Using Neutrality To Increase Shoulder Strength SUSAN M. T. McKAY, OTR/L Susan.Mckay@PresenceHealth.org

GOAL

Look at shoulder rehab in a different

way. Strength can come from

increasing flexibility and placing a joint

in proper alignment. Conversely,

strengthening a shoulder in improper

alignment can cause injury.

WHY PICK ON THE

SHOULDER?

Impairs function/limits ADL’s

Pain in shoulder

Compensatory patterns can lead to back pain

Elderly rely on upper body to move/ambulate

The sooner issues are treated, the less physiological damage there is

SHOULDER ANATOMY

Muscles and how they move

A basic review and more

Important to know…

SHOULDER ANATOMY

Supraspinatus

Initiates and assists deltoid in abduction of

arm and acts with other rotator cuff muscles.

SHOULDER ANATOMY

Infraspinatus

Laterally rotate arm; helps to hold humeral

head in glenoid cavity of scapula

SHOULDER ANATOMY

Subscapularis

Medially rotates arm and adducts it; helps to

hold humeral head in glenoid cavity of

scapula

SHOULDER ANATOMY

Teres Minor

Laterally rotate arm; helps to hold humeral

head in glenoid cavity of scapula

SHOULDER ANATOMY

Deltoid

Anterior part: flexes and medially rotates

arm; Middle part: abducts arm; Posterior

part: extends and laterally rotates arm

SHOULDER ANATOMY

Latissimus dorsi

Extends, adducts, and medially rotates

humerus; raises body toward arms during

climbing

SHOULDER ANATOMY

Teres Major

Adducts and medially rotates arm

SHOULDER ANATOMY

Pectoralis major

Adducts and medially rotates humerus;

draws scapula anteriorly and inferiorly;

Acting alone: clavicular head flexes humerus

and sternocostal head extends it

SHOULDER ANATOMY

Pectoralis Minor

Stabilizes scapula by drawing it inferiorly

and anteriorly against thoracic wall

SHOULDER ANATOMY

Coracobrachialis

Helps to flex and adduct arm

SHOULDER ANATOMY

Rhomboid Major and Minor

Retract scapula and rotate it to depress

glenoid cavity; fix scapula to thoracic wall

SHOULDER ANATOMY

Serratus Anterior

Draws scapula forward and upward; abducts

scapula and rotates it; stabilizes vertebral

border of scapula

SHOULDER ANATOMY

Trapezius Elevates, retracts and rotates scapula; superior fibers

elevate, middle fibers retract, and inferior fibers depress

scapula; superior and inferior fibers act together in

superior rotation of scapula

SHOULDER ANATOMY

Levator Scapula

Elevates scapula and tilts its glenoid cavity

inferiorly by rotating scapula

CLAVICLE AND SCAPULA

Things you may or may not know

Very important to address when

addressing the shoulder

May be the primary reason limiting the

shoulder

CLAVICLE

Looking from the front, the medial 2/3 is convex and lateral 1/3 is concave- only long bone that is horizontal in the body

Acts as a “strut” to hold the arm away from the body and allows space for veins and nerves

Muscles/Ligament attached: Trapezius muscle

Deltoid Muscle

Coracoclavicular ligament

Sternocleidomastoid muscle

Pectoralis major muscle

Subclavius muscle

CLAVICLE

Sternoclavicular (SC) Joint Structure

Articulation of clavicle with the sternum

Only direct attachment of the upper extremity to the skeleton

Clavicle moves in 3 planes (3 degrees of freedom) Elevation and Depression of SC

Protraction and retraction of SC

Axial Rotation of clavicle

All shoulder girdle movements start at the SC joint, if it is fused not only the clavicle and scapula would be limited but the entire shoulder!

CLAVICLE

The Acromioclavicular Joint (AC) allows motion in all 3 planes, allowing the scapula to maintain contact with the posterior thorax:

Upward rotation and downward rotation

Rotation in the horizontal plane

Rotation in the sagittal plane

Acromioclavicular Ligament

Joins clavicle to acromion, prevents dislocations of the scapula

CORACOLCLAVICULAR

LIGAMENT

Attaches twice on clavicle and the

coracoids process of scapula

It is responsible for bearing most of the

weight of the hanging arm. Without this

ligament, the arm is unable to hang from

the body

CORACOCLAVICULAR

LIGAMENT

SCAPULA

The scapula is only attached to the thorax by ligaments at the AC joint

suction mechanism provided by serratus anterior

subscapualaris

Main stabilizers of the scapula: Serratus anterior

Rhomboid major and minor

Levator scapulae

Trapezius

SCAPULOHUMERAL

RHYTHM

The first 30 degrees of

shoulder joint motion is

pure glenohumeral joint

motion

•After that, for every 2

degrees of shoulder flexion

or abduction that occurs,

the scapula must upwardly

rotate 1 degree

•This 2:1 ratio is known as

scapulohumeral rhythm

SCAPULAR DYSKINESIS

Winging Posterior movement of the medial border of the scapula,

Rotation about a vertical axis

Long Thoracic nerve injury

Weak serratus anterior Usually from poor posture, especially when stress is carried in

their neck- rhomboid and levator scapulae muscles are shortened

SCAPULAR DYSKINESIS

Tipping

Posterior movement of the inferior angle of

the scapula, Rotation about a transverse

axis

Pectoralis minor is shortened

RELAX

You made

It though

The hard

Part

SHOULDER POSITION

Different for everyone

Side view, ears should be in alignment

with shoulders

Shoulders should be in alignment with

hips

May not be able to achieve due to

bony/soft tissue changes and congenital

deformities

SHOULDER

POSITION/PHYSICS

Levers

The humerus is a complicated class 3 lever when

the elbow is straight. (Reminder on a class 3 lever:

Effort is in the middle (muscle): the resistance is on

one side of the effort (whatever a person is lifting)

and the fulcrum is located on the other side

(shoulder girdle))

Fulcrum is set best when the shoulder girdle is at

neutral. When shoulder girdle is no longer at

neutral, the “lever” loses effectiveness

CLASS 3 LEVER

fulcrum effort resistance

EVALUATION IS

IMPORTANT

This will mostly design how the person is treated

In my experience, most people do not have

optimal strength unless they have over 150

degrees of shoulder flexion without

compensation

Most people are upwardly rotated and abducted

Pain-where is it specifically?

Additional extension, limited internal and/or external

rotation

COMPENSATION

When a person has lost range of motion,

they learn to compensate

The job must be done!!!!

Compensatory patterns will give you

clues as to areas that need to be

addressed

TYPICAL COMPENSATION

PATTERNS

Shoulder flexion- abduction of the

shoulder, lordosis of cervical/thoracic

spine

Shoulder abduction- lateral flexion of

torso/spine, shoulder flexion, protraction

of scapula

TYPICAL COMPENSATION

PATTERNS

Shoulder internal rotation- protraction of

scapula, rotation of trunk, kyphosis of

thoracic/cervical area

Shoulder external rotation- retraction of

scapula, rotation of trunk, lordosis of

thoracic/cervical area

ASSESSING RANGE OF

MOTION

How is reduced shoulder ROM limiting

ADL’s

Limited shoulder flexion: brushing/washing

hair, donning/doffing shirt/jacket, reaching

into cabinet

Limited horizontal adduction:

Donning/doffing clothing, hair care, kitchen

tasks, peri care

ASSESSING RANGE OF

MOTION

Limited internal rotation: washing back,

hooking bra, pulling up pants, peri

care, cooking, mowing the

lawn/starting mower

Limited external rotation: brushing

teeth, brushing/washing hair, using a

walker, cooking

ASSESSING RANGE OF

MOTION

Is functional ROM causing deformity?

Does that person really have functional

movement?

Need to look at the entire body

Watch for compensatory movement

Look for pain cues (wincing, grunting, etc.)

ASSESSING RANGE OF

MOTION

Where is the block? Eg. Shoulder flexion

Look at straight flexion without allowing any other movement, you will feel a slight “stop” in the movement if there is a restriction

Where is the compensatory movement?

Limited shoulder flexion can cause compensation Cervical, thoracic, lumbar vertebrae

Spillover into abduction and external rotation

ASSESSING RANGE OF

MOTION

Long term effects Pain

Arthritis

Impingement

Decreased strength

Destruction of structures of the shoulder

Biceps

Coracobrachialis

Ultimately loss of function

TREATMENT FOR

SCAPULAE

Mostly upwardly rotated and abducted

Mobilizations and soft tissue release

We must… and scapular squeeze

Tell person to try to touch shoulder

blades together and towards bottom

AIR SPLINT

AIR SPLINT

CONTRAINDICATIONS

ANY ROM RESTRICTIONS

BACK/SHOULDER/CLAVICLE/ARM FRACTURES

DIALYSIS PORTS

PICC LINES

POOR ARTERIAL/VENOUS FLOW TO ARM/DVT

AIR SPLINT CONCERNS/

CONSIDERATIONS

Recent fractures

Cardiac history

Osteoporosis

Muscle tears

Pain tolerance

Recent back

surgeries

Vascular issues

Skin integrity

IV’s

Contractures

Mastectomy/

Lumpectomy

Severe arthritis

AIR SPLINT EXERCISES

Please see additional handout

Works better initially in supine, gravity pulls shoulder into a more neutral position breaking habitual pattern of kyphosis and other compensatory patterns

Can use towel for better positioning or to grade activity

Move into sitting once patient’s shoulder girdle becomes more stable

MOBILIZATIONS

PRECAUTIONS AND

CONTRAINDICATIONS

Any condition that has not been fully evaluated

Joint ankylosis

Joint hypermobility, if techniques that take the joint through its end range are being considered, unless a positional fault is being treated

Joints that are infected

Malignancy in area treated

Fractures

Inflammatory arthritis, especially if it is exacerbated

Metabolic bone diseases (Paget’s, TB, etc)

Debilitating diseases that compromise periarticular tissue (advanced DM)

Long term use of corticosteroids

Swelling- it takes up some of the slack in the capsule making it difficult to evaluate the joint mobility correctly

Excessive joint irritability or pain

Coagulation impairments

Skin rashes or open/healing skin lesions

Protective muscle spasms to the point mobility in the area treated is unable to be evaluated

MOBILIZATIONS

Joint mobilizations are used when

ligament or capsule resistance is

encountered

Many different ones to use

See sheet for helpful ones

Thank you!!!!!

Many thanks to those who helped me:

Heather Barnes, OTR/L

Terry Giese, OTR/L

Nancy Joneth, OTR/L

Howard Whitfield, OTR/L

Scott McKay, PAC

Chad Randolph, PT

Tim Kisner, PT

My model: Beth Kohler-Rausch, OTR/L

My Photographers: Diwi Ymson, PT and Tanvi Desai, OTR/L