1) pectoralis minor strech

▷ It may indicate that humeral elevation and external rotation to 90 are important components of pectoralis minor stretching

▷ performed bilaterally streching, which may be more effective prevent trunk rotation toward the side of the stretch, because of this mechanical block

2) posterior capsule stretch (sleeper strech)

3) Latissimus dorsi strech

4) Thoracic mobility exercise

# Effect of posture on pain and ROM

Thoracic kyphosis may not be an important contributor to the devepopment of shoulder pain. While there is evidence that reducing thoracic kyphosis facilitates greater shoudler ROM

5) Shoulder muscle exercise

▷ Conservative, Post OP treatment

large to massive tear, delay postop treatment

Impingement, early postop strengthening

6) Deltoid, Pectoralis, and Latissimus dorsi in large and massive RC tear

▷ in mRCT, The PM and LD muscles are effective in improving glenohumeral kinematics and reducing acromiohumeral pressures

▷ Increased activation of the latissimus dorsi and teres major muscles is an attempt to compensate for the deficient rotator cuff

▷ Humeral head deprssor exercises (pectoralis major and latissimus dorsi)

▷ Deltoid rehabilitation program is suitable for elderly patients with massive rotator cuff tears

7) OKC strengthening exercise

8)  more effect isolates position of supra from deltoid

▷ 30 of abduction, mild ER, and 30 of flexion

9) posterior capsular stretch VS capsular stretch + mobilization

 

10) Posterior mobilization

11) Effective position in inferior mobilization

▷ Maximal inferior translation with minimal force was found when a grade 3 mobilization was performed in the OPP

12) Mobilization with movement (MWM)

▷ Effects of Mobilization With Movement on Pain and Range of Motion in Patients With Unilateral Shoulder Impingement Syndrome: A Randomized Controlled Trial

1) Factor of internal impingement

▷ Anterior capsular laxity

▷ Posterior capsular tightness

▷ Scapular dyskinesis

▷ Hyperangulation & hyperexternal rotation

=> but internal impingement is a normal physiological phenomenon

2) Factors of SAIS(subacromial impingement syndrom)

○ Intrinsic mechanics

overuse

tension overload

trauma of the tendons

○ Extrinsic mechanisc

dysfunctional rotator cuff musculature

weak or dysfunctional scapular musculature

posterior gleno-humeral capsule tightness

postural dysfunctions of the spinal column

○ SASI may lead th a full-thickness tear of the rotator cuff tendons & tendinopathy

3) Extrinsic acromial length

○ Acromial index (ratio), positive correlation in impingement and RCT

>Greater in East Asian than North American

4) Dysfunction of rotator cuff

○ Supraspinatus weakness

○ Fatigue of the infraspinatus and teres minor

less scapular posterior tilit (scapular retraction)

○ During the 30 to 90

Subcaupualris & infraspinatus was the only muscles with decreased activity

5) Role of subscapularis

○ Subscapularis is the “hidden culprit” of the rotator cuff

○ Fibrosis or scarring of the subcaupularis

○ Primary restrict passive external rotation at AB 90 and 0, limiting ER in the adducted position.

6) Weakness & dysfunction trapezius

○ Excessive upper trapezius activation

between 40 to 100

increased anterior tilt scapulo-thoracic joint

○ Lack of activity in the middle & lower trapezius & serratus anteror

7) abnormal posture

○ Forward postuer

Abduction and elevation of the scapula

Appear winging scaupular and medial rotationof humerus

Increase thoracic khyposis angle

Relatively more elevation, protraction, anterior tilt and a downwardly rotated posture

○ Cause

Tightness of pectoralis minor, biceps short head, levator scapular, upper trapezius

Weakness of middle, lower trapezius, serratus anterior

Leading th subacromial impingement syndrome

8) Role of latissimus dorsi

○ Teres major and latissimus dorsi can also provide humeral depression forces secondary to their anatomical alignment.

○ Tight latissimus dorsi

cause of chronic shoudler pain

▷ tendinous fascia connecting the latissimus dorsi th the thoracic and lumbar spine.

9) Functionally tightened muscles

○ Pectoralis minor & biceps short head

○ Levator scapulae & upper trapezius

○ Latissimus dorsi & subscapularis

○ Superficial cervical flexor muscles

10) Inhibited or weakened functionally

○ Rhombiodeus & mid and lower trapezius & serratus anterior

○ Teres minor & infraspinatus & posterior deltoid

○ Deep flexor cervical muscles

○ Especially, lower stabilizers of the scapula (serratus anterior, middle trapezius, and lower trapezius)

Reference

The lat length test ELEATE SPORTS ACADEMY

Musculoskeletal Evidence based Treatment

Morrey BF, An KN (1990) Biomechanics of the shoulder. In: Rockwood CR, Matsen FA (ed) The shoulder. Saunders, Philadelphia, pp 208–245Google Scholar.

lippitt. clin orthop relat res (1993) Rotator Cuff Tears: causes of shoulder pain: Stabilizing effect of negative intraarticular pressure

L. Kessel, M. Watson Published 1 May 1977 Medicine The Journal of bone and joint surgery. British volume The painful arc syndrome. Clinical classification as a guide to management.

Rotsalai Kanlayanaphotporn, Ph.D. (Health Sciences), M.Appl.Sc. (Physiotherapy), B.Sc. (Physical Therapy) Published:November 04, 2013 Changes in sitting posture affect shoulder range of motion

Sally Raine, PhD, Lance T. Twomey, PhD Head and Shoulder Posture Variations in 160 Asymptomatic Women and Men

Raine S, Twomey LT. Head and shoulder posture variations in 160 asymptomatic women and men. Arch Phys Med Rehabil 1997;78:1215-23.

Journal of Orthopaedic & Sports Physical Therapy Published Online:July 1, 2004 Electromyographic Analysis of the Rotator Cuff and Deltoid Musculature During Common Shoulder External Rotation Exercises

P. Chalmers, G. Cvetanovich, +5 authors G. Nicholson Published 1 February 2016 Medicine Journal of shoulder and elbow surgery. The champagne toast position isolates the supraspinatus better than the Jobe test: an electromyographic study of shoulder physical examination tests.

Andrea J Johnson 1, Joseph J Godges, Grenith J Zimmerman, Leroy L Ounanian The effect of anterior versus posterior glide joint mobilization on external rotation range of motion in patients with shoulder adhesive capsulitis DOI: 10.2519/jospt.2007.2307

Robert C. Manske, PT, DPT*, Matt Meschke, DO, Andrew Porter, DO, Barbara Smith, PhD, PT, Michael Reiman, PT, DPTFirst Published December 22, 2009 A Randomized Controlled Single-Blinded Comparison of Stretching Versus Stretching and Joint Mobilization for Posterior Shoulder Tightness Measured by Internal Rotation Motion Loss

Choo Yeonki, PT, Ph.D Dept. of Rehabilitation Therapy, Guposungshim Hospital, Manager Effects of Mobilization with Movement Combined with Exercise(EMWM) on ADH, ROM and Functional Performance in Patients with Impingement Syndrome of the Shoulder

The effect of shoulder position on inferior glenohumeral mobilization Dexter W. Witt DHS, DPT, MHS, PT, OCS, FAAOMPT *, Nancy R. Talbott PhD, MS, PT, RMSK

1) Subacromial impinegment (External impingement)

● Exccssive superior translations with rotator cuff weakness during arm elevation

● Bursitis sid

● Severe pain

2) Internal impingement

● At ABER position(90-90 position)

Intra- articular impingemetn

● Posterio-superior rotator cuff contacts the postero-superior glenoid labrum and pinched between the labrum and GT

● Articular side layer is more vulnerable to a tensile load than the bursal side layer.

● Especially, tear of posterior supraspinatus and anterior infraspinatus tendon.

Classification of patial tears

FTRCT (full thickness rotator cuff tear)

▷ Rotator cuff full thickness tear(supraspinatus complete tear)

▷ Concomitant infraspinatus tear 40%

▷ Concomitant subscapularis tear 30~70%

Reference

CBD Wellness Centre Feb 1, 2019

Difference between Rotator Cuff Tear and Sub Acromial Impingement Syndrome

Arthroscopic classification of partialthickness rotator cuff tears according to Ellman [32 Last Updated on Wed, 16 Dec 2020 | Rotator Cuff

Musculoskeletal Evidence based Treatment

현대사회에서 팔이 아프다고하면 굽은어깨와 어깨충돌증후군을 많이들 이야기한다. 이 어깨충돌증후군은 팔을 올릴때 견갑골의 견봉과 상완골의 대결절부의 마찰이 발생하여 염증이 유발되는 병적인 상태를 어깨의 충돌증후군이라 한다. 이러한 마찰은 견봉과 대결절부 사이에 위치하는 회전근개 힘줄(극상건, 극하건의 일부), 견봉하 점액낭 등에 염증 및 손상을 초래하며 이는 어깨의 통증 및 불안정성을 야기한다. 이러한 염증은 중년에게는 흔한 어깨 통증의 원인 중 하나이다.

충돌 증후군 대표증상은 통증이다. 삼각근 부위가 아프며, 경우에 따라 상완부가 아프기도 한다. 심하지 않은 경우에는 특정한 자세나 과격한 움직임에서 통증이 유발되지만 심해지면 지속적인 통증이 발생하기도 한다. 특히 팔을 전방 거상 할 때나 외전할 때 통증이 흔히 발생하며 60도에서 120도 까지 거상 시 통증이 나타나고 120도 이상 거상 시 통증이 줄어드는 동통 궁 증후군 현상이 나타나기도 한다. 또한 야간통으로 표현되는 바와 같이 밤에 누워 자려고 하면 통증이 심해져서 잠을 못 이룰 정도록 심해지기도 하여 수면장애를 일으키기도 한다. 간혹 견봉하 조직들의 충동에 따른 염발음이 나타나기도 한다. 특정한 움직임에서 소리가 나는 것은 환자가 인식하기도 하며 심한 경우 외부에서 들릴 정도로 크게 나기도 한다.

Reference

서울대학교병원 의학정보, 서울대학교병원

shoulder impingement syndrome: symptoms, cause, diagnosis & treatmet