MUSCULOSKELETAL REHABILITATION REHABILITATION OF SECONDARY IMPINGEMENT By Howard Turner, MCSP, SRP

The process of rehabilitating secondary impingement follows direct- ly from the assessment procedure. In assessment we attempt to identify all contributing influences to the dysfunction; in rehabili- tation we attempt to resolve those biomechanical inadequacies. Both processes are obviously complex, there are myriad influences on patency of the sub-acromial and sub-coracoid spaces and con- sequentially the health of the structures within. We must attempt to deal with all of them.

The principles of rehabilitation The specific aims of rehabilitation are two-fold: 1) to maximise the space available to the humeral head 2) to optimise the control of the humeral head within that space

The specificity of what we are attempting to achieve is indicated by the often quoted statistic that in the ‘ideal’ shoulder, the humeral head translates only 2mm during use.

To achieve these

aims we may need to intervene in areas such as glenohumeral control, scapular control, posture and trunk, pelvic and lower limb control. We should aim to rehabilitate the predisposing causes of the problem to the point that likelihood of reoccurrence is reduced.

Stability is provided by the integrated function of the passive, active and control subsystems. In the early and mid stages of reha- bilitation our exercise prescription aims primarily to improve the efficiency of the control subsystem to interpret the flood of affer- ent information from the periphery and to produce the finely tuned coordination necessary for appropriate control. It is only after these motor programs have been successfully re-educated that strength and endurance become important aims.

A rehabilitation process 1) Initial treatment The rationale Initially the aims of treatment are to reduce pain and to prevent deterioration in the condition. The rotator cuff must be kept active or it is at risk of what has been termed ‘shutdown’ - inhibition due to pain and inactivity - and the greater the inhibition the greater the difficulty of regaining control.

The treatment ● Pain relief ● Initially, pain free activation of the cuff, progressing to early retraining of glenohumeral alignment as appropriate: ● Active centring of humeral head in glenoid ● Maintenance of centred position through small arcs of movement

● Taping as appropriate to reduce pain / restore alignment ● Maintenance of aerobic fitness ● Scapular and core stability training as appropriate

2) Scapular stability training The rationale Upward rotation of the scapular is of key importance because it: ● Helps maintain an efficient length/tension relationship of the rotator cuff ● Enhances the mechanical stability as the glenoid is placed under the humerus past 90 degrees elevation ● Removes the acromion from the upwardly moving humerus

Inadequate scapular rotation control reduces the mechanical stabil- ity of the glenohumeral joint, places the rotator cuff at a mechan- ical disadvantage and predisposes to impingement.

Indications ● Faulty posture of scapular ● Poor concentric and/or eccentric control of upward scapular rotation on arm elevation activities ● Poor balance of activity between scapular rotators on EMG, par- ticularly of upper vs. lower trapezius, with dysfunction presenting as a dominance of upper trapezius activity ● Correction helps - manual or taped correction of scapular pos- ture, manual or neuromuscular stimulator facilitation of lower trapezius activity or active correction of posture and movement control eases symptoms

The treatment ● Early ● Encouragement of isolated, sustained activation of lower trapezius in static postures progressing to small arcs of glenohumeral movement

● Reduction of upper trapezius/levator scapulae/rhomboids overactivity

● Re-education of postural aspects as appropriate (see over) SportEX 13