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Adhesive capsulitis (AC), often referred to as Frozen Shoulder, is characterized by initially painful and later progressively restricted active and passive glenohumeral (GH) joint range of motion with spontaneous complete or nearly-complete recovery over a varied period of time.

Common names for AC include:

• Frozen Shoulder
• Painful stiff shoulder
• Periarthritis

This inflammatory condition causes fibrosis of the GH joint capsule, is accompanied by gradually progressive stiffness and significant restriction of range of motion (typically external rotation).

In clinical practice it can be very challenging to differentiate early stages of AC from other shoulder pathologies.

Epidemiology /Etiology

Glenohumeral Joint

Presently unclear for this condition.

• The patho-aetiology of frozen shoulder is, however, complex and multifactorial with both genetic and environmental factors playing an important role.
• Long held hypothesis based on arthroscopic and pathologic observations, that there is an inflammatory component within the axillary fold. This is followed by stiffness and adhesions, which results in fibrosis of the synovial lining, which is associated with the inflammation.

AC may be:

1. Primary – Onset is generally idiopathic (it comes on for no attributable reason)
2. Secondary – Results from a known cause, predisposing factor or surgical event. A secondary frozen shoulder can be the result of several predisposing factors. For example, post surgery, post-stroke and post-injury. Where post-injury, there may be an altered movement pattern to protect the painful structures, which will in turn change the motor control of the shoulder, reducing the range of motion, and gradually stiffens up the joint.

• Three subcategories of secondary frozen shoulder include:
  1. Systemic (diabetes mellitus and other metabolic conditions);
  2. Extrinsic factors (cardiopulmonary disease, cervical disc, CVA, humerus fractures, Parkinson’s disease)
  3. Intrinsic factors (rotator cuff pathologies, biceps tendinopathy, calcific tendinopathy, AC joint arthritis).

Adhesive capsulitis more prevalent

• In women, as approximately 70% of individuals who present with a frozen shoulder, are females.
• Among individuals 35-65 years old, with an occurrence rate of approximately 2-5% in the general population, In China and Japan, it’s called the 50 year old shoulder due to its prevalence at that age.
• Within the diabetic population, with an occurrence rate of 20% . 
• If an individual has had AC (5-34% chance of having it in the contralateral shoulder at some point as well). Simultaneous bilateral involvement has been found to occur in approximately 14% of cases. 

Risk Factors & Red Flags

• Diabetes mellitus (with a prevalence of up to 20%)
• Stroke
• Thyroid disorder
• Shoulder injury (FOOSH, direct impact, dislocation)
• Dupuytren disease
• Parkinson’s
• Complex regional pain syndrome
• Avascular necrosis (rare, but can occur)
• Tuberculosis
• Shortness of breath, severe cough, any compromises to the quality of the breath
• Metastatic disease
• Rheumatisms
• Multiple joint involvement
• Fever, chills, severe (inexplicable) pain
• History of cancer (to the individual, or family)
• Any suspicion of a systemic pathology or condition.

Specific populations and populations to consider

• Diabetics: There is a high incidence of adhesive capsulitis in diabetic patients (prevalence is as high as 10 to 22 percent of individuals with diabetes mellitus versus as 2 to 4 percent of the general population). These patients generally do not respond well to treatment, as well as non diabetic patients do.
• Hypothyroidism: Can have an influence because we can develop muscle aches and tenderness and stiffness with hypothyroidism.
• Metabolic syndrome: Metabolic syndrome is a cluster of conditions occurring together that increase the risk of, amongst other things, type two diabetes.

Pathology

The disease process affects the antero-superior joint capsule, axillary recess, and the coracohumeral ligament.

• Patients tend to have a small joint with loss of the axillary fold, tight anterior capsule and mild or moderate synovitis but no actual adhesions. 
• Contracture of the rotator cuff interval has also been seen in adhesive capsulitis patients, and greatly contributes to the decreased range of motion seen in this population.

There is continued disagreement about whether the underlying pathology is an inflammatory condition, fibrosing condition, or an algoneurodystrophic process.

• Evidence suggests there is synovial inflammation followed by capsular fibrosis, in which type I and III collagen is laid down with subsequent tissue contraction.
• Elevated levels of serum cytokines have been noted and facilitate tissue repair and remodelling during inflammatory processes.
• In primary and some secondary cases of adhesive capsulitis cytokines have shown to be involved in the cellular mechanism that leads to sustained inflammation and fibrosis.
• It is proposed that there is an imbalance between aggressive fibrosis and a loss of normal collagenous remodelling, which can lead to stiffening of the capsule and ligamentous structures.

Characteristics/Clinical Presentation

Patients presenting with adhesive capsulitis will often report an insidious onset with a progressive increase in pain, and a gradual decrease in active and passive range of motion.

One of the main presenting factors is loss of external rotation (ER) in a dependent position with the arm down by the side.

Patients frequently have difficulty with grooming, performing overhead activities, dressing, and particularly fastening items behind the back. Adhesive capsulitis is considered to be a self-limiting disease with sources stating symptom resolution as early as 6 months up to 11 years. Unfortunately, symptoms may never fully subside in many patients.

The literature reports that adhesive capsulitis progresses through three overlapping clinical phases:

• Acute/freezing/painful phase: Gradual onset of shoulder pain at rest with sharp pain at extremes of motion, and pain at night with sleep interruption which may last anywhere from 2-9 months.
• Adhesive/frozen/stiffening phase: Pain starts to subside, progressive loss of GH motion in capsular pattern. Pain is apparent only at extremes of movement. This phase may occur at around 4 months and last till about 12 months.
• Resolution/thawing phase: Spontaneous, progressive improvement in functional range of motion which can last anywhere from 5 to 24 months. Despite this, some studies suggest that it’s a self limiting condition, and may last up to three years. Though other studies have shown that up to 40% of patients may have persistent symptoms and restriction of movement beyond three years. It is estimated that 15% may have persistent pain and long term disability. Effective treatments which shorten the duration of the symptoms and disability will have a significant value on reducing the morbidity.

Disturbed Sleep

In the early part and middle part of this condition (Freezing and Frozen phase, respectfully), sleeping is often interrupted and disturbed. As the patient’s condition progresses, this can get worse and there’s good evidence that the lack of sleep, pain and depression form a tightly interconnected triangle where changes in one will affect the other two. Therefore it’s important that clinicians monitor sleep quality and use outcome measures to quantify signs and symptoms. Helpful questionnaires include the Pittsburgh Sleep Quality Index and The Medical Outcomes Study Sleep Scale (MOS-Sleep), which includes 12 items assessing sleep disturbance, sleep adequacy, somnolence, quantity of sleep, snoring, and awakening short of breath or with a headache.

Anatomical Considerations for Adhesive Capsulitis:

There is a change in the available space and the available volume around the GH joint as the patient develops contractures through a frozen shoulder.

It is suspected that the space surrounding the GH joint reduces from between 15 to 35 cubic centimetres (cm), to 5 to 6 cubic cm. Moreover, it is suggested that capsular changes are similar to those changes which take place in the hand due to a Dupuytrens contracture. There may also be a thickening and fibrosis of the rotator interval at the top of the cuff, which then causes contractions and fibrosis of the GH ligaments. That contraction of the inferior glenohumeral ligament seems to be the one which makes the biggest difference.

When considering the anatomical location of the inferior glenohumeral ligament, it acts as the “hammock” at the bottom of the joint with an anterior posterior band. If that ligament tightens, it can reduce the amount of accessory movement which is available at the GH joint.

A quick word about the capsule: It allows an estimated 2 to 3 millimetres of distraction, which is important for the GH joint. On its own, it provides little contribution to joint stability. However, the tendons of the rotator cuff muscles insert into the capsule. Therefore, the dynamic action of the rotator cuff can have an effect on the tension within the capsule. On a whole, both ligaments and muscles insert directly into the capsule, providing an indirect link to the joint stability of the GH joint.

A final consideration is the neurovascularity, which may change locally due to the inflammatory response, which can be attributed to our understanding of a “capsulitis”.

Assessment

Subjective Assessment

Patient History

• Listen carefully to the patient’s past medical history (PMHx), this may well rule out red flags and guide the shoulder examination.
• History of presenting condition (Hx PC).
• Pain distribution and severity: Strong component of night pain, pain with rapid or unguarded movement, discomfort lying on the affected shoulder, pain easily aggravated by movement. Pain can be anywhere from the base of the skull, from down the arm into the hand.
• Aggravating activities – limited reaching, particularly during overhead (e.g., hanging clothes) or to-the-side (e.g., fasten one’s seat belt) activities. Patients also suffer from restricted shoulder rotations, resulting in difficulties in personal hygiene, clothing and brushing their hair. Another common concomitant condition with frozen shoulder is neck pain, mostly derived from overuse of cervical muscles to compensate the loss of shoulder motion

Observation of Posture and Positioning

• Scapular winging of the involved shoulder may be observed from the posterior and/or lateral views.

Screen: Upper quarter exam (UQE) and neurological screen (dermatomes, myotomes, reflexes)

• A full UQE should be performed to rule out cervical spine involvement or any neurological pathologies.

Range of Movement Assessment – Active/Passive/Overpressure

Cervical, thoracic, shoulder ROMs with OP as well as rib mobility should be performed. Reduced forward flexion, abduction, external rotation, and internal rotation range of motion are key clinical signs of adhesive capsulitis. 

• Scapular substitution frequently accompanies active shoulder motion

Shoulder Flex/ABd/ER/IR

• The method of measuring ER and IR ROM in patients with suspected adhesive capsulitis varies in the literature
• Patients with adhesive capsulitis commonly present with ROM restrictions in a capsular pattern. A capsular pattern is a proportional motion restriction unique to every joint that indicates irritation of the entire joint. The shoulder joint has a capsular pattern where external rotation is more limited than abduction which is more limited than internal rotation  (ER limitations > ABD limitations > IR limitations). In the case of adhesive capsulitis, ER is significantly limited when compared to IR and ABD, while ABD and IR were not seen to be different

Controversy regarding the “Capsular Pattern” of the GH Joint

When we consider the traditional teachings of Cyriax, it revolved around the capsular pattern of the GH joint. He suggested that the patient would have the greatest limitation in passive external (lateral) rotation followed by the next limitation in passive abduction, and then the last limitation in passive internal (medial) rotation.

According to Cyriax, if the patient presented in this typical capsular pattern, then they most likely had arthritis of the GH joint. If the limitations of movement didn’t follow this capsular pattern, then it was suspected to be a non-capsular pattern, suspecting a derangement or an extra articular pathology.

In the past, there has been some debate within the literature as to whether the capsular pattern of the shoulder does exist. Nonetheless, this is certainly something to consider when examining a patient.

The Importance of Evaluating the GH Ligaments

• Inferior GH ligament: The “Hammock” at the bottom of the joint. It has an anterior band, a posterior band and a less taught section in the middle (the pouch). The anterior band stabilizes the joint in ABDuction and external (lateral) rotation. As the arm moves into ABDuction and external (lateral) rotation, the anterior band will move up, across the front of the joint, providing an anterior stabilization (clinically relevant for throwing movements).
• Middle GH ligament: Stabilizes the GH joint in ADDuction plus external rotation and in ABDuction and external rotation (roughly 45 degrees of ABDuction).
• Superior GH ligament: Stabilizes the GH joint in ADDuction. Limits external (lateral) rotation and inferior translation of the humeral head.
• Coracohumeral ligament: Limits extension through it’s anterior portion. Limits flexion through the posterior portion. Also limits inferior and posterior humeral head translation.

When assessing the joint capsule, you are assessing the available freedom of movement, or accessory movement at the joint. At 60° of ABDuction, you have equal tension across all GH ligaments. This position will give an overall indication of global stiffness of the GH joint. You want to compare to the contralateral shoulder as well.

Assessment of the Superior GH ligament and the Coracohumeral ligament

Patient is supine on the treatment table, where the scapula is supported with the arm by the side. And we passively apply external (lateral) rotation until we reach the end range. Then apply an anterior glide to the humeral head, which will assess the posterior and lateral band of these two ligaments. If then you further extend the shoulder by 10 degrees, that will assess the anterior and medial band of the coracohumeral ligament.

If there is a tightening of these specific structures (GH ligaments), we can observe a change to the arthrokinematics of the shoulder joint, with increased anterior superior translation in flexion. Which will then reduce that already small subacromial space and could compromise the soft tissues transiting through the space. Moreover, there may be decreased inferior translation, decreased anterior translation at 0° and decreased posterior translation in flexion. Which in turn can lead to compromising the subacromial space and the self fulfilling prophecy of causing pain and dysfunction.

Assessment of the Middle GH ligament

Again, patient lying in supine on the treatment bed, so their scapular is stabilized with the arm by the side. You then take the glenohumeral joint into 10° extension. Apply external (lateral) rotation to the end of range. At that point, move the shoulder into 45° of ABDuction and then apply an antero-medial glide in the plane of the scapula. You are basically placing a sort of posterior anterior pressure, again in the plane of the scapula. Evaluate the degree of translation and compare that to the contralateral side.

Assessment of the Inferior GH Ligament

The Anterior Band: Patient lying supine on the treatment table with the scapular supported. Have them in the same position as they were before for the evaluation of the other GH ligaments. Move the shoulder from that 45° position with extension, towards 90° of ABDuction with external rotation. Then apply an anterior-medial glide, so to apply pressure to the head of the humerus. Evaluate the quality and quantity of the humeral head translation. Practice caution in this position if you suspect any sort of instability. This is similar to the Apprehension Test. Be cautious of a subluxation or a dislocation.

The Posterior Band: Patient lying supine on the treatment table with the scapular supported. Bring the shoulder into ABDuction and internal (medial) rotation. Similarly, this band moves up across the middle of the back of the joint to give it that posterior stability. Their shoulder is in 90° abduction and 10° of extension. Apply full internal (medial) rotation. Apply a gentle anterior-lateral glide to the GH joint. Apply pressure and evaluate the quality and quantity of the accessory movements.

Assessment of the Posterior Capsule: Patient lying supine on the treatment table with the scapular supported. Place the shoulder in 90 degrees of flexion, full internal (medial) rotation, and then end range of horizontal ADDuction. Apply an axial stress in a posterior lateral direction. You are going across the plane of the scapula and you are looking for that translation. This is similar to testing for posterior instability of the GH joint (that test is for a posterior labral tear). We aware of the response from the patient in this position.

Resisted Muscle Tests 

Shoulder external rotation (ER)/ Internal rotation (IR)/abduction (ABd) (seated) should be performed.

• Patients with adhesive capsulitis present with weakness in shoulder ER, IR and ABd relative to the asymptomatic side.
• Patients may also present with significant muscle guarding. Be aware of the stage of Adhesive Capsulitis you suspect your patient to be in, before subjecting them to muscle testing (manual muscle testing or with an isokinetic dynamometer).

Joint Accessory Movements

Glenohumeral joint:

• Anterior 
• Inferior
• Posterior
• Posterior capsule stretch

A reminder of the arthrokinematics of the shoulder joint. A review of coupled movements:

• Flexion / internal (medial) rotation / horizontal flexion = anterior superior translation of the humeral head.
• Extension and external (lateral) rotation / abduction and external (lateral) rotation = posterior translation of the humeral head.

In patients with adhesive capsulitis, the anterior and inferior capsule will be the most limited but joint mobility will be restricted in all directions.

Why accessory movements with Adhesive Capsulitis?

Evaluating accessory movements will provide the clinician with an indication of the global stiffness of the shoulder joint. When assessing a shoulder, it is important to always compare any movements (including accessory glides) to the contralateral shoulder. Keep in mind that the assumption is that contralateral shoulder is “normal”. As previously outlined, this is not always the case with a frozen shoulder. The quality of the movement / accessory movements is just as important as the quantity.

Understanding the capsule – Proprioceptive Role

If the capsule is tight, then the glenohumeral translations (accessory movements) will occur earlier in range of motion and most likely to greater excess. Also, the capsule is not simply a passive structure which holds everything “together” with a couple of identified thickenings (ligaments). It is also a major proprioceptive end organ.

If the capsule becomes tight, it will have an effect on the proprioception system as this will stimulate the localized mechanoreceptors and increase the feed forward mechanism within the joint; which could in turn increase capsular tightness. This could cause a continuous loop of tightening the capsule, stimulating the mechanoreceptors, increasing the local stabilizing muscles (such as the rotator cuff), which will ultimately increase the tension around the joint. It is highly suspected the adhesive capsulitis has a strong neurological component.

Special Tests

Shoulder Shrug Sign (inability to lift the arm to 90° abduction without elevating the whole scapula or shoulder girdle)  Previously was associated with rotator cuff disease, but more commonly was associated with glenohumeral arthritis, adhesive capsulitis, and massive cuff tears.

Yang et al. investigated the reliability of 3 function related tests in patients with shoulder pathologies via a non-experimental study

Hand to neck (Figure 1A)

• Shoulder flexion + abduction + ER
• Similar to ADLs such as combing hair, putting on a necklace

Hand to scapula (Figure 1B)

• Shoulder extension + adduction + IR
• Similar to ADLs such fitting a bra, putting on a jacket, getting into back pocket

Hand to opposite scapula (Figure 1C)

• Shoulder flexion + horizontal ADDuction (The Scarf Test – cross body adduction).

These tests require appropriate elbow, scapulothoracic, and thoracic mobility and these areas should be cleared of pathology first. If a patient is unable to complete the motion, other structures outside of the shoulder joint may be the limiting factor.

Reliability of the three tests was excellent and correlation between them was moderate.

These functional measures appear to be helpful for their objectivity in measuring shoulder dysfunction. However, even though the tests mimic fundamental ADL movements, the direct relationship between these tests and activities of daily living cannot be assumed.

Other

No specific clinical test for adhesive capsulitis has been reported in the literature and there remains no gold standard to diagnose adhesive capsulitis. While there are no confirmed diagnostic criteria, a recent study determined a set of clinical identifiers that achieved a general consensus amongst experts for the early stages of primary (idiopathic) adhesive capsulitis. The following tools can be used to help determine the stage of adhesive capsulitis and/or its irritability status.

Consensus was achieved on eight clinical identifiers collated into two discrete domains (pain and movement) as well as an age component.

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Movement

• Global loss of active and passive ROM
• Pain at end-range in all directions

Onset

• > 35 years of age

Physical Therapy Management

The definitive treatment for adhesive capsulitis remains unclear even though multiple interventions have been studied. For most patients, enrolling in a physical therapy program is the key to recovery. Also, a meta-analysis carried out by Tedla & Sangadala in 2019 concluded that PNF is very effective in decreasing pain, increasing ROM, improving function, and reducing disability.

Importance of Patient Education

For the treatment of adhesive capsulitis, patient education is essential in helping to reduce frustration and encourage compliance. It is important to emphasize that although full range of motion may never be recovered, the condition will spontaneously resolve and stiffness will greatly reduce with time. It is also helpful to give quality instructions to the patient and create an appropriate home exercise program (HEP) that is easy to comply with as daily exercise is critical in relieving symptoms. The below video gives a good outline of a HEP for the 3 phases of AC.

Techniques

Initial Phase: Painful, Freezing

Pain relief and the exclusion of other potential causes of your frozen shoulder is the focus during this phase.

Very gentle shoulder mobilisation, muscle releases, acupuncture, dry needling and kinesiology taping for pain-relief can assist during this painful inflammation phase.  The application of a TENS machine was shown reduce pain and increase range of motion.

Modalities, such as hot packs, can be applied before or during treatment. Moist heat used in conjunction with stretching can help to improve muscle extensibility and range of motion by reducing muscle viscosity and neuromuscular mediated relaxation. In a randomised study by Bal et al., patients improved with combined therapy which involved hot and cold packs applied before and after shoulder exercises were performed.^[6] However, Jewell et al, claimed that ultrasound, massage, iontophoresis and phonophoresis reduced the chances of positive outcomes. Green et al. suggested that there is no evidence of the effect of ultrasound in shoulder pain (mixed diagnosis), adhesive capsulitis or rotator cuff tendinitis.

As alluded to, treatment should be customised to each individual based on the stage of the condition.

Pain relief should be the focus of the initial phase, also known as the painful, freezing Phase. During this time, any activities that cause pain should be avoided. Better results have been found in patients who performed simple pain free exercise, rather than intensive physical therapy In patients with high irritability, range of motion exercises of low intensity and short duration can alter joint receptor input, reduce pain, and decrease muscle guarding. Stretches may be held from one to five seconds in a pain free range, 2 to 3 times a day. A pulley may be used to assist range of motion and stretch, depending on the patient’s ability to tolerate the exercise. Core exercises include pendulum exercise, passive supine forward elevation, passive external rotation with the arm in approximately 40 degrees of abduction in the plane of the scapula, and active assisted range of motion in extension, horizontal adduction, and internal rotation.

Although performed on a single patient only, Ruiz et al performed positional stretching of the coracohumeral ligament in the initial phase of adhesive capsulitis. The patient’s Disabilities of Arm Shoulder and Hand (DASH) scores improved from 65 to 36 and Shoulder Pain and Disability Index (SPADI) scores improved from 72 to 8 and passive external rotation increased from 20 to 71 degrees. The stretches performed focused on providing positional low load and prolonged stretch to the CHL and the area of the rotator interval capsule following anatomical fibre orientation. The rationale behind this was to produce tissue remodelling through gentle and prolonged tensile stress on the restricting tissues. While a cause and effect relationship cannot be inferred from a single case, this report may help with further investigation regarding therapeutic strategies to improve function and reduce loss of range of motion in the shoulder and the role that the CHL plays in this.

In the case of adhesive capsulitis, physical therapy can also be a complement to other therapies (such as steroid injections as discussed previously), especially to improve the range of motion of the shoulder. Bal et al suggested that concomitant exercises to steroid injections should include isometric strengthening in all ranges once motion returned to 90% of normal ranges, theraband exercises in all planes, scapular stabilisation exercises, and later, advanced muscular strengthening with dumbbells.)

Second Phase: Decreased Range of Movement

Gentle and specific shoulder joint mobilisation and stretches, muscle release techniques, acupuncture, dry needling and exercises to regain your range and strength are used for a prompt return to function. Care must be taken not to introduce any exercises that are too aggressive. In particular, mobilisation with movement (MWM) style techniques appears the most effective and more effective than stretching exercises alone.MWM’s are specific-techniques performed by suitably-trained shoulder physiotherapists.

A prospective study by Griggs et al, demonstrated success of a non-operative treatment through a four-direction shoulder stretching exercise programme in which 90% of the patients reported a satisfactory outcome. During the second phase of treatment, movement with mobilisation and end range mobilisations are recommended.Mobilisation with movement can also correct scapulohumeral rhythm significantly better than end range mobilisation. The goal for end range mobilisation is not only to restore joint range, but also to stretch contracted peri-articular structures, whereas mobilisation with movement aims to restore pain free motion to the joints that had antalgic limitation of range of motion.

Gaspar and Willis. demonstrated that physical therapy paired with dynamic splinting had better outcomes compared to physical therapy alone or dynamic splinting alone. The patients in this group of combined treatments received physical therapy twice a week and a Shoulder Dynasplint System (SDS) for daily end range stretching. The combination of physical therapy with dynamic splinting had significant improvements in active, external rotation in patients with adhesive capsulitis.

Third Phase: Resolution

Provide you with exercise progressions including strengthening exercises to control and maintain increased range of movement.

Physiotherapy is most effective during this thawing phase.Progressed primarily by increasing stretch frequency and duration, whilst maintaining the same intensity, as tolerated by the patient. The stretch can be held for longer periods and the sessions per day can be increased. As the patient’s irritability level reduces, more intense stretching and exercises using a device, such as a pulley, can be performed to influence tissue remodelling.

Rational for Specific Techniques

Mechanical changes that occur as a result of mobilisations may include the break- up of adhesions, realignment of collagen, or increased fibre glide when specific movements stress certain parts of the capsular tissue. These techniques are intended to increase joint mobility by inducing changes in synovial fluid formation. High grade mobilisation techniques (HGMT) have been shown to be helpful for improving range of motion in patients with adhesive capsulitis for at least three months. In a study by Vermeulen et al., patients were given inferior, posterior, and anterior glides as well as a distraction to the humeral head. These techniques were performed at greater elevation and abduction angles if glenohumeral joint range of motion increased during treatment. Patients who received HGMT received these mobilisations at Maitland Grades III and IV according to the subjects’ tolerance with the intention of treating the stiffness. Patients were allowed to report a dull ache as long as it did not alter the execution of the mobilisations or persist for more than four hours after treatment. However, patients who received low-grade mobilisation techniques (LGMT) at Mailtand Grades I or II reported no pain. Statistically significant greater change scores were found in the HGMT group for passive abduction (at 3 and 12 months) and for active and passive external rotation (at 12 months) when compared with the low-grade mobilisation techniques. High grade mobilisation techniques appear to be more effective for increasing joint mobility and reducing disability. Further studies are needed, however, to investigate whether HGMTs applied during earlier stages of adhesive capsulitis are as effective.

Johnson et al. reported that joint mobilisations, in particular posterior glenohumeral glides, can help decrease deficits in external rotation, more so than anterior glenohumeral glides. Both techniques had a significant decrease in pain, but there was greater improvement in external rotation range of motion with the posterior mobilisation treatment. End range mobilisation is also more effective than mid-range mobilisation in increasing motion and functional mobility. Overall, there are significant beneficial effects of joint mobilisation and exercise for patients with adhesive capsulitis.

Rationale for Stretching

Research regarding connective tissue stretch duration and intensity has produced 3 findings. Firstly, that high intensity, short duration stretching aids the elastic response, whilst low intensity, prolonged duration stretching aids the plastic response. Secondly, a direct correlation exists between the resulting proportion of plastic, permanent elongation and the duration of a stretch. Lastly, a direct correlation exists between the degree of either trauma or weakening of the stretched tissues and the intensity of a stretch. McClure et al, stated that the maximum TERT (Total End Range Time) or the total amount of time the joint is held at near end range position, will be different for each person and is often affected by personal circumstances such as their job or other responsibilities that may prevent a patient from increasing TERT.

Progressions

Manual techniques and exercise should only be progressed as the patient’s irritability reduces. Patient response to treatment should be based on their pain relief, improved satisfaction, and functional gains, rather than restoration of range of motion. Usually, patients are discharged when significant pain reduction is reached, a plateau of motion gains are noticed for a period of time, and after improved functional motion and satisfaction have reached their peak. Progression for stretching via dynamic splinting is based on patient tolerance, as well. Gaspar and Willis, suggested that if patients experience discomfort or stiffness lasting more than an hour after the splint is removed, the duration of treatment is reduced for the next two stretching sessions. Only after stretching for a total of 60 minutes (30 minutes twice a day) is tolerated, is it suggested that the tension is then increased, every two weeks based on tolerance, without discomfort lasting more than one hour following every stretching session.

Despite extensive research, further prospective randomized studies comparing different treatments are needed to formulate precise guidelines about diagnosis and treatment of idiopathic adhesive capsulitis. The lack of validity, poor standardization of terminology, methodology, and outcome measures in the investigations undermines clinical application. Therefore, more rigorous investigations are needed to compare the cost and effectiveness of physical therapy interventions.

Exercise examples:

Figure 1: Active assisted end range movements in flexion, external rotation and extension. Figure 2: Active assisted end-range movements in internal rotation, horizontal adduction and flexion.

Figure 3: Coracohumeral Ligament Stretch

Figure 4: Active assisted movements in elevation and external rotation with a cane.

Figure 5: Posterior mobilizations of the humeral head in supine.

Figure 6: Anterior mobilizations of the humeral head in supine.

The definitive treatment for adhesive capsulitis remains unclear even though multiple interventions have been studied. Previously published prospective studies of effective treatment have demonstrated conflicting results for improving shoulder range of motion in patients with this condition. Non-operative interventions include patient education, modalities, stretching exercises, and joint mobilizations. Levine et al. reported that 89.5% of ninety eight patients with frozen shoulder responded well to non-operative management. Reviewed studies suggest that many patients have benefited from physical therapy and showed reduced symptoms, increased mobility, and/or functional improvement. A Cochrane Review by Green et al, however, states that there is no evidence that physiotherapy alone is of benefit for adhesive capsulitis.

Rational for Motor Control Exercises

There is emerging scientific support that “muscle guarding” and pathological motor control of the shoulder may play a significant role in the restrictive movements of the shoulder; rather than solely a contracted capsule. Therefore, motor control and exercise therapy is indicated in a clinical setting.

Goals:

• Restoration of normalized recruitment pattern.
• Balanced recruitment of agonists / antagonists / synergistic muscles of the shoulder (in terms of strength, timing, and coordination).
• Appropriate level of muscle recruitment for low and high loads for the shoulder (a pathological shoulder tends to use high levels of muscle recruitment for low loads).
• Restore motor control during isometric, concentric and eccentric muscle activity.

Additional considerations for clinical practice

Because Adhesive Capsulitis is painful, chronic and generally stressful for a person, relaxation techniques are important to consider and integrate into a treatment plan. Some strategies include:

• Desensitization techniques
• Breathing exercises
• Cognitive behavioural therapy
• Distracting the patient during more “aggravating” treatments or exercises.

The importance of considering the shoulder complex as a member of a kinetic chain

It is estimated that during shoulder movement, 50% of forces produced in the shoulder girdle come from the waist down (lower extremities), 30% comes from around the trunk (core stabilization) and 20% comes from local efforts (upper extremities and the shoulder complex). If we can start to incorporate the kinetic chain as a whole during rehabilitation, this will allow for much more efficient movements around the shoulder joint. What is required is mobility and stability throughout the kinetic chain, in order to optimize the function of the shoulder.

Conservative Rehabilitation – What works?

What do we do? With respect to manual therapy, there is an interesting Cochrane review by Page et al. 2014 which shows that the combination of manual therapy and exercise may not be as effective as a steroid injection in the short-term. However, the results are generally inconclusive.

Vermeulen et al. (2006) showed that it is possible to increase range and decrease pain with high grade mobilizations (Grade III & IV) of the GH joint. Contrastingly, Page et al. suggested that there was limited evidence or benefit of manual therapy and exercise when used in isolation to treat Adhesive Capsulitis. The strongest support at the moment suggests that conservative treatments (manual therapy and exercise) should be used in adjunct with a corticosteroid injection.

Differential Diagnosis

Some conditions can present with similar impairments and should be included in the differential diagnosis. These include, but are not limited to, osteoarthritis, acute calcific bursitis/tendinitis, rotator cuff pathologies, parsonage-Turner syndrome, a locked posterior dislocation, or a proximal humeral fracture. 

• Shoulder Osteoarthritis (OA). Both may have limited abduction and external rotation AROM but with OA, PROM will not be limited. OA will also present with the most limitations with flexion whereas this is the least affected motion with adhesive capsulitis. Radiography can be used to rule out pathology of osseous structures.
• Acromioclavicular joint dysfunction: Likely to occur with a high arch of pain, pain with a cross-body adduction (Scarf Test), and palpation of the acromioclavicular joint itself.
• Bursitis. Bursitis presents very similarly to adhesive capsulitis, especially compared to the early phases. Patients with bursitis will present with a non-traumatic onset of severe pain with most motions being painful. A main difference will be the amount of PROM achieved. Adhesive capsulitis will be extremely limited and painful whilst patients with bursitis, although painful, will have a larger PROM.
• Parsonage-Turner Syndrome (PTS). PTS occurs due to inflammation of the brachial plexus. Patients will present without a history of trauma and with painful restrictions of all motions. The pain with PTS usually subsides much quicker than with adhesive capsulitis and patients eventually display neurological problems (atrophy of muscles or weakness) that are seen several weeks after the initial onset of pain.
• Rotator Cuff (RC) Pathologies. The primary way to distinguish RC pathologies from adhesive capsulitis is to examine the specific ROM restrictions. Adhesive capsulitis presents with restrictions in the capsular pattern while RC involvement typically does not. RC tendinopathy may present similarly to the first stage of adhesive capsulitis because there is limited loss of external rotation and strength tests may be normal. MRI and ultrasonography can be used to identify soft tissue abnormalities of the soft tissue and labrum.
• Posterior Dislocation. A posteriorly dislocated shoulder can present with shoulder pain and limited ROM, but, unlike adhesive capsulitis, it is related to a specific traumatic event. If the patient is unable to fully supinate the arm while flexing the shoulder, the clinician should suspect a posterior dislocation.
• “Active Muscle Guarding” (Motor Control Dysfunction) Hollmann et al. (2015) reported in their study that all of the patients suspected to have Frozen Shoulder showed a significant increase in range of motion under anesthesia, which confirms that some cases might have been falsely diagnosed with Frozen Shoulder and that the loss of range of motion cannot only explained by capsular contractions.

Outcome Measures

Currently the diagnosis of primary adhesive capsulitis is based on the findings of the patient history and physical examination. 

The following outcome measures have been used in studies researching adhesive capsulitis.

• Shoulder Pain and Disability Index (SPADI)
• Disability of the Arm, Shoulder and Hand scale (DASH)
• American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES)
• Simple Shoulder Test (SST)
• Penn Shoulder Scale (PSS)
• NPRS
• VAS
• SF-36

Roy et al examined the psychometric properties of the SPADI, DASH, ASES and SST were examined. Reliability, construct validity and responsiveness were all found to be favourable for various shoulder pathologies, but the review did not address their strength relative to adhesive capsulitis, specifically.

Medical Management

Although Adhesive Capsulitis is a self-limiting condition, it can take up to two to three years for symptoms to resolve and some patients may never fully regain full motion.Treatment for pain, loss of motion, and limited function rather than take the wait-and-see approach is therefore important. Various interventions have been researched that address the treatment of the synovitis and inflammation and modify the capsular contractions such as oral medications, corticosteroid injections, distension, manipulation, and surgery. Even though many of these treatments have shown significant benefits over no intervention at all, definitive management regimens remain unclear. It is suggested that the primary treatment for adhesive capsulitis should be based around physical therapy and anti-inflammatory measures, these outcomes, however, are not always superior to other interventions.

Corticosteroid Injections

Corticosteroid injections are often used to manage inflammation as it is understood that inflammation is a key factor in the early stages of the condition. The injections aim to reduce the painful synovitis occurring within the shoulder. This can limit the development of fibrosis and adhesions within the capsule, potentially shortening the natural history of the disease. Hence they are thought to be more useful in the early, painful and freezing stage of the condition due to the involvement of inflammation, rather than in the latter stages when fibrous contractures are more apparent.

An important to note to consider is that often when we inject a steroid, there is a local anaesthetic that will reduce the pain and that could aid with improving the motor control of the shoulder complex.

Many studies have been performed and reviewed comparing corticosteroid injections to physical therapy, but results have been contradictory. It has been concluded that corticosteroid injections provide significantly greater short term benefits (4-6 weeks), especially in pain relief, but there is little to no difference in outcomes by 12 weeks compared to physical therapy. The majority of studies, however, investigating corticosteroid injection as a treatment option do not define what stage the patients are in and had variations in the volumes of corticosteroid used. It has been shown that the benefits may not only be dose dependent, but also dependent on the duration of symptoms as well. Therefore, the earlier the injection is received, the quicker the individual will recover. Contraindications to corticosteroids use include a history of infection, coagulopathy, or uncontrolled diabetes.

Ultimately, corticosteroid injections have been shown to have success rates ranging from 44-80% with rapid pain relief and improved function occurring mainly in the first weeks of treatment. It is a first line treatment for patients with pain as their predominant complaint in the early stages of adhesive capsulitis. Though intra-articular steroid injection may be beneficial early on, its effect may be small and not well maintained and should be offered in conjunction with physical therapy.

Location of the injections:

i) Sub-acromial injection

ii) Intra-articular injection

A recent study by Cho et al. found that a combination of both injections had an additive effect on increasing range of motion around the shoulder.

Recommendations:

• Injection for relieving shoulder disability and pain. Physical therapy for improving motion in the painful freezing stage
• If patients fail to progress within 3-6 weeks with physical therapy alone or patient’s symptoms worsen, they should be offered the option of a corticosteroid injection.

Manipulation Under Anesthesia (MUA)

An extensive post-manipulation programme begins immediately after release of the capsule. They are often prescribed active assisted range of motion exercises that should be performed every two hours during waking hours, for the next 24 hours. Patients are also instructed to ice their shoulder for 20 minutes every two hours with their hand resting behind their head. Post manipulation programs are designed to maintain gains in shoulder mobility and should specifically address each individual’s impairments.

Translation Mobilisation under Anesthesia

An alternative to traditional MUA is translation mobilization under anesthesia, which has been identified in an attempt to avoid the complications associated with the traditional approach. This procedure involves the use of gliding techniques with static end range capsular stress with a short amplitude high velocity thrust, if needed, as opposed to the angular stretching forces in manipulation under anesthesia.2 to 3 30 second sets of low velocity, oscillatory mobilizations (Maitland Grade IV-IV+) are performed initially in the same directions as traditional manipulation under anesthesia (anteriorly, posteriorly, and inferiorly). If an immediate increase in passive range of motion is not seen, a high velocity, low amplitude manipulation may be performed. This technique appears to be a safe and efficacious alternative for treatment of patients resistant to conservative treatment, however, higher level studies are needed for verification. 

• If a patient has persistent symptoms, particularly in decreased shoulder motion, after at least 6 months of conservative treatment, manipulation under anesthesia is an effective technique to improve mobility, pain and disability.
• Contraindications and complications do exist and should be relayed to the patient.

Arthroscopic Capsular Release (Arthroscopic arthrolysis)

Arthroscopic capsular release is the preferred method over open release in patients with painful, disabling adhesive capsulitis that is unresponsive to at least 6 months of non-operative treatment.

The purpose of this surgical intervention is a capsular release, where they cut and remove the thickened, swollen, inflamed capsule as well as to help restore normal movement of the joint.

It has been found to be a reliable and effective method for restoring range of motion and is especially recommended for diabetics and in post-operative or post-fracture adhesive capsulitis patients. It has become the most popular method of treating non-responsive adhesive capsulitis despite the lack of higher level trials comparing it to MUA. This is because it allows a more controlled and selective release of the contracted capsule compared to manipulation which ruptures the capsuloligamentous structures and avoids the complications associated with MUA. Debate exists over which structures should be arthroscopically released with the rotator cuff and coracohumeral ligament being the most common structures released. 

Recommendations:

• If patient is unresponsive to at least 6 months of conservative treatment, arthroscopic capsular release alone or in conjunction with manipulation, has been shown to be effective in restoring range of motion.
• Avoids complications associated with manipulation under anesthesia and is recommended in diabetics and post-operative or post-fracture adhesive capsulitis patients.

Post Surgical Considerations

Post surgery, whatever surgical technique was employed, clinicians need to consider the integrity of the local nerves. They could be disturbed by the arthroscopy as well, because there are many local nerves surrounding the shoulder joint (in close proximity to where the arthroscopy portals are located).

Also, the shoulder will not have been overly mobile for months (possibly years). Following surgery, there could be a sudden restoration of movement, which could in turn irritate the nerves.

The main nerves of concern are:

• Radial
• Ulnar
• Median
• Axillary
• Suprascapular
• Musculocutaneous
• Long thoracic
• Also possibly the brachial plexus as a whole
• The evaluation of the cervical spine and nerve root mobility should also be a priority post-surgery.

Other Treatments

Non-steroidal anti-inflammatory drugs (NSAIDs) have traditionally been given to patients with adhesive capsulitis, but there is no high level evidence that confirms their effectiveness.^[1][35] 

Oral steroids have also been utilized in these patients and result in some improvement in function, but their effects have not shown long term benefits and combined with their known adverse side effects, should not be regarded as a routine treatment.^[1][35][38] Another technique that shows some short term benefit with rapid relief of symptoms is distension arthrography. This technique involves the injection of a solution (saline alone or combined with corticosteroids) causing rupture of the capsule by hydrostatic pressure. It is still undetermined whether joint distension with saline solution combined with corticosteroids provides more benefit than distension with saline alone or corticosteroid injection alone. There is a lack of reliable evidence when determining the effectiveness of this technique and further research needs to be performed to verify any clinical benefit.

Suprascapular nerve blocks are thought to temporarily disrupt pain signals to allow normalization of the pathological, neurological processes perpetuating pain and disability. There is some evidence of benefit with suprascapular nerve blocks, though the exact mechanism behind this benefit remains unclear and higher level evidence is needed to establish this as a treatment for adhesive capsulitis.

Hydrodilatation (distension arthrography) has emerged as a potential non-surgical option in the management of frozen shoulder. Although therapeutic regimens will differ between units, common to most is the instillation of a large volume of saline containing steroid, local anaesthetic and contrast material (dye) into the GH joint under imaging guidance (30 ml). The goal is capsular expansion.

The stated benefits of the procedure are achieved through hydraulic distension of the capsule (sometimes referred to as “pops” in the capsule) and the main purpose of initial work was to achieve capsular rupture. However, there is little in the way of evidence to determine whether capsule rupture must be achieved in order for the procedure to be successful, or whether it is the capsular distension which is most important. Most studies comment on their intention to achieve capsular rupture but have not investigated this.

A Cochrane review in 2008 demonstrated only silver-level evidence to support hydrodilatation as a treatment modality to improve short-term pain and function, up to three months.

Clinical Bottom Line

According to a Cochrane review by Green et al, there is little evidence to support or refute the use of any of the common interventions listed for Adhesive Capsulitis. There are also no studies with objective data supporting the timing of when to switch to invasive treatments such as manipulation under anesthesia or arthroscopic release, which are not usually performed until 6 months of conservative treatment have been unsuccessful. Unfortunately this exposes more than 40% of patients with Adhesive Capsulitis to a long period of disability and pain.

Treatments should be tailored to the stage of the disease because the condition has a predictable progression. Moreover, we need to consider the causative factors (the primary and the secondary factors) of the disease for the individual.

We also need to be upfront with our patients with regards to the nature of the disease as well as factors which may not be directly addressed with physiotherapy (for example, if the patient is diabetic, it will potentially be a longer recovery and require the intervention of a multi-disciplinary team). Managing expectations with your patient is key to a successful recovery.

We, as clinicians, need to consider an appropriate intervention at the right stage. We need to manage the pain levels as soon as possible. It’s very important, and again, if we can do things that can help them sleep, that can have a massive benefit on their pain levels, but also their emotional state.

During the painful freezing stage, treatment should be directed at pain relief with pain guiding activity. NSAIDs, physical therapy and steroid injection are all suggested interventions during this stage of adhesive capsulitis. Once the patient is in the adhesive stage, injections are no longer indicated because the inflammatory stage of the disease has passed. The focus should instead switch to more aggressive stretching and MUA or surgical release if symptoms are unresponsive to conservative treatment and quality of life is compromised.

There is no definitive treatment for adhesive capsulitis. However, the literature suggests interventions should be tailored to the stage of the disease based on its progressive nature. During the initial/painful freezing stage, treatment should be directed at pain relief with pain guiding activity. NSAIDs and steroid injection, stretching, strengthening and range of motion exercises, as well as Maitland Grade I-II mobilizations have been suggested to improve function and reduce pain and disability. As the patient progresses to the adhesive stage, intervention should focus on aggressive, end-range stretches combined with Maitland Grade III-IV mobilizations. At six months, if functional disability persists despite conservative treatment, mobilizations under anaesthesia (MUA) or arthroscopic capsular release may be indicated.

The bottom line remains individualizing the treatment plan to the patient as well as focusing on the quality of the movement, not overly obsess with the quantity of the movement.

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Muscles play a part in every function of the body. The muscular system is made up of over 600 muscles. These include three muscle types: smooth, skeletal, and cardiac.

Only skeletal muscles are voluntary, meaning you can control them consciously. Smooth and cardiac muscles act involuntarily.

Each muscle type in the muscular system has a specific purpose. You’re able to walk because of your skeletal muscles. You can digest because of your smooth muscles. And your heart beats because of your cardiac muscle.

The different muscle types also work together to make these functions possible. For instance, when you run (skeletal muscles), your heart pumps harder (cardiac muscle), and causes you to breathe heavier (smooth muscles).

Keep reading to learn more about your muscular system’s functions.

1. Mobility

Your skeletal muscles are responsible for the movements you make. Skeletal muscles are attached to your bones and partly controlled by the central nervous system (CNS).

You use your skeletal muscles whenever you move. Fast-twitch skeletal muscles cause short bursts of speed and strength. Slow-twitch muscles function better for longer movements.

2. Circulation

The involuntary cardiac and smooth muscles help your heart beat and blood flow through your body by producing electrical impulses. The cardiac muscle (myocardium) is found in the walls of the heart. It’s controlled by the autonomic nervous system responsible for most bodily functions.

The myocardium also has one central nucleus like a smooth muscle.

Your blood vessels are made up of smooth muscles, and also controlled by the autonomic nervous system.

Did you know?

1. Your heart is considered the body’s hardest-working muscle.

3. Respiration

Your diaphragm is the main muscle at work during quiet breathing. Heavier breathing, like what you experience during exercise, may require accessory muscles to help the diaphragm. These can include the abdominal, neck, and back muscles.

4. Digestion

Digestion is controlled by smooth muscles found in your gastrointestinal tract. This comprises the:

• mouth
• esophagus
• stomach
• small and large intestines
• rectum
• anus

The digestive system also includes the liver, pancreas, and gallbladder.

Your smooth muscles contract and relax as food passes through your body during digestion. These muscles also help push food out of your body through defecation, or vomiting when you’re sick.

5. Urination

Smooth and skeletal muscles make up the urinary system. The urinary system includes the:

• kidneys
• bladder
• ureters
• urethra
• penis or vagina
• prostate

All the muscles in your urinary system work together so you can urinate. The dome of your bladder is made of smooth muscles. You can release urine when those muscles tighten. When they relax, you can hold in your urine.

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6. Childbirth

Smooth muscles are found in the uterus. During pregnancy, these muscles grow and stretch as the baby grows. When a woman goes into labor, the smooth muscles of the uterus contract and relax to help push the baby through the vagina.

7. Vision

Your eye sockets are made up of six skeletal muscles that help you move your eyes. And the internal muscles of your eyes are made up of smooth muscles. All these muscles work together to help you see. If you damage these muscles, you may impair your vision.

8. Stability

The skeletal muscles in your core help protect your spine and help with stability. Your core muscle group includes the abdominal, back, and pelvic muscles. This group is also known as the trunk. The stronger your core, the better you can stabilize your body. The muscles in your legs also help steady you.

9. Posture

Your skeletal muscles also control posture. Flexibility and strength are keys to maintaining proper posture. Stiff neck muscles, weak back muscles, or tight hip muscles can throw off your alignment. Poor posture can affect parts of your body and lead to joint pain and weaker muscles. These parts include the:

• shoulders
• spine
• hips
• knees

The bottom line

The muscular system is a complex network of muscles vital to the human body. Muscles play a part in everything you do. They control your heartbeat and breathing, help digestion, and allow movement.

Muscles, like the rest of your body, thrive when you exercise and eat healthily. But too much exercise can cause sore muscles. Muscle pain can also be a sign that something more serious is affecting your body.

The following conditions can affect your muscular system:

• myopathy (muscle disease)
• muscular dystrophy
• multiple sclerosis (MS)
• Parkinson’s disease
• fibromyalgia

Talk to your doctor if you have one of these conditions. They can help you find ways to manage your health. It’s important to take care of your muscles so they stay healthy and strong.

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Brian R. Mulligan qualified as a physiotherapist in 1954 and gained his diploma in Manipulative Therapy in 1974. He has been the author of numerous articles published in New Zealand Journal of Physiotherapy. He is also the author of two books:

1. “Manual Therapy “NAGS”,”SNAGS”, “MWMS”,etc’ (2003) for Physiotherapists.
2. ‘Self Treatment for the Back, Neck and Limbs’ for Public.

Description

• NAGS- Natural Apophyseal Glides.
• SNAGS – Sustained Natural Apophyseal Glides.
• MWMS- Mobilization with Movements.
• The concept of Mobilizations with movement (MWM) of the extremities and SNAGS (sustained natural apophyseal glides) of the spine were first coined by Brian R. Mulligan

Mobilization with movement (MWM) is the concurrent application of sustained accessory mobilization applied by a therapist and an active physiological movement to end range applied by the patient. Passive end-of-range overpressure, or stretching, is then delivered without pain as a barrier.

Concept of Positional Fault

• Mulligan proposed that injuries or sprains might result in a minor “positional fault” to a joint causing restrictions in physiological movement.
• The techniques have been developed to overcome joint `tracking’ problems or `positional faults’, i.e. joints with subtle biomechanical changes.
• Normal joints have been designed in such a way that the shape of the articular surfaces, the thickness of the cartilage, the orientation of the fibres of ligaments and capsule, the direction of pull of muscles and tendons, facilitate free but controlled movement while simultaneously minimizing the compressive forces generated by that movement
• Normal proprioceptive feedback maintains this balance. Alteration in any or all of the above factors would alter the joint position or tracking during movement and would provoke symptoms of pain, stiffness or weakness in the patient. It is common sense then that a therapist would attempt to re-align the joint surfaces in the least provocative way

Principles of Treatment

1. A passive accessory joint mobilization is applied following the principles of Kaltenborn. This accessory glide must itself be pain free.
2. During assessment the therapist will identify one or more comparable signs as described by Maitland. These signs may be; a loss of joint movement, pain associated with movement, or pain associated with specific functional activities
3. The therapist must continuously monitor the patients reaction to ensure no pain is recreated. The therapist investigates various combinations of parallel or perpendicular glides to find the correct treatment plane and grade of accessory movement.
4. While sustaining the accessory glide, the patient is requested to perform the comparable sign. The comparable sign should now be significantly improved
5. Failure to improve the comparable sign would indicate that the therapist has not found the correct treatment plane, grade of mobilization, spinal segment or that the technique is not indicated.
6. The previously restricted and/or painful motion or activity is repeated by the patient while the therapist continues to maintain the appropriate accessory glide.

While applying “MWMS” as an assessment, the therapist should look for PILL response to use the same as a Treatment .

• P– Pain free.
• I– Instant result.
• LL– Long Lasting.

 If there is No PILL response, that technique should not be advocated. The second principle is CROCKS

• C– Contra-indications (No PILL response is a contraindication)
• R – Repetitions (Only three reps on the day one)
• O– Over pressure
• C– Communications
• K – Knowledge (of treatment planes and pathologies)
• S– Sustain the mobilization throughout the movement.

Techniques

SNAGs

• SNAGs stand for Sustained Natural Apophyseal Glides.
• SNAGs can be applied to all the spinal joints, the rib cage and the sacroiliac joint.
• The therapist applies the appropriate accessory zygapophyseal glide while the patient performs the symptomatic movement.
• This must result in full range pain free movement.
• SNAGs are most successful when symptoms are provoked by a movement and are not multilevel.
• They are not the choice in conditions that are highly irritable.
• Although SNAGs are usually performed in weight bearing positions they can be adapted for use in non weight bearing positions.

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Headache SNAG

If a patient is suffering from a headache of upper cervical origin then one of the mobilisations or the traction to be described should, as it is being applied, stop the pain. Mulligan assumes that if a headache stops with a manual technique involving the upper cervical spine then, this must be diagnostically significant as to the site of the lesion causing the problem and the fact that there is a mechanical component.

Technique

• Position of Patient: sitting
• Position of therapist: stands beside the patient, while his\her head is cradled between your body and your right forearm (when you stand at his\her right side)
  Application:
  • Start by placing your right index, middle and ring fingers at the base of the occiput. The middle phalanx of the same hand and the little finger lie over the spinous process of C2. Then place the lateral border of the left thenar eminence on top of your right little finger.
  • Gentle pressure is now applied in a ventral direction on the spinous process of C2 while the skull remains still due to the control of your right forearm. (The really gentle moving force to do this comes from your left arm via the thenar eminence over the little finger on the spine of C2).
  • The pressure applied by the index finger moves the lower vertebra forward under the first until the slack is taken up, then the first vertebra moves forward under the base of the skull. This is quickly taken forward until end range is felt and this position is maintained for at least 10 seconds. If indicated the headache will relieve, repeat the HEADACHE SNAG six to ten times. Some patients have a more favourable response when the position is sustained for a much longer time- up to a minute. 

Important, when applying the “ Headache SNAG” the good manual therapist will imperceptibly alter the direction of the glide to effect a change. Small adjustments in direction may be necessary as the true facet plane directions vary between individuals.

NAGs

• NAGs stand for ‘Natural Apophyseal Glides”.
• NAGs are used for the cervical and upper thoracic spine.
• They consist of oscillatory mobilizations instead of sustained glide like SNAGs, and it can be applied to the facet joints between 2nd cervical and 3rd thoracic vertebrae.
• NAGs are mid-range to end range facet joint mobilizations applied antero-superiorly along the treatment planes of the joint selected.
• Useful for grossly restricted spinal movement.
• NAGs for the treatment of choice in highly irritable conditions

Peripheral MWM 

• Once the aggravating movement has been identified, an appropriate glide is chosen. 
• The decision to use weight-bearing or Non-weight bearing movement depends upon the severity, irritability and nature of the condition.
• Once the glide has been chosen it must be sustained throughout the physiological movement until the joint returns to its original starting position
• Mobilizations performed are always into resistance but without pain
• Immediate relief of pain and improvement in ROM are expected.
• If this is not achieved, vary the glide parameters

Spinal Mobilization with Limb Movement (SMWLMs)

• Here a transverse pressure is applied to the side of the relevant spinous process as the patient concurrently moves the limb through the previously restricted range of movement.
• The assumption here is that the restriction of movement is of spinal origin of course.
• This does not necessarily imply neural compromise since spinal movement must occur when a limb moves beyond a certain point.
• Thus the technique addresses a spinal structural/ mechanical restriction, but this may have neural implications too.

MWM for the lumbar spine, sitting

• Extension- Superior anterior force on spinous process, assist with extension with hand on anterior shoulder.
• Flexion- Push superiorly with hook of the pisiform and assist flexion with hand on thoracic back.

MWM for the lumbar spine

• Extension, supine
  • Two hands around the lumbar spine, compress hands (AP and PA force) patient extends back, assisting by pushing up with his hands. *Extension, standing
  • Stabilize with belt, place hand lateral to the lumbar spine, resist patients extension and apply PA force.

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“…the use of hands in a curative and healing manner or a hands-on technique with therapeutic intent…”.

There is a wide range of disciplines which use manual therapeutic methods to treat and manage pathology and dysfunction as a primary treatment method or in conjunction with other treatments. Physiotherapists are sometimes considered specialists in manual therapy but other professions such as Osteopaths, Chiropractors and Nurses employ manual therapy in treatment. Manual therapy works through a multitude of different mechanisms to be effective and understanding the physiological, neurological and psychophysiological mechanisms is critical to utilising manual therapy clinically in a competent and safe manner. 
From a Physiotherapy perspective manual therapy is an essential and commonly used treatment method for the management of tissue, joint and movement dysfunction. There are several different main stream approaches to manual therapy; arguably the most common, simplistic form of manual therapy used by physiotherapists are mobilisations from the Maitland school of thought.

The Maitland Concept

“The Maitland Concept of Manipulative Physiotherapy [as it became to be known], emphasises a specific way of thinking, continuous evaluation and assessment and the art of manipulative physiotherapy (“know when, how and which techniques to perform, and adapt these to the individual Patient”) and a total commitment to the patient.”

The application of the Maitland concept can be on the peripheral or spinal joints, both require technical explanation and differ in technical terms and effects, however the main theoretical approach is similar to both.
The concept is named after its pioneer Geoffrey Maitland who was seen as a pioneer of musculoskeletal physiotherapy, along with several of his colleagues. 

Key Terms

• Accessory Movement – Accessory or joint play movements are joint movements which cannot be performed by the individual. These movements include roll, spin and slide which accompany physiological movements of a joint. The accessory movements are examined passively to assess range and symptom response in the open pack position of a joint. Understanding this idea of accessory movements and their dysfunction is essential to applying the Maitland concept clinically.
• Physiological Movement – The movements which can be achieved and performed actively by a person and can be analysed for quality and symptom response.
• Injuring Movement – Making the pain/symptoms ‘come on’ by moving the joint in a particular direction during the clinical assessment
• Overpressure – Each joint has a passive range of movement which exceeds its available active range. To achieve this range a stretch is applied to the end of normal passive movement. This range nearly always has a degree of discomfort and assessment of dislocation or subluxation should be acquired during the subjective assessment.

Initial Assessment

The Maitland concept is a fantastic tool for approaching an initial assessment as it can be used to form a logical and deduced hypothesis about the nature of the origins of the movement disorder or pain. It is worth considering using mobilisations in your assessment process and reading the Initial Assessment section in Maitlands book Peripheral Manipulation.

As with any treatment decision a competent and effective assessment is crucial to any patient interaction. The Subjective Assessment is necessary for determining whether or not mobilisations are suitable for this patient or if they are contraindicated by looking for red flags such as cancer, recent fracture, open wound or active bleeding, infective arthritis, joint fusion and more. 

The Objective Assessment is an area which the versatile nature of mobilisations becomes clear. Additionally to being a treatment method they are available to the therapist to assess a patients joints and tissues by analysing their extensibility, pain reproduction, bony blocks or abnormal end feels.

Principles of Techniques

Decisions Which Need to be Made

1. The Direction – of the mobilisation needs to be clinically reasoned by the therapist and needs to be appropriate for the diagnosis made. Not all directions will be effective for any dysfunction.
2. The Desired Effect – what effect of the mobilisation is the therapist wanting? Relieve pain or stretch stiffness?
3. The Starting Position – of the patient and the therapist to make the treatment effective and comfortable. This also involves thinking about how the forces from the therapists hands will be placed to have a localised effect.
4. The Method of Application – The position, range, amplitude, rhythm and duration of the technique.
5. The Expected Response – Should the patient be pain-free, have an increased range or have reduced soreness?
6. How Might the Technique be Progressed – Duration, frequency or rhythm? 

How to Choose the Direction

To make sure you settle on appropriate mobilisations it is important to get the type of glide, the direction and speed correct.

Different Types of Mobilisation: How Many Glides?

Each joint has a different movement arc in a different direction to other joints and therefore care needs to be taken when choosing which direction to manipulate; this is where the Concave Convex Rule comes into use, but for now consider the number of possible glides a clinician may use:

1. A-P (Anteroposterior)
2. P-A (Posteroanterior)
3. Longitudinal Caudad
4. Longitudinal Cephalad 
5. Joint Distraction
6. Medial Glide
7. Lateral Glide

Due to anatomical position and other physical limitations not all peripheral or spinal joints can be subjected to all of the types of glide. Here are examples of mobilisations of joints of the body:

• Elbow Mobilizations
• Wrist/Hand Mobilizations
• Hip Mobilizations
• Knee Mobilizations
• Ankle and Foot Mobilisations
• Spinal_Manipulation
• Shoulder Mobilizations and  Manipulation
• Cervicothoracic Manipulation

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Concave Convex Rule: Up, down, Left or Right?

Choosing the direction of the mobilisation is integral to ensuring you are having the desired clinical outcome. This is where a knowledge of Arthrokinematics is important. In summary:

There are two important things to remember:

• When a convex surface (i.e Humeral Head) moves on a stable concave surface (i.e Glenoid Fossa) the sliding of the convex articulating surface occurs in the opposite direction to the motion of the bony lever (i.e the Humerus).

The opposite can be said for 

• When a concave surface (i.e Tibia; talocrural joint) is moving on a stable convex surface (i.e Talus) sliding occurs in the same direction of the bony level. 

Examples:

To improve shoulder flexion you would perform an A-P mobilisation due to the way the convex humerus articulates with the concave glenoid fossa.

An easier way to visualise this is to try and show this rule with your hands. (Picture from)

How to Choose the Grade: How Far into Range and Quickly or Slowly?

Grades of Mobilisations

Grade I – small amplitude movement at the beginning of the available range of movement
Grade II – large amplitude movement at within the available range of movement

Grade III – large amplitude movement that moves into stiffness or muscle spasm
Grade IV – small amplitude movement stretching into stiffness or muscle spasm

**A 5th grade is possible but further training will be required to perform safely**

In many places, you are obliged to obtain a written consent from your patient before applying grade 5 manipulation .

The grading scale has been separated into two due to their clinical indications:

• Lower grades (I + II) are used to reduce pain and irritability (use VAS + SIN scores).
• Higher grades(III + IV) are used to stretch the joint capsule and passive tissues which support and stabilise the joint so increase range of movement.

The rate of mobilisation should be thought of as an oscillation in a rhythmical fashion at:

• 2Hz – 120 movements per minute
• For 30 seconds – 1 minute

Therapeutic Effect: How and Why Does This Work; Mechanisms of Action

There are a number of complex systems which interact to produce the pain-relieving effects of mobilisations, subsequently there is not a single theory into its mechanism. Therefore this article will outline the basics and evidence for the claims and further links will be added for additional more in-depth information. 

Pain Gate Theory

The pain gate theory (PGT) was first proposed in 1965 by Melzack and Wall, and is a commonly used explanation of pain transmission. Thinking of pain theory in this way is very simplified and may not be suitable in some contexts, however when discussing pain with patients this description can be very useful.

In order to understand the PGT, the sensory nerves need to be explained. At its most simple explanation there are 3 types of sensory nerves involved of transmission of stimuli:

1. α-Beta fibres – Large diameter and myelinated – touch and pressure – Fast (50m/s)
2. α-Delta fibres – Small diameter and myelinated – temperature and pain (well localised, sharp/prickly) – Medium (15m/s)
3. C fibres – Small diameter and un-myelinated – pain (dull, poorly localised, persistent) – Slow (1m/s)

The size of the fibres is an important consideration as the bigger a nerve is the quicker the conduction, additionally conduction speed is also increased by the presence of a myelin sheath, subsequently large myelinated nerves are very efficient at conduction. This means that α-Beta fibres are the quickest of the 3 types followed by α-Delta fibres and finally C fibres. 

The interplay between these nerves is important but it is not the whole story, as you can see only two of these nerves are pain receptors α-Delta fibres are purely sensory in terms of touch. All of these nerves synapse onto projection cells which travel up the spinothalamic tract of the CNS to the brain where they go via the thalamus to the somatosensory cortex, the limbic system and other areas. In the spinal cord there are also inhibitory interneurons which act as the ‘gate keeper’. When there is no sensation from the nerves the inhibitory interneurons stop signals travelling up the spinal cord as there is no important information needing to reach the brain so the gate is ‘closed’. When the smaller fibres are stimulated the inhibitory interneurons do not act, so the gate is ‘open’ and pain is sensed. When the larger α-Delta fibres are stimulated they reach the inhibitory interneurons faster and, as larger fibres inhibit the interneuron from working, ‘close’ the gate. This is why after you have stubbed your toe, or bumped your head, rubbing it helps as you are stimulating the α-Delta fibres which close the gate

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Description

Manual therapy has a long history within the profession of physical therapy and physical therapists have greatly contributed to the current diversity in manual therapy approaches and techniques. Mechanical explanations were historically used to explain the mechanisms by which manual therapy interventions worked, new research reveals intricate neurophysiologic mechanisms are also at play and the beneficial psychological effects of providing hands-on examination and intervention should not be ignored.

The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) defines manual therapy techniques as: “Skilled hand movements intended to produce any or all of the following effects: improve tissue extensibility; increase range of motion of the joint complex; mobilize or manipulate soft tissues and joints; induce relaxation; change muscle function; modulate pain; and reduce soft tissue swelling, inflammation or movement restriction.”

According to the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) Description of Advanced Specialty Practice (DASP), orthopaedic manual physical therapy (OMPT) is defined as: any “hands-on” treatment provided by the physical therapist.

Treatment may include moving joints in specific directions and at different speeds to regain movement (joint mobilization and manipulation), muscle stretching, passive movements of the affected body part, or having the patient move the body part against the therapist’s resistance to improve muscle activation and timing. Selected specific soft tissue techniques may also be used to improve the mobility and function of tissue and muscles.

Three Paradigms for Manual Therapy Therapeutic Effects

1. Physiological: positive placebo response
2. Biomechanical and Physical: facilitates repair and tissue modelling
3. Psychological: pain relief via- stimulates gating mechanism; muscle inhibition; reduction of nocioceptive activity; reduced intraarticular or periarticular pressure

Techniques Include

• Traction
• Massage
• Trigger Point Therapy
• Active Release Techniques: A practitioner determines where adhesions are through touch, the practitioner then couples a patient’s active movement with his/her touch.
• Assisted Active Range of Motion (AAROM)

• Passive Range of Motion
• Lymph Drainage
• Stretches (muscle, neural tissue, joints, fascia)
• Instrument Assisted Soft Tissue Mobilization

• Joint Manipulation: A passive, high velocity, low amplitude thrust applied to a joint complex within its anatomical limit* with the intent to restore optimal motion, function, and/ or to reduce pain.
• Joint Mobilisation: A manual therapy technique comprising a continuum of skilled passive movements to the joint complex that are applied at varying speeds and amplitudes, that may include a small-amplitude/ high-velocity therapeutic movement (manipulation) with the intent to restore optimal motion, function, and/ or to reduce pain. 

NB The terms “Thrust Manipulation” and “Non-Thrust Manipulation” have been used in the literature.  “Thrust Manipulation” is used to describe interventions described as Manipulation by IFOMPT, and “Non-Thrust Manipulation” would be synonymous with the term Mobilization as proposed by IFOMPT.  

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Guide to Grading of Mobilisations/Manipulations

Maitland Joint Mobilization Grading Scale:

Grade I – Small amplitude rhythmic oscillating mobilization in the early range of movement

Grade II – Large amplitude rhythmic oscillating mobilization in the midrange of movement

Grade III – Large amplitude rhythmic oscillating mobilization to point of limitation in range of movement

Grade IV – Small amplitude rhythmic oscillating mobilization at end of the available range of movement

Grade V (Thrust Manipulation) – Small amplitude, quick thrust at end of the available range of movement

Kaltenborn Traction Grading Scale:

Grade I – Neutralises joint pressure without separation of joint surfaces

Grade II – Separates articulating surfaces, taking up slack or eliminating play within joint capsule

Grade III – Stretching of soft tissue surrounding joint

Additional Viewing

This 28 minute video gives a good overview of the hands-on/off debate and suggestions of when to use manual therapy.

Conclusion

Manual physical therapy is a specialised form of physical therapy delivered with the hands as opposed to a device or machine. It has an important place in Physiotherapy and when used appropriately by practitioners is a very effective set of tools literally at our fingertips.

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The primary goals of manual therapy are:

• Modulate pain
• Increase range of motion
• Reduce soft-tissue inflammation
• Improve contractile & non-contractile tissue repair, extensibility, or stability
• Facilitate movement

Manual therapy is defined as the application of manual forces of the therapist, to change/improve the quality and the range of motion of joints and soft tissues. Mobilisation is a manual technique that through repeated passive motion at low speed replicates normal joint glides at varying amplitudes, while manipulation is defined as fast with a small force, small amplitude and high speed of movement of a joint.

It is hypothesised that manual therapy improves function of the kinetic chain (joints and sot tissue) by a combination of mechanical and neuromuscular mechanisms. In particular in the knee, techniques are aimed at increasing the extensibility of collagen, optimising joint lubrication and reduction of muscle tone which all result in improved joint function and joint mobility.

Indication

The use of manual therapy is supported in the knee.  Indications for the use of manual therapy include:

1. painful neuromusculoskeletal joint disorder
2. pain in or from palpation of bony joint surfaces
3. pain in of from palpation of joint soft tissues
4. decreased or altered range of quality of motion
5. pain on joint movement.

When there is pain in combination with joint restriction, it is recommended to apply manual therapy together with exercise therapy. There is a consensus that manual therapy can be considered as a preparation for exercise therapy by having an effect on pain and joint limitations, and muscle activity.

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Clinical application

A commonly used form of manual therapy applied to joints are oriented mobilisations called ‘joint glides’, these are performed in specific planes of movement and are intended to restore specific movements. Research has demonstrated increased range of movement and function following tibiofemoral mobilisations but these positive effects are only for a short duration and cannot be considered effective for long term outcomes.  This would suggest that mobilisations may be effectively used to promote exercise performance.

Manual therapy is often used in clinical practice for osteoarthritis. Although it is often used, there is little research on the effects of the treatment of knee osteoarthritis independently of other interventions, such as exercise therapy. Studies have shown that manual therapy has a positive effect on the modulation of pain in knee osteoarthritis.  A combination of manual therapy and guided exercises has functional benefits for patients with knee osteoarthritis.  Manual therapy and a guided exercise program can reduce the burden of complaint and postpone the need for surgery therefore reducing cost.

Manipulative therapy of the knee and/or full kinetic chain combined with multimodal or exercise therapy improves patellofemoral pain syndrome Anterior knee pain is associated with the loss of strength and decreased activity of the knee extensors, which refers to a muscle inhibition. Muscle co-contraction around the knee has been shown to improve after joint mobilisations to the knee.  Spinal manipulation may also be regarded as an effective treatment to reduce muscle inhibition in the lower limb musculature

There is little or no evidence of the use of manual therapy at acute knee injury, like ligaments or meniscus injury. For such persons, other appropriate measures in their therapy should be taken such as a supervised exercise programme.

Manual therapy combined with an appropriate exercise therapy seems to be more effective for improving the muscle strength, proprioception and functional performance than exercise therapy alone.

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Joints, also known as articulations, are a form of connection between bones. They provide stability to the skeletal system as well as allowing for specialized movement.

Joints can be classified:

1. Histologically, on the dominant type of connective tissue. ie fibrous, cartilaginous, and synovial.
2. Functionally, based on the amount of movement permitted. ie synarthrosis (immovable), amphiarthrosis (slightly moveable), and diarthrosis (freely moveable).

Generally speaking, the greater the range of movement, the higher the risk of injury because the strength of the joint is reduced

The two classification schemes correlate:

1. Synarthroses are fibrous joints
2. Amphiarthroses are cartilaginous joints
3. Diarthroses are synovial joints

Fibrous Joints

In fibrous joints (synarthrodial joint) the bones are joined by fibrous tissue, namely dense fibrous connective tissue, and no joint cavity is present. The amount of movement allowed depends on the length of the connective tissue fibers uniting the bones. Although a few are slightly movable, most fibrous joints are immovable.

The three types of fibrous joints are sutures, syndesmoses, and gomphoses.

1. Sutures are immobile joints in the cranium. The plate-like bones of the skull are slightly mobile at birth because of the connective tissue between them, termed fontanelles. This initial flexibility allows the infant’s head to get through the birth canal at delivery and permits the enlargement of the brain after birth. As the skull enlarges, the fontanelles reduce to a narrow layer of fibrous connective tissue that suture the bony plates together. Eventually, cranial sutures ossify- the two adjacent plates fuse to form one bone (termed synostosis).
2. Gomphoses are the immobile joints between the teeth and their sockets in the mandible and maxillae. The periodontal ligament is the fibrous tissue that connects the tooth to the socket.
3. Syndesmoses are slightly movable joints (amphiarthroses). In syndesmosis joints, the two bones are held together by an interosseous membrane. Eg Middle Tibiofibular Joint, a fibrous joint formed by the interosseus membrane connecting the shafts of the tibia and the fibula.

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Cartilaginous Joints

Cartilaginous joints are a type of joint where the bones are entirely joined by cartilage, either hyaline cartilage or fibrocartilage. These joints generally allow more movement than fibrous joints but less movement than synovial joints.

• Primary cartilaginous joints: These cartilaginous joints are composed entirely of hyaline cartilage and are known as synchondroses. Most exist between ossification centres of developing bones and are absent in the mature skeleton, but a few persist in adults. eg First Sternocostal Joint, between first rib and manubrium (all other sternocostal joints are plane synovial joints); Growth plates.
• Image 3: synchondroses eg. growth plate
• The secondary cartilaginous joint, also known as symphysis, may involve either hyaline or fibrocartilage. These joints are slightly mobile (amphiarthroses). eg The pubic symphysis: Intervertebral discs.

Synovial Joints

The primary purpose of the synovial joint is to prevent friction between the articulating bones of the joint cavity. While all synovial joints are diarthroses, the extent of movement varies among different subtypes and is often limited by the ligaments that connect the bones. Nearly all joints of the limbs and most joints of the body fall into this class.

A key structural characteristic for a synovial joint that is not seen at fibrous or cartilaginous joints is the presence of a joint cavity. The joint cavity contains synovial fluid, secreted by the synovial membrane (synovium), which lines the articular capsule. This fluid-filled space is the site at which the articulating surfaces of the bones contact each other. Hyaline cartilage forms the articular cartilage, covering the entire articulating surface of each bone. The articular cartilage and the synovial membrane are continuous. A few synovial joints of the body have a fibrocartilage structure located between the articulating bones. This is called an articular disc, which is generally small and oval-shaped, or a meniscus, which is larger and C-shaped.

Physiotherapy

Physiotherapists are qualified health care professionals who are experienced at assessing joints of the human body. See links to below conditions for some examples.

• Arthritis – inflammation that causes stiffness and pain in the joints eg rheumatoid arthritis or gout, or degeneration (osteoarthritis)
• Bursitis – inflammation of the bursae (fluid-filled sacs that cushion and pad bones)
• Tendonitis – inflammation, irritation and swelling of a tendon that is attached to the joint.
• Injury – including strain or sprain of a ligament or nearby tendon or muscle, or bone fracture.

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Biomechanics in sport incorporates a detailed analysis of sport movements in order to minimise the risk of injury and improve sports performance. Sport and exercise biomechanics encompasses the area of science concerned with the analysis of the mechanics of human movement. It refers to the description, detailed analysis and assessment of human movement during sport activities. Mechanics is a branch of physics that is concerned with the description of motion/movement and how forces create motion/movement. In other words, sport biomechanics is the science of explaining how and why the human body moves in the way that it does. In sport and exercise, that definition is often extended to also consider the interaction between the performer and their equipment and environment. Biomechanics is traditionally divided into the areas of kinematics which is a branch of mechanics that deals with the geometry of the motion of objects, including displacement, velocity, and acceleration, without taking into account the forces that produce the motion while kinetics is the study of the relationships between the force system acting on a body and the changes it produces in body motion. In terms of this, there are skeletal, muscular and neurological considerations we also need to consider when describing biomechanics.

Application 

According to Knudson human movement performance can be enhanced in many ways as effective movement encompasses anatomical factors, neuromuscular skills, physiological capacities and psychological/cognitive abilities. Biomechanics is essentially the science of movement technique and as such tends to be most utilised in sports where technique is a dominant factor rather than physical structure or physiological capacities. The following are some of the areas where biomechanics is applied, to either support the performance of athletes or solve issues in sport or exercise: 

• The identification of optimal technique for enhancing sports performance 
• The analysis of body loading to determine the safest method for performing a particular sport or exercise task 
• The assessment of muscular recruitment and loading 
• The analysis of sport and exercise equipment e.g., shoes, surfaces and rackets.

Biomechanics is utilised to attempt to either enhance performance or reduce the injury risk in the sport and exercise tasks examined.

Principles of Biomechanics

It is important to know several biomechanical terms and principles when examining the role of biomechanics in sport and exercise.

Forces and Torques

A force is simply a push or pull and it changes the motion of a body segment or the racket. Motion is created and modified by the actions of forces (mostly muscle forces, but also by external forces from the environment). When force rotates a body segment or the racquet, this effect is called a torque or moment of force. Example – Muscles create a torque to rotate the body segments in all tennis strokes. In the service action internal rotation of the upper arm, so important to the power of the serve, is the result of an internal rotation torque at the shoulder joint caused by muscle actions (latissimus dorsi and parts of the pectoralis major and deltoid). To rotate a segment with more power a player would generally apply more muscle force.

Newton’s Laws of Motion

Newton’s Three Laws of Motion explain how forces create motion in sport. These laws are usually referred to as the Laws of Inertia, Acceleration, and Reaction.

1. Law of Inertia – Newton’s First Law of inertia states that objects tend to resist changes in their state of motion. An object in motion will tend to stay in motion and an object at rest will tend to stay at rest unless acted upon by a force. Example – The body of a player quickly sprinting down the field will tend to want to retain that motion unless muscular forces can overcome this inertia or a skater gliding on ice will continue gliding with the same speed and in the same direction, barring the action of an external force.
2. Law of Acceleration – Newton’s Second Law precisely explains how much motion a force creates. The acceleration (tendency of an object to change speed or direction) an object experiences is proportional to the size of the force and inversely proportional to the object’s mass (F = ma). Example – When a ball is thrown, kicked, or struck with an implement, it tends to travel in the direction of the line of action of the applied force. Similarly, the greater the amount of force applied, the greater the speed the ball has. If a player improves leg strength through training while maintaining the same body mass, they will have an increased ability to accelerate the body using the legs, resulting in better agility and speed. This also relates to the ability to rotate segments, as mentioned above.
3. Law of Reaction – The Third Law states that for every action (force) there is an equal and opposite reaction force. This means that forces do not act alone, but occur in equal and opposite pairs between interacting bodies. Example – The force created by the legs “pushing” against the ground results in ground reaction forces in which the ground “pushes back” and allows the player to move across the court (As the Earth is much more massive than the player, the player accelerates and moves rapidly, while the Earth does not really accelerate or move at all). This action-reaction also occurs at impact with the ball as the force applied to the ball is matched with an equal and opposite force applied to the racket/body.

Momentum

Newton’ Second Law is also related to the variable momentum, which is the product of an object’s velocity and mass. Momentum is essentially the quantity of motion an object possesses. Momentum can be transferred from one object to another. There are different types of momentum which each have a different impact on the sport. 

Linear Momentum

Linear momentum is momentum in a straight line e.g. linear momentum is created as the athlete sprints in a straight line down the 100m straight on the track.

Angular Momentum

Angular momentum is rotational momentum and is created by the rotations of the various body segments e.g. The open stance forehand uses significant angular momentum. The tremendous increase in the use of angular momentum in ground strokes and serves has had a significant impact on the game of tennis. One of the main reasons for the increase in power of the game today is the incorporation of angular momentum into ground stroke and serve techniques. In tennis, the angular momentum developed by the coordinated action of body segments transfers to the linear momentum of the racquet at impact.

Centre of Gravity

The Center of Gravity (COG) is an imaginary point around which body weight is evenly distributed. The center of gravity of the human body can change considerably because the segments of the body can move their masses with joint rotations. This concept is critical to understanding balance and stability and how gravity affects sport techniques.

The direction of the force of gravity through the body is downward, towards the center of the earth and through the COG. This line of gravity is important to understand and visualise when determining a person’s ability to successfully maintain balance. When the line of gravity falls outside the Base of Support (BOS), then a reaction is needed in order to stay balanced.

The center of gravity of a squash racquet is a far simpler process and can usually be found by identifying the point where the racket balances on your finger or another narrow object.

Balance

Balance is the ability of a player to control their equilibrium or stability. You need to have a good understanding of both static and dynamic balance:

Static Balance

The ability to control the body while the body is stationary. It is the ability to maintain the body in some fixed posture. Static balance is the ability to maintain postural stability and orientation with center of mass over the base of support and body at rest.

Dynamic Balance 

The ability to control the body during motion. Defining dynamic postural stability is more challenging, Dynamic balance is the ability to transfer the vertical projection of the center of gravity around the supporting base of support. Dynamic balance is the ability to maintain postural stability and orientation with center of mass over the base of support while the body parts are in motion.

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Correct Biomechanics

As mentioned above, correct biomechanics provide efficient movement and may reduce the risk of injury. In sport, it is always good to consider abnormal or faulty biomechanics as a possible cause of injury. These abnormal biomechanics can be due to anatomical or functional abnormalities. Anatomical abnormalities such as leg length discrepancies cannot be changed, but the secondary effects can be addressed such as a shoe build up or orthotics for example. Functional abnormalities that can occur can be muscle imbalances after a long period of immobilisation.

Incorrect technique can cause abnormal biomechanics which can lead to injuries. Below are some examples of the relationship between faulty technique and associated injuries.

Sport	Technique	Injury
Cricket	Mixed bowling action	Pars interarticularis stress fractures
Tennis	Excessive wrist action with backhand	Extensor tendinopathy of the elbow
Swimming	Decreased external rotation of the shoulder	Rotator cuff tendinopathy
Running	Anterior pelvic tilt	Hamstring injuries
Rowing	Change from bow side to stroke side	Rib stress fractures
Ballet	Poor turnout	Hip Injuries

Lower Limb Biomechanics

As humans, ambulation is our main form of movement, that is we walk upright and are very reliant on our legs to move us about. How the foot strikes the ground and the knock on effect this has up the lower limbs to the knee, hips, pelvis and low back in particular has become a subject of much debate and controversy in recent years. 

Lower limb biomechanics refers to a complex interplay between the joints, muscles and nervous system which results in a certain patterning of movement, often referred to as ‘alignment’. Much of the debate centers around what is considered ‘normal’ and what is considered ‘abnormal’ in biomechanical terms as well as the extent to which we should intervene should abnormal findings be found on assessment. This section examines the biomechanics of the lower extremity in particular the anatomy and biomechanics of the foot and ankle, the impact of Q Angle on the mechanics of the hip and knee and finally the implications of this on gait.

Foot and Ankle Biomechanics

The foot and ankle form a complex system which consists of 26 bones, 33 joints and more than 100 muscles, tendons and ligaments. It functions as a rigid structure for weight bearing and it can also function as a flexible structure to conform to uneven terrain. The foot and ankle provide various important functions which include: supporting body weight, providing balance, shock absorption, transferring ground reaction forces, compensating for proximal malalignment, and substituting hand function in individuals with upper extremity amputation/paralysis all which are key when involved with any exercise or sport involving the lower limbs. This page examines in detail the biomechanics of the foot and ankle and its role in locomotion. 

Q Angle

An understanding of the normal anatomical and biomechanical features of the patellofemoral joint is essential to any evaluation of knee function. The Q angle formed by the vector for the combined pull of the quadriceps femoris muscle and the patellar tendon, is important because of the lateral pull it exerts on the patella.

The direction and magnitude of force produced by the quadriceps muscle have great influence on patellofemoral joint biomechanics. The line of force exerted by the quadriceps is lateral to the joint line mainly due to the large cross-sectional area and force potential of the vastus lateralis. Since there exists an association between patellofemoral pathology and excessive lateral tracking of the patella, assessing the overall lateral line of pull of the quadriceps relative to the patella is a meaningful clinical measure. Such a measure is referred to as the Quadriceps angle or Q angle. It was initially described by Brattstrom.

Biomechanics of Gait

Sandra J. Shultz describes gait as: “…someone’s manner of ambulation or locomotion, involves the total body. Gait speed determines the contribution of each body segment. Normal walking speed primarily involves the lower extremities, with the arms and trunk providing stability and balance. The faster the speed, the more the body depends on the upper extremities and trunk for propulsion as well as balance and stability. The legs continue to do the most work as the joints produce greater ranges of motion through greater muscle responses. In the bipedal system the three major joints of the lower body and pelvis work with each other as muscles and momentum move the body forward. The degree to which the body’s center of gravity moves during forward translation defines efficiency. The body’s center moves both side to side and up and down during gait.” Bipedal walking is an important characteristic of humans. This page will present information about the different phases of the gait cycle and important functions of the foot while walking. 

Upper Limb Biomechanics

Correct biomechanics are as important in upper limb activities as they are in lower limb activities. The capabilities of the upper extremity are varied and impressive. With the same basic anatomical structure of the arm, forearm, hand, and fingers, major league Baseball Pitchers pitch fastballs at 40 m/s, swimmers cross the English Channel, gymnasts perform the iron cross, and olympic boxers in weight classes ranging from flyweight to super heavyweight showed a range of 447 to 1,066 pounds of peak punching force.

The structure of the upper extremity is composed of the shoulder girdle and the upper limb. The shoulder girdle consists of the scapula and clavicle, and the upper limb is composed of the arm, forearm, wrist, hand, and fingers. However, a kinematic chain extends from the cervical and upper thoracic spine to the fingertips. Only when certain multiple segments are completely fixed can these parts possibly function independently in mechanical roles.

This section reviews the anatomical structures enabling these different types of movement and examines the biomechanics or ways in which the muscles cooperate to achieve the diversity of movement of which the upper extremity is capable.

Scapulohumeral Rhythm

Scapulohumeral rhythm (also referred to as glenohumeral rhythm) is the kinematic interaction between the scapula and the humerus, first published by Codman in the 1930’s. This interaction is important for the optimal function of the shoulder. When there is a change of the normal position of the scapula relative to the humerus, this can cause a dysfunction of the scapulohumeral rhythm. The change of the normal position is also called scapular dyskinesia. Various studies of the mechanism of the shoulder joint that have attempted to describe the global motion capacity of the shoulder refer to that description, Can you evaluate the shoulder to see if the function is correct and explain the complex interactions between components involved in placing the hand in space?

Sport Specific Biomechanics

Running Biomechanics

Running is similar to walking in terms of locomotive activity. However, there are key differences. Having the ability to walk does not mean that the individual has the ability to run. There are some differences between the gait and run cycle – the gait cycle is one third longer in time, the ground reaction force is smaller in the gait cycle (so the load is lower), and the velocity is much higher. In running, there is also just one stance phase while in stepping there are two. Shock absorption is also much larger in comparison to walking. This explains why runners have more overload injuries.

Running Requires:

• Greater balance
• Greater muscle strength
• Greater joint range of movement 

Cycling Biomechanics

Cycling was initially invented by Baron Carl von Drais in 1817, but not as we know it. This was a machine which initially had two wheels that were connected by a wooden plank with a rudder device for steering. It involved people running along the ground whilst sitting down; giving them the name of a ‘running machine’ (in all senses) or a velocipede. This was solely used by the male population at the time of invention. The velocipede then made a huge design development in the 1860s at the Michaux factory in Paris. They added leaver arms to the front wheel which were propelled by pedals at the feet. This was the first conventional bicycle, and since then and up until the current day the bicycle has made great design and technological advances.
A survey in 2014 estimated that over 43% of the United Kingdom population have or have access to a bike and 8% of the population aged 5 and above cycled 3 or more times a week. With such a large amount of people cycling, whether it be professional, recreational or for commuting this increase the chance of developing an injury, so it is time we understood the biomechanics of cycling.

Baseball Pitching Biomechanics

Baseball pitching is one of the most intensely studying athletic motions. Although the focus has been more on the shoulder movement, entire body movement is required to perform baseball pitching. Throwing is also considered one of the fastest human motions performed, and maximum humeral internal rotation velocity reaches about 7000 to 7500o/second.

Tennis Biomechanics

Tennis biomechanics is a very complex task. Consider hitting a tennis ball. First, the athlete needs to see the ball coming off their opponent’s racket. Then, in order, they have to judge the speed, spin, trajectory and, most importantly, the direction of the tennis ball. The player then needs to adjust their body position quickly to move around the ball. As the player prepares to hit the ball the body is in motion, the ball is moving both in a linear and rotation direction if there is spin on the ball, and the racquet is also in motion. The player must coordinate all these movements in approximately a half a second so they strike the ball as close to the center of the racket in order to produce the desired spin, speed and direction for return of the ball. A mistake in any of these movements can create an error.

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Human beings are able to produce a variety of postures and movements giving them the ability to move from one place to another, i.e. the locomotive function. This is made possible by our musculoskeletal system that supports body loads and movement of body segments. This function is embedded in the principles of human biomechanics.

Biomechanics is considered to be one of the underpinning principles in physiotherapy practice to provide optimal care for movement-related injuries or conditions.

Image 1: Position of the centre of gravity “T” at different positions of the human body

Biomechanics major applications areas: improving movement performance; reduction of movement impairment; intervention in movement-related injuries or conditions.

Physiotherapists make use of biomechanical principles in eg

1. Therapeutic exercises: range of motion; active and passive insufficiency; concave-convex rule; Newton’s laws of motion.
2. Ergonomic training and the design of modern orthopaedic devices eg advanced walking aids are based on the application of the biomechanics concept.

How Do We Solve Problems in Biomechanics?

Knowing that biomechanical principles have a role in physiotherapy practice it is important to understand how to solve problems relating to biomechanics. Biomechanics provides information for a variety of kinesiology professions to analyze human movement to improve effectiveness or decrease the risk of injury. How the movement is analyzed falls on a continuum between a qualitative analysis and a quantitative analysis.

1. Quantitative analysis involves the measurement of biome-chanical variables and usually requires a computer to do the voluminous numerical calculations performed. Even short movements will have thousands of samples of data to be collected, scaled, and numerically processed.
2. Qualitative analysis has been defined as the “systematic observation and introspective judgment of the quality of human movement for the purpose of providing the most appropriate intervention to improve performance”. Knudson and Morrison.

Image 2: X-ray, orthopedic performance and biomechanics – Epiphysesis of the knee joints used to stop the growth by fixing the growth plate with metal clamps ( used to compensate for the unequal growth of the length of the limbs).

Basic Biomechanics Terminology

Mechanics is a branch of science that deals with forces and the effects produced by these forces.

The application of this science to the biological system is referred to as biomechanics.

• Human biomechanics focuses on how forces act on the musculoskeletal system and how the body tissue responds to these forces.
• Using the forces involved in the production of movement and posture, biomechanics can be viewed in the context of either external or internal biomechanics.

1. External biomechanics describes external forces on body segments and their effect on body movement,
2. Internal biomechanics are forces generated by the body tissues and their effect on movement.”This included the muscle forces and the forces in bones and joints that result from transmission of the muscle forces through the skeleton”.

External Forces (External Biomechanics)

Mechanics Domain

There are two domains of mechanics (biomechanics):

1. Static: describes mechanics that analyse the bodies at rest or in uniform motion
2. Dynamics: the study of conditions under which an object moves.

The dynamics concept can be further discussed under kinematics and kinetics.

• The kinetics concept: deals with body motion and the forces that cause it to move.Kinematics describes: body motion without regard to the forces that produce that motion.

Kinematics Variables

In kinematics, there are five variables of interest:

1. Type of motion or displacement,
2. The location,
3. The direction,
4. The magnitude
5. Rate of the motion or displacement.

1.Type of motion

Human motion is described as general motion (a complex combination of linear and angular components of motion). Most of the time human motion is analysed as either linear or angular motion as these two types of motion are basically considered “pure” motion.

• Linear motion (or translatory or translational motion): all parts of the body are moving in the same direction and at the same speed. If this motion occurs along a : straight line it is referred to as linear or rectilinear motion; a curved path it is referred to as curvilinear path.
• Angular motion is described as a rotation that occurs around a central imaginary line known as the rotation axis.

Pure linear movement in humans, like in walking, running and swimming rarely occur as the orientation of body segments to each other changes continually.

• In activities like skating and ski jumping there might be brief moments of pure linear motion.

The movement of a multi-segmented body, like the human body, which involves simultaneous linear and angular motion of the segments, is usually referred to as general motion. In humans, whole-body movements are described as general motion, as explained in the following examples

• When a person walks, the head and trunk movements are fairly linear, but the legs and arms movements are linear and angular simultaneously as the person’s body translates forward
• In cycling, the head, trunk and arms move in a fairly linear fashion but the legs move simultaneously in a linear and angular motion.

2. Magnitude of Motion

For angular motion, its magnitude can be measured and recorded in radians or degrees with the use of a goniometer. While the linear motion of a segment is measured by the linear distance that the object covered and this can be evaluated with walking assessment tools like 6-minute walk test.

3. Rate of Motion

Speed or velocity is used to measure the rate of motion and change in velocity is acceleration.

4. Location of Joint Motion in Space

One common reference system for location joint motion is that of anatomical planes and axes. A plane of motion can be described as a particular dimension of motion that runs through an imaginary flat surface of the body and an axis is an imaginary line that the body segment is rotating about. There are three planes of motion in the body, namely the sagittal, frontal and transverse planes.

• A sagittal plane has its axes as mediolateral, also known as transverse axes
• The frontal (coronal) and transverse planes have their axes as anteroposterior and longitudinal respectively.

5. Direction of Motion

The direction of motion can be described in terms of how the movement occurs along the plane and axis.

• When a motion reduces joint angle in the sagittal plane it is called flexion and a motion that increases the joint angle extension. Other common direction of motion in the sagittal plane are dorsiflexion and planter-flexion.
• Movement to the extremes of the range of motion are often referred to as “hyper,” as is the case with hyperextension, and this also occurs in the sagittal plane.
• The motion of a segment away from the midline in the frontal plane is called “abduction,” while the movement back toward the midline is called “adduction”. Other directions of motion that is common in this plane include eversion and inversion.
• Common motion along the transverse plane are internal rotation and external rotation, pronation and supination are also common motion along the transverse plane.

There are other directional terms to help describe the position of the body segment relative to the anatomical position eg

• Superior and inferior, which describes body position towards the head and the feet, respectively.
• Anterior and posterior can be used to describe objects related to the body as the front or back orientation to the body, respectively.
• Parts or movement towards the midline of the body is called medial, while motion or position towards the sides of the body is lateral.

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Kinematic Chain

The kinematic chain (also referred to as the kinetic chain in literature). Combinations of the degree of freedoms form kinematics chain – kinematics chain can be opened or closed.

1. In an open kinematic chain, the degree of freedom describes the number of directions that a joint allows a body segment to move and it is the number of independent coordinates that is used to precisely specify the position of the object in space.
2. Closed Kinetic Chain (CKC) exercises or closed chain exercises are exercises or movements where the distal aspect of the extremity is fixed to an object that is stationary.

Levangie and Norkin, elucidated that the open and closed park position concept help to describe movements that are taking place under weight-bearing and non-weight-bearing conditions and it is important to take note of these when exercise is to target single or multiple joints.

An order of natural kinetic chain in the upper and lower extremity involves an integrated biomechanical task that when impaired results in dysfunctional biomechanical output leading to pain and/or injury.

• Eg in the shoulder, when deficits exist in the preceding links, they can negatively affect the shoulder. Therefore, while managing shoulder dysfunction, an attempt should be made to restore all kinetic chain deficits and therapeutic sessions should follow integrated exercises on proprioception, flexibility, strength and endurance with kinetic chain order.

PRINCIPLES OF BIOMECHANICS

Acceleration. the rate at which speed changes.

• agonist. the muscle most directly involved in creating movement. …
• anatomical position. the body standing erect with arms down and palms forward.
• angle of pennation. …
• angular displacement. …
• angular velocity. …
• antagonist. …
• biomechanics.

Kinetic Concept in Motion Analysis

While kinematic concepts describe a segment of a body’s motion, the concept of kinetics gives us an idea of the forces associated with that movement. When discussing the kinetic concept of motion analysis we need to define force in biomechanics. Force is a simple way to represent load in biomechanics and can be defined as the action of one object to another. Force can be external or internal.

• External forces either pull or push on the body that occurs from sources outside the body
• Internal forces are those forces that act on the structures of the body and are generated by the body tissue.

Forces

• Cam change the shape and the state of motion of an object.
• Characterized by magnitude, direction and point of application.

All these factors determine the effect of force on an object. There are multiple forces that act on an object and it is possible to resolve these forces into a single ‘resultant’ force that has the same effect as all other forces acting together. The process of combining these two or more forces into a single resultant force is known as the composition of forces. Having understood what force is, it is essential to look into some of the laws guiding the force application.

Levangie and Norkin, reiterated that there are three primary rules of forces:

1. A force that acts on a segment must come from something
2. Anything that contacts a segment must create a force on that segment
3. Gravity is considered to have a force effect on all objects.

The principle of understanding the biomechanics of movement is an in-depth understanding of force, Newton’s laws of motion, work and energy

FORCES AND TORQUES  :

A force is simply a push or pull and it changes the motion of a body segment or the racket. Motion is created and modified by the actions of forces (mostly muscle forces, but also by external forces from the environment). When force rotates a body segment or the racquet, this effect is called a torque or moment of force

NEWTON’S LAW  :

1) Law of Inertia –

Newton’s First Law of inertia states that objects tend to resist changes in their state of motion. An object in motion will tend to stay in motion and an object at rest will tend to stay at rest unless acted upon by a force.

2) Law of Acceleration

Newton’s Second Law precisely explains how much motion a force creates. The acceleration (tendency of an object to change speed or direction) an object experiences is proportional to the size of the force and inversely proportional to the object’s mass.

3) Law of Reaction

– The Third Law states that for every action (force) there is an equal and opposite reaction force. This means that forces do not act alone, but occur in equal and opposite pairs between interacting bodies.

TYPE OF MOMENTUM

1) LINEAR MOMENTUM

Linear momentum is momentum in a straight line e.g. linear momentum is created as the athlete sprints in a straight line down the 100m straight on the track.

2) ANGULAR MOMENTUM

Angular momentum is rotational momentum and is created by the rotations of the various body segments e.g. The open stance forehand uses significant angular momentum. The tremendous increase in the use of angular momentum in ground strokes and serves has had a significant impact on the game of tennis. One of the main reasons for the increase in power of the game today is the incorporation of angular momentum into ground stroke and serve techniques. In tennis, the angular momentum developed by the coordinated action of body segments transfers to the linear momentum of the racquet at impact.

*CENTER OF GRAVITY

Center of Gravity (COG) is an imaginary point around which body weight is evenly distributed. The center of gravity of the human body can change considerably because the segments of the body can move their masses with joint rotation

*BALANCE
Balance is the ability of a player to control their equilibrium or stability.

1) STATIC BALANCE

The ability to control the body while the body is stationary. It is the ability to maintain the body in some fixed posture[12]. Static balance is the ability to maintain postural stability and orientation with center of mass over the base of support and body at rest

2) DYNAMIC BALANCE

The ability to control the body during motion. Defining dynamic postural stability is more challenging, Dynamic balance is the ability to transfer the vertical projection of the center of gravity around the supporting base of support.Dynamic balance is the ability to maintain postural stability and orientation with center of mass over the base of support while the body parts are in motion.

IMPORTANCE OF BIO-MECHANICS

In sport and exercise, bio-mechanics refers to the study of human movements, including the interaction between the athlete, sport equipment and the exercise environment. Athletes are always trying to find ways to get faster, higher and stronger with minimal injury

Q ANGLE :
An understanding of the normal anatomical and bio-mechanical features of the patello-femoral joint is essential to any evaluation of knee function. The Q angle formed by the vector for the combined pull of the quadriceps femoris muscle and the patellar tendon, is important because of the lateral pull it exerts on the patella.

The direction and magnitude of force produced by the quadriceps muscle has great influence on patellofemoral joint biomechanics. The line of force exerted by the quadriceps is lateral to the joint line mainly due to large cross-sectional area and force potential of the vastus lateralis. Since there exists an association between patellofemoral pathology and excessive lateral tracking of the patella, assessing the overall lateral line of pull of the quadriceps relative to the patella is a meaningful clinical measure. Such a measure is referred to as the Quadriceps angle or Q angle. It was initially described by Breaststroke

USE OF BIOMECHANICS FOR SPORTS AND EXERCISE
Sports biomechanics studies human motion during exercise and in sports. Physics and the laws of mechanics are applied to athletic performance. Biomechanics can be applied to individuals, analyzing their movements and coaching them for more effective movement during exercise and sports movement.

INJURIES DUE TO INCORRECT BIO-MECHANICS :

Sport	Technique	Injury
Cricket	Mixed bowling action	Pars inter_ articularis stress fractures
Tennis	Excessive wrist action with backhand	Extensor tendinopathy of the elbow
Swimming	Decreased external rotation of the shoulder	Rotator cuff tendino pathy
Running	Anterior pelvic tilt	Hamstring injuries
Rowing	Change from bow side to Change from bow side to	rib stress fracture
Ballet	Poor turnout	Hip Injuries

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Your skin has tiny holes called pores that can become blocked by oil, bacteria, dead skin cells, and dirt. When this occurs, you may develop a pimple or “zit.” If your skin is repeatedly affected by this condition, you may have acne.

According to the American Academy of Dermatology, acne is the most common skin condition in the U.S. Although acne isn’t a life-threatening condition, it can be painful, particularly when it’s severe. It can also cause emotional distress.

Acne that appears on your face can affect your self-esteem and, over time, may cause permanent physical scarring.

There are many effective treatments for acne that reduce both the number of pimples you get and your chance of scarring.

Acne is a skin condition that occurs when your hair follicles become plugged with oil and dead skin cells. It causes whiteheads, blackheads or pimples. Acne is most common among teenagers, though it affects people of all ages.

Effective acne treatments are available, but acne can be persistent. The pimples and bumps heal slowly, and when one begins to go away, others seem to crop up.

Depending on its severity, acne can cause emotional distress and scar the skin. The earlier you start treatment, the lower your risk of such problems.

Causes

Four main factors cause acne:

• Excess oil (sebum) production
• Hair follicles clogged by oil and dead skin cells
• Bacteria
• Inflammation

Acne typically appears on your face, forehead, chest, upper back and shoulders because these areas of skin have the most oil (sebaceous) glands. Hair follicles are connected to oil glands.

The follicle wall may bulge and produce a whitehead. Or the plug may be open to the surface and darken, causing a blackhead. A blackhead may look like dirt stuck in pores. But actually the pore is congested with bacteria and oil, which turns brown when it’s exposed to the air.

Pimples are raised red spots with a white center that develop when blocked hair follicles become inflamed or infected with bacteria. Blockages and inflammation deep inside hair follicles produce cystlike lumps beneath the surface of your skin. Other pores in your skin, which are the openings of the sweat glands, aren’t usually involved in acne.

Certain things may trigger or worsen acne:

• Hormonal changes. Androgens are hormones that increase in boys and girls during puberty and cause the sebaceous glands to enlarge and make more sebum. Hormone changes during midlife, particularly in women, can lead to breakouts too.
• Certain medications. Examples include drugs containing corticosteroids, testosterone or lithium.
• Diet. Studies indicate that consuming certain foods — including carbohydrate-rich foods, such as bread, bagels and chips — may worsen acne. Further study is needed to examine whether people with acne would benefit from following specific dietary restrictions.
• Stress. Stress doesn’t cause acne, but if you have acne already, stress may make it worse.

Acne myths

These factors have little effect on acne:

• Chocolate and greasy foods. Eating chocolate or greasy food has little to no effect on acne.
• Hygiene. Acne isn’t caused by dirty skin. In fact, scrubbing the skin too hard or cleansing with harsh soaps or chemicals irritates the skin and can make acne worse.
• Cosmetics. Cosmetics don’t necessarily worsen acne, especially if you use oil-free makeup that doesn’t clog pores (noncomedogenics) and remove makeup regularly. Nonoily cosmetics don’t interfere with the effectiveness of acne drugs.

Symptoms

Acne signs vary depending on the severity of your condition:

• Whiteheads (closed plugged pores)
• Blackheads (open plugged pores)
• Small red, tender bumps (papules)
• Pimples (pustules), which are papules with pus at their tips
• Large, solid, painful lumps under the skin (nodules)
• Painful, pus-filled lumps under the skin (cystic lesions)

Acne usually appears on the face, forehead, chest, upper back and shoulders.

When to see a doctor

If self-care remedies don’t clear your acne, see your primary care doctor. He or she can prescribe stronger medications. If acne persists or is severe, you may want to seek medical treatment from a doctor who specializes in the skin (dermatologist or pediatric dermatologist).

For many women, acne can persist for decades, with flares common a week before menstruation. This type of acne tends to clear up without treatment in women who use contraceptives.

In older adults, a sudden onset of severe acne may signal an underlying disease requiring medical attention.

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The Food and Drug Administration (FDA) warns that some popular nonprescription acne lotions, cleansers and other skin products can cause a serious reaction. This type of reaction is quite rare, so don’t confuse it with any redness, irritation or itchiness that occurs in areas where you’ve applied medications or products.

Seek emergency medical help if after using a skin product you experience:

• Faintness
• Difficulty breathing
• Swelling of the eyes, face, lips or tongue
• Tightness of the throat

Complications

People with darker skin types are more likely than are people with lighter skin to experience these acne complications:

• Scars. Pitted skin (acne scars) and thick scars (keloids) can remain long-term after acne has healed.
• Skin changes. After acne has cleared, the affected skin may be darker (hyperpigmented) or lighter (hypopigmented) than before the condition occurred.

Risk factors

Risk factors for acne include:

• Age. People of all ages can get acne, but it’s most common in teenagers.
• Hormonal changes. Such changes are common during puberty or pregnancy.
• Family history. Genetics plays a role in acne. If both of your parents had acne, you’re likely to develop it too.
• Greasy or oily substances. You may develop acne where your skin comes into contact with oil or oily lotions and creams.
• Friction or pressure on your skin. This can be caused by items such as telephones, cellphones, helmets, tight collars and backpacks.

How is acne diagnosed?

If you have symptoms of acne, your doctor can make a diagnosis by examining your skin. Your doctor will identify the types of lesions and their severity to determine the best treatment.

How is acne treated?

At-home care

There are a few self-care activities you can try at home to prevent pimples and clear up your acne. Home remedies for acne include:

• cleaning your skin daily with a mild soap to remove excess oil and dirt
• shampooing your hair regularly and keeping it out of your face
• using makeup that’s water-based or labeled “noncomedogenic” (not pore-clogging)
• not squeezing or picking pimples, which spreads bacteria and excess oil
• not wearing hats or tight headbands
• not touching your face

Medication

If self-care doesn’t help with your acne, a few over-the-counter acne medications are available. Most of these medications contain ingredients that can help kill bacteria or reduce oil on your skin. These include:

• Benzoyl peroxide is present in many acne creams and gels. It’s used for drying out existing pimples and preventing new ones. Benzoyl peroxide also kills acne-causing bacteria.
• Sulfur is a natural ingredient with a distinctive smell that’s found in some lotions, cleansers, and masks.
• Resorcinol is a less common ingredient used to remove dead skin cells.
• Salicylic acid is often used in soaps and acne washes. It helps prevent pores from getting plugged.

Sometimes, you may continue to experience symptoms. If this happens, you may want to seek medical advice. Your doctor can prescribe medications that may help reduce your symptoms and prevent scarring. These include:

• Oral or topical antibiotics reduce inflammation and kill the bacteria that cause pimples. Typically, antibiotics are only used for a short time so that your body doesn’t build up a resistance and leave you prone to infections.
• Prescription topical creams such as retinoic acid or prescription-strength benzoyl peroxide is often stronger than over-the-counter treatments. They work to reduce oil production. Benzoyl peroxide serves as a bactericidal agent that prevents the resistance of acne-causing bacteria to antibiotics. It also has moderate comedone-destroying and anti-inflammatory properties.

Women with hormonal acne may be treated with birth control pills or spironolactone. These medications regulate hormones that can cause acne through a decrease in oil production.

Isotretinoin (Accutane) is a vitamin-A-based medication used to treat certain cases of severe nodular acne. It can cause serious side effects, and it’s only used when other treatments don’t work.

Your doctor may recommend procedures to treat severe acne and prevent scarring. These procedures work by removing damaged skin and reducing oil production. They include:

• Photodynamic therapy uses medication and a special light or laser to reduce oil production and bacteria. Other lasers may be used alone to help improve acne or scarring.
• Dermabrasion removes the top layers of your skin with a rotating brush and would be best for treating acne scarring as opposed to a treatment for acne. Microdermabrasion is a milder treatment that helps remove dead skin cells.
• A chemical peel removes the top layers of your skin. That skin peels off to reveal less damaged skin underneath. Chemical peels can improve mild acne scarring.
• Your doctor may suggest using cortisone injections if your acne consists of large cysts. Cortisone is a steroid naturally produced by your body. It can reduce inflammation and speed healing. Cortisone is usually used along with other acne treatments.

What is the outlook for someone with acne?

Treatment for acne is often successful. Most people can expect their acne to begin clearing up within six to eight weeks. However, flare-ups are common and may require additional or long-term treatment. Isotretinoin is the treatment most likely to provide permanent or long-term positive results.

Acne scarring can cause emotional distress. But, prompt treatment can help prevent scarring. Also, your dermatologist will have treatment options designed to treat scarring.

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