Musculoskeletal Musculoskeletal DysfunctionDysfunction

In The AthleteIn The Athlete(The Shoulder)(The Shoulder)

John M. Lavelle DOJohn M. Lavelle DO

Spine PhysiatristSpine Physiatrist

Shoulder DysfunctionShoulder Dysfunction

• Very common in the athlete. Very common in the athlete. – Pain, weakness and limited mobility overheadPain, weakness and limited mobility overhead

• Local extremity dysfunction, axial skeletal Local extremity dysfunction, axial skeletal problem or combination of both.problem or combination of both.

• Orthopeadic problem –Orthopeadic problem –– Tendonitis, Impingement, RTC tear, Hill-Sachs Tendonitis, Impingement, RTC tear, Hill-Sachs

deformity, Dislocation, etc deformity, Dislocation, etc

• Is there a Somatic Component?Is there a Somatic Component?

Anatomy• Shoulder:Shoulder:

– Mobile joint with a shallow Mobile joint with a shallow glenoid fossa. glenoid fossa.

– Minimal osseous support. Minimal osseous support. – JointJoint of greatest mobility, thus of greatest mobility, thus

joint of greatest instability.joint of greatest instability.• Four joints: Four joints: Scapulothoracic, Scapulothoracic,

Acromioclavicular, Acromioclavicular, Glenohumeral, Glenohumeral, SternoclavicularSternoclavicular – Restriction in any one of these Restriction in any one of these

can alter proper shoulder can alter proper shoulder mechanics mechanics • Assess them all for any Assess them all for any

restrictions in motion. restrictions in motion. • RTC:RTC:

– Supraspinatous, infraspinatous, Supraspinatous, infraspinatous, subscapularis, teres minorsubscapularis, teres minor• Supraspinatous torn in Supraspinatous torn in

approx 90% of RTC approx 90% of RTC tendonitis casestendonitis cases

Adduction

Abduction

Flexion

Extension

Int. Rot

Ext. Rot

Coracobrachialis

Supraspinatous

Coraco-brachialis

Lat dorsi Subscap

Infra-spinatous

Pec Major Mid Deltiod Ant Deltoid

Post Deltoid

Lat dorsi

Teres Minor

Teres Major Pec Major

Teres Major

Teres Major

Post Deltoid

Lat dorsi Pec Major

Ant Deltoid

Main Shoulder Motions

HistoryHistory

• SportSport – Pitching, GolfPitching, Golf– Rock climbingRock climbing– TennisTennis– GymnasticsGymnastics

• How long season?, Level of play?, Equipment?How long season?, Level of play?, Equipment?• Why presenting now?: Improving?, Same?, Why presenting now?: Improving?, Same?,

Worse?Worse?• FOOSH injury/Collisions/Trauma FOOSH injury/Collisions/Trauma - -

MacrotraumaMacrotrauma

• Repetitive Overuse Repetitive Overuse (lifting, bending, twisting, etc)(lifting, bending, twisting, etc)– MicrotraumaMicrotrauma

Thoracic DysfunctionThoracic Dysfunction

• Somatic dysfunction of the thoracic Somatic dysfunction of the thoracic spine/ribs may produce shoulder symptoms spine/ribs may produce shoulder symptoms – Extended Type II dysfunction common Extended Type II dysfunction common

• Segmental dysfunction alters the scapular stabilizing Segmental dysfunction alters the scapular stabilizing muscles, affecting the gliding movement of the scapula muscles, affecting the gliding movement of the scapula over the thoracic cage. over the thoracic cage.

• Only the first 20-30° of shoulder abduction occurs Only the first 20-30° of shoulder abduction occurs

without scapulothoracic motion.without scapulothoracic motion. – RTC muscles become irritable and tenderRTC muscles become irritable and tender

• The sympathetic autonomic outflow for the The sympathetic autonomic outflow for the UE/neck: T1-T4.UE/neck: T1-T4. – Somatic dysfunction in this region can lead to Somatic dysfunction in this region can lead to

increased stimulation of the sympathetics.increased stimulation of the sympathetics.

Cervical DysfunctionCervical Dysfunction• The cervical spine also affects the shoulder.The cervical spine also affects the shoulder.

– CC55-C-C88 nerve roots exit the c-spine thru nerve roots exit the c-spine thru intervertebral foraminae and coalesce in the intervertebral foraminae and coalesce in the brachial plexus - brachial plexus - innervates the UE. innervates the UE.

– Somatic dysfunction of the neck.Somatic dysfunction of the neck. • Impingement at the nerve root. Impingement at the nerve root. • Compression at the brachial plexus.Compression at the brachial plexus.

– Anterior and middle scalenes, first rib and/or clavicular Anterior and middle scalenes, first rib and/or clavicular dysfunction, and myofascial strain dysfunction, and myofascial strain

– RTC patients tend to “hike” shoulder:RTC patients tend to “hike” shoulder:• Scalene hypertonicity, upper trap tender points, type II Scalene hypertonicity, upper trap tender points, type II

cervical dysfunction, elevated 1cervical dysfunction, elevated 1stst rib, T rib, T11 dysfunction dysfunction

Latissimus DorsiLatissimus Dorsi• Connection between the pelvis and the UE Connection between the pelvis and the UE

through latissimus dorsi muscle.through latissimus dorsi muscle.

– Attaches to the iliac crest, the spinous Attaches to the iliac crest, the spinous processes of the lumbar and lower thoracic processes of the lumbar and lower thoracic vertebrae and the bicipital groove. vertebrae and the bicipital groove.

– In addition, this muscle often attaches to the In addition, this muscle often attaches to the inferior angle of the scapula as it passes over inferior angle of the scapula as it passes over the scapula. the scapula.

• Somatic dysfunction at the thoracolumbar Somatic dysfunction at the thoracolumbar junction can lead to dysfunction of the junction can lead to dysfunction of the UEUE.

Functional ExaminationFunctional Examination

• Orthopeadic pathology vs Functional Orthopeadic pathology vs Functional conditionsconditions– Evaluate performing sport specific Evaluate performing sport specific

movementmovement– Musculoskeletal compensationsMusculoskeletal compensations

• normal vs abnormalnormal vs abnormal

– Consider center of gravity, ground Consider center of gravity, ground reaction forces, muscle firing patterns reaction forces, muscle firing patterns and postural patternsand postural patterns

Osteopathic ExamOsteopathic Exam

• Observation: Observation: – Osteopathic standing structural exam. Osteopathic standing structural exam.

• Any asymmetry by comparing the mastoid Any asymmetry by comparing the mastoid process, AC joint, spine of the scapula and process, AC joint, spine of the scapula and inferior angle of the scapula bilaterally. inferior angle of the scapula bilaterally.

• Muscle wasting? - focusing on the Muscle wasting? - focusing on the supraspinatous, infraspinatous, trapezius, supraspinatous, infraspinatous, trapezius, deltoid muscles, rhomboids, biceps, triceps deltoid muscles, rhomboids, biceps, triceps and levator scapulae muscles. and levator scapulae muscles.

– AROM: AROM: look at cervical’s and shoulder for look at cervical’s and shoulder for restrictionsrestrictions

Osteopathic ExamOsteopathic Exam

• Palpation:Palpation:– Compare both shoulders - healthy shoulder first. Compare both shoulders - healthy shoulder first. – Palpate the c-spine - restrictions of movement in Palpate the c-spine - restrictions of movement in

PROM PROM – Any segmental, Fryette type II, restrictions in the Any segmental, Fryette type II, restrictions in the

c-spine. c-spine. – Palpate the thoracic spine - any somatic Palpate the thoracic spine - any somatic

dysfunction within the thoracic vertebrae, ribs or dysfunction within the thoracic vertebrae, ribs or musculature.musculature. • Remember that somatic dysfunction in this area will Remember that somatic dysfunction in this area will

affect scapulothoracic motion and thus the motion of affect scapulothoracic motion and thus the motion of the entire shoulder joint.the entire shoulder joint.

Osteopathic ExamOsteopathic Exam• Palpation:Palpation:

– Along supraspinatous and infraspinatous musclesAlong supraspinatous and infraspinatous muscles– Subscapularis muscle tender pointSubscapularis muscle tender point

• Place your palpating finger anterior to the posterior Place your palpating finger anterior to the posterior axillary fold and palpate the anterior boarder of the axillary fold and palpate the anterior boarder of the scapula. scapula.

– Biceps tendon Biceps tendon • Place the patients hand in supination and arm in Place the patients hand in supination and arm in

external rotation to open the bicipital groove and external rotation to open the bicipital groove and palpate along the biceps tendon for tenderness. palpate along the biceps tendon for tenderness.

– Any medial scapular winging - weakness in the Any medial scapular winging - weakness in the serratus anterior serratus anterior • Ask the patient to elevate/flex the arm as you depress Ask the patient to elevate/flex the arm as you depress

the arm with one hand and palpate the scapula with the the arm with one hand and palpate the scapula with the other. other.

Neurological ExamNeurological Exam• Upper extremity neurological testing Upper extremity neurological testing

– Manual muscle tests, Muscle stretch reflexes, SensationManual muscle tests, Muscle stretch reflexes, Sensation

Shoulder ExamShoulder Exam

• PROM PROM – shoulder flexion, extension, abduction, shoulder flexion, extension, abduction,

adduction, internal and external rotation. adduction, internal and external rotation.

• MMTMMT– All planesAll planes

• Special Tests…Special Tests…– Neer, Drop arm, Empty can, Hawkins, O’Brien, Neer, Drop arm, Empty can, Hawkins, O’Brien,

Apley scratch, Lift-off, Speed’s, Yergason’s, Apley scratch, Lift-off, Speed’s, Yergason’s, Sulcus sign, Apprehension, Relocation testSulcus sign, Apprehension, Relocation test

OMTOMT• ShoulderShoulder::

– Start with upper thoracics, rib and c-spineStart with upper thoracics, rib and c-spine– Stay away from painful arcs of motionStay away from painful arcs of motion– Postural exercises, scapular stabilization, core Postural exercises, scapular stabilization, core

strengthening – then shoulder strengthening.strengthening – then shoulder strengthening.– Indirect techniques until ROM improvesIndirect techniques until ROM improves

• Acute – treat distant yet related areasAcute – treat distant yet related areas• Chronic – treat key somatic dysfunctionChronic – treat key somatic dysfunction

• Remember phases of healingRemember phases of healing – ““aggressive conservatismaggressive conservatism””

ConclusionConclusion

• Clincal exam/history gives you most of the Clincal exam/history gives you most of the information. information.

• Further work-up with radiographs.Further work-up with radiographs.• Reserve MRI/Electrodiagnostics for when Reserve MRI/Electrodiagnostics for when

diagnosis is equivocal, management is in diagnosis is equivocal, management is in question or surgery is considered.question or surgery is considered.

• Begin treatment with conservative Begin treatment with conservative measuresmeasures– OMT, NSAIDS, physical therapy.OMT, NSAIDS, physical therapy.

Thank You!Thank You!• References:References:

– Nelson KE. Somatic Dysfunction in Osteopathic Family Nelson KE. Somatic Dysfunction in Osteopathic Family Medicine. LWW, Baltimore MD, 2007: 139-151.Medicine. LWW, Baltimore MD, 2007: 139-151.

– Malanga GA. Musculoskeletal Physical Examination. Malanga GA. Musculoskeletal Physical Examination. Elsevier, Philadelphia PA, 2006: 59-115.Elsevier, Philadelphia PA, 2006: 59-115.

– Griffin LY. Essentials of Musculoskeletal Care . AAOS, Griffin LY. Essentials of Musculoskeletal Care . AAOS, 2005:145-2332005:145-233

Myofascial Release (MFR): Scapulothoracic

Release Technique Kristin Garlanger OMS III, OMM

FellowChicago College of Osteopathic

Medicine

Scapulothoracic Release Technique 

• Dysfunction: Restricted motion of the left scapula on the thoracic cage• Objective: Improve scapular motion• Discussion: This technique can be use for both evaluation and treatment•    

Patient Position: The patient lies on his/her right side with the affected side up.  The patient’s hips and knees are flexed (for stability) and a small pillow is placed under his/her head for comfort.

• Physician Position: The physician stands along side the table facing the patient.

•    Procedure:

• Drape the patients left arm over your right shoulder • Contact the patient’s medial scapular border with your fingertips.  Take

one step back with your caudad foot for increased stability. • Control the scapula with both hands and gently assess its full range of

motion.  Keep in mind the muscular restrictions that would cause a loss of motion.

• Restriction in motion can be relieved by: •  a.  Holding against a barrier with traction (load and hold)•  b.  Holding in a position of ease (unload and follow)•  c.  ROM/ stretching or articulating against the barrier• Reassess the scapulothoracic motion and treat any remaining restrictions. 

HVLA: Knee in the Back

Pratik Shah OMS IV, OMM FellowChicago College of Osteopathic

Medicine

Knee in back flexed dysfunction Knee in back extended dysfunction

Knee is on segment below on opposite side of dysfunction

Knee is on the dysfunction

Key Considerations:1. Don’t grasp wrists too firmly

2. Always use a pillow3. Technique is most effective for T2-T6

4. Keep weight balanced over the ischial tuberosities5. Engage the barrier with lateral translation primarily

Treating Rib Dysfunction with

Functional TechniquePaula Ackerman OMSV, OMM

Fellow Ohio University College of

Osteopathic Medicine

Treatment Treatment

1. 1. Patient is lateral Patient is lateral recumbentrecumbent

2.2. Physician stands Physician stands in front of patientin front of patient

3.3. Arm supported Arm supported cephalad to elbowcephalad to elbow

4. 4. Unsupported Unsupported elbow hangs elbow hangs toward the floortoward the floor

5.5. Physician monitors Physician monitors at rib angleat rib angle

6.6. Motion input is Motion input is through upper through upper extremityextremity

7.7. Monitor increasing Monitor increasing ease through ease through “stacking”motion“stacking”motion

8.8. Following successful Following successful release, return to release, return to midline and re-testmidline and re-test