This past weekend I had the great pleasure of speaking to a group of Athletic Therapists and Strength and Conditioning Specialists at the Ontario Human Performance Symposium held at Sheridan College. I spoke on Rotator Cuff Impingement Secondary to Scapular Dyskinesis. The take home message from my lecture can be summarized in one sentence: “clients suffering from impingement may have a decreased scapular upward rotation and posterior tipping.”
After the lecture, I was fortunate enough to spend some time sharing Manual Therapy techniques around assessing shoulder girdle dysfunctions. Two of the clinically useful Manual Therapy palpation techniques that I demonstrated were as follows:
The First Manual Therapy Technique
4 Point Palpation Technique of the Scapula (Watson and Dalziel, 1997 &1998)
Client standing, therapist behind, therapist uses two hands to assess scapula position
Right hand: thumb on posterolateral corner of acromion, middle finger on anterolateral acromial edge
Left hand: thumb on inferior angle of the scapula, index finger on the medial end of the spine of the scapula
The Second Manual Therapy Technique
Humeral Head Position Palpation
Palpate the anterior and posterior edge of the acromion with one hand.
Then palpate the lesser tubercle and the posterior aspect of the humeral head with the other hand.
Divide the acromion width into 3 equal parts and determine if the humeral head falls within the posterior 1/3 section relative to the acromion width. If it does, it is considerd to be normal, if greater than a third then it is considered to be an anterior migration of the humeral head which could be a culprit of Impingement Syndrome.
Stay tuned for access to the audio for this lecture…
After teaching the client how to properly pattern their scapula, the external rotation patterning exercise was introduced. This was performed prior to initiating external rotation strengthing in standing with resistance.
Click on the 1 minute video to see the exercise progression!
Previously, I discussed a case on the shoulder and sent the client home with a patterning exercise to improve their external rotation strength. What I didn’t mention is that I first taught them a scapular patterning exercise as a basis for progression. Check out this video of a scapular patterning exercise targeting upper fibres of trapezius. This would provide a solid base to build upon when strengthening the rotator cuff muscles!
I recently saw a client who presented with a one month history of ‘catching’ pain in the shoulder.
The client recalls reaching overhead which precipitated the pain and has noticed intermittent pain since then with varied movements.
The client presented with a mild anteriorly migrated humeral head and no other significant postural defaults. Shoulder ROM was limited with external rotation at zero degrees abduction only, all other movements were normal. A mild strength deficit was noted with external rotation tested at zero degrees of abduction.
Other findings included:
hypomobility of the superior anterior GH capsule, hypermobility of the posterior middle capsule, thickening of the long head of bicep’s tendon, hypertonicity of the infraspinatus muscle and bicep’s muscle.
My thought on this case was that the hypermobility of the posterior middle capsule (likely from a previously unrecalled minor trauma) caused a hypertonic response in the infraspinatus muscle, which then caused the humeral head to migrate anteriorly. This anterior migration may have triggered irritation of the long head of the bicep’s tendon causing its synovial sheath to thicken. The thickened synovial sheath was the factor causing the ‘catching’ pain.
SO NOW WHAT?
I used manual therapy to treat the problem.
I targeted the bicep’s muscle and tendon with massage to release tension and increase circulation, I then targeted the infraspinatus muscle with a dry point needling technique to release its tension. And finally, I mobilized the anterior superior capsule with an inferior glide and external rotation technique (glide and wind).
The end result after one treatment was a dramatically improved external rotation motion with no ‘catching’ pain and ultimately a happy client! The client was sent home with a re-patterning exercise for external rotation and will be followed up.
The point is that sometimes a few simple manual therapy techniques such as massage and mobilization can make the world of difference…
A consensus study of US chiropractors defined manual therapy as “Procedures by which the hands directly contact the body to treat the articulations and/or soft tissues.”
Alternatively, Korr (1978) described manual therapy as the “Application of an accurately determined and specifically directed manual force to the body, in order to improve mobility in areas that are restricted; in joints, in connective tissues or in skeletal muscles.”
WHERE CAN I FIND MORE INFO ON MANUAL THERAPY?
The Journal of Manual and Manipulative Therapy, Manual Therapy, and the Journal of Manipulative and Physiological Therapeutics are PubMed indexed journals that have provided readers with useful research on manual therapy for over 15 years.