Presented by: Dr. Brad M. Gilden, DPT, MS PT, CFMT, CSCS

1. Recognition & Prevention of Shoulder Impingement March 20th, 2013 Presented by: Dr. Brad M. Gilden, DPT, MS PT, CFMT, CSCS

2. Human Body Built for bi-pedal movement. Problems with prolonged sitting Reinforces poor postural habits Shoulder injuries Epidemiology – 2nd only to LBP Impingement most common 2 Requests

3. Agenda • Functional Shoulder Anatomy • Function of Rotator Cuff • Shoulder Stability • Posture – Normal vs Poor • Shoulder Impingement – What is it and why should I care? • Pain and Inflammation • The Gym can help me injure my shoulder! • Exercise – Compare and Contrast “Good” vs “Bad” • Preventative & Postural Exercises • When to seek Medical Help? • Appendix • A. Sports Specific Exercises B. Muscle List C.& D Nutrition

4. Anatomy/Biomechanics • Full shoulder flexion = 180° • Not accomplished by just GHJ • Full arm elevation involves… • Upper thoracic extension • 1st and 2nd ribs must depress and move posterior • Scapula needs to rotate upwards • Clavicle needs to elevate and roll backwards • Glenohumeral joints needs to glide downward and roll upward • Old Injuries can play a roll – ex. Scar Tissue from Abdominal surgery

5. Shoulder Girdle 1. Acromial-Clavicular Joint 2. Sterno-Clavicular Joint 3. Scapulothoracic Joint 4. Gleno-humeral Joint

6. Static Stabilization • Increased Mobility = Decreased Stability • Large Humeral Head vs. Small Glenoid Fossa • Labrum - fibrocartilagenous circle attaching glenohumeral ligaments.

7. What’s it called? Rotor Cup Rotator Cuff • Supraspinatus – Abduction • Infraspinatus – External Rotation • Subscapularis – Internal Rotation • Teres Minor – External Rotation Shoulder Stabilization

8. Dynamic Stability • Deltoid “Prime Mover” • Anterior Stability of GHJ – Subscapularis, supraspinatus • Posterior Stability of GHJ – Infraspinatus and teres minor

9. Shoulder Stability Continued • Synergistic action of Rotator Cuff SST IST Sub Teres

10. Secondary Stabilizers • Long Head of the Biceps brachii- • Serratus Anterior – Laterally rotates and protracts scapula

11. POSTURE • What is good posture? • Vertebrae Stack properly • Joints aligned • Muscles @ normal Resting Length • Reduced tension • Vertical Compression Test • Importance of Good Posture • Promotes movement efficiency • Good Neuro-muscular control • Reduce need for compensatory movements • Three natural curves • Muscles – Flexible yet strong

12. Posture • We are a product of our environment • Flexion, flexion and more flexion • Affect on Vital Organs • Shoulder Flexion Test • Impact Test

13. Shoulder Impingement • What causes shoulder impingement? Theory # 1: Mechanical-anatomic • Overuse • Fibrosis forms • Bony changes, spurs on humeral tuberosity • LEADS to RTC tears Theory #2: Vascular compromise • Increased stress to RTC • Inflammatory response • Scar tissue or calcific deposition • Poor repair secondary to poor vascularity • Leads to tear of tendon • Combined effect of poor blood flow and continued stress does not allow for adequate maturation of healing tissue

14. Impingement Continued • Theory #3: Kinesiological – poor neuromuscular control and limited scapular movement • Reflex inhibition and or disuse • Proper rotator cuff strengthening is essential to prevent disuse/RI • MEDICAL INTERVENTION • Implications of steroid injections –Anti-anabolic effect on connective tissue (Not Mark Maquire’s Steroids…) • Local steroids will relieve pain through inhibiting inflammatory response – may result in weakening of the injected tendon • Proceed gradually with strengthening

15. INFLAMMATION Pain is an output, not an input. Inflammation is a necessary process for healing Chronic inflammation is a problem a. Irritation to nerves and surrounding tissues b. Inhibition of core muscle contractions  Instability and compensatory patterns c. Breakdown of healthy tissue How to deal with Inflammation Best anti-inflammatory - good postural alignment Proper Nutrition - Acidic vs. Alkaline (Appendix C & D) Avoidance of irritating movements (no pain no gain is nonsensical) Hydration Ice (other modalities) NSAIDS (Topical or Oral) Steriodal anti-inflammatories (Rx required) Minimally Invasive Surgical intervention – PRP/Regenokine

16. Gym Woes • Rarely Good the Bad and the Ugly BAD UGLY

17. Preventative Exercises • Stretch, don’t overstretch! • Add an Isometric contraction to your stretch. • If radicular signs are present, Do Not Stretch – Good time for PT consultation • Neck Stretches • General Rule: Stay away from cervical extension 1. Chin Tuck – Axial Extension • Purpose: To achieve neutral position of cervical spine and to strengthen cervical extensor muscles • Remember Axial elongation is necessary for full shoulder ROM • Shoulders should be relaxed. Chin should tuck down & back. You can use a finger on the chin as a guide • A verbal cue is to lengthen your neck, crown of head toward the ceiling

18. Postural Exercises • ELBOW FLEXION TEST • Pivot Prone – Postural Exercise Purpose – Aligns shoulder girdle properly over ribcage, taking tension off of neck. • Head/Neck neutral, shrug shoulders 1/3 way up, turn palms back while pinching shoulder blades, then reach fingers toward the floor. • Hold this position for 10 seconds • Doorway Stretch Purpose – Elongate pec minor muscle • Place R or L forearm against doorframe, and place opposite hand over corocoid process (just inside to front shoulder). Abdominals should be tight with head in neutral position (axial elongation) • Stagger feet, and slowly lean into wall until stretch is felt. Hand on front of coracoid blocks shoulder from coming forward • Press forearm into wall and hold for 3 seconds, slowly release and take up the slack into the new range of motion. • Repeat 3-5 times

19. Postural Exercises Axial Elongation Place fingers along center of neck over spinous processes Make fist and place thumb under chin. Lightly press tongue to roof of mouth and press spinal segments back into fingers and tuck chin. Think of elongating the neck. Once in position, apply force with fingers on spine forward and thumb up toward ceiling. Head/Neck should not move. Hold 20 seconds and repeat as prescribed by therapist/trainer ALTERNATIVE – Repeat as above but use theraband instead Pivot Prone Against Wall Stand against wall with knees slightly bend and pillow behind neck/head. Palms facing the wall. Place buttocks against wall and draw stomach in pressing lumbar spine into wall and progressing upwards until entire spine is touching the wall and neck in axial elongation. Maintain this position of spine, lift shoulders up, turn palms forward (thumbs back) and pinch shoulder blades together, then reach fingers toward floor dropping shoulders into place. Hold this position for 30s/60s/90s or as prescribed by your therapist/trainer

20. Exercises for Shoulder Pain Glenohumoral Joint Setting – “The Vacuum” Band above door, place high into arm pit b. Using just the RTC muscles (no pecs or lats), suction the shoulder in toward the body against the band and hold for 5 seconds c. Slowly release, then repeat suction motion and hold while providing an isometrically resisted force on the outside of the wrist and hold 5 sec d. Repeat as prescribed by your therapist/trainer Pivot Prone With palms back, head/neck neutral, elevate shoulders slightly Rotate palms forward/thumbs back and pinch shoulder blades together. Reach hands toward the floor, being sure not to elevate the sternum. Hold 10 seconds, then relax Repeat throughout the day at least once every ½ hour

21. Exercises for Shoulder Pain Shoulder Clocks – Keep in pain free range a. Pretend the shoulder is a clock, begin in the center of the clock and move the shoulder up to 12:00 (toward ceiling), then back to center. b. Progress toward 1:00 (toward nose), then return to center and continue around the clock hitting each number. c. Once back to start, repeat in opposite direction Pendulums – Distraction and relaxation for shoulder Lean over table or counter and let arm completely dangle toward floor With legs wide, begin to weight shift into your legs right and left, creating momentum that lets your arm swing. Repeat with legs shifting front to back to have arm swing fwd/back. Can also repeat in circles. Repeat for 1-3 minutes ** KEY: Must remain relaxed in the shoulder and leg your body do the work A. Neck Clocks Active figure 8’s (If acute) Begin with eye motions into small figure eight patterns Start with very slow small figure eights or making infinity sign with nose, and slowly increase range of motion to lubricate neck Repeat for 30 seconds

22. OUR GIFT TO YOU

23. Shoulder Stretching C. Arm Circles on side – Improves mobility of entire upper extremity Lie on right side with top leg bent and left hand resting on knee of right leg. Reach right hand toward floor keeping head/eyes on hand throughout exercise Bring arm around body in wide circle with head following As arm comes over head inhale, exhale as arm comes down. Repeat 10x’s clockwise & 10x’s counter clockwise D. Sleeper Stretch – To improve posterior capsule and IR Lie on right or left side with arm out at 90° Roll onto shoulder until a tightness is felt behind shoulder Bend elbow to 90° and place left hand over wrist Bring arm slowly toward floor until stretch is felt. Perform isometric by pushing right hand into wrist, not allowing movement to occur – Hold 5 seconds Relax, and push further into more internal rotation Repeat 5 times Do not push through pain

24. Strengthening • Dumbell or Front Squats • Straight arm pull-downs • Standing Rows • RTC strengthening • External Rotation • Internal Rotation

25. Strengthening • I’s, Y’s, T’s & Advanced W’s • Bent Over Rows • Single Arm Rows • Prone T-band ER

26. What’s more fun than a plank?

27. How should I know if I need PT? • Pain with shoulder movements without resistance • Pain waking you up at night • Experience numbness or tingling down arm or scapula • Shoulder Pain with neck movements • Suffered fall or accident and has persistent shoulder pain > 3 days • Lingering shoulder pain (3 weeks or more) that seems to be staying the same or getting worse.

28. Appendix A Sport Specific Exercises Need to strengthen muscles responsible for deceleration – eccentric muscle control!!!

29. Appendix B What am I Training? • External Rotation – Infraspinatus and Teres minor • Internal Rotation – Subscapularis & Pectorals • Prone lateral raise with thumb up – Rhomboid • Prone lateral raise thumb down – Mid trapezius • Prone scaption thumb up – Lower trapezius • Prone scaption thumb down - Supraspinatus • Scaption - Supraspinatus

30. Appendix C

31. Appendix D

32. Questions???