Chapter 15 Corrective Strategies for Shoulder, Elbow, and Wrist Impairments

Question 1

Corrective Strategies
for Shoulder, Elbow, and Wrist Impairments

Answer 1

Upon completion of this chapter, you will be able to:

• Understand the basic functional anatomy of the shoulder, elbow,
• and wrist.
• Understand the mechanisms for common shoulder, elbow, and wrist injuries.
• Determine common risk factors that can lead to shoulder,
• elbow, and wrist injuries.
• Incorporate a systematic assessment and corrective exercise
• strategy for shoulder, elbow, and wrist impairments.

Question 2

INTRODUCTION—SHOULDER

Answer 2

Shoulder pain is reported to occur in up to 21% of the general population
with 40% persisting for at least 1 year ( 3 ) at an estimated annual cost of $39 billion. Shoulder impingement is the most prevalent diagnosis accounting for 40 to 65% of reported shoulder pain ( 5 ), whereas traumatic shoulder dislocations account for an additional 15 to 25% of shoulder pain. The persistent nature of shoulder pain may be the result of degenerative changes to the shoulder’s capsuloligamentous structures, articular cartilage, and tendons as the result of altered shoulder mechanics.

Question 3

Corrective Strategies
for Shoulder, Elbow, and Wrist Impairments

INTRODUCTION—SHOULDER​

cont

Answer 3

As many as 70% of individuals with shoulder dislocations experience recurrent instability within 2 years and are at risk of developing glenohumeral osteoarthritis secondary to the increased motion at the glenohumeral joint. Degenerative changes
may also affect the rotator cuff by weakening the tendons with time through intrinsic and extrinsic risk factors such as repetitive overhead use (>60 degrees of shoulder elevation), increased loads raised above shoulder height ( 21 ), and forward head and rounded shoulder posture, as well as altered scapular kinematics and

Question 4

Review of Shoulder Functional
Anatomy

Answer 4

The unique anatomy of the shoulder girdle enables the joint to balance maximum mobility while maintaining stability through dynamic and static stabilizing structures.

Stability is derived primarily from the muscles about the shoulder girdle, and mobility is permitted by the relatively loose capsuloligamentous structures. Stability is maintained by the static and dynamic stabilizers that must work together to create the synchronous motion that allows for the high velocities, large torques, and precise timing such as full circumduction during swimming and powerful throwing motions that generate forces at the shoulder in excess of three times one’s body weight

Question 5

Shoulder Functional Anatomy

Bones and Joints

Glenohumeral (GH), Acromioclavicular (AC), Sternoclavicular (SC), and Scapulothoracic joints

Answer 5

Circumduction -The circular movement of a limb.

humerus,

scapula,

clavicle,

rib cage (thorax),

sternum = GH, AC & SC joints

Question 6

Shoulder Functional Anatomy

Bones and Joints

Answer 6

The glenohumeral joint is a ball-and-socket articulation between the head of the humerus and the glenoid of the scapula. The joint affords a vast range of motion and great mobility that sacrifices stability.

Question 7

Shoulder Functional Anatomy

Bones and Joints

Dynamic stabilizers

Answer 7

The dynamic stability of the glenohumeral joint is dependent on the musculature that surrounds the joint, including the rotator cuff and the scapular stabilizers. The rotator cuff is the primary steering mechanism of the glenohumeral joint. The rotator cuff is made up of the supraspinatus and subscapularis anteriorly, with the infraspinatus and teres minor posteriorly.

Question 8

Shoulder Functional Anatomy

Bones and Joints

Function of the Scapula

Answer 8

The function of the Scapula The scapulothoracic articulation allows shoulder movement beyond the 120 degrees of elevation provided by the glenohumeral joint. It also plays an important role in providing motion and shoulder girdle stability through the 17 muscles that attach to the scapula. When these muscles function properly, they provide a stable base for the humerus to glide on and allow for an efficient transfer of force from the lower extremities and trunk. This accomplished through force-couples of the upper, middle, and lower trapezius as well as the serratus anterior. Therefore, the pectoralis
minor plays an important role in scapula malposition as it can pull
the scapula into a more protracted and anteriorly tilted position

Question 9

Common Shoulder Injuries
and Associated Movement
Deficiencies

Answer 9

Shoulder injuries can be broadly categorized into those that aff ect
the rotator cuff muscles or those that affect the capsuloligamentous structures of the shoulder. Rotator cuff conditions such as strains, ruptures, and tendinopathies account for approximately 75 to 80% of shoulder injuries. Rotator cuff strains occur when a muscle group is overexerted, causing microdamage within the muscle belly and tendon, resulting in immediate inflammation and decreased muscle function. see table attached

Question 10

Common Shoulder Injuries
and Associated Movement
Deficiencies

Shoulder Impingement

Answer 10

(SAIS) A common diagnosis broadly defined as compression of the structures that run beneath the coracoacromial arch, most often from a decrease in the subacromial space.

Dyskinesis
An alteration in the normal position or motion of the scapula during scapulohumeral movements.

Question 11

Common Shoulder Injuries
and Associated Movement
Deficiencies​

Shoulder Instability

Answer 11

Shoulder instability results from many different mechanisms,
but regardless of the mechanism, instability most often manifests itself as anterior or multidirectional. These forms of instability differ greatly in terms of the involved structures and injury mechanisms. Even though the exact injury mechanism may differ, all forms of shoulder instability may occur by means of atraumatic injury mechanisms associated with improper mechanics and poor conditioning.

Deafferentation:
The elimination or interruption of sensory nerve impulses by destroying or injuring the sensory nerve fibers.

Question 12

Common Shoulder Injuries
and Associated Movement
Deficiencies​

Distal Injuries

Answer 12

As mentioned earlier, because of the connectivity of the structures and tissues of the kinetic chain, shoulder dysfunction can migrate toward or stem from imbalance or injury in the LPHC, knee, and foot and ankle complex, which includes low back pain; sacroiliac joint dysfunction; hamstring complex, quadriceps, and groin strains; patellar tendonitis; iliotibial band (IT-band) tendonitis; plantar fasciitis; Achilles’ tendonitis; and posterior tibialis tendonitis (shin splints).

Question 13

Assessment and Corrective Exercise
for Shoulder Impairments

SYSTEMATIC PROCESS TO DETERMINE SHOULDER IMPAIRMENTS

Answer 13

Because of the extreme degrees of freedom of the shoulder joint, its limited
contact surface, and its association with the LPHC and cervical spine, there
are a number of key elements to assess for shoulder dysfunction.

Question 14

SYSTEMATIC PROCESS TO DETERMINE SHOULDER IMPAIRMENTS

Answer 14

STATIC POSTURE

As mentioned earlier in this chapter, a common static postural distortion syndrome that is associated with shoulder dysfunction is the upper crossed syndrome. This position can lead to altered arthrokinematics of the shoulder girdle, increased stress to the shoulder complex,
and potential injury.

see chart

Question 15

SYSTEMATIC PROCESS TO DETERMINE SHOULDER IMPAIRMENTS

TRANSITIONAL MOVEMENT ASSESSMENTS​

Answer 15

The lateral view of the overhead squat test as described in chapter six is most important in the prevention of shoulder injuries. From the lateral view, two main checkpoints, the LPHC, and upper body should be observed for the following compensations: excessive lumbar lordosis (low-back arching) and arms falling forward. The table included here provides a review of the potential overactive and underactive muscles for each compensation.

The horizontal abduction test, rotation test, and shoulder flexion test can be very helpful for the health and fitness professional to determine potential shoulder dysfunction and limited range of motion (chapter six). The three common compensations seen during the upper extremity functional tests include shoulder elevation (shrugging), elbow flexion, and excessive lumbar extension.

Question 16

SYSTEMATIC PROCESS TO DETERMINE SHOULDER IMPAIRMENTS

DYNAMIC MOVEMENT ASSESSMENTS

Answer 16

The upper extremity Davies test (see photos) is used for dynamic assessment of the upper extremity (UE) as described by Davies et al. (51). This test has been shown to be reliable and is associated with return of rotator cuff strength as well as functional performance of the shoulder (52). Individuals without shoulder dysfunction should be able to complete at least 20 repetitions in 30 seconds.
Previous research suggests that closed-chain activities similar to this task are
reflective of the rotator cuff and scapular muscle function.

Question 17

SYSTEMATIC PROCESS TO DETERMINE SHOULDER IMPAIRMENTS

DYNAMIC MOVEMENT ASSESSMENTS

cont

Answer 17

Additionally, the quality of the movement should be assessed during this dynamic assessment. The inability to maintain a neutral LPHC during UE activity may suggest a deficit in core stability. Increased scapular elevation, superior or medial border approximation or medial border prominence suggests a loss of scapular control and stability

Question 18

SYSTEMATIC PROCESS TO DETERMINE SHOULDER IMPAIRMENTS

TRANSITIONAL MOVEMENT ASSESSMENTS

RANGE OF MOTION ASSESSMENTS​

Answer 18

The lateral view of the overhead squat test as described in chapter six is most important in the prevention of shoulder injuries. From the lateral view, two main checkpoints, the LPHC, and upper body should be observed for the following compensations: excessive lumbar lordosis (low-back arching) and arms falling forward. The table included here provides a review of the potential overactive and underactive muscles for each compensation.

The horizontal abduction test, rotation test, and shoulder flexion test can be very helpful for the health and fitness professional to determine potential shoulder dysfunction and limited range of motion (chapter six). The three common compensations seen during the upper extremity functional tests include shoulder elevation (shrugging), elbow flexion, and excessive lumbar extension.

Question 19

SYSTEMATIC CORRECTIVE EXERCISE STRATEGIES FOR SHOULDER
IMPAIRMENTS

STRENGTH ASSESSMENTS

Answer 19

The Sample Shoulder Assessment Process and Observations
the table provides a summary of key muscles to be tested on the basis of the
compensation(s) seen in the movement assessment.

Question 20

SYSTEMATIC CORRECTIVE EXERCISE STRATEGIES FOR SHOULDER
IMPAIRMENTS

Answer 20

The following section will provide sample programming strategies using the
Corrective Exercise Continuum for three common shoulder impairments: arms
fall forward during the overhead squat; shoulder elevating during upper extremity transitional movement assessments as well as any pushing, pulling, and pressing movements; and scapular winging when performing the push-up assessment appropriate tables). Which exercises are used will be dependent on the findings of the assessments and the individual’s physical capabilities (integration exercises).

Question 21

SYSTEMATIC CORRECTIVE EXERCISE STRATEGIES FOR SHOULDER
IMPAIRMENTS​

SHOULDER IMPAIRMENT: ARMS FALL FORWARD

Answer 21

Step 1: Inhibit Key regions to inhibit with foam rolling include the latissimus dorsi and thoracic spine.

Step 2: Lengthen Key lengthening exercises with static stretches include the latissimus dorsi and pectorals.

Step 3: Activate Key activation exercises with isolated strengthening exercises or positional isometrics include the mid and lower trapezius, rhomboids, and rotator cuff (ball combo II with dowel rod). The ball combo II can also be performed with dumbbells.

Step 4: Integration An integration exercise that could be implemented for this compensation could be a squat to row. This exercise can be progressed by performing it with alternating arms, to one arm, to one arm with trunk rotation, and then going through this same progression on one leg.

Question 22

SYSTEMATIC CORRECTIVE EXERCISE STRATEGIES FOR SHOULDER
IMPAIRMENTS​

SHOULDER ELEVATION

Answer 22

Step 1: Inhibit Key regions to inhibit with foam rolling and apparatus-assisted modalities include the thoracic spine, upper trapezius, and levator scapulae.

Step 2: Lengthen Key lengthening exercises with static stretches include the pectorals, upper
trapezius, and levator scapulae.

Step 3: Activate Key activation exercises with isolated strengthening exercises or positional isometrics include the mid and lower trapezius (ball cobra).

Step 4: Integration An integration exercise that could also be implemented for this compensation could be a single-leg Romanian deadlift with PNF (proprioceptive neuromuscular facilitation) pattern.

Question 24

SYSTEMATIC CORRECTIVE EXERCISE STRATEGIES FOR SHOULDER
IMPAIRMENTS​​

SCAPULAR WINGING

Answer 24

Step 1: Inhibit Key regions to inhibit with foam rolling include the latissimus dorsi and thoracic spine.

Step 2: Lengthen Key lengthening exercises with static stretches include the latissimus dorsi and
pectorals.

Step 3: Activate Key activation exercises with isolated strengthening exercises or positional isometrics include the serratus anterior (push-up with plus) and mid and lower trapezius (ball combo I).

Step 4: Integration An integration exercise that could also be implemented for this compensation could be a standing one-arm cable chest press.