3-D Shoulder: Rotator Cuff Impingement Overview and Probable Suspects

A big THANK YOU to Dr . David Tiberio of the Gray Institute for inspiring me to write this blog post based on his wonderful webcasts during the GIFT Program!

In my last post, I introduced the 3-D Shoulder. As I study it more, I'm finding that the shoulder really is an amazing piece of work. The simple complexity of the shoulder really can make your head spin, but if we are looking at it through Applied Functional Science glasses, we can start to appreciate and understand the complex simplicity.

As we look at the shoulder, we realize its wonderful function, but at the same time, it can be dismally dysfunctional. In this post, we will look at rotator cuff impingements through AFS and then look at PROBABLE SUSPECTS.



Shoulder pathologies can affect any age, race, or sex without discrimination. In the last year, I have seen clients with rotator cuff tears over the age of 55 as well as impingement of teenage baseball players. Coincidentally, I was going through the GIFT Program at the Gray Institute. and was able to learn much more about this pathology in detail as well as some functional assessements, strategies and techniques to help my clients.  (NOTE:If you are a PT,CPT, ATC, MD, DO, DC, etc, this program should be on the top of your list to go through if you really want to learn about Chain Reaction Biomechanics and Applied Functinonal Science.)

As we look at various pathologies and how to effectively and efficiently deal with any rehabilitation, post-rehabiliation, or training and conditioning, we cannot get stuck on the pathology. Through our functional thought process we have to learn to "outsmart" the pathology. Using Applied Functional Science, with its Principles of Function, is going to allow us do this.


ROTATOR CUFF IMPINGEMENT

NOTE: IF YOU ARE EXPERIENCING ANY SHOULDER PAIN, PLEASE CONSULT A PHYSICIAN BEFORE ATTEMPTING ANY EXERCISES. THEY WILL BE ABLE TO GIVE YOU A DIFFERENTIAL DIAGNOSIS IN REGARDS TO YOUR PAIN AS WELL AS AN APPROPRIATE COURSE OF ACTION.

In the research article "Impingement Syndrome in Athletes" by Hawkins et. al,  refer to impingement syndrome as an "impingement of the vulnerable avascular region of the supraspinatus and biceps tendon. With the passage of time, degeneration and tears of the rotator cuff may result. Pathologically, the syndrome has been classified into Stage I (edema and hemorrhage), Stage II (Fibrosis and tendonitis) and Stage III (tendon degeneration, bony changeds and tendon ruptures).

As you know the Rotator Cuff is made up of 4 muscles (Supraspinatus, Infraspinatus, Teres Minor, Subcapularis) and as we have discussed before, muscles in UPRIGHT FUNCTION, contrary to popular belief, decelerate tri-planar motion (Eccentric action) and then accelerate tri-planar motion in the oppositive direction (Concentric action). However, if joints and bones are not moving the way that they should, we can start to get irregular motion and improper neuromuscular loading and unloading throughout the body that can lead to injury.

As we look at the simple side of Rotator Cuff Impingement we know that Function is 3-D, so when we move our arm in any or all of the 3 planes of motion, the scapula (shoulder blade) MUST go along with the it. If not, we are more likely to acquire an impingment. If this is the case, we are not only talking about the subacromial space and glenohuemeral joint, we are INITIALLY talking about the scapulothoracic motion of the body.

As we look at the scapulothoracic motion, we remember that the shoulder complex and by extension the scapulothoracic motion requires Mobile Stability or MOSTABILITY, especially in the scapula. Dr. David Tiberio gives the example of the need for MOSTABILITY. He says that is obvious to us that the deltoid causes ABduction of the shoulder, but if there is limited motion in the scapula, than the contraction of the deltoid muscles will cause a downward rotation of the scapula that will cause an impingement.

3 consideration when looking at rotator cuff impingement

• TRUE RESTRICTION DUE TO SCAPULA MOBILITY
• In this case, the scapula could have limited mobility due to tight muscles. Remember that the scapula has 17 muscles that attach to it so when one of these muscles is dyfunctional, we will see a GLOBAL dysfunction not only with that particular joint, but with the rest of the body. (Can an immobile scapular cause lower back pain???? You guessed it....sure it can!) If you have a PT, MD, DO or DC that specializes in manual therapy, they will most likely also investigate the motion at the Acromioclavicular (AC) joint as well as the Sternoclavicular (SC) joint, as those can also limit scapula mobility.
• NEUROMUSCULAR TIGHTNESS
• After a traumatic event, like an AC joint sprain or shoulder dislocation, our clients/patients may have been in a sling. This immobilization can cause the muscles the get tight and dysfunctional. Proprioceptively, this can make sense as the muscles are sensing an instability in the traumatized joint and will reflexively lock down. Until they are proprioceptively stimulated and encouraged that the trauma is over and in the process of healing, they may continue to lock down and limit motion GLOBALLY.
• FATIGUE OF SCAPULOTHORACIC MUSCULATURE
• In function, there is a certain threshold that our muscles have. Once it reaches that threshold, the muscles can become very fatigued. When this happens, the muscles that are scapulothoracic in nature can lose the ability to stabilize the scapula. When this happens, we see the scapula having increased mobility so that the sequencing of the humerus and scapula is off. Conversely, we can also so fatigue actually shut muscles down and them become OVERSTABILIZED which will create a similiar situation of impingement.

PROBABLE SUSPECTS

1. Same side shoulder complex dysfunction: as described above with the associated pain.
2. Opposite side shoulder complex: as lack of quality motion in this area can adversely affect the Thoracic Spine and the corresponding neuromuscular system.
3. Thoracic Spine limitations: Making sure that there is quality of motion and proper sequencing in Type I and Type II motions as described by Fryette as well as Type III motions described by Gray and Tiberio which adds the Sagital Plane (Flexion and Extension) to the Type I and Type II motions.
4. Cervical Spine Restrictions: If in function, the client or athlete must keep their gaze fixed on one place as the C-Spine rotates, a restriction there could tranlsate to loss of ROM in another joint like the GH or Scapulothoracic joints causing the impingment.
5. Hip Mobility: must ALWAYS be assessed. Again, a lack of motion here will not allow for a proper load or explode and this may find its way up the kinetic chain affecting the MOSTABILITY of the shoulder complex.

When I have an athlete who is post-rehabilitation with me, we will address all of the above through the 3-D DUMBBELL LUNGE MATRIX! As soon as some of athletes comes back to the area, we will be able to post many videos that I have been promising.

As always, I welcome feedback. You can either post to the COMMENTS section or email me directly at yoga-pilates_will@hotmail.com

My next post will be on the Suble Shoulder Instability. Look for it soon!!!!!

Happy Thursday!!!

Will