Yudu - sportEX medicine - 1999-2010

SHOULDER IMPINGEMENT

tion through to extension, abduction with external rotation

2. Flexion, adduction and extension All other movements of the shoulder (flex- ion, adduction and extension) should be strengthened under resistance band, increasing the strength of the resistance band as pain decreases and strength increases.

For all resistance band exercises aim for 30 repetitions divided into 3 x 10 or 2 x 15 depending on patient fatigue.

If resisted abduction is painful on assess- ment, resistance band rotator cuff strengthening exercises should be avoided into abduction to avoid initially aggravat- ing the impingement. Once pain has set- tled, resisted abduction may then be intro- duced in a pain-free range.

The role of the rotator cuff in main- taining humeral head position (15) During movement at the GH joint, a combi- nation of forces from activated rotator cuff muscles and passive forces from stretched capsular ligaments, maintain the humeral head in the correct position in the glenoid fossa. The infraspinatus muscle contracts to produce active external rotation at the GH joint and because part of the infraspinatus muscle attaches into the capsule, its con- traction prevents the posterior capsule from slackening during the motion. This mainte- nance of tension in the posterior capsule, combined with the tension from the acti- vated infraspinatus muscle, stabilises the posterior side of the joint during active external rotation. In the healthy shoulder, the anterior side of the joint is also well stabilised during active external rotation.

Passive tension in the stretched subscapu- laris muscle, anterior capsule, middle GH capsular ligament and corocohumeral liga- ment all add rigidity to the anterior cap- sule; forces therefore are generated on both sides of the joint during active external rotation, serving to stabilise and centralise the humeral head against the glenoid fossa. A similar mechanism exists during active internal rotation. Instability occurs when a weakened rotator cuff is present as the humeral head is not able to be maintained against the glenoid fossa.

SCAPULAR STABILITY Restoration of range, strength, stability and scapulohumeral rhythm is vital, using pain as an exercise progression indicator.

Several muscles are worked to obtain scapular stability and should all be worked in scapular neutral. The focus should be on serratus anterior, the scapulothoracic joint and lower/middle fibres of trapezius.

Serratus anterior exercises For abnormal movement/recruitment, the medial border of the scapula will wing at rest and/or with movement.

Exercise 1 In standing, assume a press up position against the wall. The shoulder girdle should be in neutral with the scapula flat on the thorax, no medial border winging. Alternate lifting a hand off the wall and hold the position.

Exercise 2 In four-point kneeling, make sure the shoulder girdle is in neutral, the scapula position is flat on the thorax and there is no medial border winging. Rock side to

side/forward and back. Alternate hand lift and hold.

Exercises for scapulothoracic joint Make sure the scapular is in neutral with all the exercises ■ Shoulder flexion to 900 ■ Abduction to 600 ■ Medial and lateral rotation, supine lying, arm abducted to 900

■ Medial/lateral rotation, standing arm adducted to side, elbow at 900

■ Lateral rotation (prone lying arm over- head) - lift wrist

■ Medial rotation (prone lying arm over- head) - lift elbow

■ Full range overhead movement flexion and abduction.

Tip: Do not progress unless pain-free on previous exercise and the patient can maintain a neutral scapula.

Exercises for lower and middle fibres of trapezius: for poor scapu- lar control ■ Standing or sitting. Obtain correct pos- ture/position of scapula and hold.

■ Prone, lying arms by side, palms on thighs. Lift hand 1” off plinth, 10 x 10 seconds holds (Figure 9)

■ Prone lying, hands above head. Lift hands off plinth, 10 x 10 second holds maintaining scapula neutral (Figure 10)

■ Prone lying, hands above head. Lift elbows, 10 x 10 second holds maintain- ing scapula neutral (Figure 11)

■ Prone lying, hands above head. Lift fore- arms, 10 x 10 second holds maintaining scapula neutral (Figure 12)

■ Prone lying, arms above head, elbows extended. Lift arms above head, 10 x 10 second holds maintaining scapula neutral.

Figure 7: Insertion of infraspinatus muscle into capsule 20

Figure 8: Resultant joint force vector influences of the rotator cuff muscles www.sportex.net