Manage shoulder chap 21 and 17 Flashcards
Compression and irritation of soft tissues in suprahumeral space
Impingement Syndrome
Shoulder Impingement pg 349 shank
this shoulder impingement refers to mechanical compression of the rotator cuff tendoms, primarily the supraspinatus tendon, as they pass under the
primary
Mechanical compression
Intrinsic or extrinsic
Testing associated with Subacromial RTC Impingement
Neer painful arc test
Pain with shoulder elevation and IR
Hawkins-Kennedy test
Figure 21-1, pg 350 Shankman
Impingement Syndrome
Degenerative changes can also result in decreased ________ __________ between the rotator cuff and the coracoacromial arch
subacromial space
Shoulder Impingement
RTC Impingement
what motions cause ?
Repeated ABD and ADD motions compromise blood supply to tendon
Primary impingement
Supraspinatus tendinitis
Tears within the RTC
RTC Impingement
What kind of posture may this patient assume?
Forwar head, anterior tipped scap wth decrese thoracic mobiltiy
RTC Impingement
Muscle imbalances
- Hypomobile pec major and minor, levator scapulae, and IR of the GH joint
- Stretch or strengthen? ceiling punches
- Weak serratus and lateral rotators
- Tight GH capsule posteriorly- arm across body
- Faulty kinematics with humeral elevation
- What activities would allow you to target these imbalances? be aware of shoulder hiking and uncoordinated scap/hum rhythm
scap motion kc 542 and 543
scap/hum rythm
for evry 2 degrees of gh flx or abd after first 30 degrees of shldr
What activities could you implement to begin improve scapulohumeral rhythm?
brushing hair
washing hair
reaching upward
RTC edu with dressing?
put bad arm in shirt first
RTC imp
stages 1,2,3
pg shank 349
and phase of rehab 1,2,3
Phase i
- prefuncitonal
- pt ed
- control inflammation and promote healing
- modailties
- immobilaztion
- maintain integrity and mobiltiy - pendulums
- develop support in related regions
RTC Impingemen fyi
Important to modify (not eliminate) activities
Shoulder impingement can be very painful in acute stage so your patients may not adhere to your exercise program.
Review ways to foster adherence
K & C Box 1.22
look up
look up
What signs and symptoms would indicate that the patient is no longer acute and has moved to the second stage?
No inflammation
inc ROM
decrease pain
Phase II – Return to Function
whats involved?
- Patient education
- Improve postural awareness
- Advanced scapular stabilization ex
- OKC exercises
Phase II – Return to Function
If exercise is too difficult, what might you see?
- rowing
- scaption- full cans /empty cans
- press ups/ over head press
- push ups with scap protraction - push ups with a+
What do the exercises target?
- rowing
- scaption- full cans /empty cans
- press ups/ over head press
- push ups with scap protraction - push ups with a+
upper middle lower trap
levator scapula
rhomboid major
pectoralis minor
middle and lowr serratus
Phase III – Return to Activity
whats involved?
- Process is slow and must be done cautiously
- Endurance
- Plyometrics
- Oscillatory training
- Body blade - Shankman – Fig 21-5
- Specificity of training
- Increase speed of exercise performance
RTC-Consider how the exercises differ in each stage.
Note progression/regressions
Muscles targeted
ISOM vs Resistance?
Mechanical vs. Manual
Surgical Management
Shoulder Impingement and RTC Tears
RTC Tears
- Acute
- Partial or full tears
Surgical Repair
Factors that Influence Progression of Rehab After Repair of the RTC
Table 17.4
K & C
fyi
General Exercise Guidelines and Precautions After Repair of a Full Thickness RTC Tear
Box 17.10
K & C
Mrs T had us highlight look in book
fyi
RTC Repair
With small repairs (less than 1 cm) what are the phases
Phase I – Prefunctional Phase
Phase II – Return to Function Phase
Phase III – Return to Activity Phase
Review time frames associated with each stage
Terms to be aware of
Positional recruitment
Promotes decompression
Rehabilitation after RTC repair or subacromial decompression (SAD) closely follows that of non-operative rehabilitation.
What considerations may a PTA take when working with this patient?
- size of tear
- physcian order
- WB restrictions
- sling-be aware of poor posture
- pre op strength
kc 572 17.4
How would treatment differ with a massive RTC repair?
What things may you, as the PTA, take into consideration?
faster than the massive
Terms to be aware of
Shoulder hiking
Compensation
Massive RTC Repairs
No active shoulder motion
What exercise could be implemented to keep the joint lubricated and does not require active motion?***
- no active concentric or eccentric contractions for 2-3 months after surgery
- no active shoulder motion
Pendulum Exercise or same as what?
Codman’s
Massive RTC Repairs
Note: AAROM activities can begin 2-3 mos following surgery
What type of early AAROM exercises would promote return of functional ROM?
How can those activities be progressed into more challenging exercises in the return to function and return to activity stages?
look up
When avoiding active shoulder motion and active concentric and eccentric strengthening for the first 2-3 months post surgery, what types of exs may be implemented?
phase 1,2,3
bikes
isometrics
RTC Repairs
Note: Shoulder is immobilized post surgery
Phase I
Isometrics
Added cautiously 4 to 12 wks post surgery
When can resistance be added?
wait 3 mos and make sure have FROM
When avoiding active shoulder motion and active concentric and eccentric strengthening for the first 2-3 months post surgery, what types of exs may be implemented?
Adhesive Capsulitis
Affects women more than men
40-60 yrs of age
name 2 types
- Primary idiopathic adhesive capsulitis
- Secondary adhesive capsulitis
- Stages I – IV**
- Note characteristics and time frames for healing
547 kc
adhesive capsit
stage 1
2
3
4
1
2 freez
3 froze
4 thawed
Adhesive Capsulitis
Acute
- Modalities
- Interventions to promote relaxation of :
- GH joint
- Cervical area
- ST muscles
- PROM, AROM, AAROM
- What type of exercises would promote regaining functional ROM?
- Joint mobilizations
CRPS (RSD)
What exercise(s) may help this patient?
Education
ROM
Edema
STM
When pt demos improve GH motion and appropriate scapulohumeral rhythm, strengthening exs can begin
deltoids
scapular muscles
RTC muscles
Upper arm muscles
Adhesive Capsulitis
Last Phase- whats involved
To promote normalized function
CKC resistance
How?
Task specific exercises
Very important to determine functional limitations to guide your treatment and demonstrate progress
Adhesive Capsulitis
Clinical Note:
HEP compliance must be continuously encouraged
Education
avoid pain provoking symptoms
Dislocation/Subluxation
Did you know…
Anterior more common than posterior
Anterior MOI: er and abd
Axillary nerve commonly injured
Posterior MOI: flex, add and IR
Falling on an outstretched arm
RTC tears are sometimes involved
30% in 40 yrs and >
80% in 60 yrs and >
Why is the method of injury (MOI) important when treating patients with dislocations/subluxations?
so you can allow for healing and don’t stretch the stuff that just got stretched
Dislocation/Subluxation
Terms to know:
Bankart Lesion**
Hills-Sachs Lesion**
Bankart Lesion** avulsion of the capsule ad glenoid labrum off the anterior rim of the glenoid resulint from atnerior dislcoation kc 578
Hills-Sachs Lesion** impact of fx of the post lat aspect of humerad d/t anterior shoiulder instabiltiy shank 354
Dislocation/Subluxations
Common Impairments
Common Functional Limitations/Disabilities
579 shank
Operative and Nonoperative Management
Dislocations/Subluxations
Prefunctional Phase
Progressive IR/ER can begin once pt can demonstrate near max isometrics
Dislocations/Subluxations
Return to Function Phase
Combined Shoulder ABD and ER are avoided
3 months after immobilization (sling)
physician will tell you
Dislocation/Subluxation
Hallmark of return to function phase
- Progressive strengthening of
- RTC
- Anterior shoulder muscles
- Scapular stabilization exercises
- Eccentric strengthening
Dislocations/Subluxations
Always address scapulohumeral rhythm
Focus on normalized scapular motion and stabilizations ex
How can PTA address functional motions and enhance proprioception through therapeutic exercise?
kc 356-7 shank
Dislocations/Subluxations
Corrective Surgery for Capsular Redundancy
See Pg 356 – Shankman
NOTE: Recommended slow and protected ER performed up to 12 weeks post op
ER incrimination listed in Shankman pg 356
Dislocations/Subluxations
Clinically, remember:
The degree and direction of shoulder motion is specific to
- Surgical procedure
- Wishes of the physician
- Direction of the PT
Dislocations/Subluxations
Elevation is normally progressed to______degrees (or pt tol) 6 wks post op
ABD
135
TSA
Prefunctional or Acute Stage
Positioning
Box 17.5 K & C
Precautions
Box 17.6 K & C
What types of exercises may promote motion in the early phase of rehab, as tolerated by patient and allowed by the physician?
556-557 kc
wand ex
scap mobs pg 363 shank
TSA
Functional use can be expected around _____months postoperatively
4
Goals of TSA
Pain relief
Functional mobility
Monitor pt carefully of TSA
Be aware of signs of hardware loosening
Tissue damage
What is TOS?
Encompasses a variety of clinical problems in the shoulder region
Thoracic Inlet Syndrome may be used as considered more anatomically appropriate
Figure 20-17 – Shankman
Figure 13.19 – K & C
Common TOS Symptoms
Radicular pain
Numbness
Tingling
Weakness
Skin and temp changes consistent with neurovascular tissue compression
What is TOS?
Pg 395-98 K & C
Brachial plexus in the thoracic outlet
Contributing factors
Common functional limitations
Guidelines for Managing TOS
TOS-Tests***
Adson’s maneuver/Halstead
K & C
Wright Allen Test
Pt’s hand is up with arm abducted from side.
Pt instructed to look away
If radial pulse disappears, test is positive
Military Brace Test
Roos Test
Shoulder Impingement pg 349 shank
This shoulder impingement is realted to glenohumeral instabilty that creates a reduced subacromial space because the humeral head elevates and minimizes the area under the coracoacromial ligament.
secondary shoulder impingement
