Restricted Shoulder Abduction (Full Version)

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apolipo -> Restricted Shoulder Abduction (September 13, 2005 9:24:00 AM)

Here is my dilemma. I seem to be constantly treating shoulder problems with a variety of diagnoses: RCT both before and after repair, OA, tendinitis, adhesive capsulitis, and everybodies favorite "shoulder sprain".

In general, results are good (decreased pain, increased motion, RTW). The trouble comes with shoulder abduction, or more specifically, humeral head inferior glide. Many of my pts. seem to get stuck at 90ish degrees abduction and have difficulty progressiong past this. As I watch them abduct, it appears the humeral head does not want to glide down.

I do GH inferior glides, both static and oscillatory. I work on scapular upward/cranial rotation in multiple positions (against gravity and gravity eliminated) and with and without therapist assist. I also work on other scapular motions (retraction, inferior glide, protraction). I have frequently tried Mulligan's MWM for flex/abd without a great deal of success. I check the AC jt., but probably not consitently enough.

Any thoughts/suggestions?

mike t



lesain -> Re: Restricted Shoulder Abduction (September 13, 2005 10:25:00 AM)

Mike, you must evaluate the rotator cuff. May be this cuff are weak and the humerus do not go down and the bursa is pressed.
In this case you must strengthen it.
Good luck



FLAOrthoPT -> Re: Restricted Shoulder Abduction (September 13, 2005 10:40:00 AM)

even more probable, poor stab of scapulae, treat the scap, watch these people try to lift and their motor control is all jacked up



jma -> Re: Restricted Shoulder Abduction (September 13, 2005 2:28:00 PM)

Yes, stabilize the scapula muscles. Watch the scapular movement and see where the weakeness are. Example, see rising scapula, get the depressors strong again.



coloradojulie -> Re: Restricted Shoulder Abduction (September 13, 2005 5:49:00 PM)

A recent study showed that excessive upper trap activation occured at 90 and peaked at 120 with a relatively poor low trap activation. Release work and education for relaxation in antigravity or active assist positions is good, along with low trap strength work at end range.

Restriction at 90 is most likely capsular and anything above 120 is subscap or posterior inferior glenohumeral ligament. Add a posterior component to your inferior glide and do it at end range. Several posterior glide positions. If internal rotation is less than 60 in abduction with scap and humeral head stabilized this can also pin point posterior capsular tightness. The sleep stretch is a good home program. Self mobilization for inferior glide is placing the hand on the wall at the restricted, pain free level and pressing down as if trying to return the arm to your side...this creates an inferior glide.

If there is a significant difference between IR and ER strength, ie. IR alot stronger than ER, the stabilization of the GH joint is compromised. This is usually accompanied by an over use of the trap and deltoid leading to compression in a superior direction (impingement) rather than the perpendicular forces of stabilization. Balancing the IR and ER is important. The most isolating exercise for ER is sidelying, top arm the exercising arm. Elbow adducted and flexed to 30 degrees. Externally rotate the weight with a focus on eccentric lowering (slowly) repeat to fatigue two sets. A good functional goal is 2 sets of 15-20 with 5-8 pounds, more with a high level athlete.

If the scapula is sitting anteriorly ie. tight pec minor (pec major does not attach to the scapula) and weak scapular retractors, then the true axis of movement or the scapular plane is more anterior. As a result abduction posterior to the "new" scapular pain is often pain full due to the excessive anterior capusular load with the resultant shift of the humeral head. Measure abduction slightly forward of the body (up to 30 degrees. If it improves or is higher this could be an issue. Release the pec minor (carefully so as not to continue aggravation of the anterior structures...corner stretch terrible for this) and strengthen scapular musculature. Re-edcuate as to scap-humeral mechanics to diminish overload to the Gh joint...share the burden with the scapula.

Thoracic kyphosis can also aggravate the above posture. Often releasing or moblizing the TS and improving TS extension will help shoulder ROM.

Excessive downward rotation of the scapula caused by overuse of rhomboids could also be approximating the acromion with the humeral head with elevation. Restoring upward rotation of the scapula can help. Serratus work could be beneficial (best done at 120 degrees of flexion) prone or on an incline bench (MMT in supine at 90 and 120). Should be rock solid if you can break it it could be a problem. I think is it more a proprioception problem than true weakness...Lower trap as well. Best positions are prone arms 90/90 and flexed above the head, thumb up. Eccentric focus again, try weight of arm than add weights...

Donatelli is a great reference for this stuff...and it works...and is very evidence based



FLAOrthoPT -> Re: Restricted Shoulder Abduction (September 13, 2005 7:00:00 PM)

i do admit that post was too long for me to read at this hour...but do you really think you stretch the IGHL? if so, how? not trying ot be a smart as$, really would like to know



Sebastian Asselbergs -> Re: Restricted Shoulder Abduction (September 14, 2005 1:47:00 AM)

how 'bout leuko tape (or kinesio tape)? Great for poprioceptive facilitation and affectingpatterns..



lesain -> Re: Restricted Shoulder Abduction (September 14, 2005 2:50:00 AM)

Mike,when I strength the serratus, balance IR/ER ( stretching and strengthening ), work on propioception and perform lower descent of humeral head with Kaltenborn I have a very good results.
Ahhh, a question. What anatomical characteristic has the acromion?



Jon Newman -> Re: Restricted Shoulder Abduction (September 14, 2005 3:53:00 AM)

Mike,

When you say "stuck", do you mean that you cannot even passively take them through shoulder abduction?

If so, are they guarding as you take them through a painful spot or are they literally stuck?

jon



apolipo -> Re: Restricted Shoulder Abduction (September 14, 2005 4:57:00 AM)

Thanks for the replies.

I know I can't describe my pts. well enough such that everyone knows exactly what I am talking about, but this is what I often note.

The pt. will usually have significantly improved flex/scaption with reasonably good scapular motion. When I ask them to abduct, I note that there is what seems to be a good beginning to scap upward rot. As I look at the area of the humeral head/acromion, it looks like there is little inf. glide, almost as if the humeral head is rolling upward, rather than pivoting. Imagine the difference between a teeter-totter and a door swinging on a hinge. I get the feeling that the scap would continue to move appropriately if the GH jt was able to continue with normal movement.

I have considered tightness of the teres major, I use inf./post/postlateral glides frequently. I also work on the pec minor to acheive a more retracted scap position.

I see improvements in jt. mobility and ms. length, but often the abd remains restricted. I guess I must strongly consider the neuromuscular role of the RC combining with proper contribution of the traps, rhom, and serratus anterior. This is easier said than done. Any thoughts?

When it comes to the traditional RC exercises, especially for the supraspinatus, they never seen that functional to me. What does laying on your side and performing resisted ER have to do with reaching up and out to the side? I ask this not to insult anyones techniques, just as a genuine question. I know these exercises often get good EMG results, but as I have heard asked before, are they singing or are they screaming?

mike t



JLS_PT_OCS -> Re: Restricted Shoulder Abduction (September 14, 2005 5:32:00 AM)

Mike, I have a self-mobilization exercise for this, if you want it, PM me.
It seems like you are on the right track to me, and I think Julie's post makes good sense also.

Have you looked at the patient from a neurodynamic perspective?
Perhaps this is some restriction of nervous tissue, as we all know very common after shoulder injury/surgery.
Worth a look.

J



dosrinc -> Re: Restricted Shoulder Abduction (September 14, 2005 6:51:00 AM)

One point to consider, if there is a big spur hanging off the underside of the A/C, there is not much any of us can do to restore that ABduction motion.
Rick



apolipo -> Re: Restricted Shoulder Abduction (September 14, 2005 8:05:00 AM)

Jason,

Julie's post was quite good. Better stated than I could have done. I tend to forget about the neurodynamic stuff, despite the fact I just read Shacklock's "Clinical Neurodynamics". I can fall into the trap of "They had surgery for an orthopedic problem, so they should be treated orthopedically".

Rick,

I have thought of the acromion spur also, but many of these pts. have already had surgery, so I would hope any spurs would have been removed. It brings up the question of how long does it take a spur to form?

mike t



coloradojulie -> Re: Restricted Shoulder Abduction (September 14, 2005 8:42:00 AM)

Fla PT...yes I think you can stretch the posterior inferior structures, specifically capsule? I don't have lit to back it up...other than clinical outcomes. There was a case study done on pro baseball players looking at incidence of impingment and shoulder pathology, and they found that with a deficit in interal rotation I think if was less than 60% of external rotation all players had shoulder problems. Of the players who regularly performed a "sleeper stretch" and who did not have this restriction, none had pathology. It was pretty interesting and strong evidence. Was it the capsule? Hard to isolate I am sure. I do know that with prolonged shoulder biomechanical faults the anterior capsule will become lax and the humeral head will shift forward in the glenoid. If it stretchs...why wouldn't the rest of the capsule?

It is hard to say how this happens though...the IPHL getting tight...worked with a former olympic swimmer who had both shoulders repaired after her retirement, and she had significant loss pre op of internal rotation. Pathology was all anterior structures, SLAP etc. It seems that the looser the anterior and more shifted the humerous, the tighter the posterior and the less internal rotation you have.

As far as functional nature of the specific exercise, I asked Donnatelli this, and he had some literature to back up that isolated strength work DID carry over to functional activity. I would have to look that up. He stated that focusing on the eccentric component was part of this, and that exercises like rapid motions to mimic throwing for example maybe worked proprioception but had minimal effect on overall strength and power.

I like to think of it as starting at specific isolating exercises to establish a) good neuromuscular connections and b) baseline strength (the ability of the muscle to handle load without the need for compensatory patterning) and then go to more Global or functional exercises that use the muscle in ways that mimic activity or expose high risk movments or actions.



FLAOrthoPT -> Re: Restricted Shoulder Abduction (September 14, 2005 9:50:00 AM)

donnelly did most of the research with the philly's for the scap on posterior capsule stretching. Have you even seen what makes up the post capsule sling in a cadaver or in surgery? the iglh lig is pretty hefty and it doesn't get tight, it gets thick. I have a hard time believing anyone can stretch this, what they maybe can do is reduce neural tension in this area, loosen some RTC musculature, etc, but i just think anatomically people are kidding themselves to think they can stretch this ligament. Finally if this is really the problem, wouldn't surgery to lance open the ighl be the route to go? not arguing, just food for though, calleneging accepted paradigms and whatnot



Jon Newman -> Re: Restricted Shoulder Abduction (September 14, 2005 9:56:00 AM)

A low tech solution that seems to work well for me is lots of AAROM in a variety of gravity influenced postions. Also providing various tactile cues helps--I find cueing the elbow versus the wrist is helpful for some reason.

jon



coloradojulie -> Re: Restricted Shoulder Abduction (September 14, 2005 10:14:00 AM)

I think I stated that there was no conclusive evidence that the IGHL was stretching...whatever it is, it works. And yes I have seen the ligament in fresh (ortho docs do an annual dissection for us on the knee and shoulder) and preserved cadavers.

Read a study recently on the effect of anterior capsular tightening on the mechanics of the shoulder, and the results were that the overall biomechanics and joint stability signifcantly decreased and that the posterior structures had to increase effort to effect stabilization. Perhaps this is the same mechanism we see in reverse with posterior capsular tightness? Donatelli described it as changing the axis of the shoulder, off center. (He does some research, however he uses others studies to guide his pratice...and the baseball study I was referring to was actually done by an athletic trainer.

Discussion is good and challenging information is definitely important. I would say that with any movement study, to isolate a variable is virtually impossible, and that saying, this is what I am doing now...eg. stretching the IGHL is like saying you are cutting a blade of grass when you are mowing the lawn...



ginger -> Re: Restricted Shoulder Abduction (September 14, 2005 2:20:00 PM)

Dear Mike T, consider the following options,
1, get two fish, preferably dead, tuna is good, hold them by the tail area with each hand, bend your hips and make a humming sound over the patients shoulders , while slapping the fish rythmically together every second or two.
Step back and reassess. put down fish.

2.put some earth from the ground in your local church yard into a bag along with a few scraps of the toenails of your patient, bury these in same church yard at midnight( along with the fish)
go home and have a good lie down.

Neither of these treatments will make any difference to the outcomes in your shoulder joint problems. Much the same really as any "treatment " that fails to address the prospect of a referred pain and altered recruitment effect from cervical and upper thoracic facet joints.First things first, treat the cervical joints. MOBILISE them. Don't manipulate them it wont work. Don't massage them it won't work either. Attend to the most likely contributor to altered recruitment and pain associated with shoulders, The Gregory Peck.Just try it Mike , hate me for being blunt, all you others do your worst, but I'm right. There you go , I couldn't hold back a second longer.



JLS_PT_OCS -> Re: Restricted Shoulder Abduction (September 15, 2005 4:13:00 AM)

Thanks, Geoff/ginger for your usual strong pronouncements of your unsupported opinion presented as if it were fact.

I strongly disagree with your post, because as everyone knows, it works better with live perch fish, and to suggest dead tuna or the unnecessary burying technique is to show your place as a rank amateur. Or your lack of access to the proper treatment.
:)
J

ps Mike, in a pinch, bass will also work, but definitely stay away from the tuna! The concept of using deep coldwater fish as a treatment is really laughable. Everyone knows you need warm freshwater fish for this problem. I know, hate me if you must, and ginger do your worst, but I couldn't keep quiet any longer...

And no, I don't have any "evidence" for my treatment. I see people from all over the earth and mars, and I teach my students the live perch technique all the time, with wonderfully stupendous results. I don't have time to prove anything, I know it sounds crazy, but just try it and see if it helps. A side benefit of this treatment is that the fish get to live, and put back in the tank (much cheaper to maintain than the usual gamut of modality devices), and can therefore be used for multiple treatments. So it's ethically sound as well.

Just some humor attempt on a thurday morning...



cindyn -> Re: Restricted Shoulder Abduction (September 15, 2005 4:28:00 AM)

Mike-

What about trying scaption and progressing to abduction?



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