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TitleDiagnosis and Treatment of Movement Impairment Syndromes
File Size80.8 MB
Total Pages466
Table of Contents
                            Front Cover
Back Cover
Cover Page
Chapter 1
: Introduction
Chapter 2
: Concepts and Principles of Movement
Chapter 3: Movement Impairment Syndromes of the Lumbar Spine
Chapter 3: Appendix
Chapter 4: Movement Impairment Syndromes of the Hip
Chapter 4: Appendix
Chapter 5: Movement Impairment Syndromes of the Shoulder Girdle
Chapter 5: Appendix
Chapter 6: Lower and Upper Quarter Movement Impairment Examinations
Chapter 7: Corrective Exercises- Purposes and Special Considerations
Chapter 8: Exercises to Correct Movement Impairment Syndromes
Document Text Contents
Page 2

Djagnodjd anD Treatment of
Movement Impairment S~noromet1

Authored by an acknowledged expert on muscle and movement imbalances, this
well-illustrated book presents a classification system of mechanical pain syndromes
that is designed to direct the exercise prescription and the correction of faulty move-
ment patterns. Dia(JnoiJiiJ an~ Treatment of Movement Impairment S~n~romeiJ
presents the diagnostic categories, associated muscle and movement imbalances, rec-
ommendations for treatment, examination procedures, exercise principles, specific
corrective exercises, and modification of functional activities for case management.
This book gives you an organized and structured method of analyzing the mechanical
cause of movement impairment syndromes, the contributing factors, and the best
strategy for management.

Inside this one-of-a-kind resource, you'll find:

• All of the tools you need to identify movement imbalances, establish the
relevant diagnosis, develop the corrective exercise prescription, and
carefully instruct the patient on how to carry out the exercise program.

• Coverage of both the evaluation process and therapeutic treatment.

• Detailed, easy-to-follow descriptions of exercises for the student or

• Handouts that can be photocopied and given to the patient for future

• Clear, distinctive illustrations that highlight key concepts.

• Muchmore!

Page 233

Movement Impairment S~noromeiJ of the shou[oer GiroCe ____________________________________________________________ ~ ______ ~ ______ ~ __________________ ~ 22

Her bra straps add to the depressed shoulder postur-
ing. The downward pull from the bra straps was exag-
gerated because her breast size increased as the result
of having breast-fed three children. Lifting and holding
her three children also contributed to the downward
pull on her shoulders.

The patient should identify ways that she can sup-
port her arms with the shoulders horizontal rather than
depressed. Even when lifting and holding her children,
she should shrug her shoulders before lifting and should
maintain this position while lifting. After lifting or hold-
ing her children, she should perform shoulder flexion
with the shrugging exercise. When holding her children
while sitting, she should have a pillow under her fore-
arms so that her shoulders are at the correct level.

Outcome. The patient's symptoms are immediate-
ly decreased when passive support is applied to her
shoulders. She returned three times over 5 weeks for
monitoring and modification of her program. Al-
though her shoulders remain somewhat depressed,
she is pain free during all activities and has corrected
her movement patterns for most activities. Her mus-
cle strength grades improve by one grade over the
treatment period.

Scapular Abduction Syndrome

• Glenohumeral joint impingement
• Humeral subluxation (anterior)
• Tendinopathy-biceps, infraspinatus, and supra-

• Bursitis-infra deltoid
• Interscapular pain in the rhomboids and middle

• Sternoclavicular joint pain

scapular abduction during glenohumeral joint flexion/
abduction. At the end of shoulder flexion/elevation, the
axillary border of the scapula protrudes laterally more
than 1f2 inch beyond the thorax or the inferior angle of
the scapula reaches beyond the midaxillary line of the
thorax (Figure 5-46).

The scapula remains relatively stationary during
the first half of shoulder flexion with movement of the
humerus being the source of most of the motion, which
is markedly different than the 1 degree of scapular
motion to 2 degrees of glenohumeral motion. During
the phase from about 90 to 180 degrees of flexion, the
scapula and humerus move in a one-to-one ratio. One
reason for this movement pattern impairment is postu-
ral abduction of the scapula. The abducted scapular
position is associated with excessive length of the



Excessive scapular abduction. A, The scapula is excessively abducted
during shoulder flexion. ~ The patient can actively limit the degrees of
scapular abduction.

trapezius, possibly the rhomboid muscles, and short-
ness of the serratus anterior muscle. Alterations in the
length-tension relationships of these muscles interfere
with their ability to properly control the scapula, par-
ticularly for the final phase of scapular upward rotation
and depression.

When the patient is prone with his or her arm
abducted to 90 degrees, the scapula will abduct during
glenohumeral lateral rotation instead of remaining in a
constant position on the chest wall during arm motion.
This is a direct result of the excessive length of the tho-
racoscapular muscles and accompanied by shortness
of the scapulohumeral muscles. The contraction of the
lateral rotators moves the lighter segment, namely the
scapula, because it is not well controlled by the trapez-
ius and rhomboid muscles.

The impaired scapular abduction can occur during
active glenohumeral joint flexion/abduction but may not
be observed when the same motions are performed pas-
sively by the examiner. This movement pattern impair-
ment occurs not because of a lack of length of the
thoracoscapular muscles but because the thoraco-
humeral muscles do not work effectively at the length
that would hold the scapula correctly on the thorax. The
contraction of the scapulohumeral muscles moves the
scapula toward the humerus until the adapted longer
length of the rhomboids and trapezius muscles is reached.

Page 234



• With kyphosis, the curvature of the ribs contributes to an abducted

position of the scapula because the curvature moves the scapula
laterally, lengthening the thoracoscapular muscles.

• With long arms, the weight of the arms contributes to abduction of

• Often a large thorax contributes to shoulder abduction and short-
ness of the deltoid muscle. Shortness of the deltoid muscle can
contribute to the abducted scapula position. Individuals with a
large thorax often need a greater excursion of the scapulae to
reach in the front of the body. This excursion contributes to the
shortness of the serratus anterior muscle.

• Large breasts contribute to abducted scapulae because the
increased dimension of the chest forces the patient to abduct the
scapula to increase the excursion of the arms in front of the body.

• With scoliosis, the thoracic rib hump causes the ipsilateral scapula
to be abducted because of the structural barrier.


• A posturally abducted scapula (more than 3 inches from the verte-
bral spine) can result from performing activities in the front of the
body, such as playing the cello or the double bass or doing weight-
training exercises that include many repetitions of bench presses
that require contraction of the pectoralis major and minor muscles.
Push-up exercises that are performed with excessive scapular
abduction result in a posturally abducted scapula.

• Medial rotation of the humerus, particularly when the pectoralis
major muscle is short, can contribute to scapular abduction. Medial
rotation of the humerus is often incorrectly interpreted as being an
abnormal posture. When the scapula is abducted and the glenoid is
faCing anteriorly, what appears to be humeral medial rotation is
actually the correct alignment of the humerus. This alignment can
be verified by correcting the scapular position and reassessing the
humeral position.

• Lateral rotation of the humerus associated with scapular abduc-
tion may be misinterpreted as the correct degree of rotation when
the antecubital fossa is aligned forward . If the abducted scapular
position is corrected, the humerus will be in lateral rotation.
Assessment of the length of the lateral rotators, which should be
short, is necessary to confirm the impression of humeral lateral

• An abducted scapula in the quadruped position must be carefully
assessed. When the scapula is allowed to adduct to the correct
position on the thorax, the scapula will wing. The winging of the
scapula is attributed to the adaptive shortening of the serratus
anterior muscle that alters its length-tension properties. When
subjected to a load at a longer length, the muscle cannot develop
sufficient tension to prevent winging. Stiffness or shortness of the
scapulohumeral muscles can also contribute to the winging of the
scapula because of their effect on limiting horizontal adduction of
the glenohumeral joint and contribute to excessive scapular

Thoracoscapular joint motion occurs more readily than
glenohumeral joint motion, thus the scapular move-
ment into abduction may exceed the normal range. The

patient is unable to dissociate glenohumeral joint
motion from thoracoscapular joint motion. The stiff-
ness or shortness of the scapulohumeral muscles con-
tributes to compensatory motion of the scapula.

Muscle recruitment patterns. The scapulohumer-

al muscles, along with the pectoralis minor, pectoralis
major, and serratus anterior muscles, exert a more
dominant effect than the rhomboid and trapezius mus-
cles. This is evident in the excessive abduction and lim-
ited upward rotation of the scapula.

The posterior deltoid may also be more dominant
than the infraspinatus and teres minor. Dominance of
the posterior deltoid muscle contributes to the devel-
opment of shortness of this muscle, which can pull
the scapula into abduction because contraction of the
deltoid causes the scapula to move toward the

Muscle length and strength impairments
• Shortness of the deltoid or supraspinatus muscles

that holds the humerus in an abducted position at
rest can pull the scapula into the abducted posi-
tion when the counterbalancing rhomboid and
trapezius muscles are not performing effectively.

• Hypertrophied and short scapulohumeral mus-
cles, along with hypertrophy of the pectoralis
major muscle can lead to scapular abduction.

• Long and/or weak trapezius and rhomboid mus-
cles are unable to hold the scapula in normal align-
ment, which is approximately 3 inches from the
vertebral spine. The result is a position of scapular

• Short pectoralis major muscles hold the humeri in
medial rotation and horizontal adduction. Com-
bined with the shortness of the scapulohumeral
muscles, the pectoralis major muscles acting on
the humeri passively pull the scapulae into abduc-
tion during shoulder flexion and horizontal
CONFIRMING TESTS. The therapist passively corrects

the scapular position at rest · and then passively con-
trols the degree of scapular abduction. The therapist
assists with upward rotation at the end of the motion
during shoulder flexion and assesses whether the pos-
tural correction results in reduction in symptoms.

TREATMENT. The focus of treatment is to stretch the
short glenohumeral and thoracohumeral muscles.
Treatment should also be directed toward improving
the performance of the adductor components of the
lower and middle trapezius muscles in particular.
Therefore the key exercises are the progressions for
the lower trapezius muscles with the emphasis placed
on scapular adduction and not on scapular depression.
A good initial exercise for the patient is to face a wall,

Page 465

Inoex _______________________________________________________________________________________________________ \ 459

Single-leg standing, in corrective exercise, 369-370

nornlal alignment and impairments of lumbar spine
during, 54-57

tests for assessment during, 82, 84
Sitting hip flexion test, 314, 314f
Sitting knee extension and ankle dorsiflexion, 310-313, 310f
Sitting position, corrective exercises in, 393-395
Sitting tests, 310-315, 325-326

alignment, 310
hip rotation, 314
sitting hip flexion, 314, 314f
sitting knee extension and ankle dorsiflexion, 310-313,


Sitting to standing, tests for assessment during, 84
Skeletal system, base element impairments of, structural

variations in joint alignment, 34-35, 34f
Skeletal systems, neuromuscular and, peripheral,

dysfunction of, 1-2
SLR. See Straight leg raise test
Soleus, 140, 142
Spinal rotation test, 274
Spine, degenerative conditions of, 74. See also Lumbar

rotation-extension syndrome with or without
radiating symptoms

Spine, lumbar
assessnlento~ 53f
motions of, 57-74

compression, 63-64
extension of lumbar spine, 60-61
flexion, 58-60, 63, 64f
path of instantaneous center of rotation (PIeR), 57-58
return from flexion, 60
rotation, 61-63
translation, 63

movement impairment syndromes of, 51-119. See also
Specific impairment syndrome

muscular actions of, 65-74
abdominal muscles, 69-73
back muscles, 65-69
sitting, 54-57
standing, 52-54, 52!, 53!, 54!, 55f

normal alignment of the lumbar spine, 52-57
osteoarthritis of, 74, 76
test for, 322

movement impairment syndromes of, 45
shape of, 52f
thoraCiC, 199

PSIS. See Superior posterior iliac spine
Spondylolisthesis, 63, 74, 75
Stair climbing, tests for assessment during, 84
Standing, normal aligmnent and impairments of lumbar

spine during, 52-54, 52!, 53!, 54!, 55f

Standing, tests for assessment during, 76-77, 82-83, 84
back to wall tests, 360
facing wall tests, upper quarter exanlination, 356-360,

356!, 358f
Standing movement tests, 268-274, 320-321

bilateral hip/knee flexion (partial squat), 268-270
forward bending, 270-272
return from forward bending, 272
side bending, 272
single-leg stance, 270
spinal rotation, 274

Standing position, corrective exercises in, 368-370
Standing tests, 263-268, 316-317, 320, 362-363

alignment, 264-268
back to wall, 316, 316f
position, 264

Statics, effects of gravitational forces, 42-44
Stenosis, spinal, 74-75
Sternoclavicular joint pain, 218
Sternocleidomastoid, 58
Stiffness, 28-33, 30!, 33f

anatomic variations due to, 33f
clinical relevance of, 32
lumbar spinal, 61, 63
variations in, 30-31, 33f

Straight-leg raise, assessment of, 78
Straight leg raise test, 284-286, 284f
Straight-leg raises, in corrective exercises, 378
Straight-leg raising, 37

and decreased muscle strength, 19
increased muscle length secondary to, 20-23, 2lf
of right thoracoscapular muscles, 22f

Stress, tissue response to, 46f
Stress requirement, 3
Stretching, passive, effects of, 26. See also Specific exercises
Subluxation, humeral, 218, 225
Subscapularis, 215

hypertrophy of, 198
Supine position

corrective exercises in, 37l-382
tests for assessment during, 77-78

Supine test, lower abdominal, external oblique, and rectus
abdominis performance, 280-282, 280f

Supine tests, 274-292, 321-322, 363-364
double knee to chest, 274, 274f
hip abductionllateral rotation with hip flexed, 288-290,

hip flexor length test, 276-278, 276f
iliopsoas test, 286-288
straight leg raise test, 284-286, 284f
trunk curl-sit up, 282-284, 282f
unilateral hip and knee flexion (single knee to chest),

290-292, 290f

Page 466


Support elements, impairment of, 47-48
Supraspinatus, 214
Supraspinatus tendon, compression of, 215f
Swayback posture, 37, 137, 139f
Symptom source and restricted use approach, 6
System-focused approach, 6


Taping, in treatment of muscle strain, 22, 22f
Tendinitis, calcific, 234
Tendinopathy, 194

in scapula, 225
supraspinatus, 234

Tensor fascia lata (TFL), 15,28,63
Tensor fascia lata-iliotibial band (TFL-ITB), 128, 1281, 136f
Tensor fascia lata-iliotibial band stretch, 384
Teres major, 216
Teres minor, 215
Tests. See Examinations for lower and upper quarter

movement impairment; Specific tests
TFL-ITB. See Tensor fascia lata-iliotibial band
TFL. See Tensor fascia lata
Thixotropy, 29
Thoracic outlet or neural entrapment, 218. See also Thoracic

outlet syndrome
Thoracic outlet syndrome, 210
Thoracic spine, alignment of, 199
Thoracohumeral muscles, 211-212

strain of, 22f
Thorax, large, in scapular abduction syndrome, 226
Tibial varum. See Genu varum
Tibialis anterior, 140, 141, 142f
Tibialis posterior, 142

of scapula, 252-253
pelvic, 134

assessment of, 122, 123f

angle of, 125
tests of, 127

Torsion, tibial, 131, 1321, 1331, 134f
Translation motion, 63
Transversus abdominis, 35, 73, 135
Trapezius, 207

upper quarter tests for, 348-350
Trapezius muscle exercise progression, 388-389
Trandelenburg test, 155
Tribology, 12
Trochanter, greater, 16
Trunk-curl sit-up in corrective exercise, 376-377
Trunk curl-sit up test, 282-284, 282f

Unilateral hip and knee flexion (single knee to chest) test,

290-292, 290f
Unilateral hip/knee flexion test, 322-323
Upper trapezius, dominance of, 35-36

Vastus intermedius, 138
Vastuslateralis, 138
Vastus medialis oblique (VMO), 46, 138
Vertebrae. See Spine, lumbar
VMO. See Vastus medialis oblique


corrective exercises in, 398-399
tests for assessment during, 82, 84

consequences of, 1
muscle, causes of, 17
over-stretch, 19

case presentation, 20
Winging of scapula, 252-253, 41f
Wolffs law, 43
Wrist flexion during finger extension, 40, 41f

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