How to Perform a Thorough and Systematic Clinical Examination – Part 2

The latest Inner Circle webinar recording on How to Perform a Thorough and Systematic Clinical Examination – Part 2 is now available.


How to Perform a Thorough and Systematic Clinical Examination – Part 2

This month’s Inner Circle webinar is on How to Perform a Thorough and Systematic Clinical Examination – Part 2.  In this presentation, I discuss some of the concepts behind how to structure an excellent clinical examination process.  This will assure that you are always following a systematic process to detect an structural and functional issues, and that you can easily create a plan of treatment to help the person reach their goals.  This is part 2 of 2 and will focus on the objective, assessment, and planning portions of the exam.

This webinar series will cover:

  • The 4 main buckets of any clinical examination process
  • How to assure you follow a systematic approach each and every time
  • How to look for structural pathology, as well as find any suboptimal areas of function that may be related
  • How to take your exam and make an effective assessment and treatment plan

To access this webinar:

 

 

Special Tests for Rotator Cuff Tears

Rotator cuff tears are one of the most common injuries we see in orthopedic physical therapy.

During the clinical examination of the shoulder, we want to perform special tests designed to detect a rotator cuff tear.  

Below are my 4 favorite special tests for rotator cuff tears that I perform during my clinical examination of the shoulder.  These 4 tests do a good job detecting larger tears that are causing dysfunction.

As rotator cuff tears become more common, we are starting to see them in younger and more active patients.  In these patients, they often have smaller tears and it is much more difficult to detect with our special tests.  These types of patients often present with pain and weakness, and not as much dysfunction as you would see in a traditional older patient with a more degenerative tear.  

This is likely because their rotator cuff tear is either small or partial.  These are often just isolated to the supraspinatus muscles as well, and their other rotator cuff muscles are functioning well.  

As a rotator cuff tear becomes larger, retracted, and more degenerative in nature, the patient’s shoulder dysfunction will become more apparent as it becomes difficult for the rotator cuff as a group to function well.

 

Shoulder Shrug Sign

The first special test I perform to diagnose a rotator cuff tear is the shoulder shrug sign.

During this test, the key to check if they can actively elevate their arm if you help them past their shrug arc.  When the shoulder is positioned below 90 degrees, the line of pull and the force vector of the deltoid muscles is superior.  This is often counterbalanced by the line of pull and force vector of the rotator cuff.

In the image below, the left is the line of pull of the deltoid at various shoulder positions.  The picture on the right is the supraspinatus. Notice how the deltoid starts to have a similar line of pull as the rotator cuff once the shoulder reaches 90-120 degrees of elevation:

If the rotator cuff is torn, then the deltoid is the dominant muscle and the resultant force vector is more superior.  

This is the shrug.

However, one you get the arm overhead, the deltoid is now more in line with the rotator cuff and can help center the humeral head within the glenoid fossa.  

So, you want to passively help them get above this position to see if they can elevate towards the upper range of elevation.

There isn’t really any information in the literature regarding this test.  It’s not something you’d probably find as a specific test for a rotator cuff tear, but something I have clinically found to be relevant to me.

 

Shoulder Drop Arm Test

The next rotator cuff tear special test that I perform is the drop arm test.  The concept of this test is pretty similar to the shrug sign. You passively elevate the arm and see if they can hold that position without the arm dropping, or shrugging.

If the arm drops or shrugs, then the rotator cuff likely isn’t able to counterbalance the superior line of pull of the deltoid.

The research has shown that the sensitivity of the drop arm test is low to moderate, but specificity is high from 80-100%.  This is consistent with most of your clinical examination of the shoulder. You usually have to have a significant tear to start seeing these tests positive.

 

Rotator Cuff Lag Sign

The rotator cuff lag signs are similar special tests as the drop arm test.  Essentially, they are like a drop arm for external rotation of the shoulder instead of elevation.

As rotator cuff tears get larger, they tend to extend from the supraspinatus into the infraspinatus.  The lag signs show a difficulty in the external rotators holding the arm against gravity.

The test appears to be specific in the literature with specificity between 88-100% and several studies in the 90% range.  Sensitivity has varied in studies, but has shown 45-56% sensitivity to detect full thickness supraspinatus tears, 70% in infraspinatus tears, and 100% in teres minor tears.  This makes sense to me as it’s a better test for larger tears extending into the infraspinatus and teres minor.

 

Lag Sign at 90 Degrees

I also like to perform a variation of the lag sign at 90 degrees of elevation.  It is the same test as the traditional lag sign, however, I have found this test to be even more challenging.  I have seen patients that had a positive lag sign at 90 degrees of elevation, and a negative lag sign at 20-30 degrees.  It’s simply a more challenging position for the cuff.

The research has shown this to have specificity between 70-100%, however varying sensitivity from 20-100%.  But again, for the same reasons as the lag sign above.

 

Special Tests for Rotator Cuff Tears

If you use all four of the above special tests as a cluster, I think you’ll often be able to detect a large full thickness rotator cuff tear during your clinical examination.  These tests tend to be more sensitive to larger tears in older and more degenerative patients.

But remember, special tests are just a piece of the puzzle.

 

 

The 5 Biggest Mistakes People Make Returning to Training After a Shoulder Injury

Today’s post is an amazing guest post from two of my colleagues at Champion, Dave Tilley and Dan Pope. It’s really an honor to get to work with these guys everyday, as they are some of the brightest minds in the performance therapy and training industry right now. They recently release an educational product that I recommend everyone check out called Peak Shoulder Performance, learn more about it below, plus take advantage of a special discount for my readers!


We are very fortunate to work at a facility that is on the cutting edge of shoulder rehabilitation and sports performance. As a team at Champion, we have combined our ideas in a collaborative format to innovate some of the most effective methods for optimal shoulder training.

We have also been very fortunate that our professional work has given us first-hand experience helping a very diverse population of clients for shoulder-related issues. We have been lucky to see the systems we’ve created at Champion successfully help clients with shoulder injuries who are Division 1 and professional athletes, elite gymnasts, internationally competitive Olympic weightlifters, CrossFit games competitors, power lifters, and some of the most intense general population fitness enthusiasts out there. We can be very honest in saying that these people push their shoulders to the absolute limit with training and competition.

We mention these things not to seem egotistical or to brag. It is to highlight that a properly designed rehabilitation and performance program can get someone back to the highest level of training in sports.

The 5 Biggest Mistakes People Make Returning to Training After a Shoulder Injury

With this being said, we have found helping someone return to these highly demanding training environments following a shoulder injury is one of the trickiest areas to navigate. The knowledge our mentors have taught us and the experiences working with clients at Champion has given us some great insight to this challenge. We’ve experienced what works, what didn’t, and what really derails people when trying to get back to the training they love. In an effort to help readers out, here are five of the most common errors we see made when trying to return back to training following shoulder injury.

1. Rapidly Increasing Workload When Pain is Gone, or When Athletes are “Cleared”

This is without a doubt the most common error we have made as younger clinicians, and see others make regularly. Nothing is more exciting than when an athlete comes into the clinic saying they have been pain-free or got cleared by a doctor to train. However, we have to be very cautious about how much work we allow people to return to following shoulder injury.

Maybe you’ve heard clients say this:

“My shoulder was feeling much better so I jumped back into training. My pain has flared up again pretty bad. What happened?”

Yikes, not fun. We’ve had that stomach dropping moment more times than we care to admit. But, these things happen and it’s how we learn. With that said, it often feels like a problem that could have been avoided.

To help with this, we recommend you educate clients early in the rehabilitation process. Once you start feeling better, it’s not time to return to training full on. Things may be feeling great, but we still need to follow the continual game plan of progressive loading.

Start with the educational process, and then implement an objective plan of attack for rehabilitation. Things to keep in mind are the basic shoulder demands seen in a traditional training program. Things like vertical pushing and pulling, horizontal pushing and pulling, rotator cuff maintenance care and dynamic stability all come to mind. The plan must be outlined well in advanced and must take into account goals, timelines, and mild fluctuations in progress. If we plan and execute fully on this plan we can avoid athletes having flare up when they return to training.

2. Not Restoring Unilateral Strength Symmetry Before Bilaterally Loading The Shoulder

Everyone is going to have a dominant arm, and many sports require asymmetry for success (throwing sports come to mind). With that said, we see clients every week at Champion who continue to have shoulder pain because they failed to regain the most basic foundation of unilateral shoulder strength and stability before jumping back to training. Must people want to jump back into more fun exercises like bench pressing, pull ups, and push-ups before restoring symmetry.

We have to remember that with almost all shoulder injuries or pain comes protective inhibition and some degree of minor disuse atrophy. The severity of strength loss ranges widely based on the nature and severity of the injury. This is without considering that there may have been unilateral imbalances (right to the left) or training imbalances (push to pull ratios) that may have contributed to the injury in the first place.

At Champion, for athletes that are not asymmetrically biased, we like to see an objective 85% – 90% symmetry index for their baseline strength before progressing to advanced bilateral shoulder exercises in training. Sometimes we do this with dynamometers for basic strength. Other times we follow more multi-joint exercise comparisons for single arm floor presses, single arm pulldowns, single arm bent over rows, and 1/2 kneeling presses. If someone can single overhead press 40lbs for five reps on their uninvolved shoulder but struggles to get five clean repetitions with 20lbs on their involved side, returning to a bilateral barbell press may not be the best route at that time.

There is large variability based on the injury, athlete, and sport, but we suggest trying to write programs that close the gap and then focus in on more progressions. Again, it can save a lot of headaches down the road.

3. Treating the Cause of Shoulder Pain, Not Only The Site of Pain

This is very cliché in the Sports Medicine world, but remains extremely important. As Brandon Buchard says, “Just because it is common knowledge, doesn’t mean it is common practice.”

Before creating a return to a training program for a client, ask yourself,

“Have I considered all of the variables that may have contributed to this shoulder injury in the first place.”

Common overlooked factors include workload ratios, technique, programming, problems in joints adjacent to shoulder joint (lumbopelvic, thoracic, elbow), necessary baseline range of motion, strength, and exercise selection.

Now, there may be too many factors to address at once. Some factors may be out of your control. With that said as medical providers, athletes, and sport coaches we should try to tackle as many as we can. We should aim to educate the client as much as possible. Prioritize the main issues and have an open conversation with the client, parent, or coach for why addressing these issues is so important for both performance and re-injury risk. This drastically helps minimize a recurring problem snow balling down the road.

4. Medical Providers Not Creating Individualized, Objective, Return to Fitness Programs

This point goes in line directly with number one. Without a detailed roadmap for getting back to training goals, athletes often feel scattered and overwhelmed. I have found the best method is to start with a conversation on the primary goals or when the athlete desires to be back to sport. From that date, you can reverse engineer the progressions in training needed to aim for that end goal. Once the timeline is established, you can create a progression of exercises, sets, repetitions, and metabolic work in a periodized fashion. Here is a simplified example I use all the time at Champion

Goal: Pain-Free Body Weight Pull Ups in 2 months

Week 1 & 2:

  • Half kneeling single band pulldowns with bent elbow
  • 4×10, 2x/week, with 3-second eccentric tempo
  • Starting in 150 degrees of shoulder elevation and progressing to full 170 of shoulder elevation

Week 3 & 4:

  • Kneeling single arm Kieser or Weight Stack Pull Downs with bent elbow
  • 4×8, 2x/week, with 3-second eccentric tempo
  • Once 90% symmetry established, switch to bilateral Keiser/Weight Stack Pull Downs

Week 5 & 6:

  • Self-spotted pull-ups, standing on box for lower body assistance as needed
  • 5×5, 2x/week, focusing 1 second top and bottom hold

Week 7 & 8:

  • Progression to appropriate band assistance for 5×5, 2x/week
  • Reducing assistance until light or no band is needed

The exercises, sets, reps, and progression rate can be adjusted based on the injury type, client, and training age. Educate clients that the initial program you write is just the first attempt, and that you may need to adjust on the fly based on good or bad days. There may be small amounts of pain, but we personally tell people no more than a 3/10 and it can’t last for more than 24 hours.

Remember it’s less about the specific exercise prescription, and more about understanding the principles underlying the goal the client says they have. Doing this for the primary movements can be extremely helpful for the client and help you design a better program.

5. Not Continuing Basic Soft Tissue and Cuff Care for Maintenance

This is another shockingly common problem that comes up following successful reintegration to training. Athletes and coaches must remember that just because there is no pain, doesn’t mean you’re back to full function. As athlete’s train more they naturally acquire soft tissue stiffness, fatigue, and imbalances around their shoulder joint. This is variable based on the repetitive activates they are doing. Most commonly, we see the latissimus dorsi, teres major, pecs, upper trap, and subscapularis as culprits that cause losses in basic range of motion. Letting this slowly creep up is an easy way for pain to creep back in.

We must be dedicated to regular soft tissue management, strength balance work and high-level cuff strength. This is for a very similar reason as above. The more athletes tend to train, the more they focus on larger primary muscle groups and miss the same amount of development for their smaller stabilizers. When this imbalance creeps up it may create a situation for injury.

In an ideal world, the importance of this has been explained to the client and they maintain visits coming to see you as a provider. Manual therapy, hands-on strength work, and tweaking programs based on changes are incredibly helpful for athletes to get the most out of their shoulders. We are proud to have a lot of athletes realize the importance of this and continue to come on a bi-weekly or monthly basis for tune-ups.

Bonus – Lack of Communication Between All Parties

Open communication with parents, sport coaches, trainers and physicians is essential for athletes returning back to sports. Everyone needs to be on the same page with the athlete’s rehab. If any link in this chain is broken, athletes can be left frustrated and injuries can linger around. Having this communication ensures the bridge back to performance is successful and each professional is doing their part for the athlete.

If the athlete is an individual competitor, the most critical communication is between yourself and the athlete. The more transparent you can be, and the more open you are to answering athlete questions, the better.

Never be afraid to answer questions or concerns that come up. Be honest about the reality of ups and downs for returning to training, and also the possible positive or negative outcomes that come with big decisions. Discussing timelines, pain levels, proactive exercises, and prognosis can really ease the athletes mind and help them establish high levels of trust with you.

For what it’s worth, we have found that the higher the level of the athlete, the more they value honest and open communication. High level athletes are just people, and really appreciate the down to earth professionals who have their best interest in mind above all else.

Peak Shoulder Performance: The Ultimate Guide to Getting Out of Pain and Returning to High Level Fitness

If you enjoy this information, we’re happy to say it’s just the tip of the iceberg on how we approach returning to training after a shoulder injury. If you want to learn exactly how we return athletes back to high level fitness after a shoulder injury, be sure to check out our recently released online course that has been very well received.

We dive deep into the exact exercise progressions, principles, and maintenance care we use on athletes every day. This course is intended to help athletes themselves, medical providers, and coaches better understand this often-frustrating topic.

We know this information can help a lot of people, so we are going to offer a monster deal and chop off $50 from the original price just for Mike’s readers this week. Check out the link below to learn more, and enter “Reinold50” to cash in on the discount, good for this week only!  Offer ends Friday 3/9/18 at midnight EST:

 

 

Dan Pope DPT, OCS, CSCS, CF L1
CEO of Fitness Pain Free
Dave Tilley DPT, SCS, CSCS
CEO of SHIFT Movement Science

 

 

Should We Delay Range of Motion After a Rotator Cuff Repair Surgery?

Over the last several years, there has been a trend among orthopedic surgeons to delay the start of rehabilitation, specifically range of motion exercises, following rotator cuff repair surgery.

It’s my opinion that this trend started in response to the research that has been reported in the past that show issues with tendon healing rates and a large percentage of rotator cuff repairs are not intact at follow up examination.

For example, I previously discussed the outcomes of arthroscopic rotator repairs and noted that at the one year follow up after surgery, 68% had an intact rotator cuff. 32% had a full thickness tear again.

So physicians did what they tend to do… They started to get more conservative and delayed the start of rehabilitation. I’ve discussed a similar to approach to rehabilitation following total shoulder replacement.

But does delaying the start of range of motion after rotator cuff repair surgery even help improve outcomes?

Does immobilization after rotator cuff repair increase tendon healing?

A systematic review was published in the Archives of Orthopaedic and Trauma Surgery that looked at 3 randomized control trials comparing immediate versus delayed range of motion follow rotator cuff repair surgery.

The authors reported a few findings.

Most importantly, there was no difference in tendon healing rate, showing that early range of motion is safe to perform and not the reason why people may retear.

Range of motion improved earlier in the immediate range of motion group, but was similar at the year mark. This is consistent with many past studies. Again physicians read into this and use this stat to favor delayed range of motion, stating that patients are all the same at 1 year postoperative. However, as we all know, restoring motion is key to the patient’s’ subjective and functional outcomes. Similarly, functional outcomes were achieved sooner in the immediate range of motion group.

Based on this systematic review, I would continue to recommend performing control range of motion following rotator cuff repair surgery as it appears to be safe and effective at restoring motion and function sooner than if we delay rehabilitation.

Learn More About How I Evaluate and Treat the Shoulder

I’m pretty excited to announce I have revised my acclaimed online program teaching you exactly how I evaluate and treat the shoulder to now include a lesson on the arthritic shoulder! If you want to learn more about how I work with rotator cuff repairs, and everything else related to the shoulder, you’re going to want to take my online course.

 

Should We Delay Range of Motion After a Total Shoulder Replacement?

Total shoulder replacement surgery is being performed more and more each year.  Our current patients were more active in sports in their youth, potentially increasing the chances of developing an arthritic shoulder.  They also want to remain active as they age, potentially increasing the likelihood that they want to have a total shoulder arthroplasty surgery to allow them to remain active.

Over the years, the surgical technique for a total shoulder replacement has improved, though I’m not sure our rehabilitation approach has also improved.  If our patients are younger and want to be more active after total shoulder replacement, then perhaps our rehabilitation programs should adjust based on their goals.

Rehabilitation Following Total Shoulder Replacement

Historically, a conservative approach was appropriate for many patients, as their needs and activity goals were less aggressive than many patients today.  It was acceptable to have a moderate loss of range of motion in exchange for less pain in their shoulder.

Many surgeons continue to recommend a conservative approach to the restoration of range of motion following surgery.

It is true that one of the primary goals of the postoperative rehabilitation following total shoulder replacement is to protect the subscapularis.  The subscapularis muscle is taken down to some extent during the surgical procedure and the integrity of this muscle has been correlated to the overall outcome of the procedure.

Other motions, such as behind the back and shoulder extension behind their body, also place the arthroplasty in a disadvantageous position and can lead to dislocation of the joint.

But even with these precautions, I am still an advocate of early range of motion, especially if you respect these restrictions.

Passive ROM and Active ROM are Not the Same

A recent report was recently published in Journal of Shoulder and Elbow Surgery that may actually be causing some confusion on when to start range of motion.

In the study, the authors compared a group of patients that began range of motion immediately versus a group that delayed 4 weeks.  The authors reported that the immediate range of motion group gained more motion, restored it earlier, and also showed an earlier increase in functional outcome scores.

However, 96% of the patients that delayed range of motion showed healing of the lesser tuberosity osteotomy, while only 82% of the immediate range of motion group showed healing.  Furthermore, functional outcomes scores 3 months and 1 year after surgery were similar between the groups.

This has led to many recommending a delay in range of motion.  But…

When looking deeper at the methods, the authors chose to use the rope and pulley and stick elevation range of motion exercises.  As we all know, these are not passive range of motion exercises, they are active assisted range of motion exercises.

There’s a big difference between passive and active range of motion exercises!

Previous EMG studies have shown the rotator cuff to be between 18-25% active and the deltoid to be between 21-43% active during these exercises.  Not very passive.  Conversely, passive range of motion exercises have been shown to be between 3-10% active.

This is a big difference.  I believe passive range of motion is appropriate, as long as you respect the restrictions on restoring external rotation to protect the subscapularis and avoid behind the body and behind the back motions to protect the replacement.
Immediate Range of Motion Restores Function Faster

Since we all work with these patients after surgery, we know that they are always happier when they restore their motion sooner.  And this increase in range of motion is likely related to the earlier improvement in functional outcome scores.

I think there is a middle ground of immediate, yet cautious, passive range of motion.  Again, I want to reiterate, “passive” range of motion.  Not active.

By focusing on this, I believe our patients will have much better outcomes.

Learn More About How I Evaluate and Treat the Shoulder

I’m pretty excited to announce I have revised my acclaimed online program teaching you exactly how I evaluate and treat the shoulder to now include a lesson on the arthritic shoulder!  If you want to learn more about how I work with the arthritic shoulder, patients following total and reverse shoulder replacements, and everything else related to the shoulder, you’re going to want to take my online course.

 

Dry Needling for Scapular Winging

This week’s article is a guest post from Michael Infantino.  Michael reached out to me on Facebook and sent me the below videos of a patient’s improvement in scapular winging after dry needling the serratus anterior.

I wanted to share the below article that Michael wrote showing the videos, but also talk about how trigger points may be involved.

I’m not sure what to make of these videos, if trigger points are involved, or exactly how dry needling the serratus anterior helped this patient’s winging.  But I am sure that I was impressed with the results.  I wish we knew more about the reasoning and mechanism, but in the meantime I’m happy we can help people feel and move better.

Dry Needling for Scapular Winging

Can we correct scapular winging in a matter of minutes?  This obviously depends on the cause of the scapular winging.

It is well documented that injury to the long thoracic nerve or cervical spine may lead to medial border scapular winging or dyskinesia of the scapula (Meininger, 2011). These are always challenging.  Ruling out neuromuscular cause can be done with a nerve conduction velocity test or EMG.  

But a recent patient of mine, made me think…

Research has continually shown that muscles with trigger points demonstrate the following:

  • Altered muscle activation patterns on EMG (Lucas, 2010; Wadsworth, 1997)
  • Reduced muscle strength (Celik, 2011)
  • Accelerated muscle fatigue (Ge, 2012)
  • Reduced antagonist muscle inhibition (Ibarra, 2011)  
  • Increased number of trigger points on the painful side (Alburquerque-Sendin, 2013; Bron, 2011; Fernandez-de-las-Penas, 2012; Ge, 2006; Ge, 2008)

Appreciating these findings would lead most to conclude that treatment of trigger points could improve scapular mobility and timing. This was my immediate thought when I noticed a significant medial border scapular winging while watching my patient raise and lower his arm.

It wasn’t until I read this research that I began using dry needling to do more than just manage pain. The results seen following dry needling to the serratus anterior were remarkable.

After seeing this amount of scapular winging, I dry needled his serratus anterior muscle.  Note the remarkable improvement:

How Trigger Point Dry Needling May Impact Scapular Winging

It is well documented that appropriate muscle activation patterns (MAP) surrounding the shoulder is necessary for efficient and pain free mobility (Lucas, 2003). Lucas and group actually gauged the effect of trigger point dry needling on MAP in subjects with latent trigger points (LTrP).

“Latent myofascial trigger points (LTrPs) are pain free neuromuscular lesions that are associated with muscle overload and decreased contractile efficiency” (Simons et al., 1999, p. 12). MAP’s of the upper trapezius, serratus anterior, lower trapezius, infraspinatous and middle deltoid were compared in a group with LTrP’s and one without. Following surface EMG, the LTrP’s were treated with trigger point dry needling. Surface EMG was performed after treatment as well.

Findings from this study were as follows:

  • Muscle activation of the upper trapezius in the LTrP group pre-treatment.
  • Early activation of the infraspinatous in the LTrP group pre-treatment.
  • Increased variability of muscle activation in all muscles assessed in the LTrP group pre-treatment compared to the control group.  
  • Altered MAP of distal musculature (infraspinatous and middle deltoid) were consistent with co-contraction, a finding that has been attributed to increased muscle fatigability (Chabran et al., 2002).
  • Improved muscle activation times in the LTrP group following dry needling.
  • Significant decrease in the variability of muscle activation in the LTrP group following dry needling, except for the serratus anterior.
  • The serratus anterior and lower trapezius showed increased variability in both the control and LTrP group, which may be why the results did not reach significance. This is also consistent with the latest research in JOSPT that found dyskinesia to be normal in asymptomatic populations. (Plummer, 2017).

Based on the both my clinical experiences and the research presented in this paper, it would seem highly valuable to focus on the treatment of trigger points to restore muscle activation patterns surrounding the shoulder complex.

Being able to press the “reset button” on a muscle is important for re-establishing normal muscle activation patterns prior to exercise. Inclusion of other manual therapy and exercise techniques is important for optimizing function of the local musculature (range of motion, hypertrophy, strength and endurance).

No research that I am familiar with has compared dry needling to other manual therapy techniques for restoring MAP in muscles adjacent to the shoulder. Future research that compares various trigger point treatments for restoration of normal MAP would be beneficial.

 

About the Author

Dr. Michael Infantino, DPT, is a physical therapist who works with active military members in the DMV region. You can find more articles by Michael at RehabRenegade.com.

References

  • Alburquerque-Sendin, F., Camargo, P.R., Vieira, A., Salvini, T.F., 2013. Bilateral myofascial trigger points and pressure pain thresholds in the shoulder muscles in patients with unilateral shoulder impingement syndrome: a blinded, controlled study. Clin. J. Pain 29 (6), 478e486.
  • Bron, C., de Gast, A., Dommerholt, J., Stegenga, B., Wensing, M., Oostendorp, R.A., 2011a. Treatment of myofascial trigger points in patients with chronic shoulder pain: a randomized, controlled trial. BMC Med. 9, 8.
  • Chabran, E., Maton, B., Fourment, A., 2002. Effects of postural muscle fatigue on the relation between segmental posture and movement. Journal of Electromyography and Kinesiology 12, 67–79.
  • Celik, D., Yeldan, I., 2011. The relationship between latent trigger point and muscle strength in healthy subjects: a double-blind study. J. Back Musculoskelet. Rehabil. 24 (4), 251e256.
  • Cummings, T.M., White, A.R., 2001. Needling therapies in the management if myofascial trigger point pain: a systematic review. Archives of Physical and Medicine and Rehabilitation 82, 986–992.
  • Ge, H.Y., Arendt-Nielsen, L., Madeleine, P., 2012. Accelerated muscle fatigability of latent myofascial trigger points in humans. Pain Med. 13 (7), 957e964.
  • Ge, H.Y., Fernandez-de-las-Penas, C., Arendt-Nielsen, L., 2006. Sympathetic facilitation of hyperalgesia evoked from myofas- cial tender and trigger points in patients with unilateral shoul- der pain. Clin. Neurophysiol. 117 (7), 1545e1550.
  • Ge, H.Y., Fernandez-de-Las-Penas, C., Madeleine, P., Arendt- Nielsen, L., 2008. Topographical mapping and mechanical pain sensitivity of myofascial trigger points in the infraspinatus muscle. Eur. J. Pain 12 (7), 859e865.
  • Hillary A. Plummer, Jonathan C. Sum, Federico Pozzi, Rini Varghese, Lori A. Michener. Observational Scapular Dyskinesis: Known-Groups Validity in Patients With and Without Shoulder Pain. J Orthop Sports Phys Ther:1-25.  
  • Ibarra, J.M., Ge, H.Y., Wang, C., Martinez Vizcaino, V., Graven- Nielsen, T., Arendt-Nielsen, L., 2011. Latent myofascial trigger points are associated with an increased antagonistic muscle activity during agonist muscle contraction. J. Pain 12 (12), 1282e1288.
  • Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166
  • Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166Meininger, A.K., Figuerres, B.F., & Goldberg, B.A. (2011). Scapular winging: an update. The journal of The American Academy of Orthopaedic Surgeons, 19(8), 453-462.
  • Simons, D.G., Travell, J.G., Simons, L.S., 1999. The Trigger Point Manual, Vol 1, 2nd Edition. Williams and Wilkins, Baltimore, USA.
  • Wadsworth, D.J.S., Bullock-Saxton, J.E., 1997. Recruitment patterns of the scapular rotator muscles in freestyle swimmers with subacromial impingement. International Journal Sports Medicine 18, 618–624.

 

5 Reasons Why I Don’t Use the Sleeper Stretch and Why You Shouldn’t Either

Ah, the sleeper stretch.  Pretty popular right now, huh, especially in baseball players?  Seems like a ton of people are preaching the use of the sleeper stretch and why everyone needs to use it.  It’s so popular now that physicians are asking for it specifically.

I don’t like the sleeper stretch and I rarely use it, in fact I haven’t used it in years.  I don’t think you should use it either.

There, I said it, I felt like I really had the get that off my chest!

Every meeting I go to, I see more and more people talking like the sleeper stretch is the next great king of all exercises.  Then I get up there and say I don’t use it and everyone looks at me like I have two heads!  Call me crazy, but I think we probably shouldn’t be using it as much as we do.

In fact, I actually think it causes more harm than good.

 

5 Reasons Why Shouldn’t Use the Sleeper Stretch

I haven’t used the sleeper stretch in over a decade and have no issues restoring and maintaining shoulder internal rotation in my athletes with safer and more effective techniques.

If you have followed me for some time, you know that I rarely talk in definitive terms, as I always strive to continue to learn and grow.  I know my opinions will change and things aren’t black and white.  However, over the years my stance on NOT using the sleeper stretch has only strengthening.  As I learn more and grow, I actually feel more strongly that we shouldn’t be using this common stretch.

So why don’t I use the sleeper stretch?  There are actually several reasons.

 

It’s Often Performed for the Wrong Reason

The sleeper stretch is most often recommended for people with a loss of shoulder internal rotation.  When a person has a loss of internal rotation, it can be from several reasons, including:

  1. Soft tissue / muscular tightness
  2. Joint capsular tightness
  3. Joint and boney alignment of the glenohumeral joint and scapulothoracic joint
  4. Boney adaptations to repetitive tasks, such as throwing a baseball and other overhead sports

You must assess the true cause of loss of shoulder motion and treat accordingly.

Of the above reasons, you could argue that only joint capsular tightness would be an indication to perform the posterior capsule.  But see my next point below…

Performing the sleeper stretch for the other reasons could lead to more issues, especially in the case of boney adaptations.  The whole concept of glenohumeral internal rotation deficit (GIRD), is often flawed due to a lack of understanding of the normal boney adaptations in overhead athletes.

I can’t tell you how many people think they have GIRD that I evaluate and that they in fact do NOT have GIRD.  Click here to learn more about how I define GIRD.

 

It Stretches the Posterior Capsule

If you have heard me speak at any of my live or online courses, you know that I am not a believer in posterior capsule tightness in overhead athletes.  Maybe it happens, but I have to admit I rarely (if ever) see it.  In fact, I see way more issues with posterior instability.  Please keep in mind I am talking about athletes.  Not older individuals and not people postoperative.  They can absolutely have a tight posterior capsule.

But for athletes, the last thing I want to do is make an already loose athlete looser by stretching a structure that is so thin and weak, yet so important in shoulder stability.

Urayama et al in JSES have shown that stretching the shoulder into internal rotation at 90 degrees of abduction in the scapular plane does not strain the posterior capsule.  However, by performing internal rotation at 90 degrees of abduction in the sagittal plane, like the sleeper stretch position, places significantly more strain on the posterior capsule.

Based on the first two points I’ve made so far, if you have a loss of shoulder internal rotation, you should never blindly assume you have a tight posterior capsule.

Assess, don’t assume.

But be sure you know how to accurately assess the posterior capsule.  Many people perform it incorrectly.  Click here to read how to assess for a tight posterior capsule.

 

It is an Impingement Position

This one cracks me, check out the photos below, if you rotate a photo of the Hawkins-Kennedy impingement test 90 degrees it looks just like a sleeper stretch.  I personally try to avoid recreating provocative special tests as exercises.

sleeper stretch impingement reinold

 

This is a provocative test for a reason, by performing internal rotation in this position, you impinge the rotator cuff and biceps tendon along the coracoacromial arch.  If you actually had a tight posterior capsule, you’d get subsequent translation anteriorly during this stretch and further impingement the structures.

So based on this, even if you have a tight posterior capsule, I wouldn’t use the sleeper stretch.  I would just perform joint mobilizations in a neutral plane.

 

People Often Perform with Poor Technique

So far we’ve essentially said that people often perform the sleeper stretch for the wrong reasons and can end up torquing the wrong structure (the posterior capsule) and irritating more structures (the rotator cuff and biceps tendon).

Even if you have the right person with the right indication, the sleeper stretch is also often performed with poor technique, which can be equally as disadvantageous.

People often roll too far over onto their shoulder or start in the wrong position.  If you are going to perform the sleeper stretch, at least follow my recommendations on the correct way to perform the sleeper stretch.

 

People Get WAY too Aggressive

Despite the above reasons, this may actually be the biggest reason that I don’t use the sleeper stretch – people just get way too aggressive with the stretch.  The whole “more is better” thought process.  Being too aggressive is only going to cause more strain on the posterior capsule and more impingement.  You may actually flare up the shoulder instead of make it better.

I always say, if you have a loss of joint mobility, torquing into that loss of mobility aggressively is only going to make it worse.

 

When the Sleeper Stretch is Appropriate

There are times when the sleeper stretch is probably appropriate.  But it’s not as often as you think and it’s most often not in athletes.  The older individual with adhesive capsulitis or a postoperative stiff shoulder may be good candidates for the sleeper stretch.  But I honestly still don’t use it in these populations.  There are better things to do.

But of course, there are good ways to perform the sleeper stretch and there are bad ways, technique is important.

For more information on some alternatives to the sleeper stretch, check out my article on sleeper stretch alternatives.

 

6 Keys to Shoulder Instability Rehabilitation

Shoulder instability is a common pathology encountered in the orthopedic and sports medicine setting.

But “shoulder instability” itself isn’t that simple to understand.

Would you treat a high school baseball player that feels like their shoulder is loose when throwing the same as a 35 year old that fell on ice onto an outstretched arm and dislocated their shoulder?  They’re both “shoulder instability,” right?

There exists a wide range of symptomatic shoulder instabilities from subtle recurrent subluxations to traumatic dislocations. Nonoperative rehabilitation is commonly utilized for shoulder instability to regain previous functional activities through specific strengthening exercises, dynamic stabilization drills, neuromuscular training, proprioception drills, scapular muscle strengthening program and a gradual return to their desired activities.

I’ve had great success rehabilitating dislocated shoulders and helping people return back to full activities without surgery.  But to truly understand shoulder instability, there are several key factors that you must consider.

 

Key Factors When Designing Rehabilitation Programs for Shoulder Instability

Because there are so many different variations of shoulder instability, it is extremely important to understand several factors that will impact the rehabilitation program.  This will allow us to individualize programs and enhance recovery.

There are 6 main factors that I consider when designing my rehabilitation programs for nonoperative shoulder instability rehabilitation.  I’m going to cover each in detail.

 

Factor #1 – Chronicity of Shoulder Instability

The first factor to consider in the rehabilitation of a patient with shoulder instability is the onset of the pathology.

Pathological shoulder instability may result from an acute, traumatic event or chronic, recurrent instability. The goal of the rehabilitation program may vary greatly based on the onset and mechanism of injury.

Following a traumatic subluxation or dislocation, the patient typically presents with significant tissue trauma, pain and apprehension. The patient who has sustained a dislocation often exhibits more pain due to muscle spasm than a patient who has subluxed their shoulder. Furthermore, a first time episode of dislocation is generally more painful than the repeat event.

Rehabilitation will be progressed based on the patient’s symptoms with emphasis on early controlled range of motion, reduction of muscle spasms and guarding and relief of pain.

The primary traumatic dislocation is most often treated conservatively with immobilization in a sling and early controlled passive range of motion (ROM) exercises especially with first time dislocations. The incidence of recurrent dislocation ranges from 17-96% with a mean of 67% in patient populations between the ages of 21-30 years old. Therefore, the rehabilitation program should progress cautiously in young athletic individuals. It should be noted that Hovelius et al has demonstrated that the rate of recurrent dislocations is based on the patient’s age and not affected by the length of post-injury immobilization. Individuals between the ages of 19 and 29 years are the most likely to experience multiple episodes of instability. Hovelius et al also noted patients in their 20’s exhibited a recurrence rate of 60% whereas patients in their 30’s to 40’s had less than a 20% recurrence rate. In adolescents, the recurrence rate is as high as 92% and 100% with an open physes.

Conversely, a patient presenting with atraumatic instability often presents with a history of repetitive injuries and symptomatic complaints. Often the patient does not complain of a single instability episode but rather a feeling of shoulder laxity or an inability to perform specific tasks.

Rehabilitation for this patient should focus on early proprioception training, dynamic stabilization drills, neuromuscular control, scapular muscle exercises and muscle strengthening exercises to enhance dynamic stability due to the unique characteristic of excessive capsular laxity and capsular redundancy in this type of patient.

Chronic subluxations, as seen in the atraumatic, unstable shoulder may be treated more aggressively due to the lack of acute tissue damage and less muscular guarding and inflammation. Rotator cuff and periscapular strengthening activities should be initiated while ROM exercises are progressed. Caution is placed on avoiding excessive stretching of the joint capsule through aggressive ROM activities.

The goal is to enhance strength, proprioception, dynamic stability and neuromuscular control especially in the specific points of motion or direction which results in instability complaints.

 

Factor #2 – Degree of Shoulder Instability

Bankart LesionThe second factor is the degree of instability present in the patient and its effect on their function.

Varying degrees of shoulder instability exist such as a subtle subluxation or gross instability. The term subluxation refers to the complete separation of the articular surfaces with spontaneous reduction. Conversely, a dislocation is a complete separation of the articular surfaces and requires a specific movement or manual reduction to relocate the joint. This will result in underlying capsular tissue trauma. Thus, with shoulder dislocations the degree of trauma to the glenohumeral joint’s soft tissue is much more extensive.

Speer et al have reported that in order for a shoulder dislocation to occur, a Bankart lesion must be present and also soft tissue trauma must be present on both sides of the glenohumeral joint capsule.

Thus, in the situation of an acute traumatic dislocation, the anterior capsule may be avulsed off the glenoid (this is called a Bankart lesion – see pictures to the right) and the posterior capsule may be stretched, allowing the humeral head to dislocate. This has been referred to as the “circle stability concept.”

The rate of progression will vary based upon the degree of instability and persistence of symptoms. For example, a patient with mild subluxations and muscle guarding may initially tolerate strengthening exercises and neuromuscular control drills more than a patient with a significant amount of muscular guarding.

 

Factor #3 – Concomitant Pathology

Hill Sachs LesionThe third factor involves considering other tissues that may have been affected and the premorbid status of the tissue.

As we previously discussed, disruption of the anterior capsulolabral complex from the glenoid commonly occurs during a traumatic injury resulting in an anterior Bankart lesion. But other tissues may also be involved.

Often osseous lesions may be present such as a concomitant Hill Sach’s lesion caused by an impaction of the posterolateral aspect of the humeral head as it compresses against the anterior glenoid rim during relocation. This has been reported in up to 80% of dislocations. Conversely, a reverse Hill Sach’s lesion may be present on the anterior aspect of the humeral head due to a posterior dislocation.

Occasionally, a bone bruise may be present in individuals who have sustained a shoulder dislocation as well as pathology to the rotator cuff. In rare cases of extreme trauma, the brachial plexus may become involved as well. Other common injuries in the unstable shoulder may involve the superior labrum (SLAP lesion) such as a type V SLAP lesion characterized by a Bankart lesion of the anterior capsule extending into the anterior superior labrum. These concomitant lesions will affect the rehabilitation significantly in order to protect the healing tissue.

 

 

Factor # 4 – Direction of Shoulder Instability

Shoulder Multidirectional InstabilityThe next factor to consider is the direction of shoulder instability present. The three most common forms include anterior, posterior and multidirectional.

Anterior shoulder instability is the most common traumatic type of instability seen in the general orthopedic population. It has been reported that this type of instability represents approximately 95% of all traumatic shoulder instabilities. However, the incidence of posterior instabilities appears to be dependent on the patient population. For example, in professional or collegiate football, the incidence of posterior shoulder instability appears higher than the general population. This is especially true in linemen. Often, these posterior instability patients require surgery as Mair et al reported 75% required surgical stabilization.

Following a traumatic event in which the humeral head is forced into extremes of abduction and external rotation, or horizontal abduction, the glenolabral complex and capsule may become detached from the glenoid rim resulting in anterior instability, or a Bankart lesion as discussed above.

Conversely, rarely will a patient with atraumatic instability due to capsular redundancy dislocate their shoulder. These individuals are more likely to repeatedly sublux the joint without complete separation of the humerus from the glenoid rim.

Posterior shoulder instability occurs less frequently, only accounting for less than 5% of traumatic shoulder dislocations.

This type of instability is often seen following a traumatic event such as falling onto an outstretched hand or from a pushing mechanism. However, patients with significant atraumatic laxity may complain of posterior instability especially with shoulder elevation, horizontal adduction and excessive internal rotation due to the strain placed on the posterior capsule in these positions.

Multidirectional instability (MDI) can be identified as shoulder instability in more than one plane of motion. Patients with MDI have a congenital predisposition and exhibit ligamentous laxity due to excessive collagen elasticity of the capsule.

Shoulder Sulcus SignOne of the most simple tests you can perform to assess MDI is the sulcus sign.

I would consider an inferior displacement of greater than 8-10mm during the sulcus maneuver with the arm adducted to the side as significant hypermobility, thus suggesting significant congenital laxity.  You can see this pretty good in this photo to the right, the sulcus is clearly larger than my finger width.

Due to the atraumatic mechanism and lack of acute tissue damage with MDI, ROM is often normal to excessive.

Patients with recurrent shoulder instability due to MDI generally have weakness in the rotator cuff, deltoid and scapular stabilizers with poor dynamic stabilization and inadequate static stabilizers. Initially, the focus is on maximizing dynamic stability, scapula positioning, proprioception and improving neuromuscular control in mid ROM.

Also, rehabilitation should focus on improving the efficiency and effectiveness of glenohumeral joint force couples through co-contraction exercises, rhythmic stabilization and neuromuscular control drills. Isotonic strengthening exercises for the rotator cuff, deltoid and scapular muscles are also emphasized to enhance dynamic stability.

 

Factor #5 – Neuromuscular Control

neuromuscular controlThe fifth factor to consider is the patient’s level of neuromuscular control, particularly at end range.

Injury with resultant insufficient neuromuscular control could result in deleterious effects to the patient. As a result, the humeral head may not center itself within the glenoid, thereby compromising the surrounding static stabilizers. The patient with poor neuromuscular control may exhibit excessive humeral head migration with the potential for injury, an inflammatory response, and reflexive inhibition of the dynamic stabilizers.

Several authors have reported that neuromuscular control of the glenohumeral joint may be negatively affected by joint instability.

Lephart et al compared the ability to detect passive motion and the ability to reproduce joint positions in normal, unstable and surgically repaired shoulders. The authors reported a significant decrease in proprioception and kinesthesia in the shoulders with instability when compared to both normal shoulders and shoulders undergoing surgical stabilization procedures.

Smith and Brunoli reported a significant decrease in proprioception following a shoulder dislocation.

Blasier et al reported that individuals with significant capsular laxity exhibited a decrease in proprioception compared to patients with normal laxity.

Zuckerman et al noted that proprioception is affected by the patient’s age with older subjects exhibiting diminished proprioception than a comparably younger population.

Thus, the patient presenting with traumatic or acquired instability may present with poor neuromuscular control that must be addressed.

 

Factor # 6 – Pre-Injury Activity Level

The final factor to consider in the nonoperative rehabilitation of the unstable shoulder is the arm dominance and the desired activity level of the patient.

If the patient frequently performs an overhead motion or sporting activities such as a tennis, volleyball or a throwing sport, then the rehabilitation program should include sport specific dynamic stabilization exercises, neuromuscular control drills and plyometric exercises in the overhead position once full, pain free ROM and adequate strength has been achieved.

Patients whose functional demands involve below shoulder level activities will follow a progressive exercise program to return full ROM and strength. The success rates of patients returning to overhead sports after a traumatic dislocation of their dominant arm are often low, but possible.

Arm dominance can also significantly influence the successful outcome. The recurrence rates of instabilities vary based on age, activity level and arm dominance. In athletes involved in collision sports, the recurrence rates have been reported between 86-94%.

 

Keys to Shoulder Instability Rehabilitation

To summarize, nonoperative rehabilitation of shoulder instability has many subtle variations.  To simplify my thought process, I always think of these 6 key factors before I decide what I want to do.  I hope these factors help you too.  What other factors do you consider when designing rehabilitation programs for shoulder instability?

 

Learn How I Evaluate and Treat the Shoulder

shoulder seminarWant to learn exactly how I rehabilitate shoulder instability?

I have a whole lesson on this as part of my comprehensive online program on the Evidence Based Evaluation and Treatment of the Shoulder at ShoulderSeminar.com.  If you want to learn exactly how I evaluate and treat the shoulder, including shoulder instability, this course is for you.  You’ll be an expert on shoulders!