THERAPEUTIC TAPING,
EXERCISE & POSTURE
TECHNIQUES
Tambra Marik, OTD, OTR/L, CHT
Apple Physical Therapy
Gig Harbor/Tacoma WA
Moving Towards Function/Marik
1
Course Agenda
•
•
•
•
•
Characteristics of Tape
Theoretical Constructs of Rigid Tape
Theoretical Constructs of Elastic Tape
What is our evidence for taping?
The Shoulder: From Basic Anatomy, Biomechanics,
Pathology to Posture and Treatment
• Rotator Cuff Tendinopathy/Impingement
•
Lab: Shoulder Girdle Taping and Exercise
•
Lab: Evidence for Impingement taping
Moving Towards Function/Marik
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Course Agenda
• The Shoulder (cont)
–Instabilities
• Lab: Anterior Instability, Multidirectional
Instability, AC Joint taping (type I & II)
• Lab: TOS taping, review hemiplegia taping,
cervical taping, myofascial shoulder pain
taping, Upper Quadrant taping
Moving Towards Function/Marik
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1
PTAPTM_1275
Course Agenda
• The Elbow
– Basic Anatomy
– Elbow Instabilities related to ligamentous
structures
• Medial ulnar collateral ligament injuries
• Lateral radial collateral ligament injuries
• Taping and Exercise lab
– Tendinopathy at medial and lateral elbow
– Taping and Exercise Lab
Moving Towards Function/Marik
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Course Agenda
• The Elbow
– Basic Anatomy
– Elbow Instabilities related to ligamentous
structures
• Medial ulnar collateral ligament injuries
• Lateral radial collateral ligament injuries
• Taping and Exercise lab
– Tendinopathy at medial and lateral elbow
– Taping and Exercise Lab
Moving Towards Function/Marik
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CHARACTERISTICS/TYPES OF TAPE
• ATHLETIC TAPE
• RIGID TAPE
–Leuko Tape
• ELASTIC
–Rock Tape
–Kinetic/Kinesiology
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2
PTAPTM_1275
BENEFITS OF RIGID TAPE
Pain Relief
Neuromuscular
Proprioception
Tissue
De-loading
Moving Towards Function/Marik
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THEORETICAL CONSTRUCTS FOR
RIGID TAPE
• PAIN REDUCTION
–Mechanical Effects:
–Joint support
–Joint Re-Alignment
–Biomechanical Correction
Moving Towards Function/Marik
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THEORETICAL CONSTRUCTS FOR RIGID
TAPE
• NEUROMUSCULAR EFFECTS
–Muscle facilitation and/or inhibition
• Theory Based: Across muscle inhibits and
along muscle facilitates
• Evidence indicates taping along muscle (LT)
facilitate muscle activity (Alexander et al 2003)
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3
PTAPTM_1275
THEORETICAL CONSTRUCTS FOR RIGID
TAPE
• NEUROMUSCULAR EFFECTS
–Muscle Facilitation
• Theory: Muscle held in a
shortened position will have
optimal actin-myosin overlap
during the cross bridge cycle
Photo from: Morrissey
2000
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THEORETICAL CONSTRUCTS FOR RIGID
TAPE
Photo from: Morrissey 2000
• NEUROMUSCULAR EFFECTS
–Muscle Inhibition
• Theory: Hold muscle in lengthened
position resulting in decreased
actin-myosin overlap
Moving Towards Function/Marik
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THEORETICAL CONSTRUCTS FOR
RIGID TAPE
• PROPRIOCEPTION ENHANCEMENT
–Enhances muscle control over targeted joint
Cutaneous
Mediated
Proprioceptive
Feedback
Image retrieved from:
http://content.answcdn.com/main/c
ontent/img/oxford/Oxford_Sports/0
199210896.reflex-arc.1.jpg
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4
PTAPTM_1275
THEORETICAL CONSTRUCTS FOR
RIGID TAPE
• TISSUE DELOADING
–Surrounding or gathering the tissue around
the painful area to deload the tissue
Moving Towards Function/Marik
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THEORETICAL CONSTRUCTS FOR
RIGID TAPE
• PSYCHOLOGICAL EFFECTS
–Feelings of increased confidence, strength
and decreased anxiety
Moving Towards Function/Marik
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ELASTIC TAPE
Moving Towards Function/Marik
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5
PTAPTM_1275
ELASTIC TAPE
I CUT
Y CUT
FAN CUT
X CUT
Moving Towards Function/Marik
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TAPE APPLICATION
•
•
•
•
Apply to clean, dry skin. Remove oils from skin
Can use skin adhesives for improved contact
Typically tape is applied to stretched skin
Tape is stretched (~10%) when applying to nonstretched skin
• Additional stretch required when applying for
mechanical correction
• Tape likely to adhere better to skin where hair has
been clipped or shaven
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PRECAUTIONS/CONTRAINDICATIONS
Avoid applying tape to persons with:
•
•
•
•
•
•
Skin allergies or sensitivity to tape
Open wounds
Skin infections/conditions
Fresh scars
Fragile and sensitive skin
Circulatory conditions (bleeding or clotting
disorders)
• Sensory loss in taped region or distal to tape
• Pregnancy avoid selective acupuncture points
• Lymphedema requires knowledge of pathways
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PTAPTM_1275
PRECAUTIONS/CONTRAINDICATIONS
Avoid applying tape to persons with:
•
•
•
•
Peripheral vascular disease
Peripheral neuropathies
Diabetes
Prolonged use of steroids or anticoagulant
medications
• Cognitive loss (patient is unable to report any
negative effects of tape)
Moving Towards Function/Marik
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PRECAUTIONS/CONTRAINDICATIONS
Avoid applying tape to persons with:
•
•
•
•
Peripheral vascular disease
Peripheral neuropathies
Diabetes
Prolonged use of steroids or anticoagulant
medications
• Cognitive loss (patient is unable to report any
negative effects of tape)
Moving Towards Function/Marik
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ROCK TAPE
An Elastic Tape
p
97% COTTON
3%NYLON
HYPO-ALLERGENIC
ACRYLIC BASED
ADHESIVE
Stretches in
One Direction
No Latex
Thought to
accelerate
healing
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7
PTAPTM_1275
ROCK TAPE
THEORETICAL CONSTRUCT
• FASCIAL MOVEMENT
TAPING
–Reduce swelling
–Accelerate blood flow
–Contribute to
optimizing movement
patterns
Picture retrieved from:http://davidlasnier.com/
Moving Towards Function/Marik
wp-content/uploads/2012/02/anatomy-trains-fascial-arms-line.jpg
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OTHER THEORETICAL CONSTRUCTS
FOR ELASTIC TAPE
• MECHANICAL CORRECTION
• FASCIA CORRECTION
• SPACING CORRECTION
• MUSCULOSKELETAL CORRECTION
(TENDON/LIGAMENT)
• FUNCTIONAL CORRECTION
Moving Towards Function/Marik
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Kase K, Wallis J, Kase T. Clinical Therapeutic Applications of the KinesioTaping Method. Tokyo, Japan:Ken Ikai Co. Ltd;2003.
THEORETICAL OBJECTIVES
• MECHANICAL CORRECTION/Skin Function
GOAL:
1) Position muscle, fascia, or joint. Tape provides
feedback to mechanoreceptors
resulting in the body adjusting to minimize
tension
2) Elasticity in tape assists the body to adjust to
desired position
OR
3) Block movement
– Stretch qualities and pressure of the tape provide
sensory input to mechanoreceptors
Kase K, Wallis J, Kase T. Clinical Therapeutic Applications of the KinesioTaping Method. Tokyo, Japan:Ken Ikai Co. Ltd;2003.
Moving Towards Function/Marik
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PTAPTM_1275
Mechanical Correction Theory: Tape
Provides Input to Mechanoreceptors
• Method 1 Tail Tension/Lateral Epicondylosis Example
– 1) Mechanical correction for tennis elbow. Cut Y
tape with 1 inch base and 2 inch tails. Place
forearm in supination and elbow flexed at 90°
flexion. Apply strip base on distal humerus.
Hold base with one hand. Apply 50% to 75%
tension with downward pressure on each tail
over wrist extensor group.
– Leave one inch to the tail and lay down with no
tension.
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Theoretical Concept
Mechanical Correction / Lateral
Epicondylosis
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Mechanical Correction Theory:
Tape Blocks Motion
• Method 2: Blocking lateral epicondylosis example
1. Place the elbow at 30° flexion and forearm in
supination.
2. Use the center of an I strip with 50% to 100% tension
in the middle of the strip.
3. Apply directly over supinator extensor mass. The
patient actively moves to pronation/elbow
extension(extension for sensory feedback to not move
to end range extension) and the ends are laid down.
4. No tension to the ends of I strip. One end at distal
posterior distal humerus and one end at volar mid
forearm.
Moving Towards Function/Marik
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PTAPTM_1275
Theoretical Concept
Mechanical Correction / Lateral
Epicondylosis
Moving Towards Function/Marik
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THEORETICAL OBJECTIVES
• FASCIA CORRECTION
GOAL:
1) Elasticity of tape is used to move fascia
or limit fascia movement
or
2) Hold fascia in position or limit
fascial movement after manual
techniques
Kase K, Wallis J, Kase T. Clinical Therapeutic Moving
Applications
of the
KinesioTaping Method. Tokyo, Japan:Ken Ikai Co. Ltd;2003.
Towards
Function/Marik
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Theory: Limit Fascia Movement
Medial Epicondylitis Example
1. Cut Y strip with a 2 inch base and 2
inch tail.
2. Manually lift the flexor wad from
the medial epicondyle.
2. Place the base of the Y strip
proximal to the medial epicondyle
without tension at the base.
3. Apply the remainder of the base
with 50% tension in a volar radial
distal direction.
*Hold
the corrective position or limit the
unwanted position with tape.
Moving
Function/Marik
Kase K, Wallis J, Kase T. Clinical Therapeutic Applications
ofTowards
the KinesioTaping
Method. Tokyo, Japan:Ken
Ikai Co. Ltd;2003.
30
10
PTAPTM_1275
Theoretical Concept
Fascia Correction / Medial
Epicondylosis
Moving Towards Function/Marik
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THEORETICAL OBJECTIVES
• SPACING CORRECTION
GOAL:
1) Lift fascia & soft tissue in painful region.
2) Create more space in the area above pain,
inflammation or edema resulting in
decreased pressure in the injured area.
3) Possible increase circulation to injured area
by creating more space.
4) Stimulation of mechanoreceptors possibly
decreasing pain.
Moving
Function/Marik
Kase K, Wallis J, Kase T. Clinical Therapeutic Applications
ofTowards
the KinesioTaping
Method. Tokyo, Japan:Ken Ikai Co. Ltd;2003. 32
Spacing Correction Theory:
Tape Pulls Connective Tissue To Area
• Method 1 long head of biceps (LHB)
1. Cut a 4 inch I piece. Tear in the
middle and apply 25% to 50%
tension to the middle of the tape.
2. Place the tensioned tape
horizontally on LHB with the
shoulder in 90° of flexion and ER. http://upload.wikimedia.org
wikipedia/commons/f/f2/
3. Move the shoulder to extension Gray411.png
and lay down the ends with no
tension.
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11
PTAPTM_1275
Theoretical Concept
Spacing Correction
p Longg Head Biceps
p
Example:
Start shoulder flexion 90°
Apply tape with 2550% stretch as the
patient moves
Into extension
Moving Towards Function/Marik
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Spacing Correction Theory:
Tape Pulls Connective Tissue To Area
Method 2 LHB
1. Cut 4-5 in strip with tails at each end. Cut
a hole 1/3 larger than the region you want
to lift up.
2. Place the shoulder in 90° of scaption/ER.
http://upload.wikimedi
wikipedia/commons/f/f2/Gray
Tear away center of hole.
411.png
3. Apply 25% to 50% tension in center for the
hole and apply to painful region.
4. Place the shoulder in extension and lay
down ends without tension.
5. Splay the ends.
Moving Towards Function/Marik
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Theoretical Concept
Spacing Correction
Example 2: Long Head Biceps
25-50% stretch
Moving Towards Function/Marik
Shoulder extended lay ends down
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PTAPTM_1275
THEORETICAL OBJECTIVES
• MUSCLE FACILITATION/INHIBITION
GOAL:
1) Facilitation a muscle contraction by using
tape to displace the skin in the direction of
contraction/origin to insertion
2) Inhibit muscle contraction by using the tape
to displace the skin in the direction of the insertion
to origin thereby, reducing a muscle contraction
Kumbrink B, K Taping: An illustrated Guide. Berlin Heidelberg: Springer-Verlag;2012.
Moving Towards Function/Marik
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Muscle Facilitation Theory: Tape Restores
Force on the Skin towards Direction of
Muscle Origin
Method 1: Facilitate/Increase Tone (Deltoids)
– Apply tape from muscle origin to insertion
– Place shoulder to side in neutral rotation
– Apply I strip to acromion
– Lie strip down with no tension up to 0 to 50% to
deltoid tuberosity
*Authors vary regarding recommendations for
tension
Moving Towards Function/Marik
Kumbrink B, K Taping: An illustrated Guide. Berlin Heidelberg: Springer-Verlag;2012.
38
Theoretical Concept
Muscle Facilitation
Example: Deltoids
Tape shrinks towards origin.
Moving Towards Function/Marik
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PTAPTM_1275
Muscle Inhibition Theory: Tape Restores
Force on the Skin towards Direction of
Muscle Insertion
Method 1: Inhibit/Decrease Tone (Deltoids)
– Apply tape from muscle insertion to origin
– Place shoulder to side in neutral rotation
– Apply I strip to deltoid tuberosity
– Lie strip down with no tension up to 50% to
acromion
*Authors vary regarding recommendations for
tension
Moving Towards Function/Marik
Kumbrink B, K Taping: An illustrated Guide. Berlin Heidelberg: Springer-Verlag;2012.
40
Theoretical Concept
Muscle Inhibition
Example: Deltoids
Tape shrinks towards insertion.
Moving Towards Function/Marik
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THEORETICAL OBJECTIVES
• LIGAMENT SUPPORTING
GOAL:
1) Tape increases stimulation of joint
mechanoreceptors for the brain to interpret as
normal tissue Kase K, Wallis J, Kase T. Clinical Therapeutic Applications of the KinesioTaping
Method. Tokyo, Japan:Ken Ikai Co. Ltd;2003.
2) Tape pulls ligaments to the middle
Kumbrink B, K Taping: An illustrated Guide. Berlin Heidelberg: Springer-Verlag;2012.
Moving Towards Function/Marik
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PTAPTM_1275
Ligament Support: Tape pulls osseous
segments together
Example 1: PIP joint index finger
1. Cut an I strip 1” x 1”
2. Tear I strip in the middle
3. Place digit in extension
4. Lie the tape down at lateral & medial 50% to
100% stretch
5. Lie ends down with no tension
6. Apply 1” x 1” cross tape (volar/dorsal support)
Moving
Towards
Function/Marik
Kumbrink B, K Taping: An illustrated
Guide.
Berlin
Heidelberg: Springer-Verlag;2012.
43
Theoretical Concept
Ligament Support/PIP Joint Sprain
2
1
3
4
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Ligament Support: Tape pulls osseous
segments together (LCL ankle joint)
Method 1 Ankle
1. Cut an I strip ~1 inch long & 1 inch wide
2. Tear I strip in the middle
3. Place foot in plantar flexion
4. Lie the tape down with 50% to 100% stretch on
talofibular ligament
5. Lie ends down with no tension
Kumbrink B, K Taping: An illustrated Guide. Berlin Heidelberg: Springer-Verlag;2012.
Moving Towards Function/Marik
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PTAPTM_1275
Theoretical Concept
Ligament Support/Talo-Fibular Joint
Sprain
Moving Towards Function/Marik
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THEORETICAL OBJECTIVES
• Functional Taping
GOAL:
1) Limit joint motion through sensory stimulation
provided from the tape
Kase K, Wallis J, Kase T. Clinical Therapeutic Applications of the KinesioTaping Method. Tokyo, Japan:Ken Ikai
Co. Ltd;2003.
.
Moving Towards Function/Marik
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Functional Tape: Tension on during
undesired motion and off during desired
motion.
Method 1 (limiting wrist extension):
– Cut a 6 inch I strip with two diamond shape holes at
one end of tape
– Place the index & long fingers through the holes to
apply tape on the volar surface
– Place the wrist in flexion
– Hold the base down with no tension
– Apply 50% to 100% tension in the middle making a
bridge. Move the wrist towards extension while
rubbing on the tape.
Kase K, Wallis J, Kase T. Clinical Therapeutic Applications of the KinesioTaping Method. Tokyo,
Japan:Ken Ikai Co. Ltd;2003.
Moving Towards Function/Marik
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PTAPTM_1275
Theoretical Concept
Functional Taping/Limit Wrist Flexion
Moving Towards Function/Marik
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Functional Tape: Tension on during
undesired motion and off during desired
motion.
Method 1 (limiting plantar flexion):
– Cut a 6 inch I strip with two diamond shape holes at
one end of tape
– Place the 2nd & 3rd toe through the holes to apply
tape on the volar surface
– Place the ankle in dorsiflexion
– Hold the base down with no tension
– Apply 50% to 100% tension in the middle making a
bridge. Move the ankle towards while rubbing on
the tape.
Kase K, Wallis J, Kase T. Clinical Therapeutic Applications of the KinesioTaping Method. Tokyo,
Japan:Ken Ikai Co. Ltd;2003.
Moving Towards Function/Marik
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Theoretical Concept
Functional Taping/Limit Plantar
Flexion
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PTAPTM_1275
THEORETICAL OBJECTIVES
• Hand Edema ReductionTaping for
Patient with Healthy Lympthatics
GOAL: Enhance vascular transport systems
by creating space between the skin and
subcutaneous tissue
–Space is created by lifting the skin
–Movement contributes to loosening of
connective tissue
–Tape channels the movement of the fluid
–Fluid moved to lower pressure area
MovingSpringer-Verlag;2012
Towards Function/Marik
Kumbrink B, K Taping: An illustrated Guide. Berlin Heidelberg:
52
Edema Tape for High Volume
Insufficiency following Trauma
Fan Tape Method
– The base is affixed to
promote flow towards
lymph nodes
– Place patient is a stretched
position
– Apply strips with 15% to
25% tension
Kumbrink B, K Taping: An illustrated Guide. Berlin
Moving Towards Function/Marik
Heidelberg: Springer-Verlag;2012
Retrieved from: http://www.lytnyc
.com/wp-content/uploads/2012/03/l
ymphatic-system-benefits-from-rebounding.
53
Edema Tape for High Volume
Insufficiency following Trauma
Fan Tape Hand Edema
– Affix base proximal medial
epicondyle
– Pt’s elbow extended and
wrist flexed
– Apply each strip with 15%
to 25% tension and affix
strips between digits
Kumbrink B, K Taping: An illustrated Guide. Berlin
Moving Towards Function/Marik
Heidelberg: Springer-Verlag;2012
Retrieved from: http://www.lytnyc
.com/wp-content/uploads/2012/03/l
ymphatic-system-benefits-from-rebounding.
54
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PTAPTM_1275
Direct Fans Towards Lymph Nodes
http://www.anatomyatlases.org/
AnatomicVariants/Cardiovascular/
Retrieved from: http://upload.wikimedia. Images0400/0455.gif
Moving Towards Function/Marik
org/wikipedia/commons/a/aa/Gray606.png
55
Theoretical Concept
Edema Reduction/Hand
Moving Towards Function/Marik
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WHAT YOU NEED TO KNOW!
EVIDENCE
EBM
Retrieved and adapted from: medresidents.stanford.edu/EBP.html on 10/13/08.
Adapted from: Sackett DL, Rosenberg MC, Gray JA, Haynes RB, Richardson WS. Evidence
based medicine: what it is and what it isn't. BMJ. 1996;312: 71-72.
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PTAPTM_1275
RIGID TAPE
HIGH EVIDENCE
Improved posture for patients with
shoulder impingement (Lewis et al
2005)
Upper Trapezius Inhibition for
patients with shoulder impingement
(Smith et al 2009)
Hemiplegic patients had increased
days without pain (Griffin et al 2006)
Moving Towards Function/Marik
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RIGID TAPE
MODERATE EVIDENCE
Delay onset of pain in hemiplegia
shoulder (Ancliff 1992)
Increase GH rotation in healthy
subjects (McIntosh 2009)
L.T. facilitation/U.T. inhibition in
shoulder impingement (Selkowitz et
al 2007)
Moving Towards Function/Marik
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RIGID TAPE
MINIMAL EVIDENCE
• Pain relief 3 weeks post injury in patient with
grade III AC ligament injury (Shammus &
Shammus, 1997)
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PTAPTM_1275
ELASTIC TAPE
HIGH EVIDENCE
MacDermid’s Quality Evaluation Rating:
• Immediate decreased pain with ROM, no
difference at 3 days in patients with impingement
(Thelan et al 2008)
• Increased scapular posterior tilt and L.T. facilitation
baseball players with impingement (Hsu et al
2009)
• Decreased pain at one week, no difference at two
weeks in impingement (Kaya et al 2010)
Moving Towards Function/Marik
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ELASTIC TAPE
HIGH EVIDENCE
MacDermid’s Quality Evaluation Rating:
• Gonzalez-Inglesias et al 2009 short
term pain relief with cervical taping
• Immediate increase with ROM and
pain reduction up to 24 hours
• Changes were small may not be
clinically meaningful
Moving Towards Function/Marik
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ELASTIC TAPE
MODERATE EVIDENCE
MacDermid’s Quality Evaluation Rating:
• Increase force sense, but no increase
with grip strength in healthy
individuals (Chang et al 2010)
• Increase grip strength (Lee et al 2010)
• No difference b/w groups treated
with standard decongestive
lymphatic therapy and pnuematic
pump with and without taping (Tsa
et al 2009)
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PTAPTM_1275
STUDIES NOT MAKING THE CUT
• Miller et al 2009 trend towards
pain relief at 2 wks, no difference
at 6 wks
• Shamus & Shamus 1997 AC joint
taping
• Grieg et al 2008 postural taping
for kyphosis
Moving Towards Function/Marik
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STUDIES NOT MAKING THE CUT
Low Evidence
• Muro et al 2009 case
report on treatment of
myofascial pain
• Karatas et al 2011
decreased neck and low
back pain in surgeons
Moving Towards Function/Marik
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STUDIES NOT MAKING THE CUT
• Schneider et al
improved wrist extensor
strength in tennis
athletes
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PTAPTM_1275
THE SHOULDER & POSTURE
•
•
•
•
•
•
•
•
•
•
Basic Anatomy
Shoulder Girdle Posture and Biomechanics
Lab: UE posture assessment, taping, exercise
Dynamic Stabilizers
Rotator Cuff/Impingement
• Taping and Exercise
Static Stabilizers
GH Instabilities/Arthropathy
Lab: Taping and Exercise
TOS taping
Review Hemiplegic Shoulder Taping
BONES OF THE SHOULDER GIRDLE
STATIC STABILIZERS
• CLAVICLE
Illustration from:
Terry G, Chopp
T. Functional
anatomy of the
shoulder. Jour
Athl Training,
2000;
35(3):248-255
• HUMERUS
• SCAPULA
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Joint Anatomy: 4 Articulations
Stabilizers
• Sternoclavicular
• Acromioclavicular
• Glenohumeral
• Scapulothoracic
Retrieved on 2/26/12 from:
http://upload.wikimedia.org/
wikipedia/commons/thumb/5/59/
Pectoral_girdles-en.svg/510pxMoving Towards Function/Marik
Pectoral_girdles-en.svg.png
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23
PTAPTM_1275
Shoulder Girdle Muscles
The Dynamic Stabilizers
• Scapulohumeral
• Axioscapular
• Axiohumeral
Illustrations:
http://upload.wikimedia.org/wikipedia/common
Moving Towards Function/Marik
s/8/8f/Gray412.png
70
SCAPULA POSTURE POSTERIOR LANDMARKS
• ACROMION
• SPINE OF SCAPULA
• LATERAL BORDER
• MEDIAL BORDER
Dorsal Scapula
• INFERIOR ANGLE
• SUPERIOR ANGLE
Retrieved and modified on 06/06/09 from:
http://www.courses.vcu.edu/
DANC291-003/scapula_landmarks.jpg
Moving Towards Funnction/Marik
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Anterior Landmarks
• Coracoid process
• Acromion process
• Superior angle
• Medial border
• Lateral border
• Inferior angle
Retrieved from:
http://upload.wikimedia.org/wikipe
dia/commons/4/41/Gray202.png
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PTAPTM_1275
Alignment of the Scapula
• Vertical Medial Border
• Medial Border ~2 to 3
inches from the spine
• Position between
~T2 and T7
Dorsal Scapula
• Spine of Scapula at ~T4
Retrieved and modified
06/06/09 from:
http://www.courses.vcu.edu/
DANC291003/scapula_landmarks.jpg
• 20 to 30 Degree Anterior Tilt
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Sahrmann 2002
• Glenoid fossa shallow
and slightly concave.
• Oriented anteverted
and upwards facing.
Retrieved on 4/11/10 from:
http://www.actaortho.gr/v57t3/U1.jpg
Freidman et al 1992
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Moving Towards Function/Marik
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PTAPTM_1275
Glenohumeral Alignment
• Glenohumeral head should be < 1/3 anterior
to acromion
• Neutral rotation
• Proximal and distal humerus are vertical
Moving Towards Function/Marik
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Changing Posture Has Effect on
Shoulder ROM
• Lewis J, Wright C, Green A.
Subacromial Impingement
Syndrome: The effect of changing
posture on shoulder range of
motion. J Orthop Sports Phys
Ther,2005;35:72-87.
• Kyphosis associated with decreased
subacromial space (Gumina et al
2008)
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POSTURE SPINAL ALIGNMENT
• CERVICAL: SLIGHTLY
CONVEX CURVE ANTERIOR
• THORACIC: SLIGHTLY
CONVEX CURVE
POSTERIOR
• LUMBAR: SLIGHTLY
CONVEX CURVE ANTERIOR
Retrieved from: http://upload.
wikimedia.org/wikipedia/commons/
f/f8/Illu_vertebral_column.jpg
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PTAPTM_1275
POSTURE PELVIS ALIGNMENT
Is anterior superior illiac
spine (ASIS) postured in:
• Neutral
• Anterior
• Posterior
Retrieved from: http://upload.wikimedia.org/
wikipedia/commons/3/32/Gray435.png
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Posture Lab/Assess Your Partner’s
Posture
Assessment form located in the back of
manual
• Assess your partner. Where is scapula
positioned?
• Where is glenohumeral joint positioned?
Moving Towards Function/Marik
80
POSTURE PELVIS ALIGNMENT
• Anterior Pelvis Tilt
– Hip flexors shorten and
hip extensors lengthen
Retrieved from: http://upload.wikimedia.org/wikipedia/
commons/thumb/e/e2/Anterior_Hip_Muscles_2.PNG/400
Anterior_Hip_Muscles_2.PNG
Moving Towards Function/Marik
81
27
PTAPTM_1275
POSTURE PELVIS ALIGNMENT
• Posterior Pelvis Tilt
– Hip flexors lengthen and
hip extensors shorten
Retrieved from: http://upload.wikimedia.org/wikipedia/
commons/thumb/e/e2/Anterior_Hip_Muscles_2.PNG/400
Anterior_Hip_Muscles_2.PNG
Moving Towards Function/Marik
82
Abdominal/Pelvis & Pect. Minor
Connection
Retrieved on 06/09/09 from:
http://www.midlandstech.com/
Retrieved on 06/09/09 from:
science/kelleherk/210/Images/
Moving Towards Function/Marik
83
http://dic.academic.ru/dic.nsf/
PracticeQuiz/muscles2.jpg
enwiki/1085537
KINEMATIC CONNECTION
BETWEEN SHOULDER
GIRDLE AND ANTERIOR PELVIS
Short external obliques,serratus
anterior, and pectoralis major
could contribute to anterior
pelvis tilt.
Retrieved from: http://upload.wikimedia.
org/wikipedia/commons/thumb/5/55/Serratus_
anterior_muscle_2.jpg/800pxMoving Towards Function/Marik
Serratus_anterior_muscle_2.jpg
84
28
PTAPTM_1275
KINEMATIC CONNECTION BETWEEN
SHOULDER
GIRDLE AND POSTERIOR PELVIS
org/wikipedia/com
mons/thumb/5/55/S
erratus_
anterior_muscle_2.j
pg/800pxSerratus_
anterior_muscle_2.j
pg
• Tight rectus could contribute too posterior
pelvis tilt.
Tight pectoralis minor likely contributing to
scapula anterior tilt.
Moving Towards Function/Marik
1.
85
Posture Taping
Changing Posture May Effect Shoulder
ROM
Ask patient to extend their
thoracic spine.
2. Place protective tape from T1
to T7 followed by strap tape.
3. Ask patient to retract and
depress their scapula.
4. Apply protective tape followed
by strap tape from middle of
the scapula spine to T12
diagonally towards spine.
Moving Towards Function/Marik
Lewis et al 2005
86
org/wikipedia/commons/thumb/5/
5/Serratus_anterior_muscle_
2.jpg/800px-Serratus_anterior_
muscle_2.jpg
Stretch Quadratus
Lumborum in
the laterally flexed hip.
• Supine with ankles dorsiflexed.
• Pelvis stabile.
• Reach from waist to opposite side keeping
the pelvis stabile.
Moving Towards Function/Marik
87
29
PTAPTM_1275
MORE
POSTURE TAPING
Posture Taping for Kyphosis
T6
Greig et al 2008
Moving Towards Function/Marik
89
Posture Taping for Kyphosis
1. Ask the patient to elongate their crown of the
head towards the ceiling and draw the shoulder
blades down and together.
2. Apply protective tape from each anterior acromion
over the trapezius moving diagonally to T6. Tape
crosses at T6.
3. Firmly apply the rigid tape to the anterior AC joint
and follow tape to T6.
4. Apply bilaterally.
Moving Towards Function/Marik
90
30
PTAPTM_1275
Extension Over The Chair
1. Sit tall with the top of back rest ending at the level of
the mid back.
2. Hands behind your neck and gently arch back in the
chair.
3. Keep cervical spine in neutral (avoid extension).
4. Keep pelvis stable. Should not feel movement at
lumbar spine.
Moving Towards Function/Marik
91
Posture Exercise
Thoracic Extension
1. Tighten core and activate transversus Photo retrieved from”
http://upload.wikimedia.org
abdominis. Pelvis neutral and stabile. /
wikipedia/commons/3/32/Ill
u_trunk_muscles.jpg
2. Inhale prepare
3. Exhale push up from mat with cervical spine
in neutral. Should not feel any tension in LB.
4. Inhale and return to neutral.
Moving Towards Function/Marik
92
Moving Towards Function/Marik
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31
PTAPTM_1275
Moving Towards Function/Marik
94
FORWARD HEAD POSTURE
• POSSIBLE SHORT SCALENES, LEVATOR SCAPULA,
AND/OR UPPER TRAPEZIUS.
• STRETCH TIGHT MUSCLE AND TEACH GENTLE
NODS.
Retrieved from: http://upload.wikimedia.org/wikipedia/commons/6/6e/Scalenus.png
Moving Towards Function/Marik
95
1. Stand, holding hand behind back.
2. Lower left shoulder, then tilt your head to the
right.
3. Slowly roll head backwards until a stretch is
felt. Hold for 10-15 seconds.
4. Repeat for other side.
5. Repeat cycle three times, at least three times
daily.
Retrieved on 3/29/10http://img.medscape.com/pi/emed/
Moving Towards Function/Marik
ckb/rehabilitation/305143-316715-29.jpg
Scalene Stretch
96
32
PTAPTM_1275
Role of Dynamic Stabilizers
SHOULDER GIRDLE
BIOMECHANICS
Motions of the scapula, humerus,
& clavicle
Ludewig et al (2009). Motion of the Shoulder
Complex during Multiplanar Humeral Elevation. Jour
Bone & Joint Surg, 91:378-89
3 Dimensional Motions of Scapula
Upward
Rotation
Posterior
Tilt
From Int.
Rot.
Towards
Ext. Rot.
Retrieved on
06/3/12:http://nicktumminello.com/wpcontent/uploads/2010/07/F1.large_Moving Tows Function/Marik
98
300x220.jpg
3 Dimensional Motions of Scapula
Upward
Rotation
Posterior
Tilt
From Int.
Rot.
Towards
Ext. Rot.
Retrieved on 06/07/09:
http://www.flzine.com/wpcontent/uploads/2009/03/rotator.gif
Moving Towards Function/Marik
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33
PTAPTM_1275
Upper Trapezius and
Serratus Anterior
provide
rotatory force early
needed for
Upward Rotation.
Upper Trapezius
limiting scapular
internal rotation.
Picture adapted from:
Donatelli, R. (1997).
Moving Towards Function/Marik
Picture adapted from: Donatelli, R.
(1997).
100
•Serratus Anterior
provide
force for upward
rotation & post
tilt.
•Lower/Middle
Trapezius pulls
inferior for ER.
•UT limits scap IR
•Trapezius
contributes to
post tilt
Moving Towards Function/Marik
101
Motions of the Glenohumeral Joint
Retrieved on 08/02/09
from:
http://www.bosshin.com/
_userfiles/image/winging
%20and%20instability.jpg
• Head of humerus moves superior in the glenoid.
Rolls and spins ~2 mm to stay centered in the
glenoid fossa. Moves towards external rotation.
Donatelli, R. (1997). Physical
of shoulder. Philadelphia, PA:102
MovingTherapy
Towards Function/Marik
Churchill Livingston.
34
PTAPTM_1275
Anterior and Posterior Balance Forces Needed
to Keep the Glenohumeral Joint Centered
Phase I: 0.7 to
2.7mm of anterior
translation.
Phase II: 0-1.5mm
of posterior
translation.
Phase III: 4.5mm
posterior
translation.
Retrieved on 6/3/12 from:
http://upload.wikimedia.org/wikipedia/commons/9/
90/Shoulderjoint.PNG Moving Towards Function/Marik
Ludewig & Cook, 2002.
103
CLAVICLE MOTION
Sternoclavicular Joint
Relative to Thorax
Retraction
15 Degrees
Elevation
>10 degrees
Retrieved on 06/07/09
from:http://images.goo
gle.com/imgres?imgurl
=http://moon.ouhsc.
Posterior
Rotation
30 Degrees
Moving Towards Function/Marik
104
SCAPULAR MOTION
Relative to the
Acromio-clavicular Joint
– SCAPULAR UPWARD ROTATION = SC elevation
and posterior rotation with AC upward rotation
– POSTERIOR TILT = SC elevation & post rot couples
with AC posterior rotation
– EXTERNAL ROTATION = SC retraction couples with
AC internal rotation
Illustration from: Ludewig P, Braman
J. Shoulder impingement: Biomechanical105
Moving Towards Function/Marik
considerations in rehabilitation. Manual Ther, 2011;16:33-39
35
PTAPTM_1275
Rotator Cuff
Tendinopathy/Impingement
OUCH!
Retrieved on 6/3/12 from:
http://upload.wikimedia.org/wikipedia/
commons/d/d3/MRI._Subacromial_impi
ngement..jpg
Moving Towards Function/Marik
106
Pain Localization
• Rotator cuff tendinopathy referred
pain at anterior lateral arm and night
pain
• Acromioclavicular arthritis or AC
injury pain at superior anterior
shoulder
• Radiculopathy presents as medial
scapular pain and/or parathesia
below the elbow
Moving Towards Function/Marik
107
Changes to the Relationship of the Humerus and
Scapula
• Primary Impingement
• Secondary Impingement
• Posterior Impingement(internal or undersurface)
• Anterior Impingement
• Coracoid Impingement Syndrome
Moving Towards Function/Marik
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36
PTAPTM_1275
Hawkins & Kennedy Test
Scapular Plane
Position of test for impingement against
the coracoacromial arch forcing rotator
cuff tendons under arch
Moving Towards Function/Marik
and against coracoid process.
109
Hawkins & Kennedy Test
Patient Position:
90 degree flexion in scapular plane.
Examiner:
Examiner’s hand on patient’s elbow while other hand
applies overpressure towards IR.
Positive Test:
Pain at anterosuperior shoulder.
Moving Towards Function/Marik
110
Palpate Supraspinatus Tendon
Retrieved on 6/20/10
from:http://www.thefreelibrary.com/
Optimal+methods+for+shoulder+tendon+palpation
:
+a+cadaver+study-a018061609
Moving Towards Function/Marik
Image retrieved on
9/17/11 from:
http://t2.gstatic.com/ima
?q=tbn:ANd9GcQOmUSo
V2iYOXqf0YxxoUYT4ikh
v0vrAOg2TVHd9TYloV9fC
111
37
PTAPTM_1275
Palpation of Subscapularis Tendon
Illustration from: Mattingly
Mackeray. Optimal
Moving Towards&
Function/Marik
112
Method for Shoulder Tendon Palpation. Phy Ther, 1996; 76(2):167-
Palpate Infraspinatus Tendon
Illustration from Mattingly &
Mackeray, Phy Ther, 1996; 76(2):167-174.
Retrieved on 9/17/11 from:
http://t1.gstatic.com/images?q=tbn:ANd9GcR
96vynm9uTd8IYbJTFwHihOQhxpONZNybXZjhq
0EaTsLSkiVtW
Moving Towards Function/Marik
113
Hung C, Jan M, Lin Y, Wang T, Lin J.
Scapular kinematics and impairment
features for classifying patients with
subacromial impingement syndromes.
Manual Ther, 2010;15:547-551.
Prediction Variables for Impingement
Moving Towards Function/Marik
114
38
PTAPTM_1275
EVIDENCE
• Ludewig, P., Cook, T. (2000). Alterations in
Shoulder Kinematics and Associated Muscle
Activity in People with Symptoms of Shoulder
Impingement. Physical Therapy, V 80, 3, 276291
Retrieved on 03/20/09 from
http://images.google.com/
Moving Towards
Function/Marik
images?hl=en&q=sheet+
metal+workers&btnG
115
EVIDENCE
• Ludewig, P., Cook, T. (2002). Translations of
the Humerus in Persons with Shoulder
Impingement Symptoms. Jour Ortho & Sports
Phys Ther, 32 (6), 248-259.
Retrieved on 05/30/09 from
Moving Towards Function/Marik
http://www.rehab.research.va.gov/jour/03/4
0/4/mcmahonf04.gif
116
Biomechanic Mechanisms
Mechanism
Inadequate Serratus
Activation
Excessive Upper Trapezius
Recruitment
RTC inadequate
Posterior Capsule Tight
Effect
Ludewig & Reynolds, 2009
• Decreased upward
rotation/posterior tilt
• Increased clavicle
elevation & decreased
posterior tilt
• GH not centering
• Increased scapula anterior
tilt, humerus translation
ant or sup
• Humeral and/or scapula IR
Pect Major and/or Pect
Minor Tightness
Moving Towards Function/Marik
117
39
PTAPTM_1275
THERAPEUTIC GOALS
1. Decrease clavicle elevation & scapula posterior tilt
– Inhibit Upper Trapezius activity & SA recruitment
2. Increase upward rotation/posterior tilt
– Facilitate Serratus Anterior and Lower Trapezius
3. GH not centering
– Improve extensibility of capsule & cuff
– Improve strengthMoving
of Towards
rotator
cuff
Function/Marik
118
THERAPEUTIC GOALS
4. Decrease humerus translation anterior or
superior
– Increase extensibility posterior capsule/cuff
5. Humeral and/or scapula IR
Increase extensibility of pectoralis minor &
thoracohumeral muscles (pect major/lat dorsi)
Moving Towards Function/Marik
119
TAPING
AND
EXERCISE LAB
Moving Towards Function/Marik
120
40
PTAPTM_1275
Goal #1: Decrease clavicle elevation & posterior
tilt
-Inhibit Upper Trapezius activity & SA recruitment
Goal #2: Increase upward rotation/posterior tilt
-Facilitate Serratus Anterior and Lower Trapezius
•
•
•
•
•
Rigid Tape for Impingement: UT Inhibit
Elastic Tape for UT Inhibition
Lower Trapezius (LT) Exercises
Serratus Anterior (SA) Facilitory Taping
SA Exercises
Moving Towards Function/Marik
121
Rigid Tape for Impingement:
UT Inhibit
1. Apply protective tape over the
skin
2. The base is placed at the
ant/medial clavicle and extends
posterior in a caudal direction
towards paraspinal region just
proximal to LT origin.
3. Apply rigid tape on top with
compression over the UT.
•
SELKOWITZ 2007
Moving Towards Function/Marik
122
Elastic Tape:
UT Inhibition for Impingement
1. Cut a Y strip ~8-9 inches
2. Place the base at acromion
with pt positioned in
contralateral side flexion.
3. Envelop UT with tape tails
& light stretch. Tails lie
down without tension.
4. Some authors recommend
up to 50% tension, Hsu
studied described no
tension.
(Hsu et al 2008)
Moving Towards Function/Marik
123
41
PTAPTM_1275
Lower Trapezius Facilitation
• Cut an I piece from ~T12
to acromion.
• Place patient’s arm in
horizontal abduction.
• Apply base with no
tension in region of T12.
• With 0% to 50% tension
apply tape towards
acromion.
• No tension at tail.
Moving Towards Function/Marik
124
Option Elastic Tape:
LT Facilitation for Impingement
1. Cut a Y strip ~8-9 inches
2. Place the base at acromion
(per Hsu study).
3. Envelop the muscle with
light stretch. Bring tails to
~T12. Apply the tails with
minimal tension.
4. Some authors recommend
up to 50% tension, Hsu
studied described no
tension.
Pt in Horz Abd
(Hsu et al 2008)
Moving Towards Function/Marik
125
EXERCISE GOAL
• FACILITATE LOWER TRAPEZIUS
• FACILITATE SERRATUS ANTERIOR
• INHIBIT UPPER TRAPEZIUS
• Goal #1: Decrease clavicle elevation & increase
posterior tilt
-Inhibit Upper Trapezius activity & SA recruitment
Goal #2: Increase upward rotation/posterior tilt
-Facilitate Serratus Anterior and Lower Trapezius
Moving Towards Function/Marik
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42
PTAPTM_1275
Perform Exercises after Taping
Phase I: Lower Trapezius Exercises
Small lift from the pillow and pull the inferior border
of the scapula towards the spine. Hold contraction
6 seconds.
Moving Towards Function/Marik
127
Phase II For Lower Trapezius
Emphasis on adduction combined with
depression
when working on scapula force couple.
Moving Towards Function/Marik
128
Phase III: Lower Trapezius
Patient is supine with arms in external rotation.
Patient lifts his arms to approximately 125°
horizontal abduction. Instruct the patient to hold
arms at shoulder level while sliding the scapula
down (towards back pocket).
De Mey et al 2009
Moving Towards Function/Marik
129
43
PTAPTM_1275
SERRATUS ANTERIOR FACILITATION
TAPING FACILITATE SERRATUS
1. Apply tape I strip anchoring
at the upper 6,7,8,9 ribs.
2. Follow the tape up to medial
border of the scapula with up
to 50% tension.
3. Rub to activate glue.
Photo retrieved from: http://
openphysio.co.za/images/
thumb/5/5d/Levator_
scapulae.jpg/150px-Levator
_scapulae.jpg
Moving Towards Function/Marik
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Serratus Anterior Facilitation
Moving Towards Function/Marik
131
Phase I: Serratus Anterior
Inferior Glide: Arm is scaption to 90°, wrist neutral,
elbow extended, fist clenched on a supportive
surface. Patient applies pressure towards
adduction and inferiorly depressing the scapula.
Hold 6 seconds. Ekstrom et al 2003.
Moving Towards Function/Marik
132
44
PTAPTM_1275
Phase II: Serratus Anterior
Wall Slides:
• Ulnar side of forearm
pushes into the wall as
patient slides up the
wall. Relax on the way
down.
• One foot forward and
one foot back.
• Engage core.
Suenaga et al 2003
Moving Towards Function/Marik
133
Phase III: Serratus Anterior
Dynamic Hug: Horizontal flexion of humerus at 60°
elevation. The hands follow an imaginary arcc until
maximum protraction is attained.
Decker et al, 2003
Moving Towards Function/Marik
134
Phase IV: Serratus Anterior
Push-Up Plus: Patient performs a standard push up
followed by a protraction.
Can start push-ups on the wall, progress to knee pushups.
Moving Towards Function/Marik
135
45
PTAPTM_1275
Goal #3: Center GH in Glenoid
-Improve extensibility of capsule & cuff
-Improve strength of rotator cuff
Goal #4: Decrease humerus translation anterior
or superior
-Increase extensibility posterior capsule/cuff
• Tape to decrease/feedback to decrease anterior
translation of humeral head
• Mobilize and stretch tight muscles and capsule
Moving Towards Function/Marik
136
Elastic Tape to Decrease GH Anterior
Translation
Pt’s GH joint
in neutral
rotation.
1. Cut an I strip to wrap ant/posterior humeral head.
2. Tear the tape in the middle.
3. Apply tape with 50% to 75% tension on the anterior
humeral head.
4. Lie tails down without tension.
Moving Towards Function/Marik
137
Stretching Posture Capsule
• Stabilize the lateral
border of the scapula
with the heal of one
hand.
• Apply overpressure
towards horizontal
adduction while
stabilizing the scapula.
Moving Towards Function/Marik
138
46
PTAPTM_1275
Taping and Exercise Lab:
Posterior Capsule Stretching
MOBILIZE GH JOINT
• POSTERIOR CAPSULE/CUFF STRETCHING
Moving Towards Function/Marik
139
Goal #5 :Humeral and/or scapula IR
-Increase extensibility of pectoralis minor &
thoracohumeral muscles
• Stretch Tight Muscles
– Stretch Pectoralis Minor
– Stretch Pectoralis Major
– Stretch Latissimus Dorsi
Consider Kinetic Chain
Photos retrieved from:
from:http://images.google.com/imgres
?imgurl=http://upload.wikimedia.org/wikipedi
Moving Towards Function/Marik
140
Taping for Tight Pectoralis Major
Inhibit Pectoralis Major:
1. Measure I strip from
intertubercle groove to
sternum with abd/ER(90/90).
2. Apply the base at the
intertubercle groove.
3. Lie one tail down along the
clavicle and the other tail on
sternocostal head with light
tension while the patient is
in 90/90 position.
Photo retrieved from:
Moving Towards
Function/Marik
: http://openphysio.co.za/images/
141
thumb/5/5d/Levator_scapulae.jpg/150px-
47
PTAPTM_1275
Possible Muscle Imbalances
Anterior
Tilt
Anterior tilted scapula
– Tight pectoralis minor?
– Does the inferior angle of the scapula protrude
from the thorax?
– Is there an asymmetry between the posterior
acromions when patient is supine
Moving Towards Function/Marik
142
Taping for Scapular Anterior Tilt
Inhibit Pectoralis Minor:
1. Cut a Y strip measure
from coracoid process to
rib 3, 4, & 5.
2. Patient pulls his scapulae
together and down.
3. Place the base at the
coracoid process.
4. Place each tails down
with light tension.
Photo retrieved from:
: http://openphysio.co.za/images/
thumb/5/5d/Levator_scapulae.jpg
/150px-Levator_scapulae.jpg
Moving Towards Function/Marik
143
Evidence for Pectoralis Minor
Stretching
1
2
2
Unilateral Self Stretch
3
Borstad, J., Ludwig,P. (2006). Comparison
of three
stretches for the pectoralis minor muscle.
Moving Towards
Function/Marik
144
J Shoulder & Elbow Surgery, 15:324-330.
48
PTAPTM_1275
PECT. MINOR STRETCHING & MANUAL
TECHNIQUES FOLLOW WITH TAPING
1. Stabilize pect minor at the coracoid process in a loose
position with arm adducted to the side.
2. Bring the arm to ~140° horizontal abduction. The arm
should be parallel to the table without extending the GH
joint below the table.
Technique retrieved from: http://www.mikereinold.com/wp-content/uploads/blogger/12Moving Towards Function/Marik
image%5B64%5D.png
145
IMPINGEMENT
TAPING
Moving Towards Function/Marik
146
Immediate Pain Relief for Pain Free Abd
STEP 1
1. Cut a Y strip the length
of supraspinatus from
origin to insertion.
2. Pt side bends cervical
spine to opposite side
and involved hand
internally rotated
behind the back.
3. Apply base with no
tension.
4. Apply tails to surround
supraspinatus.
Thelan et al 2008
Moving Towards Function/Marik
147
49
PTAPTM_1275
Immediate Pain Relief for Pain Free Abd
Step
1. Cut a Y piece from deltoid
insertion to origin.
2. Place base of Y strip at
deltoid insertion.
3. Place patient external
rotation with the shoulder
abducted to 90°
4. Anterior tail is applied to
anterior deltoid with light
tension.
Thelan et al 2008
Moving Towards Function/Marik
148
Immediate Pain Relief for Pain Free Abd
Step 3
1. Place patient in internal
rotation and slight
horizontal abduction.
2. Posterior tail is applied to
posterior deltoid with
light tension. with the
patient in horiz. Abd and
internal rotation.
Thelan et al 2008
Moving Towards Function/Marik
149
Immediate Pain Relief for Pain Free Abd
Step 4
1. Cut an I tail measuring from
coracoid process to scapula.
2. Apply the base of tape at the
coracoid process.
3. Hold base down.
4. Apply tape with ~75% tension with
downward pressure around the
head of the humerus.
5. Patient actively flexes the shoulder
with slight IR while tape is being
applied.
Towards Function/Marik
Thelan Moving
et al 2008
150
50
PTAPTM_1275
Rigid Taping for Impingement Pain
Relief
• 1st strap anchored over
anterior deltoid and extends
posterior along spine of
scapula.
• 2nd strap anchored at corocoid
process and extends posterior
and inferomedially over
scapula to imitate the line of
pull of LT
Miller et al 2009
Moving Towards Function/Marik
151
Taping to Increase GH Rotation
Secondary Impingement and/or
Posterior Impingement?
1. Apply protective piece at
anterior humeral head.
2. Pass tape over and lateral
to the acromion process.
3. Finish tape at the inferior
angle of the scapula.
4. Rigid tape is applied over
the protective piece
tension over the head of
the humerus.
Moving Towards Function/Marik
152
Long Head of Biceps Taping
Step 1
1. Cut a Y strip from cubital
fossa to glenoid fossa.
2. Patient’s elbow is
extended.
3. Apply the base of the strip
at the radial head with no
tension.
4. Apply each tail with paper
off tension surrounding the
bicep muscle.
Moving Towards Function/Marik
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51
PTAPTM_1275
Long Head of Biceps Taping
Step 2
1. Cut a Y strip from the pain
point to lateral shoulder.
2. Patient’s shoulder is
extended.
3. Apply the base to the pain
point without tension.
4. Apply the tails with 25%
tension in the transverse
direction.
Moving Towards Function/Marik
154
CONTRIBUTIONS OF GH
STATIC STABILIZERS
Moving Towards Function/Marik
155
GLENOHUMERAL STABILIZERS
STATIC
DYNAMIC
• Geometry of GH joint
• Muscles
– Scapular Stabilizers
• Glenoid Labrum
– Rotator Cuff Muscles
• Negative intra-articular
– Long head of the
pressures
biceps
• Ligaments/Capsule
Finnoff J, Doucette S, Hicken G. Glenohumeral instability and dislocation. Phys
Moving2004;15:575-605.
Towards Function/Marik
156
Med and Rebab Clinics of N Amer,
52
PTAPTM_1275
Static Stabilizers
1. Bone Congruency/Geometry of Glenohumeral
Joint
Retr:
• Humeral head to shaft
angle 130° to 150°
• Retroverted 30°
Contributes to posterior
inferior stability.
Illustration: http://upload.wikimedia.org/
wikipedia/commons/thumb/0/04/Leonardo_da
_Vinci_-_Anatomical_studies_of_the_
shoulder_-_WGA12824.jpg/421px-Leonardo
_da_Vinci_-_Anatomical_studies_of_the_shoulder_-_WGA12824.jpg
Moving Towards Function/Marik
157
Static Stabilizers
2. Glenoid Labrum
Fibrocartilaninous Structure
• ^ depth of glenoid
fossa by 50%
• Provides attachment of
GH ligaments
• Firmly attached in all
regions except loosely
superiorly
Illustration retrieved from”
http://www.sportsinjuryclinic.net/
gallery/shoulder/glenoid_labrum2.jpg
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Static Stabilizers
3. Negative intra-articular pressures
4. Negative Intra-articular Pressure
• Creates a vacuum effect across GH joint
• Primary stabilizer against inferior instability
• Also prevents instability in other directions
Illustration retrieved on 2/26/12 from:
Moving Towards Function/Marik
http://www.shoulderdoc.co.uk/images/uploaded/labrum_depth.jpg
159
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PTAPTM_1275
Static Stabilizer
4.Capsule & Ligaments
• Superior
• Middle
• Inferior
• Coracohumeral
Illustrations:
http://upload.wikimedia.org/wikipe
dia/commons/3/3b/Gray326.png
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Capsule Instabilities
LH BICEPS
SGHL
Posterior
Capsule
MGHL
ANT. BAND
IGHL
IGHL
Post. Band
IGHL
CAPSULE
Retrieved and modified on 7-4-10 from:
http://www.eorif.com/Shoulderarm/Shoulder%20anat/Images
Moving Towards Function/Marik
/Shoulder-ligaments.jpg
Download from
website
161
ANTERIOR INSTABILITY
Picture retrieved from: http://upload.wikimedia.org/wikipedia/commons/3/3b/Gray326.png
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Stabilizers Against Anterior Dislocation
• Humerus adducted: Subscapularis
• Humerus abducted 45°: Subscapularis, Middle
anterior GH Ligament, and Superior portion of
Inferior Anterior GH Ligament
• Humerus at 90° abduction: Inferior Anterior GH
Ligament
Retrieved from: http://www.radsource.
us/_images/0909_6.jpg
Moving Towards Function/Marik
Turkel et al 1981
Illustration retrieved on 3/5/12 from
http://www.acta-ortho.gr/v57t3/U5.jpg
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164
Anterior Instability
• Instability of the anteriorinferior glenohumeral
joint capsule.
OR
• Detachment of the
http://images.conquestchronicles.
com/images/admin/shoulder_bankart_lesion_85905_2.jpg
anterior-inferior glenoid
labrum from the glenoid
rim.
Illustrationfrom:http://www.bosshin.com/_
userfiles/image/normal%20hammock.jpg
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PTAPTM_1275
Apply an antero-medial glide to humeral
head
0 to 30 degrees
Ant/Sup Capsule
45 to 60 degrees
Ant/Middle
Capsule
90 degrees
Ant/Middle Capsule
Moving Towards Function/Marik
• Acute
166
Frequency
– Acute injury resulting in
subluxation or dislocation
– TUBS: traumatic, unilateral,
bankart
• 98% of cases dislocate anteriorly, 2%
posterior
• Chronic
– Repetitive instability episodes
– AMBRI: atraumatic,
multidirectional, bilateral,
rehabilitation, inferior shift
Moving Towards Function/Marik
Illustration retrieved from:
http://www.theshouldercenter.com
/images/RecurrentInstabilityGrap
h.JPG
Illustration retrieved from:
http://images.conquestchronicles.com/i
167
mages/admin/shoulder_bankart_lesion
85905 2.jpg
SECONDARY IMPINGEMENT
Retrieved on 4/4/09 from:
http://www.baseballmusings
.com/archives/JeterThrow5150361
_Yankees_v_Royals.jpg
Impingement related to an anterior
instability.
Andrews & Alexander, 1995.
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PTAPTM_1275
LAB: TAPING FOR ANTERIOR
INSTABILITY
• Tape is applied to anterior
humeral head.
• Pull tape diagonally across
the scapula.
• End the tape medial to the
inferior border of the
scapula.
Finn off J, Doucette S, Chicken G.
Moving Towards Function/Marik
Glenohumeral instability and dislocation. Phys Med
and Reba Clinics of N Amer 2004;15:575-605
•
169
Instability Superior Labrum AnteriorPosterior
SLAP
Etiology: Fall on an
outstretched abducted arm
or sudden contraction of
biceps tendon or repetitive
stress.
• Symptoms:
– Painful popping,
clicking, or catching
– Pain when moving arm
overhead
Illustration retrieved on 3/5/12 from:
from:http://www.athleticadvisor.com/
images/shoulder/SLAP/SLAP_types2.gif
Illustration from:
http://www.ptclinic.com/medlibrary/
images/v2/slapbankart.gif
Moving Towards
Function/Marik
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SLAP:Superior Labrum Anterior Posterior
• Type I/Fraying
• Type II/Biceps & Labrum are
becoming detached
• Type III/Biceps & Labrum are
stable on glenoid, but a flap
hangs down
• Type IV/Bucket handle tear
extending into the biceps
Moving Towards Function/Marik
Retrieved on 7-4-10
from:http://www.athleticadvisor.com/
images/shoulder/SLAP/SLAP_types2.gif
171
57
PTAPTM_1275
Peel Back Mechanism in Throwing
Athletes
Retrieved from: http://2.bp.blogspot.com/_
BsgqbRhgCnQ/SRtejHI0PvI/AAAAAAAAANA/
vMjopqYdgrs/s400/SLAP-peel-back.jpg
Retrieved from: Braun S, Kokmeyer D, Millett P.
Current Concepts Review: Shoulder Injuries in the
Throwing Athlete. Jour Bone & Jt Surg, 2009;91(4):
• High eccentric activity of the biceps during
arm deceleration.
• Torsional peel back force detaching labral
anchor.
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Lab: Taping to Improve IR for Individuals with
Humeral Head Anterior Translation (2 strips)
Mc Intosh 2009
1. Apply two protective
pieces of tape from
anterior aspect of
humeral head.
2. Apply tape passing
over and lateral to the
acromion and finish at
inferior angle of the
scapula.
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Elastic Tape to Decrease GH Anterior
Translation
Pt’s GH joint
in neutral
rotation.
1. Cut an I strip to wrap ant/posterior humeral head.
2. Tear the tape in the middle.
3. Apply tape with 50% to 75% tension on the anterior
humeral head.
4. Lie tails down without tension.
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58
PTAPTM_1275
Taping and Exercise Lab:
Posterior Capsule Stretching
MOBILIZE GH JOINT
• POSTERIOR CAPSULE/CUFF STRETCHING
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LATE PHASE
• ISOTONIC RTC & SCAPULAR STABILIZATION
EXERCISES
10/10 (ER/ABD) to 45/45 TO 90/90
POSITION
RTC STRENGTHENING
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Proprioception Training
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