement. Your doctor may recommend non-operative or operative treatments to treat internal impingement of the shoulder. 14), care must be taken to stabilize the scapula, with the patient supine so that the patients body weight can minimize scapular motion as the examiner uses a posteriorly directed force on the anterior aspect of the coracoid and shoulder. 572 0 obj <> endobj It should be pointed out that incorrect use of this posterior glide assessment technique may lead to the false identification of posterior capsular tightness. One area that has received a great deal of attention in the scientific literature is the presence of an IR ROM limitation, particularly in the overhead athlete with rotator cuff dysfunction.33,34 To determine the course of treatment for the patient with limited IR ROM, clinical assessment strategies must be employed to determine whether the limitation and subsequent treatment strategy to address the limitation in glenohumeral joint IR should be targeted for the muscletendon unit or the posterior capsule. False This total rotation ROM concept can be used to guide the clinician during rehabilitation, specifically in the application of stretching and mobilization exercises, to best determine what glenohumeral joint requires additional mobility. This technique is most often referred to as the posterior load and shift or posterior drawer test.35,36 Figure 1-3 shows the recommended technique for this examination maneuver whereby the glenohumeral joint is abducted 90 degrees in the scapular plane (note the position of the humerus 30 degrees anterior the coronal plane). Neers Stages of Impingement 1 Rehabilitation of Shoulder Impingement: Primary, Secondary, and Internal, 5 Rehabilitation of Acromioclavicular Joint Injuries, 6 Classification and Treatment of Scapular Pathology. PJT,*$(dsJE5N i> *A%QL&1+ul|n0\IpLxm! This more-posterior orientation of the tendons aligns them such that the undersurface of the tendons rubs on the posterior-superior glenoid lip and becomes pinched or compressed between the humeral head and the posterosuperior glenoid rim.19 In contrast to patients with traditional outlet impingement (either primary or secondary), the area of the rotator cuff tendon that is involved in posterior or undersurface impingement is the articular side of the rotator cuff tendon. Ischiofemoral impingement has also been proposed as an etiology in sciatic nerve compression and proximal hamstring tendinopathy. Initial Phase Hence, despite bilateral differences in the actual IR and/or ER ROM in the glenohumeral joints of baseball pitchers, the total arc of rotational motion should remain the same. Contact us at (415) 563-3110 for an appointment. Placement of the shoulder in the 90/90 position causes the supraspinatus and infraspinatus tendons to rotate posteriorly. Questions regarding the progress Dr. Sameer Nagda, MD is an Orthopedic Surgery Specialist in Alexandria, VA. The game that everyone can play, and all can get hurt. 6 Classification and Treatment of Scapular Pathology shoulder internal impingement non-operative guidelines The following internal impingement guidelines were developed by HSS Rehabilitation and are categorized into five phases with the Several authors recommend measurement of glenohumeral IR with the joint in 90 degrees of abduction in the coronal plane.3941 During IR ROM measurement (Fig. Research by Kibler et al47 and Roetert et al48 has identified decreases in the total rotation ROM arc in the dominant extremity of elite tennis players correlated with increasing age and number of competitive years of play. Types of Rotator Cuff ImpingementPrimary Impingement or Compressive DiseaseSecondary ImpingementPosterior, Internal, or Undersurface ImpingementAnterior Internal Impingement Further research is needed to better define the optimal application of these stretches; however, this research does show improvement in IR ROM with a home stretching program.56, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Rehabilitation of Shoulder Impingement: Primary, Secondary, and Internal, Primary Impingement or Compressive Disease, Posterior, Internal, or Undersurface Impingement, Rehabilitation of Rotator Cuff Impingement. The position of the shoulder in forward flexion, horizontal adduction, and internal rotation (IR) during the acceleration and follow-through phases of the throwing motion is likely to produce subacromial impingement due to abrasion of the supraspinatus, infraspinatus, or biceps tendon against the overlying structures.9 These data provide scientific rationale for the concept of primary impingement or compressive disease as an etiology of rotator cuff pathology. Impingement of the undersurface of the rotator cuff on the posterosuperior glenoid labrum may be a cause of painful structural disease in the athlete practicing sports with overhead movement. Due to the increased humeral head translation, the biceps tendon and rotator cuff can become impinged secondary to the ensuing instability.13,14 A progressive loss of glenohumeral joint stability is created when the dynamic stabilizing functions of the rotator cuff are diminished from fatigue and tendon injury.14,17 The effects of secondary impingement can lead to rotator cuff tears as the instability and impingement continue.3,14 This is meant to be held for a longer period of time so the inert posterior capsule can also make the appropriate changes.Visit our website: http://themuscledoc.com/Check out my Tweets: https://twitter.com/the_muscle_docLike us on Facebook: https://www.facebook.com/themuscledoc/Follwow me on Instagram: https://www.instagram.com/the_muscle_doc/Check out our videos: https://www.youtube.com/channel/UCzXqjJB345oP7LqrTUB52XQCome see us at: The Muslce Doc241 Polaris Avenue,Mountain View CA, 24043P: (408) 966-7690 These findings have provided the rationale for the early use of internal and ER isometrics or submaximal manual resistance in the scapular plane with low levels of elevation to prevent any subacromial contact early in the rehabilitation process. 14), care must be taken to stabilize the scapula, with the patient supine so that the patients body weight can minimize scapular motion as the examiner uses a posteriorly directed force on the anterior aspect of the coracoid and shoulder. Measured using anteroposterior radiographs, it was 7 to 13 mm in size in patients with shoulder pain3 and 6 to 14 mm in normal shoulders.4 Flatow et al5 have shown that elevation of the humerus leads to predictable and reproducible patterns of subacromial impingement of the rotator cuff tendons against the overlying acromion and coracoacromial ligament. Paley et al22 also published a series on arthroscopic evaluation of the dominant shoulder of 41 professional throwing athletes. This technique is most often referred to as the, Classification and Treatment of Scapular Pathology, Rehabilitation of Acromioclavicular Joint Injuries, Use of Interval Return Programs for Shoulder Rehabilitation, Use of Taping and External Devices in Shoulder Rehabilitation, Modification of Traditional Exercises for Shoulder Rehabilitation and a Return-to-Lifting Program. Impingement or compressive symptoms may be secondary to underlying instability of the glenohumeral joint.13,14 Though relatively common knowledge today, this concept was not well understood or recognized in the medical community even through the mid- to late 1980s. A key technique in the early management of rotator cuff impingement is scapular stabilization. The typical age range for this stage of injury is 25 to 40 years. Adobe PDF Library 15.0 Use of examination procedures to assess the accessory mobility of the glenohumeral joint is of critical importance in guiding this portion of the treatment. Jobe defined three stages in the clinical presentation of internal impingement. Anterior Internal Impingement The second important test to determine the presence of IR ROM limitation is the assessment of physiological ROM. In a Pickle? Figure 14 Technique used to measure more isolated glenohumeral joint internal rotation with the shoulder in 90 degrees of abduction in the coronal plane. Go until tension and hold for 3 seconds and repeat 5 times, Holding the band with both hands and with it wrapped around a doorknob, pinch shoulder blades and pull back towards you as if rowing a boat. The straight posterior force compresses the humeral head into the glenoid because of the anteverted position of the glenoid; this would inaccurately lead to the assumption by the examining clinician that limited posterior capsular mobility is present. Impingement of the undersurface of the rotator cuff on the posterosuperior glenoid labrum may be a cause of painful structural disease in the athlete practicing sports with overhead movement. 5 Rehabilitation of Acromioclavicular Joint Injuries This more-posterior orientation of the tendons aligns them such that the undersurface of the tendons rubs on the posterior-superior glenoid lip and becomes pinched or compressed between the humeral head and the posterosuperior glenoid rim.19 In contrast to patients with traditional outlet impingement (either primary or secondary), the area of the rotator cuff tendon that is involved in posterior or undersurface impingement is the articular side of the rotator cuff tendon. Its extra-articular, internal impingement is intra-articular. Outcomes Research by Kibler et al47 and Roetert et al48 has identified decreases in the total rotation ROM arc in the dominant extremity of elite tennis players correlated with increasing age and number of competitive years of play. Drive your hands into the floor like youre doing a pushup, but keep your arms straight, and move only at If you think about the rotator cuff, its classic impingement with a rotator cuff pathologies is technically external, which means its on the outside or the top layer of the rotator cuff. Treatments for impingement syndrome include rest, ice, over-the-counter The examiner is careful to utilize a posterolaterally directed force (in the direction of the arrow) along the line of the glenohumeral joint. Neer1,2 has outlined three stages of primary impingement as it relates to rotator cuff pathology. (flat), type II (curved), and type III (hooked). A type III or hooked acromion was found in 70% of cadaveric shoulders with a full-thickness rotator cuff tear, whereas a type I acromion was only associated with 3% of this group.11 Additionally, in a series of 200 clinically evaluated patients, 80% with a positive arthrogram confirming a full-thickness rotator cuff tear had a type III acromion.12, Impingement or compressive symptoms may be secondary to underlying instability of the glenohumeral joint.13,14 Though relatively common knowledge today, this concept was not well understood or recognized in the medical community even through the mid- to late 1980s. Standard of Care: Shoulder Impingement ICD 9 Codes: 726.10 - Rotator cuff syndrome of shoulder and allied disorders 840 - Sprains and strains of shoulder and upper arm Case Type / Diagnosis: Shoulder impingement. In the presence of posterior capsular tightness, the humeral head will shift in an anterior-superior direction, as compared with a normal shoulder with normal capsular relationships. endstream endobj 488 0 obj <. A key technique in the early management of rotator cuff impingement is scapular stabilization. If measurement of that patients nondominant extremity rotation, however, reveals 90 degrees of ER and 60 degrees of internal rotation, the current recommendation based on the total rotation ROM concept would be to avoid extensive mobilization and passive stretching of the dominant extremity because the total rotation ROM in both extremities is 150 degrees (120 ER + 30 IR = 150 dominant arm/90 ER and 60 IR = 150 total rotation non-dominant arm). This occurs from repeated episodes of mechanical inflammation and can include thickening or fibrosis of the subacromial bursae. Direct visualization during arthroscopy revealed undersurface tears of the rotator cuff due to the contact that occurs between the anterosuperior labrum and undersurface of the rotator cuff, similar to that described by Walch et al19 in posterior impingement. Download a Guide to our Shoulder-Saving Procedures. The straight posterior force compresses the humeral head into the glenoid because of the anteverted position of the glenoid; this would inaccurately lead to the assumption by the examining clinician that limited posterior capsular mobility is present. default The development of the concept that impingement could occur secondary to instability, rather than as a primary cause, has had significant ramifications altering evaluation methods and treatment/rehabilitation.15,16 388 0 obj <>stream Protocol R1 Non-Operative Rehabilitation Program for Acute Glenohumeral Joint Dislocation. There can be additional harm caused by the posterior deltoid if the rotator cuff is not functioning properly. To further illustrate the role of ROM and passive stretching during this phase of the rehabilitation, Figures 15 and 16 show versions of clinical IR stretching positions that utilize the scapular plane and can be performed in multiple and varied positions of glenohumeral abduction. Lucas7 estimated this force at 10.2 times the weight of the arm. Sitting or standing up straight, pinch shoulder blades together as if pinching a peanut between them. Internal (posterosuperior) impingement syndrome is typified by a painful shoulder due to impingement of the soft tissue, including the RC, joint capsule and the posterosuperior part of Modalities such as electrical stimulation, ultrasound, and iontophoresis can be applied to promote improved blood supply and decrease pain levels; however, a clearly superior modality or sequence of modalities for the early management of tendon pathology in the human shoulder is lacking. 4 Rehabilitation of Adhesive Capsulitis nonsurgical treatment for shoulder impingement. Due to the increased humeral head translation, the biceps tendon and rotator cuff can become impinged secondary to the ensuing instability.13,14 A progressive loss of glenohumeral joint stability is created when the dynamic stabilizing functions of the rotator cuff are diminished from fatigue and tendon injury.14,17 The effects of secondary impingement can lead to rotator cuff tears as the instability and impingement continue.3,14. Learn about procedures that can help you return to sports & delay or avoid an artificial shoulder replacement. Stage Iedema and hemorrhageresults from the mechanical irritation of the tendon; this is caused by impingement incurred from overhead activity. Paley et al22 also published a series on arthroscopic evaluation of the dominant shoulder of 41 professional throwing athletes. Neers stage III impingement lesion, termed bone spurs and tendon rupture, is the result of continued mechanical compression of the rotator cuff tendons. To rehabilitate the patient with glenohumeral joint impingement requires a careful, systematic evaluation to identify the type of impingement and, more importantly, to determine the underlying cause of the impingement to ensure that an evidence-based nonoperative rehabilitation program can be developed. Peak forces against the acromion were measured in a range of motion (ROM) between 85 degrees and 136 degrees of elevation.8 This position is a functionally important one for daily activities, sport-specific movements,9,10 and situations commonly encountered on a job as well. Several proposed mechanisms have been discussed attempting to explain this glenohumeral ROM relationship of increased ER and limited IR.33,45,46The tightness of the posterior capsule as well as the muscle tendon unit of the posterior rotator cuff has been believed to limit internal glenohumeral joint rotation. Activation of the serratus anterior and lower trapezius force couple is imperative to enable scapular upward rotation and stabilization during arm elevation.29 Rhythmic stabilization applied to the proximal aspect of the extremity progressing to distal with the glenohumeral joint in 80 to 90 degrees of elevation in the scapular plane (Fig. Anterior internal impingement has recently been described as a source of pain in patients with a stable shoulder and positive traditional impingement signs.23 Struhl23 reported this phenomenon during arthroscopic evaluation of patients who had clinical signs of traditional outlet impingement and anterior-based pain presentations. Described by Dr. Stone as a "gift to his patients," this short, weekly blog focuses on sports, performance, & orthopaedic care. If you would like help relieving your shoulder pain, our team of highly-trained therapists can alleviate the pain with personalized 1:1 physical therapy sessions. In all types of impingement listed above, scapular dysfunction either can be the underlying cause or can greatly exacerbate the impingement process with altered scapular kinematics in patients with both rotator cuff instability and impingement.2426 Initial rehabilitation begins with the protection of the rotator cuff from stress but not function. Figure 11(A, B) Manual scapular stabilization in sidelying position for scapular retraction (A), and protraction (B). Peak forces against the acromion were measured in a range of motion (ROM) between 85 degrees and 136 degrees of elevation.8 This position is a functionally important one for daily activities, sport-specific movements,9,10 and situations commonly encountered on a job as well. 2017-11-09T08:49:37-06:00 Clinical application of the total rotation ROM concept is best demonstrated by a case presentation of a unilaterally dominant upper-extremity sports athlete. In this chapter, the main types of rotator cuff impingement are discussed together with both general and specific rehabilitation principles and strategies based on the available evidence. Call for information or to book an appointment to see us in person. Approximately 10 degrees less total rotation ROM can be expected in the dominant arm of the uninjured elite junior tennis player as compared with the nondominant extremity. Recently, my colleagues and I measured the bilateral total rotation ROM in both professional baseball pitchers and elite junior tennis players.33 Our findings showed the professional baseball pitchers to have greater dominant arm ER and significantly less dominant arm IR when compared with the contralateral nondominant side. In all types of impingement listed above, scapular dysfunction either can be the underlying cause or can greatly exacerbate the impingement process with altered scapular kinematics in patients with both rotator cuff instability and impingement.2426 Initial rehabilitation begins with the protection of the rotator cuff from stress but not function. Figure 12 Rhythmic stabilization performed with scapular protraction. Each utilizes an inherent anterior hand placement; this gives varying degrees of posterior pressure to minimize scapular compensation and to provide a check against anterior humeral head translation during the IR stretch. Several authors recommend measurement of glenohumeral IR with the joint in 90 degrees of abduction in the coronal plane.3941 During IR ROM measurement (Fig. Shoulder impingement usually takes about three to six months to heal completely. More severe cases can take up to a year to heal. However, you can usually start returning to your normal activities Figure 13 Posterior glenohumeral joint translation test at 90 degrees of abduction in the scapular plane. This can occur from repetitively moving the shoulder into a stressful or suboptimal positioncommon in climbing. Additionally, with this technique a protracted scapular position can be utilized to increase the activation of the serratus anterior muscle30,31; several studies have identified decreased muscular activation of this muscle in patients diagnosed with glenohumeral impingement and instability.25,32. Additionally, Crockett et al45 have shown unilateral increases in humeral retroversion in throwing athletes, which would explain the increase in ER with accompanying IR loss. I Recently, my colleagues and I measured the bilateral total rotation ROM in both professional baseball pitchers and elite junior tennis players.33 Our findings showed the professional baseball pitchers to have greater dominant arm ER and significantly less dominant arm IR when compared with the contralateral nondominant side. In this chapter, the main types of rotator cuff impingement are discussed together with both general and specific rehabilitation principles and strategies based on the available evidence. Placement of the shoulder in the 90/90 position causes the supraspinatus and infraspinatus tendons to rotate posteriorly. These effects of altered posterior capsular tension on in vivo posterior glenohumeral joint capsular tightness highlight the clinical importance of utilizing a reliable and effective measurement methodology to assess IR ROM during examination of the shoulder. Results showed even submaximal contractions increased perfusion during all 1-minute contractions; but they also produced a postcon-traction latent hyperemia following the muscular contraction. Specific changes in the program will be made by the physician as appropriate for the individual patient. Why? The understanding of this new clinical entity is essential for both diagnosis and treatment of patients with the clinical appearance of outlet impingement and an anterior pain presentation. Patients with secondary rotator cuff impingement due to underlying instability cannot receive accessory mobilization techniques to increase mobility because this would only compound their existing capsular laxity. A common error in this exam technique is the use either of the coronal plane for testing or of a straight posteriorly directed force by the examiners hand rather than the recommended posterolateral force. So its on the undersurface of the rotator cuff now. Contact us at (415) 563-3110 for an appointment. In these professional throwing athletes, 93% had undersurface fraying of the rotator cuff tendons and 88% showed fraying of the posterosuperior glenoid. Posterior, Internal, or Undersurface Impingement Figure 14 Technique used to measure more isolated glenohumeral joint internal rotation with the shoulder in 90 degrees of abduction in the coronal plane. Significant advances in basic research in the anatomy and biomechanics of the human shoulder have led to the identification of multiple types of impingement, each with underlying pathomechanical causes. Dines JS, Frank JB, Akerman M, Yocum LA. Stage Iedema and hemorrhageresults from the mechanical irritation of the tendon; this is caused by impingement incurred from overhead activity. Full-thickness tears of the rotator cuff, partial-thickness tears of the rotator cuff, biceps tendon lesions, and bony alteration of the acromion and acromioclavicular joint may be associated with this stage.12 In addition to bony alterations that are acquired with repetitive stress to the shoulder, the native shape of the acromion is of relevance. Measured using anteroposterior radiographs, it was 7 to 13 mm in size in patients with shoulder pain3 and 6 to 14 mm in normal shoulders.4 Flatow et al5 have shown that elevation of the humerus leads to predictable and reproducible patterns of subacromial impingement of the rotator cuff tendons against the overlying acromion and coracoacromial ligament. Manual Therapy. Mike Reinold: With more-extensive amounts of posterior capsular tightness, the humeral head was found to shift posterosuperiorly. Results showed even submaximal contractions increased perfusion during all 1-minute contractions; but they also produced a postcon-traction latent hyperemia following the muscular contraction. The presence of anterior translation of the humeral head with maximal ER and 90 degrees of abduction, which has been confirmed arthroscopically during the subluxation-relocation test, can produce mechanical rubbing and fraying on the undersurface of the rotator cuff tendons. An additional type of impingement more recently discussed as an etiology for rotator cuff pathology that can often progress to an undersurface tear of the rotator cuff in the shoulder of a young athletic patient is termed posterior, internal or inside, or undersurface impingement.18,19 This phenomenon was originally identified by Walch et al19 upon performing shoulder arthroscopy with the shoulder placed in the 90 degrees of abduction and 90 degrees of external rotation (ER) (90/90) position. Figure 12 Rhythmic stabilization performed with scapular protraction. fraying of posterior rotator cuff (supraspinatus-infraspinatus interval) posterior and superior labral lesions. 487 0 obj <> endobj 1 Rehabilitation of Shoulder Impingement: Primary, Secondary, and Internal Figure 11A shows the specific technique I use with my patients to resist scapular retraction manually. The total rotation ROM did differ between extremities. The posterior deltoids angle of pull compresses the humeral head against the glenoid, accentuating the skeletal, tendinous, and labral lesions.18 Walch et al19 arthroscopically evaluated 17 throwing athletes with shoulder pain during throwing and found undersurface impingement that resulted in eight partial-thickness rotator cuff tears and 12 lesions in the posterosuperior labrum. Stage II compressive disease outlined by Neer is termed fibrosis and tendonitis. Wall Slides. uuid:1670d8ce-a002-1740-aa91-1bca29250ba9 Adobe InDesign CC 13.0 (Macintosh) If you would like help relieving your shoulder pain, our team of highly-trained therapists can alleviate the pain with personalized 1:1 physical therapy sessions. Perform 15 - 20 reps, Stand with a towel rolled underarm, your elbow bent 90, and the Theraband across the front of you and attached to a door. Neers stage III impingement lesion, termed bone spurs and tendon rupture, is the result of continued mechanical compression of the rotator cuff tendons. Rehabilitation Guidelines for Posterior Shoulder Reconstruction with or without Labral Repair PHASE III (begin after meeting Phase II criteria, usually 8 weeks after surgery) Appointments To determine the tightness of the posterior glenohumeral joint capsule, an accessory mobility technique to assess the mobility of the humeral head relative to the glenoid is recommended. Primary impingement, also known as compressive disease or outlet impingement, is a direct result of compression of the rotator cuff tendons between the humeral head and the overlying anterior third of the acromion, cora-coacromial ligament, coracoid, or acromial-clavicular joint.1,2 The physiologic space between the inferior acromion and superior surface of the rotator cuff tendons is termed the subacromial space. A very common pathology in overhead-throwing athletes is posterior shoulder pain resulting from internal impingement. #5. They found, with either imbrication of the inferior aspect of the posterior capsule or imbrication of the entire posterior capsule, that humeral head kinematics were changed or altered. How do you repair it? Biomechanical analysis of the shoulder has produced theoretical estimates of the compressive forces against the acromion with elevation of the shoulder. The development of the concept that impingement could occur secondary to instability, rather than as a primary cause, has had significant ramifications altering evaluation methods and treatment/rehabilitation.15,16, Attenuation of the static stabilizers of the glenohumeral joint, such as the capsular ligaments and labrum from the excessive demands incurred in throwing or overhead activities, can lead to anterior instability of the glenohumeral joint. 0 Clinical application of the total rotation ROM concept is best demonstrated by a case presentation of a unilaterally dominant upper-extremity sports athlete. Hold 15 seconds and repeat 5 times, Holding onto a table with fingertips and arm relaxed, stand up and away from arm to distract arm from shoulder. 2 Rehabilitation of Micro-Instability Halbrecht et al21 has confirmed via magnetic resonance imaging (MRI) that physical contact of the undersurface of the supraspinatus tendon against the posterior-superior glenoid was found in 10 collegiate baseball pitchers when their pitching arm was placed in the position of 90 degrees of ER and 90 degrees of abduction. Explore all your options. Rotator cuff injury A more severe cause of posterior shoulder pain could be a rotator cuff injury. Biomechanics and theories of pathology. Table 11 contains the descriptive data from the professional baseball pitchers and elite junior tennis players.33 More research including additional subject populations is needed to outline the total rotation ROM concept further. Among several other pathologies, calcific tendinopathy of the rotator cuff tendons is frequently observed during the ultrasound examination of patients with painful shoulder. Equally important is which extremity should not experience additional mobility due to the obvious harm induced by increases in capsular mobility and increases in humeral head translation during aggressive upper-extremity exertion. Poppen and Walker6 calculated this force at 0.42 times body weight. The shoulder is known as a ball and socket joint; this type of joint is comparable to a golf ball on its tee. However, patients with primary impingement often present with underlying capsular hypo-mobility and are definite candidates for specific mobilization techniques to improve glenohumeral joint arthrokinematics. The primary symptoms and physical signs of this stage of impingement or compressive disease are similar to the other two stages and consist of a positive impingement sign, painful arc of movement, and varying degrees of muscular weakness.2. The goal of treatment for shoulder impingement syndrome is to reduce your pain and restore shoulder function. Indications for Treatment: Subacromial impingement with rotator cuff tendinopathy is a very common condition Anterior internal impingement has recently been described as a source of pain in patients with a stable shoulder and positive traditional impingement signs.23 Struhl23 reported this phenomenon during arthroscopic evaluation of patients who had clinical signs of traditional outlet impingement and anterior-based pain presentations. Figure 11A shows the specific technique I use with my patients to resist scapular retraction manually. top. It is important to use consistent measurement techniques when documenting ROM of glenohumeral joint rotation. SHOULDER INTERNAL IMPINGEMENT NON-OPERATIVE GUIDELINES Phase 1: Recovery (Weeks 1-2) Restoration of posterior shoulder flexibility . 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