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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE March 2023 Improving Clinical Decision Making on Scapular Dyskinesis with Subacromial Shoulder Pain by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 50 yr old female with chronic shoulder pain and stiffness comes to the office for a consult after failing two prior bouts with physical therapy and numerous injections. Recent MRI shows RC tendinopathy and small labral tearing. She is not in acute distress but limited significantly with ADL and fitness/recreational activities. AROM into elevation and abd’d rotations is most restricted along with neutral ER. She has painful weakness with RC testing but no signs of frank tearing. Scapular dyskinesis noted during descent from flexion and with resisted flexion at 1300. She did have prior dx of Adhesive Capsulitis and did not recover fully but did not feel PT was helping. She demonstrated a typical PT HEP routine of GH stretches and scapular retraction, serratus protraction/plus, and RC PRE. My clinical thinking is: Consider arthroscopy since PT and injections failed. Consider MUA to recover ROM unable to be attained through standard PT care and compliant HEP. Refer to PT for more thorough manual therapy and customized exercise including specifically serratus work to reduce scapular dyskinesis contributing to ongoing RC overload/irritation. Refer for deep tissue work with LMT to attempt ROM recovery and then send back to PT. CURRENT EVIDENCE Tangrood ZJ, Sole G, Riberio DC. Is there an association between changes in pain or function with changes in scapular dyskinesis: A prospective cohort study. Musculoskeletal Science and Practice. (48) 2020. 1-7. https://doi.org/10.1016/j.msksp.2020.102172 (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) SUMMARY: Shoulder pain is a common diagnosis seen by physicians/orthopedists. Oftentimes scapular dyskinesis (SD) may be present. Testing for SD using reliable methods and determining potential meaningfulness contribute to clinical decision making regarding treatment recommendations, especially in the case of “failed” conservative care where more invasive procedures are not called for or necessary yet. Current data has both variable and contradictory findings surrounding SD and the related serratus anterior and/or lower trapezius involvement, along with a lack of clear causal level relationships to pain and/or injury. Tangrood et al demonstrated an association over 8 weeks in a group of 44 participants with shoulder pain that improvements in scapular dyskinesis testing was associated with improved PSFS self-report function scores. One confounding variable included that 65% of those completing all testing were receiving physical therapy and 35% were not. These groups were not separately analyzed which may have shed more light on causes for improvement. Common SD approaches in physical therapy often involve activation of the serratus anterior (SA) that utilizes a “plus” movement (i.e. protraction). While the SA certainly does and can protract the shoulder this risks activation of the pec minor as well with the ongoing risk of facilitating a protraction posturing that otherwise has been identified as a potential risk factor for shoulder pain. In overhead activities the scapula must tilt posteriorly while upward rotating. Many traditional methods of testing and training for SD also utilize long lever positions that painful shoulders struggle in. Authentic biomechanics approaches are necessary to promote scapular integrity via medial border stabilization (superior through inferior angles) along with upward rotation without compromising biceps or rotator cuff tendons or labral structures. A physician’s ability to identify SD in clinical exams in order to prescribe and monitor appropriate PT is often key in achieving optimal outcomes. Background: Scapular dyskinesis (SC) is a debated topic and it is unclear whether it is causative of shoulder dysfunction and subacromial pain or a consequence of symptoms, and, whether the presence of and changing of SD affects function or pain. Purpose: To assess the association of changes in subacromial shoulder pain or function with SD changes over time. Methods: Observational, prospective, cohort study of 44 participants (37 who completed baseline and 8 wk follow up testing), with 24 receiving physical therapy and 13 no treatment, using Numeric Pain Rating Scale (NPRS) 0-10 scale for “at rest” and “during movement” , self-report Patient Specific Functional Scale (PSFS), and the scapular dyskinesis test (0=normal scapular movement and 6= highest scapular dyskinesis, summing using Kibler et al system scoring). Findings: Improvement in function showed a fair association with improved SD (correlation coefficient = -0.4) while no associations found for pain at rest or pain with movement to changes in SD. 89% of patients showed subtle to obvious SD at baseline. Participants showed no changes in “pain at rest”, medium improvements of “pain during movement”, and large function improvements (28.0 mean PSFS score difference w p=0.000) but no significant SD changes. Author's Conclusion: Improved function in patients with subacromial pain was associated with improvements in scapular dyskinesis. Future studies needed to determine causal effects. THE PEAK PERFORMANCE PERSPECTIVE Shoulder pain is one of the most common orthopedic complaints seen by orthopedists and PCP’s alike. One of the most frequent diagnoses includes some form of RC syndrome (tendinitis, tendinosis, tears, impingement, etc.) which contributes to subacromial shoulder pain. Physicians discerning best practices for non-operative care recommendations are often tasked with determining obvious contributing factors they expect to be addressed in physical therapy. Understanding and testing for scapular dyskinesis underlies prescribing practices for these patients and especially for cases of “failed care” where more simple protocol based therapy approaches have not worked. It is also potentially a great example of the concept “because a muscle can doesn’t mean that it does” - in regard to how we classically test and exercise in comparison to how it actually functions. Directing care for shoulder pain of various sorts, whether it be tendon related, bursal, labral, or instability related can be difficult when considering there are few or even no clear truly “BEST practices” approaches that have been proven clearly superior to others. Many studied are more so “only practices” or “doing this happens to work” versus actually finding “bests” in treatment. That makes prescribing care and designing rehab difficult. Certainly there is a blending of science with “art”/experience etc. Secondarily, other kinetic chain contributing factors, whether local to the scapulothoracic articulation, the thoracic spine, or even related to more distal/distant joints (especially when considering complex body movements such as overhead athlete mechanics or total body lifting/reaching ADL demands) have construct validity but often lack clear “evidence” in the literature. Scapular dyskinesis (SD) is one of those entities that has been identified but suffers from conflicting evidence as to its contribution and meaningfulness. Nevertheless, it may be one of those important factors for physicians to consider when prescribing physical therapy. Physicians must therefore consider how SD should be assessed in the office and how are therapists/athletic trainers addressing this through exercises. Kibler et al (2013) and others have identified abnormal scapular mechanics, or scapular dyskinesis, as a potential contributing factor. Kibler proposed a four pattern grading system with Pattern I being inferior angle prominence (tipping), Pattern II being medial border prominence (winging), Pattern III being early scapular elevation or excessive upward rotation (elevation), and Pattern IV being normal rhythm. In-office measurement of scapular dyskinesis can be done utilizing the scapular dyskinesis test (SDT) by Kibler. Arms are raised into flexion to maximum elevation and lowered 3-5x (adding 3-5# to each hand for up to 10 repetitions may be used to accentuate abnormal findings). Most often altered motion occurs during the eccentric descent. Ramiscal et al (Clin Shoulder & Elb 2022) showed grouping Patterns I-III as a “yes” and Pattern IV as a “no” resulted in intra-rater reliability kappa of 0.92 and inter-rater values of 0.85 for expert PT’s with asymptomatic individuals. This sort of chunking certainly reduces potential for reliability errors related to the challenge of ensuring consistency with limited/poor objective measurable means of determining when exactly a “winging” event at the respective scapular reference points has occurred. Break tests of flexion at 1300, abduction at 130-1500, and extension with arms at the side - looking for significant scapular movement should also be done. Kibler wisely has reminded (Int J Sports PT 2022) that lack of research agreement is, in part, related to multiple muscles attaching to the scapula allow for simultaneous and synchronous activation and stabilization during arm movement” causing variability in how individuals perform the same task, thoracic anatomy and varied muscle fiber orientation does not allow for single plane scapular movement - scapular motion involves complex translations/rotations w coupled muscle activation. He differentiates “neurologic” winging that remains disconnected through ascent and descent phases while “altered scapular positioning” is more so evident in descent phases. This differentiation on the surface would seem plausible, however, length-tension relationships, impacts of tissue tightness at different arm positions, and nuances of force couples may otherwise explain why the dyskinesis of abnormal scapular movement often occurs with eccentric phases only or more so than during concentric phases. Causal effects of scapular dyskinesis to pain and/or injury has not been clearly established Finally, Kibler also cautions that scapular dyskinesis is not a “diagnosis” in medical terms but an impairment therefore clinical utility, measuring diagnostic accuracy, is difficult and even inappropriate when no gold standard exists for comparison. Tangrood et al provide some evidence of an association of scapular dyskinesis reduction with improved shoulder function on self-report PSFS questionnaire responses. Repeated measures correlation coefficient showed 16% of the variability in PSFS score changes is explained by scapular dyskinesis changes. Strength of findings are weakened because confounding factors (symptom duration, physical demands, etc.) were not controlled for, especially the fact that 65% of those completing all testing participated in physical therapy (without known parameters) while 35% did not, creating a heterogeneous sample. Data was not analyzed for differences between these groups. Since blinding was not done the risk of examiner bias cannot be ruled out. Subtle dyskinesis made up 57% of the baseline group test findings. Measurement properties make determining change for these subjects more difficult to ascertain. Clinically speaking we find not only for a high percentage of shoulder pain patients that SD is present in some manner but that especially for many of the “failed PT” cases we see that this has not been addressed in rehab or maybe more importantly was only addressed with simple protraction exercises. One consideration is determining the authentic function of a muscle in ADL or sport. Again, we would caution that “because a muscle can doesn’t mean that it does” in regard to certain tests traditionally done or exercises utilized. During elevation function so often related to shoulder overloads and pain the scapula does need to upward rotate but that is coupled with posterior tipping/adduction especially for cocking positions of overhead athletics. The majority of SD exercises, owing to the classically viewed Serratus Anterior role in its capacity to protract the scapula, are most often pre-engaged or emphasized by intentional or forceful protraction. We would contend that in many typical ADL and athletic arm movements the authentic biomechanics necessary contradict coupling upward rotation with anterior tipping/abduction (ie protraction). Yes, that “works” and “fatigues” the Serratus Anterior, leading to a self-fulfilling prophecy of sorts that the exercise is effective. Functional biomechanics would seem to differ with that conclusion. In unique demands of pushing and throwing/propelling the arm and related objects forward certainly serratus function protracting the scapula is an absolute necessity. Relegating the majority of serratus anterior training for the sake of reducing SD though may be oversimplifying muscle function. Because it can doesn’t mean that it is…in this movement or case. Most testing and exercises related to SD factors (i.e. serratus and lower traps) tend to place the arm in longer lever positions. While this creates loads that may quickly increase lever arm effects and identify inadequacies it also risks eliciting pain in inflamed or damaged tissues that causes inhibition of otherwise potentially normal muscles. This is especially true for the “T” and “Y” tests and exercises so often done to address SD. We attempt to approach SD with a functional biomechanics mindset that we are seeking scapular integrity on the thoracic cage wall, with whatever posterior or anterior tipping required, and with adequate and not excessive upward rotational mechanics. While this is not easy to measure objectively or to isolate to singular muscles, due in part to the related pain generating tissue implications noted above, it leads to what we believe is a more authentic approach to scapular dyskinesis through “de-winger” thinking versus promotion of protraction dominated successful activation of serratus anterior that risks over stimulus of pec minor and what would otherwise be abnormal posturing. Kinetic chain biomechanics involving facilitation of thoracolumbar coupling, for example, into same sided rotation and side bending along with extension during cocking phases for overhead athletes, must be addressed if scapular positioning is to be optimized. This involves testing for and addressing Type I and Type II spinal mechanics along with other core and hip function. Too often we see patients having failed traditional PT approaches because classic exercises essentially rely on long lever arm loading into at-risk positions that cause pain of the irritated rotator cuff tendons or labral injury. Care must be taken in many cases of shoulder pain to customize loading of the Serratus Anterior and/or Lower Trapezius to achieve scapular integrity while avoiding symptom exacerbation. The case below involves a patient who had scapular dyskinesis as a contributing factor that required careful attention in testing and exercise. THE PEAK PERFORMANCE EXPERIENCE Holli said: “I had tried a couple of rounds of physical therapy elsewhere with not a lot of improvement in my shoulder after two years of pain. I’m so happy I was finally able to get my range of motion back and not be in pain all day!” History: 50 yr old female nurse fell in 2020 injuring her wrist and then developing L non-dominant shoulder pain. She had PT at a local hospital based outpatient clinic and transitioned to HEP but developed adhesive capsulitis and was then seen for PT several more months. Pt had a total of 4 corticosteroid injections. Now presenting two years after the original fall to address ongoing issues. Subjective: 6/10 max pain with reported function at 80%. Symptoms aggravated by elevation ADL, unable to sleep L sidelying, unable to do pushups and other fitness exercises, cannot kayak. Objective: (*=pain) Eval 5 mo DC ReEval Flexion AROM 1330 / 1660 1670 900 Abd IR AROM 130 / 300 350 900 Abd ER AROM 950 / 1200 NT Wall Serratus Anterior test L @ 4 / 5 with < moderate winging 5- / 5 Pec minor Scapular Retraction (hand @ head) Mod L tight < Min Flexion isometric 1.8 kg * (24%) 5.5 kg (74%) OH reaching (pressing) 5# 33x ( < 66%) 12# 12x (71%) 800 Abd w 900 ER test NT 8# 76% painfree Key Findings: At evaluation Pt had limited elevation AROM along with posterior RC/capsule restriction in Horz Abd and Abd IR. Isometric testing revealed weak/painful elevation and Abd ER along w weak Serratus Anterior during wall scapular integrity resistive test - showing scapular winging medial border. Thoracic L rotation was asymmetrically limited. Impingement / RC tendonitis special tests were (+). Treatment: Manual therapy emphasis to pec minor release, thoracic rotation mobilizations, and especially GH jt mob’s for all motions and capsular restrictions using holding style techniques vs std oscillation approach. Sustained stretching HEP initiated including for pec minor and thoracic L rotation combined with AROM integration drills immediately following. Scapular dyskinesis addressed with Serratus drills in both NWB and WB environments, focusing on “de-winging” emphasis of maintaining scapular integrity during related modified lever arm loaded LUE movements to optimize successful maintenance of scapular positioning…first accomplished in scapular plane and increasingly loaded in sagittal plane. These were eventually moved to upright 900 and then overhead demand positions to mimic authentic biomechanics necessary for ADL and fitness needs. Progressive shoulder/scapular PRE were done moving from BID high reps/low load toward eventual TIW 3x10-12 reps work and including functional considerations for fitness goal movements. Outcome: Pt happy with her progress and wanted to continue remaining work on her own with (I) HEP only. She had had challenges with regular attendance due to other life and work schedule demands. Holli rated function at 90% with Quick DASH 7% and Sport rating 24%. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester, and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE December 2021 New Evidence of Essential Thoracic Mobility for Normal Upper Limb Function by Allison Pulvino, PT, MSPT, CMP, FAFS Clinical Scenario...What would you do? A 35 yr old male firefighter who enjoys playing volleyball on an intermediate level 6's team at the local indoor courts gradually developed complaints of R dominant hitting arm shoulder pain superior/anteriorly during volleyball hitting > blocking and with overhead work and ADL demands. Plain films are unremarkable. Clinical exam shows tenderness at the supraspinatus and LHB tendons, (+) impingement - Rotator cuff syndrome tests, weakness/pain especially with elevation and ER resistive tests. He has a typical "poor posture" both statically and also during AROM testing. You're ordering Physical Therapy and seeing him back in 4 weeks to consider if he is progressing adequately and to decide if further diagnostic testing is necessary. Your expectations of his PT evaluation/report......subsequent treatment would be...? Palpation, special testing, resistive testing.....modalities + simple shoulder stretching & strengthening program AROM shoulder/trunk, palpation, special testing, resistive testing....modalities, manual therapy to trunk/scap and shoulder prn, stretches prn, strengthening scapulothoracic and shoulder muscles/function per findings AROM, resistive testing...simple shoulder protocol (Jobe's exercises or Thrower's Ten) AROM shoulder + kinetic chain trunk/scapula, special testing, palpation, resistive testing... Class IV laser, stretching sleeper/pec major/Hor Add posterior RC, strengthening RC....address thoracic spine if not improving CURRENT EVIDENCE Heneghan et al. Thoracic Spine Mobility, An Essential Link In Upper Limb Kinetic Chains in Athletes: A Systematic Review. Translational Sports Medicine. 2019, 2(6). 301-305. https://doi.org/10.1002/tsm2.109 SUMMARY: Upper limb injury and pain is a commonplace issue, especially of the shoulder, for many athletes and non-athletes alike. Determining and prescribing what "standard care" is for shoulder and upper limb injuries/pain often focused solely on the local tissues but new evidence presented by Heneghan et al supports the concepts of kinetic chain "regional interdependence" that must understood by all musculoskeletal providers in order to optimally care for our patients. These biomechanics relationships, in this case with the thoracic spine, provide a potential source for contributing factors causing tissue overload and kinetic chain issues that also may delay recovery. Understanding these are critical for prescribing treatment and especially performing successful physical therapy in these cases. Heneghan et al provide some important insights into the relationship between normal shoulder ROM and associated thoracic spine mobility, especially noted during end ranges of shoulder flexion more so than other elevation directions and mutually more so than during other motions. Achieving unilateral or bilateral elevation ranges produced the greatest thoracic spine mobility demand, that being extension during shoulder flexion. Clinically we often see kinetic chain factors either addressed generically or not at all. Prescriptions rarely specify expectations of thoracic/scapular assessment and care. Patients seen due to "failed PT" elsewhere often report being handed a generic exercise sheet to learn and perform at home...the same sheet other shoulder patients were using. Assessing and restoring WNL thoracic/scapular kinetic chain function is necessary for the shoulder/upper limb to perform normally. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) You can read the full version below Background: Traditional exercising and rehabilitation for shoulder limitations and injuries continue to be heavily focused on GH joint function and strength/mobility, and active and athletic populations can at times have recovery programs falling short to achieve full function. This study looks at thoracic mobility in unilateral and bilateral UE overhead ROM to assess kinetic chain connections in regards to necessities with functional movement. Methods: A systematic review through June 2018 of 554 initially retrieved studies resulted in seven meeting eligibility criteria that included a population of healthy 18-40 year old men and women (Males= 33%) with a sample size of 168 individuals, including 20 athletes. Thoracic spine extension, rotation, and lateral flexion were assessed during upper limb abduction, right scapular elevation, flexion, extension and scapular elevation, flexion and abduction, external rotation, functional flexion and (B) elevation using various data acquisition/measurement systems. Results: Unilateral and bilateral UE full flexion elevation resulted in 6.7-8.0 deg and 12.0 – 15.0 deg of thoracic extension, respectively. Unilateral and bilateral UE abduction elevation resulted in 3-4 degrees 9.0 – 12.8deg of thoracic extension. Lateral flexion ranged from 2.7 – 9.0 deg between various studies during different planes of unilateral end ranges of elevation, most often in contralateral direction and at lower thoracic segments especially. Thoracic rotation ranged from 2.1 – 11 deg for the various planes of elevation, greatest being scaption and abduction. Lateral flexion and rotation were negligible during (B) maximal elevation. Thoracic movement in early/mid ranges of movement have poor evidence/agreement with singular studies reporting 11 deg extension at mid range flexion and 8.9 deg during ER AROM. Author's Conclusion: There was significant thoracic extension occurring in flexion, abduction and scapular elevation in unilateral and bilateral UE elevation. Although the evidence quality is low, sample size small, and more research would be beneficial in an athletic population, a more thorough thoracic spine focus is warranted for practitioners working with athletes on functional UE movements involving the kinetic chain. THE PEAK PERFORMANCE PERSPECTIVE: As a referring physician you’re often challenged by making determinations of what treatments to recommend or what “good” therapy entails when prescribing physical therapy for various upper limb conditions. Common expectations for traditional physical therapy would certainly include possibly local modalities to reduce pain and inflammation, manual therapy, and local stretching and strengthening. Evidence has been lacking regarding the kinetic chain importance of the thoracic spine’s mobility and shoulder/upper limb function. Heneghan et al provide some valuable data that helps identify the relationship of thoracic motion during arm movements, providing a basis for prescribing and expecting that shoulder/upper limb care will assess and treat related thoracic spine limitations that may be contributing factors or could be a source of slow recovery or “failed” conservative care. Individuals coming into a physical therapy clinic with pain and limitations with their shoulder or elbow do not expect that their pain is caused from joints or muscle limitations from a region not directly at the site of their pain. But what we find as movement specialists during kinetic chain assessments, supported by Heneghan et al's findings, is that thoracic spine limitations in any one of the three planes, can play a role in limiting arm mobility (especially thoracic extension related to overhead function) resulting in negative effects during work, ADL, and/or athletic activities performed. These limitations more proximally at the thoracic spine certainly happen for a variety of reasons, most commonly sedentary work duties (especially with prolonged neck flexion or computer screen use) , poor posturing in general, or activities involving prolonged/repetitive spinal flexion such as masonry and lifting from lower levels. Another key component can be attributed to classic forms of fitness training that many have become accustomed to involving isolated single plane movements such as weight machines or group fitness classe. These are commonly performed with bilateral upper extremities simultaneously which can be safe and effective for some, but if there are other mobility restrictions such as with the spine, then not just the shoulder but the more distal joints can be stressed more and in abnormal locations. Those forms of exercises also do not necessarily train one's body for the stresses of athletic events including spiking a volleyball, swimming freestyle or backstroke for example, or throwing/serving overhand in baseball, volleyball or tennis. The repeated stresses on those more mobile joints such as the shoulder, in the presence of thoracic mobility limitations, can then lead to instability and possible more serious tissue damage and even the need for surgery when not addressed in time. Heneghan et al reminds that there exists very little literature on how more proximal segments in the kinetic chain, including the thoracic spine and pelvis, affect more distal segments in athletic events. They do, however, cite that other researchers have discovered approximately 55% of total force and kinetic energy during a throw is derived from the thoracic spine and approximately 80% of total axial rotation is utilized. They also noted prior research demonstrating a 3x higher elbow/shoulder injury prevalence for softball players with limited trunk rotation mobiity. This leads to the question - “Why do so many shoulder rehab programs only focus the involved shoulder, elbow, or wrist?” It has been our experience that many traditional UE strength exercise movements are not tolerated well by patients in a rehabilitation program for "shoulder pain", including unilateral isolated, typically long lever type movements with either weights or resistance bands, as they can excessively stress GH jt structures, and sometimes even bring on more impingement symptoms or joint crepitus, and pain in general - especially because they are oftentimes taught in very strict postures that prevent thoracic mobility contribution to total motion. Some examples include traditional long lever exercises like flexion and abduction raises, empty cans, full can scaption, T-Y-I (mid/lower trap stimulus), wall walking, door sliders (abd press in ER) among others. While these aren't "bad" exercises, they can easily be inappropriately applied at the wrong time during recovery, through ROM that is irritating, and often are done intentionally preventing scapulothoracic motion under the auspices of "strict technique" and "isolation" concepts. These patients or fitness enthusiasts often have increased thoracic kyphosis and anteriorly tipped scapulae, which then prevents fluid and necessary humeral head mobility and control. So if proximal structures that are limited are not addressed, oftentimes recovery is slow or absent leading the patient to report back to their physician complaining that nothing has changed, or the pain has not decreased, or they still cannot play their favorite sport. The appearance of a potential “failed case” of PT then may trigger more expensive testing or injections etc when, in fact, it was simply more thorough kinetic chain care that was needed. Once addressing thoracic and lumbar spine limitations, the scapular and GH joint mechanics and ultimately functional use tends to improve. A great example would be the financial planner sitting 40 to 50 hours per week and then reporting he/she is feeling frustrated when one shoulder hurts when they play in their once weekly volleyball league. Working on transverse and frontal plane thoracic mobility, as well as thoracic extension, will allow for kinetic chain scapular posterior tipping/adduction/upward rotation. This will allow for full overhead GH jt mobility with successful humeral inferior gliding to prevent impingement when serving/hitting overhead, and ipsilateral lateral spinal flexion for loading into overhand serving. Without the thoracic mobility, the scapula will be blocked and rotator cuff impingement will likely happen. With all UE overhead movements, Heneghan et al’s systematic review noted a constant, that all UE movements initiated some level of thoracic ROM, but only at mid to end range of UE elevation. The greatest thoracic ROM needs were found to be thoracic extension with full UE overhead flexion elevation (6.7-8deg uniliateral and 12-15 degrees for B UE), followed closely by scapular elevation (4-8.9 deg unilateral ) and UE abduction (9-12.8 deg bilateral). The limitations for this systematic review do state only one study looked at an athletic population, and some sports with a greater proximal restriction including wheelchair basketball may require more focus and more thorough assessment. The meta analysis does have some limitations. The quality of studies was generally low, the study population was mostly females, and these were not athletes per say but “of athletic age” rather. Therefore the generalizability to other populations must be considered, however, there was a consistency among studies demonstrating thoracic motion relationship to shoulder elevation end ranges especially. Physicians prescribing PT for shoulder and UE conditions have an evidence basis for appreciating the importance of and expecting a full kinetic chain assessment, especially including the thoracic spine, for their patients being prescribed PT for UE pain or limitation, regardless of age, sex or activity. We may also want to consider including more spine focus in post-operative protocols, along with respect to healing the injured and repaired tissue. By considering the authentic biomechanics effecting and contributing to stresses and healing potential of involved tissues. We will be doing a more positive service to our patients and they may even have improved function and mobility than they have ever had prior. THE PEAK PERFORMANCE EXPERIENCE Greg stated: "I don't have any pain with activities!" HX: Greg was performing push-ups during a workout and felt a pop and grinding in his R shoulder and pain continued with even light exercises and movements from that point on for approximately one year. Using his R arm during his job tasks started to become uncomfortable. Pain levels could reach 8/10 at times. Any lifting and reaching with his R arm became an issue. Objective Data: MEASURE ( *=pain) Evaluation DC Thoracic Posture Kyphotic Scapular Posture Protracted Thoracic Rotation 59 / 50 Shoulder Abd IR 50 56 IR up back T10 T8 Overhead Press Reach Unable * 5# done 10x Speed's (+) (-) O'Brien's (+) (-) Jobe's (+) (-) Sulcus sign (+) (+) Treatment: Manual: Post/inferior humeral mobs, pec minor release, horizontal abd with IR stretching Exercises: Posterior capsule stretching, T-spine extension/SB/rotation stretching, T-spine frontal plane/transverse plane strength with dumbbells, T-spine extension drills with shoulder OH pressing with biases towards rotation, resistance tubing RC strength with in-sync T-spine rotation and SB, dumbbell push-pull drills for scap stability, serratus strength with tubing and DBs progressing in scaption and SG plane OH. Outcomes: Painfree ADLs, Painfree incline push-ups ~3ft elevation table, painfree plyo shoulder drills and no limitations with work tasks. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patient's functional goals.

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE November 2021 Finding Alternative Therapies for Arthritic Patients: Effective Natural Anti-infammatory Option RCT by Mike Napierala, PT, SCS, CSCS, FAFS CURRENT EVIDENCE Deutsch L. Evaluation of the Effect of Neptune Krill Oil on Chronic Inflammation and Arthritic Symptoms. J of Amer College of Nutrition. 26(1). 2007. 39-48. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) What would you do? Clinical Scenario..... A 65 yr old female c/o 7 yrs of L knee pain w/o obvious trauma, worsening over the past 6 mo with mild swelling, crepitus, and sometimes painful giving way during her favorite activity of doubles pickle ball and also descending stairs. She has used OTC NSAID's regularly over the past 2-3 yrs with limited success. She does have a h/o GI disorders and varying adverse reactions to attempted doubling of OTC ibuprofen or naproxen. She presently uses Tylenol for pain control. Plain radiographs show moderately advanced medial compartment knee degenerative changes. Clinical exam shows asymmetric mild varus deformity L knee and AROM reduced to 7-125deg (R 2-135deg). Single squat is limited/painful with audible crepitation. Patient's goal is avoiding surgery and continuing with fitness and pickle ball with her friends. She inquires if there are any dietary or supplement changes that could help. I would... Start with prescription NSAID's course, allow her to continue playing and reassess in 4 wks. Start with prescription NSAID's course but advise to DC playing for 3-4 wks and then reassess. Encourage anti-inflammatory diet and trial with supplement options such as krill oil or turmeric before considering NSAID's, plus order Physical Therapy. Begin viscosupplementation injection therapy. Order an MRI to R/O symptomatic degenerative meniscal tear. SUMMARY: Deutsch examined the use of a proprietary blend of krill oil (Neptune Krill OilTM ) vs a placebo in an RCT comparing 44 and 43 patients, the majority of whom had osteoarthritis or rheumatoid arthritis (40 of 44 Group A and 38 of 43 Group B placebo). The 30 day trial showed significant reductions in CRP within 7 days and continued decreases over the 30 days compared to the placebo group. “Rescue” acetaminophen use was reduced significantly by the krill oil group and WOMAC scores were more significantly improved for the NKOTM group. Many patients with arthritic symptoms looking for immediate symptom control either prefer non-pharmacologic options, have had GI issues in the past already from prolonged NSAID use, or have comorbidities making them at risk for adverse events with continued NSAID use. This study provides both inflammatory marker and functional WOMAC scale evidence for the (+) impacts related to NKOTM supplementation. While NSAID prescription and OTC use recommendations are commonplace in medicine/orthopedics this provides encouraging alternatives for consideration by physicians looking for effective alternatives to help reduce symptoms and improve function short term, at least, for arthritis sufferers wanting reduced GI and cardiac risks. The case study presents a patient who was preparing for TKA who, through manual therapy and functional exercise, was able to improve adequately to resume goal activities and delay/avoid surgery. Background: C-reactive protein (CRP) has been a strong predictor of future cardiovascular events per the Framingham risk score and it’s production in arthritic joints reflective of proinflammatory cytokines essential to cartilage degradation. A strong association has been shown between CRP and clinical severity of patients with knee or hip OA. Dietary intake of Omega-3 vs Omega-6 fatty acids is critical to inflammatory processes. Neptune Krill Oil is extracted from zooplankton in the Antarctic Ocean and has high EPA and DHA fatty acids and potent antioxidants, especially astaxanthin. Numerous studies have demonstrated the anti-inflammatory properties of these compounds. With increasing evidence of adverse events related to NSAID’s use, the otherwise gold standard for chronic inflammation care, safe alternatives need to be found. Methods: Prospective double blinded RCT with 90 patients from PCP offices in Ontario, Canada randomly assigned to Group A (300mg qd morning NKOTM) or Group B (neutral placebo). NKO contained 17% EPA, 10% DHA and Omega-3:6 ratio of 15 to 1. Fasted blood testing done at baseline (after 1 wk washout) and then at 7, 14, and 30 days. Patients kept a diary of any “rescue” acetaminophen use to maximum of 1-2 capsules q8hr. Forty four patients completed Group A and 43 patients Group B care. Mean age was 54.6 and 55.3 yrs respectively with 55.6% males in Group A and 48.9% in Group B. To avoid acute inflammation cases CRP measured weekly - those > 1mg/dl (no fluctuations > 0.5mg) blindly randomized for treatment and testing. WOMAC completed for those with arthritic disease along with Likert 5-point scale (0 best and 4 worst) for outcome. Findings: No differences between groups at baseline for concomitant medications, CRP levels or three WOMAC scores (pain, stiffness, functional impairment). Patients in Group A taking NKO reduce rescue med’s by 31.6% by 30 days vs Group B placebo only 5.6% reduction (p=0.012). After 7 days of treatment Group A reduced CRP by 19.3% vs 15.7% increase in Group B(p=0.049). CRP further reduced by 29.7% and 30.9% in Group A by 14 and 30 days respectively while Group B increased by 32.1% by 14 days and then reduced by 25.1% at 30days. NKOTM group WOMAC pain scores significantly reduced more than Group A at all three visits as did stiffness and functional impairment. Author's Conclusion: NKOTM at 300mg daily may inhibit inflammation with 7—14 days by reducing CRP and significantly alleviate symptoms caused by OA and RA. THE PEAK PERFORMANCE PERSPECTIVE Arthritis is one of the most common musculoskeletal diagnoses seen in physician’s offices. The routine care of these patients includes consideration of pharmacologics that can be used to quickly control symptoms to improve quality of life. The CDC reports in 2013-2015 22.7% of US adults had some form of arthritis (OA, RA, gout, lupus , fibromyalgia) with 44% reporting some related activity limitation. By 2025 it is projected that 67 million US adults will have an arthritis related diagnosis. In 2013 arthritis attributable wage losses were $164 billion in the US. (https://www.cdc.gov/arthritis/data_statistics/arthritis-related-stats.htm) Physicians are faced with the challenge oftentimes of patients with risk factors for GI adverse events ( > 65 yrs , h/o peptic ulcer, concomitant aspirin or anticoagulant use, alcohol or tobacco use, and others) as well as risks for cardiovascular, renal, or other reported side effects concerns. NSAID users have been shown to have 4-5x relative risk of peptic ulcer vs nonusers (Sostres et al, Arthritis Res Ther 2013)(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3890944/). A 2016 article in British Journal of General Practice cited NSAID’s were responsible for 30% of hospital admissions for adverse drug reactions. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4809680/) These facts along with increasing interest by patients for non-pharmacologic alternatives and/or supportive nutritional supplements that reduce inflammation, makes these findings by Deutsch very pertinent in musculoskeletal care. While as a standalone study it would be inappropriate to fully alter clinical practices regarding NSAID use these findings do add to the body of evidence that options do exist for those needing or wanting to avoid/minimize NSAID use for various reasons. In this study the Neptune Krill Oil (NKOTM) use allowed Group A participants to reduce “rescue” acetaminophen use by 30% from baseline vs only 6% in the placebo group over the 30 days. CRP levels were significantly reduced within 7 days and throughout the 30day testing period and also vs the placebo group mean CRP levels. WOMAC scores for pain were significantly reduced vs placebo Group B scores, as were the change scores for stiffness and functional limitation as well. These positive indicators all clearly support consideration of NKOTM for arthritic symptoms. Although no adverse events were reported in the short 30 day treatment/testing period further research into safety and dosing is certainly necessary. Also, these findings cannot be generalized to all krill oil supplements and require additional testing to determine what minimal and optimal levels of EHA and DPA, anti-oxidant, and/or omega-3 to omega-6 ratios are necessary for therapeutic benefits. As Physical Therapists we are able to give generic nutritional advice but cannot prescribe or recommend specific dietary or supplement intakes to patients. However, many patients also are disinterested or unwilling to formally see a registered dietician or clinical nutritionist for guidance. Nevertheless, patients do often inquire about any diet based or nutritional supplements they might take for anti-inflammatory purposes. The access to information on the internet obviously leaves the public with an endless resource of material ranging from completely unfounded conjecture all the way to excellent expert opinion to peer reviewed studies. For those lacking formal background and training to discern fact from fiction there remains a need for guidance. Physicians remain in an excellent position to share these supplement options with their patients. Conservative care remains the first and most necessary step in the treating of osteoarthritis. Physical Therapy is a most often effective means of both providing an intervention/treatment but also equipping the patient with proper self-help techniques and exercises to reduce symptoms and increase function. While traditional and simple regimens often have significant benefit we find for many patients that more substantial improvements or additional gains after “failed PT” occur when more in-depth biomechanical assessment and exercise/manual therapy approaches are employed. Due to the “regional interdependence” concept of the kinetic chain the appreciation for the impact limitations at adjacent and even distant body segments can have on a symptomatic arthritic joint cannot be overstated. The “failed PT” patients with OA that we see typically were given generic programs doing a rote series of common lower extremity stretches for large muscle group (hamstrings, quads, ITB etc) along with WB/NWB strengthening that is not customized to their ROM and/or symptom issues. There is commonly a lack of attention to less visible planes of motion (transverse plane) such as restoring hip IR for a hip or knee OA case developing progressive varus alignment, or with utilizing unique paths of movement to optimize loading through healthier portions of the articular surfaces (ie. promoting slight dyn valgus for medial knee OA to optimize lateral knee articular cartilage load dispersion). The case below illustrates a patient with knee OA who was able to avoid an anticipated TKA due to the extent of symptom relief and functional improvements he attained through Physical Therapy. THE PEAK PERFORMANCE EXPERIENCE Bud said: "My arthritic left knee was limiting my activities. Now I can mow my yard and walk my dog, and do the stairs better! I'm no longer thinking about a knee replacement." HX: 67 yr old male with 20+ yr h/o knee sx, underwent TKA 2013 R knee and presently c/o worsening L knee sx past 3-4 yrs. Plain films (+) for significant DJD. Pt indicated TKA being considered. Subjective: L knee 6/10 max sx w 75% self-report function. CC with walking dog on uneven surfaces/hills, walking 4-5mi, stairs, standing > 5min. WOMAC 40%. Key Findings: MEASURE ( *=pain) Evaluation Final ReEval @ 3mo AROM L knee ext (deg.) 50 20 AROM L knee flexion (deg.) 1230 1430 PROM hip IR L/R (deg.) 18/60 28 / 120 AROM STJ eversion (deg.) 4 / 80 NT Single leg balance L/R 5 / >15sec 15*/20 (75%) FWB knee ext (deg) 1680* /1830 1720 L knee(no sx) Squat L/R (deg) 400* / 580 65 / 580 WB DF (deg) 24 / 210 NT WB hip ext (deg) 80 flex / 00 10.1/9.6 (105%) Quad isometric 19.2 kg(83%) 30.6kg (94%) WB Ant Stepdown Quads 6” 15# NT >36x / 25x (>100%) Treatment: Pt began with BIW treatments focusing on manual therapy to improve L knee flexion and extension along with (B) hip IR and extension, as well as DF and eversion. Stretching/PROM HEP instructed to compliment mobilization work utilizing long duration 20-30sec sets. Neuromuscular re-integration movements were also used to optimize transfer into ADL use. Once simple single plane movements were successful then stretches were advanced toward multiplanar techniques to improve adaptability to patient’s frequent navigation of uneven surfaces in his large yard/property. Painfree strengthening especially for quads to enhance squat function were done using subtle path deviations to determine and optimize sx-free status throughout for stepdowns, stepups and “hangback” pole squats, attempting to increase loading preferentially to the lateral compartment to avoid medial joint overloading and symptoms. This was done using combinations of proximal and distal pre-positioning along with weight shifting to customize for patient response. Rotational balance work to promote use and control of femoral IR (unloading varus knee tendency) was done. Hip extension and combined ankle DF work of eccentric hip flexors and plantarflexors to normalize gait also included. Outcome: Pt reported sx overall reduced to max of L 3/10 and R 2/10 occurring ~ TIW frequency with walking his lawnmower through rough ground, carrying 40# for distances, sitting > 1 hr. He indicated stairs and getting off floor were much easier. WOMAC reduced to 18% and self-report function 90%. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE June 2021 Is Shoulder Pain and Mobility Loss Really The Shoulder’s Fault? by Allison Pulvino, PT, MSPT, CMP, FAFS CURRENT EVIDENCE Malmstrom et al. A Slouched Body Posture Decreases Arm Mobility And Changes Muscle Recruitment In The Neck And Shoulder Region. Euro J Appl Physiol, 2015. 115: 2491-2503. Background: Shoulder pain is one of the more common areas of the body to develop pain and limitations, and it is thought that having a slouched posture due to congenital reasons, prolonged desk work, or ADLs requiring repeated flexed postures. When the body alignment changes, joints, and muscles have to change how they move through their available range and Malmstrom et al. want to see if there is a correlation between increased thoracic kyphosis and increased work for shoulder muscles as a result, including upper trap, lower trap and serratus anterior. Methods: Twelve male subjects (23.3 +/- 1.5 years) performed maximum arm elevation in both upright and slouched postures with a 3D movement and EMG recording arm movement and spine movement, as well as EMG activity in the upper trap, lower trap, and serratus anterior. Results: Slouched posture resulted in a decreased total arm elevation by 15degrees and a decreased arm velocity by 8% during upward and downward arm movements. The peak muscle activity in a slouched posture also increased in all three muscles: UT +32.3%, LT +48.6%, SA +20.9%. The total muscle work with upward movements in a slouched posture increased significantly as well: UT +36.6%, LT +89.0%, SA +19.4%. Downward movements had increased total muscle work as well: UT +29.8%, LT +122.5%. Limitations: The main limitation in this study is the 12 participants being asked to create an increased thoracic kyphosis. Although the position of the spine will be the same nonetheless, the muscle recruitment could possibly be much different if there is a prolonged positional spinal change for true chronic spinal positions instead of an instantaneous forced conscious change. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) SUMMARY: While there is not a singular “cause” underlying non-traumatic shoulder pain the topic of “poor posture” often is acknowledged but risks becoming so routine in the minds of clinicians and certainly the public that its role too often gets neglected or even dismissed during rehab. This study provides good foundational “mechanisms” of evidence to compel both clinicians and patients to fully appreciate the literal negative impact accentuated kyphosis has on shoulder demands and function. Malmstrom et al examined the association between an increased thoracic kyphosis and changes in shoulder kinematics and muscle recruitment/activity in the upper trap, lower trap, and serratus anterior. Their findings showed a positive correlation with both a decrease in maximal overhead shoulder ROM and an increase in muscle work required to elevate the shoulder overhead during increased thoracic kyphosis as compared to normal posture. This study provides valuable data to motivate patients to take the connection of postural-focused manual therapy and especially exercise to their shoulder recovery seriously. It also provides a valuable reminder to referring physicians as they order Physical Therapy and also are scrutinizing care choices for patients who may appear to be “failing” initial therapy. THE PEAK PERFORMANCE PERSPECTIVE It has been pretty commonplace to assess a patient with shoulder pain and hear the main aggravating movement is reaching overhead. Both doctors and physical therapists alike have heard this many times over, yet each patient may have other limiting factors needing further assessment. As a referring physician, the expectation most often is that the Physical Therapist must “play further detective” to see what body structures are potentially contributing to pain and limitations, determining how to address both the local tissue pain/inflammation along with necessary ROM/strength/neuromuscular retraining work. At Peak Performance PT we’re in full agreement with what Malmstrom et al confirmed in this particular study, that an increased thoracic kyphosis does affect overhead shoulder mobility and muscle efficiency. And while that fact may not seem like “rocket science” (and is generally well known and understood in musculoskeletal care), it all too often ends up being brushed by the wayside by all the various local shoulder exercises available. When hearing a patient’s history of their present shoulder complaint, repetitive overhead reaching activities obviously stand out in our mind as physicians or therapists as being potential causes for why this individual is in our office. For example, gardening for 4 hours in the afternoon which includes leaning over (kyphosis) and reaching out or maybe it’s painting walls...and then pain is felt later that night putting dishes away in the top kitchen cabinets or changing a light bulb. Malmstrom et al’s data help provide a “connecting of the dots” for many cases that help us as clinicians appreciate why the shoulder pain developed but also empowers patients to realize how this talk about posture is more than just your grandmother’s old warnings about sitting up straighter. It helps bridge the gap between a shoulder that is painful and the thoracic spine that “feels fine” to them and therefore seems unimportant and unrelated. For some patients, the thoracic kyphosis was induced by positioning, as in the gardening example with temporary thoracic flexion posturing. For others, they do have generally accentuated thoracic kyphosis, which leads also to the protracted scapula and pec minor shortening, affecting scapulohumeral mechanics. We see shoulder patients who’ve sometimes been given generic HEP sheets or found shoulder rehab programs on the internet that may even include “postural exercises” like simple scapular retractions. We don’t find those adequate at stimulating change in most patients, despite possibly “checking the box” as having addressed posture. Other times we see “failed PT” cases where plenty of appropriate local shoulder exercises were done but too often patients indicate “the therapist never put their hands on me” (ie. manual therapy) - especially for the thoracic spine and scapula. While as clinicians we both know these cases aren’t surgical, but as referring physicians it’s difficult to motivate patients to “try PT again” If they had already been through physical therapy and they only feel slightly better and are still limited at tennis or lifting their toddler into the car seat...etc. Patients are simply looking for answers and solutions that work...but they also often ask “what’s going to be different ‘this time with my PT?” As a referring physician, you also play a key role in prefacing the PT experience too. Providing patients evidence like Malmstrom et al found, noting the significantly increased load on muscles and the loss of ROM with increased kyphosis it helps “connect the dots” for the patient as to why “out of the blue” this developed. When you confidently note that their PT will be addressing their postural issues it also reinforces that their physician and PT are on the same page and to feel confident they actually don’t need shoulder surgery like their sister or neighbor did, and physical therapy can help them recover. Protocol type approaches may work for a limited number of patients long term but at Peak Performance, we find a very high percentage of our shoulder pain patients do have scapulothoracic factors that potentially are contributing. They’re evaluated on Day One as one of our clinical standards. It’s a simple concept associated with our specialization in Applied Functional Science – the kinetic chain components, especially adjacent joints/structures, must be evaluated as integral parts of understanding the stresses on that local injured/painful shoulder tissue. We find that working on the body as a whole system will always find other regions that are secondary factors of pain, but still affect ADL life. For example, if someone sits for work 40 hours per week and has a slightly increased thoracic kyphosis, they may also need to have their psoas and pectoralis minor flexibility in the sagittal (but also frontal and transverse) plane assessed likely potential kinetic chain limiters of full overhead shoulder mobility. Tight hip flexors can lead to a forward pitched spine in standing and therefore disadvantage full elevation similarly to a thoracic kyphosis pre-positioning. A restricted pec minor that prevents adequate posterior tipping, as per the commonly referred Upper Crossed Syndrome, and also popularized by Kibler and others will clearly lead to abnormal forces at the shoulder and impingement. Since flexion reaching while bent over in thoracic flexion or upright in kyphotic postures disadvantages normal shoulder function, then a key focus should be improving thoracic extension, scapular posterior tipping, and upward rotation. Although it’s not always easy to directly focus solely on gaining sagittal plane mobility. Traditional PT exercises work serratus anterior as a scapular protractor, isn’t scapular protraction related to more thoracic flexion? Is a lack of protraction function what the serratus was lacking? Asking a patient how their prior PT was going and what exercises they were doing can shed some light on this topic. They may have been performing typical overhead arm stretching, scapular protraction exercises with weights, and then standing or prone back extensions. But these exercises initiate movement in neutral (their kyphosis) where the maximum spinal range may already be achieved. Focusing away from the end range and tweaking spinal extension while biased in another plane may be more beneficial and help stay away from the pain provocation. Addressing the “other” thoracic planes of motion can also be critical, though not a specific point of the Malmstrom et al study. Seeing frontal plane thoracic limitations with proper mobility assessment can shed some light on why abduction or lateral overhead shoulder reaching is painful, as the scapular upward rotation has to happen to prevent impingement in the subacromial space. In the same way that a sagittal plane thoracic kyphosis affects especially sagittal plane scapular and thereby GH mechanics for elevation, we must remember that frontal and transverse plane thoracic to shoulder mobility connections also exist. It is not common to have pure sagittal shoulder overhead flexion without coupling in some side bending and rotational movement, for example with swimmers and throwers. Every individual has specific limitations when shoulder pain is the primary complaint. Directly assessing someone’s multiplane shoulder ROM but also especially adjacent (and distant) kinetic chain 3D function can shed some light on how many different regions of the upper quadrant or even the hips and pelvis can be affecting their life in a negative and inhibiting manner. Normal and pain-free shoulder elevation with proper scapulohumeral rhythm can be achieved when proper spinal mobility and the correct use of shoulder muscle recruitment is trained, always in a manner that is specific for each patient. The case below demonstrates how important manual therapy and specific functional exercise approaches were helpful in resolving symptoms and restoring function for a very typical shoulder pain case. THE PEAK PERFORMANCE EXPERIENCE Doris states: “Watch how I can lift my arm all the way now! It doesn’t even hurt!” HX: Doris is a 72-year-old female with ℅ L shoulder pain from “reaching too far and too much” she believes. Sx’s started to be referred down to the elbow and she lost the ability to reach her L arm in all directions. She also reported that sleep became almost impossible. No trauma reported in the past. Subjective: Doris reported 8/10 L shoulder pain with any active L shoulder movement. She was unable to use it for any ADLs initially and could not sleep well or lean on L arm. Objective: Unable to tolerate any active ROM so special tests NT. TTP all RC muscle bellies and tendons including proximal bicep. No neural involvement. All UE dermatomes intact. Cspine mobility screening negative for radicular sx’s. Severe Tspine kyphosis with dowager’s hump. MEASURE ( *=pain) Evaluation (limited due to severity of Sx) Discharge Shoulder flexion (deg.) 130* (PROM only) 1520 AROM Abduction (deg.) NT due to pain 1200AROM ERn (deg.) 42* 650 ER 90(deg.) NT due to pain 700 IR 90 (deg.) NT due to pain 800 Tspine rotation L 180, R 300 NT Cspine rotation L 50%, R 75% B 75% Cspine ext 50%* 75% Cspine SB L 50%, R 25% 50% B Tspine ext UNABLE d/t L pain 50% with L shoulder flexion overhead Apley's Scratch test ER L Unable, R T1 T1 B shoulders Apley's Scratch test IR L L5*, R L1 L3 B shoulder (no pain) Treatment: Modalities: High-intensity laser treatment, 2 sessions, entire L GH jt capsule, and periscapular soft tissue. Manual: Tspine rotation and extension mobs with WB lateral flexion mobs. GH mobs for post and inf capsular mobility. Soft tissue mobilization UT, levator, teres major, pec minor, and infraspinatus. Exercises: Spinal extension active self-mobilizations in WB, spinal AROM drills for FR and TR plane spinal mobility, PROM GH flexion/abduction/ER. AROM UE overhead drills with spinal extension and scapular elevation with BW and weights for progression, TR plane spinal rotation with weighted diagonal pattern TR plane loading and spinal extension loading in standing, FR plane spinal load for shoulder and ROM progressing from AAROM to AROM with weight. Outcome: Pt is able to sleep without pain, carry groceries in L arm, reach overhead in flexion and abduction without pain onset, and can grab objects in her kitchen cabinets overhead without pain.