Mechanical Diagnosis and

Therapy
of The Shoulder

Scott Herbowy, PT, Dip. MDT

Faculty McKenzie Institute International
Faculty McKenzie Institute USA
Private Practice Austin, Texas USA
 Bienvenue
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I grew up in.
I moved to.
I now live.
 MDT Classification

• The MDT system of classification is similar

in the spine and the extremities

• The primary difference is in the sub-

classification
 Posture Syndrome
• Abnormal stress on normal tissue
• Symptoms may include parasthesia or
tingling
• Common in everyday life
• Clinically extremely rare
 Dysfunction Syndrome
• Two primary sub classifications

• Articular dysfunction is closely analogous

to dysfunction syndrome in the spine

• Contractile dysfunction is clinically distinct

with many differences from the spine
 Articular Dysfunction
• Articular dysfunction and spinal
dysfunction have analogous clinical
presentations
• Structurally impaired tissues secondary to
scar, adhesions, adherence, etc.
• Pathology is peri-articular
• Chronic, unchanging, intermittent pain
 Articular Dysfunction

• Consistent presentation under mechanical

load both functionally and clinically
• Intermittent pain, produced at end range,
NW
• Movement loss due to restriction
• Remodeling is time dependent and
requires production of pain
 Contractile Dysfunction
• Structurally impaired
• Tissue degeneration
not inflammation
 Pain produced with
resisted mechanical
load
 Contractile Dysfunction
• Clinical presentation has key differences
from articular dysfunction and spinal
dysfunctions
• Pathology is extra-articular
• Pain is produced during movement rather
than at end range!
• Pain is produced as a result of active,
resisted loading
• Movement loss is uncommon
 Derangement
• Disruption or displacement of articular
surfaces
• Many characteristics are similar as to
derangement in the spine
• Pathology is intra-articular
• Hallmark characteristics are rapid change
under mechanical load and obstruction to
movement
 Deragement
• There are key differences between spinal
and extremity derangements
• There are no sub-classifications
• Centralization/peripheralization is not
identified
• Acute deformities and neurological deficit
are not present
 History & Physical Exam
• Format closely follows MDT spine exam

• Always rule out spine first

• Establish classification first

• Classification determines treatment

 Physical Exam
• Symptomatic, mechanical and functional
baselines are established
• Movement loss assessment should
consider PROM, AROM and PROM with
overpressure!
• Resisted testing becomes essential when
considering contractile dysfunction,
testing should be through entire range
Overpressure is needed to
assess movement loss!
Movement loss Assessment
 Treatment of Articular
Dysfunction
• Treatment is remodeling not stretching!
• Consistent mechanical load over time is
necessary to achieve results
• Loading should be performed 5-6X day
• Amount of load is determined by symptom
response, produce/not worse
• Care should be taken not to overload
 Treatment of Articular
Dysfunction
• Most articular dysfunctions are multi –
directional
• Loading will begin in Internal Rotation or
Flexion
• Despite loading in one direction, as tissue
remodels all movements improve
• Resolution requires a minimum of 6-8
weeks of consistent effort
 Treatment of Contractile
Dysfunction
• Treatment is also a remodeling process
• Improvement is time dependent
• Loading is required in the “target zone”
• Loading is achieved with resisted force
• Resistance may be isometric, concentric
or eccentric
 Treatment of Contractile
Dysfunction
• Care must be taken to not overload and
“kick” back into inflammation
• Patient cannot be worse the day after
beginning loading
• If in doubt use less force rather than more
force
 Treatment of Contractile
Dysfunction
• Loading should be performed 3 X Day
beginning with 15 repetitions, with a goal
of 3 x 30
• Repetitions are increased over time
• No increase in the first 7-10 days
• Force is progressed based on symptom
response
• Pain intensity of 4-7/10 VAS is optimal
Derangement, The BIG One!
How am I going to treat this?

THERE’S NO DISC!!!!!
 Treatment of Derangement
• Directional preference is established
through symptomatic and mechanical
responses
• Approach is not to simply push into the
most limited or painful movements
• Most joints have a “key’ movement
 Treatment of Derangement
• Loading should be performed 5-6 X day
and before and after aggravating activities
• Rapid improvement is often followed by
plateaued response which requires force
progression
• Force progression may be with
overpressure, static loading, and often
resistance
 Derangement Pattern #1
• Patient demonstrates;

– Painful or limited elevation (Flexion/Abduction)

– Painful of limited Internal Rotation &/or Extension

 Derangement Pattern #1
• Begin with either Internal Rotation or
Extension
 Derangement Pattern #1
• Plateau in improvement should be
addressed as follows;
• Change from IR to Ext or opposite
• Combine the two movements
 Force Progressions
• Progression will be more repetitions,
sustained, or resistance.
 Derangement Pattern #2
• Patient demonstrates;

– Painful or limited elevation (Flexion/Abduction)

– No loss of Internal Rotation or Extension

 Derangement Pattern #2
• Begin with Horizontal Adduction
Force Alternative
 Force Progressions
• Progression will be more repetitions,
sustained, or resistance.
 If worse;
• Horizontal Adduction
 Derangement Pattern #3
• Patient presents with;

– Painful or limited elevation (Flexion/Abduction)

– No limitation or pain into Internal Rotation or

Extension
 Derangement Pattern #3

• Begin with External Rotation in 90°

Flexion
 Force Alternatives
• Increase or decrease the amount of flexion
with a bias towards increasing
• Add a small amount of either horizontal
adduction or horizontal abduction with a
bias toward horizontal adduction
 Force Progressions
• Progression will be more repetitions,
sustained, or resistance.
 Residual Pain in Elevation
• Eccentric flexion or abduction
 Derangement Summary
• Make sure to get to END RANGE!
• Expect treatment to last at least 6 weeks
• Need to consider avoidance of
aggravating movements
• Force progressions are usually required
• Including sustained and resisted loads
“From the Patients We Learn”
Je vous remercie