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Shoulder and upper limb injuries

Whether it is adhesive capsulitis, a labral tear, a rotator cuff tear or tendinopathy, or inflammation of the tendon of the long biceps these problems are primarily affecting the gleno-humeral joint. While most will only focus on the GH joint itself, we should ask the question why the tissue worn out in the first place(unless a traumatic injury) or in other words what mechanism caused the that particular site of the injury to become the weakest point in the chain to "break". The answer to that question will probably not be found only in the gleno-humeral joint but more in the synchrony or asynchrony of the movements of the various joints of the shoulder girdle and how the shoulder girdle as a whole relates to the thoracic cage and cervical spine in that given individual.

For example: if the thoracic spine curvature is slightly increased the scapular plane changes resulting in scapular protraction that may or may not results in a relative external rotation of the humeral bone. This could cause more posterior tension and pressure on the glenoid fossa. If I keep making use of the full range of the shoulder when playing tennis or lifting weights overhead, sooner or later my shoulder will pay the price.

The shoulder girdle consists of 5, some of which are true anatomical while the rest are physiological joints.

The gleno-humeral joint, the sub-deltoid joint, the scapula-thoracic joint, the acromio-clavicular joint and the sterno-clavicular joint.

If the movement of any of these joints are restricted, it will either result in decreased range of motion in the shoulder as a whole or if the range isn't reduced another joint of the complex has to compensate for the restricted joint and therefore likely to be "overworking" its capsular, ligamentous, fascial and muscular apparatus. While the temporary transfer of load is part of the normal function of any joint in a movement sequence, overload will eventually result in wear and tear.

If we don't address the cause of that overload, the given tissue will have a difficult time to heal and will likely to get re-injured so correcting the dysfunctional pattern that caused the injury should be just as important as addressing the state of the injured tissue with the appropriate treatment for the stage in which the anatomy is at at the given time.

After an injury or surgery, the shoulder is immobilised for a given period of time. While it is important to offload the healing tissue, in reality this may be a bad strategy as lack of movement causes adaptations in the connective tissue of the complex that can make the rehabilitation process considerably longer costing weeks for the patient to return to their desired activities. This may be especially important for athletes where an extra couple weeks can cost heavily on many levels.

In certain cases rehabilitation could start sooner than normally advised but that doesn't mean that I'll start at the site of the injury. If I have a problem with the GH joint I can gently start working on the other 4 joints without touching the gleno-humeral joint. By working on the small intrinsic movement of the sternoclavicular joint, for instance, I'm affecting the AC and GH joint. I can start working indirectly on the injury by starting to work the joint distal to it. If I work on the movement of the elbow I indirectly affect the GH joint. It will be far enough to be safe yet the connective tissue links between the distal and proximal joint will be affected which will help the the circulation, gliding of adjacent layers and intrinsic metabolism of the connective tissue, so when GH is ready to be moved, there will be no soft tissue restrictions as a result of immobilisation and the limitation will solely be the one in the GH.

This, however, is not a protocol based approach and will need to be highly individualised and adapted on the spot based on the patients response to the treatment.

If the problem in the GH was, say a labral tear, I might want to focus on its relationship to its immediate anatomy to avoid uneven tension and compression. I want to make sure that the tension from the long head of the biceps and triceps, both of which have expansions to the labrum, are in balance. It would be optimal to have even engagement or rather surface coverage between the anterior, posterior, inferior, superior part of the humeral head and the glenoid. If my subscap is too tight it will bring the head forward with medial rotation and anterior "compression", if my infraspinatus and teres minor are tight they will likely to do the opposite etc. And so on..

I tend to be slightly suspicious of “rotator cuff strengthening” that I see at the gym and in some rehab programs where there is usually one or two selected angles for external/lateral rotation, usually performed with heavier weights and without strict isolation of the muscles e.i. inaccurate scapulo-humeral angles and with a lot of movement of the scapula - which is a bit pointless because you are not only compensating with an accessory movement but train the muscles only in that short range especially that the angle and range is not necessarily the range you want a better contraction force from those muscles. Also, I don't see people stretch any of their rotator cuff muscles. If your external rotation is limited, which muscle do I need to stretch?

This is when segmental reinforcement and stretching becomes very important. So as we treat the tissue, we want to address the muscle imbalance to offload the injured tissue and to optimal movement mechanics.

In a true sense when we isolate, we want to make sure that the muscles gets maximum pre-tension and its proximal and distal links are fixed within its fascial chain so there is no compensation in the movement. Each muscle has a different angle where its force is most advantageous.

The same injuries have many different representations far beyond my brief train of thought above. Noticing and addressing the small details can make a big difference in the results.

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