1. A RTHROSCOPIC A CROMIOPLASTY Angela Whittington

2. DEFINITION Bursitis or tendonitis  impingement Causes the tissues underneath the AC joint to be pinched against the bone Produces irritation and pain MOI Rotator cuff muscles become stretched  laxity Arm abducted > 90◦ head drops & longhead biceps tendon/supraspinatus becomes impinged

3. ACROMION PROCESS Three types (shapes of acromion processes) Type I: Flat Figure A Type II: Gently curved Figure B Type III: Sharply hooked Figure C

4. P ATIENT H ISTORY Female 20 y/o Division I Collegiate Volleyball athlete S/S: pain with overhead activity Dec ROM Crepitus w/ GH motion Pain w/ GH ABD & FLEX Decreased rotator cuff strength Special Tests (+) Neer Impingement & Hawkins Impingement

5. PATIENT HISTORY CONT. Image Findings Radiographs confirm Type III Acromion Process

6. I MAGING Normal Rotator Cuff Torn Rotator Cuff

7. Patient chose conservative treatments at first Rest Ice NSAIDs Rehabilitation Conservative treatment failed to return her to preinjury level Surgical intervention recommended

8. ARTHROSCOPIC ACROMIOPLASTY Ellman (1987) introduced technique for subacromial decompression Meant for pt’s who did not respond to Six mo. of conservative treatment NSAIDS, steroid injections Physical therapy Three small skin portals Spares deltoid muscle & ↓ post-op movement restriction

9. SURGICAL INTERVENTION Goal is to smooth ANT acromial undersurface Subacromial space and bursa is debrided Acromioplasty performed Recommended anterior-inferior acromioplasty Detaching deltoid muscle from ANT subacromial process & AC joint Osteosome removes ANT & undersurface of acromion process Portion of coracoacromial ligament removed to decompress the space Arthroscopic acromioplasty preferred

10. PROCEDURE Orthosports - Orthopaedic & Sports Medicine Physicians - Shoulder Impingement

11. REHABILITATION: PHASE 1 Goals Limit Pain Restore Motion Reduce Swelling

12. TREATMENT RECOMMENDATIONS Ice Sling (if necessary) E-Stim Joint Mobilization (grade 1 and 2) Rom (passive and active assisted pain free) Pendulum Exercises

13. REHABILITATION: PHASE 2 Goals Eliminate Pain Restore full active motion Restore good glenohumeral and scapulohumeral rhythm 4/5 strength or upper extremity muscles

14. TREATMENT RECOMMENDATIONS Continue modalities as needed Start with active range of motion Add isometrics below shoulder level Flexibility of cervical, shoulder, and scapular muscles

15. PRECAUTIONS All active and isometric exercises should be muscle specific All movements and activity increasing symptoms should be eliminated Isometrics are modified if patients symptoms are made worse

16. REHABILITATION: PHASE 3 Attain full pain free ROM Achieve 5/5 strength in all shoulder girdle muscles Full pain free resistive range of motion Negative Neer Sign Negative Hawkins Sign Symmetrical scapulohumeral rhythm

17. TREATMENT RECOMMENDATIONS Continue use of ice as necessary Continue with previous exercises Progress resistance to overhead and above horizontal Add resistance to scapular exercises Work on quality of motion and not just resistive training Work on balance of rotator cuff muscles Start with sport/work specific exercises Water resistive activities

18. PRECAUTIONS Do not neglect the rest of the body!

19. REHABILITATION: PHASE 4 Goals Full pain free ROM 5/5 strength in all upper extremity and scapular muscles Normal scapulohumeral rhythm w/ and w/o resistance Able to complete throwing sport specific or work tasks pain free, and w/o signs of instability or impingement

20. PRECAUTIONS It should be noted that time frames for these phases overlap time frames for these phases can’t be given. It is based on exercise intensity, pain, underlying instability, healing time, and strength Rehab should be progressive always achieving and then maintaining a pain free state

21. TREATMENT RECOMMENDATIONS Continue use of ice as necessary Continue with previous exercises Progress resistance to overhead and above horizontal Add resistance to scapular exercises Work on quality of motion and not just resistive training Work on balance of rotator cuff muscles

22. THINGS TO REMEMBER Core Strengthening Cardio Workouts Team involvement If athlete is sore after exercises, bring down Do not progress or overwork!

23. FUNCTIONAL EXERCISE Dig & Roll Practice defense and going to the floor after a dig. Use groups of three or four. Line starts at middle back position. Coach hits a ball to the right. Player must read coach's shoulders and dig ball. After the dig the player must roll. Coach alternates hits right and left. Continue for a set number of digs for each player.

24. FUNCTIONAL EXERCISE Cross Court Digging To practice digging balls a good distance away from the net and from different angles. 1.Hitters alternate hitting balls at the defenders. 2.The defenders dig the balls to the target. 3.After the defender digs the ball they alternate lines. 4.Repeat until a set number of digs is

25. FUNCTIONAL EXERCISE No Fear Defense Teach aggressiveness on defense. Teach defenders to get under balls hit down Coach stands on a box in the middle of the net, where they can hit the ball down inside 10' line. Coach continuously hits balls to the defenders. After a set number of hits the defender can only exit the drill when they can pass a ball straight up and catch it.