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Clinical pearls for the shoulder/arm exam and the treatment
What is seeing you-are you seeing it
W. Ben Kibler, MD
Medical director
Case 1• 18 y/o R hand dominant high school
pitcher, with 6 week hx gradual onset of anterior shoulder pain while pitching in season. Sore in cocking to acceleration and at ball release, no click or pop. Decreased velocity and endurance. No pain at night or in other activities. PT- no relief. Dx- impingement> surgery
Case 2• 19 y/o R tennis player- chronic
pain in shoulder during, after play. Pain localized to posterior joint line and lateral acromion, worse in cocking and ball impact. Also mild episodic back pain, does not keep him from playing. PT including modalities, rubber tubing, and massage gives no relief. Injection of unknown type gave no relief
Case 3• 45 y.o. worker, chronic (L)
shoulder pain, worse with overhead motion, decreased use over last 6 mos, painful arc, weakness. PT- no relief, injection- short term benefit. Dx- impingement- surgery
Case 4• 20 y.o college pitcher, 2 mo
pain (L) elbow, no acute injury, decreased velocity/ location, pain @ ball release, no swelling, no neuro sx, elbow exercises, modalities- no relief
BODY ASA SYSTEM OF LINKS
(SEGMENTS)
HANAVAN MODEL
Adapted from Hanavan, EP. Mathematical Model of the Human Body. Wright-Patterson Air Force
Base, Ohio, 1964, AMRL-TR, 64-102.
3
1
2 76
9
5
8
4 1110
1312
14 15
Kinetic chain• Sequenced coordination of
activation- body segments• Kinematic- body motions• Kinetic- force development• Kinetic- general term for
both activation chains
Kinetic chain• Purposes- efficient:
– Force development– Sequenced motions– Force transfer– Joint protection
• Prox stability >distal mobility
THE KINETIC CHAIN
Legs
Trunk and Back
Shoulder
ElbowWrist
0
F
O
R
C
E
TIMEAdapted From Groppel
Kinetic Chain• Body as a multi-segmented
mechanism• 244 possible DOF – multiple
possible pathways• Task specific requirements• “Bernstein’s problem”
Kinetic Chain• Dec. DOF to efficiently
accomplish tasks– Develop motions– Apply loads– Muscle activations: force generation, joint stability
Kinetic Chain• Closed system for force
production/transfer• Alterations in one area
require compensations from other areas to maintain same output/progression
What is seeing you• Leg/hip- flexibility/strength/
injury- 50%• Core stability/strength- 65%• Scapular dyskinesis- 90%• GIRD, GERD, TROMD- 90%• Altered anatomy- 100%
What is seeing you• Standardized approach- rule
in/rule out all factors• Screening exam tests• Detailed evaluation- (+) tests• Comprehensive information
Shoulder rotation, flexibility, strengthInternal
derangement
Scapular dyskinesisevaluation
Leg stability series
Hip rotationPlank
Knee stabilityAnkle ROM
Hip, leg, core• Ankle ROM• Knee ROM, P-F, meniscus• 1 leg stability- stance/squat• HIP ROM- ER, IR• 3 way core stability
Scapular dyskinesis• Position at rest• Motion- flexion/extension• Low row strength• Flexibility- pec minor, lat• Corrective tests- SAT, SRT
Shoulder joint• IR- scapula stable• ER- arm neutral, pronated• Rotator cuff- scapula stable• AC joint stability• Joint- labrum, rot cuff,
biceps, instability
Conclusions• Kinetic chain- mechanism
by which coordination of the multiple segments for specific tasks is achieved
• Body works as a unit • Kinetic chain framework
Conclusions• Body fails as a unit• Patterns of failure• Catch up, compensations• Victims and culprits• Overview, screening,
detailed exam
Case 1• 18 y/o R hand dominant high school pitcher, with 6
week hx gradual onset of anterior shoulder pain while pitching in season. Sore in cocking to acceleration and at ball release, no click or pop. Decreased velocity and endurance. No pain at night or in other activities.
• (+) Neer, Hawkins sign• Weak supraspinatus in forward flexion, empty can• GIRD – 35 degrees, (-) labral testing, (-) instability,
sulcus• (+) SAT, SRT• X-ray (-)
Case 2• 19 y/o R hand dominant college tennis player with season
long pain in shoulder and back. Worse while playing also hurts after play. Pain localized to posterior joint line and lateral acromion, worse in cocking and ball impact. Also noted some mild back pain which seems to come and go, does not keep him from playing. PT including modalities, rubber tubing, and massage gives no relief. Injection of unknown type gave no relief
• (+) Neer, Hawkins sign, (+) painful arc• Weak supraspinatus/infraspinatus• (+) M-DLS with (+) SRT, (-) anterior instability• GIRD 45 deg. With scapular wind-up, Type I/III scapular
dyskinesis• Lumbar lordosis, (+) single leg stability w/ Trendelenburg• Non-contrast MRI (-)
Case 3• 45 y.o. worker, chronic (L) shoulder pain,
worse with overhead motion, decreased use over last 6 mos, painful arc, weakness. PT- no relief, injection- short term benefit. Dx-impingement- surgery
• (+) Neer, Hawkins, painful arc, (+) SAT• Decreased rot cuff strength, (+) SRT• Taping, massage, dry needling- no benefit• X-ray- Type 2 acromion, MRI- “tendinopathy”
Case 4• 20 y.o college pitcher, 2 mo pain (L) elbow,
no acute injury, decreased velocity/ location, pain @ ball release, no swelling, no neuro sx, elbow exercises, modalities- no relief
• Pain medial elbow- epicondyle, ulna• (+) valgus stress, (-) post med stress• (-) neuro- ulnar nerve• Tight GH ROM, scapula • Kinetic chain deficit
THANK YOU