Lecture 7, Hypomobility of Shoulder Flashcards
Shoulder Stats
GH accounts for 12-25% of complaints
increases in frequency w/age
more female vs male
Who is at increased risk for shoulder symptoms?
repetitive and forceful work
previous neck and shoulder injuries
high demand work-place
post-stroke
spinal cord injuries
High risk occupations
manual labor
dental healthcare providers
hair stylists
overhead athletes
using 1 hand/side for job
regular keyboard use (more than 4 hours)
10% of day spent in 90° of flexion
Where are the symptoms coming from?
C-spine
Neurological
Internal organ
C-spine pain
pain with cervical ROM
pain distal to elbow
Internal organ pathology
visceral referral–refers pain to arm and shoulder
Bottom line for shoulder pain that is not the shoulder
clearn the c-spine in the presence of suspected referral
age >30 yrs, non-traumatic origin, neck pain
Broader areas of pain
C4 = up the neck, shoulder
C5 = back of the shoulder
Specific area of shoulder pain
AC pattern
subacromial pattern
GH pattern
Joint stability of GH is provided by
inert = capsule, labrum, ligament
muscles
remember that joint stability is a prereq for full active range of motion
Scapulohumeral rhythm
2 degrees of GH motion to 1 degree of scapular rotation
above 90 –> 1:1 ratio
humerus has to ER to clear greater tuberosity
Limitations in the ______ ________ will decrease ability to reach overhead
thoracic extension
Hypomobility can be caused by
RA
OA
trauma
post-immobilization
frozen shoulder/adhesive capsulitis
Acute phase of Arthritis
pain, muscle guarding
swelling deep in capsule
Subacute phase of Arthritis
capsular tightness
loss, greatest at ER, followed by abduction
pain at end of ROM
limited joint play
Chronic phase of arthritis
progressive increase in capsule tightness
loss of function, aching in deltoid
Definition of Adhesive Capsulitis
- ROM loss >25% in at least 2 movement planes
- at least 50% loss of passive ER
- duration of complaints >3 months
Pattern of ROM loss
ER
abduction
IR
flexion
Risk factors for idiopathic AC
female
age over 40 years
having AC on one side for opposite arm involvement
Risk factors for secondary AC
increased inflammation
diabetes
Risk for traumatic AC
following a trauma
prolonged immobilization of GH joint
Stage 1 of AC
inflammatory stage
gradual onset of pain w/movement
RC is strong
3 months duration
no adhesions or contracture at exam
Stage 2 of AC
painful/freezing
more intense pain at rest, all ROM limited
PT may not be beneficial at this stage
3-9 months
aggressive synovitis at exam
Stage 3 of AC
frozen
pain only during movement, compensated by scapula
atrophy of deltoid, RC, biceps, triceps
9-15 months
fibrosis at exam
Stage 4 of AC
thawing
minimal pain, resolving pain
may be showing some improvement in ROM
15-24 months
complex fibrosis at exam
Treatment approach for AC
level of irritability often reflects the tissue’s ability to accept physical stress
match intervention strategies to level of irritability
High level of irritability AC
not ready for significant physical stress being applied to the affected tissues
activity modification, manual therapy, low intensity levels for GH exercises, encourage motion at adjacent regions, limit # of visits
Moderate level of irritability AC
apply controlled physical stress to tissues
progressive manual therapy
mild stretching and strengthening activities
basic functional activities
Low level of irritability AC
progressive physical stress to tissues
stretching, manual therapy, resistive exercise, higher-demand physical activities
Patient Education for AC
home exercise programs are highly effective, but patient must have high levels of self-efficacy
corticosteriod injections can also help
Common limitations with general GH joint hypomobility
inability to reach overhead, behind headm to the side, behind back
dressing, grooming
lifting weighted objects
pain at night
Posture with GHJ hypomobility
scapular protraction, anterior tilt, elevated
Compensation and substitution w/hypomobility
scapular elevation
Acute phase Goals for GH joint hypomobility
maintain soft tissue and joint integrity and mobility
maintain integrity and function
control pain, edema, joint effusion
precaution = pain that increases w/intervention
contraindications = no stretching w/RA
Subacute goals for hypomobility
progressively incerease joint and soft tissue mobility
correct faulty mechanics
improve joint tracking
improve muscle performance
Self-mobilization can be done in the _____ phase
subacute
Return to function phase goals GHJ hypo
progressively increase flexibility and strength
prepare for functional demands
GH Distraction
indications = testing, initial treatment, general capsular mobility
separating joint can be perpendicular to treatment plane
MWM
mobilization with movement
- No pain should be produced
- overpressure is provided to end range
- results are expected at time of MWM
- results are long lasting
What should you do if you produce pain with MWM?
change direction of the accessory movement
change the amount of force
technique may not be indicated
Indications for MWM
full orthopedic exam has been completed
specific biomechanical analysis reveals loss of movement
comparable signs
manual therapy not contraindicated
Goals of MWM
increase active range of motion
decrease pain at rest with active motion
Dosage of MWM
6 to 10 times
reassess comparable sign and fatigue level
repeat 2-4 more sets as tolerated
