L8: Management Overview of the Shoulder

Question 1

What are the 4 treatments approaches for shoulder?

Answer 1

1. Pathology-based approach
2. Symptom-based approach
3. Impairment-based approach
4. Protocol-based approach

Question 2

What is the pathology-based approach for management?

Answer 2

Need to understand pathology, but targeting management solely at that will not address all problems (or possibly the reason why they have symptoms)

• Eg. How long it will take to heal?

Question 3

What are the 2 features of pathology-based approach for management?

Answer 3

1. e.g. pain, stiffness
2. May help, but may not address the reason why they have symptoms
   
   • Give them symptomatic relief

Question 4

What are the 3 features of impairment-based approach for management?

Answer 4

1. Address the specific relevant impairments that the patient presents with
   
   • To why they have symptoms or the pathology
2. TDTs help to determine whether impairments are contributing to symptoms
3. Functional, patient-centred focus

Question 5

What are the 2 features of protocol-based approach for management?

Answer 5

1. e.g. clinical pathways, clinical guidelines, medical protocol
2. Not going to work for every patient
   
   • While it can be a good guide
   • Healing is not based on time rather on individual (different factors)

Question 6

What are the 4 pathological features of an acute anterior GHJ dislocation?

Answer 6

1. Damaged/stretched capsule/ligaments of anterior shoulder + Bankart lesion (labral tear)
2. Inflammatory response
3. Muscle inhibition and guarding (Protective spasm)
4. Altered proprioception

Question 7

What are the 4 impairments of the acute anterior GHJ dislocation?

Answer 7

1. Restricted and painful elevation & ER
2. Fear of movement, feeling of instability
3. Scapula dyskinesia
4. May have restricted accessory glides

Should start with impairments to address problems

Question 8

What are the 2 features in the integrative approach to management?

Answer 8

1. Prioritise and ensure treatment is staged appropriately
2. Assess and reassess – clinical and objective outcomes

Question 9

What are features of the patient’s primary compliant, pathology, functional problems, impairments, contributing factors and scope of practice?

Answer 9

1. Patient’s primary complaint: pain, weakness, instability; how do these interact?
2. Pathology: instability, adhesive capsulitis; how relevant are any structural deficits?
3. Functional problems:
   
   • What specific activity, which part of range, which structures are affected
   • ADL, ergonomics, sports performance
4. Impairment: strength, control, stiffness, instability, etc.
5. Associated or contributing problems
   
   • Cervical, thoracic, neural, functional kinetic chain (e.g. if thrower, ankle impairment can affect UL)
6. Scope of your practice: physiotherapy skill and expertise; other profession?
   
   • Eg. do they need medicine just to help relieve plan in acute stage (medical practitioner)

Question 10

What are 11 treatment options for management?

Answer 10

1. Nothing (wait & see)
2. Advice, education, reassurance
3. Ergonomics
4. Manual therapy
5. Soft tissue techniques
6. Exercise therapy
7. Taping/bracing
8. Electrophysical agents- Needs to have a very strong rationale to use (compared to other options)
9. Multimodal/combined intervention
10. Further investigations
11. Non-physiotherapy interventions – possible referral

Question 11

What are the 6 features of advice, education and reassurance?

Answer 11

1. Don’t underestimate the value of rapport and good quality communication
2. Understand what the patient wants to know
   
   • Cancer, fracture, surgery, permanent disability, etc.
   • Goals
   • Functional requirements
   • Sometimes they want to know exactly what the problem is –> motivates them. Sometimes, it is better not to.
3. Reassurance
4. Time frames (How long until Return to sport RTS)
   
   • Based on known time frames for tissue healing but will dependent on commitment to rehab and other factors (progress)
5. Prognosis (once clear)
6. Management strategies to achieve goals

Question 12

What are 3 features of ergonomics?

Answer 12

1. What work/recreation factors can be modified?
   
   • Desks/chair or unsuitable job for current injury
2. What alternative activities can the patient do if not modifiable?
3. Changes needed may appear subtle (but habitual), e.g.:
   
   1. Sitting in rotation
   2. Phone position- Phone between shoulder
   3. Mouse reach outside neutral zone
   4. Arm positioned in ER – can lead to tightness of posterior structures
   5. Sleeping postures (ACJ)- Sleeping on side (compress ACJ and GHJ)
   6. Reaching to clean top of blinds/curtains

Question 13

What are 6 changes that may appear subtle (but habitual) in ergonomics?

Answer 13

1. Sitting in rotation
2. Phone position- Phone between shoulder
3. Mouse reach outside neutral zone
4. Arm positioned in ER – can lead to tightness of posterior structures
5. Sleeping postures (ACJ)- Sleeping on side (compress ACJ and GHJ)
6. Reaching to clean top of blinds/curtains

Question 14

What are 6 possible effects of manual therapy?

Answer 14

1. Pain relief – afferent input
2. Biomechanical/pathomechanical
   
   1. Improve ROM – stiff vs. hypermobile vs. unstable
   2. Sustained techniques for tight/stiff structures
      
      • For 30-60secs = can start to induce creep in the tissues = can be a better effect
3. Physiological/pathophysiological
   
   1. Condition
   2. Improve healing of structures (collagen matrix)
4. Facilitate deficient movement – MWM
5. Symptomatic approach –Maitland; may not work for specific pathology
6. Differential diagnosis – treat multiple planes/joints and see what has the biggest effect on symptoms

Question 15

What is the benefit of a sustained manual therapy technique?

Answer 15

For 30-60secs = can start to induce creep in the tissues = can be a better effect

Question 16

What are the 4 degrees of mobilisation in passive manual therapy techniques?

Answer 16

Question 17

What are the 2 features of position in manual therapy for the shoulder (irritable pain)?

Answer 17

1. Comfort
2. ⁃Loose packed – neutral rotation, 30o flexion, 30o adduction

Question 18

What are the 2 features of grade and duration in manual therapy for the shoulder (irritable pain)?

Answer 18

1. Depends on severity and irritability
2. The more irritable the joint, or earlier in range the pain starts, or the more rapidly the pain increases in intensity early in range, the smaller the amplitude of mobilisation
   
   • Make sure they don’t exacerbate symptoms –> might cause latent flare up
   • Quite irritable or pain starts early in ROM = lower grades

Question 19

What are 4 possible techniques for irritable pain (shoulder) using manual therapy?

Answer 19

1. GHJ caud glide
2. AP, PA
3. GHJ lateral distraction
4. Physiological – Flex III

Question 20

What is the aim for manual therapy (pathology) with a reduced suacromial space and pain?

Answer 20

Increase subacromial space (temporary or lasting effect)

• Eg. impingement type symptoms

Question 21

What is the grade and duration for manual therapy (pathology) with a reduced suacromial space and pain?

Answer 21

Depends on severity and irritability

Question 22

What are 4 possible techniques for reduced subacromial space and pain (shoulder) using manual therapy?

Answer 22

1. GHJ caud glide
2. GHJ caud glide in abduction
3. GHJ PA at EOR flexion
4. MWM

Apply a glide in the direction that causes aggravation (if the right glide) = should decrease symptoms

Question 23

What are 3 features of capsular/ligamentous restriction for stiffness, EOR pain for manual therapy?

Answer 23

1. Which structure?
2. Sustained stretch?
3. What position of the joint – EOR? Neutral? Combined position? Target specific structure (e.g. 90o abduction for IGHL)

Question 24

What is the grade and duration for manual therapy (pathology) with a stiffness, EOR pain?

Answer 24

If not irritable, can use higher grade

Question 25

What are 2 possible techniques for stiffness and EOR pain (shoulder) using manual therapy?

Answer 25

1. Accessory (Is more effective in a stiff joint) vs. physiological (More general)
2. Direction will depend on specific part of the capsule you want to target

Question 26

What are 3 assessment features of capsular tightness when interpreting assessment findings?

Answer 26

1. Posterior capsule (vs. posterior shoulder tightness)
   
   1. Restricted IR, horizontal adduction and flexion – moving forward
   2. Restricted posterior glide
   3. Humeral head may sit anteriorly
2. Anterior capsule
   
   • Restricted abduction, ER, extension and horizontal abduction – moving backward and outward
   • Restricted anterior glide, or posterior glide
   • Humeral head may sit also sit anteriorly (capsule pulls HH forward), or superiorly if anteroinferior capsule is tight
3. Inferior capsule
   
   • Restricted abduction – moving upward/outward
   • Restricted inferior glide
   • Humeral head may sit superiorly

Question 27

What are 3 clinical features of posterior capsule stiffness?

Answer 27

1. Restricted IR, horizontal adduction and flexion – moving forward
2. Restricted posterior glide
3. Humeral head may sit anteriorly

Question 28

What are 2 possible techniques for posterior capsule (shoulder) using manual therapy?

Answer 28

1. GHJ AP at a point in range
2. GHJ AP with restricted movement (IR, horizontal adduction, flexion)
3. GHJ AP in HBB
4. GHJ AP in EOR elevation (target posteroinferior capsule)

Question 29

What are 3 clinical features of anterior capsule stiffness?

Answer 29

1. Restricted abduction, ER, extension and horizontal abduction – moving backward and outward
2. Restricted anterior glide, or posterior glide
3. Humeral head may sit also sit anteriorly (capsule pulls HH forward), or superiorly if anteroinferior capsule is tight

Question 30

What is a possible techniques for anterior stiffness (shoulder) using manual therapy?

Answer 30

1. GHJ AP or PA in restricted position (abduction, ER, extension, horizontal abduction)
   
   • Direction of glide will depend on assessment findings

Question 31

What are 3 clinical features of inferior capsule stiffness?

Answer 31

1. Restricted abduction – moving upward/outward
2. Restricted inferior glide
3. Humeral head may sit superiorly

Question 32

What is a possible techniques for inferior capsule (shoulder) using manual therapy?

Answer 32

• GHJ caud glide in 90˚ abduction
  
  • Can bias direction to more anterior or posterior

Question 33

What are 4 features of a MWM for shoulder?

Answer 33

1. Similar concept to TDT
   
   • Identify aggravating movement
   • Apply a sustained glide to the joint while patient repeats the movement
2. Should not be pain provocative
3. Must produce an immediate beneficial effect
4. Repetitions (Do not sustain the glide through all repetitions?)

Question 34

What are 4 possible techniques for MWM (shoulder) using manual therapy?

Answer 34

1. GHJ AP glide with flexion, abduction or horizontal adduction
2. GHJ caud glide with flexion, abduction or HBB
3. ACJ AP glide with EOR flexion
4. Scapula glides with arm elevation
   
   • Encourage upward rotation when in flexion/abduction

Question 35

What are 3 assessments of soft tissue techniques?

Answer 35

1. Identify which is the primary structure limiting movement
   
   • Musculotendinous? Capsuloligamentous?
2. Think about why this structure has become short or tight
   
   • Chronic pain?
   • Ergonomics, posture?- Holding shoulder in different position
   • Repetitive movement (e.g. thrower- GIRD)
3. Respect pathology e.g. instability, adhesive capsulitis (Frozen shoulder –> can become very irritable)

Question 36

What are 2 soft tissue techniques for shortening of capsuloligamentous structures?

Answer 36

1. Manual therapy
2. Sustained stretches

Question 37

What are 2 soft tissue techniques for posterior shoulder tightness?

Answer 37

1. Sleeper stretch
2. Horizontal adduction stretch

Question 38

What are 3 reasons why true muscle shortening occurs?

Answer 38

1. Chronic pain
2. Ergonomics/posture (eg. phone between ear)
3. Repetitive movement (e.g. thrower)

Question 39

What are 3 treatments for true muscle shortening?

Answer 39

1. Treat the problem, change habits
2. Stretching
3. Massage

Question 40

What are 2 reasons why overactivity occurs?

Answer 40

1. Protective response (adaptive) – pain, instability
2. Habitual (maladaptive) – poor patterning / substitution (e.g. for weakness)

Question 41

What are 3 treatments for overactivity?

Answer 41

1. Treat the problem, change habits
2. Reciprocal inhibition
3. Massage

Question 42

What are the 2 purposes of taping?

Answer 42

1. Positional/postural correction
2. Support/proprioception

Question 43

How long does the mechanical effects of taping last?

Answer 43

Mechanical effect of tape lasts for 20-30mins

Question 44

What is rigid tape vs k tape?

Answer 44

Rules out rigid

• Allergies

K tape

• Less allergies but while there is proprioceptive input not enough to stop movement

Question 45

What are 2 adjacent structures of the shoulder?

Answer 45

Cervical spine:

• In people with shoulder impingement and no Cx spine symptoms, lateral glide mobilisations of C5-7 resulted in:
  
  • Immediate reduction in pain (<2cm on VAS)
  • Immediate improvement in ROM of painful arc in abduction

Thoracic spine:

• In people with shoulder impingement, thoracic mobilisations resulted in:
  
  • Reduced pain during Neer, Hawkins Kennedy, empty can, resisted ER, resisted IR and active abduction
  • Improved SPADI score

Question 46

What are 4 features of referral?

Answer 46

1. Capabilities within your scope
2. Referral to expert physiotherapists
   
   • Identify someone with high level expertise in shoulder conditions
   • Specialist Musculoskeletal or Sports Physiotherapist (FACP)
3. Role of the physiotherapist with the GP and musculoskeletal health
4. Other medical professionals (Red flags, imaging..etc)