Multidirectional instability in the overhead athlete: CONSERVATIVE - - PowerPoint PPT Presentation

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Multidirectional instability in the overhead athlete: CONSERVATIVE - - PowerPoint PPT Presentation

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Multidirectional instability in the overhead athlete: CONSERVATIVE TREATMENT Prof dr Ann Cools, PT, PhD Dept Rehab. Sciences & Physiotherapy Ghent University, Belgium Ann Cools Malm sept 2012 Purpose of this presentation

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Multidirectional instability in the

  • verhead athlete:

CONSERVATIVE TREATMENT

Prof dr Ann Cools, PT, PhD Dept Rehab. Sciences & Physiotherapy Ghent University, Belgium

Ann Cools Malmö sept 2012

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Purpose of this presentation

Classification of instability: where does

the overhead athlete with instability fit in?

Research findings, relevant for rehab

approach

General guidelines for conservative

treatment of MDI

Specific issues based on the sport

(gymnast, swimmer, volleyballplayer)

Ann Cools Malmö sept 2012

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Ann Cools Malmö sept 2012

TRAUMATIC UNIDIRECTIONAL BANKART SURGERY ATRAUMATIC MULTIDIRECTIONAL BILATERAL REHABILITATION INFERIOR ACQUIRED INSTABILITY OVERSTRESS SURGERY

Classification of Instability (1)

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Classification of Instability (2)

Stanmore triangle:

Ann Cools Malmö sept 2012

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Classification of Instability (2)

Stanmore triangle:

Ann Cools Malmö sept 2012

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Classification of instability (3)

FEDS classification

Ann Cools Malmö sept 2012

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Discussion & summary:

MDI = symptomatic instability in 2 or more

directions with or without associated hyperlaxity

instability in the overhead athlete is often

“subtle”

“minor instability” versus “excessive laxity” Overhead athletes: often combination of

hyperlaxity, overuse and minor structural damage

Ann Cools Malmö sept 2012

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Scientific background for conservative treatment

1.

Muscle recruitment patterns in MDI patients – Increased activation of pectoralis major and latissimus dorsi (Barden 2005, Jaggi 2008, 2010)

Increased forces in PM en LT increase

anteriorly directed forces in end-range positions, resulting in decreased joint stability (Konrad 2006)

Ann Cools Malmö sept 2012

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Dominance latt dorsi and pect maj

Ann Cools Malmö sept 2012

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Scientific background for conservative treatment

1.

Muscle recruitment patterns in MDI patients – Increased activation of pectoralis major and latissimus dorsi (Barden 2005, Jaggi 2008, 2010)

Increased forces in PM en LT increase

anteriorly directed forces in end-range positions, resulting in decreased joint stability (Konrad 2006) – Decreased activation in deltoid, rather than rotator cuff (Morris 2004)

Deltoid is an important stabilizer of the GH

joint and avoids inferior translation of the humeral head (Gagey 2000, Donatelli 2004)

Ann Cools Malmö sept 2012

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Scientific background for conservative treatment

2.

Closed chain exercises improve static stability of the joint and stimulate intra- and periarticular mechanoreceptors (Lephart & Fu 2000, Jaggi BJSM 2010)

Ann Cools Malmö sept 2012

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General guidelines MDI conservative treatment

Improve local dynamic joint stability through

activation of the deltoid (Yamazaki 2003, Milner 2002)

Use by preference closed chain exercises

to guarantee static joint approxiation (Uhl 2003,

Dillman 1994)

Improve scapular muscle control and

strength (Cools 2008, Ludewig 2009)

avoid activity of latt dorsi and pect

major during exercises(Jaggi 2010))

Challenge sportspecific demands (Bahu 2008,

Beasley 2000)

Ann Cools Malmö sept 2012

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Deltoid co-contraction:

low load closed chain exercises

Ann Cools Malmö sept 2012

(Uhl 2003)

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Multidirectional Instability: low load CKC exercises

Ann Cools 2012 14

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Ann Cools 2012

How to avoid latt dorsi and pect maj to be activated: external rotation component!

(Kibler 1998, Vanderhoeven 2006, Kibler 2006, Cools & Walravens 2005, Cools 2008)

15

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Scapular rehabilitation in closed chain

Ann Cools Malmö sept 2012

Sidelying Forward flexion Sidelying Ext Rotation Prone Hor Abd + Ext Rot

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Scapular rehabilitation in closed chain

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6 modalities of the push-up plus exercise (N=32)

1 (Maenhout & Cools BJSM 2009)

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6 modalities of the push-up plus exercise (N=32)

Integration Kinetic Chain into closed chain shoulder rehabilitation exercises

2 5 4 7 6 3 (Maenhout & Cools BJSM 2009)

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Ann Cools Malmö sept 2012

Results: EMG-activity and muscle balance ratios

Highest SA activity (44%MVC) en best

UT/SA ratio (0.40) when ipsilateral leg is extended

3 (Maenhout & Cools BJSM 2009)

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Results: EMG-activity and muscle balance ratios

Highest activity in MT & LT, when

contralateral leg is extended (LT=20%MVC)

2 (Maenhout & Cools BJSM 2009)

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Challenge sportspecific demands?

Rehabilitation of MDI in 1/ gymnast 2/ swimmer 3/ volleyballplayer

Ann Cools Malmö sept 2012

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MDI in the gymnast

Ann Cools Malmö sept 2012

Len Vande Lanotte – Flemish Gymnastic Federation

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MDI in the gymnast

Ann Cools Malmö sept 2012

Len Vande Lanotte – Flemish Gymnastic Federation

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MDI in the gymnast

Ann Cools Malmö sept 2012

Len Vande Lanotte – Flemish Gymnastic Federation

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MDI in the gymnast

Ann Cools Malmö sept 2012

Len Vande Lanotte – Flemish Gymnastic Federation

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Value of Sling therapy?

Ann Cools Malmö sept 2012

13 weeks 6x/w Open versus Sling exercises “Sling exercises are equally as effective as open chain exercises in a strength training program for women, with a small advantage for sling regarding push-up”

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Value of sling therapy

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Ann Cools Malmö sept 2012

With

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Ann Cools Malmö sept 2012

Conclusion of the study: “The large

glenohumeral muscles were highly activated when using RS, especially the pectoralis major during the push- up and knee prone bridging exercise and the posterior deltoid and latissimus dorsi during the pull-up exercise.”

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Preparing the athlete for the “impact”

Ann Cools Malmö sept 2012

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Preparing the athlete for the “impact”

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MDI in the swimmer

Lots of repetitions / endurance Focus on core stability prone/supine Swim-specific positions

Ann Cools Malmö sept 2012

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MDI in the swimmer

Ann Cools Malmö sept 2012

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MDI in a volleybal player

From closed to open kinetic chain Challenge throwing and smashing Core-stability training Strength lower extremities

Ann Cools Malmö sept 2012

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MDI in a volleyball player

External rotation

with slight abduction

Deltoid activation Compression force

  • n GH joint

LT activation with

low UT activity (Cools

AJSM 2007)

Ann Cools Malmö sept 2012

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MDI in a volleyball player

Plyometric

exercises in abd – ER

Core stability

training on swiss ball with minimal input from the feet

Ann Cools Malmö sept 2012

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Take home message

The gymnast’s shoulder: in between

MDI and sportsrelated instability

Basic rehabilitation in closed chain

with focus on neuromuscular coordination

Advanced rehabilitation in sportspecific

positions

Ann Cools Malmö sept 2012

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THE SHOULDER IN THE OVERHEAD ATHLETE: CHALLENGES FOR SCAPULAR REHABILITATION AND RETURN TO PLAY AFTER INJURY FRIDAY 29th MARCH 2013 Het Pand, Gent, Belgium www.europeanshoulderconference.ugent.be

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