PENGELOLAAN FISIOTERAPI PADA

SHOULDER IMPINGEMENT
SYNDROME

Oleh: Sugijanto,
Disampaikan pada: Webinar Perfi CAB JAKARTA BARAT
OKTOBER 2021
Sugijanto 2021
 SHOULDER IMPINGEMENT SYNDROME

• Shoulder impingement syndrome adalah kondisi nyeri anggota atas

akibat penyempitan structural dari subacromial space (Creech and Silver,
2021)
• SIS terjadi ketika myotendinous junction dari rotator cuff, paling sering
tendon supraspinatus kontak dengan permukaan bawah acromion, a
subacromial spur, or penebalan AC joint (Sapp, 2021)
• External shoulder impingement syndrome:
• Jepitan jaringan subacromial oleh head of humerus dan acromion
• Internal shoulder impingement syndrome:
• Jepitan humerus dengan tepian glenoid

Sugijanto 2021
 SHOULDER PAIN AND DISABILITIES
- The incidence in the Dutch primery care is 15 - 25 per 1000
- The primairy cause of nocisensoric of shoulderpain is mostly
localized in the rotatorcuff tendon.
- 75% of the non-traumatic shoulderpain is diagnostic as an
impingement syndrome.

Luime , Koes , Verhagen, SJR. 2004

Sevinsky S, 2004
 Shoulder
Impingement
syndromes

External Internal
Impingement Impingement

Primer Sekunder

Cools e.a.2008

Sugijanto, 2021
 Shoulder
Impingement
syndromes

External Internal
Impingement Impingement

Primer Sekunder

Impingemnet terhadap Impingement antara caput

jar. lunak sub acromial humerus dan tepi glenoid.

Cools e.a.2008

Sugijanto, 2021
 Shoulder
Impingement
syndromes

External Internal
Impingement Impingement

Primer Sekunder

Cuff pathology Scapular

GIRD
dyskinesia
SLAP GH
lesion Instability

Cervical
Thoracal spine
spine Costa I – XII,
ACJ, SCJ
Sugijanto, 2021
Fisioterapi profesional

Sugijanto, 2021
 BAGAIMANA ANDA MENGANALISIS ICD
DALAM ICF?
• APAKAH JARINGAN SPESIFIK DAN MEKANIK
YANG TERGANGGU PADA SHOULDER
1. IMPINGEMENT?
Environment
Person

DISEASE / DISORDER
ICD / ICPC
• APAKAH KETERBATASAN AKTIVITAS DAN
HAMBATAN PARTISIPASI PADA SHOULDER
functions / anatomical
characteristics
(Impairments)
(limitations in)
activities
(restrictions in)
participation
2. IMPINGEMENT?
FUNCTIONING
external factors personal factors
• APAKAH FAKTOR INTERNAL DAN EKSTERNAL
YANG BERPENGARUH TERHADAP
3. PENYEMBUHAN PADA SHOULDER IMPINGEMENT?

• Use of the ICF Model as a Clinical Problem-Solving Tool in Physical Therapy and
Rehabilitation Medicine (Steiner et al, 2002)
Sugijanto, 2021
PERTANYAAN NO 1 TENTANG ANALISIS ICD KE
DALAM ICF
Bagaimana meng analisis patologi penyakit (disease = ICD) ke dalam
gangguan gerak dan fungsi sesuai ICF
• Pada shoulder impingement syndrome?
• Body structure impairment: Muscle? Capsules?
• Body function impairment: Painful arc? Joint stability? Scapular
dyskinesis?
• Activity limitation: ADL? Hand activities?
• Participation restriction: Work? Sport?
• Contextual factors? DM?

Sugijanto, 2021
 BODY STRUCTURE (ANATOMICAL)
ASPECT
Tulang & persendian pembentuk shoulder complex:
• Scapula dengan glenoid cavity bersedi dengan humerus dan
acromion bersendi dengan claviculae serta dengan thoracis
• Humerus dengan caput humeri bersendi dengan glenoid cavity
sebagai sendi Glenohumeral joint
• Clavicula bersendi dengan acromion sebagai acromioclavicular
joint
• Sternum bersendi dengan clavicula sebegai sternoclavicular joint
• Costae bersendi dengan scapula sebagai scapulothoracic “joint”
dan bersendi dengan vertebra sebagai costo vertebral-transversal
• Cervicothoracic junction secara tak langsung melalui otot terlibat
gerak shoulder complex
Sugijanto, 2021
 GLENOHUMERAL JOINT
• Persendian:
• Glenoid cavity cekung landai dengan tepian
labrum bersendi dengan head of humerus bulat.
• Glenoid cavity posisi menghadap sedikit keatas
depan sehingga humerus sedikit menumpang
• G-H joint capsules
• Anterior: tebal dengan 3 ligament glenohumeral
lig.
• Inferior: membentuk lipatan longgar
• Posterior: lebih tipis
• Mobilitas luas
• Fleksi-ekstensi: S 1800 /00/600
• Abduksi-adduksi: F 1800 /00/450
• Rotasi internal-eksternal: T 950/00/850
Sugijanto, 2021
 GLENOHUMERAL JOINT (lanjutan)

• Stabilitas dibentuk oleh otot cuff muscles, L H biceps,

deltoid, pectoral m, latissimus (struktur neural) disamping
oleh system capsule-ligament (mekanis)
• Stabilitas sendi oleh “muscle stiffness” melalui gamma-
muscle spindle system.

Sugijanto, 2021
ACROMIOCLAVICULAR JOINT

• AC Joint mobility:
• Elevasi-depresi, dan
• Protraksi-retraksi,
• Hypomobility menimbulan penyimpangan gerak
scapulohumeral → impingement
• AC Joint stability:
• AC capsule
• Coracoclavicular lig.
• Costoclavicular lig
• Ligament laxity menimbulan penyimpangan gerak
scapulohumeral → impingement
• AC Joint Instability test:
• Palpasi untuk mengetahui dislokasi acromion dan ujung distal
clavicle dan beri tekanan 4 arah
• Penebalan AC joint dan osteophyte menimbulkan
impingement.
Sugijanto, 2021
 STERNOCLAVICULAR JOINT

• SC Joint mobility:
• Elevasi-depresi:
• Protraksi-retraksi:
• SC Joint stability:
• SC joint capsule
• Interclavicular lig.
• Claviculocostal lig.
• SC Joint Instability test:
• Lakukan tekanan pada SC joint ke anterior, superiorl dan
inferior
• Determine stability or pain associated with a joint sprain

Sugijanto, 2021
 SCAPULOTHORACIC ‘JOINT’
• Scapulothoracic Joint mobility
• Elevasi-depresi
• Abduksi-adduksi
• Rotasi keatas-kebawah
• Scapulothoracic Joint stabibility
• Sepenuhnya oleh otot
• Scapulothoracic Joint movement impairment
(dyskinesis)
1. Scapular winging
2. Capular shrugging
3. Scapular winging,
• Ketiganya menimbulkan penyimpangan gerak →
impingement

Sugijanto, 2021
Mobility shoulder – shouldergirdle – CTO
(Stenvers)
Sugijanto, 2021
NYERI BERASAL DARI JARINGAN
SPESIFIK (ANATOMIS)
Wound healing process

Inflammation Nosisensoric sensitization

Hypoxia necrosis
Ischemic
SPECIFIC Inflammation necrosis
TISSUE Connective tissue Cross links
Adhesion
Myofibrile Tightness

Acidosis Erosi - Lysis necrosis

Sensitization Hiperalgesia
Sugijanto 2021
 PERTANYAAN NO 2 TENTANG NYERI
• Apakah patologi/impairment yang dapat menimbulkan sensasi
nyeri kompleks bahu?
• Bagaimana membuktikan nyeri berasal dari inflamasi jaringan
otot? Contoh pada m. supraspinatus tears?
• Bagaimana membuktikan nyeri berasal dari iritasi osteofit sendi
acromioclavicular? Contoh cuff tendinitis oleh osteofit ACJ?
• Bagaimana membuktikan nyeri berasal dari instabilitas
glenohumeral joint? Contoh subacromial impingement akibat
glenohumeral anterior instability?
Sugijanto, 2021
 BODY STRUCTURE IMPAIRMENT ASSESSMENT & INTERVENTION

Jar. tubuh Tes intervensi Modalitas, Metode dan teknik

Joint Passive test Joint mobilization US/SWD contra planar, CPM
capsules Joint play stretching Mulai traksi osilasi MLPP,
movement test Joint stabilization End range static traction / glide
Stability test end range mobilization,
Roll glide
Mobilization with movement
Sugijanto, 2021
 SISTEM CAPSULOLIGAMENTAIR

• Sisten capsule-ligamentair yang berpengaruh pada shoulder

impingement:
• Glenohumeral anterior instability
• Glenohumeral superior capsule tightness
• AC joint hypomobility
• AC joint instability
• SC joint hypomobility
• CTJ joint hypomobility

Sugijanto, 2021
PERTANYAAN NO 3 TENTANG KAPSUL SENDI

• Apakah keluhan pasien bila penyebab gangguan adalah

kelemahan (laxity) kapsul sendi glenohumeralis? Apa tes untuk
membuktikannya?
• Apakah keluhan paien bila penyebab kontraktur kapsul sendi
glenohumeralis? Apa tes untuk membuktikannya?

Sugijanto, 2021
 MUSCULAR

Sisten neuromuscular yang berpengaruh pada

shoulder impingement:
• Semua otot yang melekat pada:
• Scapula dan humerus
• Scapula dan costae
• Scapula dan vertebra
• Humerus dan costae
• Humerus dzn vertebra
• Otot stabilizator trunki

Sugijanto, 2021
 MUSCULAR
• Deltoid m.
• Trapezius:
• Upper
• Middle
• Lower
• Levator scapulae
• Teres mayor
• Rhomboid mayor & minor
• Latissimus dorsi
• Pectoralis mayor
• Pectoralis minor

Sugijanto, 2021
MUSCULAR: CUFF MUSCLE
1. Supraspinatus
• Memulai abduksi
• Paling sering cidera
2. Infraspinatus
3. Teres Minor
• Keduanya rotasi eksternal humerus
4. Subscapularis
• Rotasi internal humerus

Sugijanto, 2021
 BODY STRUCTURE IMPAIRMENT ASSESSMENT & INTERVENTION

Jar. tubuh Tes intervensi Modalitas, Metode dan teknik

Muscle Isometric test Muscle relaxation MWD, SWD coplanar, US parallel application
Palpasi Muscle release Jacobson’s relaxation exercise,
Contract relax stretch Muscle mobilization Ischemic compression technique, Myofascial release,
test Muscle stretching Muscle energy technique,
Strength test Strengthening ES under tension
Static-/eccentric stretching/ contract relax stretching,
Nerve electrical stimulation,
PRE, PNF, de Lorme, endurance training
Sugijanto, 2021
PERTANYAAN NO 4 BODY STRUCTURE: OTOT
SHOULDER COMPLEX

• Apakah jenis keluhan (anamnesis) yang berasal dari jaringan rotator

cuff muscle?
• Bagaimana membuktikan nyeri berasal dai jaringan otot subscapular
tendon?
• Bagaimana membuktikan nyeri berasal dari pemendekan otot levator
scapula?
• Bagaimana membuktikan nyeri berasal dari kelemahan otot serratus
anterior?

Sugijanto, 2021
BODY FUNCTION IMPAIRMENT
• PAIN  Balance
• PAIN IN REST
◦ Sitting disbalance
• PAIN IN MOVEMENT
• REFERRED PAIN ETC ◦ Standing disbalance
• JOINT MOBILITY: ◦ Walking disbalance,
• ANKYLOSING etc
• HYPOMOBILITY  Gait:
• JOINT BLOCKADE
◦ Antalgic gait
• JOINT STABILITY:
◦ Duchene gait
• HYPERMOBILITY
• INSTABILITY
◦ Trendelen burg gait, etc
• MUSCLE PERFORMANCE:  Hand function:
• MUSCLE WEAKNESS ◦ Grip weakness
• MUSCLE PARESIS ◦ Prehension disability, etc
Sugijanto 2021
 POSTURE OF THE SHOULDER
• Anterior position of the head of humerus
• Penyimpangan posisi (positional vault) yang
paling banyak ditemui
• Banyak pada shoulder impingement
• Penyi mpangan posisi memulai kesalahan
gerak
• Superior position of the head of humerus
• Sub acromial space yang sempit penyebab
utama shoulder impingement

Sugijanto 2021
 Dynamic Shoulder Stabilizers
• Group I
• Origo vertebra dengan insersi humerus
• Latissimus dorsi, pectoralis major
• Group II
• Origo Scapulae
• Deltoid, teres major, coracobrachialis
• Subscapularis, teres minor, supraspinatus, infraspinatus
• Short rotators (rotator cuff) integrated into joint capsule
• Rotator bersama biceps membentuk stabilisasi dinamis, mencega
loslokasi humerus
• Rotator cuff membentuk beberapa gaya yang menjaga tekanan
humerus terhadap glenoid mencegah gerak luncur berlebih
• Dynamic equilibrium
• Imbalances menyebabkan mekanis abnormal → impingement
Sugijanto, 2021
 Static Stabilizers
• Glenohumeral ligaments
• Anterior glenohumeral ligament membatasi ekstensi, abduksi dan
rotasi eksternal
• Posterior glenohumeral ligament membatasi ekstensi dan rotasi
eksternal n
• Inferior glenohumeral ligament
• Membatasi abduksi, ekstensi dan rotasi eksternal
• Critical for overhead stabilization
• Joint capsule
• Rotator cuff tendons menghasilkan dynamic capsular tightening
• Tegangan terbesar saat rotasi internal
• Laxity capsul dan ligament menimbulkan instabilitas → impingement
• Labrum
• Increases glenoid depth approximately two times
• Tilted superiorly 5 degrees to assist in inferior glenohumeral stability

Sugijanto, 2021
 Stability in Shoulder Joint

• Maintaining stability of the shoulder complex while allowing for a

high degree of mobility is critical for normal shoulder function
• Instability is often the cause of many specific shoulder injuries
• While the GH joint is inherently unstable the coordinated and
synchronous actions of the static and dynamic stabilizers provide joint
stability

Sugijanto, 2021
JOINT MOTIONS
Joint
Laxity hypermobility
Ligamenter-
Capsular Rupture Instability

Hypermobility & Bony- structure Deformity

instability
Weakness
Active
Tendomuscular hypermobility
Rupture

Positional vault Active

Movement
hypermobility
impairment
Movement deviation Sugijanto 2021
Functional / mechanic
• Scapulohumeral Rhythm (Freivald A, 2004)
• Gerak relative scapula terhadap humerus
• Awal 300 G-H abduction
• Tidak berhubungan degan gerak scapula
• Setting phase
• 300 - 900 G-H abduction
• Scapula abd dan rotasi keatas 10 tiap 20 elevasi humerus
• Diatas 900 G-H abduction
• Scapula dan humerus gerak dengan rasio 1:1

Sugijanto, 2021
PERAN SINERGI OTOT SHOULDER COMPLEX
Scapulohumeral Rhythm
• Sinergi otot shoulder complex sebagai stabilisator
dan penggerak utama menghasilkan gerak sinkon,
dan kordinatif

Sugijanto, 2021
 PENYIMPANGAN SCAPULOHUMERAL RHYTHM
• Bila pada awal gerak abduksi bahu tidak mampu kelemahan m. supraspinatus
• Bila rasio gerak humerus : scapula terbalik dikenel sebagai Reverse Humeroscapular
Rhythm, penyimpangan gerak khas pada frozen shoulder
• Bila terasa nyeri/menyimpang pada abduksi 600 – 1200 dikenal sebagai painful arc,
merupakan gejala khas subacromial impingement
• Bila timbul bunyi clicking (& nyeri) pada abduksi 600 – 1200 dikenal sebagai
pianophenomen akibat subluksasi aromioclavicular joint
• Bila pada abdulsi 1600 – 1800 timbul nyeri dikenal sebagai ACJ/SCJ painful arc,
akibat patologi (OA) sendi tersebut
• Bila hiper abduksi semutan pada tangan dikenal sebagai hyper abduction syndrome
akibat pemendekan m. pectoralis minor
Sugijanto 2021
PERTANYAAN NO 5 TENTANG PENYIMPANGAN
GERAK BAHU

• Apakah penyimpangan gerak yang terjadi pada painful arc?

Apa penyebabnya?
• Apakah penyimpangan gerak yang terjadi pada scapular tiping?
Apa penyebabnya?
• Apakah penyimpangan gerak yang terjadi pada reverse
scapulohumereal rhythm? Apa penyebabnya?

Sugijanto, 2021
Sugijanto 2021
ICD: THE YOUNG, ADULT AND OLDER SHOULDER
PATIENT

Sugijanto 2021
 NCCI Research Brief:
Thinking About the Aging Workforce (Restrepo 2005)

Lost-Time Frequency Ranks by Age for the Top 10 Diagnosis Codes Sugijanto, 2021
SHOULDER PAIN AND DISABILITIES
- Merupakan keluhan muskuloskeletal ke 3
- Penyebab utama shoulder pain kebanyakan dari
rotatorcuff tendon.

- 75% non-traumatic shoulderpain di diagnosis

impingement syndrome.

Luime , Koes , Verhagen, SJR. 2004

Sugijanto, 2021
SHOULDER EXTERNAL IMPINGEMENT

• CUFF PATHOLOGY PADA

EXTERNAL IMPINGMENT
• Supraspinatus
• Infraspinatus
• Subscapularis
• Long head Biceps tendon
• Subacromial bursa

Sugijanto 2021
SHOULDER EXTERNAL IMPINGEMENT
PATOMEKANIK PENYEBAB IMPINGMENT
• Penyempitan subacromial space:
• Supraspinatus tightness
• Superior capsule contracted
• Long head Biceps tendon
• Anterior position of the head of humerus
• Posterior capsule laxity
• Pectoralis mayor tightness
• Subscapular tightness
• Scapular dyskinesis
• Scapular tiping
• Scapular winging
• Scapular shrugging
• Glenohumeral joint instability
• Anterior instability
• Penebalan/osteophyte AC joint
• Menyebabkan gerusan langsung saan gerak GH joint
Sugijanto 2021
 CLINICAL
Nyeri pada bahu
REASONING
Impingement syndrome
FUNGSI DAN DISABILITAS Contextual factors

Internal External
Anatomic impairment factors factors

Cuff muscle SLAP

Bursa Lesion
AC
Joint subacromial Pectoralis minor,
Capsule/ Participation
levator scapulae Functional Activity
lig laxity restriction
impairment limitation
osteophyte
Serratus anterior

Inflamation- Tightness
Supraspinatus calc formation
GH
Weakness Instability
Subscapularis, Over head Work
infraspinatus,
activity
Internal
Inflamation Scapular impingement
dyskinesis Carrying Sport
Inflamation
Tight- Lifting Recreation
hypertrophy

External The used of

impingement arm in ADL
Shoulder pain
Sugijanto 2021
 MENGANALISIS DARI ICD KE ICF, CONTOH: SHOULDER
IMPINGEMENT (ICD)
Jaringan apa yg Fungsi Keterbatasan Hambatan Prognosis factors
terganggu? (mekanik) apa aktivitas berpartisipasi Internal Eksternal
yg terganggu? (sosial)
Hypertrophy-
tight
m.supraspinatus
Capsular/ligam
ent laxity
Tigthness/weak
ness pd otot
scapula
Penebalan
capsule AC joint/
Osteophyte

Sugijanto 2021
 MENGANALISIS DARI ICD KE ICF, CONTOH: SHOULDER
IMPINGEMENT (ICD)
Jaringan apa yg Fungsi Keterbatasan Hambatan Prognosis factors
terganggu? (mekanik) apa aktivitas berpartisipasi Internal Eksternal
yg terganggu? (sosial)
Hypertrophy- Posisi head of
tight humerus tinggi
m.supraspinatus
Capsular/ligam Glenohumeral
ent laxity instability
Tigthness/weak Scapular
ness pd otot dyskinetic
scapula
Penebalan Hypomobility
capsule AC joint/ ACJ, Painful arc
Osteophyte

Sugijanto 2021
 MENGANALISIS DARI ICD KE ICF, CONTOH: SHOULDER
IMPINGEMENT (ICD)
Jaringan apa yg Fungsi Keterbatasan Hambatan Prognosis factors
terganggu? (mekanik) apa aktivitas berpartisipasi Internal Eksternal
yg terganggu? (sosial)
Hypertrophy- Posisi head of Nyeri aktivitas
tight humerus tinggi angkat lengan
m.supraspinatus
Capsular/ligam Glenohumeral Nyeri aktivitas
ent laxity instability tertentu pd
Tigthness/weak Scapular posisi lengan
ness pd otot dyskinetic tertentu
scapula
Penebalan Hypomobility Terbatas & Nyeri
capsule AC joint/ ACJ, Painful arc full ROM
Osteophyte Nyeri gerak
lengan
Sugijanto 2021
 MENGANALISIS DARI ICD KE ICF, CONTOH: SHOULDER
IMPINGEMENT (ICD)
Jaringan apa yg Fungsi Keterbatasan Hambatan Prognosis factors
terganggu? (mekanik) apa aktivitas berpartisipasi Internal Eksternal
yg terganggu? (sosial)
Hypertrophy- Posisi head of Nyeri aktivitas Bekerja,
tight humerus tinggi angkat lengan olah raga
m.supraspinatus ataupun
Capsular/ligam Glenohumeral Nyeri aktivitas rekreasi
ent laxity instability tertentu pd menggunakan
posisi lengan tangan
Tigthness/weak Scapular
ness pd otot dyskinetic tertentu
scapula
Penebalan Hypomobility Terbatas & Nyeri
capsule AC joint/ ACJ, Painful arc full ROM
Osteophyte Nyeri gerak
lengan
Sugijanto 2021
 MENGANALISIS DARI ICD KE ICF, CONTOH: SHOULDER
IMPINGEMENT (ICD)
Jaringan apa yg Fungsi Keterbatasan Hambatan Prognosis factors
terganggu? (mekanik) apa aktivitas berpartisipasi Internal Eksternal
yg terganggu? (sosial)
Hypertrophy- Posisi head of Nyeri aktivitas Bekerja, Motivasi sembuh Apatis
tight humerus tinggi angkat lengan olah raga tinggi Memiliki
m.supraspinatus ataupun Kesehatan fisik komorbid: DM,
baik Sakit jantung, dll
Capsular/ligam Glenohumeral Nyeri aktivitas rekreasi
Peralatan rumah Lingkungan
ent laxity instability tertentu pd menggunakan tangga rumah
posisi lengan tangan ergonomis menghambat
Tigthness/weak Scapular
ness pd otot dyskinetic tertentu
scapula
Penebalan Hypomobility Terbatas & Nyeri
capsule AC joint/ ACJ, Painful arc full ROM
Osteophyte Nyeri gerak
lengan
Sugijanto 2021
 NYERI DARI OTOT &TENDON

Weakness Atrophy

Strain/ Inflammation Nyeri diam

rupture
Muscle Nyeri
MUSCLE- spasm kontraksi
TENDON
Tightness/
Nyeri regang
Contracture

Myofascial Nyeri regang

Immobilsation Adhesion
contracture
Sugijanto 2021
 MUSCLE &TENDON
Painful arc Isometric abd test

Supraspinatus Palpation in borgol

tendon

Painful arc Isometric ext rot

Infrapinatus
tendon Palpation in sphinx
MUSCLE-
TENDON
Subsapular
Painful arc Isometric ext rot
tendon
Palpation in sphinx

Long head biceps Painful arc Isometric int rot

tendon
Palpation in netral
Sugijanto 2021
TENDON SUPRASPINATUS
EVIDENCE BASE TEST
• Drop arm test
• Empty can test
• Abduction resisted test
• Palpasi posisi borgol

Sugijanto 2021
 TENDON SUBSCAPULARIS

EVIDENCE BASE TEST

• Abdominal press test
• Internal rotation resisted test
• Palpasi posisi netral → medial sulcus
bicipitalis

Sugijanto 2021
TENDON INFRASPINATUS

• External rotation lag sign

• Isometrik rotasi eksternal
• Palpasi posisi sphynx

Sugijanto 2021
 SCAPULAR DYSFUNCTION
Tipping ACCORDING TO KIBLER
Winging
Shrugging

Type 3 dyskinesie
Prominentie angulus
superior scapulae
Type 2 dyskinesie mediorotatiestand
Prominentie margo “shrugging”
Type 1 dyskinesie medialis scapulae “winging
Prominentie angulus
inferior “tipping” The Role of Scapulothoracic Dyskinesis, Johnson et al, 2003
Sugijanto 2021
 Abduction- Palpation lower angel on
Scapular Tippng
elevation the scapula

Contract relax stretch test of

pectoralis minor m

SCAPULAR Scapular Abduction- Palpation to medial

DYSKINESIS winging elevation margin

Strength test for serratus

anterior m

Scapular Abduction- Palpation to medial

shrugging elevation margin of the scapula

CRS Levator scapular m

Sugijanto 2021
 PATTERNS OF SCAPULAR DYSKINESIS
• Type I Scapular tiping = abnormal motion
around a horizontal axis so that the
scapula has abnormal anterior tilt; the
clinical manifestation is prominence of the
inferior medial scapular border on arm
motion.
Kibler WB. Management of the scapula in glenohumeral
instability. Techniques in Shoulder & Elbow Surgery 4(3): 89-98,
September 2003.

Sugijanto 2021
 PATTERNS OF SCAPULAR DYSKINESIS
• Type II Scapular winging = abnormal
motion around a vertical axis so that
the scapula has abnormal lateral or
external rotation; the clinical
manifestation is prominence of the
entire medial scapular border.

Sugijanto 2021
 PATTERNS OF SCAPULAR DYSKINESIS

• Type III Scapular shrugging = abnormal

motion around a sagittal axis so that the
medial scapula translates superiorly and
the lateral scapula translates inferiorly; the
clinical manifestation is prominence of the
superior medial border.

Sugijanto 2021
 ANALISIS SCAPULAR WINGING DAN
GLENOHUMERAL INTERNAL ROTATION

• Menggambarkan lemahnya posture scapulae.

• Mengindikasikan postur dada tegang, protraksi
girdle dan lemahnya otot mid-back.
• Merupakan predisposisi timbulnya keluhan kronik
rotator cuff tendons, mid-back, shoulder, dan neck
pain
• Internal glenohumeral rotation menggambarkan
hyperkyphosis dan scapular winging.
Glenohumeral internal rotation deficit inthe asymptomatic professional pitcher and its
relationship to humeral retroversion, Tokish et al, 2008, Sugijanto 2021
UPPER TRAPEZIUS PERFORMANCE

• Test in shortened length (break test)

• If cannot hold in test position 10-15 =
long upper trapezius
• If cannot hold in whole range – weak

Sugijanto 2021
LEVATOR SCAPULAR SHORTEN

• Saat abduksi elevasi terjadi Shrugging

• Contract relax stretch test posisi abduksi
glenohumeral positif

Sugijanto 2021
SERRATUS ANTERIOR

• Fleksi 110 protraksi scapula dan lakukan

break test
• Bila tidak dapat bertahan dalam posisi tes
10-15 → long SA
• Bila tidak dapat bertahan dalam seluruh
range → weakness

Sugijanto 2021
 SCAPULA TILTED/TIPPED

• Angulus inferior menonjol keluar dari rib cage

• Anterior scapular tilt > 10
• Shorthened pectoralis minor
• Shorthened anterior deltoid and/or
coracobrachialis: correct scapula - shoulder still
flexed

Sugijanto 2021
PECTORALIS MINOR SHORTHENING

• Bila posisi acromion posterior lebih 1 inchi dari

bed.
• Contract relax stretch test

Sugijanto 2021
GLENOHUMERAL INSTABILITY
• Joint instability
• Passive instability
• Active instability
• Capsular stretch test
• Apprehension test
• Relocation test (Load and sift test)
• Isometric stability test

Sugijanto 2021
 ANTERIOR AND POSTERIOR
APPREHENSION TESTS
• Anterior Apprehension Test
• Posisi awal glenohumeral abd
900, elbow flex 900, tes gerak
rotasi eksternal dan dorong
humerus ke anterior.
• Posterior Apprehension Test
• Posisi awal ‘arm cross’ dilakukan
dorongan ke posterior

Sugijanto 2021
 RELOCATION TEST

• Tes 1: pada posisi awal rotasi eksternal, lakukan

reposisi glenohumerl. Positif bila berulang kembali
posisi awal
• Tes 2: Mulai tes gerak rotasi eksternal kemudian
rotasi internal diukur ROM
• Lanjut dilakukan relokasi glenohumeral dan di
fiksasi, dilakukan gerak rotasi eksternal kemudian
rotasi internal kemudian diukur ROM, positif bila
ROM meningkat.
• Uses external rotation and posteriorly directed
pressure to allow for increased external rotation

Sugijanto 2021
GLENOHUMERAL INTERNAL ROTATION DEFICIT (GIRD)

Burkhart S.S. 2003

• Merupakan movement impairment

• Tidak ada anatomic impairment
• Sleeper exercise
• Anterior position humerus
• Posterior capsule weakness
• Contracture otot subscapulatis dan pectorlis minor
• Positional correction test
Sugijanto 2021
GLENOHUMERAL INTERNAL ROTATION DEFICIT (GIRD)
• Pada movement impairment dilakukan latihan
‘Sleepers stretch’
• Pada posterior ligament laxity

Sleepers stretch

Sugijanto 2021
SLAP LESION

• Slap test
• Athroscopy

Sugijanto 2021
 SLAP LESION
• Slap test
• Athroscopy

Active Compression Test

O Brien’s test

Biceps Load Test

Sugijanto 2021
 Client complain
Body structure
(anatomic) Activities
impairment Non Pathologi/ Limitation
Pathologi
Body Function Participation
(biomechanic) Gangguan Gerak-Fungsi Restriction
impairment
HOAC 2 Assessment E B(C)P

Critical thinking
Clinical
reasoning Clinical
Diagnosis and prediction
Clinical prognosis rule
decision
making
Analisis Strategi perencanaan
Prosedur intervensi

Evaluasi dan
penilaian hasil Sugijanto 2021
 PROSES PELAYANAN FISIOTERAPI
1. HISTORY TAKING

2. INSPEKSI

3. REGIONAL SCREENING &

QUICK TEST

4. REVIEW OF SYSTEM &

RED FLAG

5. ASSESSMENT EVIDENCE BASE

CLINICAL PRACTICE

6. DIAGNOSIS AND FUNCTIONAL

PROGNOSIS

7. PLANING

8. INTERVENTION

9. EVALUATION

10. DOCUMENTATION
Sugijanto 2021
Nyeri bahu dan lengan impingement syndrome
Ha: Shoulder Keluhan nyeri area deltoid,
terutama angkat lengan, crepitasi. Ganti hipotesis
Impingement syndrome
tdk
Ya
Pada tes abduksi elevasi tampak Ganti hipotesis
paiful arc humeroscapular rhythm, tdk
Ya
•Jobe’s test;
•Neer test Pemeriksaan red flag:
H5-7 Penyebab • Hawkin Kennedy test Pancoast tumor, Cervical
impingement •Isometric resisted external rot. tdk instability/disc lesion, dll

EXTERNAL SHOULDER IMPINGEMENT

Glenohumeral INTERNAL SHOULDER IMPINGEMENT
H1: Superior capsel
instability

H1: Supraspinatus H2: Subacromial

H3: Infraspinatus H4: Subscapularis H8: SLAP lesion
Traksi caudal: no pain bursa
and No sulcus sign Abdominal press
Empty can test, External rot
Neer-Hawkin test, Internal rot
Abduksi isometric isometric,
test, Crepitasi isometric, palpasi
dan Palpasi posisi Palpasi posisi
dan palpasi posisi netral
borgol sphynx
Superior capsule posisi ekstensi
contracture penyebab
impingement Tendinitis Subacromial Tendinitis Tendinitis
supraspinatus akibat bursitis akibat infraspinatus akibat subscapularis
impimgement impimgement impimgement impimgement

Scapulothoracal
dyskinetic

Scapular tiping Scapular shrugging Scapular winging Sugijanto 2021

 ASSESSMENT NO 1: ANAMNESIS
MULAI WAWANCARA UNTUK MEMBUKTIKAN DUGAAN PATOLOGI
DILANJUTKAN DUGAAN IMPAIRMENT DAN DISABILITAS

DUGAAN PATOLOGI PERTANYAAN HIPOTESIS Ya/Tdk

Dugaan Shoulder Apakah nyeri bahu ketika mengangkat lengankesamping? Ya
Impingement Apakah nyeri bahu ketika menumpu dengan lengan/tangan? Ya
syndrome Apakah nyeri bahu berkurang ketika lengan disangga? Ya
Ya
Differential diagnosis:
Osteo artritis Cervical Apakah Nyeri dan kaku leher bangun tidur; Tidak
Apakah Posisi tengadah & grk rotasi cervical nyeri/ Tidak
Apakah nyeri meningkat tengadah dan berkurang menunduk Tidak
Frozen shoulder Apakah nyeri dan kaku bahu ketika diputar? Tidak
Apakah berlangsung lama? Misal sebulan-2bulan? Tidak
Tidak
Sugijanto 2021
 ANAMNESIS KHUSUS RANAH GERAK DAN
FUNGSI (ICF)

DUGAAN PERTANYAAN HIPOTESIS Ya/Tdk

IMPAIRMENT
Glenohumeral Apakah nyeri ketika mangangkat lengan? Mendorong atau
muscle tightness menarik barang? Ya
Apakah lebih nyaman ketika lengan ditarik kebawah? Ya
Apakah ada bunyi ujung bahu ketika lengan digerakkan? Ya

Tendiniitis Apakah nyeri ketika mengankat lengan kesamping? Ya

supraspinatus Apakah tidak mampu mempertahanka posisi lengan
terangkat disamping tubuh? Ya

Sugijanto, 2021
 ASSESSMENT NO 2: INSPEKSI

DUGAAN INSPEKSI Ya/Tdk

PATOLOGI
Dugaan Cervical flat (straight neck) Ya
Osteoarthritis Forward head posture Ya
cervical (ICD)
Dugaan shoulder Posisi humerus lebih kedepan dan protraksi? Ya
anteroposition Ya
Dugaan scapular Scapular shrugging? Scapular tipping? Atau Ya
dyskinesis (ICF) scapular winging? ya

Sugijanto 2021
 ASSESSMENT NO 3: REGIONAL
SCREENING & TES ORIENTASI

UNTUK MEMASTIKAN REGIO ASAL PATOLOGI

UNTUK MEMASTIKAN PENYEBAB

PATOLOGI DENGAN TES CEPAT
Sugijanto, 2021
 NECK, SHOULDER & ARM PAIN
Analisis
patologi

Cervical spine Thoracic spine Shoulder Thoracic outlet

muscles tendomuscl
disc Capsules Glenohumeral Positional
fault
Joint surface facet neurovege costoverte bursae
& uncinate
Inflamasi muscle
Myofascial Blockade tightness
osteofit adhesion
Micro Contracture Capsulo-lig
circulation contracture
iritasi radix
tightness
calcification brachial nerve
Iritasi Jar ischemic hipertone
sensitif entrapment

nyeri lokal/
tight contract referal nerve ischemic

Radicular Pseudo fibrosis

pain radicular

Nyeri leher dan lengan

Sugijanto 2021
SCREENING OF THE CERVICAL SPINE AS
THE COUSE OF COMPLAIN
Client came to physiotherapist because of neck pain
refer to arm. Pain and tingling especially when
he/she flexed his/her neck Movement of the cervical
spine added the ‘over pressure’ at:
• Cervical Flexion-extension in upright siting or
standing
• 3D extension to the right and left
• The test positive when provocate the neck-arm pain
during that test

Sugijanto, 2021
THE EXAMINATION TO IDENTIFY THAT
IMPAIRMENT FROM THORACIC SPINE
• Client complain of upper back pain and
sometimes referred to the chest
• Anamnesis:
• Are that provocate by position & movement
of the thoracic spine?
• Provocate by deep breathing while thorax
extension?
• Located on segmental of the thoracic spine then
movement test done by cervical motion or arm.
• PACVP and LPAVP test
Sugijanto, 2021
THE EXAMINATION TO IDENTIFY
THORACIC OUTLET IMPAIRMENT
• Client complain of shoulder pain that referred to upper arm,
especially when she carrying a heavy things.
• Anamnesis for suspect thoracic outlet origine:
• Paresthesia rise when hyper abduction but decrease when
arm down
• Or paresthesia rise when arm down but decrease when
hyper abduction
• Adson’s Test
• Hyperabduction test

Sugijanto, 2021
THE EXAMINATION OF SHOULDER
COMPLEX PROBLEM
• Client with shoulder-deltoid pain when arm lifting.
• Anamnesis khusus terkait keluhan berasal dari impairment shoulder
complex:
• Apakah keluhan tersebut meningkat bila gerak tangan
dibelakang leher dan tangan dibelakang punggung
• Apakah juga terprovokasi oleh gerak bahu tertentu seperti
lengan kesamping-depan tubuh
• Gerak abduksi-elevasi dalam ritme/lingkup tertentu keluhan nyeri
leher-lengan ter provokasi
• Pada posisi abduksi bahu dimana terprovokasi keluhannya,
kemudian dilakukan ‘over pressure caput humeri kearah superior
(impingement), kearah anterior (instabilisasi) atau kearah rotasi
eksterna (frozen)
• Tes positif bila keluhan nyeri leher-lengan ter provokasi oleh gerak

Sugijanto, 2021
 QUICK TEST (ORIENTASI) FOR
SHOULDER EXTERNAL IMPINGEMENT

Abd-elevation → Painful arc

Drop armr test: nyeri, tidak

Nyeri gerak mampu mempertahankan
posisi tengah posisi

Inferior traction nyeri

berkurang, sulcus sign
negatif

Sugijanto 2021
PERTANYAAN NO 6 TENTANG REGIONAL SCREENING

• Apakah test untuk menyisihkan asal patologi/ impairment dari

Cervical spine?
• Apakah test untuk menyisihkan asal patologi/ impairment dari
Upper thoracic joint/Cervico thoracic junction?
• Apakah test untuk menyisihkan asal patologi/ impairment dari
thoracic outlet?

Sugijanto, 2021
ASSESSMENT NO 4: REVIEW OF SYSTEM
AND RED FLAG
• Review of Systems
• Serious pathology (Red Flag)

Sugijanto, 2021
Sugijanto 2021
 ROS & RED FLAG IN CERVICAL SPINE-SHOULDER
No Regio ROS Red flag Red flag:
Anamnesis Anamnesis - Test
1 Cervical Musculoskeletal Fracture; instability Apakah sakit kepala dan leher disertai kaku otot leher
spine syst: berat?
Nyeri meningkat ketika menunduk=tengadah? atau
Arthritis/ Bamboo miring ke kanan-kiri?
spine Pusher test; Alar lig test; dan
Tectorial lig test
X ray
Cardio vascular VBI/ Apakah menderita sakit kepala kronis disertai episode
muntah? Apakah pusing mual bila menengok ke satu sisi?
Apakah pernah kepala memutas satu arah dalam wahktu
lama terasa pusing, mual-muntah? VBI test
Vertigo Epley maneouvre

Immune system Cancer Pancoast test

Neuromuscular Tekanan tinggi Neri test
intracranial Nafziger test
Cervical cord lesion Sensoric- Motoric & reflex test Sugijanto, 2021
 RED FLAG UNTUK CERVICAL SPINE

Vertebro Basilar Iinsufficiency test

Cervical instability test

Sugijanto, 2021
 PERTANYAAN NO 7 TENTANG REVIEW OF
SYSTEM AND RED FLAG

• Mengapa fisioterapis harus mengidentivikasi system tubuh dan Menyisihkan

red flag?
• Apakah pertanyaan dan test untuk menyisihkan keluhan berasal dari
Cardiovasular? Apakah yang harus diperhatikan bila diduga gangguan
Myocard infark?
• Apakah pertanyaan dan test untuk menyisihkan keluhan berasal dari
Musculoskeletal? Apakah test untuk Cervical instability?

Sugijanto, 2021
PERTANYAAN NO 7 TENTANG REVIEW OF SYSTEM
AND RED FLAG

• Apakah pertanyaan dan test untuk mengetahui keluhan berasal dari gastro
intestinal? Apakah yang harus diperhatikan bila diduga gangguan Colon
cancer?
• Apakah pertanyaan dan test untuk mengetahui keluhan berasal dari deficit
neurologi? Apakah test untuk cauda iquina syndrome?

Sugijanto, 2021
 ASSESSMENT NO 5A: BODY STRUCTURE IMPAIRMENT TEST
UNTUK MEMASTIKAN GANGGUAN JARINGAN SPESIFIK PEYEBAB PATOLOGI
SEHUNGGA DAPAT MENETAPKAN BODY STRUCTURE IMPAIRMENT

Jaringan tubuh Tes Temuan

Shoulder capsular Passive test Terbatas, ROM: external rot<Abduction<internal rot
laxity elastic end feel hingga firm end feel
Joint play movement test Nyeri. empty end feel
Apprehension test Positif: Fear / laxty
Relocation test Positif: No / decrease pain.
Muscle: I. Static stretch test Supraspinatus, Subscapular, Pectoralis mayor-minor
Cuff muscle 2. Isometric test posisi Nyeri, tightness, weakness
Pectoralis mayor 3. Contract relax stretch test Tegang, contracture

Sugijanto, 2021
PROSEDUR PEMERIKSAAN FISIOTERAPI
Berdasar evidence Base Clinical Practice:
• Pemeriksaan terhadap shoulder external
impingement:
• Abduction-elevation: painful arc
• Neer test
• Jobe’s test
• Hawkin & Kennedy test
• Isometric external rotation

Sugijanto 2021
PROSEDUR PEMERIKSAAN FISIOTERAPI

Berdasar evidence Base Clinical Practice:

• Pemeriksaan Capsules:
• Stability test: Apprehension test, relocation test.
• Joint Play Movement Test: inferior taction of humerus → firm
end feel

Sugijanto 2021
PROSEDUR PEMERIKSAAN FISIOTERAPI
Berdasar evidence Base Clinical Practice:
• Pemeriksaan panjang otot:
• Supraspinatus tigthness
• Pemeriksaan Otot stabilisator:
• Stabilization test

Sugijanto 2021
PROSEDUR PEMERIKSAAN FISIOTERAPI
Berdasar evidence Base Clinical Practice:
• Pemeriksaan Otot stabilisator:
• Stabilization test

Sugijanto 2021
• Pemeriksaan Scapular dyskinesis:
• Glenohumeral Abduction-elevation dan Tolak pinggang identivikasi:
• Scapular tipping
• Scapular shrugging
• Scapular winging

• Pemeriksaan AC joint:
• Mobility test
• Stability test
• Osteophyte
• Pemeriksaan mobilitas regio cervicothoracic junction:
• Melalui gerak bahu dan melalui gerak leher.
• Pemeriksaan lain:
• X ray

Sugijanto 2021
 TES EVIDENCE BASE SHOULDER
EXTERNAL IMPINGEMENT SYNDROME
SUB ACROMIAL SPACE TERLALU SEMPIT
• Traksi statis humerus arah inferior dipertahankan 30 detik
• Pembuktian: Nyeri berkurang,
• Tidak tampak sulcus sign
• GHJoint:
• Superior capsule.
• ACJ: Superior glide (elevation), anterior glide (protraction)
• Cervico Thoracic Junction: Rotation, NAGs test

Sugijanto 2021
 BILA DUGAAN MUSCLES
PROBLEMS
MUSCLE LENGTH TEST & CONTRACT RELAX STRETCH
TEST
• UPPER TRAPEZIUS M
• Fleksi lateral cervical kontralat, depresi girdle ipsilat
• PECTORALIS MAYOR M.
• Posisi glenohumeral Abduction -horizontal abduction.
• PECTORALIS MINOR M.
• Posisi girdle retraction
• ROTATOR CUFF MS.
• Supraspinatus m: Traksi statis arah inferior
• Subscapular m: Posisi extrernal rot

Sugijanto 2021
 PERTANYAAN TENTANG TES DARI HIPOTESIS
BODY STRUCTURE IMPAIRMENT

• Menngapa fisioterapi harus menegakkan gangguan anatonis pada kasus frozen

shoulder?
• Apakah test untuk membuktikan impairment? Apakah yang dibuktikan?
• Apakah test untuk membuktikan impairment pada otot skelet? Apakah yang
dibuktikan?

Sugijanto 2021
 ASSESSMENT NO 5B: BODY FUNCTION IMPAIRMENT

UNTUK MEMASTIKAN GANGGUAN MEKANIK PEYEBAB PATOLOGI SEHINGGA DAPAT

MENETAPKAN BODY FUNCTION IMPAIRMENT

Fungsi Pemeriksaan Temuan

Pain Pain provocation: 1. Nyeri akibat anatomic impairment
1. jaringan tertentu 2. Nyeri akibat movement impairmen
2. Gerak tertentu
Mal 1. Glenohumeral Position measure 1. Anteroposisi
alignment 2. Pengukuran alignment 2. Kyphosis, scoliosis, round back,
3. Test penggunakn device tertentu 3. Kebutuhan orthotic device

Sugijanto, 2021
 BODY FUNCTION IMPAIRMENT ASSESSMENT

Kinetik tubuh Tes Temuan

Hypomobility Structural hypomobility
• Capsular test Terbatas dalam capsular pattern dengan en feel elastis – firm
• Muscle length test Otot antagonis tightness – contracture
Functional hypomobility
• Positional corrected Koreksi posterior glide Mobilitas meningkat (+)
movement Koreksi inferior traction Mobilitas meningkat (+)

Sugijanto, 2021
 PERTANYAAN TENTANG TES DARI HIPOTESIS
BODY FUNCTION IMPAIRMENT

• Mengapa fisioterapi harus menegakkan penyimpangan kinetic pada frozen

shoulder?
• Apakah test untuk membuktikan impairment kaku sendi? Apakah alat ukurnya?
• Apakah test untuk membuktikan penyimpangan alignment bahu? Apa alat
ukurnya?

Sugijanto 2021
 ASSESSMENT NO 5C: DISABILITIES
Disabilities Outcome measure Temuan
Hand and arm Shoulder Pain Disability Index Score
function Disability of Arm Shoulder and Hand

 INTERVENTION
ADL IADL Unable, full support, partial support,
supervision or able to do at specific task

Work Work in office, work in field, work in Unable, support, super vision, able to do

Sport Individual sport Unable, support, super vision, able to do

Team sport etc
Recreation In door recreation Unable, support, super vision, able to do
Out door recreation

Sugijanto, 2021
 ASSESSMENT NO 6 PEMERIKSAAN PENUNJANG
• Sebagai penegakan hasil temuan dari asesmen fisioterapi
• Memberikan data-data dalam bentuk ukuran tertentu
• Mempertegas Diagnosis yang dibangun
• Menjadi pertimbangan dalam penetapan program
• Menyisihkan differential diagnose
• Data evaluasi program yang objektif
• Beberapa penunjang diagnosis
• Laboratorium; X Ray; MRI; Ultrasonography musculoskeletal; EMG, dll

Sugijanto, 2021
ASSESSMENT NO 7: PROGNOSTIC
(CONTEXTUAL) FACTORS
• Faktor internal yang memperberat atau sebagai penyulit
• Commorbidities atau penyakit lain terkait atau Faktor psikososial yang menghambat

• Faktor eksternal yang memperberat atau sebagai penyulit

• Faktor lingkungan yang mengganggu sakitnya

• Faktor internal yang memperingan atau sebagai pefasilitasi

• Faktor sosial, intelegensi dan lainnya yang membantu proses penyembuhannya

• Faktor eksternal yang memperingan atau sebagai pefasilitasi

• Faktor lingkungan dan sosial yang membentu proses penyembuhannya

Sugijanto, 2021
 KELUARAN ASSESSMENT:
PT DIAGNOSIS DAN FUNCTIONAL PROGNOSIS
• Diagnosis merupakan simpulan pada pemeriksaan dalam lingkup gerak dan fungsi (ICF)
yang berdasar patologi (ICD). Diagnosis menurut APTA (2017)
• Muscle pain and tightness sec. myofascial syndrome
• Pain and instability sec, Lumbar spondylolisthesis
• Neck pain with radiating pain (radicular) sec. HNP
• Dalam lingkup gerak dan fungsi tanpa patologi.
• Neck pain with mobility deficits (in capsular pattern)
• Low back pain sec. Hip joint hypermonbility.
• Neck pain sec forward head posture
• Lumbopelvic pain sec, leg discrepancy
• Dll

Sugijanto, 2021
 PERTANYAAN TENTANG PROSES
ASSESSMENT FISIOTERAPI PADA SHOULDER IMPINGEMENT

• Apakah pemeriksaan orientasi pada frozen shoulder?

• Apakah tes algoritme capsul sendi glenohumeralis?
• Apakah tes algoritme pada shoulder girdle?
• Apakah tes algoritme otot penyangga dan penggerak shoulder complex?

Sugijanto 2021
 PROSES INTERVENSI FISIOTERAPI
1. HISTORY TAKING

2. INSPEKSI
3. REGIONAL SCREENING &
QUICK TEST

4. REVIEW OF SYSTEM &

RED FLAG

5. ASSESSMENT EVIDENCE
BASE CLINICAL PRACTICE
6. DIAGNOSIS AND
FUNCTIONAL PROGNOSIS

7. PLANNING
8. INTERVENTION
9. EVALUATION

10. DOCUMENTATION
Sugijanto, 2021
 PLANNING
• Penjelasan tentang patologi, diagnosis, target, tujuan, rencana intervensi dan
hasil yang diharapkan
• Persetujuan pasien terhadap target, tujuan dan tindakan intervensi fisioterapi
• Target harus jelas:
• BODY STRUCTURE (Anatomic) IMPAIRMENT TARGET:
• Capsules
• Muscles
• BODY FUNCTION (Kinetic) IMPAIRMENT TARGET :
• Mobility of Glenohumeral, scapulothoracal, Acromioclavicular-Sternoclavicular and
Cervicothoracic junction
• ACTIVITY LIMITATIN TARGET:
• ADL
• Hand activities
• PARTICIPATION RESTRICTION TARGET:
• Work
• Sport
• Recreation
Sugijanto, 2021
 shoulder impingement

Shoulder girdle Shoulder movement Cervico Thoracic

Capsules Muscles Shoulder arm
Junction
impairment disability
Hypomobiliy

Joint Weakness Scapular

mobilization mobilization
Joint mobilization Functional activity
Muscle Acromioclavicular joint and participation
Tightness Nelson traction
strengthening mobilization education

Muscle
1. Traksi osilasi pd endurance 1. Static inferior traction-
MLPP posterior glide
2. Traksi inferior end 2. MWM ininferior- posterior
Active stabilization Muscle
range position glide correction
exc Stretching
3. Roll glide

Functional
training Sugijanto 2021
 INTERVENSI FISIOTERAPI
SHOULDER IMPINGEMENT

• Pemilihan Modalitas
• Pemilihan metode dan Teknik intervensi
• Latihan
• Edukasi

Sugijanto 2021
INTERVENSI FISIOTERAPI
• MODALITAS DAN METODA
• Body structure Impairment target:
• US / SWD contra planar tepat utk capsule yg tegang
• Scapular mobilization
• Shoulder joint mobilization, traction at end range position and Roll glide
• Stabilizing exercise tepat utk kelemahan otot bahu.
• Body function Impairment target:
• Latihan mobilisasi sendi
• Latihan stabilisasi bahu
• Disability target
• Activity limitation target
• Paticipation target
Sugijanto 2021
 PEMILIHAN MODALITAS, METODE DAN TEKNIK
INTERVENSI SPESIFIK

Static stretching
Shoulder MWD/SWD Ischemic compression technique
Muscle contraplanar Longitudinal stretching
Tightness/ US longitudinal Myofascial release technique
contracted application Muscle energy technique
Contract relax stretching

EBPP (I), Electrical Stimulation No recommendation for: Rot cuff, dislocation, SLAP tear, AC jt.,
Frozen Shoulder (Hegmann et al, 2011)

NMES to supraspinatus: At days 45 and 90; No appreciable change in strength (Blum et al

2009)

Sugijanto, 2021
• Muscle static stretching, Contract relax stretching,
dan Muscle Energy Technique (MET).
• Supraspinatus m
• Posisi lengan netral disamping tubuh
• Static stretching
• Subscapular m
• Posisi lengan abduksi 900 disamping tubuh
• Contract relax stretching atau MET
• infraspinatus m
• Posisi lengan menyilang depan tubuh
• Contract relax stretching atau MET
• Levator scapular m
• Posisi cervical lateral fleksi kontra lateral,glenohumeral
abduksi dan girdle depresi

Sugijanto 2021
CONTRACT RELAX STRETCHING &
MUSCLE ENERGY TECHNIQUE

• PECTORALIS MINOR M.
• Peregangan static elevasi-retraksi
• Expiration dan girdle retraction in girdle retraction

• PECTORALIS MAYOR M.
• Expiration dan horizontal adduction. In shoulder abducted

Sugijanto 2021
 PEMILIHAN MODALITAS, METODE DAN TEKNIK
INTERVENSI SPESIFIK,

Mulai oscillated traction in MLPP

SWD contraplanar
Joint Capsular static stretching
Alignment correction
Capsular End range joint mobilization
contracture Joint mobilization
Joint manipulation
Joint manipulation
Joint mobilization exercises

EBCP--Elastic Therapeutic Taping: Immediate improvement, decreased pain with shoulder

abduction (raising out to side), but no significant difference after 6 days (Thelen 2008)

EBCP-- Infrared Light/Low Level (cold) Laser: Insufficient, No recommendation (Hegmann et

al, 2011) dan (Dogan et al 2010) Sugijanto, 2021
MANUAL THERAPY … THE EVIDENCE
• “Manual physical therapy applied by an experienced physical therapist
combined with supervised exercise … is better than exercise alone for increasing
strength, decreasing pain, and improving function in patients with shoulder
impingement syndrome” (Bang et al. 2000)
• Shoulder mobilization (non-thrust) with active patient movement
• Increases ROM and decreases pain (Teys et. al, 2008)
• Thoracic manipulation (grade 5, thrust)
• Rib and spine therapy for shoulder pain
• Immediate decrease in pain and increase in ROM
• No adverse affects (Strunce et al, 2009)
• SLAP (labrum) tears (non-surg)
• (I) Insufficient evidence, No recommendation (Hegmann et al, 2011)

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 GLENOHUMERAL JOINT &
SHOULDER GIRDLE TARGET
Glenohumeral Capsular
• Static GH posterior glide
• Traksi osilasi MLPP, Traksi inferior, Roll glide dan
MWM

Shoulder girdle capsular/muscucular

• ACJ mobilization

Cervicothoracic junction capsular

• LPAVP upper thoracic junction
• Nelson traction
Sugijanto, 2021
 Glenohumeral mobilization:
INTERVENSI
• Oscillated traction in MLPP
• Traksi arah lateral grade 4
• Mulai static dilanjut osilasi 3-5 Hz
• Inferior traction
• Traksi static
• Posterior glide mobilization
• Translasi static
• Roll glide abduction
• Roll glide gerak abduksi
• Kombinasi rotasi internal/eksternal
• Kombinasi fleksi/ ekstensi
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 GLENOHUMERAL MOBILIZATION

• Mobilization under inferior traction

• Traksi inferiorl ditambahkan rotasi internal dan eksternal

• Mobilization under inferior and posterior glide

• Inferior & posterior glide ditambahkan rotasi internal dan
eksternal (Mall cat mobilization)

• MWM under posterocaudal positional vault correction

• Belt memberikan control dan fiksasi kearah posterior dan
sedikit interior
• Pasien menggerakkan lengan ke anterior

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 INTERVENSI
• ACJ mobilization
• Traction to lateral
• Elevation,
• Retraction
• SCJ mobilization (bila perlu)

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INTERVENSI MT

MOBILISASI SEGMENTAL UPPER THORACIC SPINE:

• LPAVP pada thoracic facet arah 300
ventrocaudal.
• NAGs dilakukan dengan mendorong proc.
spinosus arah 600 ventrocranial

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MANIPULATION CTJ - NELSON

 NELSON TRACTION
◦ Sand back pd spinous proc upper thoracal.
◦ Manipulasi dgn menarik bahu pasien dan
mendorong sand bag keventral dengan teknik
HVLA.
◦ Utk minimal capsular pattern

Rob Langhout, MMT, 2005, medical adviser of NEC,

Nijmegen, Belanda
Sugijanto, 2021
 LATIHAN ACTIVE BAHU SAMBIL
MENJINJING BEBAN

Scapular kinematics and scapulohumeral rhythm during resisted shoulder

abduction – Implications for clinical practice, Forte et al, 2009)

Sugijanto, 2021
TERAPI LATIHAN
• Latihan
• Postural correction
• Stabilization
• Stretching
• Mobilization

Sugijanto 2021
 EXERCISES
• Closed Kinetic Chain
• Closed Chain Scapular
Motion
• Scapular Clocks
• Low Row
• TheraBand Neutral Shoulder
• TheraBand Scapular
Adduction
• TheraBand Scapular
Adduction with Shldr ER
• TheraBand Prone on Elbows
Shldr ER
 EXERCISES
• Closed Kinetic Chain
• Closed Chain Scapular
Motion
• Scapular Clocks
• Low Row
• TheraBand Neutral Shoulder
• TheraBand Scapular
Adduction
• TheraBand Scapular
Adduction with Shldr ER
• TheraBand Prone on Elbows
Shldr ER
 EXERCISES
• Closed Kinetic Chain
• Closed Chain Scapular
Motion
• Scapular Clocks
• Low Row (retraction/ext)
• TheraBand Neutral Shoulder
• TheraBand Scapular
Adduction
• TheraBand Scapular
Adduction with Shldr ER
• TheraBand Prone on Elbows
Shldr ER
 EXERCISES
• Closed Kinetic Chain
• Closed Chain Scapular
Motion
• Scapular Clocks
• Low Row
• TheraBand Neutral Shoulder
• TheraBand Scapular
Adduction
• TheraBand Scapular
Adduction with Shldr ER
• TheraBand Prone on Elbows
Shldr ER
 EXERCISES
• Closed Kinetic Chain
• Closed Chain Scapular
Motion
• Scapular Clocks
• Low Row
• TheraBand Neutral Shoulder
• TheraBand Scapular
Adduction
• TheraBand Scapular
Adduction with Shldr ER
• TheraBand Prone on Elbows
Shldr ER
 EXERCISES
• Closed Kinetic Chain
• Closed Chain Scapular
Motion
• Scapular Clocks
• Low Row
• TheraBand Neutral Shoulder
• TheraBand Scapular
Adduction
• TheraBand Scapular
Adduction with Shldr ER
• TheraBand Prone on Elbows
Shldr ER
 EXERCISES
• Closed Kinetic Chain
• Closed Chain Scapular
Motion
• Scapular Clocks
• Low Row
• TheraBand Neutral Shoulder
• TheraBand Scapular
Adduction
• TheraBand Scapular
Adduction with Shldr ER
• TheraBand Prone on Elbows
Shldr ER
 EXERCISES

• Closed Kinetic Chain

• Serratus Anterior with TheraBand

• Subscapularis with TheraBand

 EXERCISES

• Open Kinetic Chain Exercises

• Side lying Shldr ER
• Standing Shoulder Abduction Open
Can with DB
• Standing Shoulder Flexion with DB
• Prone Scapular Adduction with
Depression
• Arms at Side
• Flexed Elbows, Thumbs Up (Prone
Bird)
• Prone Lower Trapezius (Super Man)
• Supine Serratus Anterior with DB
 EXERCISES
• Open Kinetic Chain Exercises
• Side lying Shldr ER
• Standing Shoulder Abduction
Open Can with DB
• Standing Shoulder Flexion with
DB
• Prone Scapular Adduction with
Depression
• Arms at Side
• Flexed Elbows, Thumbs Up
(Prone Bird)
• Prone Lower Trapezius (Super
Man)
• Supine Serratus Anterior with
DB
 EXERCISES
• Open Kinetic Chain Exercises
• Side lying Shldr ER
• Standing Shoulder Abduction
Open Can with DB
• Standing Shoulder Flexion with
DB
• Prone Scapular Adduction with
Depression
• Arms at Side
• Flexed Elbows, Thumbs Up
(Prone Bird)
• Prone Lower Trapezius (Super
Man)
• Supine Serratus Anterior with DB
 EXERCISES
• Open Kinetic Chain Exercises
• Side lying Shldr ER
• Standing Shoulder Abduction
Open Can with DB
• Standing Shoulder Flexion with
DB
• Prone Scapular Adduction with
Depression
• Arms at Side
• Flexed Elbows, Thumbs Up
(Prone Bird)
• Prone Lower Trapezius (Super
Man)
• Supine Serratus Anterior with DB
 EXERCISES
• Open Kinetic Chain Exercises
• Side lying Shldr ER
• Standing Shoulder Abduction Open
Can with DB
• Standing Shoulder Flexion with DB
• Prone Scapular Adduction with
Depression
• Arms at Side
• Flexed Elbows, Thumbs Up (Prone
Bird)
• Prone Lower Trapezius (Super Man)
• Supine Serratus Anterior with DB
 EXERCISES
• Open Kinetic Chain Exercises
• Side lying Shldr ER
• Standing Shoulder Abduction Open
Can with DB
• Standing Shoulder Flexion with DB
• Prone Scapular Adduction with
Depression
• Arms at Side
• Flexed Elbows, Thumbs Up (Prone
Bird)
• Prone Lower Trapezius (Super Man)
• Supine Serratus Anterior with DB
 EXERCISES
• Open Kinetic Chain Exercises
• Side lying Shldr ER
• Standing Shoulder Abduction
Open Can with DB
• Standing Shoulder Flexion with
DB
• Prone Scapular Adduction with
Depression
• Arms at Side
• Flexed Elbows, Thumbs Up
(Prone Bird)
• Prone Lower Trapezius (Super
Man)
• Supine Serratus Anterior with DB
ALAT UKUR/EVALUASI FISIOTERAPI
• Pengukuran nyeri:
• NRS, VAS, Mc. Gill queston score
• Pengukuran ROM:
• Universal goniometer
• Pengukuran fleksibilitas/ekstensibilitas otot:
• Tape measure dalam cm
• Pengukuran disabilitas/fungsi:
• SPADI, DASH

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 CLINICAL PATHWAY SHOULDER IMPINGEMENT SYNDROME
No Problem Assessment Intervensi Alat ukur/ Kondisi yg Jumlah
fisioterapi evaluasi diharapkan kedatangan
Nyeri dan Pemeriksaan Impingement US/SWD Nyeri diukur Nyeri Ringan: 3x/
disabilitas bahu (positif minimal 3): subacromial, traksi – dgn VAS/ berukrang mgg, 1 sesi
akibat external Painful arc translasi static caudal, NRS tiap kunjungan
impingement Jobe’s test Mobilisasi saat caudal Painful arc: Sedang: : 3x/
syndrome Neer test traction, MWM goniometer Fungsi normal mgg, 2 sesi
Hawkin Kennedy test Disabilitas: <2-4 mgg
External rotation SPADI/ Berat: : 2x/
isometric test DASH/ mgg, 4 sesi
+subacromial Bursa subacromial mobilization under
bursitis Neer & Hawkin test caudal traction,
+supraspinatus Palpasi pisisi ekstensi Contract relax
tendinitis M Supraspinatus stretching
Jobe’s/Empty can test
Isometric Abd pada
MLPP
Palpation posisi borgol

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Sugijanto, 2021
PERTANYAAN TENTANG PROSES PENGELOLAAN FISIOTERAPI
PADA SHOULDER IMPINGEMENT SYNDROME

• Mengapa fisioterapis harus melakukan essessment untuk menegakkan

diagnosis?
• Apakah metode dan Teknik mobilisasi sendi glenohumeralis?
• Apakah metode dan Teknik mobilisasi Scapulohumeral?
• Apakah metode dan Teknik muscle stretching?

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SAMPAI JUMPA

Sugijanto 2021