From Irritating Impingement to Shoulder Press Success TIM KEELEY
From Irritating Impingement to Shoulder Press Success presented by
Tim Keeley B.Phty, Cred.MDT, APAM
Principal Physiotherapist Physio Fitness Australia
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Today’s session… • Sub-acromial impingement’…what’s going wrong? • Signs and symptoms…what to look for • Physio treatment and rehab… what we need to do • Rehab exercises… the hard stuff • Progression to normal training… more hard stuff • Program adherence…the even harder stuff
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Sub-acromial impingement • • • • • • • • •
Shoulder pressing mechanism and the impingement zone Scapulo-humeral rhythm – the need for perfection Degrees of movement of humerus vs scapula First 30º: Stable, 30-180º: 2:1 Ratio Ligamentous stability, reliance on muscle control Scapular stability and the role of the rotator cuff Dynamic centre of joint, not just static Positional faults and effect on the rhythm Anterior, posterior, elevation of head
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From Irritating Impingement to Shoulder Press Success TIM KEELEY
Sub-acromial impingement • Positional fault + overload = primary cause • Incorrect movement of humeral head into sub-acromial space • Sub acromial pain, tissue damage and inflammation – Supraspinatus tendonitis / tendinopathy / tears – Bursitis, capsule, ligaments, labrum
• Relative weakness of rotator cuff and scapula stabilisers – Muscle tightness and loss of ROM around the GHJ – Scapular angle (winging and tilt) – Change in motor patterning
• Viscous circle of muscle inhibition, weakness and compensation • Acromion and thoracic abnormalities / hypermobility / dislocations • Patient understand what’s happening – better outcomes 1300 233 300
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Signs and symptoms • • • • • • • • • •
Volunteer from crowd? - Zaver Constant and intermittent pain ‘Painful arc’: 0-30º / 90-180º Change in scapulo-humeral rhythm Scapular abduction: conc. / eccentric Scapula winging and elevation Compensation of rhomboids / upper traps conc/eccen. Posterior cuff and capsule tightness, atrophy Clicking and clunking Muscle inhibition / weakness on testing – Resisted external rotation, Empty beer can sign, Pain through passive quadrant
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Physio treatment and rehab • Assessment / referral to Physio / confirmation • Acute care / settle symptoms – Soft tissue release, joint mobilisation / stretching, dry needling, kinesio taping
• Advice and program instruction *(see below) – Ice, anti-inflammatories, relative rest / change in exercise, home program
• • • • • • •
Restore correct scapulo-humeral rhythm Build strength, control and endurance Integrate into gym routine / Progression to normal training *Physio role of education – ‘getting them on board’ Not enough treatments = poor outcomes “The pain is gone” syndrome Onward referral, scans etc
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From Irritating Impingement to Shoulder Press Success TIM KEELEY
Rehab exercises • Scapula stabilisation exercises – Serratus anterior function – Lower, mid and upper traps – Role of rhomboids
• Rotator cuff exercises – Compound stabilisation – Isolated rotation, abduction, adduction, extension – Theraband over cable and dumbbell
• Isometric and Isokinetic • Oscillatory • Reps and Sets 1300 233 300
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Scapula stabilisation exercises • • • • • • • • •
Prone scapula press / wall press One arm skydive Opposite arm and leg raise One arm row Isometric ball wall press One arm wall press Two arm BOSU skydive One arm eccentric pulls Straight arm supine press
• Rotator cuff working with every exercise! 1300 233 300
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Prone scapular press / Wall press • • • •
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Thoracic kyphosis Lumbar spine neutral Wrist tightness Upper traps
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From Irritating Impingement to Shoulder Press Success TIM KEELEY
One arm skydive • Upper traps • Core stabilisation • Depression > retraction • Progression: arm forward
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Opposite arm and leg raise • Weight distribution • Loss of core stability • Winging and drop into retraction • Pilates progressions • Theraband
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One arm row • • • • • •
Scapulo-humeral rhythm Eccentric control Rhomboids / upper traps Bending of elbow Protraction of scapula ‘Shoulder - arm, arm - shoulder’
VIDEO
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From Irritating Impingement to Shoulder Press Success TIM KEELEY
Isometric ball wall press • Diagonal • 30 sec holds • Shoulder off ground
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One arm wall press • Watch drop of opposite shoulder • Eccentric control • Straight arm • Can do only eccentric if needed • Progression to bent arm
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Two arm BOSU skydive • Over extension of lumbar spine • Head position • Upper traps • Progression: arms forward
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From Irritating Impingement to Shoulder Press Success TIM KEELEY
One arm eccentric pulls • Eccentric control • Bending of elbow • ‘shoulder - arm, arm - shoulder’ • Rings, fixed bar • Angle of straps • **VIDEO**
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Straight arm supine press • • • •
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Medicine ball for stability Shoulder on/off ground Eccentric control Straight arm
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Rotator cuff exercises • • • • •
Extension Adduction External rotation Internal rotation Abduction
• • • • •
Isometric – first week Isokinetic neutral (0˚ abduction) 45˚ abduction 90˚ abduction Oscillatory – inner and outer ranges
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From Irritating Impingement to Shoulder Press Success TIM KEELEY
Extension • Scapular tilt • Eccentric control • Straight arm
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Adduction • ‘Squeezing armpit muscle’
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External rotation • • • •
The classic Common flaws Pain free range Elbow and scapula set position
• 45° abduction • 90° abduction
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From Irritating Impingement to Shoulder Press Success TIM KEELEY
Internal rotation • • • •
Band tension Pain free range Elbow and scapula set position ‘Pull back when pulling forward’
• 45° abduction • 90° abduction
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Abduction • • • •
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45º limit only Watch elevation / scapula set Pain-free range!! Band tension
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Progressions to normal training • Warm up the rotator cuff! • Apply rehab principles of movement • • • • • •
BOSU push up One arm cable pull down One arm cable press Band Diagonals One arm front press Prone Y’s
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From Irritating Impingement to Shoulder Press Success TIM KEELEY
BOSU push up • • • •
½ range to start Hips forward! Watch drop into retraction Full protraction at top
• Setting up bench press and push ups
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One arm cable pulldown • Remember rhythm! • Watch early elevation of shoulder
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One arm cable press • Remember rhythm! • ‘Arm - shoulder, shoulder - arm’ • Eccentric control of scapula
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From Irritating Impingement to Shoulder Press Success TIM KEELEY
Band diagonals • Combined movement • Elevation and setting of scapula
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TRX push up • Don’t go past neutral • Watch drop into retraction • Increase the decline
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Prone Y’s • Control the movement
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From Irritating Impingement to Shoulder Press Success TIM KEELEY
One arm front press • Theraband or dumbbells • Scapulo-humeral rhythm • Move to 45º
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Things to be aware of… • • • • • • • • •
Thoracic ROM -> foam roller extension stretches Shoulder / chest ROM -> Supine foam roller stretches Muscle balance chest vs back Tendon tears Front press > normal press Incline shoulder press > vertical or military press Dumbells > fixed bar Swimming Avoid long lever shearing shoulder movement – Lateral raises – Front raises
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Program adherence • • • • •
Pain free at rest:1-2 weeks Pain free arc: 2-3 weeks Rehab exercise no pain < 90º abd: 3-4 weeks > 90º: 4-8 weeks Normal weights / training / sport: 6-8 weeks
• Maintenance of rehab exercises in program – – – – –
Use in warm up Relative exercises on ‘body part days’ Personal trainer programming Regular reviews with Physio to keep on track Education on ‘pumping up the tyres’
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