The shoulder complex requires coordinated movements to take place at the acromioclavicular (A-C), sternoclavicular (S-C), glenohumeral (GH), scapulothoracic joints, the rotator cuff, and the scapular stabilizer muscles in order to function properly. The glenohumeral articulation allows for high degrees of mobility which requires dynamic stabilization of the muscular system. The muscular system utilizes "force couple" to control the position of the humerus and scapula at all phases of arm position. These force couples or coordinated contraction of muscles to systematically move the scapula in the proper relationship to humerus to allow efficient motion. Any pathology changes at the joints, it's surrounding soft tissse (labrum,tendons,bursa) or the movement dysfunctions of the muscular system will result in pain syndromes.
How do these movement dysfunctions occur?
Treatment Principles for Movement System Dysfucntions:
- Postural adaptation to gravity with soft tissue shortening to this chronic poor posture.
- Interference of normal articular reflexes( neuroreflexive) due segmental restriction (Wyke).
- Loss of reciprocal interaction between agonist and antagonist.
- Response to painful stimulus causing a change in sequence of motor recruitment(Wyke).
- Response to fatigue and inhibition due to overload.
- Reeducate movement patterns preventing reoccurring compensatory patterns. Stretch short structures prior to strengthening inhibited muscles. (Janda).
- Strengthen the antagonist that is too long in its optimal position and often not necessary to stretch short structures. Emphasis on quality of motion during functional activitiesl (Sahrmann).
Rehabilitation considerations incorporate the principle of STRUCTURE
. Goals and progression for rehabilitation need to be customized for the individual based on this principle. The throwing athlete requires different parameters to return to play versus individuals that do not require overhead loads to the shoulder complex.
The key to recovery is Motion. The primary reason for loss of motion is pain which will inhibit the muscles. After the pain is reduced, pain free motion can be introduced. Once motion is regained, emphasis on strengthening and muscle re-education. This muscle re-education requires "specificity of training" to restore proper motor patterns and force couples.
"PRACTICE DOES NOT MAKE PERFECT... PERFECT PRACTICE MAKES PERFECT"
It is the quality of movement during strengthening. Restoring the proper recruitment patterns and sequencing of the muscles is the key to restoring proper motor patterns.
"Shoulder Rehabilitation" video clip
Windows Media Video file, 1.9 MB
MANUAL THERAPY CONSIDERATIONS in SHOULDER REHABILITATION
It is often necessary to restore proper biomechanics of the shoulder complex (arthrokinematics) prior to strengthening. This is the most overlooked entity in shoulder rehabilitation. Traditional physical therapy does not address these small accessory motions or inhibitory patterns that will limit or prevent the restoration of the motor patterns necessary to function of the shoulder complex.
The acromioclavicular joint, first and second rib motion restriction most overlooked source of upper extremity problems, specifically rotator cuff tendonitis and impingement syndromes(Greenman).The first and second rib will influence S-C joint motion.
Key to restore rotary component of the A-C joint prior to the abduction restriction (Greeman).
Common mechanical restrictions that influence the shoulder complex:
An elevated first rib will minic cervical radiculopathy due to C8 spinal nerve entrapment between the clavicle and first rib. Acute elevated first rib and inhalation restriction will minic acute rotator cuff tear due to patient inability to elevate arm due to pain, not weakness as in rotator cuff pathology.
Levator scapulae often shortened will affect scapular motion.
Common Inhibition patterns that influence the shoulder complex:
Tight posterior shoulder capsule(unilateral forward shoulder) will inhibit the rotator cuff external rotator muscles from being recruited efficiently.
Thoracic facet restriction T7-9 primarily in extension will inhibit lower trapezius recruitment (Bookout).
Thoracic facet restriction T3-5 primarily in flexion will inhibit serratus anterior and rhomboid recruitment. The flat back posture with decreased kyphosis is predisposed to this pattern.
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