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THERAPEUTIC TAPING,

EXERCISE & POSTURE

TECHNIQUES
Tambra Marik, OTD, OTR/L, CHT
Apple Physical Therapy
Gig Harbor/Tacoma WA

Moving Towards Function/Marik

Course Agenda

Characteristics of Tape
Theoretical Constructs of Rigid Tape
Theoretical Constructs of Elastic Tape
What is our evidence for taping?
The Shoulder: From Basic Anatomy, Biomechanics,
Pathology to Posture and Treatment
Rotator Cuff Tendinopathy/Impingement

Lab: Shoulder Girdle Taping and Exercise

Lab: Evidence for Impingement taping


Moving Towards Function/Marik

Course Agenda
The Shoulder (cont)

Instabilities
Lab: Anterior Instability, Multidirectional
Instability, AC Joint taping (type I & II)
Lab: TOS taping, review hemiplegia taping,
cervical taping, myofascial shoulder pain
taping, Upper Quadrant taping
Moving Towards Function/Marik

PTAPTM_1275

Course Agenda
The Elbow

Basic Anatomy
Elbow Instabilities related to ligamentous
structures
Medial ulnar collateral ligament injuries
Lateral radial collateral ligament injuries
Taping and Exercise lab
Tendinopathy at medial and lateral elbow
Taping and Exercise Lab
Moving Towards Function/Marik

Course Agenda
The Elbow

Basic Anatomy
Elbow Instabilities related to ligamentous
structures
Medial ulnar collateral ligament injuries
Lateral radial collateral ligament injuries
Taping and Exercise lab
Tendinopathy at medial and lateral elbow
Taping and Exercise Lab
Moving Towards Function/Marik

CHARACTERISTICS/TYPES OF TAPE
ATHLETIC TAPE
RIGID TAPE
Leuko Tape

ELASTIC
Rock Tape
Kinetic/Kinesiology
Moving Towards Function/Marik

PTAPTM_1275

BENEFITS OF RIGID TAPE


Pain Relief
Neuromuscular

Proprioception
Tissue
De-loading

Moving Towards Function/Marik

THEORETICAL CONSTRUCTS FOR


RIGID TAPE

PAIN REDUCTION
Mechanical Effects:
Joint support
Joint Re-Alignment
Biomechanical Correction
Moving Towards Function/Marik

THEORETICAL CONSTRUCTS FOR RIGID


TAPE
NEUROMUSCULAR EFFECTS
Muscle facilitation and/or inhibition
Theory Based: Across muscle inhibits and
along muscle facilitates
Evidence indicates taping along muscle (LT)
facilitate muscle activity (Alexander et al 2003)

Moving Towards Function/Marik

PTAPTM_1275

THEORETICAL CONSTRUCTS FOR RIGID


TAPE
NEUROMUSCULAR EFFECTS
Muscle Facilitation
Theory: Muscle held in a
shortened position will have
optimal actin-myosin overlap
during the cross bridge cycle
Photo from: Morrissey
2000
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THEORETICAL CONSTRUCTS FOR RIGID


TAPE

Photo from: Morrissey 2000

NEUROMUSCULAR EFFECTS
Muscle Inhibition

Theory: Hold muscle in lengthened


position resulting in decreased
actin-myosin overlap
Moving Towards Function/Marik

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THEORETICAL CONSTRUCTS FOR


RIGID TAPE
PROPRIOCEPTION ENHANCEMENT
Enhances muscle control over targeted joint
Cutaneous
Mediated
Proprioceptive
Feedback

Image retrieved from:


http://content.answcdn.com/main/c
ontent/img/oxford/Oxford_Sports/0
199210896.reflex-arc.1.jpg

Moving Towards Function/Marik

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PTAPTM_1275

THEORETICAL CONSTRUCTS FOR


RIGID TAPE
TISSUE DELOADING
Surrounding or gathering the tissue around
the painful area to deload the tissue

Moving Towards Function/Marik

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THEORETICAL CONSTRUCTS FOR


RIGID TAPE
PSYCHOLOGICAL EFFECTS
Feelings of increased confidence, strength
and decreased anxiety

Moving Towards Function/Marik

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ELASTIC TAPE

Moving Towards Function/Marik

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PTAPTM_1275

ELASTIC TAPE
I CUT

Y CUT

FAN CUT

X CUT

Moving Towards Function/Marik

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TAPE APPLICATION

Apply to clean, dry skin. Remove oils from skin


Can use skin adhesives for improved contact
Typically tape is applied to stretched skin
Tape is stretched (~10%) when applying to nonstretched skin
Additional stretch required when applying for
mechanical correction
Tape likely to adhere better to skin where hair has
been clipped or shaven
Moving Towards Function/Marik

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PRECAUTIONS/CONTRAINDICATIONS
Avoid applying tape to persons with:

Skin allergies or sensitivity to tape


Open wounds
Skin infections/conditions
Fresh scars
Fragile and sensitive skin
Circulatory conditions (bleeding or clotting
disorders)
Sensory loss in taped region or distal to tape
Pregnancy avoid selective acupuncture points
Lymphedema requires knowledge of pathways
Moving Towards Function/Marik

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PTAPTM_1275

PRECAUTIONS/CONTRAINDICATIONS
Avoid applying tape to persons with:

Peripheral vascular disease


Peripheral neuropathies
Diabetes
Prolonged use of steroids or anticoagulant
medications
Cognitive loss (patient is unable to report any
negative effects of tape)
Moving Towards Function/Marik

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PRECAUTIONS/CONTRAINDICATIONS
Avoid applying tape to persons with:

Peripheral vascular disease


Peripheral neuropathies
Diabetes
Prolonged use of steroids or anticoagulant
medications
Cognitive loss (patient is unable to report any
negative effects of tape)
Moving Towards Function/Marik

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ROCK TAPE
An Elastic Tape
p
97% COTTON
3%NYLON

HYPO-ALLERGENIC
ACRYLIC BASED
ADHESIVE

Stretches in
One Direction

No Latex

Thought to
accelerate
healing

Moving Towards Function/Marik

21

PTAPTM_1275

ROCK TAPE
THEORETICAL CONSTRUCT
FASCIAL MOVEMENT
TAPING
Reduce swelling
Accelerate blood flow
Contribute to
optimizing movement
patterns
Picture retrieved from:http://davidlasnier.com/
Moving Towards Function/Marik
wp-content/uploads/2012/02/anatomy-trains-fascial-arms-line.jpg

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OTHER THEORETICAL CONSTRUCTS


FOR ELASTIC TAPE
MECHANICAL CORRECTION
FASCIA CORRECTION
SPACING CORRECTION
MUSCULOSKELETAL CORRECTION
(TENDON/LIGAMENT)
FUNCTIONAL CORRECTION
Moving Towards Function/Marik

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Kase K, Wallis J, Kase T. Clinical Therapeutic Applications of the KinesioTaping Method. Tokyo, Japan:Ken Ikai Co. Ltd;2003.

THEORETICAL OBJECTIVES

MECHANICAL CORRECTION/Skin Function


GOAL:
1) Position muscle, fascia, or joint. Tape provides
feedback to mechanoreceptors
resulting in the body adjusting to minimize
tension
2) Elasticity in tape assists the body to adjust to
desired position
OR
3) Block movement
Stretch qualities and pressure of the tape provide
sensory input to mechanoreceptors
Kase K, Wallis J, Kase T. Clinical Therapeutic Applications of the KinesioTaping Method. Tokyo, Japan:Ken Ikai Co. Ltd;2003.

Moving Towards Function/Marik

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PTAPTM_1275

Mechanical Correction Theory: Tape


Provides Input to Mechanoreceptors
Method 1 Tail Tension/Lateral Epicondylosis Example

1) Mechanical correction for tennis elbow. Cut Y


tape with 1 inch base and 2 inch tails. Place
forearm in supination and elbow flexed at 90
flexion. Apply strip base on distal humerus.
Hold base with one hand. Apply 50% to 75%
tension with downward pressure on each tail
over wrist extensor group.
Leave one inch to the tail and lay down with no
tension.
Moving Towards Function/Marik

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Theoretical Concept
Mechanical Correction / Lateral
Epicondylosis

Moving Towards Function/Marik

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Mechanical Correction Theory:


Tape Blocks Motion
Method 2: Blocking lateral epicondylosis example
1. Place the elbow at 30 flexion and forearm in
supination.
2. Use the center of an I strip with 50% to 100% tension
in the middle of the strip.
3. Apply directly over supinator extensor mass. The
patient actively moves to pronation/elbow
extension(extension for sensory feedback to not move
to end range extension) and the ends are laid down.
4. No tension to the ends of I strip. One end at distal
posterior distal humerus and one end at volar mid
forearm.
Moving Towards Function/Marik

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PTAPTM_1275

Theoretical Concept
Mechanical Correction / Lateral
Epicondylosis

Moving Towards Function/Marik

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THEORETICAL OBJECTIVES
FASCIA CORRECTION
GOAL:
1) Elasticity of tape is used to move fascia
or limit fascia movement
or
2) Hold fascia in position or limit
fascial movement after manual
techniques

Kase K, Wallis J, Kase T. Clinical Therapeutic Moving


Applications
of the
KinesioTaping Method. Tokyo, Japan:Ken Ikai Co. Ltd;2003.
Towards
Function/Marik
29

Theory: Limit Fascia Movement


Medial Epicondylitis Example
1. Cut Y strip with a 2 inch base and 2
inch tail.
2. Manually lift the flexor wad from
the medial epicondyle.
2. Place the base of the Y strip
proximal to the medial epicondyle
without tension at the base.
3. Apply the remainder of the base
with 50% tension in a volar radial
distal direction.
*Hold

the corrective position or limit the


unwanted position with tape.

Moving
Function/Marik
Kase K, Wallis J, Kase T. Clinical Therapeutic Applications
ofTowards
the KinesioTaping
Method. Tokyo, Japan:Ken
Ikai Co. Ltd;2003.

30

10

PTAPTM_1275

Theoretical Concept
Fascia Correction / Medial
Epicondylosis

Moving Towards Function/Marik

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THEORETICAL OBJECTIVES

SPACING CORRECTION

GOAL:
1) Lift fascia & soft tissue in painful region.

2) Create more space in the area above pain,


inflammation or edema resulting in
decreased pressure in the injured area.
3) Possible increase circulation to injured area
by creating more space.
4) Stimulation of mechanoreceptors possibly
decreasing pain.
Moving
Function/Marik
Kase K, Wallis J, Kase T. Clinical Therapeutic Applications
ofTowards
the KinesioTaping
Method. Tokyo, Japan:Ken Ikai Co. Ltd;2003. 32

Spacing Correction Theory:


Tape Pulls Connective Tissue To Area
Method 1 long head of biceps (LHB)
1. Cut a 4 inch I piece. Tear in the
middle and apply 25% to 50%
tension to the middle of the tape.
2. Place the tensioned tape
horizontally on LHB with the
shoulder in 90 of flexion and ER. http://upload.wikimedia.org
wikipedia/commons/f/f2/
3. Move the shoulder to extension Gray411.png
and lay down the ends with no
tension.
Moving Towards Function/Marik

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11

PTAPTM_1275

Theoretical Concept
Spacing Correction
p Longg Head Biceps
p
Example:

Start shoulder flexion 90

Apply tape with 2550% stretch as the


patient moves
Into extension

Moving Towards Function/Marik

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Spacing Correction Theory:


Tape Pulls Connective Tissue To Area
Method 2 LHB
1. Cut 4-5 in strip with tails at each end. Cut
a hole 1/3 larger than the region you want
to lift up.
2. Place the shoulder in 90 of scaption/ER.
http://upload.wikimedi
wikipedia/commons/f/f2/Gray
Tear away center of hole.
411.png
3. Apply 25% to 50% tension in center for the
hole and apply to painful region.
4. Place the shoulder in extension and lay
down ends without tension.
5. Splay the ends.
Moving Towards Function/Marik

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Theoretical Concept
Spacing Correction
Example 2: Long Head Biceps

25-50% stretch

Moving Towards Function/Marik

Shoulder extended lay ends down

36

12

PTAPTM_1275

THEORETICAL OBJECTIVES
MUSCLE FACILITATION/INHIBITION
GOAL:
1) Facilitation a muscle contraction by using
tape to displace the skin in the direction of
contraction/origin to insertion
2) Inhibit muscle contraction by using the tape
to displace the skin in the direction of the insertion
to origin thereby, reducing a muscle contraction
Kumbrink B, K Taping: An illustrated Guide. Berlin Heidelberg: Springer-Verlag;2012.

Moving Towards Function/Marik

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Muscle Facilitation Theory: Tape Restores


Force on the Skin towards Direction of
Muscle Origin
Method 1: Facilitate/Increase Tone (Deltoids)
Apply tape from muscle origin to insertion
Place shoulder to side in neutral rotation
Apply I strip to acromion
Lie strip down with no tension up to 0 to 50% to
deltoid tuberosity
*Authors vary regarding recommendations for
tension
Moving Towards Function/Marik

Kumbrink B, K Taping: An illustrated Guide. Berlin Heidelberg: Springer-Verlag;2012.

38

Theoretical Concept
Muscle Facilitation
Example: Deltoids

Tape shrinks towards origin.


Moving Towards Function/Marik

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13

PTAPTM_1275

Muscle Inhibition Theory: Tape Restores


Force on the Skin towards Direction of
Muscle Insertion
Method 1: Inhibit/Decrease Tone (Deltoids)
Apply tape from muscle insertion to origin
Place shoulder to side in neutral rotation
Apply I strip to deltoid tuberosity
Lie strip down with no tension up to 50% to
acromion
*Authors vary regarding recommendations for
tension
Moving Towards Function/Marik

Kumbrink B, K Taping: An illustrated Guide. Berlin Heidelberg: Springer-Verlag;2012.

40

Theoretical Concept
Muscle Inhibition
Example: Deltoids

Tape shrinks towards insertion.


Moving Towards Function/Marik

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THEORETICAL OBJECTIVES

LIGAMENT SUPPORTING
GOAL:

1) Tape increases stimulation of joint


mechanoreceptors for the brain to interpret as
normal tissue Kase K, Wallis J, Kase T. Clinical Therapeutic Applications of the KinesioTaping
Method. Tokyo, Japan:Ken Ikai Co. Ltd;2003.

2) Tape pulls ligaments to the middle


Kumbrink B, K Taping: An illustrated Guide. Berlin Heidelberg: Springer-Verlag;2012.

Moving Towards Function/Marik

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14

PTAPTM_1275

Ligament Support: Tape pulls osseous


segments together
Example 1: PIP joint index finger
1. Cut an I strip 1 x 1
2. Tear I strip in the middle
3. Place digit in extension
4. Lie the tape down at lateral & medial 50% to
100% stretch
5. Lie ends down with no tension
6. Apply 1 x 1 cross tape (volar/dorsal support)
Moving
Towards
Function/Marik
Kumbrink B, K Taping: An illustrated
Guide.
Berlin
Heidelberg: Springer-Verlag;2012.

43

Theoretical Concept
Ligament Support/PIP Joint Sprain
2
1

Moving Towards Function/Marik

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Ligament Support: Tape pulls osseous


segments together (LCL ankle joint)
Method 1 Ankle
1. Cut an I strip ~1 inch long & 1 inch wide
2. Tear I strip in the middle
3. Place foot in plantar flexion
4. Lie the tape down with 50% to 100% stretch on
talofibular ligament
5. Lie ends down with no tension
Kumbrink B, K Taping: An illustrated Guide. Berlin Heidelberg: Springer-Verlag;2012.
Moving Towards Function/Marik

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15

PTAPTM_1275

Theoretical Concept
Ligament Support/Talo-Fibular Joint
Sprain

Moving Towards Function/Marik

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THEORETICAL OBJECTIVES

Functional Taping

GOAL:
1) Limit joint motion through sensory stimulation
provided from the tape

Kase K, Wallis J, Kase T. Clinical Therapeutic Applications of the KinesioTaping Method. Tokyo, Japan:Ken Ikai
Co. Ltd;2003.
.

Moving Towards Function/Marik

47

Functional Tape: Tension on during


undesired motion and off during desired
motion.
Method 1 (limiting wrist extension):
Cut a 6 inch I strip with two diamond shape holes at
one end of tape
Place the index & long fingers through the holes to
apply tape on the volar surface
Place the wrist in flexion
Hold the base down with no tension
Apply 50% to 100% tension in the middle making a
bridge. Move the wrist towards extension while
rubbing on the tape.
Kase K, Wallis J, Kase T. Clinical Therapeutic Applications of the KinesioTaping Method. Tokyo,
Japan:Ken Ikai Co. Ltd;2003.
Moving Towards Function/Marik

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16

PTAPTM_1275

Theoretical Concept
Functional Taping/Limit Wrist Flexion

Moving Towards Function/Marik

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Functional Tape: Tension on during


undesired motion and off during desired
motion.
Method 1 (limiting plantar flexion):
Cut a 6 inch I strip with two diamond shape holes at
one end of tape
Place the 2nd & 3rd toe through the holes to apply
tape on the volar surface
Place the ankle in dorsiflexion
Hold the base down with no tension
Apply 50% to 100% tension in the middle making a
bridge. Move the ankle towards while rubbing on
the tape.
Kase K, Wallis J, Kase T. Clinical Therapeutic Applications of the KinesioTaping Method. Tokyo,
Japan:Ken Ikai Co. Ltd;2003.
Moving Towards Function/Marik

50

Theoretical Concept
Functional Taping/Limit Plantar
Flexion

Moving Towards Function/Marik

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17

PTAPTM_1275

THEORETICAL OBJECTIVES

Hand Edema ReductionTaping for


Patient with Healthy Lympthatics
GOAL: Enhance vascular transport systems
by creating space between the skin and
subcutaneous tissue
Space is created by lifting the skin
Movement contributes to loosening of
connective tissue
Tape channels the movement of the fluid
Fluid moved to lower pressure area

MovingSpringer-Verlag;2012
Towards Function/Marik
Kumbrink B, K Taping: An illustrated Guide. Berlin Heidelberg:

52

Edema Tape for High Volume


Insufficiency following Trauma
Fan Tape Method
The base is affixed to
promote flow towards
lymph nodes
Place patient is a stretched
position
Apply strips with 15% to
25% tension
Kumbrink B, K Taping: An illustrated Guide. Berlin
Moving Towards Function/Marik
Heidelberg: Springer-Verlag;2012

Retrieved from: http://www.lytnyc


.com/wp-content/uploads/2012/03/l
ymphatic-system-benefits-from-rebounding.
53

Edema Tape for High Volume


Insufficiency following Trauma
Fan Tape Hand Edema
Affix base proximal medial
epicondyle
Pts elbow extended and
wrist flexed
Apply each strip with 15%
to 25% tension and affix
strips between digits
Kumbrink B, K Taping: An illustrated Guide. Berlin
Moving Towards Function/Marik
Heidelberg: Springer-Verlag;2012

Retrieved from: http://www.lytnyc


.com/wp-content/uploads/2012/03/l
ymphatic-system-benefits-from-rebounding.
54

18

PTAPTM_1275

Direct Fans Towards Lymph Nodes

http://www.anatomyatlases.org/
AnatomicVariants/Cardiovascular/
Retrieved from: http://upload.wikimedia. Images0400/0455.gif
Moving Towards Function/Marik
org/wikipedia/commons/a/aa/Gray606.png

55

Theoretical Concept
Edema Reduction/Hand

Moving Towards Function/Marik

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WHAT YOU NEED TO KNOW!


EVIDENCE

EBM

Retrieved and adapted from: medresidents.stanford.edu/EBP.html on 10/13/08.


Adapted from: Sackett DL, Rosenberg MC, Gray JA, Haynes RB, Richardson WS. Evidence
based medicine: what it is and what it isn't. BMJ. 1996;312: 71-72.

Moving Towards Function/Marik

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19

PTAPTM_1275

RIGID TAPE
HIGH EVIDENCE
Improved posture for patients with
shoulder impingement (Lewis et al
2005)
Upper Trapezius Inhibition for
patients with shoulder impingement
(Smith et al 2009)
Hemiplegic patients had increased
days without pain (Griffin et al 2006)
Moving Towards Function/Marik

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RIGID TAPE
MODERATE EVIDENCE
Delay onset of pain in hemiplegia
shoulder (Ancliff 1992)
Increase GH rotation in healthy
subjects (McIntosh 2009)
L.T. facilitation/U.T. inhibition in
shoulder impingement (Selkowitz et
al 2007)
Moving Towards Function/Marik

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RIGID TAPE
MINIMAL EVIDENCE
Pain relief 3 weeks post injury in patient with
grade III AC ligament injury (Shammus &
Shammus, 1997)

Moving Towards Function/Marik

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20

PTAPTM_1275

ELASTIC TAPE
HIGH EVIDENCE
MacDermids Quality Evaluation Rating:

Immediate decreased pain with ROM, no


difference at 3 days in patients with impingement
(Thelan et al 2008)
Increased scapular posterior tilt and L.T. facilitation
baseball players with impingement (Hsu et al
2009)
Decreased pain at one week, no difference at two
weeks in impingement (Kaya et al 2010)
Moving Towards Function/Marik

61

ELASTIC TAPE
HIGH EVIDENCE
MacDermids Quality Evaluation Rating:

Gonzalez-Inglesias et al 2009 short


term pain relief with cervical taping
Immediate increase with ROM and
pain reduction up to 24 hours
Changes were small may not be
clinically meaningful
Moving Towards Function/Marik

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ELASTIC TAPE
MODERATE EVIDENCE
MacDermids Quality Evaluation Rating:

Increase force sense, but no increase


with grip strength in healthy
individuals (Chang et al 2010)
Increase grip strength (Lee et al 2010)
No difference b/w groups treated
with standard decongestive
lymphatic therapy and pnuematic
pump with and without taping (Tsa
et al 2009)
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21

PTAPTM_1275

STUDIES NOT MAKING THE CUT


Miller et al 2009 trend towards
pain relief at 2 wks, no difference
at 6 wks
Shamus & Shamus 1997 AC joint
taping
Grieg et al 2008 postural taping
for kyphosis

Moving Towards Function/Marik

64

STUDIES NOT MAKING THE CUT


Low Evidence
Muro et al 2009 case
report on treatment of
myofascial pain
Karatas et al 2011
decreased neck and low
back pain in surgeons

Moving Towards Function/Marik

65

STUDIES NOT MAKING THE CUT


Schneider et al
improved wrist extensor
strength in tennis
athletes

Moving Towards Function/Marik

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22

PTAPTM_1275

THE SHOULDER & POSTURE

Basic Anatomy
Shoulder Girdle Posture and Biomechanics
Lab: UE posture assessment, taping, exercise
Dynamic Stabilizers
Rotator Cuff/Impingement
Taping and Exercise
Static Stabilizers
GH Instabilities/Arthropathy
Lab: Taping and Exercise
TOS taping
Review Hemiplegic Shoulder Taping

BONES OF THE SHOULDER GIRDLE


STATIC STABILIZERS
CLAVICLE
Illustration from:
Terry G, Chopp
T. Functional
anatomy of the
shoulder. Jour
Athl Training,
2000;
35(3):248-255

HUMERUS
SCAPULA

Moving Towards Function/Marik

68

Joint Anatomy: 4 Articulations


Stabilizers
Sternoclavicular
Acromioclavicular
Glenohumeral
Scapulothoracic

Retrieved on 2/26/12 from:


http://upload.wikimedia.org/
wikipedia/commons/thumb/5/59/
Pectoral_girdles-en.svg/510pxMoving Towards Function/Marik
Pectoral_girdles-en.svg.png

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23

PTAPTM_1275

Shoulder Girdle Muscles


The Dynamic Stabilizers

Scapulohumeral
Axioscapular
Axiohumeral

Illustrations:
http://upload.wikimedia.org/wikipedia/common
Moving Towards Function/Marik
s/8/8f/Gray412.png

70

SCAPULA POSTURE POSTERIOR LANDMARKS

ACROMION

SPINE OF SCAPULA
LATERAL BORDER
MEDIAL BORDER
Dorsal Scapula

INFERIOR ANGLE
SUPERIOR ANGLE

Retrieved and modified on 06/06/09 from:


http://www.courses.vcu.edu/
DANC291-003/scapula_landmarks.jpg
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Anterior Landmarks

Coracoid process

Acromion process
Superior angle
Medial border
Lateral border
Inferior angle

Retrieved from:
http://upload.wikimedia.org/wikipe
dia/commons/4/41/Gray202.png

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24

PTAPTM_1275

Alignment of the Scapula


Vertical Medial Border
Medial Border ~2 to 3
inches from the spine
Position between
~T2 and T7

Dorsal Scapula

Spine of Scapula at ~T4

Retrieved and modified


06/06/09 from:
http://www.courses.vcu.edu/
DANC291003/scapula_landmarks.jpg

20 to 30 Degree Anterior Tilt


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Sahrmann 2002

Glenoid fossa shallow


and slightly concave.
Oriented anteverted
and upwards facing.

Retrieved on 4/11/10 from:


http://www.actaortho.gr/v57t3/U1.jpg

Freidman et al 1992

Moving Towards Function/Marik

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25

PTAPTM_1275

Glenohumeral Alignment
Glenohumeral head should be < 1/3 anterior
to acromion
Neutral rotation
Proximal and distal humerus are vertical

Moving Towards Function/Marik

76

Changing Posture Has Effect on


Shoulder ROM
Lewis J, Wright C, Green A.
Subacromial Impingement
Syndrome: The effect of changing
posture on shoulder range of
motion. J Orthop Sports Phys
Ther,2005;35:72-87.
Kyphosis associated with decreased
subacromial space (Gumina et al
2008)
Moving Towards Function/Marik

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POSTURE SPINAL ALIGNMENT


CERVICAL: SLIGHTLY
CONVEX CURVE ANTERIOR
THORACIC: SLIGHTLY
CONVEX CURVE
POSTERIOR
LUMBAR: SLIGHTLY
CONVEX CURVE ANTERIOR

Retrieved from: http://upload.


wikimedia.org/wikipedia/commons/
f/f8/Illu_vertebral_column.jpg

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26

PTAPTM_1275

POSTURE PELVIS ALIGNMENT


Is anterior superior illiac
spine (ASIS) postured in:
Neutral
Anterior
Posterior
Retrieved from: http://upload.wikimedia.org/
wikipedia/commons/3/32/Gray435.png
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Posture Lab/Assess Your Partners


Posture

Assessment form located in the back of


manual
Assess your partner. Where is scapula
positioned?
Where is glenohumeral joint positioned?
Moving Towards Function/Marik

80

POSTURE PELVIS ALIGNMENT


Anterior Pelvis Tilt
Hip flexors shorten and
hip extensors lengthen

Retrieved from: http://upload.wikimedia.org/wikipedia/


commons/thumb/e/e2/Anterior_Hip_Muscles_2.PNG/400

Anterior_Hip_Muscles_2.PNG
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27

PTAPTM_1275

POSTURE PELVIS ALIGNMENT


Posterior Pelvis Tilt
Hip flexors lengthen and
hip extensors shorten

Retrieved from: http://upload.wikimedia.org/wikipedia/


commons/thumb/e/e2/Anterior_Hip_Muscles_2.PNG/400

Anterior_Hip_Muscles_2.PNG
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Abdominal/Pelvis & Pect. Minor


Connection

Retrieved on 06/09/09 from:


http://www.midlandstech.com/
Retrieved on 06/09/09 from:
science/kelleherk/210/Images/
Moving Towards Function/Marik
83
http://dic.academic.ru/dic.nsf/
PracticeQuiz/muscles2.jpg
enwiki/1085537

KINEMATIC CONNECTION
BETWEEN SHOULDER
GIRDLE AND ANTERIOR PELVIS
Short external obliques,serratus
anterior, and pectoralis major
could contribute to anterior
pelvis tilt.

Retrieved from: http://upload.wikimedia.


org/wikipedia/commons/thumb/5/55/Serratus_
anterior_muscle_2.jpg/800pxMoving Towards Function/Marik
Serratus_anterior_muscle_2.jpg

84

28

PTAPTM_1275

KINEMATIC CONNECTION BETWEEN


SHOULDER
GIRDLE AND POSTERIOR PELVIS
org/wikipedia/com
mons/thumb/5/55/S
erratus_
anterior_muscle_2.j
pg/800pxSerratus_
anterior_muscle_2.j
pg

Tight rectus could contribute too posterior


pelvis tilt.
Tight pectoralis minor likely contributing to
scapula anterior tilt.
Moving Towards Function/Marik

1.

85

Posture Taping
Changing Posture May Effect Shoulder
ROM
Ask patient to extend their

thoracic spine.
2. Place protective tape from T1
to T7 followed by strap tape.
3. Ask patient to retract and
depress their scapula.
4. Apply protective tape followed
by strap tape from middle of
the scapula spine to T12
diagonally towards spine.
Moving Towards Function/Marik

Lewis et al 2005

86

org/wikipedia/commons/thumb/5/
5/Serratus_anterior_muscle_
2.jpg/800px-Serratus_anterior_
muscle_2.jpg

Stretch Quadratus
Lumborum in
the laterally flexed hip.
Supine with ankles dorsiflexed.
Pelvis stabile.
Reach from waist to opposite side keeping
the pelvis stabile.
Moving Towards Function/Marik

87

29

PTAPTM_1275

MORE
POSTURE TAPING

Posture Taping for Kyphosis

T6

Greig et al 2008

Moving Towards Function/Marik

89

Posture Taping for Kyphosis


1. Ask the patient to elongate their crown of the
head towards the ceiling and draw the shoulder
blades down and together.
2. Apply protective tape from each anterior acromion
over the trapezius moving diagonally to T6. Tape
crosses at T6.
3. Firmly apply the rigid tape to the anterior AC joint
and follow tape to T6.
4. Apply bilaterally.
Moving Towards Function/Marik

90

30

PTAPTM_1275

Extension Over The Chair

1. Sit tall with the top of back rest ending at the level of
the mid back.
2. Hands behind your neck and gently arch back in the
chair.
3. Keep cervical spine in neutral (avoid extension).
4. Keep pelvis stable. Should not feel movement at
lumbar spine.
Moving Towards Function/Marik
91

Posture Exercise

Thoracic Extension
1. Tighten core and activate transversus Photo retrieved from
http://upload.wikimedia.org
abdominis. Pelvis neutral and stabile. /
wikipedia/commons/3/32/Ill
u_trunk_muscles.jpg
2. Inhale prepare
3. Exhale push up from mat with cervical spine
in neutral. Should not feel any tension in LB.
4. Inhale and return to neutral.
Moving Towards Function/Marik

92

Moving Towards Function/Marik

93

31

PTAPTM_1275

Moving Towards Function/Marik

94

FORWARD HEAD POSTURE

POSSIBLE SHORT SCALENES, LEVATOR SCAPULA,


AND/OR UPPER TRAPEZIUS.
STRETCH TIGHT MUSCLE AND TEACH GENTLE
NODS.
Retrieved from: http://upload.wikimedia.org/wikipedia/commons/6/6e/Scalenus.png
Moving Towards Function/Marik

95

1. Stand, holding hand behind back.


2. Lower left shoulder, then tilt your head to the
right.
3. Slowly roll head backwards until a stretch is
felt. Hold for 10-15 seconds.
4. Repeat for other side.
5. Repeat cycle three times, at least three times
daily.

Retrieved on 3/29/10http://img.medscape.com/pi/emed/
Moving Towards Function/Marik
ckb/rehabilitation/305143-316715-29.jpg

Scalene Stretch
96

32

PTAPTM_1275

Role of Dynamic Stabilizers

SHOULDER GIRDLE
BIOMECHANICS

Motions of the scapula, humerus,


& clavicle
Ludewig et al (2009). Motion of the Shoulder
Complex during Multiplanar Humeral Elevation. Jour
Bone & Joint Surg, 91:378-89

3 Dimensional Motions of Scapula


Upward
Rotation
Posterior
Tilt
From Int.
Rot.
Towards
Ext. Rot.

Retrieved on
06/3/12:http://nicktumminello.com/wpcontent/uploads/2010/07/F1.large_Moving Tows Function/Marik
98
300x220.jpg

3 Dimensional Motions of Scapula


Upward
Rotation
Posterior
Tilt
From Int.
Rot.
Towards
Ext. Rot.

Retrieved on 06/07/09:
http://www.flzine.com/wpcontent/uploads/2009/03/rotator.gif

Moving Towards Function/Marik

99

33

PTAPTM_1275

Upper Trapezius and


Serratus Anterior
provide
rotatory force early
needed for
Upward Rotation.
Upper Trapezius
limiting scapular
internal rotation.

Picture adapted from:


Donatelli, R. (1997).
Moving Towards Function/Marik

Picture adapted from: Donatelli, R.


(1997).

100

Serratus Anterior
provide
force for upward
rotation & post
tilt.
Lower/Middle
Trapezius pulls
inferior for ER.
UT limits scap IR
Trapezius
contributes to
post tilt

Moving Towards Function/Marik

101

Motions of the Glenohumeral Joint

Retrieved on 08/02/09
from:
http://www.bosshin.com/
_userfiles/image/winging
%20and%20instability.jpg

Head of humerus moves superior in the glenoid.


Rolls and spins ~2 mm to stay centered in the
glenoid fossa. Moves towards external rotation.
Donatelli, R. (1997). Physical
of shoulder. Philadelphia, PA:102
MovingTherapy
Towards Function/Marik
Churchill Livingston.

34

PTAPTM_1275

Anterior and Posterior Balance Forces Needed


to Keep the Glenohumeral Joint Centered
Phase I: 0.7 to
2.7mm of anterior
translation.
Phase II: 0-1.5mm
of posterior
translation.
Phase III: 4.5mm
posterior
translation.

Retrieved on 6/3/12 from:


http://upload.wikimedia.org/wikipedia/commons/9/
90/Shoulderjoint.PNG Moving Towards Function/Marik
Ludewig & Cook, 2002.

103

CLAVICLE MOTION
Sternoclavicular Joint
Relative to Thorax

Retraction
15 Degrees

Elevation
>10 degrees
Retrieved on 06/07/09
from:http://images.goo
gle.com/imgres?imgurl
=http://moon.ouhsc.

Posterior
Rotation
30 Degrees
Moving Towards Function/Marik

104

SCAPULAR MOTION
Relative to the
Acromio-clavicular Joint

SCAPULAR UPWARD ROTATION = SC elevation


and posterior rotation with AC upward rotation
POSTERIOR TILT = SC elevation & post rot couples
with AC posterior rotation
EXTERNAL ROTATION = SC retraction couples with
AC internal rotation
Illustration from: Ludewig P, Braman
J. Shoulder impingement: Biomechanical105
Moving Towards Function/Marik
considerations in rehabilitation. Manual Ther, 2011;16:33-39

35

PTAPTM_1275

Rotator Cuff
Tendinopathy/Impingement
OUCH!

Retrieved on 6/3/12 from:


http://upload.wikimedia.org/wikipedia/
commons/d/d3/MRI._Subacromial_impi
ngement..jpg

Moving Towards Function/Marik

106

Pain Localization

Rotator cuff tendinopathy referred


pain at anterior lateral arm and night
pain
Acromioclavicular arthritis or AC
injury pain at superior anterior
shoulder
Radiculopathy presents as medial
scapular pain and/or parathesia
below the elbow
Moving Towards Function/Marik

107

Changes to the Relationship of the Humerus and


Scapula
Primary Impingement
Secondary Impingement
Posterior Impingement(internal or undersurface)
Anterior Impingement
Coracoid Impingement Syndrome
Moving Towards Function/Marik

108

36

PTAPTM_1275

Hawkins & Kennedy Test


Scapular Plane

Position of test for impingement against


the coracoacromial arch forcing rotator
cuff tendons under arch
Moving Towards Function/Marik
and against coracoid process.

109

Hawkins & Kennedy Test


Patient Position:
90 degree flexion in scapular plane.
Examiner:
Examiners hand on patients elbow while other hand
applies overpressure towards IR.
Positive Test:
Pain at anterosuperior shoulder.

Moving Towards Function/Marik

110

Palpate Supraspinatus Tendon

Retrieved on 6/20/10
from:http://www.thefreelibrary.com/
Optimal+methods+for+shoulder+tendon+palpation
:
+a+cadaver+study-a018061609
Moving Towards Function/Marik

Image retrieved on
9/17/11 from:
http://t2.gstatic.com/ima
?q=tbn:ANd9GcQOmUSo
V2iYOXqf0YxxoUYT4ikh
v0vrAOg2TVHd9TYloV9fC
111

37

PTAPTM_1275

Palpation of Subscapularis Tendon

Illustration from: Mattingly


Mackeray. Optimal
Moving Towards&
Function/Marik
112
Method for Shoulder Tendon Palpation. Phy Ther, 1996; 76(2):167-

Palpate Infraspinatus Tendon

Illustration from Mattingly &


Mackeray, Phy Ther, 1996; 76(2):167-174.
Retrieved on 9/17/11 from:
http://t1.gstatic.com/images?q=tbn:ANd9GcR
96vynm9uTd8IYbJTFwHihOQhxpONZNybXZjhq
0EaTsLSkiVtW
Moving Towards Function/Marik

113

Hung C, Jan M, Lin Y, Wang T, Lin J.


Scapular kinematics and impairment
features for classifying patients with
subacromial impingement syndromes.
Manual Ther, 2010;15:547-551.

Prediction Variables for Impingement


Moving Towards Function/Marik

114

38

PTAPTM_1275

EVIDENCE
Ludewig, P., Cook, T. (2000). Alterations in
Shoulder Kinematics and Associated Muscle
Activity in People with Symptoms of Shoulder
Impingement. Physical Therapy, V 80, 3, 276291

Retrieved on 03/20/09 from


http://images.google.com/
Moving Towards
Function/Marik
images?hl=en&q=sheet+
metal+workers&btnG

115

EVIDENCE
Ludewig, P., Cook, T. (2002). Translations of
the Humerus in Persons with Shoulder
Impingement Symptoms. Jour Ortho & Sports
Phys Ther, 32 (6), 248-259.

Retrieved on 05/30/09 from


Moving Towards Function/Marik
http://www.rehab.research.va.gov/jour/03/4
0/4/mcmahonf04.gif

116

Biomechanic Mechanisms
Mechanism
Inadequate Serratus
Activation
Excessive Upper Trapezius
Recruitment
RTC inadequate
Posterior Capsule Tight

Effect

Ludewig & Reynolds, 2009

Decreased upward
rotation/posterior tilt
Increased clavicle
elevation & decreased
posterior tilt
GH not centering
Increased scapula anterior
tilt, humerus translation
ant or sup
Humeral and/or scapula IR

Pect Major and/or Pect


Minor Tightness
Moving Towards Function/Marik

117

39

PTAPTM_1275

THERAPEUTIC GOALS
1. Decrease clavicle elevation & scapula posterior tilt
Inhibit Upper Trapezius activity & SA recruitment

2. Increase upward rotation/posterior tilt


Facilitate Serratus Anterior and Lower Trapezius

3. GH not centering
Improve extensibility of capsule & cuff
Improve strengthMoving
of Towards
rotator
cuff
Function/Marik

118

THERAPEUTIC GOALS
4. Decrease humerus translation anterior or
superior
Increase extensibility posterior capsule/cuff

5. Humeral and/or scapula IR


Increase extensibility of pectoralis minor &
thoracohumeral muscles (pect major/lat dorsi)
Moving Towards Function/Marik

119

TAPING
AND
EXERCISE LAB
Moving Towards Function/Marik

120

40

PTAPTM_1275

Goal #1: Decrease clavicle elevation & posterior


tilt
-Inhibit Upper Trapezius activity & SA recruitment
Goal #2: Increase upward rotation/posterior tilt
-Facilitate Serratus Anterior and Lower Trapezius

Rigid Tape for Impingement: UT Inhibit


Elastic Tape for UT Inhibition
Lower Trapezius (LT) Exercises
Serratus Anterior (SA) Facilitory Taping
SA Exercises
Moving Towards Function/Marik

121

Rigid Tape for Impingement:


UT Inhibit
1. Apply protective tape over the
skin
2. The base is placed at the
ant/medial clavicle and extends
posterior in a caudal direction
towards paraspinal region just
proximal to LT origin.
3. Apply rigid tape on top with
compression over the UT.

SELKOWITZ 2007

Moving Towards Function/Marik

122

Elastic Tape:
UT Inhibition for Impingement

1. Cut a Y strip ~8-9 inches


2. Place the base at acromion
with pt positioned in
contralateral side flexion.
3. Envelop UT with tape tails
& light stretch. Tails lie
down without tension.
4. Some authors recommend
up to 50% tension, Hsu
studied described no
tension.
(Hsu et al 2008)

Moving Towards Function/Marik

123

41

PTAPTM_1275

Lower Trapezius Facilitation


Cut an I piece from ~T12
to acromion.
Place patients arm in
horizontal abduction.
Apply base with no
tension in region of T12.
With 0% to 50% tension
apply tape towards
acromion.
No tension at tail.
Moving Towards Function/Marik

124

Option Elastic Tape:


LT Facilitation for Impingement
1. Cut a Y strip ~8-9 inches
2. Place the base at acromion
(per Hsu study).
3. Envelop the muscle with
light stretch. Bring tails to
~T12. Apply the tails with
minimal tension.
4. Some authors recommend
up to 50% tension, Hsu
studied described no
tension.

Pt in Horz Abd

(Hsu et al 2008)
Moving Towards Function/Marik

125

EXERCISE GOAL

FACILITATE LOWER TRAPEZIUS

FACILITATE SERRATUS ANTERIOR


INHIBIT UPPER TRAPEZIUS
Goal #1: Decrease clavicle elevation & increase
posterior tilt
-Inhibit Upper Trapezius activity & SA recruitment
Goal #2: Increase upward rotation/posterior tilt
-Facilitate Serratus Anterior and Lower Trapezius
Moving Towards Function/Marik

126

42

PTAPTM_1275

Perform Exercises after Taping


Phase I: Lower Trapezius Exercises

Small lift from the pillow and pull the inferior border
of the scapula towards the spine. Hold contraction
6 seconds.
Moving Towards Function/Marik

127

Phase II For Lower Trapezius


Emphasis on adduction combined with
depression
when working on scapula force couple.

Moving Towards Function/Marik

128

Phase III: Lower Trapezius

Patient is supine with arms in external rotation.


Patient lifts his arms to approximately 125
horizontal abduction. Instruct the patient to hold
arms at shoulder level while sliding the scapula
down (towards back pocket).
De Mey et al 2009
Moving Towards Function/Marik

129

43

PTAPTM_1275

SERRATUS ANTERIOR FACILITATION


TAPING FACILITATE SERRATUS
1. Apply tape I strip anchoring
at the upper 6,7,8,9 ribs.
2. Follow the tape up to medial
border of the scapula with up
to 50% tension.
3. Rub to activate glue.

Photo retrieved from: http://


openphysio.co.za/images/
thumb/5/5d/Levator_
scapulae.jpg/150px-Levator
_scapulae.jpg

Moving Towards Function/Marik

130

Serratus Anterior Facilitation

Moving Towards Function/Marik

131

Phase I: Serratus Anterior

Inferior Glide: Arm is scaption to 90, wrist neutral,


elbow extended, fist clenched on a supportive
surface. Patient applies pressure towards
adduction and inferiorly depressing the scapula.
Hold 6 seconds. Ekstrom et al 2003.
Moving Towards Function/Marik

132

44

PTAPTM_1275

Phase II: Serratus Anterior


Wall Slides:
Ulnar side of forearm
pushes into the wall as
patient slides up the
wall. Relax on the way
down.
One foot forward and
one foot back.
Engage core.
Suenaga et al 2003
Moving Towards Function/Marik

133

Phase III: Serratus Anterior

Dynamic Hug: Horizontal flexion of humerus at 60


elevation. The hands follow an imaginary arcc until
maximum protraction is attained.
Decker et al, 2003

Moving Towards Function/Marik

134

Phase IV: Serratus Anterior

Push-Up Plus: Patient performs a standard push up


followed by a protraction.
Can start push-ups on the wall, progress to knee pushups.
Moving Towards Function/Marik

135

45

PTAPTM_1275

Goal #3: Center GH in Glenoid


-Improve extensibility of capsule & cuff
-Improve strength of rotator cuff
Goal #4: Decrease humerus translation anterior
or superior
-Increase extensibility posterior capsule/cuff
Tape to decrease/feedback to decrease anterior
translation of humeral head
Mobilize and stretch tight muscles and capsule
Moving Towards Function/Marik

136

Elastic Tape to Decrease GH Anterior


Translation
Pts GH joint
in neutral
rotation.
1. Cut an I strip to wrap ant/posterior humeral head.
2. Tear the tape in the middle.
3. Apply tape with 50% to 75% tension on the anterior
humeral head.
4. Lie tails down without tension.
Moving Towards Function/Marik

137

Stretching Posture Capsule


Stabilize the lateral
border of the scapula
with the heal of one
hand.
Apply overpressure
towards horizontal
adduction while
stabilizing the scapula.

Moving Towards Function/Marik

138

46

PTAPTM_1275

Taping and Exercise Lab:


Posterior Capsule Stretching
MOBILIZE GH JOINT

POSTERIOR CAPSULE/CUFF STRETCHING

Moving Towards Function/Marik

139

Goal #5 :Humeral and/or scapula IR


-Increase extensibility of pectoralis minor &
thoracohumeral muscles
Stretch Tight Muscles
Stretch Pectoralis Minor
Stretch Pectoralis Major
Stretch Latissimus Dorsi
Consider Kinetic Chain
Photos retrieved from:
from:http://images.google.com/imgres
?imgurl=http://upload.wikimedia.org/wikipedi
Moving Towards Function/Marik

140

Taping for Tight Pectoralis Major


Inhibit Pectoralis Major:
1. Measure I strip from
intertubercle groove to
sternum with abd/ER(90/90).
2. Apply the base at the
intertubercle groove.
3. Lie one tail down along the
clavicle and the other tail on
sternocostal head with light
tension while the patient is
in 90/90 position.

Photo retrieved from:


Moving Towards
Function/Marik
: http://openphysio.co.za/images/

141

thumb/5/5d/Levator_scapulae.jpg/150px-

47

PTAPTM_1275

Possible Muscle Imbalances


Anterior
Tilt

Anterior tilted scapula


Tight pectoralis minor?
Does the inferior angle of the scapula protrude
from the thorax?
Is there an asymmetry between the posterior
acromions when patient is supine
Moving Towards Function/Marik

142

Taping for Scapular Anterior Tilt


Inhibit Pectoralis Minor:
1. Cut a Y strip measure
from coracoid process to
rib 3, 4, & 5.
2. Patient pulls his scapulae
together and down.
3. Place the base at the
coracoid process.
4. Place each tails down
with light tension.
Photo retrieved from:

: http://openphysio.co.za/images/
thumb/5/5d/Levator_scapulae.jpg
/150px-Levator_scapulae.jpg
Moving Towards Function/Marik

143

Evidence for Pectoralis Minor


Stretching
1

2
2

Unilateral Self Stretch

Borstad, J., Ludwig,P. (2006). Comparison


of three
stretches for the pectoralis minor muscle.
Moving Towards
Function/Marik
144
J Shoulder & Elbow Surgery, 15:324-330.

48

PTAPTM_1275

PECT. MINOR STRETCHING & MANUAL


TECHNIQUES FOLLOW WITH TAPING

1. Stabilize pect minor at the coracoid process in a loose


position with arm adducted to the side.
2. Bring the arm to ~140 horizontal abduction. The arm
should be parallel to the table without extending the GH
joint below the table.
Technique retrieved from: http://www.mikereinold.com/wp-content/uploads/blogger/12Moving Towards Function/Marik
image%5B64%5D.png

145

IMPINGEMENT
TAPING
Moving Towards Function/Marik

146

Immediate Pain Relief for Pain Free Abd


STEP 1

1. Cut a Y strip the length


of supraspinatus from
origin to insertion.
2. Pt side bends cervical
spine to opposite side
and involved hand
internally rotated
behind the back.
3. Apply base with no
tension.
4. Apply tails to surround
supraspinatus.

Thelan et al 2008

Moving Towards Function/Marik

147

49

PTAPTM_1275

Immediate Pain Relief for Pain Free Abd


Step
1. Cut a Y piece from deltoid
insertion to origin.
2. Place base of Y strip at
deltoid insertion.
3. Place patient external
rotation with the shoulder
abducted to 90
4. Anterior tail is applied to
anterior deltoid with light
tension.

Thelan et al 2008

Moving Towards Function/Marik

148

Immediate Pain Relief for Pain Free Abd


Step 3
1. Place patient in internal
rotation and slight
horizontal abduction.
2. Posterior tail is applied to
posterior deltoid with
light tension. with the
patient in horiz. Abd and
internal rotation.
Thelan et al 2008
Moving Towards Function/Marik

149

Immediate Pain Relief for Pain Free Abd


Step 4

1. Cut an I tail measuring from


coracoid process to scapula.
2. Apply the base of tape at the
coracoid process.
3. Hold base down.
4. Apply tape with ~75% tension with
downward pressure around the
head of the humerus.
5. Patient actively flexes the shoulder
with slight IR while tape is being
applied.

Towards Function/Marik
Thelan Moving
et al 2008

150

50

PTAPTM_1275

Rigid Taping for Impingement Pain


Relief

1st strap anchored over


anterior deltoid and extends
posterior along spine of
scapula.
2nd strap anchored at corocoid
process and extends posterior
and inferomedially over
scapula to imitate the line of
pull of LT
Miller et al 2009

Moving Towards Function/Marik

151

Taping to Increase GH Rotation


Secondary Impingement and/or
Posterior Impingement?
1. Apply protective piece at
anterior humeral head.
2. Pass tape over and lateral
to the acromion process.
3. Finish tape at the inferior
angle of the scapula.
4. Rigid tape is applied over
the protective piece
tension over the head of
the humerus.

Moving Towards Function/Marik

152

Long Head of Biceps Taping


Step 1
1. Cut a Y strip from cubital
fossa to glenoid fossa.
2. Patients elbow is
extended.
3. Apply the base of the strip
at the radial head with no
tension.
4. Apply each tail with paper
off tension surrounding the
bicep muscle.

Moving Towards Function/Marik

153

51

PTAPTM_1275

Long Head of Biceps Taping


Step 2
1. Cut a Y strip from the pain
point to lateral shoulder.
2. Patients shoulder is
extended.
3. Apply the base to the pain
point without tension.
4. Apply the tails with 25%
tension in the transverse
direction.
Moving Towards Function/Marik

154

CONTRIBUTIONS OF GH
STATIC STABILIZERS
Moving Towards Function/Marik

155

GLENOHUMERAL STABILIZERS
STATIC

DYNAMIC

Geometry of GH joint
Muscles
Scapular Stabilizers
Glenoid Labrum
Rotator Cuff Muscles
Negative intra-articular
Long head of the
pressures
biceps
Ligaments/Capsule

Finnoff J, Doucette S, Hicken G. Glenohumeral instability and dislocation. Phys


Moving2004;15:575-605.
Towards Function/Marik
156
Med and Rebab Clinics of N Amer,

52

PTAPTM_1275

Static Stabilizers
1. Bone Congruency/Geometry of Glenohumeral
Joint
Retr:

Humeral head to shaft


angle 130 to 150
Retroverted 30

Contributes to posterior
inferior stability.

Illustration: http://upload.wikimedia.org/
wikipedia/commons/thumb/0/04/Leonardo_da
_Vinci_-_Anatomical_studies_of_the_
shoulder_-_WGA12824.jpg/421px-Leonardo
_da_Vinci_-_Anatomical_studies_of_the_shoulder_-_WGA12824.jpg

Moving Towards Function/Marik

157

Static Stabilizers
2. Glenoid Labrum
Fibrocartilaninous Structure
^ depth of glenoid
fossa by 50%
Provides attachment of
GH ligaments
Firmly attached in all
regions except loosely
superiorly
Illustration retrieved from
http://www.sportsinjuryclinic.net/
gallery/shoulder/glenoid_labrum2.jpg

Moving Towards Function/Marik

158

Static Stabilizers
3. Negative intra-articular pressures

4. Negative Intra-articular Pressure


Creates a vacuum effect across GH joint
Primary stabilizer against inferior instability
Also prevents instability in other directions
Illustration retrieved on 2/26/12 from:
Moving Towards Function/Marik
http://www.shoulderdoc.co.uk/images/uploaded/labrum_depth.jpg

159

53

PTAPTM_1275

Static Stabilizer
4.Capsule & Ligaments
Superior
Middle
Inferior
Coracohumeral

Illustrations:
http://upload.wikimedia.org/wikipe
dia/commons/3/3b/Gray326.png
Moving Towards Function/Marik

160

Capsule Instabilities
LH BICEPS
SGHL

Posterior
Capsule
MGHL
ANT. BAND
IGHL
IGHL

Post. Band
IGHL
CAPSULE

Retrieved and modified on 7-4-10 from:


http://www.eorif.com/Shoulderarm/Shoulder%20anat/Images
Moving Towards Function/Marik
/Shoulder-ligaments.jpg

Download from
website
161

ANTERIOR INSTABILITY

Picture retrieved from: http://upload.wikimedia.org/wikipedia/commons/3/3b/Gray326.png


Moving Towards Function/Marik

162

54

PTAPTM_1275

Stabilizers Against Anterior Dislocation


Humerus adducted: Subscapularis
Humerus abducted 45: Subscapularis, Middle
anterior GH Ligament, and Superior portion of
Inferior Anterior GH Ligament
Humerus at 90 abduction: Inferior Anterior GH
Ligament

Retrieved from: http://www.radsource.


us/_images/0909_6.jpg
Moving Towards Function/Marik

Turkel et al 1981

Illustration retrieved on 3/5/12 from


http://www.acta-ortho.gr/v57t3/U5.jpg
Moving Towards Function/Marik

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164

Anterior Instability
Instability of the anteriorinferior glenohumeral
joint capsule.
OR
Detachment of the
http://images.conquestchronicles.
com/images/admin/shoulder_bankart_lesion_85905_2.jpg
anterior-inferior glenoid
labrum from the glenoid
rim.
Illustrationfrom:http://www.bosshin.com/_
userfiles/image/normal%20hammock.jpg
Moving Towards Function/Marik

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Apply an antero-medial glide to humeral


head

0 to 30 degrees
Ant/Sup Capsule

45 to 60 degrees
Ant/Middle
Capsule

90 degrees
Ant/Middle Capsule

Moving Towards Function/Marik

Acute

166

Frequency

Acute injury resulting in


subluxation or dislocation
TUBS: traumatic, unilateral,
bankart
98% of cases dislocate anteriorly, 2%
posterior

Chronic

Repetitive instability episodes


AMBRI: atraumatic,
multidirectional, bilateral,
rehabilitation, inferior shift
Moving Towards Function/Marik

Illustration retrieved from:


http://www.theshouldercenter.com
/images/RecurrentInstabilityGrap
h.JPG

Illustration retrieved from:


http://images.conquestchronicles.com/i
167
mages/admin/shoulder_bankart_lesion
85905 2.jpg

SECONDARY IMPINGEMENT

Retrieved on 4/4/09 from:


http://www.baseballmusings
.com/archives/JeterThrow5150361
_Yankees_v_Royals.jpg

Impingement related to an anterior


instability.
Andrews & Alexander, 1995.
Moving Towards Function/Marik

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PTAPTM_1275

LAB: TAPING FOR ANTERIOR


INSTABILITY
Tape is applied to anterior
humeral head.
Pull tape diagonally across
the scapula.
End the tape medial to the
inferior border of the
scapula.
Finn off J, Doucette S, Chicken G.
Moving Towards Function/Marik
Glenohumeral instability and dislocation. Phys Med
and Reba Clinics of N Amer 2004;15:575-605

169

Instability Superior Labrum AnteriorPosterior


SLAP
Etiology: Fall on an

outstretched abducted arm


or sudden contraction of
biceps tendon or repetitive
stress.
Symptoms:

Painful popping,
clicking, or catching
Pain when moving arm
overhead

Illustration retrieved on 3/5/12 from:


from:http://www.athleticadvisor.com/
images/shoulder/SLAP/SLAP_types2.gif

Illustration from:
http://www.ptclinic.com/medlibrary/
images/v2/slapbankart.gif
Moving Towards
Function/Marik

170

SLAP:Superior Labrum Anterior Posterior


Type I/Fraying
Type II/Biceps & Labrum are
becoming detached
Type III/Biceps & Labrum are
stable on glenoid, but a flap
hangs down
Type IV/Bucket handle tear
extending into the biceps
Moving Towards Function/Marik

Retrieved on 7-4-10
from:http://www.athleticadvisor.com/
images/shoulder/SLAP/SLAP_types2.gif

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Peel Back Mechanism in Throwing


Athletes

Retrieved from: http://2.bp.blogspot.com/_


BsgqbRhgCnQ/SRtejHI0PvI/AAAAAAAAANA/
vMjopqYdgrs/s400/SLAP-peel-back.jpg

Retrieved from: Braun S, Kokmeyer D, Millett P.


Current Concepts Review: Shoulder Injuries in the
Throwing Athlete. Jour Bone & Jt Surg, 2009;91(4):

High eccentric activity of the biceps during


arm deceleration.
Torsional peel back force detaching labral
anchor.
Moving Towards Function/Marik

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Lab: Taping to Improve IR for Individuals with


Humeral Head Anterior Translation (2 strips)
Mc Intosh 2009
1. Apply two protective
pieces of tape from
anterior aspect of
humeral head.
2. Apply tape passing
over and lateral to the
acromion and finish at
inferior angle of the
scapula.

Moving Towards Function/Marik

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Elastic Tape to Decrease GH Anterior


Translation
Pts GH joint
in neutral
rotation.
1. Cut an I strip to wrap ant/posterior humeral head.
2. Tear the tape in the middle.
3. Apply tape with 50% to 75% tension on the anterior
humeral head.
4. Lie tails down without tension.
Moving Towards Function/Marik

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PTAPTM_1275

Taping and Exercise Lab:


Posterior Capsule Stretching
MOBILIZE GH JOINT

POSTERIOR CAPSULE/CUFF STRETCHING

Moving Towards Function/Marik

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LATE PHASE
ISOTONIC RTC & SCAPULAR STABILIZATION
EXERCISES
10/10 (ER/ABD) to 45/45 TO 90/90
POSITION
RTC STRENGTHENING

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Proprioception Training

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