This patient here is a nurse who injured her shoulder resuscitating a baby. She presented with a positive cluster for impingement. The question is what type of impingement. One of the more common ones is subacromial impingement. With a positive Painful Arc Sign, Infraspinatus Test, and Hawkins Kennedy Test, it might have made sense to jump towards that diagnosis. However, the patient had a positive anterior drawers test on the R shoulder and presented with pain with abduction in internal rotation. Check out the video below:
If you watch closely, the first attempt you actually see the humerus gliding anteriorly with abduction as she attempts to abduct (sorry for the poor camera work!). On the second attempt, she focuses on centralizing the humerus while abduction. It may look like she is retracting and depressing her scapula, but the important component is centralization. This is a prime example of why we need to not forget where we come from as movement analysis specialists. If we were to simply rely on special tests, odds are this patient may have been treated inappropriately for a couple weeks. The key is closely watching (and sometimes palpating) the joint during movement - especially the painful/limited movement. The treatment for this patient has been to do self-mobilizations to the posterior capsule in quadruped while rocking back. This also helps to retrain the neuromuscular system for proper scapulohumeral rhythm. Additionally, we have been strengthening the the external rotators from an internally rotated position to help build an anterior restraint. The HEP included IR and ER using a theraband and focusing on centralization of the humeral head.
There were several lessons that can be learned from our first movement analysis experiment that can be directly translated to the clinic:
1) Your outcomes will greatly depend on how compliant your patients are with their home exercise program. Unfortunately, Jim performed his HEP less than anticipated. Some changes were noted, but overall performance did change as anticipated. Being able to effectively teach an HEP will be important for your success as a therapist.
2) The ideal movement may not be attainable for all people. Since Jim has a pathological right shoulder, his end-range flexion and abduction will not be the same as his left shoulder. Due to some SC joint problems, the "perfect" movement was not possible for him based on the HEP we prescribed. We did not address the SC impairments specifically. Additionally, it must be considered that he is right handed. As Mike Reinold states, "we are unilateral creatures...and typically function in predominant movement patterns." We must work on proper alignment in addition to solely addressing muscular imbalances.
Some of the things we noted upon follow-up:
1. Increased scapular winging bilaterally (L >R)
2. Increased Upper Trapezius Muscle Activity (L> R)
3. R scapula relatively lower than L scapula
4. Asymmetrical Lateral Trunk Curvatures. It was noted that the asymmetry became worse during end-range flexion and abduction and improved upon return to starting position.
5. L Inferior Scapula border tilted anteriorly
One positive aspect we observed was smoother scapulohumeral eccentric control. Jim attributes this change to being most compliant with his seated theraband scapular retraction intervention & focusing on postural awareness.
What did we miss? Point out other asymmetries you observe & give us your thought process to why it might be occurring!
Finally, we want to apologize for delaying this follow-up post longer than expected. Our next movement analysis will be much more timely!
Summary: During the motions, we noted poor dynamic stabilization of the scapular stabilizers due to a lack of fluid rotation at the scapulothoracic and glenohumeral joints. Because of the lack of scapular stability, Jim's rotator cuff has been excessively working to maintain the humeral head in the glenoid fossa. Many impairments could be seen more significantly on the Right vs. Left due to a recent thoracic surgery. It is evident that the surgery has altered him mechanics and his axioscapular muscles are not functioning at the proper length/ tension relationship.
Over the next 3 weeks, we have prescribed Jim the following exercises to improve the timing, coordination, and neuromuscular endurance of the scapular stabilizers:
1) Seated theraband scapular retractions, emphasizing eccentric control.
3 sets x 15 repetitions, with a 5 second eccentric contraction.
2) Push-up Plus
3 sets x 12 repetitions
3) Plank Plus
2 sets x 12 repetitions
4) Standing wall "W's" w/ arms externally rotated and forearms pronated (little finger against the wall)
2 sets x 15 repetitions
Each exercise will be performed daily.
Check back in 3 weeks to see an update on Jim's Shoulder Mechanics!