SECONDARY IMPINGEMENT

● Weight bearing and impact activities for those patients whose activity either involves falls (rugby players) or weight bearing sta- bility (dancers and gymnasts) through their upper limbs.

4) Spinal mobilisation The rationale The spine must be considered both as a referral source of symptoms to the shoulder and a factor in the development of abnormal move- ment postures.

Spinal motion is intimately related to shoulder

movement. A reduction in the spinal motion, particularly of the tho- racic spine, will place excessive demands on other areas and may lead to dysfunction. Faulty posture, in particular an excessive tho- racic kyphosis, will not only reduce the thoracic spine’s contribution to movement but may promote abnormal movement in the shoulder girdle. The shortening of muscles such as anterior deltoid, levator scapulae, rhomboids and pectoralis minor and the lengthening of lower trapezius and serratus anterior associated with this posture leads to imbalances in the activation of these muscles to the detri- ment of the shoulder.

Indications ● The spine as a referral source: ● In nociceptive pain patterns, a cervical source of symptoms is often recognisable by the presence of associated cervical symptoms and aggravating/easing factors that relate to the cervical spine

● Such a predictable stimulus - response relationship may not be present in central and affective pain mechanisms or when symptoms are due to latent ischaemic or inflammatory processes

● Spinal contribution to motion: ● Excessive thoracic kyphosis ● Poor contribution by the thoracic spine to overhead movements of the arm

● Palpable hypomobility in the thoracic spine ● Excessive contribution to motion elsewhere eg. knee flexion, extension of the lumbar spine or thoraco-lumbar junction or excessive translation of the head of humerus on overhead movements of the arm.

The treatment ● The spine as a referral source: ● Mobilisation and stabilisation as appropriate, and treatment of associated soft-tissue manifestations eg. trigger points

● Spinal contribution to motion ● In the hypomobile thoracic spine - general mobilisation of all articular and fascial contributions to hypomobility

● In the normally mobile thoracic spine - re-education of (primarily) spinal extension with facilitation of thoracic spine extensors. The thoracic extensors and the lower trapezius are closely associated so re-education of one assists recruitment of the other.

5) Optimisation of neural mechanics The rationale As well as contributing to the symptomology of shoulder com- plaints, neural pathomechanics may contribute to the maintenance of sub-optimal movement patterns. Upper trapezius overactivity is often associated with disorders of neural irritation. Before this overactivity can be corrected the neural irritation causing it must

be addressed. Inappropriately working to inhibit the upper trapez- ius in this situation, for example by compressively taping it, may overload the neural elements with a consequential increase in symptoms.

6) Trunk and lower limb stability training The rationale The link between shoulder and the trunk has been highlighted by Hodge’s finding that transversus abdominus activity precedes the activity of the delto-pectoral muscles on shoulder movement. It is estimated that the trunk and lower limbs generate around 50% of the force of a throw and contribute similarly to the dissipation of energy during follow-through.

Thus the shoulder of the throwing

athlete can be protected from excessive and possibly damaging forces by efficient transfer of energy through the body. This trans- fer of energy has elements of core stability, power and flexibility and relates to the specific biomechanics of the sport being per- formed.

In swimming, by contrast, the position of the body is important as it has a direct effect on the positioning of the shoulder joint under load. An inadequate or excessive amount of body roll can have detrimental effects of the position of the shoulder and/or can affect the fluidity of the body’s passage through the water.

As well as assessing for specific deficits in core and lower limb con- trol, the particulars of the athlete’s sporting activity must be analysed with professional assistance where possible.

7) Muscle lengthening The rationale Muscle lengthening techniques are not an early priority for two rea- sons.

Firstly, the effectiveness of such techniques must be ques-

tioned when movement patterns do not exist to maintain the length of these muscles in functional activities. Secondly, these muscles appear to be inhibited by an enhancement in the function of the postural stabilizers.

Improving the function of these stabilizers,

therefore, is the main thrust of early treatment and may render lengthening techniques obsolete. Where necessary, however, mus- cle and fascial mobilisation is a necessary ingredient as the length of these structures directly affects their function.

8) Return to activity Throughout the rehabilitative process exercises should aim to repro- duce the demands of the patient’s sport, work or daily life. As the load to the shoulder is gradually increased the stage is reached where return to activity is simply a progression of the exercises that preceded it. At this point the main themes of rehabilitation should be incorporated into the patient’s sporting or activity specific envi- ronment. It should be emphasized to the patient that their improvement has been brought about by corrections in movement and motor control and that they are less likely to deteriorate if they continue the strategies that helped them improve.

Howard Turner is a chartered physiotherapist from Australia. He worked in the NHS for 5 years before moving into private prac- tice. He lectures extensively on the shoulder and sacroiliac joint and was part of the UK McConnell teaching programme until 2000. He now runs a private clinic in Cheshire and can be con- tacted on 01625 530794 or by e-mail HMT@fizziostuff.co.uk

SportEX 15