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Atraumatic Shoulder Instability |
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Mike Lawler
November 13, 2003
Sports Medicine Conference
Start with Gymnastics Videos
n on Still Rings
n on High Bar
n on Parallel Bars
Atraumatic Shoulder Instability
The Shoulder Shift Program
Muscle Control Over Instability
Mike Lawler MA, LAT, ATC
Senior Athletic Trainer
The University of Iowa
Mechanisms Responsible for Shoulder Stability
n Static Stabilizers
n Glenoid labrum
n Capsule/Glenohumeral ligaments
n Rotator interval
n Dynamic Stabilizers
n Rotator cuff
n Biceps tendon
n Scapular rotators/stabilizers
Relationship Between Static and Dynamic Stabilizers
n There is a complex, interrelating relationship between the static and
dynamic stabilizers of the glenohumeral joint.
n Working together, they lend stability to the glenohumeral joint.
n Glenohumeral instability occurs when there is an imbalance in the
static-dynamic relationship.
n Imbalance may occur by traumatic injury or by atraumatic overuse.
Normal Laxity
n Normal degrees of translation have been studied and are variable.
Anterior translation should not exceed 25% of the glenoid surface and
posterior and inferior translation should be less than 50% of the
glenoid surface.
Abrams JS. Special Shoulder Problems in the Throwing Athlete, Clinics in
Sports Medicine: Vol. 10, No. 4, October 1991,839-861.
Glenohumeral Shoulder Instability
n Glenohumeral instability refers to excessive, symptomatic translation
of the humeral head on the glenoid fossa, and reflects altered static
and dynamic structures for stabilization.
“Functional Assessment and Rehabilitation of Shoulder Proprioception for
Glenohumeral Instability” Borsa PA, Lephart SM, Kocher MS, and Lephart
S. Journal of Sports Rehabilitation, Vol. 3, No. 1, 84-104.
Glenohumeral Shoulder Instability
n It is useful to define instability as a clinical condition in which
unwanted translation of the [humeral] head on the glenoid compromises
the comfort and function of the shoulder.
n By contrast, laxity refers only to the ability of the humeral head to
be passively translated on the glenoid fossa.
Matsen FA, Harryman DT, Sidles JA: Mechanics of Glenohumeral
Instability. Clinics in Sports Medicine. Vol. 10, No. 4, October 1991,
783-788.
Method of Classification of Shoulder Instability Pathology
T U B S
n Traumatic,
n Unidirectional, often associated with a
n Bankart lesion, and usually requires
n Surgery
Method of Classification of Shoulder Instability Pathology
A M B R I
n Atraumatic etiology of the instability, which is usually
n Multidirectional and often
n Bilateral and will often respond to
n Rehabilitation, thus avoiding surgery. If surgery is necessary, an
n Inferior capsular shift should be performed.
Matsen FA. Method of Classification of Shoulder Instability Pathology
Management Options
n Surgery followed by rehabilitation
or
n Conservative approach of rehabilitation
Atraumatic Cause and Effect
n A relationship exists between shoulder instability and injury, i.e.
rotator cuff tendinitis, subacromial bursitis, rotator cuff tears.
Cause and Effect Progression
n Static stabilizers are stretched, injured
n Increased translation of glenohumeral joint
n Rotator cuff fatigue and weakness develops
n Failure to control glenohumeral joint
n Secondary trauma occurs
n Gymnastics – controlled motion requiring balance, momentum, and power.
n Swimming – the average competitive swimmer will perform significantly
more repetitions of his/her shoulder movements each year than a baseball
player. The average male competitive swimmer will perform some 50,000
strokes per arm per year over a career lasting 10 to 15 years.
Richardson AB. Overuse Syndromes in Baseball, Tennis, Gymnastics, and
Swimming. Clinics in Sports Medicine, Vol. 2, No. 2, July 1983.
Conservative Approach to Rehabilitation
The Shoulder Shift Program
n The shoulder is a delicate balance between mobility and stability.
n Shoulder movement involves coordinated muscular strength and
endurance, flexibility, and neuromuscular control.
n Often, emphasis is placed on improving or restoring muscular strength
and endurance, GH joint flexibility, but neuromuscular control is a
second thought.
n By including neuromuscular control in the rehabilitation process,
better glenohumeral joint stability can be achieved.
n Proprioceptive Neuromuscular Facilitation - PNF
Neuromuscular Mechanism
n Articular mechanoreceptors
n Sensations of kinesthesia and joint position
n Joint capsule
n Peripheral receptors responsible for joint proprioception
n Only respond at the extremes of joint ROM or during situations when it
receives strong stimuli such as distraction, compression, or deep
pressure.
n Muscle
n Muscle spindle and Golgi tendon organ receptors sense change in muscle
tension
Shoulder Shift Program - PNF
n Recognition of instability
n Develop muscular control using dynamic stabilizers
n Rotator cuff muscles
n Scapular stabilizers
n Rough and crude to reflexive
n Develop muscular strength and endurance
n Develop proprioception and neuromuscular control
n Open Kinetic Chain Exercises
n Dynamic Muscular Control
n Rhythmic Stabilization
n PNF
n Closed Kinetic Chain Exercises
n Plyometrics
n Sports-specific
Video Demonstration
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