Be sure to convert to your own time zone at www.worldhealthwebinars.com.au PREVIEW ONLY These notes are a preview. Slides are limited. Full notes available after purchase from www.worldhealthwebinars.com.au The Sporting Shoulder With Andrea Mosler B. App. Sc (Physiotherapy) M. App. Sc (Sports Physiotherapy) Andrea Mosler - Specialist sports physiotherapist - Australian Institute of Sport - Sports medicine coordinator for National women’s Water Polo - Olympic Water Polo Physiotherapist since 2000, 2004 and 2008 - Professional interests include management of disorders of the shoulder complex and hip and groin injuries. Introduction four articulations all move together to provide synchronous motion Examine all components of shoulder complex Glenohumeral Joint
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The Sporting Shoulder With Andrea Mosler
B. App. Sc (Physiotherapy) M. App. Sc (Sports Physiotherapy)
Andrea Mosler
- Specialist sports physiotherapist
- Australian Institute of Sport
- Sports medicine coordinator for National women’s Water Polo
- Olympic Water Polo Physiotherapist
since 2000, 2004 and 2008
- Professional interests include management of disorders of the shoulder
complex and hip and groin injuries.
Introduction
four articulations
all move together to provide
synchronous motion
Examine all components of shoulder
complex
Glenohumeral Joint
Ligaments
considerable variation in all studies
primary restraint at EOR
tightening of the capsule results in
coupled translations and rotations
capsular and tonal imbalance can
interfere with these coupled motions
Inferior glenohumeral ligament complex
O’Brien et al 1990
Static stability
ligaments act as static passive restraints at EOR
anterior support shifts from superior to inferior structures with elevation
HOH should remain centred in glenoid except in cocking position (Howell et al 1988, Bowen et al 1992, Shiffern et al
2002)
HOH relocated to the centre of glenoid with horizontal flexion
potential shearing stress on the artic cartilage and labrum
Static stability of HOH
O’Brien et al 1990
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von Eisenhart-Rothe
O’Brien et al 1990
Jobe and Pink 1991
Dynamic stability
• primary stabilising mechanism in mid-range
• resting muscle tone (Shiffern et al 2002)
ROTATOR CUFF
• maintain HOH in glenoid cavity, and ↑capsular stiffness
• large collagen component to subscap tendon
• feedback loop between ligaments and RC
• LHB contributes to anterior stability through ↑ torsional tension
• Emerging evidence!
Rodosky et al 1994
Long head of biceps complex PREVIEW ONLY
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Long head of biceps
Pagnani et al 1996
Anatomical Connections
Scapular rotators
• scapula supported by muscles and ligaments
• full elevation requires adequate stability and
rotation of the scapula
• position the scapula and stabilise it against the
thoracic cage
• place the scapula under the HOH so
movements occur with the maximum stability
Must have effective and balanced function of
all these muscles for normal scapular
motion and scapulothoracic/glenohumeral
synchrony
Scapular Rotators PREVIEW ONLY
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Biomechanics of arm elevation
• Large variation
between and
within individuals
• Overall ratio of 2:1
• 3 phases of rotation
• Axis of scapular rotation moves from
RSS→ACjt
Scapular Mechanics
Kinetic chain
allows generation, summation, transfer and
regulation of forces from legs to the hand and thus to
the object
sequential involvement of each link required to create
the energy, produce the force and stabilise the joints
for optimum performance without injury
shoulder is often the link that breaks
FAILURE IN ONE LINK FAILURE IN ANOTHER
Contributions of the force and
kinetic energy of the chain
Link Acc (m/s) %kinetic
energy
%force
Hip/trunk 13.5 51 54
Shoulder 33 13 21
Elbow 53 21 15
Wrist 65 15 10
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Six stages of throwing
Kvitne et al 1995 Shortcut to VTS_13_1.VOB.lnk
Rizzo 2006.m4v
Martial Arts/Wrestling PREVIEW ONLY
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Sporting Shoulder Injuries
• Acute injuries/contact
• Overuse injuries
• Mixed
• Degenerative conditions
• Arthropathies
Sporting Shoulder Injuries
• Acjt, Scjt injuries
• Snapping scapula
• Rotator cuff/LHB tendinopathy
• Impingement- internal vs SAS;1° and 2°
• Labral Injuries
• Nerve Injuries
• Instability
AC jt injuries
• Mechanism- usually
(70%) from a direct
blow to point of
shoulder, but also
indirect mechanism
from FOOSH
• Injuries classified as
Type 1-6 (Rockwood
1996)
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AC jt injury classification Type I: partial tear AC ligt but no change
in position of the distal clavicle wrt acromion.
Type II: Rupture AC ligt with partial tear of
C-C ligts. Distal end clavicle displaced wrt acromion but < full width of the clavicle
Type III: Rupture AC ligt with partial tear of C-C ligts. Distal end clavicle displaced wrt acromion but >full width of the clavicle
Type IV: Rupture all ligts with post displacement distal clavicle through aponeuroses of trapezius.
Type V: Distal clavicle severely displaced superiorly toward base of the neck, covered only by skin and subcutaneous tissue, complete rupture of the deltoid- trapezius musculature
Type VI: Inferior dislocation of clavicle under either acromion or coracoid process
AC jt injuries
Most studies demonstrate favourable results with
conservative management for all but really
severe injuries (Type 4-6)
Distal clavicle osteolysis (DCO) and
OA can also be cause of
symptoms, especially in
athletes
Beware of stress #
(Constantinou and Kastanos 2008)
Scjt Injuries
• Acute injuries
• Rare, but can be
life threatening!
• Overuse instability
Hoekzema et al 2008
Specific pathomechanics thrower’s
shoulder
• Scarring/tightening posterior shoulder
(?structures) + bony changes →→↓GH internal
rotation range (GIRD)
• Abnormality in coupled movements, migration of
glenoid contact point
• ↑Load dynamic stabilisers
• Dysfunctional sensorimotor acuity
• Damage to labrum
• ?? Stretching of anterior capsule
• ??Uncontrolled translation HOH
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Rotator cuff/LHB pathology
• ??Inflammation (bursa)
• Impingement- cause or effect???
• Degenerative process
• Partial→full thickness tears
• Most tears on articular surface, near
insertion (??critical zone, also area of
↑load) ?poor vascularisation a factor
• trauma can also occur
Rotator Cuff pathological process
• Similar deg process to other tendons
• Large compressive component to load and
?progression of pathology
• Neer- 3 Stages of impinge/RC disease; is
not supported with current literature
• Deg changes ↓ tendon capacity to cope
with tensile and compressive loads
Rotator Cuff tendinopathy
• Need to understand and embrace current
concepts of tendon pathology and
management and apply it to the shoulder
Specifically;
• Mechanotransduction
• Pathological process/staging
• Pain mechanisms
• Adapt current management methods for
tendinopathy in other parts of the body
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AC
SST
HOH
Supraspinatus tendinopathy SAS Impingement PRIMARY- is this a clinical entity?
• Os acromiale
• Variation in acromion shape/size, deg
• CAL thickening
• Acjt degenerative changes
• Swelling, fibrosis and/or thickening of subacromial bursa
SECONDARY
• Xs superior migration of the HOH due to muscle imbalance or structural changes
• Rotator cuff tendinopathy continuum
bony spur on the inferior
surface of the acromion Superior migration of HOH
Congenital or acquired?
Achilles Enthesis organ (Shaw and Benjamin 2007)
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Internal Impingement
Elevation/ER
Pinching between HOH and post-sup edge glenoid rim
Undersurface fraying RC
Labral,?osteochondal changes
Flexion
Sup-ant glenoid and sup translated HOH with type II SLAP