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Shoulder Stability

Why Don't Our Shoulders Subluxate?

by Martin Krause (1986 & 1996 & 2003)

Taber's cyclopedic medical dictionary describes subluxation as a partial or incomplete dislocation (p.1384). The shoulder provides a unique opportunity to examine joint stability and hence resistance to subluxation from an aspect of neuromuscular co-ordination as the shoulder has little other anatomical constraints to prevent subluxation. To stabilise the shoulder the humeral head (ball) needs to be kept closely applied to the surface of the glenoid (socket) and in such a fashion that it is not allowed to slip or lose position when force is applied during hand placement.

The upper extremity serves as an instrument to place the hand in a position of function (Rothman, Maverl, Heppenstall 1975). Perry (1978) noted that a person can accurately differentiate one degree of motion which means that in the glenohumeral joint with an average of 150 degrees of flexion and 30 degrees of extension, 180 distinct positions to differentiate exist in the sagital plane. If this is combined with 90 degrees of abduction then 16,000 distinct positions are possible. The addition of 50 degrees of rotation further increases the potential for the number of selected hand positions which need to be differentiated ( Turvey, Fitch, Tuller 1982) for joint stability (Rothman et al 1975).

In contrast to the hip, the shoulder appears to have little bony stability. The humeral head is inclined 130-150 degrees relative to the shaft, and retroverted an average of 20 degrees relative to the distal end of the humerus (Sarrafian 1983). The humeral articular surface represents approximately 1/3 of an irregular sphere (Cailliet 1980) with an average vertical dimension of the surface being 48mm, and a 25mm radius of curvature; the average transverse dimension is 45mm, with a 22mm radius of curvature (Sarrafian 1983). However, the oval glenoid surface has an average vertical dimension of 35mm, and a tranverse diameter of only 25mm (Sarrafian 1983). The concave and rather flat glenoid surface is approximately 1/4 the size of the convex humeral head, and hence little element of stability is provided by their fit (Sarrafian 1983, Cailliet 1980). Radiographic investigations reveal no anatomical differences between normal shoulders and those which recurrently subluxate (Paavolainen, Magnus, Bjorkenheim, Ahovuo, Slatus 1984; Cyprien, Vasey, Burdet, Bonvin, Kritsikis, Vuagnat 1983). Unfortunately, the attachment of the glenoid labrum does not substantially increase the depth of the concave surface (Sarrafian 1983), however its detachment has been referred to as the 'essential lesion' leading to recurrent anterior subluxations (Bankart 1938, Paavolainen et al 1984). Thus the shoulder possesses little bony stability required for hand placement.

The ligaments of glenohumeral joint also appear to provide little stability for the shoulder. The superior segment of the glenohumeral capsule and the coracohumeral ligament contribute to the vertical stability of the humeral head (Sarrafian 1983, Turkel, Panio, Marshall, Girgis 1981). The contribution of the anterior capsulo-ligamentous complex to the anterior stability of the humeral head is limited. The anterior, middle and inferior glenohumeral ligaments are mere thickenings of the capsule. Furthermore, a foramen of variable size, the foramen ovale of Weitbrecht, is present between the superior and the middle glenohumeral ligaments (Sarrafian 1983; Cailliet 1980). The inferior glenohumeral ligament is the largest and strongest of the three glenohumeral ligaments with its location between the subscapularis and teres minor tendons, reinforcing the inferior glenohumeral capsule (Sarrafian 1983). This anatomical feature is significant in that beyond 90 degrees abduction, the subscapularis tendon no longer provides anterior stability of the humeral head (Cailliet 1980; Baleman 1978; Kummel 1979; Turkel et al 1981; Paarvolainen et al 1984) so that the anterior stability must be provided by the axillary pouch of the inferior glenohumeral ligament (Turkel et al 1981; Sarrafian 1983; Ovesen and Nielsen 1985; Cailliat 1980; McGlynn and Caspari 1984).

The posterior stability of the humeral head is provided by the tendons of the infraspinatus and teres minor (Baleman 1978; Cailliet 1980). Sarrafian (1983) described these tendons as 'true active ligaments'. Together with the long head of biceps and the subscapularis, the teres minor and infraspinatus provide a dynamic anterior-posterior stability required for glenohumeral function and hence hand-placement (Burkhart 1991). Further, for superior-inferior stability, the deltoid contraction must be matched by teres minor, infraspinatus and subscapularis contraction (Burkhart 1991). In fact the infraspinatus, teres minor, and subscapularis are each thought to cover 3/10 of the capsule with the remaining 1/10 covered by the long head of biceps (Watson 1985). Tears of the rotator cuff tendons revealed three kinematic patterns of movement abnormalities which included "stable fulcrum kinematics" associated with tears of the supraspinatus (and part of the infraspinatus), "unstable fulcrum kinematics" associated with massive tears involving virtually all of the superior and posterior rotator cuff and "captured fulcrum kinematics" associated with massive tears of a major portion of the posterior rotator cuff and a major portion of the subscapularis resulting in an 'awning-effect' of the acromion (Burkhart 1992) . These investigations suggest that if any part of the antero-posterior stability is affected then at the very least an "impingement syndrome" "painful arc" may result.

Also important to consider is the movement of the scapular which acts to maintain a position of stability for the glenohumeral joint by orienting the glenoid so that contraction of the rotator cuff muscles results in compression of the humerus against the glenoid during activities involving arm elevation. Saha's (1983) analysis of scapulo-humeral movement was considered in three phases :

Phase I involves elevation to 60 degrees flexion or to 30 degrees abduction by

  1. elevation of the outer end of the clavicle by approximately 12-15 degrees.

  2. scapular rotation in an antero-posterior axis taking place in an irregular direction termed the "setting phase of the scapula".

  3. increasing the angle between the scapula spine and clavicle by about 10 degrees through a counter-clockwise rotation of the scapula around a vertical axis through the acromioclavicular joint.

Phase II involves elevation from the end of phase I to 90 degrees flexion or abduction through

  1. further elevation of the outer end of the clavicle to its final position (i.e. 30-36 degrees over its usual bearing with the midsagittal plane).

  2. no change in the spino-clavicular angle

  3. scapular rotation in the antero-posterior axis

  4. no rotation of the clavicle in its long axis

Phase III encompasses elevation vertically overhead from the end of phase II position

  1. no further elevation of the clavicle

  2. a second quota of rotation of the scapula around the vertical by about 10 degrees

  3. clavicular rotation in a 'crankshaft' fashion, with the glenoid tubercle pointing downwards through about 30-40 degrees

  4. external rotation of the humerus as is necessary for elevation in the coronal plane.

Three dimensional acromioclavicular joint motions during elevation of the arm (Teece et al J Orthop Sports Phys Ther, 38(4), 181-90). During active scapula plan abduction from rest to 90 degrees, avarage A/C joint angular values demonstrated increased internal rotation (4.3 degrees), increased upward rotation (14.6 degrees), and increased posterior tilting (6.7 degrees).

Scapulohumeral rotation was considered to be an average of a 2:1 ratio for abduction.

Poppen and Walker (1976) found the centre of rotation of the glenohumeral joint, for abduction in the plane of the scapula, to be located within 6mm of the geometric centre of the humeral ball. The average excursion of the humeral ball in the face of the glenoid in the superior-inferior plane between each 30 degree arc of motion was less than 1.5mm in normal subjects. With this constraint of motion in mind, the theoretical construct of Saha (1983) may be examined.

If the glenoid cavity can be considered as a part of a sphere having its centre at G and radius R, and if the articular surface of the humerus is part of the surface of a smaller sphere with its centre at O and radius r then the following calculations may be constructed (see fig 1). Glenohumeral coordinates

Figure 1. Glenohumeral coordinates.

In every position of the head, the point of contact C and the centres O and G are co-linear. Letting the centre of gravity of the limb act at m, the line m and O is the axis of the limb and when produced meets the articular surface at P. Therefore for different positions of the limb in a plane of the paper, angles POC and PGC will vary.

Letting the two angles in a particular position be u and V with the constant lines PO and PG respectively, then a rotation over a small surface (in the plane of the paper ds, in an instant dt) would be represented by

du = ds /r and dV = ds /R

so that the respective displacements are

du/dt = 1/r x ds/dt 1

dV/dt = 1/R x ds/dt 2

1 - 2

du/dV x R/ r

du = R/r x dV

u = R/r .V + k 3

however when P becomes the contact point C, then u = 0, v = 0

therefore the value K becomes zero, thus 3 reduces to

u = R/r .V 4

(Saha 1983, p7).

Now equation 4 states that even if the glenoid was stationary when there was a counter-clockwise rotation of the limb around O, there would occur counter-clockwise rotation of the head around G, but to a smaller extent (since r is less than R). So the head rolls to a new position governed by the equation (Saha 1983). Since the shortest distance from one point to another on an ovoid surface is a cord, and the shortest displacement is a cardinal displacement, then when two cardinal displacements follow each other at 90 degrees then spin or axial rotation must be introduced (Sarrafian 1983). Rolling movements are more economical to form than sliding or gliding movements thereby the ball rolls to minimise shear between the faces (Saha 1983) thereby attaining greater stability (Sarrafian 1983).

Saha (1983) believes that every position of the glenoid can be studied from two aspects

  1. forces which bring the arm to a new position

  2. forces which are responsible for fixation in a particular position

The humeral head contacts the glenoid at the point C. Thus COG is the direction of reaction due to contact, assuming after P1, P2, etc, the different pulls of muscles have brought the limb to a given position. With weight W acting at the centre of gravity M somewhere beyond the upper 1/3 of the forearm, the force at P1, P2, etc and W acting on the humerus cannot be in equilibrium because C is not a fixed fulcrum, neither is enough reaction resistance available to compress the head at C thus making the humerus liable to glide down on the glenoid without the intervention of other forces using the formula of equilibrium

where (alpha) a 1, a 2, a 3, etc are the angle at which the muscles pull at the limb whereas (beta) b is the angle made by the direction of weight with respect to the axis of rotation. Thus the compressive action of the infraspinatus, teres minor, and subscapularis are necessary to increase the reaction at the point of contact (P1,P2,etc) to hold the head against the glenoid (Baleman 1978; Cailliet 1980; Saha 1983) . The resulting acting forces are maximum at 90 degrees of elevation where shear and compression forces are equal (Post, Silver, Singh 1983), whereas the maximum shear forces occur at 60 degrees of abduction (Poppen et al 1978).

Muscular reactive forces to the pull of deltoid

Figure 2 : Muscular reactive forces to the pull of deltoid.

Contraction of the deltoid alone (whilst in the neutral position) results in vertical shear of the head with respect to the glenoid and unless the head is rotated, depressed and compressed by the rotator cuff muscles the deltoid loses the power required during abduction (Baleman 1980; Neviasser 1980) . If the rotator cuff function is impaired even slightly then the normal fulcrum at C will be lost and abnormal translation (Subluxation) will result (Cailliet 1980). It is probable that if one force component of the rotator cuff is compromised then greater tension is exerted in the remaining rotator cuff muscles resulting in shear and compression of muscle capillaries with concomitant hypoxic damage to collagen fibres (Poppen et al 1976; Post et al 1983). Indeed "impingement syndrome" has been associated with posterior capsular tightness and a relative weakness of the external rotators and that anterior instability is associated with excessive external rotation and weakness of the internal rotators of the shoulder (Warner, Micheli, Arslanian, Kennedy, Kennedy 1990).

Importantly, for complete abduction, external rotation is required to allow the greater tuberosity to pass posterior to the acromial process and coracoacromial ligamentous arch (Cailliet 1980; Sarrafian 1983; Schenkman, de Cartaya 1987). Furthermore, scapula rotation is also required to provide efficiency of contraction (line of pull) to the rotator cuff and hence deltoid muscles (see fig.3) (Cailliet 1980). Suspension of the scapula is accomplished by the clavicle acting as a strut compressing at its inner end against the sternoclavicular joint. The suspensory mechanism is both static and dynamic and under constant stress due to gravity. The suspensory ligaments include the acromioclavicular, coracoclavicular and sternoclavicular ligaments, whereas the suspensory muscles include trapezius, sternocleidomastoid and levator scapulae (Baleman 1978). Upper fibres of trapezius pull the scapula upward and inward, pivoting about the acromioclavicular (A/C) joint (Cailliet 1980). The middle fibres of trapezius stabilise the scapula whereas the lower fibre of trapezius pull the medial border of the scapula down and hence rotate the glenoid up (Cailliet 1980). In association with the serratus anterior the upper and lower fibres of trapezius pivot the scapula about the A/C joint, thus elevating the glenoid fossa and contributing to scapulo-humeral rhythm (Cailliet 1980; Schenkman et al 1987).

Since only 30 degrees of clavicular elevation is permitted, corresponding to 30 degrees of scapula rotation, further elevation of the clavicle is checked by the costoclavicular and coracoclavicular ligaments which act as a force couple to cause the clavicle to rotate backwards around its long axis in a "crankshaft" effect resulting in a further 30 degrees of clavicular elevation (Schenkman et al 1987 ). Loss of this motion would prevent the shift of the axis of rotation from the sternoclavicular joint to the A/C joint and hence would prevent the lower fibres of trapezius and lower digitations of serratus anterior to function as an upward rotator (Schenkman et al 1987). Furthermore, the rhomboids elevate the medial aspect of the scapula thereby causing downward rotation of the glenoid fossa and hence may create instability at the glenohumeral joint (see fig. 4). If the glenoid does not move upward during abduction then the line of pull of the rotator cuff may result in excessive translation and hence glenohumeral instability since the attachment of the rotator cuff to the scapula will mean that they are dependent upon appropriate positioning of the scapula for glenohumeral stability.

Lines of action of scapula and rotator cuff muscles Lines of action of scapula and rotator cuff muscles
Figure 3 : Lines of action of scapula and rotator cuff muscles.

Line of action of the rhomboid muscles and glenohumeral instability
Figure 4 : Line of action of the rhomboid muscles and glenohumeral instability.

The previous discussion highlights that scapulohumeral rhythm comprises of a number of relative independent muscles constrained to act as a unit to provide glenohumeral stability (Turvey, Shaw, Mace 1978; Turvey, Fitch, Tuller 1982). With such a vast number of combinations of degrees of freedom the question of neuromuscular control needs to be addressed (Bernstein 1967; Perry 1978; Turvey et al 1982). Context-conditioned variability as a fixed relationship cannot be assumed between muscle states and movement ( Turvey et al 1982) and it is the contextual setting which distinguishes 'actions' from movements (Glencross 1980; Turvey et al 1978; Whiting 1980). Nociceptive input from inflammatory substances such as bradykinin, potassium, prostaglandin and serotonin (Cairns 2007), accumulation of calcium and anaerobic metabolites (Rosendal et al 2004) interact with the function of spinal cord interneurones and motor neurones (Madelaine 2008). Together with a general inhibitory effect of nociception on agonist and antagonist gamma motoneuron proprioceptive function (Mense & Skepper 1991) suggests that any variation in muscle tone (resting electrical activity) due to reflexogenic muscle spasm from inflammation, or weakness from nerve compression may compromise the stability at the glenohumeral joint and thus constrain the number of possible 'actions'.

A "mass-spring" analogy has been generated which would dictate that no matter from which position a limb started it would maintain neuromuscular control by adjusting automatically to changes in context (Turvey et al 1982). This means that the total amount of motoneuronal activity is adjusted to the demands of function (speed, range of movement, weight) through higher centre modulation of electrical activity to all the muscles of the scapulohumeral complex. The only stability for a non-linear system whose processes degrade large amounts of free energy is a dynamic stability consisting of periodicities or cycles (Kugler, Kelso, Turvey 1980). This mechanical hypothesis is very attractive as the central nervous system appears to modulate in periodicities or cycles (Segundo, Stiber, Vibert, Hanneton 1995; Segundo, Vibert, Stiber, Hanneton 1995).

M X + KX + SX = F(t)

M=mass K=friction coefficient S=stiffness coefficient X=displacement F(t)=force function

Neural and mechanical variables in dynamic stability

Non-linear cycles have a tendency to a fixed amplitude and frequency no matter how disturbed, a tendency not to increase in amplitude when driven at their preferred frequency, and a tendency to mutually entrain or synchronize (Kugler et al 1980). Langley and Zelaznik (1984) suggest that the variables pertinent to a particular motor task can be divided into two classes

a) essential variables which determine the structure or topographic characteristics of the motor output, and therefore coordination and,

b) non-essential variables whose values can change in a scaled manner while leaving the basic movement structure in tact (Kugler et al 1980; Kelso, Putnam, Goodman 1983; Kelso, Southard, Goodman 1979; Turvey et al 1978) . See sitting vs standing cycling kinemtics at the knee elsewhere on this site , where the hamstring, quadriceps and gluteal muscles may provide powerful extension of the knee during pedalling of a bicycle. Similar, oscillatory control can be seen in the foot orthotic section of this website, where the pronation-supination of the foot and tibial oscillation at the knee provide an example of dynamic stability.

An inflection point identifies a stable configuration of the system's dimensions, i.e. a point about which the dimensions will tend to configure to subsequent perturbations. The geometric profile exhibits an inflection region at the resting length with ascending gradients on both sides. Distances may be regulated through the manipulation of the resting length while velocity and acceleration may be regulated through the manipulation of stiffness (see fig. 5) (Kugler et al 1980). Stiffness and the variable "resting length" corresponds to the selection of firing rate (Kelso 1982). Importantly, extrapolation of the inflection point to the clinical setting may mean that the 'setting phase' is critical to the correct implementation of movement.

should6 Figure 5 : Geometric variables of the "mass-spring" analogy


Importantly, in the clinical setting there will be several aspects of movement control to consider. Essentially, in the early phase of rehabilitation the pain and inflammation need to be reduced to provide the optimal interneuronal pool firing. Additionally, through the reduction of pain the cognitive focus can be on achieving the stabilising inflection point and gradually building the movement repertoire based on managing the control of the newly attained degrees of freedom. Thus, early rehabilitation uses 'closed kinetic' chain exercises where the hand is fixed to an immobile object e.g. the floor or the wall, whereas later rehabilitation uses 'open kinetic' chain visual cues to manage the degrees of freedom. This would involve higher centre calculations of trajectories and timing of impact which manipulate acceleration and deceleration variables. Clinically these later stages of rehabilitation may find that useful visual cues could involve the use of markers on walls or possibly even children's interactive computer gaming such as the Sony Wiifit.

Frequently, the emphasis of closed kinetic chain exercises is to enhance scapula mobility and stability to enable the optimal positioning of the glenoid fossa for the head of humerus. This approach also attempts to improve kinesthesia of the scapula which is frequently disrupted either due to pain and/or lack of visually reinforced input. The inflection points of stability for the scapula are highly likely to involve the interaction of the serratus anterior. For example, during the phase beyond 30 degrees of abduction, the emphasis would be on stability around the superior angle of the scapula (using upper serratus anterior, levator scapula, upper and middle trapezius and subclavius muscle tone) whilst the inferior angle maintains a forward and upward trajectory along the the thorax based on the muscle tone of the inferior serratus anterior, the latissimus dorsi (which attaches to the inferior angle) and the intercostal muscles which control the excursion of the ribs. In later phases of abduction where the axis of rotation resides at the A/C joint then interaction with descending fibres of the trapezius muscle tone increases in importance.

Since fibres of the serratus anterior blend with the external oblique, in addition to the latissimus dorsi attaching to the transverse abdominis and pelvis, the importance of abdominal stability and lumbo-pelvic control cannot be ignored when rehabilitating the shoulder. One need look no further than the big buttocks of tennis players to see how important the gluteal and trunk muscles are for controlling torques during the serving action. Therefore, the concept of providing joint stability through afferent-efferent equilibrium under higher centre control may be applied not only to the shoulder but also to every other joint in that particular synergistic movement. The simple arm action of small fast flexion-extension around 90 degrees flexion can be felt in the on-off action of the contralateral lumbar paraspinal muscles. The concept of abdominal-paraspinal muscles stabilising the lumbar spine and interacting with arm movement have been investigated (Richardson, Jull, Toppenburg, Comerford, 1995; Richardson, Toppenburg, Jull, 1995) .

closed and open kinetic chain exercises
Figure 6: closed and open kinetic chain exercises.

The "meaning" of a descending "command signal" is significantly affected by the state of the spinal interneural pools into which it is sent. Nashner and Cordo (1981) demonstrated that the latency to firing, the intensity of activity, and coordination amongst different muscles all varied according to whether the muscle was functioning as a postural stabilizer, or was a prime synergist involved in a movement. Postures, like movements, are not triggered by stimulation, but are functional organizations of supporting musculature, capable of adaptation to changing circumstances (Kelso, Putman, Goodman 1983; Nashner 1976; Reed 1982) . Where a collective of muscles functions as a unit, the efferent-afferent distinction becomes superfluous where information about the given state of a muscle is by virtue of the linkage a specification of the states of the other muscles (efference) to which it is functionally linked (Kelso et al 1980; Kugler et al 1980) . Unfortunately, if afferent input is increased due to pain then excessive efferent activity may result (Gracely, Lynch, Bennett 1992; Woolf 1983; Woolf, Shortland, Sivilotti 1994; Woolf & Swett 1984). Due to a mismatch between 'efference copy' and afferent input, dyskinesia at lower levels of neuronal processing could result. A pain adaptation model has been proposed whereby pain results in increased anatagonist and decreased agonist activity (Svensson 2008). Moreover, the deeper joint muscles have a high density of muscle spindles (Bakker & Richmond 1982) suggesting that nociceptive input can disrupt their proprioceptive stabilizing function (Pederson et al 1998, Johansson et al 1995). Furthermore, sympathetic nervous system can result in reflexogenic changes in muscle activity (Passatore & Roatta 2007) including reduced muscle spindle discharge inhibition (Grassi et al 1993). Furthermore, the mechanisms of release and reuptake of Ca ions from/into the sarcoplasmic reticulum and the activity of the Na/K pump across the sarcolemma bear importance in the development of muscle force and are affected by sympathetic activation (Bowman 1980). These changes, taken together have been shown to affect feed-forward mechanisms of shoulder-neck motor control (Falla et al 2004). Therefore, reduction in pain, improved proprioception and higher order cognitive processing through descending modulatory mechanisms are of paramount importance in the clinical setting when pain is present.


Patients frequently seek treatment for pain in various parts of the body, but infrequently present for treatment of thoracic pain. Yet, simple, quick assessment and correction of the thoracic rings frequently demonstrates a link to the pain and musculoskeletal dysfunction in areas some distance away. Wainner et al (J orthop Sports Phys Ther, 2007; 37, 658-660) describe regional interdependence as “the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint.” This perception suggests that interventions targeting adjacent anatomical areas may directly affect the outcomes of the involved joint. Boyles et al (Manual Therapy, 2009 Aug;14(4):375-80) and Strunce et al (J Man Manip Ther, 2009, 17(4): 230-236) have demonstrated the immediate effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. The latter describing  a 51% reduction in shoulder pain, 30-38 degree increase in range of motion (ROM), and a mean patient perceived global rating change of 4.2 in 21 subjects. McCormack (J Man Manip Ther., 2012 Feb;20(1):28-34) showed a 25 degree improvement in shoulder ROM when using thoracic spine manipulation in the treatment of adhesive capsulitis. Brian Mulligan described 'mobilisation with movement' (MWM) techniques on the first rib which have dramatic effects on the cervical ROM for contralateral lateral flexion and ipsilateral rotation. Canadian physiotherapist Linda Joy Lee has advocated ring shift corrections for low back pain, pelvic girdle pain and hip problems, as well as shoulder and neck issues.

Interested readers should look at the thorax apsect of this website.

Since an individual may perform a task at near maximal tolerance it is important that the muscular energy intended for the task (e.g. hitting a ball with a racquet) is not misdirected inwards and transferred to bone, ligaments, capsule, and nerve due to sudden unexpected perturbations of movement and/or pain and/or in-coordination (Jobe & Jobe 1983). Human tissue can hypertrophy and decrease the probability of injury. Also improved coordination and metabolic efficiency can be attained through an appropriate treatment regime (Astrand, Rhodal 1977; Jobe et al 1983; Sale, Macdougall 1981). Moreover, non-injurous activity results in the production of proteoglycans both in the joints and periarticular structures thereby increasing strength and flexibility of collagen (Jobe et al 1983). The general effect of appropriate long-term activity (hypertrophy, rehearsal, metabolic efficiency and flexibility) is referred to as "conditioning" (Jobe et al 1983). See the endurance training-plyometrics section elsewhere on this site.

During the rehabilitation of the shoulder the physiotherapist may need to appreciate the synergistic action of the large number of muscles acting around the shoulder. It may be important to decrease afferent input which is undesirable to efficient movement such as pain and excessive stiffness from cervical, thoracic, lumbar and shoulder structures. Therefore, joint mobilisations of the spine may play an important role in the treatment of the shoulder. Additionally, it would appear that optimal coordination will mean the use of functional, specific, pain-free movements perhaps with the aid of muscle stimulating or inhibiting tape, pain inhibitory tape and/or the use of elastic bands of varying resistance . During rehabilitation, attention to detail not only at the glenohumeral joint but also at the scapula should result in a functional stable shoulder which does not subluxate.

Ultimately, this optimisation of neural input and outputs can be seen in the relative fluidity and graciousness of expert performers versus the relative rigidity of the novice. The expert performer can chunk motor activity into object oriented subconscious anticipatory behaviour whereas the novice is still reliant on the slowness of several instances of feedback and the limited conscious level cognitive processing of short term memory.

Original paper on motor control written by Martin Krause in 1986. Influencing factors of pain on muscle tone was added in 1996.

Visual variables and cognitive reasoning in motor control has been described by me elsewhere using orienteering as an example in 2003:

Motor Learning, Cognition and Injury prevention for the development of elite Orienteering performance

Scapular Rotation to Attain the Peak Shoulder External Rotation in Tennis Serve


Medicine & Science in Sports & Exercise. 42(9):1745-1753, September 2010.


Purpose: The purposes of this study were (a) to describe the detailed movements of the shoulder complex during the cocking phase in tennis serve and (b) to determine the contribution of the scapular rotation to the peak shoulder external rotation attained at the end of the cocking phase.

Method: Twenty tennis players performed flat tennis serves with the maximum effort, and three-dimensional kinematic data of the thorax, scapula, and humerus of the dominant side were recorded by an electromagnetic tracking device (Liberty; Polhemus) at 240 Hz. The humeral rotation with respect to the thorax (named as the resultant shoulder rotation) was decomposed into the scapular rotation with respect to the thorax and the humeral rotation with respect to the scapula (named as the glenohumeral rotation). The scapular rotation that contributed to attain the peak resultant shoulder external rotation was quantitatively determined, and the ratio of the glenohumeral external rotation to the scapular rotation that contributed to attain the peak resultant shoulder external rotation was computed to represent the scapulohumeral rhythm for shoulder external rotation.

Results: Of the three components of scapular rotations, the scapular posterior tilt was the primary component that contributed to the attainment of the peak resultant shoulder external rotation. The scapulohumeral rhythm for shoulder external rotation (scapular posterior tilt-glenohumeral external rotation) exhibited during the backswing phase was 1:2.3.

Conclusions: The peak resultant shoulder external rotation was generated by a synchronized combination of the scapular posterior tilt and glenohumeral external rotation. A consistent pattern of three phases of the scapular posterior tilt and the glenohumeral external rotation that could be accurately modeled by three linear regressions was observed in preparation for the peak shoulder external rotation in tennis serve.

The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome?

Robert E. Boyles, Bradley M. Ritland, Brian M. Miracle, Daniel M. Barclay, Mary S. Faul, Josef H. Moore, Shane L. Koppenhaver, Robert S. Wainnerc

Manual Therapy 2009, 14, 375-380

The study was an exploratory, one group pretest/post-test study, with the objective of investigating the short-term effects of thoracic spine thrust manipulations (TSTMs) on patients with shoulder impingement syndrome (SIS).

There is evidence that manual physical therapy that includes TSTM and non-thrust manipulation and exercise is effective for the treatment of patients with SIS. However, the relative contributions of specific manual therapy interventions are not known. To date, no published studies address the short-term effects of TSTM in the treatment of SIS.

Fifty-six patients (40 males, 16 females; mean age 31.2±8.9) with SIS underwent a standardized shoulder examination, immediately followed by TSTM techniques. Outcomes measured were the Numeric Pain and Rating Scale (NPRS) and the Shoulder Pain and Disability Index (SPADI), all collected at baseline and at a 48-h follow-up period. Additionally, the Global Rating of Change Scale (GRCS) was collected at 48-h follow-up to measure patient perceived change.

At 48-h follow-up, the NPRS change scores for Neer impingement sign, Hawkins impingement sign, resisted empty can, resisted external rotation, resisted internal rotation, and active abduction were all statistically significant (p<0.01). The reduction in the SPADI score was also statistically significant (p<0.001) and the mean GRCS score=1.4±2.5.

In conclusion, TSTM provided a statistically significant decrease in self reported pain measures and disability in patients with SIS at 48-h follow-up.

Motion analysis study of a scapular orientation exercise and subjects’ ability to learn the exercise

Sarah L. Mottram, Roger C. Woledge, Dylan Morrissey

Manual Therapy 2009, 14, 13-18

Exercises to retrain the orientation of the scapula are often used by physiotherapists to optimise shoulder girdle function. The movements and muscle activity required to assume this position have not yet been quantified. Further, patients often find this a difficult exercise to learn accurately, with no data being available on the accuracy of repeated performance. The primary objective of this study was to quantify the movements occurring during a commonly used scapular orientation exercise. The secondary objective was to describe the ability of subjects to learn this position after a brief period of instruction. A group of normal subjects (13 subjects; mean age 32, SD=9) were taught the scapular orientation exercise. Measurement of the position and muscle actions were made with a motion analysis system and surface electromyography. Further comparison was made of the accuracy of repeated trials. The most consistent movements were upward (mean=4°, SEM=0.9°) and posterior rotation (mean=4°, SEM=1.6°). All parts of the trapezius muscle demonstrated significant activity in maintaining the position while latissimus dorsi did not. Repeated trials showed that subjects were able to accurately repeat the movement without guidance. The key movements of, and immediate efficacy of a teaching approach for, scapular orientation have been established.

Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Lynda McClatchie, Judi Laprade, Shelley Martin, Susan B. Jaglal, Denyse Richardson, Anne Agur

Manual Therapy, 2009, 14, 369-374

Generalized shoulder pain is a common problem that is difficult to treat and frequently recurrent. The asymptomatic cervical spine must be ruled out as a cause of any shoulder pain, as it can have a similar presentation to an isolated shoulder disorder. Previous studies have shown that lateral cervical glide mobilizations to the asymptomatic cervical spine at C5/6 can affect peripheral pain, but none have examined shoulder pain. A randomized, blinded, placebo-controlled, cross-over trial was used to examine the immediate effects of cervical lateral glide mobilizations on pain intensity and shoulder abduction painful arc in subjects with shoulder pain. Twenty-one subjects received interventions of both cervical mobilization and placebo over two sessions. Pain intensity using a visual analog scale (VAS) and painful arc were assessed prior to and following application of cervical mobilization or placebo intervention. Evaluation of cervical mobilization revealed the shoulder abduction painful arc (12.5° ± 15.6°, p = 0.002) and shoulder pain intensity (1.3 ± 1.1 cm, p < 0.001) were significantly decreased. The results of this study suggest that any immediate change in shoulder pain or active shoulder range of motion following cervical mobilizations indicate that treatment directed toward the asymptomatic cervical spine may expedite recovery.

The initial effects of a Mulligan's mobilization with movement technique on range of movement and pressure pain threshold in pain-limited shoulders

Pamela Teys, Leanne Bisset, Bill Vicenzino

Manual Therapy, 2008, 13, 37 to 42

There is little known about the specific manual therapy techniques used to treat painfully limited shoulders and their effects on range of movement (ROM) and pressure pain threshold (PPT). The objective of this study was to investigate the initial effects of a Mulligan's mobilization with movement (MWM) technique on shoulder ROM in the plane of the scapula and PPT in participants with anterior shoulder pain. A repeated measures, double-blind randomized-controlled trial with a crossover design was conducted with 24 subjects (11 males and 13 females). ROM and PPT were measured before and after the application of MWM, sham and control conditions. Significant and clinically meaningful improvements in both ROM (15.3%, F (2,46)=16.31 P=0.00) and PPT (20.2%, F(2,46)=3.44, P=0.04) occurred immediately after post treatment. The results indicate that this specific manual therapy treatment has an immediate positive effect on both ROM and pain in subjects with painful limitation of shoulder movement. Further study is needed to evaluate the duration of such effects and the mechanism by which this occurs.


In 2011 Dr George Murrell and Dr Stephen O'Brien described references to altered lipid metabolism and altered immune activity in the form of cytokines occuring in tendonopathy. It has been shown that regular resistance training and/or endurance exercise attenuates altered immune responses. Interested readers should have a look at immune systems and obesity elsewhere on this website.


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Last update : 4 November 2012


Trending @ Back in B Physio

  • Sat 18 Nov 2017

    Beetroot Juice Increases Human Muscle Force

    Beetroot juice increases human muscle force Beetroot juice has been shown to improve low frequency muscle force independent of Calcium-handling-proteins or REDOX reaction (Whitefield et al 2017, Med Sc Sp Ex, 49, 10, 2016-2024). Further benefits of beetroot juice are thought to include reduction of blood pressure protection from pre-mature aging aiding cancer survival lowering serveral inflammatory markers including interleukin-6, C-reactive protein and tumor necrosis factor alpha stabilising blood suger improving sexual performance anti-arthritic effects blood purification and enhanced red blood cells removing 'bad' estrogens from our blood stream Uploaded : 18 November 2017 F Read More
  • Wed 01 Nov 2017

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  • Sun 15 Oct 2017

    Neuroplasticity in Tendon Dysfunction

    Neuroplasticity in Tendinopathy by Martin Krause A multitude of contributing factors to altered motor control must be addressed when treating tendon dysfunction. What we have failed to consider in the past when dealing with chronic or recurrent tendon issues are motor control problems encompassing corticospinal control of excitation and inhibition as well as belief systems about pain and contextual factors related to imaging.  Research by Ebonie Rio et al (2015) (BJSM Sept 25, 10.1136/bjsports-2015-095215) suggest that the pain state sets up an adaptive pathway whereby the ipsilateral kinetic chain is directly inhibited by reflexogenic pathways, as well as being inhibited by contralateral hemispheric activity. Simultaneously excitation is enhanced in the opposite limb as well as in least in the case of enhanced excitation of the hamstrings in quadricep tendinopathy. If this is true, then so much for training the contralateral limb for 'cross training' purposes! This may also explain why a lot of people seem to have "all their injuries on the same side" (of the body). Furthermore, they recommend enhancing corticospinal drive through the use of 30-60 second isometric holds at 70-80% MVC to load the muscle whilst using isokinetics to load the tendon. Moreover, they recommend the use of a metronome at 60bpm (stages 1 and 2) with a count of 3 up, 2 down for quads, and 2 up, 3 down for calf isokinetics to optimally engage corticospinal drive through the visual and auditory stimuli (also shown by Kohei et al 2012 for motor imagery and M1 stimulation) more Cortical mapping of infraspinatus muscle in chronic shoulder pain demonstrating higher motor thresholds (aMT= activation MT) and hence reduced excitability on the affected side (39 vs 35) (Ngomo et al 2015 Clinical Neurophysiol, 126, 2, 365-371) Cortical mapping of pain and fear. Lots of overlap suggesting that taking away the fear from the pain with clear clinical explanations and a focused goal directed program using specific functional outcomes is important.  Individuals with patellofemoral pain (PFP) had reduced map volumes and an anterior shift in the M1 representations, greater overlap of the M1 representation and a reduction in cortical peaks across all three quadriceps (RF, VL, VMO) muscles compared with controls.(Te et al 2017 Pain Medicine, pnx036,  Uploaded : 18 October 2017 Read More
  • Mon 09 Oct 2017


    Do I need a scan? "a picture tells a thousand words" - not really! by Martin Krause A scan, in it's self, will not improve anyone's condition. The purpose of a scan is to gain more information about the pathology. Sometimes this information may be irrelevant to the management of a patient's condition. For example, if you knocked your elbow on a door frame and suffered a bruise, which was already beginning to resolve, an ultrasound scan may show some minor soft tissue damage, but that was already obvious by the fact of the bruise, and the information gained from the scan has not helped nor changed the management of the bruise. Therefore, the main reason for getting a scan would be because there is concern that the presence of certain pathologies may lead to a change in the medical management. For example, sometimes a rolled ankle can be more than sprained ligaments, and may require surgey or immobilisation in a boot. If the therapists suspects this might be the case, then they will recommend or refer for a scan (probably an X-Ray) to check the integrity of the bones (especially the fibular and talar dome), because if there is no bony damage then the patient can be managed conservatively with taping, exercises, ultrasound, massage, joint mobilisations etc. However, if there is boney damage, for example, then it might be necessary for the ankle to be immobilised in a boot for three - six weeks, for example. This dramatically different medical management depends on the results of a scan, and it is therefore worth doing. However, scans have no predictive value to the presence or severity of pain. Thirty-three articles reporting imaging findings, in the low back, for 3110 asymptomatic individuals were investigated for pathology. The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age. (Brinjikji, W et al Spine Published November 27, 2014 as 10.3174/ajnr.A4173). Hence, the results of imaging need to be assessed within the context of the entire clinical picture. Frequently too much emphasis is placed on the imaging not only by the clinician but also by the patient. Some people react to pathology seen on scanning as an affirmation of their problem and can either use it to gain clarity and become better or conversely become worse. Moreover, some people find imaging with inconclusive results as a 'panic moment' - "no one knows what is wrong". Similarly, ultrasound imaging of the tendond has good predictive diagnostic and aids in clinical reasoning when it comes to full tears. However, with partial tears it is a totally different 'ball game'. Ultrasound is highly user dependent, with specifically trained musculoskeletal radiologists able to produce high-quality images that may provide more clinically relevant information than those produced by clinicians with less experience in imaging. Sean Docking, a leading tendon researcher at Monash University, cited 7 authors who found pathological tendon chnages in 59% of asymptomatic individuals, whereas he found that 52% of asymptomatic elite AFL sportsmen had tendon pathology on imaging! Furthermore, symptomatic individuals who improved clinically to the point of resuming play, weren't shown to have improvements on imaging. Again, the clinical context and the clinical reasoning can in many instances prove to be the 'gold standard' not the imaging itself, when considering management options. Shoulder supraspintatus tendon pathology, in the abscence of trauma, is known, in many instances, to be a disorder of immune-metabolic compromise of the tendon and bursa. Imaging may show some changes in signal intensity but, unless it's a complete tear, it can reveal neither the intensity nor the severity of pain when taken outside of the clinical context. A thorough physical and subjective examination integrating all the clinical dimensions of the problem will have far greater value than any one single imaging modality. Yet, imaging still should be used in instances of progressive rapid deterioration and suspected serious pathology which may require surgery and/or immediate medical intervention. In summary, sometimes it is worthwhile getting a scan, because the information gained from that scan will determined the type of medical management that is employed. However, at other times, the scan may be unneccessary, because the information may be irrelevant or lead to an incorrect change in medical management, due to over-reporting of 'false positives'. You will be able to make this decision on the advice of your health care professional. On occasions it can actually be detrimental to have a scan, because some patients can become overly obsessed with the medical terms used to describe their scan results, which then can become the major focus for the clinician and the patient, rather than the more prefereable focus on their symptoms and functional abilities. For example, many people have lumbar buldging discs yet have no symptoms, yet sometimes when these patients have an MRI or CT scan, they can develop symptoms because they think they should have pain if the scan says so! Conversely, for some people the results of imaging can have a positive and reassuring affect. Therefore, it is very important to assess a clients attitude to scans before prescibing them so that the patient's expectations are managed appropriately, and not burdened by the additional, sometimes confusing, information supplied by a scan. Uploaded : 10 October 2017 Read More
  • Thu 14 Sep 2017

    Cervical Spine implications in concussion

    Neck aetiology, autonomic and immune implications, exercise and diet in the musculoskeletal physiotherapy management of Post Concussion Syndrome (PCS) by Martin Krause, MAPA, Titled member Musculoskeletal Physiotherapy Association of Australia  A 14 year old boy presented to A&E, in August 2016, after receiving an impact to the head during AFL (Australian Rules Football). Although his SCAT3 scores were relatively mild, he went on to suffer severe lethergy, resulting in a lengthy abscence from school, culminating in a return to school for exams in the first week of December 2016. By December, even a 30 minute walk was extremely fatiguing. To place this into perspective, he had been playing elite academy grade AFL for several seasons and was an extremely fit outdoor adventurer. Confounding Variables : end of season injury and hence no follow up from the academy suffers from Hypermobile Joint Syndrome (HJS) and possibly Ehlers Danlos Syndrome (EDS), however Beighton score 4/9. suffers from food intolerances, particularly to Glutin and diary, but also some other foods. Potential IBS and autoimmune issues. had just gone through a growth spurt (190cm) Imaging : Brain MRI normal Medical Examination : Balance remained impaired to tandem walking and single leg stance. The vestibular occular motor scale showed significant accomodation deficit of 15cm and there was a mild exacerbation of symptoms. ImPACT testing revealed adequate scores and reaction time of 0.65 which is within acceptable range. History : School holidays December - January. Return to school and was placed in the lower academic classes. Prior to his concussion he was a top 10 student at an academically selective high school. Took up basketball and rowing as summer sports. Academic results tanked. Several lower limb Basketball injuries (Feb - April 17') as a result of what apppeared to be muscular imbalances from the relatively recent growth spurt, as well as taking on a new sport. Showed little interest in returning to AFL as no-one from the AFL academy had followed up on his recovery (or in this case lack of recovery).  Current History : September 2017 showed a continued decline in academic levels. School teachers noted an inability to concentrate. Academic results still well below pre-concussion levels. Fatigue continuing to be problematic. Stopped going to school for 7 weeks due to another head impact, but this time at Basketball. Literature Review : Post Concussion Syndrom (PCS) is defined as "cognitive deficits in attention or memory and at least three or more of the following symptoms: fatigue, sleep disturbances, headache, dizziness, irritability, affective disturbance, apathy, or personality change"  One of the known risk factors for Sport Related Concussion (SRC) is a history of concussion. Although, most adults recover from concussion after 10 days, there is evidence to suggest ongoing abnormailities in the brain can pursist well beyond 10 days (Prichep et al 2013, J Head Trauma Rehabil, 28, 4, 266-273). Thus, with the above described symptoms and potential motor control problems, further complications of PCS also appear to be altered proprioception, an increased risk of musculoskeletal injury which in turn can lead to SRC. The following are the results from soccer players. Nordstrom et al (2014, BMJ Sports Med, 48, 19, Predictors of PCS are uncertain. However, the following clinical variables are considered factors at increasing risk. These include prior history of concussion, sex (females more prominant), younger age, history of cognitive dysfunction, and affective disorders such as anxiety and depression (Leddy et al 2012, Sports Health, 4, 2, 147-154). Unlike the 'good old days' which recommended a dark room and rest for several weeks post concussion, the consensus appears to be a graded return to exercise in order to restore metabolic homeostasis. Disconcertingly, highly trained young individuals can find even exercises in bed extremely demanding in the presence of sport related concussion (SRC). Kozlowski et al (2013, J Ath Train, 48, 5, 627-635) used 34 people,whereby 226 days post injury to conclude significant physiological annomalies in response to exercise which may be the result of 'diffuse cerebral swelling'. Researchers have noted lower systolic and higher diastolic blood pressure in PCS (Leddy et al 2010, Clin J Sports Med, 20, 1, 21-27). Due to autonomic dysfunction manifested in altered cardiovascular and pulmonary responses (Mossberg et 2007, Arch Phys Med Rehab, 88, 3, 15-320), wheerby some clinicians have recommended the use of the exercise program for POTS (Postural Orthostatic Tachycardia Syndrome). This is a 5 month program which recommends mainly exercise in the horizontal and sitting positions for 1-4 months, including recumbent bike, rowing ergometer and swimming laps or kicking laps with a kick board. Month 4 upright bike and Month 5 upright training such as a elliptical trainer or treadmill. Other progressive exercise therapies have also included 20 minutes per day, 6 days per week, for 12 weeks of either treadmill or home gym exercises at 80% of the heart rate at which their concussion symtoms are exacerbated. Their programs were individually modified as the heart rate provoking symptoms increased. When compared to the 'control group', this intervention was shown to improve cerebral perfusion on fMRI, increase exercise tolerance at a higher heart rate, less fatigue and were showing activation patterns in areas of the brain on performing math processing test which were now normalised (Leddy et al 2010, Clin J Sports Med, 20, 1, 21-27). Graded exercises could also have included 'motor imagery' as espouse by the NOI group and the work of Lorrimer Moseley (University South Australia) when dealing with chronic pain. Ongoing Symptoms : The literature review by Leddy et al (2012) found that ongoing symptoms are either a prolonged version of concussion pathophysiology or a manifestation of other processes, such as cervical injury, migraine headaches, depression, chronic pain, vestibular dysfunction, visual disturbance, or some combination of conditions. Anatomical considerations : Extensive anatomical connections between the eyes, neck and vestibular system (Wallwork et al 2007, JOSPT, 37, 10, 608-612) allow sensory information from neck proprioceptors to be processed together with vestibular information which, via the lateral vestibulo-spinal tract, affect the control of postural muscles such as the deep trunk muscles  (Hain 2011, Neuro-Rehabilitation, 29, 2, 127-141).  Psychological considerations : The Kubler Ross model of grief are applicable when it comes to chronic sports injuries. Physiotherapy Assessment : Current history One year PCS, fatigue continued to persist. Cognitive deficits with school work were reported to becoming more apparent. Assessment using various one leg standing tests employing oscillatory movement aroud the hips and knees for kinetic limb stability and lumbopelvic stability, which had been employed 6 months previously for his Basketball injuries were exhibiting strong deficits, despite these being 'somewhat good' previously. Significantly, during the acute phase of SRC, rugby union and rugby league players have been seen with alterations of both balance strategies and motor control of the trunk (Hides et al 2017, Musculoskeletal Sci Pract, 29, 7-19).  Physical Examination : cervical and thoracic spine Due to the Joint Hypermobility Syndrome (JHS) it was difficult to ascertain neck dysfunction based on range of movement testing. ROM were unremarkable except for lateral flexion which demonstrated altered intervertebral motion in both directions. Palpation using Australian and New Zealand manual therapy techniques such as passive accessory glides (upslopes and downslopes and traction) exhibited muscles spasms in the upper right cervical spine. In particular, the right C1/2 regions demonstrated most marked restrictions in movement. Eye - Neck proprioceptive assessment using blind folds and laser pointer also  revealed marked variance from the normal. Repositioning error (RPE) using the laser pointer with rotation demonstrated marked inability to reposition accurately from the left, tending to be short and at times completely missing the bullseye. Gaze stability with body rotation was NAD. Gaze stability whilst walking displayed some difficulty. Laser pointer tracing of the alphabet was wildly inaccurate and cognitively demanding. Thoracic ring relocation testing also revealed several annomalies, which may have also accounted for some of the autonomic dysfunction observed.  Occulomotor assessment and training Upper Cervical Spine : The upper cervical spine (atlas and axis) represents approximately 50% of the available rotation. An investigation into the environmental and physiological factors affecting football (soccer) head impct biomechanics found that rotational acceleration was one of the few factors approaching significance and concluded that more research should be undertaken to evaluate this (Mihalik et al 2017 Med Sc Sp Ex, 49, 10, 2093-2101). Headache : Commonly referred to as cervicogenic headaches, one in five headaches in the general population are thought to be due to the cervical spine. The Upper Cervical Spine is particularly vulnerable to trauma because it is the most mobile part of the vertebral column, with a complex proprioceptive system connecting the vestibular apparatus and visual systems. It also coincides with the lower region of the brainstem and fourth ventricle. The brainstem houses many neurones associated with autonomic responses to pain and balance. Imaging of the fourth ventricle for swelling of the 'tonsils' and Arnold Chiari malformations are recommended when symptoms persist. In particular, children and adolescents are more vulnerable to neck contusions due to the proportionately larger head and less developed musculature. Cervical vertigo and dizziness after whiplash can mimic symptoms of PCS.. Mechanoreceptor dysfunction and vertebrobasilar artery insufficiency should be part of the differential diagnosis. Mechanical instability of the Upper Cervical Spine should also not be missed. Cervicogenic Headaches Further Interventions : Neurocognitive rehabilitation of attention processes. Psychological intervention using cognitive behavioural therapy (CBT). Neuro-opthalmologist to assess and treat smooth pursuit eye tracking. Naturopath for food intolerances and dietician for the optimisation of diet. Diet :  In cases with chronic fatiguing factors, nutrition can be become a vital aspect into the reparative process. This may include energy and mineral rich foods such as bananas, green leafy vegetables for iron and magnesium (200-300mg), oranges for vitamin C (anit-oxidant and helps with the absorption of iron), anti-oxidant rich foods such as EPA/DHA (1000mg) fish oil, curcumin (tumeric), Cats Claw, Devils Claw, Chia seeds, fruits of the forest (berries), and CoQ10 with Vitamin B. Folate and Ferritin levels should also be checked. Calorific energy intake should balance with energy exependiture. However, as we are often dealing with young individuals, as in this case, some form of comfort food may be appropriate such as, nuts, legumes, homus and sushi. Protein intake prior to carbohydrate intake may help ameliorate any blood suger fluctuations due to Glycemic Index factors, however simple carbohydrates (high GI) should be avoided wherever practical. Even oats need to be soaked overnight and cooked briefly, otherwise they become a high GI food and may even affect the absorption of iron. The type of rice used can also influence GI, hence the addition of protein such as fish. Protein supplementations are generally over-used. Daily protein intake should not exceed 1.2g per kg of body weight per day. Dosage for children is less than that for adults. See Nutritional Section of this Site Trunk muscles : Researchers have found that a history of SRC had an increased possibility of having altered size and contraction of their trunk muscles, incuding smaller multifidus, larger quadratus lumborum muscles, and asymmetrical contraction of their transverse abdominis muscles, whereby an increased thickness and resting tone of the right anteroloateral abdominal muscle has been observed (Hides et al 2017 Med Sc Sp Ex, 49, 12, 2385-2393). In this case, by the second incident (Basketball impact), the subject was 15 years of age and 193cm in height. Apart from being very tall for his age he also has joint hypermobility. Combinations of SRC, growth spurt and hypemobility may have had a greater impact on his motor performance making secondary trauma more likely? A 3-6 increased risk of future SRC has been reported in the literature in cases of concussion (Abrahams et al 2014, Br J sp Med, 48, 2, 91-97). In our subject, using the laser repositioning error described above, marked inability to reposition the neck from the left was seen. This concurs with the findings in Australian Football Players (AFL), where a mean of 4.5 degrees of joint position error was reported on the left hand side (Hides et al 2017 Med Sc Sp Ex, 49, 12, 2385-2393). This is noteworthy, as our subjects initial concussion took place during AFL, with the subsequent concussion occurring in Basketball. It should also be remembered that this subject presented to physiotherapy for an ankle injury some 6 months after the initial concussion. Lower limb kinematic exercising ability, emphasising global balance and kinematic 'inverse dynamics' muscular energy strap transfer prinicples, demonstrated strength and balance deficits within the following prgramme. It should be noted that this regime places emphasis on repatitive loading; hence 3 x 40 reps. Interestingly, an investigation comparing lower limb (LL) and back exercises (lumbar extension LE and lumbar stabilisation LS) for runners with chronic low back pain reported  greater improvement in self-rated running capability and knee extension strength in the LL group vs LE and LS groups greater increase in running step length in LL and LE groups and similar reductions in running induced pain and improvement in back muscles across all three exercise groups. (Cai et al 2018, Med Sc Sp EX, 49, 12, 2374-2384) Extrapolation of these results to the current clinical setting suggests the importance of lower limb dynamic stability in cases of concussion. Moreover, recognition of these deficits may have prevented the second incidence of concussion? Conclusion  Investigations, into people with persisting PCS, demonstrated that they applied more force over time to control balance. Helmich et al (2016, Med Sc Ex Sp, 48,  12, 2362-2368) proposed that in regard to cognitive processes, the increase of cerebral activation indicates an increase of attention demanding processes during postural control in altered environments. This is relevant in so far as individuals with post concussive symptomatology have a variety of symptoms including headache, dizziness, and cognitive difficulties that usually resolve over a few days to weeks. However, a subgroup of patients can have persistent symptoms which last months and even years. Complications in differential diagnosis, can arise clinically, when neck dysfunction and altered motor control occur concurrently due to both neck and cerebral pathology. For example, Whiplash and other traumatic head and neck injuries can result in pathology to both regions, whereas, more discreet altered cognitive processing from concussion can result in altered neck motor control. Musculoskelatal Physiotherapy can play a vital part in the treatment of neck dysfunction including the re-establishment of occulomotor proprioception and managing localized strength and cardiovascular exercise regimes. A total body, multi-disciplinary approach which is well co-ordinated amongst practitioners is vital to an optimal outcome.    Updated : 10 February 2018. Original : 17 November 2017 Read More
  • Thu 24 Aug 2017

    Pain in the Brain - neural plasticity

    Pain in the Brain and Neural Plasticity by Martin Krause There are several mechanisms that can create a sensation of pain, which has been described as 'an unpleasent sensory and emotional experience in response to perceived or potential tissue damage'. Pain can be the result of peripheral sensitisation from peripheral inflammation, vascular compromise, necrosis, swelling, etc. Importantly, higher centres of the central nervous system not only perceive such sensitization of the peripheral nerve receptors, they can also modulate and control the intensity and tolerability of the perceived sensation through descending modulation at the peripheral receptor and in the spinal cord and through transcortical mechanisms depending on the 'meaning' and 'context given to the pain. Moreoever, the higher centres can create a 'state' of perceived 'threat' to the body through emotions such as fear and anxiety. Rather than the brain acting as a filter of unwanted sensation, in the higher centre induced pain state, rumination and magnification of sensations occur to create a pathological state.  Paradoxically, representation of body parts such as limbs and individual muscles can reduce in perceived size. In such instances the pain doesn't represent the sensation of pathology but rather pain has become the pathology. Hence, the brain generates pain in the brain, where the pain is perceived to be some sort of non-existant inflammatory or pathological sensation in the periphery. Evidence for this neural plasticity comes from imaging studies, where brain white matter structural properties have been shown to predict transition to chronic pain (Mansour et al 2013, Pain, 154, 10, 2160-2168). Specifically, differential structural connectivity to medial vs lateral prefrontal cortex and connectivity between medial prefrontal cortex and nucleus accumbens has been shown in people with persistent low back pain. In this case the back pain becomes the inciting event and given the persons' structural propensity, establishes specific functional coonectivity strength.  further reading Peripheral input is a powerful driver to neuroplasticity. Information gathered by touch, movement and vision, in the context of pain can lead to mal-adaptive plasticity, including the reorganisation of the somatosensory, and motor cortices, altered cortical excitability and central sensitisation. Examples of somatosensory reorganisation come from the work of Abrahao Baptista when investigating chronic anterior knee pain, who not only demonstrated reduced volume of Vastus Medialis but also is cortical translocation to another part of the cortex. ndividuals with patellofemoral pain (PFP) had reduced map volumes and an anterior shift in the M1 representations, greater overlap of the M1 representation and a reduction in cortical peaks across all three quadriceps (RF, VL, VMO) muscles compared with controls.(Te et al 2017 Pain Medicine, pnx036,   AKP = anterior knee pain The same researcher (Abrahao Baptista) has shown that maximal tolerable electrical stimulation (eg TENS) of muscles can induce normalisation of the cortical changes through a process called 'smudging'. Transcortical stumilation has also been applied as a cortical 'primer' prior to the application of more traditional therapy such as motor re-training, exercise, and manipulation. Body illusions are another novel way to promote the normalisation of cortical function through adaptive neuroplasticity. Examples come from people with hand athritis, whose perception of their hand size is underestimated (Gilpin et al 2015 Rheumatology, 54, 4, 678-682). Using a curved mirror, similar to that in theme parks, the visual input can be increased to perceive the body part as larger (Preston et al 2011 DOI: 10.1093/rheumatology/ker104 · Source:PubMed ) . Irrespective of size, watching a reflection of the hand while performing synchronised movements enhances the embodiment of the reflection of the hand (Whitkopf et al 2017, Exp Brain res, 23, 5, 1933-1944). These visual inputs are thought to affect the altered functional connectivity between areas of the brain thereby affecting the 'pain matrix'. Another, novel way of looking at movement and pain perception is the concept of the motor engram. This has been defined as motor skill acquisition through the modification and organisation of muscle synergies into effective movement sequences. The learning process is thought to be acquired as a child through experientially based play activity. The specific neural mechanisms involved are unknown, however they are thought to include motor map topography reflecting the capacity for skilled movement reorganisation of motor maps in a manner that reflects the kinematics of aquired skilled movement map plasticity is supported by a reorganisation of cortical microcircuitry involving changes in synaptic efficacy motor map integrity and topography are influenced by various neurochemical signals that coordinate changes in cortical circuitry to encode motor experience (Monfils 2005 Neuroscientist, 11, 5, 471-483). Interestingly, it is an intriguing notion that accessing motor engrams from patterns aquired prior to the pain experience might lead a normalisation of brain activity. My personal experience of severe sciatica with leg pain, sleepness nights and a SLR of less than 30 degrees, happened to coincide with training my 9 year old sons soccer training. I was noticing that the nights after i trained the children, I slept much better and my range of movement improved. I commenced a daily program of soccer ball tricks which i had been showing the kids, including 'juggling', 'rainbows' and 'around the worlds'. Eventually, I even took up playing soccer again after a 30 year abscence from the sport. Other than new activity related pain issues (DOMS), four years on, the sciatica hasn't returned. I can only conclude that this activity activated dormant childhood motor engram, worked on global balance, mobilised my nerve, encouraged cross cortical activity and turned my focus into finctional improvement. Further explainations for my expereience comes from evidence suggesting that a peripheral adaptive pain state is initiated, whereby transcortical inhibiton occurs by the contralaleral hemisphere to the one which controls the affected limb. Additionally, excitation cortical (M1) drive of the muscles of the contralateral limb to the one which is in pain also occurs. In such cases re-establishement of motor drive to the affected side is important. In terms of tendon rehabilitation, external audtory and visual cues using a metronome have been employed and are showing promising results (Ebonie Rio et al 2017 Personal communication). In terms of my experience with the soccer ball tricks, the external visual cues and the cross talk from using left and right feet, head, shoulders, and chest during ball juggling manouvers, whilst calling the rhythm to the kids may have been the crucial factor to overcome the dysfunctional brain induced pain - muscle inco-ordination cycle, which I was in. Additionally, I was cycling which allowed me to focus on motor drive into the affected.limb. However, work by Lorrimer Moseley on CRPS has established that 'brain laterality' must be established before commencing trans-cortical rehabilitation techniques. Lorrimer's clinical interventions use 'mirror imaging' techniques which are only effective once the patient is able to discriminate the left and right sides of the affected body parts, presented visually, in various twists and angles.   Alternatively, the altered pain state can result in a hostage like situation, whereby the pain takes control. Similar to the 'Stockholm Syndrome' where the hostage begins to sympathise with their captors, so do some peoples brain states, where it begin to sympathise with the pain, creating an intractable bondage and dysfunctional state. One screening question which may reflect commitment to the process of rehabilitatation is to question whether they were able to resist the cookie jar when they were a child? Or were they committed to any sporting endeavours as a child? This may give some indication for the presence of motor engrams which can be used to overcome dysfunctional pain induced muscle synergies (neurotags), but also indicate an ability to be self disciplined, as well as being able to reconcile and identify goal oriented objectives, in spite of the cognitive pain processes? Remember that neurons that fire together, wire together. Uploaded : 18 October 2017 Read More
  • Thu 03 Aug 2017

    Sickle Cell Trait and Acute Low Back Pain

    Researchers believe that lumbar paraspinal myonecrosis (LPSMN) may contribute to the uncommon paraspinal compartment syndrome and that sickle cell trait (SCT) may play a role. Sustained, intense exertion of these lumbar paraspinal muscles can acutely increase muscle size and compartment pressure and so decrease arterial perfusion pressure. This same exertion can evoke diverse metabolic forces that in concert can lead to sickling in SCT that can compromise perfusion in the microvasculature of working muscles. In this manner, they believe that SCT may represent an additional risk factor for LPSMN. Accordingly, they presented six cases of LPSMN in elite African American football players with SCT. See link below Read More
  • Thu 03 Aug 2017

    Ibuprofen, Resistance Training, Bone Density

    Taking Ibuprofen immediately after resistance training has a deleterious effect on bone mineral content at the distal radius, whereas taking Ibuprofen or undertaking resistance training individually prevented bone mineral loss. Read More
  • Tue 11 Jul 2017

    Mitochondrial Health and Sarcopenia

    The aging process (AKA 30 years of age onwards), in the presence of high ROS (reactive oxygen species) and/or damaged mitochondrial DNA, can induce widespred mitochondrial dysfunction. In the healthy cell, mitophagy results in the removal of dysfunctional mitochondria and related material. In the abscence of functional removal of unwanted mitochondrial material, a retrograde and anterograde signalling process is potentially instigated, which results in both motor neuronal and muscle fibre apoptosis (death) (Alway, Mohamed, Myers 2017, Ex Sp Sc Rev, 45, 2, 58-69). This process is irreversible. Investigations in healthy populations, have shown that regular exercise improves the ability to cope with regular oxidative stress by the buffering and 'mopping up' of ROS agents which are induced as a result of exercise. It is plausible and highly probable that regular exercise throughout life can mitigate against muscle fibre death (Sarcopenia). Importantly, this process of muscle fibre death can commence in the 4th decade of life. and be as much as 1% per year. Reduction of muscle mass can result in immune and metabolic compromise, including subclinical inflammation, type II diabetes as well as the obvious reduction in functional capacity for activities of daily living. Published 11 July 2017 Read More
  • Thu 22 Dec 2016

    Ehlers Danlos Syndrome

    Is your child suffering Ehlers Danlos Syndrome? Hypermobile joints, frequent bruising, recurrent sprains and pains? Although a difficult manifestation to treat, physiotherapy can help. Joint Hypermobility Syndrome (JHS) by Martin Krause When joint hypermobility coexists with arthralgias in >4 joints or other signs of connective tissue disorder (CTD), it is termed Joint Hypermobility Syndrome (JHS). This includes conditions such as Marfan's Syndrome and Ehlers-Danlos Syndrome and Osteogenesis imperfecta. These people are thought to have a higher proportion of type III to type I collagen, where type I collagen exhibits highly organised fibres resulting in high tensile strength, whereas type III collagen fibres are much more extensible, disorganised and occurring primarily in organs such as the gut, skin and blood vessels. The predominant presenting complaint is widespread pain lasting from a day to decades. Additional symptoms associated with joints, such as stiffness, 'feeling like a 90 year old', clicking, clunking, popping, subluxations, dislocations, instability, feeling that the joints are vulnerable, as well as symptoms affecting other tissue such as paraesthesia, tiredness, faintness, feeling unwell and suffering flu-like symptoms. Autonomic nervous system dysfunction in the form of 'dysautonomia' frequently occur. Broad paper like scars appear in the skin where wounds have healed. Other extra-articular manifestations include ocular ptosis, varicose veins, Raynauds phenomenon, neuropathies, tarsal and carpal tunnel syndrome, alterations in neuromuscular reflex action, development motor co-ordination delay (DCD), fibromyalgia, low bone density, anxiety and panic states and depression. Age, sex and gender play a role in presentaton as it appears more common in African and Asian females with a prevalence rate of between 5% and 25% . Despite this relatively high prevalence, JHS continues to be under-recognised, poorly understood and inadequately managed (Simmonds & Kerr, Manual Therapy, 2007, 12, 298-309). In my clinical experience, these people tend to move fast, rely on inertia for stability, have long muscles creating large degrees of freedom and potential kinetic energy, resembling ballistic 'floppies', and are either highly co-ordinated or clumsy. Stabilisation strategies consist of fast movements using large muscle groups. They tend to activities such as swimming, yoga, gymnastics, sprinting, strikers at soccer. Treatment has consisted of soft tissue techniques similar to those used in fibromyalgia, including but not limited to, dry needling, myofascial release and trigger point massage, kinesiotape, strapping for stability in sporting endeavours, pressure garment use such as SKINS, BSc, 2XU, venous stockings. Effectiveness of massage has been shown to be usefull in people suffering from chronic fatigue syndrome (Njjs et al 2006, Man Ther, 11, 187-91), a condition displaying several clinical similarities to people suffering from EDS-HT. Specific exercise regimes more attuned to co-ordination and stability (proprioception) than to excessive non-stabilising stretching. A multi-modal approach including muscle energy techniques, dry needling, mobilisations with movement (Mulligans), thoracic ring relocations (especially good with autonomic symptoms), hydrotherapy, herbal supplementaion such as Devils Claw, Cats Claw, Curcumin and Green Tee can all be useful in the management of this condition. Additionally, Arnica cream can also be used for bruising. Encouragment of non-weight bearing endurance activities such as swimming, and cycling to stimulate the endurance red muscle fibres over the ballistic white muscles fibres, since the latter are preferably used in this movement population. End of range movements are either avoided or done with care where stability is emphasized over mobility. People frequently complain of subluxation and dislocating knee caps and shoulders whilst undertaking a spectrum of activities from sleeping to sporting endeavours. A good friend of mine, Brazilian Physiotherapist and Researcher, Dr Abrahao Baptista, has used muscle electrical stimulation on knees and shoulders to retrain the brain to enhance muscular cortical representation which reduce the incidence of subluxations and dislocations. Abrahao wrote : "my daughter has a mild EDS III and used to dislocate her shoulder many times during sleeping.  I tried many alternatives with her, including strenghtening exercises and education to prevent bad postures before sleeping (e.g. positioning her arm over her head).  What we found to really help her was electrostimulation of the supraspinatus and posterior deltoid.  I followed the ideas of some works from Michael Ridding and others (Clinical Neurophysiology, 112, 1461-1469, 2001; Exp Brain Research, 143, 342-349 ,2002), which show that 30Hz electrostim, provoking mild muscle contractions for 45' leads to increased excitability of the muscle representation in the brain (at the primary motor cortex).  Stimulation of the supraspinatus and deltoid is an old technique to hemiplegic painful shoulder, but used with a little different parameters.  Previous studies showed that this type of stimulation increases brain excitability for 3 days, and so we used two times a week, for two weeks.  After that, her discolcations improved a lot.  It is important to note that, during stimulation, you have to clearly see the humerus head going up to the glenoid fossa" Surgery : The effect of surgical intervention has been shown to be favourable in only a limited percentage of patients (33.9% Rombaut et al 2011, Arch Phys Med Rehab, 92, 1106-1112). Three basic problems arise. First, tissues are less robust; Second, blood vessel fragility can cause technical problems in wound closure; Third, healing is often delayed and may remain incomplete.  Voluntary Posterior Shoulder Subluxation : Clinical Presentation A 27 year old male presented with a history of posterior shoulder weakness, characterised by severe fatigue and heaviness when 'working out' at the gym. His usual routine was one which involved sets of 15 repetitions, hence endurance oriented rather than power oriented. He described major problems when trying to execute bench presses and Japanese style push ups. In a comprehensive review of 300 articles on shoulder instability, Heller et al. (Heller, K. D., J. Forst, R. Forst, and B. Cohen. Posterior dislocation of the shoulder: recommendations for a classification. Arch. Orthop. Trauma Surg. 113:228-231, 1994) concluded that posterior dislocation constitutes only 2.1% of all shoulder dislocations. The differential diagnosis in patients with posterior instability of the shoulder includes traumatic posterior instability, atraumatic posterior instability, voluntary posterior instability, and posterior instability associated with multidirectional instability. Laxity testing was performed with a posterior draw sign. The laxity was graded with a modified Hawkins scale : grade I, humeral head displacement that locks out beyond the glenoid rim; grade II, humeral displacement that is over the glenoid rim but is easily reducable; and grade III, humeral head displacement that locks out beyond the glenoid rim. This client had grade III laxity in both shoulders. A sulcus sign test was performed on both shoulders and graded to commonly accepted grading scales: grade I, a depression <1cm: grade 2, between 1.5 and 2cm; and grade 3, a depression > 2cm. The client had a grade 3 sulcus sign bilaterally regardless if the arm was in neutral or external rotation. The client met the criteria of Carter and Wilkinson for generalized liagmentous laxity by exhibiting hyperextension of both elbows > 10o, genu recurvatum of both knees > 19o, and the ability to touch his thumbto his forearm Headaches Jacome (1999, Cephalagia, 19, 791-796) reported that migraine headaches occured in 11/18 patients with EDS. Hakim et al (2004, Rheumatology, 43, 1194-1195) found 40% of 170 patients with EDS-HT/JHS had previously been diagnosed with migraine compared with 20% of the control population. in addition, the frequency of migraine attacks was 1.7 times increased and the headache related disability was 3.0 times greater in migraineurs with EDS-HT/JHS as compared to controls with migraine (Bendick et al 2011, Cephalgia, 31, 603-613). People suffering from soft tissue hypermobility, connective tissue disorder, Marfans Syndrome, and Ehler Danlos syndrome may be predisposed to upper cervical spine instability. Dural laxity, vascular irregularities and ligamentous laxity with or without Arnold Chiari Malformations may be accompanied by symptoms of intracranial hypotension, POTS (postural orthostatic tachycardia syndrome), dysautonomia, suboccipital "Coat Hanger" headaches (Martin & Neilson 2014 Headaches, September, 1403-1411). Scoliosis and spondylolisthesis occurs in 63% and 6-15% of patients with Marfans syndrome repsectively (Sponseller et al 1995, JBJS Am, 77, 867-876). These manifestations need to be borne in mind as not all upper cervical spine instabilities are the result of trauma. Clinically, serious neurological complications can arise in the presence of upper cervical spine instability, including a stroke or even death. Additionally, vertebral artery and even carotid artery dissections have been reported during and after chiropractic manipulation. Added caution may be needed after Whiplash type injuries. The clinician needs to be aware of this possibility in the presence of these symptoms, assess upper cervical joint hypermobility with manual therapy techniques and treat appropriately, including exercises to improve the control of musculature around the cervical and thoracic spine. Atlantoaxial instability can be diagnosed by flexion/extension X-rays or MRI's, but is best evaluated by using rotational 3D CT scanning. Surgical intervention is sometimes necessary. An interesting case of EDS and it's affect on post concussion syndrome can be read elsewhere on this site. Temperomandibular Joint (TMJ) Disorders The prevelence of TMJ disorders have been reported to be as high as 80% in people with JHD (Kavucu et al 2006, Rheum Int., 26, 257-260). Joint clicking of the TMJ was 1.7 times more likely in JHD than in controls (Hirsch et al 2008, Eur J Oral Sci, 116, 525-539). Headaches associated with TMJ disorders tend to be in the temporal/masseter (side of head) region. TMJ issues increase in prevelence in the presence of both migraine and chronic daily headache (Goncalves et al 2011, Clin J Pain, 27, 611-615). I've treated a colleague who spontaneously dislocated her jaw whilst yawning at work one morning. stressful for me and her! Generally, people with JHD have increased jaw opening (>40mm from upper to lower incisors). Updated 17 October 2017  Read More
  • Fri 09 Dec 2016

    Physiotherapy with Sharna Hinchliff

    Physiotherapy with Sharna Hinchliff    Martin is pleased to welcome the very experienced physiotherapist Sharna Hinchliff to Back in Business Physiotherapy for one on one physiotherapy sessions with clients in 2017.  Sharna is a passionate triathelete and mother and has had several years experience working locally and internationally (New York and London) in the field of physiotherapy. Originally from Western Australia, Sharna graduated from the world renowned Masters of Manipulative Physiotherapy at Curtin University. read more Read More

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Updated : 10 May 2014

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Copyright Martin Krause 1999 - material is presented as a free educational resource however all intellectual property rights should be acknowledged and respected