MANUAL THERAPY pada

Shoulder Dysfunction

Oleh: Sugijanto,
Timbul Siahaan
Nurbasuki
Johanes Salim
ANATOMI TERAPAN
GLENOHUMERAL JOINT
 ‘Ball and socket joint’

 Capsul sendi:

 Otot

 Stabilitas

Sugijanto, 2014
 GLENOHUMERAL JOINT
 Merupakan ‘ball and socket joint’ dibentuk oleh
glenoid cavity yg cekung menghadap ke lateral
serong cranioventral dgn caput humeri yg
berbentuk cembung.
 Memiliki 3 derajad kebebasan gerak dalam 3 bidang
gerak dan 3 sumbu utama:
 Sumbu transversal mengontrol gerak fleksi-ekstensi
dlm bidang sagital
 Sumbu antero-posterior mengontrol gerak abduksi-
adduksi dlm bidang frontal
 Sumbu vertikal mengontrol gerak fleksi-ekstensi
dlm bidang horizontal pada posisi lengan abduksi
900
 Pada sumbu longitudinal humerus terjadi gerak
rotasi
Sugijanto 2011
Gerak aktif Fleksi berlangsung tiga tahap, tahap I yaitu
lingkup 00 sampai 50-600, dilakukan oleh otot:
 M. Deltoid anterior (n. axilaris, radiks C5,C6)
 M. Coracobrachialis (n. musculocutanius, radiks
C6,C7)
 M. Pectoralis mayor serabut clavicular
 Tahap II yaitu lingkup 60-1200, dilakukan oleh otot:
 Ditambah m. serratus anterior
 M. Trapezius ascendence
 M. Latissimus dorsi
 Tahap III yaitu lingkup 120-1800, dilakukan oleh
otot:
 m. serratus anterior
 M. Latissimus dorsi
 m. Erector spine.

Sugijanto, 2011
Sugijanto 2011
Persarafan

Sugijanto, 2011
Maximally Lose Pack Position dan
Close Pack Position

 Maximally Lose Pack Position

adalah posisi dimana kekendoran
capsuloligamentairnya maksimal,
yaitu flexion – abduction  300
dan sedikit internal rotation.
 Close Pack Position adalah posisi
sendi dimana terjadi penguncian
permukaan sendi atau koaptasi
maksimal, yaitu posisi abduction –
flexion penuh
Sugijanto, 2011
OSTEO KINEMATIK

 Flexion-extension ROM. Flx:

1800 Ext: 600 stretched end
feel (elastic).
 Abduction dg ROM 900 elastic
harder end feel.
 External rot ROM 800 elastic
end feel.
 Internal rot ROM 800 elastic
end feel.
ARTROKINEMATIK

 Gerak Abduction memiliki

arthokinematic roll kearah
cranial dan glide ke caudal
 Gerak external rot memiliki
arthokinematic roll kearah
dorsal dan glide ke ventral.
 Gerak internal rot memiliki
arthokinematic roll kearah
ventral dan glide ke dorsal.
ANATOMI TERAPAN
 Internal rot ROM 900 elastic e f,
arthokinematic dorsal translation.
 Horizontal Abd dan Horizontal Add ROM
1200 dan 300 dg elastic e f. Gerak
arthokinematic ventral translation dan
dorsal transl.
 Seluruh komponen memiliki grk
arthrokinematic Traction arah lateral
sedikit serong ventrocranial
 MLPP: flexion–abduction  300 sdkt
internal rot.
 CPP posisi abduction – flexion penuh.
 Capsular pattern ROM: External rot. 
Abduction  Internal rot.
Sugijanto, 2014
Bony Anatomy
“Static Stabilizers”

SUPRAHUMERAL (JOINT)

 Bukan sendi asli: Celah antara

acromion dan head of humeri.
 Ada Bursa subdeltoidea dan
‘rotator cuff’ (subscapular m,
supraspinatus m, dan infraspinatus
m), dan tendon long head biceps.
 Ketika abduction-elevation terjadi
benturan antara head of humerus
dg acromion, dan penekanan
jaringan isi suprahumeral.
Sugijanto, 2014
ACROMIOCLAVICULAR JOINT
 Plane joint
 Dlm klinis grk: Elevation-Depression
dan Protraction-Retraction
 Acromion konkaf: arthrokinematic
saat elevation → translasi acromion
ke cranial dan saat depression
translasi ke caudal. Saat protraction
translasi ke ventral dan retraction
→ translasi ke dorsal. Gerak
traction nya selalu kearah lateral
searah acromion ditarik.
 MLPP: posisi netral
 CPP: posisi protraction penuh.
Sugijanto, 2014
STERNOCLAVICULAR JOINT
 Saddle joint:.
 Grk fisiologis spt AC Joint, grk
arthrokinematic saat elevation:
caudal transl, saat depression:
cranial transl, dan saat retraction:
dorsal transl.
 Traction searah axis longit
claviculae
 MLPP posisi netral
 CPP posisi protraction
Sugijanto, 2014
SCAPULOTHORACAL (JOINT)
 Bukan sendi sebenarnya, pertemuan
scapula dg dinding thorax.
 Dibatasi: subscapular m. dan serratus
anterior m, stabilisasi oleh trapezius,
rhomboideus major–minor m,
serratus anterior m, dan levator
scapular m,
 Gerakan elevation–depression dan
abduction–adduction sesuai dg arah
translationnya. Gerak
arthrokinematic Traction adalah
gerak scapulae menjauh thd dinding
thorax
Sugijanto, 2014
SCAPULOTHORACAL
MOVEMENT DISFUNCTION
 Scapulothoracic
Joint (ST)
 Sendi palsu

Scapula Resting Position

Sugijanto, 2014
Scapulothoracic Joint (ST)
 scapula moves 3-dimensions
◦ Upward/downward rotation
◦ External/internal rotation

18
◦ Posterior/anterior tilt

 during elevation
scapula  upward rotation
 external rotation
 posterior tilting

clavicle retracts posteriorly and elevates

scapula more superior and posterior position
Sugijanto, 2014
INNERVATION
 Persarafan shoulder complex oleh
segment C(3), C4, C5, C6, C7, (C8-Th1),
 Area dermatome: C3 (bag leher), C4 (bag
pundak), C5 (bag deltoid sp lateral lengan
atas), C6 (dorsal lengan atas sp lengan
bawah), C7 (bag medial lengan atas dan
bawah), C8-Th1 (lengan bawah sp
kelingking).
 Sarap perifer yg memelihara menurut
area nervina terbagi atas (lihat gambar)
 Cabang saraf dari saraf sympathic
segment C3 = Th 3, C4 = Th4 dan
seterusnya C8 oleh Th8
Sugijanto, 2014
 Scapulohumeral rhythm
Abduction-elevation of shoulder.
 Scapulohumeral rhythm: shoulder abduction –
elevation terjadi grk proporsional antara humerus-
scapula,
◦ Pd abduction 0-300 terjadi grk humerus 300 scapula pd posisi
tetap atau sedikit adduction.
◦ Pd ROM 300 - 600 terjadi grk proporsional antara abduction
humerus : scapula → 2 : 1.
◦ Pd abduction 600 – 1200 humerus external rotation bertahap 900.
Sementara grk proporsional humerus-scapula 2 : 1 tetap.
◦ Pd abduction 1200 – 1800 grk proporsional tetap berlanjut. Pd
range ini mulai terjadi grk intervertebral dan costae dan
bermakna pada akhir ROM.
Sugijanto, 2014
PENYIMPANGAN
SCAPULOHUMERAL RHYTHM
Nyeri/perubahan pola pd ROM abduction 600–1200 ‘painfull
arch’: patologi suprahumeral.
Reserve humeroscapular rhythm gerak scapula lebih
besar dr humerus: capsular pattern.
Nyeri pada ROM abduction 1600–1800 dikenal sebagai
‘ACJ/SCJ painfull arc’
Bunyi pada AC Joint (Piano phenomen): sub luxatio AC
Joint
Crepitasi scapula: fibrosis m.serratus aterior /
m.subscapularis
Paraesthesia saat hyperabduction: pectoralis minor
syndrome
Sugijanto, 2014
 Scapular dysfunction according to Kibler
Tipping
Winging
Shrugging

Type 3 dyskinesie Prominentie

angulus superior scapulae
mediorotatiestand
Type 2 dyskinesie: Prominentie
“shrugging”
margo medialis scapulae
Type 1 dyskinesie “winging
Prominentie angulus
inferior “tipping”
Sugijanto, 2014
 TES KHUSUS LAIN:
◦ YERGASON’S TEST DAN SPEED’S TEST:
 Utk patologi bicipital groove
◦ DROP-ARM TEST:
 Utk rotator cuff tear
◦ IMPINGEMENT SIGN
 Utk patologi over used supraspinatus m.
◦ ANTERIOR/POSTERIOR APPREHENSION TEST
 Utk glenohumeral dislocstion
◦ TEST THORACIC OUTLET SYNDROME
 ALLEN MANEUVRE
 ADSON’S MANEUVRE
 PECTORALIS MINOR SYNDROME TEST
 COSTOCLAVICULAR SYNDROME TEST
Sugijanto, 2014
 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

Shoulder compaints
• Prognose for recovery
- 10-20% dalam 6 mgg
- 20-30% ssd 6 weeks hingga 6 bulan.
- 60% setelah 12 bulan masih ada keluhan.

• Faktor2 Prognostic chronic pain a.l;

◦ Disamping shoulderpain juga mengeluh low back
pain
- Aktualitas tinggi (NRS>7) mulai terapi.
Luime , Kuipers 2006, KNGF EBS 2010
Motion and Stability

 Mobility - Elevation
 2/3 dari Glenohumeral
 1/3 dari ScapuloThoracal
 Mobilitas SCJ dan ACJ penting utk fungsi

 Stability dari 2 struktur

 Static Stabilizers - joint morphology and
capsuloligamentous complex
 Dynamic Stabilizers - rotator cuff and other
muscles

27
Differentiated Cervicogenic Pain
 Spondylosis: “degeneration”
◦ Ache into shoulders
◦ Pain reproduced with ROM
 Radiculopathy (weakness)
◦ C 4-5: 5 root, pain to shoulder, (deltoid)
◦ C 5-6: 6 root, lat forearm, thumb (biceps, ECRL)
◦ C 6-7: 7 root, middle finger (triceps)
◦ C 7-8: 8 root, small finger (finger flexion)
◦ C8-T1: T1 root, medial arm (finger abduction)
ICD: The young shoulder patient

Sugijanto, 2014
ICD:The adult shoulder patient

Sugijanto, 2014
ICD: The older shoulder patient

Sugijanto, 2014
PROSES FISIOTERAPI

Sugijanto, 2014
 PENYEBAB NYERI (Mc. Kenzie)

 Struktur anatomis yg memiliki inervasi- bisa

sebagai asal nyeri
 Aktivasi Nociceptor oleh:
◦ Mechanical forces
◦ Chemical concentration
 Jenis:
◦ Postural syndrome
◦ Dysfunction syndrome
◦ Internal derangement
Sugijanto, 2014
CIRI MECHANICAL PAIN
 Gaya mekanis: stress  perubahan bentuk 
kerusakan jaringan
 Intermittent pain
 Bila gerak dalam lingkup yg berlebihan atau bertahan
lama pd end range position.
 Nyeri hilang bila gaya berhenti.
 Nyeri konstan - joint internal derangement
 Sharp dan shooting pain
 Terjadi perubahan oleh posisi dan gerak
 Tida mesti ada patologi
 Tidak sembuh dengan obat (kimiawi)
Sugijanto, 2014
KONSEP NYERI CYRIAX
Nyeri yg berasal dr jaringan lunak:
1. Contractile Tissue Lesion
• Tes isometrik (Pain, Strength)
2. Inert Tissue (Noncontractile) Lesion
• Tes Pasif (Nyeri, terbatas: Capsular Pattern,
perubahan Endfeels)
3. Unidentifiable Lesion
• Tidak teridentivikasi dengan tes pasif atau
isometrik
Sugijanto, 2014
 PAIN FROM TISSUE ORIGIN

Wound healing process

Inflammation
Nosisensoric sensitization

Hypoxia necrosis
SPECIFIC Ischemic
TISSUE
Inflammation necrosis

Contracture

Fatique
Sugijanto, 2014
 Pain from Ischemia
Pembuntuan Penjepitan
capiler capiler

Ischemic
Spasm Nyeri
• Hipoksia –
• Hipo gizi NECROSIS
• Free Radicals

Sugijanto, 2014
TIGHTNESS-CONTRACTURE
Tissue Tissue
inflammation immobilization

Fiber cross-links
Tight Contracted
Compression C aff
Stretch force
Tissue damage

Sugijanto, 2014
FUNCTIONAL IMPAIRMENT
 Pain  Balance
◦ Pain in rest
◦ Pain in movement ◦ Sitting disbalance
◦ Referred pain etc ◦ Standing disbalance
 Joint mobility: ◦ Walking disbalance, etc
◦ Ankylosing  Gait:
◦ Hypomobility ◦ Antalgic gait
◦ Joint blockade
◦ Duchene gait
 Joint stability:
◦ Hypermobility
◦ Trendelen burg gait, etc
◦ Instability  Hand function:
 Muscle performance: ◦ Grip weakness
◦ Muscle weakness ◦ Prehension disability,
◦ Muscle paresis etc
Sugijanto, 2014
 JOINT MOTIONS IMPAIRMENT
Capsular
pattern
Contracture
Non capsular
Capsular pattern

Ossification Blockade

Hypo- Inert Loose body

mobility structure Blockade

Tightness
Tendomuscular
Contracted
Sugijanto, 2014
 JOINT MOTIONS
Joint
Laxity hypermobility
Ligamenter-
Capsular
Rupture Instability

Hypermobility & Bony- Deformity

instability structure

Weakness
Tendomuscular Active
hypermobility
Rupture
Sugijanto, 2014
PENGUKURAN
 DASH (Disability of Arm, Shoulder and
Hand)
 PDI (Pain Disability index)
 SPADI (Shoulder Pain Disability Index)
 Shoulder Pain Score
 The McGill Pain Questionnaire (MPQ)
 Oxford Shoulde Scores (OSS)
 The Rotator Cuff Quality Of Life Measure
(RC-QOL)
PENATALAKSANAAN FISIO-
MANUALTERAPI PADA
PATOLOGI REGIO
SHOULDER COMPLEX

Sugijanto, 2014
 FUNCTIONAL IMPAIRMENT

 Hypomobility
 Suprahumeral dysfunction
 Instability
 Glenohumeral internal rotation deficit
 Scapular dysfunction

Sugijanto, 2014
 FROZEN SHOULDER
 Capsular pattern Hypomobility
 Muscle tightness/contracture

Sugijanto, 2014
Classification Frozen shoulder

Kelley M.J. 2009

 Capsular pattern Hypomobility
Frozen Shoulder
Abd-elevation 
Reverse Joint
Humeroscapular mobilization
Rhythm
Mobility
exercise
Nyeri & Pasif: Ext rot <
gerak Abd < int rot Fuctional
terbatas :elastic-firm exercise

JPM test: Pain,

elastic-firm end
feel
Sugijanto, 2014
Normal phases frozen shoulder
 3 TAHAP GEJALA KLINIS FROZEN SHOULDER
1 Painful and freez phase
Waktu hingga 10-36 mgg. Nyeri dan kaku sekeliling bahu, tdk
ada riwayat injury. Naging constant pain yg memburuk malam
Signs and hari, tidak membaik dgn steroid
symptoms 2 Adhesive phase = fozen phase
Waktu 4-12 bln. Nyeri berkurang dan hanya oleg gerak
ekstrem, tetapi tetap kaku. Pembatasan mobilitas bahu,
terutama rotasi eksternal.
3 Resolution phase = thawing phase
Membutuhkan waktu 12 – 42 bulan. Diikuti peningkatan
mobilitas secara spontan, pemulihan terbesar pd 30 bln.
 CAPSELS IMPAIRMENT
Nyeri ssd
Instability
aktifitas
Sprain/
rupture Inflamation Nyeri diam

Contracture Nyeri regang

Capsel

Immuno Nyeri &

Effusion Acidosis
reaction hydrops

Inter
Nyeri
Immobilzation Adhesion collagen
regang
space
Sugijanto, 2014
TES ORIENTASI
 Scapulohumeral rhythm: Abduksi
elevasi
 Scratch Test: Hand Behind Head and
Hand Behind Back
 Capsular contracture: rotasi
eksternal

Sugijanto, 2014
TES PASIF

 Abduksi
 Rotasi eksternal
 Rotasi internal
◦ Capsular pattern (rot.eksternal
< abduksi < rot.internal) elastic-
firm endfeel

Sugijanto, 2014
TES KHUSUS

 Joint play movement test

◦ Inferior capsel, anterior capsel,
posterior capsel dan superior capsel.
◦ Nyeri, range terbatas, elastic endfeel
 Contract relax stretch test:
◦ Terbatas atau lemah

Sugijanto, 2014
INTERVENSI
 Scapular mobilization:
 Medial rotation dari scapula
tetapi humerus tetap diam
 Protraction
 Depression

Sugijanto, 2014
GH Joint mobilization
 Oscillated traction in MLPP
 Roll glide abduction:
◦ Roll ke cranial bersamaan glide ke
caudal.
◦ Dilakukan denga variasi: lebih fleksi;
lebih ekstesi, dengan rotasi internal
dan dengan rotasi eksternal serta
kombinasi diantara gerak tsb
GH Joint mobilization

 Roll glide horizontal abduction:

◦ Gerak roll arah dorsal bersamaan
glide arah ventral
◦ Kombinasi dgn rotasi internal
◦ Kombinasi dgn rotasi eksternal
GH Joint mobilization

 Roll glide horizontal adduction.

◦ Gerak roll arah ventral bersamaan
glide arah dorsal
◦ Kombinasi dgn rotasi internal
◦ Kombinasi dgn rotasi eksternal
AC Joint mobilization

 ACJ mobilization
 Traction
IMPINGEMENT: ANATOMY

CA LIGAMENT
 ACROMIAL SHAPES

 TYPE 1 (FLAT)17%

 TYPE 2 (CURVED) 43%

 TYPE 3 (ANTERIOR
HOOK) 40%

 MORRISON & BIGLIANI

(1987)
80% PTS WITH RC TEAR
HAD TYPE 3
ACROMION
Shoulder Impingement

 Suprahumeral impingement
◦ Supraspinatus
◦ Infraspinatus
◦ Subscapularis
◦ Long head Biceps tendon
◦ Subacromial bursa

Sugijanto, 2014
 Athletes with Shoulder
Impingement

Kerri Walsh –
Olympic Gold
medalist – Beach
Volleyball

Dwight Howard –
Center for the LA
Lakers
J.D. Drew – Former
right fielder for the
Boston Red Sox
 NYERI FROM MUSCLE
&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, 2014
 Process of Physiotherapy for
Muscle impairment
Pasif: Relaksasi otot
terbatas
Transverse
springy
friction/
Nyeri Isometric: manipulation
kontraksi Nyeri
Stretching /
Palpasi: C.R.S
Nyeri -
hipertonia Myofascial
release
CRS test:
Nyeri - Stabilization-
memendek Strengthening exc
Sugijanto, 2014
 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, 2014
TENDON
SUPRASPINATUS
EVIDENCE BASE TEST
 Drop arm test
 Empty can test
 Abduction resisted test
 Palpasi posisi borgol

Sugijanto, 2014
TENDON
SUBSCAPULARIS
EVIDENCE BASE TEST
 Abdominal press test
 Internal rotation resisted test
 Palpasi posisi netral 
medial sulcus bicipitalis

Sugijanto, 2014
TENDON
INFRASPINATUS

 External rotation lag sign

 Isometrik rotasi eksternal
 Palpasi posisi sphynx

Sugijanto, 2014
 INTERVENSION
 Intervensi:
Supraspinatus
◦ Transverse friction posisi ttt,
◦ Stretching,
◦ Caudal traction/translation dan
◦ Codmann pendular exercise
◦ Scapulothoracal movement function
Infraspinatus

Subscapular Caudal traction Sugijanto, 2014

Neuromuscular Control
 SUBACROMIAL
BURSITIS

Painful arc
Subacromial
bursa
Neer-Hawkins
test

Palpation in
extension
Sugijanto, 2014
BURSA SUBACROMIALIS

 Hawkin Kennedy test

 Palpasi posisi ekstensi

Sugijanto, 2014
INTERVENSI
 Transverse friction
 Static inferior traction
 Codman pendular exercise
 Scapulothoracal movement
function

Sugijanto, 2014
SCAPULOTHORACAL
MOVEMENT DISFUNCTION
 Scapulothoracic
Joint (ST)
 Sendi palsu

Scapula Resting Position

Sugijanto, 2014
Scapulothoracic Joint (ST)
 scapula moves 3-dimensions
◦ Upward/downward rotation
◦ External/internal rotation

83
◦ Posterior/anterior tilt

 during elevation
scapula  upward rotation
 external rotation
 posterior tilting

clavicle retracts posteriorly and elevates

scapula more superior and posterior position
Sugijanto, 2014
 Scapular dysfunction
according to Kibler
Tipping
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”
Sugijanto, 2014
 MUSCLE &TENDON
Scapular Tippng Abduction- Palpation lower angel
elevation on the scapula

Contract relax stretch test of

pectoralis minor m

SCAPULAR Scapular Abduction- Palpation to medial

DYSFUNTION 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, 2014
 Patterns of Scapular Dyskinesis
 Type I = 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.
Patterns of Scapular Dyskinesis

 Type II = 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.
Patterns of Scapular Dyskinesis
 Type III = 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.
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.
Sugijanto, 2014
Serratus anterior performance

• Fleksi 110 protraksi scapula

dan lakukan break test
• Bila tidak dapat bertahan
dalam posisi 10-15 = long
Serratus Anterior
• Bila tidak dapat bertahan
dalam seluruh range = weak

Sugijanto, 2014
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, 2014
LEVATOR SCAPULAR SHORTEN

 Saat abduksi elevasi terjadi

Shrugging
 Contract relax stretch
test positif

Sugijanto, 2014
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, 2014
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, 2014
Pectoralis minor length test

• Bila posisi acromion posterior lebih 1 inchi dari bed.

• Contract relax stretch test

Sugijanto, 2014
INTERVENSI

 Stretching for Pectoralis

minor
 Strengthening for Serratus
anterior
 Stretching for Levator
scapula
Sugijanto, 2014
GLENOHUMERAL
INSTABILITY
 Joint instability
◦ Passive instability
◦ Active instability
 Capsular stretch test
◦ Apprehension test
◦ Relocation test (Load and
sift test)
 Isometric stability test

Sugijanto, 2014
Anterior and Posterior
Apprehension Tests

 Anterior
Apprehension Test

 Posterior
Apprehension Test
 Relocation Test

 Uses external rotation and posteriorly directed

pressure to allow for increased external rotation
SLAP LESION
 Slap test
 Athroscopy

Sugijanto, 2014
 SLAP LESION

O’Brien’s
Active Compression

Crank Test
Labral injury
Terapi latihan
 Latihan
◦ Postural correction
◦ Stabilization
◦ Stretching
◦ Mobilization

Sugijanto, 2014
Neck-shoulder Myofascial pain
 Akibat ischemic pd otot, timbul
inflamasi dgn abnormal cross links
myofibrile-fascia
 Dpt mengenai erector spine cervical,
girdle, upper thoracal
 Muscle taut band /twisting dgn trigger
point
 Local dan referred pain pola
dermatome/ vegetative.
 Allodynia → psudoradicular pain

Sugijanto, UIEU 2013

 Neck-shoulder Myofascial
pain
Ischemic otot  inflamasi
kronik dgn abnormal cross
links myofibrile-fascia

Erector spine cervical, girdle,

Ischemic technique –
upper thoracal Longitudinal & transverse
Bed posture manual stretching
Muscle taut band /twisting
dgn tender ponit/trigger Unproper work
point Chronic
inflamation Autostretching
Hyperalbesia/Allodynia → Muscle local
psudoradicular pain contracture Postural correction &
proper neck mechanic
Local dan referred pain pola
dermatome/ vegetative

Sugijanto, UIEU 2013

Assessment
 Nyeri pegal menyebar dlm pola
nervina/vegetatif
 Nyeri meningkat regangan otot ybs
 Nyeri meningkat kontraksi pada
otot yang bersangkutan
 Tergantung regio yang terkena
 Gerak pasif nyeri regang otot yg
terkena
 Gerak isometric nyeri yg terkena

Sugijanto, UIEU 2013

Tes khusus dan data medik
 Palpasi: trigger point, pada taut
band dan twisting, nyeri
menyebar.
 Stretch test nyeri otot yg terkena

Sugijanto, UIEU 2013

Intervension
 Ischemic technique
 Transverse/longitudinal manual muscle
stretching.
 Auto stretching/Myofascial release

Sugijanto, UIEU 20134

 Pheripheral nerve impairment
Paresthesia
Anoxia
intermittent

Neuropathic
Inflamation
Entrapment pain
Paresthesia
Fibrosis
menetap

NERVE Inflamation Neuropathic

pain

Systemic Paresthesia
menetap

Sugijanto, 2014
Process of Physiotherapy for
peripheral nerve impairment
Aktif: Membebaskan
SLR nyeri- entrapment
brudzinsky nyeri
Palpasi- Neural
Nyeri
Tinnel test mobilization
regang
saraf
Nerve
LLTT atau gliding
ULTT nyeri
Floosing
Slump test technique

Sugijanto,
STRUKTUR JARINGAN
SPESIFIK
OSTEOGEN

collagen, cell tulang Struktur pasif Kekuatan oleh

dan matrix dg lentur thd calcium,
komponen pengisi tekanan axial kelenturan oleh
calcium GAG’s torsi & collagen & Air
tangensial

spesifik

Intervensi beban
Tes kompresi dan
axial & tangensial
angulasi
Sugijanto, 2014
Scalenus vs pectoralis minor
syndrome TOS
 Gangg somestesia/brachialgia
 Gejala terbalik hiper abduksi lengan
dan depresi bahu
 Kompresi/neuropraksia posisi ttt
 Pilahkan dgn costoclavicular dan
cervical ribs syndrome
 Gangguan somestesia dan/protopatik
pd posisi vs menetap
 Forward head position vs girdle
protracted
 → psudoradicular pain
Sugijanto, UIEU 2013
 NYERI & PARESTHESIAS PD
SCALENUS VS PECTORALIS MINOR
SYNDROME TOS

Gangg somestesia/ Contract relax stretching

brachialgia

Gejala terbalik hiper

Muscle autostretching
abduksi lengan dan
depresi bahu Muscle
contracture Neural mobilization
Kompresi/neuropraksip Peripheral nerve
d posisi ttt
entrapment Postural correction &
Forward head posture Neurofibrosis proper neck – body
vs girdle protracted mechanic

Sugijanto, UIEU 2013

Assessment
 Paraesthesia lengan-tangan kdg dgn nyeri pd area
nervina
 Meningkat bl menjinjing barang (scalenus) atau
tidur lengan kekepala (pectoralis minor)
 Posisi kepala forward head position (scalenus)
girdle protracted (pectoralis minor)
 Orientasi abduksi-elevasi saat hiper abduksi
ditahan tmbul paresthesia (pectoralis minor)
 Lateral fleksi kontralat pasif paresthesia
(scalenus)

Sugijanto, UIEU 2013

Tes khusus dan data medik
 Adson test (scalenus) positif atau
hyperabduction test (pectoralis minor)
positif
 Palpasi scalenus dan nerve trunk nyeri
semutan hingga ke tangan
 Tinnel test
 Neurodinamic test via:
◦ N. Radialis
◦ N. Medianus,
◦ N. Ulnaris

Sugijanto, UIEU 2013

TES & INTERVENSI

Intervensi Scalenus Syndrome

 Contract relax stretching m. scalenus

 Mobilisasi costa1

 Neural mobilization nerve trunk via:

 N. radialis
 N. Medianus
 Postural correction retraksi cervical
(scalenus)
Reevaluasi: Pain, paresthesia
Sugijanto, UIEU 2013
Intervensi Pectoralis minor Syndrome

 Contract relax stretching m. Pectoralis minor (dan pectoralis

mayor)
 Neural mobilization nerve trunk via:
 N. Medianus
 N. Ulnaris
 Postural correction girdle retraction (pect minor).

Sugijanto, UIEU 2013

REEVALUATION

 Untuk menilai Output

 Dibuat secara serial
 Membuat penyesuaian/ perubahan
program
 Pertahap seluruh proses
 Diukur secara subjective & objective;
Kualitatif & Kuntitatif

Sugijanto, 2014
SAMPAI JUMPA

Thanks

Sugijanto, 2014