1A2 CAM/CAT AJMS MAY/IUNE 2000

f.,hewp sqtsl Medicine, Mer6l College, Dobbs Ferry, NY

Dole l. Buchberger, DC; Sandra l. HortwelLFord, DCThe New York Chiropractic College, Seneca Falls, NYAddress for correspondence/reprint requests: Sandra J.New York Chiroproctic College, 2360 State Route 89,

ete:roach

Hartwell-Ford, DC, I nstructor,Seneca Folls, NY 1 3148-0800

f n today's health care envi-Ironment more and moreprimary care physicians arebeing asked to assess andmanage athletes of varyingages and abilities with sportsrelated inluries of all types.Shoulder pain is one of themost common chief com-plaints of an athlete. It isalso one of the most uniquef oints of the body. Conse-quently, its assessment, diag-nosis, and management mustbe equally unique.l

The shoulder is the mostcomplex joint in the body.The excessive range of motionis accompanied by inherentinstability. The structure ofthe glenohumeral joint hasbeen characterized as a golf tee(the glenoid) with an over-sized ball (the humeral head)sitting on it. Jobe andIannotti2 have calculated thatat any given time, approxi-mately Z8o/o of the humeralhead is in contact with thebony glenoid cavity. Thisarrangement places the de-mand of stabilization on thesoft tissue restraints of theshoulder girdle. These are theglenohumeral capsule and lig-aments as well as the four ro-tator cuff, or SITS muscles,

(supraspinatus, infraspinatus,teres minor, and subscapu-laris). As a result of the de-mands placed on the softtissue structures, various im-pingement injuries can occur.3

Impingement is the mostcommon cause of shoulderpain in the overhand athlete.+,sNeer and Welsho originally de-scribed three stages of impinge-ment based on observation andage. Impingement was consid-ered stage one if the patient was<25 years of age. They classifiedthis as tendonitis and statedthat this stage was reversiblewith conservative manage-ment. Stage two was consideredif the patient was between theages of 2540 years, and fibrosisof the subacromial bursa androtator cuff had taken place.They recommended acromio-plasty if the patient failed con-servative management. In stagethree, patients were consideredto have full or partial thicknessrotator cuff tears, and to be >40years of age. Unfortunately,their impingement continuumdid not take into account thespecial attributes found in theathletic population.

Although the work ofNeers and Welshe is helpfulin the nonathletic popula-

tion, Jobe and Pink's1 insta-bility continuum better illus-trates the process that leadsto a symptomatic athleticshoulder. The instabilitycontinuum begins with rota-tor cuff weakness and movesto instability, subluxation,impingement, and eventualrotator cuff tearing.

FunctionolAnotomy

The shoulder consists of fourarticulations. The sternocla-vicular ioint (SCJ), acromio-clavicular joint (ACJ), gleno-humeral joint (GHJ), andscapulothoracic articulation(STA). Of the four, the SCJ isthe only true osseous articula-tion. The remaining threejoints are primarily suspend-ed by muscular, capsular, orligamentous restraints.

Restraints to static mo-tion are the glenohumeralIigaments (GHL). The GHLsare merely thickened bandsof the capsule that providereinforcement. These in-clude the superior, middle,and inferior GHLs. The infe-rior glenohumeral ligament

CAM/CAT AIMS MAY/IUNE 2OOO 183

complex (GHLC) consists ofan anterior and posteriorband. The inferior GHLC isalso the most commonly in-iured of the GHLs as theyprovide support at extremesof range of motion. TheGHLs reinforce the capsule.In the overhand athlete, itis common for the inferiorGHLC to display some re-dundancy creating an ante-rior or anterior inferior typeIaxity and for the posterioraspect of the capsule totighten in response to theanterior laxity.:

The rotator cuff musclesprovide dynamic stability ofthe GHJ during range of mo-tion. Their primarv task is toprovide compression and de-pression of the humeral headduring abduction and exter-nal rotation. This force couplemechanism keeps the humer-al head centered in relation tothe glenoid fossa. Proper func-tion of the muscular forcecouple is necessary to preventimpingement. In the over-hand athlete this task be-comes more challenging dueto the high demands resultingin overuse and repetitivestrain injury.z,s

Just as important to gleno-humeral stability are the mus-cles responsible for scapularstability. It is critical that theSTA is well maintained to createa firm base for GHJ function.e

The overhand athlete willcommonly present withweakness of the middle andlower trapezius, rhomboids,and the serratus anteri<-rr mus-cle. Together these musclesprovide retraction and eleva-tion during abduction andexternal rotation. During ad-duction internal rotation,

they provide controlled pro-traction through eccentricmuscle contraction.

ImpingementSyndrome

There are three general sub-types of impingement syn-drome. Primary impingementrefers to an external source ofimpingement against the rota-tor cuff as it courses throughthe subacromial space. Thisusually has a degenerative eti-ology, such as subacromialspurring, ACJ arthrosis,spurring of the anterioracromion, and/or a type threeacromion (Figure). The patientwith primary impingement isusually >35 years of age. Theywill commonly experience an-terior or anterolateral shoulderpain during over-hand move-ments. A painful arc is usuallypresent between 70'-130" ofcombined abduction externalrotation. This patient may ex-perience pain during the nightif they roll onto the affectedshoulder. If there is ACJ in-volvement they will also expe-rience pain with crossed bodyadduction. Causes of primaryimpingement in the <35 agepopulation include a type threeacromion or an os ag1gmi2ls.1t)

Secondary impingementrefers to external impinge-ment of the rotator cuff underthe coracoacromial arch. Thisis in response to eithel occultor subtle instability of theGHj. In the overhand athleteit may present if the athletealso has hyperlaxity with rota-tor cuff weakness. Secondaryimpingement usually occursin patients <35 years. Howev-

Figure, Variations of acromial morphology.Type l, flaf Type ll, curved; Type lll, hookCdor "beaked."34

er, it may be present in com-petitive recreational athletes>35 years. The patient willcomplain of anterior or an-terolateral shoulder pain dur-ing the overhand activity. Theonset is usually specific to theoverhand athletic activities.Typically, symptoms are notassociated with activities ofdaily living (ADL) or at restunless it has been present for asubstantial period of time.11-13Patients with more severe lev-els of laxity/instability maycomplain of transient subluxa-tion episodes with or withoutthe sensation of a "dead arm."The "dead arm" phenomenonresults when the humeralhead tractions the brachialplexus during anterior-inferiorsubluxation.s,l4 The physicianshould also be suspicious ofunderlying instability whenthe overhand athlete presentswith hand symptoms consis-tent with an ulnar nervedistribution and anterior oranterolateral shoulder pain.The shoulder pain may beworse during athletic activity,while the ulnar nerve symp-toms may exacerbate after theactivity.

184 CAM/CAT AIMS MAY/IUNE 2OOO

The third type of impinge-ment is internal glenoid im-pingement. This has also beenreferred to as posterior-superi-or glenoid impingement or inthe throwing athlete "over ro-tation syndrome." The exces-sive external rotation that iscommon in the overhandathlete results in impinge-ment of the articular or un-dersurface of the rotator cuffagainst the posterior-superi-or aspect of the glenoidlabrum and/or glenoid rim.Chronic abrasion of the cuffagainst the glenoid mayeventually lead to partialthickness tears on the articu-Iar side of the rotator cuff.This is probably the mostcommon type of impinge-ment in the overhand ath-Iete. The athlete is generally<35 years and involved in acompetitive overhand sport.If they are >35 years and notinvolved in athletics their oc-cupation may involve repeti-tive use of the shoulder inan abducted externally rotat-ed position, such as in ma-neuvering a forklift througha warehouse. They will pre-sent with posterior shoulderpain. Their posterior shoul-der symptoms are related toa specific overhand activityinvolving abduction be-tween 80'-120', maximalexternal rotation, and hori-zontal extension of the GHJ.This may include throwing abaseball, striking a volley-ball, serving a tennis ball,swimming, or even golf. Aswith secondary impinge-ment it is specific to theoverhand activity unless ithas been present for an ex-cessive period of time. In along standing problem it is

common for the patient toexperience night pain andpain with [Pl5.1s-l8

ExominotionFindings

In addition to the history, thephysical examination is themost important aspect in accu-rately diagnosing the underly-ing cause of shoulder im-pingement syndrome in theoverhand athlete.

Examination of the shoul-der should always begin witha neurovascular assessment ofthe cervical spine and upperextremities. Cervical spinerange of motion should be as-sessed in all ranges. Palpationof the cervical spine for par-avertebral or spinous processtenderness is performed. Cer-vical compression and dis-traction tests are performed torule out a herniated disc as apotential etiology of the ath-lete's shoulder pain. Shoulderdepression with the patient'shead rotated 45" to the con-tralateral side will help assessbrachial plexus injury as acause of the shoulder pain.Motor strengths, musclestretch reflexes, and pinwheelexamination of the nerveroots C5 through T1 are test-ed. Additionally, wrist andankle clonus should be as-sessed especially in the youngadult to help rule out multi-ple sclerosis (MS). Vascularexamination should include acheck of the upper extremityperipheral pulses, ausculta-tion of the head and neckvessels, and Roo's test as ascreen for thoracic outlet syn-drome (TOS).s,13

INSPECTION. The examinationbegins with a visual screeningcheck for deformity of theclavicle, ACJ hypertrophy, astep off deformity of the GHJ,scapular winging, atrophy ofthe deltoid, supraspinatus,and/or infraspinatus musclesor dermatological lesions, suchas herpes zoster.s

RANGE OF MOTION. Activeand passive shoulder range ofmotion is assessed according tothe guidelines of the AmericanShoulder and Elbow Surgeons.leIt is easiest to check extemal ro-tation in a neutral position withthe palms up first as this is theleast provocative position. Over-hand athletes commonly dis-play increased extemal rotationon the dominant side relative tothe nondominant side.2o Next.forward fleion with the thumbspointed to the sky and elbon'sfully extended should be per-formed. Pain at the end rangefelt on the superior aspect of theshoulder during the passivephase may be the first examina-tion finding of impingement.External rotation is then as-sessed with the humerus at 90'of abduction. Posterior superiorpain may indicate internal gle-noid impingement. Anteriorshoulder pain may indicate sub-tle instability, where anterior ap-prehension may indicate occultinstability. The last range is in-temal rotation. Have the patientreach behind their back asthough they are attempting totouch the contralateral scapula.Record the highest spinal levelthey can reach with theirthumb. The overhand athletewill commonly display less in-temal rotation on the dominantarm. The authors also advocatemeasuring the difference be-

185

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tween the two extremities bymarking the level with a pen.The difference should be mea-sured in centimeters. Table I pro-vides a synopsis of the cardinalranges of motion in the shoul-der with diagnostic clues.

Cuff' ssment

Several maneuvers have beenvalidated for testing the in-tegrity of the rotator cuff basedon electromyographic andarthroscopic findings.zt Thisreduces the number of maneu-vers necessary to assess the ro_tator cuff and increases theexamination accuracy.22 Ath-letes may display adequate yetpainful range of motion of theshoulder. In these cases thesupraspinatus should be testedin the scapular plane with 90"of elevation and the thumbup, or in the "full can,, posi-tion.21 This is performed firstas this is a less provocative po-sition than the traditionalthumbs down, or the ,,emptycan" position. The ,,full can,,position is less provocative andtherefore, may give a more ac-curate strength assessment.This is then followed by themore provocative "empty can,,test (humerus positioned inthe scapular plane with 90. ofelevation and the thumbpointed to the floor). An in-crease in symptoms during the"empty can" test relative to the"full can" test is another indi-cation of impingement.23 Theinfraspinatus and teres minorare tested with the humerus inneutral or 0'of abduction withthe humerus in -45' of rota-tion (internally rotated 45").21

The subscapularis is assessedusing the lift off test (LOT). Thepatient should position theirarm with the elbow flexed to90". It is then placed in the"small" of the back or approxi-mately the L3-L4 spinal seg-ment. If internal rotation isseverely limited the physicianmay have to passively positionthe patient's arm. The patient isthen asked to lift the hand andforearm off of their back. Exces-sive forward body lean, drop-ping the hand so that the elbowangle is >90o, or an inability toperform the test are indicationsof subscapularis involve-1y1snl.24,zs The serrafus anteriorshould also be assessed duringthe rotator cuff assessment. Thepatient is asked to face the wallwith the arms neutral, thepalms facing the wall, and theelbows fully extended. They arethen asked to push the palmsinto the wall while the examin-

er inspects for scapular wingmg.Subtle winging on the sympto-matic side should be consideredsignificant in the overhand ath-lete. Weakness of the serratusanterior is a validated finding inoverhand athletes with instabil-ity and secondary impinge-ment. This may be a subtleexamination finding of sec-ondary impingement.zo

,:P,,f,ovocotive,' ng fort,[,,,ppingement

Neers impingement sign (NIS)has been considered the hall-mark test for impingement.6,27The maneuver is performedwith the examiner behind thepatient. One hand contacts theacromion for the purpose ofpreventing scapular rotation.)cf-

theiiveina-:nt.as-9{)'rior{r<-norsb-:EP:t-ults ir-dentia5stn,riu.ievelieirrletes in-nantfate: be-

RaNcr op MorroN eNo Assocretro Dreclrosrrc CLUEs

Otur,R SrclrptcaNtFrNotNcs

Forward elevation Inability to perform Rotator cuff tearpain at end range Impingement

Neutral external rotation posterior pain pSGIAnterior pain

External rotation posterior pain Anterior instabilityat 90'abduction Anterior pain PSGI

Secondaryimpingement/instability

Internal rotation posterior pain Rotator cuff tendonitisPosterior apprehension posterior capsulitis

Posterior instability

PSGI=Posterior superior glenard impingement.

186

Grade I <1 cmGrade II 1-2 crnGrade III >2 cm

The other hand grasps theelbow. The examiner then per-forms passive forward flexionwith internal rotation while sta-bilizing the scapula. The sign ispresent if the patient experi-ences anterior or anterolateralshoulder pain. NIS is common-ly negative in the young athlet-ic population with secondaryimpingement or internal gle-noid impingement. It is morecommonly positive in the olderpopulation presenting with pri-mary impingement. Occasion-ally, during the performance ofNIS a palpable "clunk," or sub-Iuxation of the loint may occur.This is indicative of posteriorshoulder instability and shouldnot be quickly dismissed as in-significant in the symptomaticshoulder.2s

Hawkins impingement sign(HtSlzo has also been consid-ered an examination essentialin the diagnosis of impinge-ment syndrome. The examinershould be facing the patient.The patient's humerus is ab-ducted to 90" in the plane ofthe scapula with elbow bent to90'. The examiner performspassive internal rotation bysupporting the elbow with onehand and lowering the hand.This is performed three times.The first time is with thehumerus in the scapular plane.The second is with thehumerus in 45" of forward flex-ion and the last is with thehumerus in 90" of forward flex-ion. This creates a gradual pro-gression of adduction and

eventual compromise of thecoracoacromial arch. The ma-neuver is positive if the patientexperiences anterior or antero-lateral shoulder pain consistentwith their chief complaint. Be-cause of this mechanism, theHIS sign is a better maneuverfor the diagnosis of secondaryimpingement. This maneuverrequires internal rotation of thehumerus and, therefore, mayproduce posterior shoulderpain in a patient with a tightposterior capsule, capsulitis, oreven posterior instability.

The dynamic impingementtest (DIT)Is is a recent test thatassists in the diagnosis of inter-nal glenoid impingement. Thismaneuver has been shown tocorrelate well arthroscopically.The patient should be supine.The arm is started in the neu-tral position. The examinerthen externally rotates thehumerus. Once full externalrotation in the neutral positionis achieved, the examinerbegins to abduct and extendthe GHJ while maintaining ex-ternal rotation. The patientwith internal impingement willexperience posterior-superiorshoulder pain between70'-150' of abduction. Painlocalized to this region andwithin this arc is consideredpositive for internal glenoidimpingement.

The sulcus sign3o is used toassess the patient for inferior in-stability. The patient should beseated and relaxed. The exam-iner stabilizes the scapula withone hand while providing longaxis traction to the humerus. Ifa step off is observed at theacromion, this is indicative ofinferior capsular laxity. Table IIlists the grading criteria for asulcus sign. It is common for

normal asymptomatic shoul-ders to display excessive transla-tion. It is essential to perform a

bilateral comparison to differ-entiate between hyperlaxit,vand instability. Findings on thesulcus sign have to be correlat-ed carefully to other historicaland examination findings.

The apprehensioni and relo-cation:11 tests when combinedare the most sensitive for mi-croinstability in the overhandathlete. The apprehension testis performed with the patientsupine. The shoulder is abduct-ed and externally rotated to 90"with the elbow also positionedin 90' of flexion. The examinerthen induces maximal externalrotation and extension of theGHJ while using the otherhand to apply a posterior toanterior (P-A) force on thehumeral head. If symptoms areproduced or reproduced, theexaminer places the most me-dial hand on the anterior sur-face of the proximal humerusand applies an anterior to pos-terior (A-P) force, while rnain-taining maximal externalrotation and extension. Resolu-tion of the symptoms duringthe relocation maneuver indi-cates subtle anterior instabilitr'.If there is an excessive unilater-al sulcus sign on the involvedarm the two may indicate rnul-tidirectional instability (MDI,of an anterior-inferior type.This is a common finding inthe overhand athlete. Posteriorshoulder pain during this ma-neuver relieved by the reloca-tion test may indicate internalglenoid impingement.

O'Brien et al's32 maneu\reror the active compression test, i-\

a useful screening maneuver be-cause il will assist the examirrrrin the detection of several trpes

B7

of lesions. O'Brien et alsz origi-nally described the maneuverfor the detection of superiorIabral lesions, or SLAp (superiorlabrum, anterior to posterior)tears and ACJ pathology. Theauthors have used the maneu-ver successfully in the diagnosisof posterior instability (Buch-berger DJ and Hartwell-Ford,sunpublished data, 1999). Thepatient can be seated or stand-ing. The GHJ is forward flexedto 90'. The humerus is intemal-ly rotated fully so that thethumb points to the floor. Thehumerus is then adducted ap-proximately 15". The examinerthen applies a downward forcedistal to the elbow. Pain local-ized to the ACJ is indicative ofACJ pathology. Intemal pain tothe anterior aspect or referringdown the biceps muscle is in-dicative of a SLAp lesion.Posterior shoulder pain or ap-prehension is indicative of pos-terior instability. The maneuveris not considered positive forthe respective lesion unlessthere is resolution of respectiveprovocation, when the test isperformed with the palm up(humerus extemally rotated).

r,Rndiogrophic':A$$essment

Proper assessment of theshoulder in the overhandathlete should include aminimal impingement se-ries (Table III). Plain filmradiographic assessment isuseful in detecting osseouspathology in the youngadult as well as growthplate abnormality in theimmature athlete. The im-pingement series will estab-

lish the presence or absenceof an os acromiale, or typethree acromion, as a causeof primary impingement inthe young individual. Inthe older patient, degenera-tive processes, such as ante-rior acromial spurring, ACJspurring, and impact le-sions of the humeral head,may be evident.33

DiognosticImaging

Imaging, such as MRI, in theyoung overhand athlete is re-served for those cases that pre-sent with dramaticexaminationfindings indicating rotator cufftear or internal derangement,such as labral pathology. Ath-letes who fail a conservativemanagement approach of atleast 8-12 weeks are also candi-dates for MRI examination.

It is currently accepted thatwhen an MRI is ordered forthe overhand athlete that itbe ordered with gadolinium

contrast material. This raisesthe diagnostic capability espe-cially in the case of capsulo-labral disruption. The contrastmaterial will help delineateconfusing normal variants inthe capsulolabral complexfrom actual pathology.:+

The authors also recom-mend obtaining MRI resultsprior to consideration of cor-tisone iniection in the youngoverhand athlete. MRI resultscorrelated with the physicalexamination will allow thetreating practitioner to makea better clinical decision re-garding the use of therapeuticiniection.

Chiropractic management fo-cuses on the underlying etiol-ogy of the impingement aswell as rebuilding the kineticchain. In the case of primaryimpingement range of mo-tion, scapulohumeral dynam-ics and posture are usually of

Vrew

A-P GHJ

ACJ spot (15" cephalad tilt)

Axillary lateral

Supraspinatus outlet (y view)

LrsroNs

GH degenerative changesCalcific tendonitisACJ degenerative changesAC separationDistal clavicular osteolysisGHJ dislocationBony Bankart lesion (glenoid rim)Os acromialeHill Sachs (post humeral head)Acromial morphologyDegenerative changes anterior acromion

A-P=anterior to posterior; GH=glenohumeral; ACJ=acromioclavicular ioint;Ac=acromioclavicular; GHJ=glenohumeral ioint.

188 CAM/CAT AIMS MAY/IUNE 2OOO

concern when attempting aconservative program. If con-servative measures fail, thensubacromial decompression isusually recommended withappropriate postoperative re-habilitation.1,7,3s

Identifying and correctingthe instability is the key re-garding patients with sec-ondary impingement andinternal glenoid impinge-ment. A11 facets of the dys-function must be addressed toreturn this athlete to theiroverhand athletic activities.

The first goal of treatmentis to reduce symptoms whilerestoring range of motion.This is accomplished througha comprehensive manual ap-proach. The authors use thefollowing plan in the treat-ment of secondary and inter-nal impingements withmodification for individualvariance.

Active Release TechniquesSoft Tissue Management Sys-tem (Anfo; is applied tothe rotator cuff muscles toloosen and reduce fibrotic le-sions within or between themuscle planes. Areas of concernin the overhand athlete are theteres minor at the quadrilateralspace, the supraspinatus, andthe subscapularis. The sub-scapularis is particularly impor-tant due to its intimaterelationship to the serratus an-terior at the scapulothoracic ar-flsul3fisn.6,7,36,37

It has recently been demon-strated that the subscapularis isan issue in the athlete with sec-ondary impingement and mi-croinstability. ART@ has alsobeen shown to improve func-tion of the rotator cuff muscles,allowing for a better response torehabilitative strengthening.3s

Iurythmic stabilization is uti-lized to stimulate co-contracrionof the rotator cuff and scapularstabilizers. This is very effectivein restoring proprioception andnormal firing patterns to the ro-tator cuff muscles. Contractrelax technique is used to stretchand restore fledbility to the pos-terior capsule. It is performedwith the patient supine whilestabilizing the scapula to isolatethe posterior capsule. The GHJ isthen taken progressively intohorizontal adduction post con-traction. Chiropractic manipula-tion is performed to the cervicaland thoracic spinal articulationsto provide adequate motion inthe base of the upper extremitykinetic chain. Young et a138 havefound that restricted cervicalspine motion significantly af-fected the velocity and accuraryof a group of pitchers.

High velocity low ampli-tude manipulation is not per-formed to the GHJ in cases ofunderlying instability. Theother manual techniques out-lined in this paper address thecapsular tightness with a bet-ter risk to benefit ratio.

Manual therapy is followedwith the application of pulsedultrasound to reduce any posttreatment inflammation andassist in the healing process.

The patient is instructed ona series of isometric strengthen-ing and flexibility exercises topreserve muscle strength andvolume while restoring flexibili-ty to the posterior capsule.T

RehobilitotionWhen pain-free range of mo-tion is established, a rotatorcuff strengthening program

can be started. The patientcontinues with the previousprescribed flexibility program.The authors advocate the useof the following programbased on electromyographicfindings and clinical experi-ence for patient variation.

The standing four wayexercise provides a simplemethod of strengthening therotator cuff with minimal riskof symptom exacerbation orinjury. The patient standsholding a light handweightbetween 1-5 lbs, dependingon their current status. Rota-tor cuff strengthening exercis-es should never be performedwith >5 lbs. When resistance>5 lbs is used, the tendency isfor the patient to recruit thelarger muscles and alter tech-nique. This is counter-produc-tive to the rehabilitation goal.The patient may need to startwith something as light as asoup can. Four maneuvers areperformed. The first is to for-ward flex to 90" with thethumbs pointed to the ceilingand the elbows fully extend-ed. The patient then slowh'lowers to neutral. Secondh-,the patient lifts their arm withthe thumbs up to the ceilingin the scapular plane to 90'.The patient should then re-turn to a neutral position.Third, abduct the shoulderwith the thumbs pointed upto the 90" level. The last ma-neuver is a two arm row (flex-ing the elbows and extendingthe shoulders), pulling theweights up along the bodr-,All four of these maneuversare considered one repetitior-r,The patient should start witha light weight and perforlr.rthree sets of 1,0-12 repetitions1-2 times per day.z,:o

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CAM/CAT MAY/IUNE 2OOO

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The prone three way exer-cise will appear more difficultfor your patient because thereis less deltoid activity in thisposition compared to thestanding position. Thev mayneed to use a lighter weightfor this exercise relative to thestanding four wa,v. The firstmaneuver involves extensionof the shoulder r,r'ith theelbow fully extended and thepalm facing the floor. Thiscan be accompiished b1, lyingon the side of the bed. Thesecond maneu\rer involveshorizontal shoulder extensionfrom the prone position. Theelbow is fullv extended withthe thumb pointed to theceiling. The third is similar tomaneuver two, only theshoulder is abducted to ap-proximatelv 100". As in ma-neuver two, the thumb pointsto the ceiling.;,3e

The next maneuver utilizesa concentric (muscle shorten-ing) contraction followed byan eccentric (muscle length-ening) contraction in externalrotation and horizontal ad-duction. This is helpful intraining the overhand athletefor the deceleration phasecommon to most overhandathletic activities. The patientlies in a side lying posturewith the affected arm upward.The elbow is bent to 90'. Thepatient brings the arm intoexternal rotation while main-taining 90" of elbow flexionand supinating the hand.Then, the patient should pressthe weight to the ceiling ex-tending the elbow. When fullelbow extension is achieved,they should slowly lower theweight across their body whilepronating the hand or turningthe thumb down to the floor.

The final exercise com-bines scapulothoracic move-ment with glenohumeralmovement in a coupled pat-tern. The patient can performthis seated or prone. Howev-er, they must start with theirarms hanging down. The firstmaneuver is to retract thescapula fully. While holdingthis position the arms are ex-tended with the elbowsflexed to 90'. At this stage,the patient externally rotatesthe humerus, pointing thethumbs up to the ceiling.They reverse each motion in-dividually, releasing scapularretraction Iast. This will bethe most difficult exercise forthem to perform and it canbe anticipated to take severalweeks to accomplish. 7,'10

ConclusionThe overhand athlete placesunusual and extreme stresseson the GHJ. Participation inoverhand athletics requires theGHJ to undertake extremerange of motion. The excessiveexternal rotation predisposesthe shoulder to instability,usually in the anterior direc-tion. It is the excess range ofmotion that also predisposesthe overhand shoulder to sec-ondary or internal impinge-ment. Because instability is theunderlying cause, this must bethe entity that is addressed.Conditions, such as biceps ten-donitis and rotator cuff ten-donitis, are not the primarydiagnosis, but merely the se-qulae of underlying instability.If the sequlae is the focus ofthe treatment, the conditionwill not resolve.l

Note: Autllor or related institutiotthss received flnoncial benelit fronrresearclr in tlis sttuly.

RerenrNcrsI Jobe FW, Pink M.'Ihe ath-

letes shoulder. I Hand Ther.1994; April/June:107-1 10.2 Jobe CM, Iannotti lP. Limitsimposed on glenohumeralmotion by joint geometry.I Shoulder Elbow 9n"9.1995;4:287-285.

3 Wilk KE, Arrigo CA, AndrewsJR. Current concepts: The sta-bilizing structures of theglenohumeral ioint. I OrthopSports Phys Ther.1997;25(6):364-379.

4 Glousman RE. Instability ver-sus impingement syndromein the throwing athlete.Orthop Clin North Atn.1993;24:89-99.

5 Ireland ML, Ahuja GS. Physi-cal examination of thepainful shoulder. I MusktloMed. 1999;March: 181-199.

6 Neer CS II, Welsh RP. Theshoulder in sports. Orthop ClinNorth Am. 1977;8:583-59 1.7 Leahy PM, Mock LE. Alteredbiomechanics of the shoulderand the subscapularis. ChiroprSports Med. 7997;5:62-66.

8 Buchberger DJ. Scapular dys-functional impingement syn-drome as a cause of grade tworotator cuff tear: A case studv.Chiropr Sports Med.7993;7:38-45.

9 Kibler WB. The role of thescapula in athletic shoulderfunction. Am I Sports Med.1998;26:325-337 .

1O Jobe FW, Pink M. Classifica-tion and treatment of shoul-der dysfunction in theoverhead athlete. / OrthopSports Phys Ther.1993;78(2):427-432.

11 ScheibJS. Diagnosis and re-habilitation of the shoulderimpingement syndrome inthe overhand and throwingathlete. Rhewn Dis Clin NorthAm. 7990;16:9 71-988.

12 Fu FH, Harner CD, Klein AH.Shoulder impingement syn-drome: A critical review. C/inOrthop. 799 7;269 :162-77 3.

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