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While it is relatively early days in our understanding of this patient group there are certain factors that have been consis- tently demonstrated in patients with these presentations. We looked at the Modified Clinical Test of Sensory Integration and Balance (MCTSIB) (16) in patients with type II and type III insta- bility and a control group of normals. In this test patients are tested in four test conditions; i. eyes open, stable surface ii. eyes closed, stable surface iii. eyes open, foam surface iv. eyes closed, foam surface

The test aims to assess the patient’s ability to adapt sensory information from the vestibular, visual and somatosensory systems for postural and balance control. We also used a balance platform measuring variation in postural sway in defined test conditions to calculate a balance index. Our results demonstrated a significant correla- tion between the balance index, core stabil- ity and symptomatic instability. Furthermore there were specific trends in postural sway and the loss of directional control in the different instability groups (17).

It is clear that motor control issues else- where in the body will influence the shoulder. Authors have demonstrated spe- cific patterns of activation of the trunk

and lower limb musculature prior to ele- vation of the upper limb. These sequential activation patterns are fundamental in controlling postural perturbations and dynamic postural control during upper limb activity (18). Research would sug- gest that injury to a distal segment can alter the ‘normal’ sequential activation of proximal to distal control.

TABLE 2. SPECIFIC SEGMENTS CONTRIBUTION TO KINETIC ENERGY AND FORCE PRODUCTION IN THE TENNIS SERVE (FROM KIBLER (9))

Segment Velocity Kinetic Force (M/S) Energy(%) (%) 51 13 21 15

Leg/Trunk 2.7 Shoulder 2.2 Elbow Wrist

6.4 7.8

54 21 15 10

Bullock-Saxton (19) demonstrated that proximal hip muscle activation is delayed in patients with severe ankle joint injury compared with non-injured controls dur- ing hip active extension. Kibler describes this as ‘link fall-out’. If we consider the tennis player, Kibler illustrated how up to 54% of the force development during the tennis serve comes from the legs and trunk (Table 2). In the event of a decrease in the contribution from the

legs or trunk the shoulder has to rotate quicker or further to compensate. Potentially this increases injury risk and compromises performance. The concept that injury to a distal segment can alter normal motor programmes emphasises the necessity for addressing the ‘kinetic chain’ rather than the shoulder girdle in an isolated manner. If we consider the sway back posture we can predict com- mon patterns of motor control imbalances eg. poor gluteal and abdominal control, hamstring dominance and often inappro- priate activation of the internal obliques. If we adopt this posture ourselves and lift our arms it is easy to see how this intro- duces a flexion dominant pattern ie. we initiate the movement with protraction and pectoralis is inappropriately activat- ed. If we combine this with our knowl- edge of myofascial slings the anterior functional line links the pectoralis major, serratus anterior, rectus abdominus and adductors (Fig.4)(20).

In a flexion-dominant movement the serratus is inhibited and the pectoralis muscle works with the rectus to ‘fix’ and stabilise the trunk. This also limits dissociation of the thoracic spine and pelvis so limiting trunk segmental extension. This has the effect of creating an anterior-inferior translation shear in the glenohumeral joint.

This will be exacerbated in the presence of rotator cuff dysfunction and/or serratus dysfunction/scapula instability because the usual compressive forces are compro- mised. If we consider the posterior oblique sling (Fig.5) this links the latis- simus dorsi, the thoraco-lumbar fascia and gluteus maximus. In the presence of gluteal inhibition then latissimus works hard to compensate, however again this will have a negative effect on the gleno- humeral joint pulling the humeral head posterior-inferiorly. So, far from latissimus dorsi, pectoralis major and deltoid being the ‘bad guys’ the reality is that they are often trying to hold things together and compensate for deficits elsewhere in the kinetic chain! If this is combined with proprioceptive deficits, a decreased abili- ty to process afferent input centrally and compromised sensorimotor control it is easy to see how this abnormal sequencing could become established.

Figure 4: The anterior myofascial sling 14 Figure 5: The posterior oblique sling

Full references can be found on page 22. www.sportex.net

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