“How I examine the overhead athlete….”

A clinical reasoning algorithm

Ann M. Cools, PT, PhDGhent UniversityDept of Rehabilitation Sciences & PhysiotherapyBelgium

Shoulder pathology?

� Impingement (SA & int)

(Anderson Radiol Clin North Am 2010, Lintner Clin Sports Med 2008, Seroyer Sports Health 2009 , Reeser BJSM 2006, Briner Sports Med 1997)

Ann Cools Wrightington nov 2012

Shoulder impingement

Impingement of soft tissue (tendon) between bony components

External

(Subacromial)

Impingement

(Neer 1972)Ann Cools Wrightington nov 2012

Shoulder impingement

Impingement of soft tissue (tendon) between bony components

Internal

(postero superior glenoid)

Impingement

(Walch 1990, Drakos JBJS 2009)Ann Cools Wrightington nov 2012

Shoulder pathology?

� Impingement

� Rotator cuff dysfunction,including suprascapularnerve entrapment

(Anderson Radiol Clin North Am 2010, Lintner Clin Sports Med 2008, Seroyer Sports Health 2009 , Reeser BJSM 2006, Briner Sports Med 1997)

Ann Cools Wrightington nov 2012

Shoulder pathology?

� Impingement

� Rotator cuff pathology

� Instability (traumatic & acquired)

(Anderson Radiol Clin North Am 2010, Lintner Clin Sports Med 2008, Seroyer Sports Health 2009 , Reeser BJSM 2006, Briner Sports Med 1997)

Ann Cools Wrightington nov 2012

Shoulder pathology?

� Impingement

� Rotator cuff pathology

� Instability

� SLAP lesions

(Anderson Radiol Clin North Am 2010, Lintner Clin Sports Med 2008, Seroyer Sports Health 2009 , Reeser BJSM 2006, Briner Sports Med 1997)

Ann Cools Wrightington nov 2012

Shoulder pathology?

� Impingement

� Rotator cuff pathology

� Instability

� SLAP lesions

� Scapular dyskinesis

(Anderson Radiol Clin North Am 2010, Lintner Clin Sports Med 2008, Seroyer Sports Health 2009 , Reeser BJSM 2006, Briner Sports Med 1997)

Ann Cools Wrightington nov 2012

Shoulder pathology?

� Impingement

� Rotator cuff pathology

� Instability

� SLAP lesions

� Scapular dyskinesis

� GIRD

(Anderson Radiol Clin North Am 2010, Lintner Clin Sports Med 2008, Seroyer Sports Health 2009 , Reeser BJSM 2006, Briner Sports Med 1997)

Ann Cools Wrightington nov 2012

Impingement symptoms

ExternalSubacromial impingement

Internal(posterior)

impingement

PrimaryImpingement

SecondaryImpingement

BicepsSLAP

Rotator cuffpathology

Scapular dyskinesis instability G.I.R.D.

(Cools et al. BJSM 2008)

Ann Cools Wrightington nov 2012

Impingement tests: Jobe, Hawkins, Neer

(Hegedus 2008)Ann Cools Wrightington nov 2012

Impingement symptoms

ExternalSubacromial impingement

Internal(posterior)

impingement

PrimaryImpingement

SecondaryImpingement

BicepsSLAP

Rotator cuffpathology

Scapular dyskinesis instability G.I.R.D.

Jobe +Neer + antHawkins +

Jobe –Neer + postHawkins –

(Cools et al. BJSM 2008)

Instability tests: Apprehension “Posterior ImpingementSign”– Relocation - Release

(Meister 2004)

Ann Cools Wrightington nov 2012

Impingement symptoms

ExternalSubacromial impingement

Internal(posterior)

impingement

PrimaryImpingement

SecondaryImpingement

BicepsSLAP

Rotator cuffpathology

Scapular dyskinesis instability G.I.R.D.

Relocation -Relocation+

Release +(pain)

Jobe +Neer + antHawkins +

Apprehension +(pain) ant

Jobe –Neer + postHawkins –Apprehension +(pain) post

Relocation+Release +(pain)

(Cools et al. BJSM 2008)

Rotator cuff tendinopathy?:Full can test

(Reinold et al. JOSPT 2009)

Ann Cools Wrightington nov 2012

Impingement symptoms

ExternalSubacromial impingement

Internal(posterior)

impingement

PrimaryImpingement

SecondaryImpingement

BicepsSLAP

Rotator cuffpathology

Scapular dyskinesis instability G.I.R.D.

Relocation -Relocation+

Release +(pain)

Jobe +Neer + antHawkins +

Apprehension +(pain) ant

Jobe –Neer + postHawkins –Apprehension +(pain) post

Relocation+Release +(pain)

Full Can +

(Cools et al. BJSM 2008)

Scapular involvement?Scap Ass Test – Scap Retr Test(Rabin et al. JOSPT 2006, Kibler et al. AJSM 2006, Tate et al. AJSM 2008)

Ann Cools Wrightington nov 2012

Impingement symptoms

ExternalSubacromial impingement

Internal(posterior)

impingement

PrimaryImpingement

SecondaryImpingement

BicepsSLAP

Rotator cuffpathology

Scapular dyskinesis instability G.I.R.D.

Relocation -Relocation+

Release +(pain)

Jobe +Neer + antHawkins +

Apprehension +(pain) ant

Jobe –Neer + postHawkins –Apprehension +(pain) post

Relocation+Release +(pain)

SAT +SRT +

Full Can +

(Cools et al. BJSM 2008)

Glenohumeral laxity?Load&shift, Sulcus, posterior subluxation test

Ann Cools Wrightington nov 2012

Glenohumeral laxity?Load&shift, Sulcus, posterior subluxation test

Ann Cools Wrightington nov 2012

Impingement symptoms

ExternalSubacromial impingement

Internal(posterior)

impingement

PrimaryImpingement

SecondaryImpingement

BicepsSLAP

Rotator cuffpathology

Scapular dyskinesis instability G.I.R.D.

Relocation -Relocation+

Release +(pain)

Jobe +Neer + antHawkins +

Apprehension +(pain) ant

Jobe –Neer + postHawkins –Apprehension +(pain) post

Relocation+Release +(pain)

Laxity tests +Appr + (appr)Relocation + (appr)

SAT +SRT +

Full Can +

(Cools et al. BJSM 2008)

Biceps pathology or SLAP?O’ Brien, Speed’s, Biceps Load II

(Hegedus et al. BJSM 2008, Oh et al. AJSM 2008)

Ann Cools Wrightington nov 2012

Impingement symptoms

ExternalSubacromial impingement

Internal(posterior)

impingement

PrimaryImpingement

SecondaryImpingement

BicepsSLAP

Rotator cuffpathology

Scapular dyskinesis instability G.I.R.D.

Relocation -Relocation+

Release +(pain)

Jobe +Neer + antHawkins +

Apprehension +(pain) ant

Jobe –Neer + postHawkins –Apprehension +(pain) post

Relocation+Release +(pain)

O’Brien+Speeds+Biceps load II+

Laxity tests +Appr + (appr)Relocation + (appr)

SAT +SRT +

Full Can +

(Cools et al. BJSM 2008)

GIRD?Internal Rotation ROM in 90° abduction

(Trakis et al. AJSM 2008, Cools BJSM 2010, Borstad JOSPT 2011)

Ann Cools Wrightington nov 2012

Impingement symptoms

ExternalSubacromial impingement

Internal(posterior)

impingement

PrimaryImpingement

SecondaryImpingement

BicepsSLAP

Rotator cuffpathology

Scapular dyskinesis instability G.I.R.D.

Relocation -Relocation+

Release +(pain)

Jobe +Neer + antHawkins +

Apprehension +(pain) ant

Jobe –Neer + postHawkins –Apprehension +(pain) post

Relocation+Release +(pain)

IRROM↓

O’Brien+Speeds+Biceps load II+

Laxity tests +Appr + (appr)Relocation + (appr)

SAT +SRT +

Full Can +

(Cools et al. BJSM 2008)

Measurement of GH ROM

� Digital inclinometer (Acumar) (Cools et al.

Submitted JAT 2012)

Ann Cools Wrightington nov 2012

Measurement of GH and ST strength

� HHD (compuFET, Biometrics)(Cools et al. BJSM 2010; Cools et al. Submitted JAT 2012)

Ann Cools Wrightington nov 2012

More information?

www.standaarduitgeverij.beAnn.cools@ugent.be

In general: “ we urge caution if a diagnostic test is only been studied once, and if the originator of the test is the author of the paper” (Hegedus et al. BJSM 2008)

Ann Cools Wrightington nov 2012

29

EUSSER is proud to announce, in collaboration with Ghent University and the Flemish Society of

Shoulder and Elbow Surgeons:

THE SHOULDER IN THE OVERHEAD ATHLETE: CHALLENGES FOR SCAPULAR REHABILITATION

AND RETURN TO PLAY AFTER INJURY

FRIDAY 29th MARCH 2013

Invited international speakers:Kajsa Johansson (Sweden)

Klaus Bak (Denmark)Jo Gibson (UK)

Het Pand, Gent, Belgium

Future congress:

Ann Cools Wrightington nov 2012

Thank you!!(Gent- Belgium)