A Postural Approach to Management of Sho

A Postural Approach to Management of Shoulder Injuries : 

Torin Berge, PT, MPT Trinity Outpatient PT A Postural Approach to Management of Shoulder Injuries

Presentation Objectives : 

Presentation Objectives Explain common asymmetrical patterns of posture/movement Explain how postural asymmetry can be responsible for risk factors of shoulder injury (namely scapular malpositioning and limited shoulder internal rotation) Explain management of asymmetrical posture to rehabilitate and prevent injury of the shoulder

Kinetic Chains : 

Kinetic Chains For coordinated movement, energy and momentum are transferred through sequential body segments progressing usually from proximal to distal Pappas describes baseball pitching as a sequential activation of body segments through a linked segmentation beginning with the contralateral foot and progressing through the trunk to the rapidly accelerating arm

Kinetic Chain Cont. : 

Kinetic Chain Cont. Since overhead athletic activities such as baseball pitching, hitting a volleyball, swinging a golf club etc. are total body activities, dysfunction anywhere in the kinetic chain can lead to compensation and injury elsewhere along that chain Therefore lower-body dysfunction can cause upper extremity injury

Slide 5: 

Therefore to address shoulder injuries we need to address this muscle group…

Slide 6: 

And these joints…

Slide 7: 

And this muscle…

Slide 8: 

And these bones…

Slide 9: 

And finally this

Myokinematics : 

Myokinematics The study of motion or lack of motion produced by specific muscle force. A myokinematic focus addresses symmetrical muscle flexibility, strength and length and how they affect motion. Asymmetries in muscle strength and endurance must be balanced between agonists and antagonists. The study of myokinematic dysfunction is the study of motion ADAPTATION PATTERNS.

Injury Prevention and Treatment : 

Injury Prevention and Treatment Biomechanical ADAPTATION PATTERNS (BAPs) exist in all of us to a certain degree and can be desirable depending on the activity. For prevention and injury treatment we must inhibit overactive BAPs to reduce postural asymmetries that can result in misuse and overuse of interactive and interdependent muscles. BAPS must be reduced and balanced prior to initiation of a traditional strength and conditioning program.

Postural Asymmetries : 

Postural Asymmetries Postural asymmetries like BAPS exist in all of us to a certain degree regardless of hand dominance due to structural, environmental, and neurological factors and are reinforced with daily repetitive activities Described in literature, including Kendall’s Right handed pattern and Hruska’s L anterior interior/ R brachial chain pattern

Postural Restoration Institute (PRI) : 

Postural Restoration Institute (PRI) The Postural Restoration Institute was established by Ron Hruska PT, MPA of Lincoln, NE to explore and explain the science of postural adaptations, asymmetrical patterns and the influence of polyarticular muscle chains on the human body. Their mission is based on the development of an innovative treatment approach that addresses the primary contributions of postural kinematic movement dysfunction. The treatment theory of PRI is what this talk will be based on. See www.posturalrestoration.com for more information

The Left Anterior Interior Chain (L AIC) : 

The Left Anterior Interior Chain (L AIC) A Polyarticular muscle chain of the lower body described by Hruska that involves the diaphragm, iliacus, psoas, TFL, vastus lateralis and bicep femoris The L AIC muscle chain is important as it provides the support and anchor for abdominal counterforce, trunk rotation and flexion movement An unopposed L AIC muscle chain leads to a pattern of an anteriorly tilted and forwardly rotated hemipelvis on the left

L AIC Continued… : 

L AIC Continued… An anteriorly tilted and forwardly rotated L hemi pelvis leads to… Passive internal orientation of left femur with compensatory weakness of IR’s due to ER of femur to re-orient to midline Passive orientation of sacrum and lumbar spine to the right Compensatory upper trunk rotation to the L which affects rib position, scapular position and may cause altered Scapulo-thoracic/TS mechanics Probable numerous other lower extremity compensations to allow effective forward progression and completion of daily tasks

Why Does the L AIC Pattern Exist and Go Unopposed? : 

Why Does the L AIC Pattern Exist and Go Unopposed? We favor R L/E WB regardless of handedness due to… Organ asymmetry 3 lobes of R lung, 2 on L Heart on L side of thoracic cavity keeps L chest wall more open than R Liver (3-4#) on R reinforcing proper larger R hemidiaphragm vs. Spleen (1#) on L not reinforcing smaller L diaphragm

Why Continued… : 

Why Continued… Organ asymmetry coupled with gravity, environmental and neurological factors (lateralization) result in the tendency to WB more thru the R leg and rotate upper body to the L (R arm reaching) This pattern is reinforced with daily activities that require R leg push-off with trunk rotation to the L (throwing, reaching etc.) This leads to unopposed and hypertonic/overactive L AIC muscles and therefore an anteriorly tilted and forwardly rotated position of the L hemipelvis

Brachial Chain Pattern (BC) : 

Brachial Chain Pattern (BC) Upper body polyarticular muscle chain described by Hruska that includes the diaphragm, intercostals, pectorals, deltoid, sibson’s fascia, triangularis sterni (muscle of exhalation), SCM, scalenes Opposed (balanced) by ipsilateral lower trap and serratus anterior, contralateral internal Obliques, external rib rotators

R Brachial Chain Pattern (R BC) : 

R Brachial Chain Pattern (R BC) R BC pattern becomes unopposed as a result of upper body compensation for L AIC pattern by rotation of thorax and ribcage to the left L ribs go into ER (state of inhalation), R ribs go into IR (state of exhalation) **R Scapula becomes depressed, adducted, upwardly rotated and “winged” (“Sick” Scapula) due to resting position of scapula on internally rotated position of ribcage and inability for scapular stabilizers to work properly

Altered R Scapular Position Due to R BC Pattern Continued… : 

Altered R Scapular Position Due to R BC Pattern Continued… Scapula becomes upwardly rotated due to compensatory activation of R upper trap/levator scap to restore frontal plane motion of head and neck due to depressed R shoulder “winging” of scapula brings glenoid anteriorly and therefore may cause compensatory ER activity and concurrent limitation in IR mobility This orientation of the scapula on the thorax will lead to posterior-superior H-G impingement with limited R H-G IR at 90 degrees of abduction in relation to the thorax due to adducted position of glenoid during horizontal abduction

“Sick” Scapula : 

“Sick” Scapula Scapular malposition of described by Burkhard et al in 2003 This scapular position as well as limitation in HG IR (both of which are evident in a R BA patterned individual)has been implicated to cause numerous shoulder problems including anterior instability, SLAP lesions, RC tendonitis and impingement as well as bicipital tendonitis and impingement

L AIC/R BC Patterns : 

L AIC/R BC Patterns

More L AIC/ R BC Patterns… : 

More L AIC/ R BC Patterns… Notice R lower extremity WB with upper trunk rotation to the left and depressed R shoulder

Identification of L AIC Pattern : 

Identification of L AIC Pattern Seated hip IR/ER Extension Drop Test (Modified Thomas Test) Adduction Drop Test (Ober’s test) Supine Trunk Rotation Standing Reach Test Passive SLR

Seated Hip IR/ER : 

Seated Hip IR/ER Measure and compare seated hip rotation values for IR/ER of each leg Non-compensated L AIC pattern will demonstrate limited L FA IR (vs. R) and limited R FA ER (vs. L) due to pelvic orientation and compensatory hip position

Extension Drop Test (Modified Thomas Test) : 

Extension Drop Test (Modified Thomas Test) Patient in supine with thighs on table, hips and knees are flexed to chest to flatten lumbar spine. One leg is passively lowered to the table while maintaining low back on table. Positive test is when tested l/e (usually L) does not extend due to forward orientation of pelvis on tested side.

Adduction Drop Test** (Modified Obers Test) : 

Adduction Drop Test** (Modified Obers Test) Patient lies on side with lower leg flexed at hip and knee to 90 degrees. Passively flex, abduct, and extend the hip to neutral. Passively stabilize the pelvis and allow leg to adduct toward the ground. A positive test is indicated by a restriction from the anterior-inferior acetabular labral rim, transverse ligament and piriformis or impact of post inf femoral neck on post inferior acetabulum that does not allow femur to adduct due to anteriorly rotated hemipelvis. Positive test usually seen on L side in a L AIC oriented patient.

Supine Trunk Rotation : 

Supine Trunk Rotation Positioned in supine with knees maximally flexed and together feet flat Passively rotate knees to one side while stabilizing opposite lower rib cage. Repeat to opposite side Positive test is indicated when legs do not rotate one direction as well as the other. In L AIC pattern will see limited LTR to the L due to limitation in trunk rotation to the right due to probable L anterior pelvic rotation and sacral-lumbar spine orientation to the right

Management of L AIC Pattern : 

Management of L AIC Pattern Dependent on exam findings but should include activities to restore proper pelvic position and muscle activation in all 3 planes of movement. There are numerous manual and non-manual techniques to accomplish this which is outside the scope of this presentation but in general this is what we will try to accomplish.

90/90 Hip Lift With Hemibridge : 

90/90 Hip Lift With Hemibridge Facilitation of L hamstring in sagittal plane to restore proper pelvic position.

Sidelying Adductor Pullback : 

Sidelying Adductor Pullback Facilitation of L adductors in frontal plane to return pelvic girdle to neutral state

Left Sidelying Right Glute Max : 

Left Sidelying Right Glute Max Facilitation of R glute max in transverse plane to reorient sacrum to the left and stabilize R SI joint

Right Sidelying Left Glute Medius : 

Right Sidelying Left Glute Medius Facilitation of L glute med in transverse plane to retrain left glute med for L FA/AF IR, inhibit overactive left TFL and VL, stabilize pelvis, and allow for proper single leg stance activity

Retro Stairs : 

Retro Stairs Integrate above muscles into upright triplanar activity unilaterally and then reciprocally

Identification of R BC pattern : 

Identification of R BC pattern Observe anterior rib flare Shoulder flexion Shoulder horizontal abduction Shoulder internal rotation Apical chest wall expansion

Anterior Rib Flare : 

Anterior Rib Flare Observe patient in supine for anterior rib flare on L side indicating position of L ribs in ER (inhalation), R ribs in IR (exhalation) due to upper trunk rotation to the left

Supine Shoulder Flexion : 

Supine Shoulder Flexion Patient lies in supine with knees flexed to flatten lumbar spine. Passively take shoulder into flexion with stabilization of ipsilateral rib cage Positive test is limitation on one side compared to the opposite side Usually limited on L side in R BC oriented patient due to malpositioned scapula

Supine Shoulder Horizontal Abduction : 

Supine Shoulder Horizontal Abduction Pt in supine with knees flexed to flatten lumbar spine. Passively take arm into horizontal abduction while securing the shoulder joint with one hand and maintaining supination Limited hz abd (< 30 degrees) is positive test Usually limited on L side in R BC patient due to sternal and spinal orientation to the R and overactive L pectorals trying to “pull” sternum back to the left

Supine Shoulder Internal Rotation (HGIR) ** : 

Supine Shoulder Internal Rotation (HGIR) ** Pt in supine with feet on mat, back flat. Stabilize shoulder joint with light inferior pressure. Passively IR the humerus. Positive test is indicated by the inability to IR on one side compared to the other. Usually limited on R due to posterior-superior H-G ‘impingement’ because of glenoid passive adduction orientation on thorax (scapular position) with the humerus positioned at 90 degrees of abduction.

Apical Chest Wall Expansion : 

Apical Chest Wall Expansion Patient is positioned in supine with knees flexed and back flat. Patient inhales thru nose, upon exhalation guide L rib cage down. Hold ribs as patient attempts to fill opposite chest wall with inhalation. Repeat on opposite side. A positive test is indicated when there is a restriction in chest wall expansion on one side compared to the other. Usually limited on the right due to R rib IR/L rib ER secondary to possible compensatory rib cage rotation to the left as a result of spinal orientation to the right.

Management of R BC Pattern : 

Management of R BC Pattern As with managing the L AIC pattern utilization of manual and or non-manual techniques will be utilized depending on evaluative test findings In general here is what we will try to accomplish:

90/90 Hip Lift With Balloon : 

90/90 Hip Lift With Balloon Facilitate L diaphragm with L abdominal muscle co-activation for R apical chest wall expansion and to to ‘reposition’ or ‘reorient’ the upper trunk to the R

Seated Reciprocal Tricep Extension : 

Seated Reciprocal Tricep Extension Utilize R low trap and R tricep to restore proper resting position of R scapula on ribcage as well as reorient the thoracic spine to the L with R trunk rotation Reciprocal activity will also decrease the tendency to fall back into old learned BAPs

All 4 Belly Lift Reach : 

All 4 Belly Lift Reach Facilitate bilateral serratus anterior for proper rib and scapular position 2 actions of Serratus anterior are for scapular protraction/reaching and to retract ribs/thorax back to the scapula

Supine Resisted Right HGIR : 

Supine Resisted Right HGIR Facilitate R subscapularis to relearn proper HG IR without utilization of latissimus and pectorals as is commonly used in R BC pattern

Standing Resisted R Diagonal Flexion in PRI R AIC Single Leg Vertical Balance : 

Standing Resisted R Diagonal Flexion in PRI R AIC Single Leg Vertical Balance Integrate proper pelvic position with upright u/e activity without returning to prior learned positions Integrates L abdominals, L diaphragm, pelvic orientation to the L, with R low trap, R tricep and without accessory/compensatory muscle activation

Scapular Position Before and After Treatment With PRI Exercises : 

Scapular Position Before and After Treatment With PRI Exercises Results from PRI certified therapist utilizing PRI approach to treatment

Then What… : 

Then What… After neutral position is attained it is imperative to progress to reciprocal activity for l/e and u/e to maintain neutral position and not revert back into old biomechanical patterns (retro stairs, standing resisted reciprocal wall reaches) Then a traditional strengthening program can begin with emphasis on hamstrings, gluts, abdominal obliques, scapular stabilizers (low traps and serratus anterior specifically) and finally rotator cuff.

References : 

References Hruska RJ. Myokinematic Restoration- An Integrated Approach to Treatment of Lower Half Musculoskeletal Dysfunction. Postural Restoration Institute course manual. 2008. Hruska RJ. Postural Respiration- An integrated approach to Treatment of Patterned Thoraco-Abdominal Pathomechanics. Postural Restoration Institute course manual. 2006. Wood JD (2008, June 27). Exercise Programs to Protect Baseball Pitchers Arms from Overuse injuries. Retrieved from http://www.authorstream.com

References Cont: : 

References Cont: Burckhart SS, Morgan CD, & Kibler BW. The Disabled Throwing Shoulder: Spectrum of Pathology Part III: The SICK Scapula, Scapular Dyskinesis, The Kinetic Chain, and Rehabilitation. The Journal of Arthroscopic and Related Surgery, 2003:19(6); 641-661 Pappas AM, Zawacki RM, Sullivan TJ: Biomechanics of Baseball Pitching. A preliminary report. American Journal of Sports Medicine. 13: 216-222, 1985 Masek J. How Right to Left Imbalances Affect Pitching Performance. Part I. Performance Conditioning for Baseball/Softball Volume 7 (5) 2007. Masek J. How Right to Left Imbalances Affect Pitching Performance. Part II. Performance Conditioning for Baseball/Softball Volume 7 (6) 2007. Masek J. How Right to Left Imbalances Affect Pitching Performance. Part III. Performance Conditioning for Baseball/Softball Volume 7 (7) 2007.

For More Information… : 

For More Information… Visit www.posturalrestoration.com Contact Torin Berge, PT at Trinity Outpatient Physical Therapy