Princeton, New Jersey, USA
Monday 10th March 2014

Following on from the article I wrote discussing the treatment strategies for increasing joint range of movement when managing shoulder impingement syndrome, I promised to review the research pertaining to the muscular control and strengthening aspects of the rehabilitation process.

I haven’t forgotten…I have just been extremely busy putting the foundations in place to pursue a career with a top sports team in the USA.  After passing all my exams, I have then had to overhaul my resumé, which had been somewhat neglected over recent years.

I have been well supported by some wonderful recruitment professionals back in the UK, whilst in the US Mike Clark, the founder of Fusionetics & sports physiotherapy consultant to many of the NBA teams & Steve Gera, an operations consultant for several NFL teams, have been a great source of encouragement.  I have been very lucky to have two such knowledgeable & generous guys on the end of the phone, that believe in what I am trying to achieve over here.

I also got a little side tracked by posting the fantastic interview with Leah Washington.  Leah really does shed a different light on the rehabilitation experience & one that having been an athlete myself, I believe we need as a profession we need to be more cognisant of.  

So, since we’ve all had a few hot dinners since the last related post, below is the algorithm that Dr Anne Cools proposes to guide the rehabilitation process.

Cools et al (2013) Shoulder Rehabilitation Algorithm

To view the previous post on the management of the soft-tissue flexibility restrictions, click on the link below:

Finlay, O. (2014) Discussing the Scapular Rehabilitation Algorithm: Lack of Soft Tissue Flexiblity.

As was apparent in a number of the papers reviewed in the article I wrote regarding the assessment of shoulder impingement, many authors have reported altered muscle activity patterns in athletes with shoulder impingement (Kibler et al, 2013; Ratcliffe et al, 2013; Cools et al, 2008; Cools et al, 2010).  This may be due to changes in the strength, neuromuscular inhibition or changes in the timing properties of either one or more of the serratus anterior and lower, middle or upper fibres of the trapezius muscles.

The most commonly reported observations concern a decrease in serratus anterior strength, hyperactivity & early recruitment of the upper trapezius, in addition to decreased activity & delayed recruitment of the middle & lower portions of the trapezius (Cools et al, 2010).

Initially, the muscular control issues that I will address are related to the serratus anterior & the lower trapezius muscles.  If the upper trapezius muscle becomes too dominant, in conjunction with under recruitment of the serratus anterior & lower trapezius muscles, the scapula will demonstrate an abnormal position, such as excessive internal rotation at rest, whilst the migration pattern in combination with humeral movement will become dysfunctional.

Cools et al (2010) separate the muscle performance deficits into neuromuscular deficits, which they define as “a lack of co-contraction & force couple activity” & strength deficits.

Consequently, they consider the first stage of rehabilitation to consist of retraining conscious muscle control of the scapular muscles with the aim of improving proprioception & normalising the scapular resting position.

This philosophy is also shared by Barreto et al (2012), who suggest that, in order to address scapular dyskinesia from a neuromuscular re-education perspective, the physiotherapist must first concentrate on restoring the motor control as opposed to strengthening the muscles.

Barreto et al (2012) recommend this is best achieved in the first instance by employing low resistance exercises, typically requiring only 20% - 40% of maximum voluntary contraction, whilst fatigue must be avoided since the quality of the movement is paramount.

Mottram et al (2009) demonstrated consistent reproduction of scapular posterior tilt & upward rotation by subjects after teaching them to approximate their coracoid with their finger, before asking them to pull it away from the finger, moving the scapula backwards.  The exercise was found to result in a significant increase in scapular muscle activation.

Illustrating the nature of movement using 3D motion analysis, the authors were able to report a high correlation between assisted & non-assisted practice, which suggested that the exercise was suitable for use as a home exercise.

Personally, I have found this exercise very easy to replicate myself.  In addition, I have observed quick uptake by patients that I have used this with, so I am pleased to see that the research out there supports my clinical findings.

What’s more, De Mey et al (2012) were able to demonstrate higher activity in the lower & mid traps using surface EMG when asking subjects to perform the orientation exercise prior to conducting other dynamic shoulder exercises.

Cools et al (2013) recommend that the scapular orientation exercise is conducted in conjunction with spinal postural correction, prompting the subject to attain a neutral lumbopelvic posture, in addition to an occipital lift to address the scapulothoracic & cervical postures.  The authors declare that this may serve to reduce adverse loads on cervical joints, whilst potentially also training the deep postural stabilising muscles of the spine & upper quadrant to contribute their functional role in supporting posture. 

Clinically, I have always found that using taping to provide sustained proprioceptive input in these situations to be very useful.  This approach is advocated by Lewis et al (2005), who demonstrated that taping the scapula into extension, posterior tilt & retraction provided proprioceptive feedback to individuals with shoulder impingement, which resulted in improved trunk posture in addition to an increased shoulder range of movement. 

Historically, I have often introduced these exercises in sitting or standing with the arms by the side, with my reasoning being that is an easy position to incorporate visual feedback in using a mirror.  My selection depends on which of the two positions the patient finds it easier to achieve a neutral spinal posture in.  

Cools et al (2008) suggest integrating scapular exercises into kinetic chain training from the initial phases.  Whilst I tend to integrate the spinal control element of the kinetic chain, I tend to wait a bit before incorporating the lower limb into the equation.  As a result, I am going experiment to see what outcomes I get from introducing the exercise with elements of hip movement from the beginning.  

In sitting, this would involve lifting the foot from the floor, which will require a significant degree of core control, to maintain a neutral spine.  In standing, it is perhaps easier to progress by introducing single leg postures but of course this will depend on the individual capabilities of the patient.

I do like four-point kneeling as a start point, however, I do find that those with less postural awareness find it more difficult to achieve spinal neutral without some form of kinaesthetic input, given that it is difficult to get clear visual feedback in this position.  As a result this limits its use as a home exercise in the early stages.

Obviously, as the shoulder girdle operates in both open & closed kinetic chain activities, it is important to employ both into the programme but I do think that you have to be cognisant as to which exercise you start with according to the abilities of the individual you are working with.

The second stage of the muscle performance rehabilitation procedure that Cools et al (2013) describe involves developing the muscle control & strength necessary for executing daily activities.  Given the extent of this review, I will continue with this phase in my next blog.  In the meantime, several of the references I have cited can be viewed by clicking on the links below:

Barreto, R.P.G. et al (2012).  Lower trapezius & serratus anterior activation: which exercise to use for scapular neuromuscular reeducation?  ConS Saùde; 11(4): pp660-667

Cools, A.M. et al (2007).  Rehabilitation of scapular muscle balance: which exercises to prescribe?   Am J Sports Med; 35: pp1744-1751

Cools, al (2008).  Internal impingement in the tennis player: rehabilitation guidelines.  Br J Sports Med; 42: pp165-171

Cools, A.M. et al (2013).  Rehabilitation of scapular dyskinesis: from the office worker to the overhead athlete.  Br J Sports Med; 48(8): pp 675-676

De Mey, K. et al (2012).  Kinetic chain influences on upper & lower trapezius muscle activation during eight variations of a scapular retraction exercise in overhead athletes.  J Sci Med Sport; 16: pp65-70

Kibler, W.B. & Sciascia, A. (2010).  Current concepts: scapular dyskinesis.  Br J Sports Med; 44: pp300-305

Lewis, J.S. et al (2005).  Subacromial impingement syndrome: the effect of changing posture on shoulder range of movement.  J Orthop Sports Phys Ther; 35: pp72-87

Ludewig, P. et al (2004).  Relative balance of serratus anterior and upper trapezius muscle activity during push-up exercises.  Am J Sports Med; 32: pp484-493

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