MSK 1 midterm Flashcards
SC joint facts
saddle joint
no direct muscle activity
SC joint concave vs convex?
vertically: vex on cave
anterior to posterior: cave on vex
AC joint facts
dynamic stabilization: delt and trap
no direct muscle activity
ST joint facts
ac and sc movements control this joint
movements named in relation to glenoid fossa
GH joint facts
synovial joint
only 1/3 of humerus contacts glenoid
passive stabilizers of GH
anterior and posterior capsule and labrum
humeral head and glenoid fossa
angle of humeral retroversion
35-40 deg
when is EMG increased in biceps and triceps?
shoulder flexion and abduction
axioscapular muscles
trap*
serr anterior*
levator scapula
rhomboids*
pec minor
how can brachial plexus be injured?
stretch
compression
thoracodorsal nerve
C6-8
innervates the lat
long thoracic nerve
C5-7 raises arm to heaven
innervates serr ant
long, narrow, superficial
dorsal scapular nerve
C5
pierces middle scalene
innervates levator scapula and rhomboids
medial winging
retraction and elevation
long thoracic involvement
weakness of SA
lateral winging
elevation, upward rotation, and protraction
dorsal scap involvement
weakness of rhomboids
what % of special tests and stand alone and have high clinical utility?
4%
a line of logic
activities that limit participation
symptoms - when better and worse
mobility
neural impairments
most noticeable aspects
symptom modulation
disability: high
directional preference exercises
manipulation/mobilization
traction
nerve glides
modalities
active rest
movement control
disability: mod
sensorimotor exercises
stabilization exercises
flexibility exercises
functional optimization
disability: low
strength and conditioning
work or sport specific exercises
aerobic exercises
general fitness exercises
PT pyramid from
advanced performance
movement and control
mobility
tissue healing and symptom modulation
therapeutic alliance
motor learning summary
preparation
parameters
feedback
assessment
load
< 25% for endurance
> 40% for hypertrophy
> 85% for athletes
volume of exercies
optimal is 10 sets/muscle/week
intensity of effort
2 reps in reserve
CAN do 2 more
rest interval
2 minutes
repitition duration
6 seconds is the sweet spot
2-10 seconds range
tendon remodeling
treat the donut not the hole
need 48 hrs rest between tendon sessions
eccentric training optimal - 2 sets of 15
stretching
30 sec/attempt
total 90+ seconds
nerve glide
start at 1x10 everyday of the week
do not progress the day after
motor pattern retraining
2-5 minutes
stop when cannot self regulate or doing incorrectly
STAR shoulder
staged approach for rehabilitation classification for the shoulder
diagnoses of the shoulder
subacromial pain syndrome
adhesive capsulitis
glenohumeral instability
other
self reported measures for the shoudler
the DASH
shoulder pain & disability index (SPADI)
5 most common potential red flags
tumor
infection
fracture or dislocation
neurologic lesion
visceral pathology
what are the #1 places for visceral referred pain?
shoulder and low back
CPR for acute CAD
chest pain
SOA
upper abdominal pain or dizziness
men aged >30
women aged >40
screening for yellow flags
fear avoidance beliefs questionnaire (FABQ)
tampa scale of kinesiophobia (TSK)
patient profile (who)
age
MOI
PMH
occupation
recreation
patient’s current condition (what)
chief complaint
SINSS
labs or diagnostic
symptom pattern (who)
aggravating factors:
posture
movement
easing factors:
posture
movement
modalities
meds
location of symptoms (where)
impingement syndrome - <50% had pain below elbow
rotator cuff tear - >50% had pain below elbow
GHJ arthritis - >80% had pain below elbow
observation
starts in waiting room
posture
assess for atrophy
screening for referral: MSK causes
olecranon manubrium percussion
rotator cuff screening
bony apprehension test
clear the cervical spine
bony apprehension test
hold forearm with elbow at 90 deg angle
abduct and externally rotate arm to 45 deg
+ apprehension
clearing the cervical spine
positive ULTT (specifically median)
<60 deg cervical spine rotation on affected side
positive distraction test (relives)
positive spurlings (lateral compression, causes)
3 criteria has best specificity
apley’s scratch test
opposite shoulder - add and IR
sup angle of opp scapula - abd and ER
inferior angle of opp scapula - IR, add, ext
upper quarter Y balance test
measure arm length from C7 to longest digit
push up position
stationary arm is test arm
other reaches medially, superolaterally, inferolaterally
sum of 3 movements
normalized score = total / (3 x limb length)
SICK scapula
scapular malposition
inferior medial border prominence
coracoid pain
dyskinesis of scap movement
scapular dyskinesis test
perform up to 5 reps of shoulder flexion and abduction
+ winging or abnormal movement
scapular assistance test
elevate arm and rate pain
clinican manually assists into upward rotation and posterior tilting
+ decrease pain with assistance
scapular reposition test
finger anterior to AC
palm on spine of scap
apply pressure into posterior tilt and ER
what is subacromial pain syndrome
nontraumatic, unilateral pain
increased pain with movements above shoulder height
44-65% of shoulder pain originates from structures in subacromial space
neer’s sign
stabilize scapula
full flexion and IR until pain or end ROM
+ pain reproduced along ant or lat shoulder
hawkins-kennedy test
clinician stabilizes pt’s arm in 90 deg flexion
support elbow
full internal rotation
+ if pain is reproduced
painful arc
face client to monitor face for pain
active abduction
+ pain in 60-120 deg but none outside of this range
test cluster for subacromial impingement/pain syndrome
hawkins-kennedy
painful arc
infraspinatus test
drop arm test
affected side held in 90 deg abd
releases support of arm
pt slowly lowers to neutral
+ no control
muscle targeted: supra
full can test
arms in 90 deg in scapular plane
thumbs up position
apply inferior force
+ weakness or pain in affected arm
muscle targeted: supra
empty can test
arms in 90 deg in scapular plane
thumbs down position
apply inferior force
+ weakness or pain in affected arm compared to full can
muscle targeted: supra
external rotation lag
affected side brought to 20 deg abd and full ER
support elbow and wrist
have pt maintain external rotation
+ unable to maintain ER
infraspinatus or external rotation resistance test
elbows flexed to 90 deg
clients resists into ER
+ unable to maintain resistance due to weakness or pain
lift off test
affected side behind back
ask pt to lift hand off back
+ cannot lift hand off back
muscle targeted: subscap
belly press test
elbow flexed to 90 deg with hand on belly
press into stomach
+ elbow moves posteriorly
muscle targeted: subscap
can be used to rule out subscap tear if cannot perform lift off
speed’s test
client resists shoulder flexion through 60 deg of motion
+ shoulder pain reproduced
muscle targeted: biceps
yergason’s test
elbow flexed to 90 deg, fully pronated
palpate biceps tendon
client resists supination and ER
+ pain over origin of biceps
muscle targeted: biceps
relocation test
supine
anterior apprehension test
posterior force over humeral head
+ relief when relocation force is applied
surprise test or anterior release test
supine
anterior apprehension
apply posterior force
remove the force
+ shoulder pain after posterior force is removed
diagnostic cluster for anterior instability
anterior apprehension
relocation
posterior apprehension test
supine
shoulder flexed to 90 deg
add compressive force
add hor add and IR
Jerk test
sitting
stabilize scapula and arm in 90 deg flexion and full IR
add compression and slowly move arm into hor add and maintain IR
+ shoulder pain or clicking reproduced
hyperabduction
hold scapula down
move clients arm into abduction with elbow on 90 deg of flexion
+ apprehension or abducted past 105 deg
laxity: greater than 105 deg abd
instability: apprehension with > 105 deg abd
biceps load I
supine with arm in 90 deg abd, 90 deg flex and full supination
client resist elbow flexion
+ pain or apprehension during resistance
biceps load II
120 abd, 90 flexion, full supination
resists elbow flexion
+ pain during resistance
passive compression test
side lying with elbow flexed to 90 deg
clinician supports at elbow and scapula
compresses humerus, passively ER at 30 deg abd
extend shoulder while maintaining compression
+ pain or catching of the shoulder
o’brien’s test for labral tear or active compression test
sitting with shoulder flexed to 90 deg and horizontally adducted to 10-15 deg
fully IR the shoulder and pronate the elbow
resists flexion
repeat with neutral forearm
+ symptom reproduction or clicking in initial position and absent in second
test cluster for labral pathology
biceps load I
biceps load II
speed’s test
passive compression test
active compression test (o’brien’s)
ludington’s test
for rupture of biceps long head
interlock fingers on head
press down
+ if unable to feel contraction on affected side
popeye sign
ball of muscle on upper arm
cross body adduction test
(acromioclavicular crossover test)
stabilize scap
passively horizontally adduct arm
+ reproduction of pain at AC
resisted extension test
seated with shoulder in 90 flex and IR
elbow in 90 flex
pt horizontally abducts arm against isotonic resistance
+ pain in AC
cluster for AC joint pathology
cross body adduction
resisted extension test
active compression test
rhythmic stabilization
indication: weakness, poor co-contraction
goal: train to respond quickly
alternating isometrics
three types of rhythmic stabilization
neutral
90 deg flexion
closed chain - quadruped
what part of motor control can a therapist impact?
action and perception
define motor learning
set of processes associated with practice that lead to changes in skilled movement
what are the three stages in motor learning according to fitts and posner?
cognitive - step by step
associative - refinement
autonomous - mastery, takes no thought
where learner focuses attention
what are the three stages in motor learning according to bernstein?
establishing - freezing degrees of freedom
refining - reorganizing
exploiting - mechanics and inertia
focus of degrees of freedom
closed loop theory
trial and error
perceived correctness
same exact skill
schema theory
outcome
variety of practice
emphasize result
cognitive theory
best with low cognitive demand
need cognitive demand as they progress
hierarchical
revert to processing step by step when under stress
optimal theory
motivation helps learn quicker
verbal preparation
over explanation hinders learning
focus on what to do
auditory cues
visual prep
watching a new movement aids motor learning
observing mistakes and correction helps most
mental prep
mental practice aids learning, but physical practice is usually preferable
focus prep
an external focus is preferable to an internal focus
external = intended body movement
distance of focus should correspond to proficiency
motivation prep
learn better with high self-efficacy
give choices
link to pt goals
positive feedback
distribution
rest breaks improve performance and learning
variability
high open-task performance
high learning
good for children
contextual interference
improves learning and transfer
knowledge of performance
dependent on focus
guidance boosts performance
best suited for:
new learners
slow movements
complex tasks
tasks that may injure or fear
knowledge of results
preferable
helps to a point
fade out for optimal learning
deliver after a slight delay
2-15 trials
optimal feedback
autonomy
enhanced expectations - positive best
feedback allows redirection
effleurage
broad strokes
hand in shape of the limb
warm up the tissue
petrissage
kneading - increases circulation, mobilizes
rolling - perpendicular to muscle fibers
cross friction massage
for tendons
prevent adhesions
must be on target tissue
perpendicular
passive stretching
when hypomobility limits ROM
lengthens affected tissue
hold 15-30 seconds, release, repeat
2-4 reps
pec minor passive stretch with towel roll
towel between scapulas
thenar eminence below clavicle and press into table
hold/relax
when ROM is restricted
primarily for contractile tissue
increase ROM using autogenic inhibition
submaximal isometric contraction for 5-10 seconds
passively move through new ROM
repeat 4-6 times
stabilization should follow
GH joint mobs
when limited ROM and pain
loose packed - grade 1-2
end ROM - grade 3-4
~45 seconds or until change
use your body to guide force
GH joint distraction
hand on AC to stabilize, pull down just proximal to elbow
hand on AC, pull down with hand in a C just under axilla
GH posterior glides
stabilize elbow, push down over GH
stabilize AC, push down through elbow
GH inferior glides
come from above
stabilize elbow, push towards axilla
passive ROM
PROM restrictions
increase mobility
move through available range
DO NOT hold
flexion, abd, IR/ER
mobilization with movement
brian muligan
glide maintained as pt moves
MWM shoulder ER
posterior glide of GH
use cane to push shoulder into ER
MWM shoulder IR
lateral and inferior glide of GH
use towel to pull shoulder into IR
ST mobs
side lying, all planes
upward rotation with active flexion
considerations for effective evaluations
referral when needed
diagnosis
prognosis
what is subacromial pain syndrome?
(4 examples)
44-56% of all condition that cause shoulder pain
subacromial impingement
RC related shoulder pain
RC tendinopathy
RC disease
subacromial pain syndrome: MOI
relative over use
subacromial pain syndrome: impairments
anterior/lateral shoulder pain
painful arc
limited GH mobility
kyphosis
decreases pec minor length
scapular weakness
subacromial pain syndrome: pain pattern
deltoid region
overhead
subacromial pain syndrome: risk factors
excessive or recent increase in overhead
subacromial pain syndrome: obseravtions
posture
scapular dyskinesis
subacromial pain syndrome: examination
good ROM; painful arc
decreased scapular uprot and post tilting
weakness in abd, ER, IR, flexion
3/5 positives in cluster
no instability
subacromial pain syndrome: manual therapy
high irritability:
grade 1-2 mobs
spine manipulation
soft tissue mobs to pec
light rhythmic stabilization in neutral
low to moderate irritability:
grade 3-4 mobs, maybe at end ROM
ST, AC, SC mobs
cross friction and other STM
hold/relax for mobility
RS in varying degrees of ROM
subacromial pain syndrome: therapeutic exercises
high irri:
isos in neutral
scapular setting
table slides
mode irri:
resistive
pec stretching
scap retraction
thoracic mobs into ext and rotation
low irri:
increase load and ROM of above
pec stretching with arms in abd/ER
prone scapular strengthening
primary impingement
structural problem
narrowing of subAC space
osteophytes
hooked acr
bursitis
tendinopathy of RC and biceps
secondary impingement
functional problem
shoulder muscle imbalance
laxity/instability
scap dyskinesis
postural dysfunctions
full thickness rotator cuff tear: MOI
traumatic will require imaging
atraumatic is likely degenerative
full thickness rotator cuff tear: impairments
pain with mvmt
tender greater tub or acr
sling position
atrophy, lag signs
sever ROM restriction
full thickness rotator cuff tear: tear length classification
small: <1 cm
medium: 1-3 cm
large: 3-5 cm
massive: 5+ cm
full thickness rotator cuff tear: pain pattern
ant and lat shoulder, down arm
worse at night
full thickness rotator cuff tear: risk factors
age
falls in younger and older
full thickness rotator cuff tear: observation
arm in sling position
full thickness rotator cuff tear: examination
smaller tears may be weak and painful with resistance
massive have profound weakness and lag
shrug with elevation
full thickness rotator cuff tear: CPR
age > 65
pain at night
weakness in ER
full thickness rotator cuff tear: manual therapy
high irri:
preserve ROM
grade 1-2 mobs
RS in neutral
low to mod irri:
grade 3-4 capsular restrictions
RS in varying angles
hold/relax for ST restrictions
full thickness rotator cuff tear: therapeutic exercise
small to medium - nonsurgical:
strengthening in neutral to elevation
balance ER/IR force couples
stretching posterior capsule
scapular muscle strengthening
large and massive - nonsurgical:
AAROM to RROM
strengthen deltoid and intact RCs to gain functional elevation
long head of biceps tendinopathy or tendon rupture: MOI
continuous/repetitive shoulder motions
excessive abd with ER
for rupture: heavy lift, FOOSH
long head of biceps tendinopathy or tendon rupture: impairments
pain in superior and anterior shoulder and with overhead
pain with resisted flexion but not abd
tender bicipital groove, possible popping
possible signs of instability with labral involvement
what are examples of long head of biceps tendinopathy or tendon rupture?
bicipital tendonitis
bicipital tendinosis
biceps tendon rupture
long head of biceps tendinopathy or tendon rupture: pain pattern
deep ache of sup and ant shoulder, possible arm pain
pain with lift, push, pull
long head of biceps tendinoapthy or tendon rupture: risk factors
overhead
rupture:
heavy lift
FOOSH
age
corticosteriod use
long head of biceps tendinoapthy or tendon rupture: observations
poor scap mobility
kyphosis
long head of biceps tendinopathy or tendon rupture: examination
pain on palpations of bicipital groove
pain with resisted flexion not abd
+ speed’s, yergason’s ludington’s for rupture
long head of biceps tendinoapthy or tendon rupture: manual therapy
joint mobs:
GH - post and inf
thoracic spine
ST if hypomobile
STM/MFR:
cross friction to prox biceps tendon
STM to pecs/traps
RS
long head of biceps tendinoapthy or tendon rupture: therapeutic exercise
scap setting iso holds to resistance
RC isos if irri high
banded and isotonic RC if low irri
thoracic ext and rotation
follow pot-op protocol
adhesive capsulitis: MOI
synovial inflam with adhesions
Primary: insidious onset
secondary: trauma, immobilization, CRPS
what are the 4 stages of adhesive capsulitis?
pre freezing
freezing
frozen
thawing
adhesive capsulitis: impairments
progressive loss of active and passive movements
adhesive capsulitis: systemic considerations
DM, thyroid disorder, autoimmune
septic arthritis, malignancy, PMR
adhesive capsulitis: pain pattern
acute: localized in arm/down the arm, night pain
chronic: localized, not awakened at night
adhesive capsulitis: risk factors
females aged 45-60
history of AC in contralateral limb
adhesive capsulitis: observation
shrug with elevation
arm in add/IR
adhesive capsulitis: examination
restricted ROM in capsular pattern
adhesive capsulitis: manual therapy
scap mobs
GH mobs
passive stretching
ST mobs, hold/relax
adhesive capsulitis: therapeutic exercise
acute:
exercises to restore ROM (wand, pulleys)
isos
pendulums
chronic: self-stretching the capsule
wall climbing
PNF for functional ROM
what % of GH dislocation are anterior?
90%
glenohumeral instability: MOI
traumatic
atraumatic: repetitive OH
with or without RC tear, fracture, brachial plexus injury
glenohumeral instability: impairments
anterior instability
GIRD
posterior shoulder tightness
weakness esp IR
waht is glenohumeral instability?
shoulder pain and motor coordination deficits
glenohumeral instability: pain pattern
variable
glenohumeral instability: risk factors
bimodal age: M15-29, F70+
traumatic 7x more likely in males
glenohumeral instability: observation
altered muscle recruitment patterns
glenohumeral instability: examination
posterior shoulder tightness, check MRS
apprehension with ROM
IR strength deficits in anterior instability
+ apprehension, relocation and hyperabd
fear avoidance
+ beighton’s
may also have + impingement tests
glenohumeral instability: manual therapy
differs based in classification of instability
GH mobs as needed, avoid hypermobile areas
ST mobs
thoracic mobs
RS for proprioception
glenohumeral instability: therapeutic exercise
early:
RC and scap muscle activation
adress proprioception
middle:
resistive exercises <90
controlled AROM in safe ROM
late:
strengthening provocative positions
SINEX for traumatic
waston for atraumatic
labral lesion: MOI
repetitive OH
trauma
labral lesion: impairments
pain - worse with heavy, pushing, OH
popping in rotation
weakness
posterior shoulder tightness
types of labral lesions
SLAP tear
bankart lesion
labral lesion: pain pattern
anterior and superior arm pain
dead arm
labral lesion: risk factors
age <40
FOOSH, OH
labral lesion: observation
popping, cluncking with mvmt
labral lesion: examination
scap winging with elevation
decreased upward rotation
anterior glide of humeral head
+ o’brien’s, biceps load tests
possible instablity
labral lesion: manual therapy
GH 1-2 mob for pain
GH 3-4 mob for ROM
STM or post RC, lats, pecs
RS
labral lesion: therapeutic exercise
stabilization for force couples
strengthening starting in midrange and progressing to end range. IR/ER ratios
thoracic ext and rotation mobility
strengthening tight tissues - lats, RC, pecs
in overhead athlete:
max contribution of core and LE
proximal humeral head fracture: MOI
FOOSH
direct blow to shoulder
what is the third most common type to fracture in adults?
proximal humeral head fracture
proximal humeral head fracture: impairments
pain: severe and sharp, radiates down arm
very limited ROM
proximal humeral head fracture: pain pattern
severe, sharp shoulder pain
may radiate down arm
proximal humeral head fracture: risk factors
bimodal age
falls, trauma
higher in females 2:1
proximal humeral head fracture: observation
swelling, bruising down arm and across chest
may be immobilized
proximal humeral head fracture: examination
very limited ROM
stiffness after immobilziation
proximal humeral head fracture: manual therapy
may depend on type and grade
passive ROM as tolerated
ER may be restricted by physician
proximal humeral head fracture: therapeutic exercise
AROM gripping, wrist, forearm, elbow, scap pro/ret
PROM to AAROM, AROM once healing occurs
submaximal isos
theraband
acromioclavicular injury: MOI
force to top of shoulder
FOOSH where humeral head moves superior to acr
primary or secondary OA
acromioclavicular injury: impairments
scapular depression in lig tear
palpable step off clavicle
pain in sup shoulder; insidious OA
ROM limitations secondary to pain
3 types of acromioclavicular injury
AC joint sprain
AC joint separation
AC joint OA/arthropathy
acromioclavicular injury: pain pattern
top of shoulder
possible ant shoulder
acromioclavicular injury: risk factors
traumatic: age <35 male, contact sports
OA: heavy manual work, OH trauma
acromioclavicular injury: observation
trau: post or sup migration of clavicle
OA: small bump at ACJ
acromioclavicular injury: examination
trau: palpation/paxinos sign
+ cross body add, active compression, resisted extension
acromioclavicular injury: manual therapy
AC mobs if hypomobile
ST mob if hypo
PROM, GH mobs to increase ROM
modalities as needed for pain
acromioclavicular injury: therapeutic exercise
P to AROM as tolerated
avoid hor add, IR, and end ROM initially
RC and scap strengthening
delt and trap strengthening
posterior internal impingement: MOI
repetitive OH
younger, active
what is posterior internal impingement?
impingement of posterior RC between glenoid and humeral head
posterior internal impingement: impairments
pain in post shoulder
joint hypermobility
post capsule and soft tissue restriction
poor scapular retraction and posterior tilt
GIRD
posterior internal impingement: pain pattern
post or lateral shoulder pain
posterior internal impingement: risk factors
generalized hypermobility
repetitive OH
GIRD
posterior internal impingement: observation
prominent medial scap
posterior internal impingement: examination
RC weakness, tender under posterior acr
+ apprehension and relocation
posterior pain
poor scapular movements
posterior capsule and RC stiffness
+ scapular relocation test
posterior internal impingement: manual therapy
mobs:
posterior GH
ST retraction and post tilt
ST:
posterior RC
pec minor
RS for stability
hold/relax for mobility
posterior internal impingement: therapeutic exercise
stretching of tight: post capsule, RC, pec minor
strengthening of scap retractors and RC
re ed of proper scap movements
glenohumeral osteoarthritis: MOI
degen changes over time
heavy labor
prior trauma
what % of pts with shoulder pain have symptomatic OA?
5%
glenohumeral osteoarthritis: impairments
progressive stiffness and loss of ROM
crepitis in ROM
pain worse at night
pain with joint compression
glenohumeral osteoarthritis should be suspected in which pts?
> 60 with adhesive capsulitis
glenohumeral osteoarthritis: pain pattern
worse at night and with activity
glenohumeral osteoarthritis: risk factors
age >60 with AC
females
previous shoulder injury
heavy manual labor
glenohumeral osteoarthritis: observation
shrug sign with elevation
glenohumeral osteoarthritis: examination
crepitus with ROM
weakness
glenohumeral osteoarthritis: manual therapy
gentle ROM
1-2 mobs for pain
3-4 mobs for mobility
RS for stability
hold/relax for mobility
glenohumeral osteoarthritis: therapeutic exercises
joint protection for OA!!!!
mild to mod:
gentle stretching and self mob
rc and scap strengthening
thoracic ext/rot
possible medical management for symptoms
posterior SC mob with movement
horizontal adduction
airplane position then to clapping position
inferior SC mob with movement
shoulder flexion
AC joint mobs
inferior - push on clavicle
posterior - push on acromion
thoracic spine mob
push down into table
can be central or unilateral
define nerve sliders
lengthening one joint while tensioning at another
in acute
define nerve tensioners
lengthening across all moving joints
in chronic
median nerve slider and tensioner
slider:
flex elbow, extend wrist
extend elbow, flex wrist
tensioner:
flex and extend elbow with wrist extension
ulnar nerve slider and tensioner
slider:
flex elbow, flex wrist
extend elbow, exend wrist
tensioner:
flex and extend elbow with wrist extension
radial nerve slider and tensioner
slider:
depress scap with hip, abd arm and elevate shoulder
tensioner:
maintain scap depr while abd the shoulder
3 self mobilization glides
caudal:
careful if hypermobile or nervy
hold onto sitting surface and lean opposite
anterior:
least often
propped up on elbows on back
posterior:
push up position with stomach on table
AAROM into elevation (3 examples)
supine AA elevation:
on back
use uninjured arm to move injured arm
forward bow:
hands on table
squat through shoulder ROM
wall slides:
forearm against wall and go through ROM
3 codman’s pendulums
uninjured hand on table, use body’s momentum to move injured arm
CW/CCW circles
forward/backward
side to side
wand AAROM
can be done sitting for supine
flexion
abd - best in sitting
external rotation
shoulder internal rotation AAROM
wand BBIR stretch:
hands behind back and pull wand up
make sure not to flex thoracic spine
towel BBIR stretch:
injured arm behind back, uninjured in front and pulls towel done
pulleys
high irri:
flexion
scaption
abduction
low irri:
BBIR
posterior capsule stretching
sleeper stretch:
lay on injured arm
hand on wrist
make sure not to rotate
horizontal adduction stretch:
supine
pull injured arm across body at elbow
scapular setting
standing or sitting
draw scapula into retraction and depression
“tuck into back pocket”
make sure to do it unilateral
shoulder isometrics
when pt is high irri but cleared for strengthening
arm at 90/90 for each
use a towel
in doorway
extension
ER
flexion
IR
adduction
abduction
basic theraband shoulder exercises
grip strength helps activate muscles
doorway
ER - watch protraction, towel
IR - watch thoracic rotation, towel
abduction
extension
flexion
adduction
supine or standing flexion and diagonals
flexion:
straight up above head
resisted diagonals with D2 pattern:
watch shoulder hiking
take sword out of pocket
thumb to hip, thumb points behind body
dumbbell rotator cuff/shoulder strengthening
full cal abduction:
in scapular or frontal plane
side lying ER:
something you add early and take out late
skeleton key for practical
many scapula compensations
elbow to side, towel for comfort
serratus strengthening
supine punch:
supine
arm straight and protract to punch
can go from 90/90
standing band punch:
identical to supine but standing
scapular wall slides
stay in pain free ROM
press through hand rather than elevating through shoulder girdle to decres ulnar tension
push elbow into wall
can add band to wrists
standing theraband extensions/rows (low level)
extensions:
band at waist level
keep arms straight through extension
low rows:
for high irri
band at waist level
depress and retract scapula
straight arms to 90/90
pinch scaps together
standing theraband high row and horizontal abduction (higher level)
high row:
band comes from above head
straight arms to flexed elbows
pinch scaps
resisted horizontal abduction:
band at waist level
arms straight in front to straight out at sides
“give a hug and come out of it”
prone middle trap strengthening progression
retraction without arm movement:
no shoulders at ears
pinch scaps
arms at 90/90
retraction with forearm lift:
no shoulders at ears
pinch scaps
arms at 90/90
retraction with horizontal abduction (T’s):
arms straight out to the side
retraction with resisted horizontal abd:
rare
band under table
torando drill position can be good for a young athlete
prone lower trap strengthening progression
retraction/depression with or w/o forearm lift:
arms on table above head
retraction/depression with modified arm lift:
hands on back of head
watch for trunk ext
retraction/depression with arm lift (Y’s):
core can wear out before shoulder
can do unilateral
retraction/depression with arm lift (Y’s) with resistance:
rare to add resistance
muscle length: pec major/minor
pec major stretch:
put elbow on corner of wall and push forward
pec minor stretch:
arms behind back and push away form back
arm by side pec stretch:
stretched both muscles
push GH into corner of wall
thoracic mobility: extension
sitting:
in chair with hands behind head or neck
supine:
foam roller right below scapulas
can hold or do small oscillations
thoracic mobility: rotation
side lying
both legs bent
arms out in front (alligator arms)
bring top arm to other side of body (opening a book)
head and eyes will follow moving arm
progression: straighten bottom leg and keep top leg bent
what are examples of anti-inflammatories?
OTC: ibuprofen, naproxen
prescription only: meloxicam, celebrex, oral corticosteroids
who benefits from anti-inflammatories?
pts with pain/inflammation
what are implications for PT treatment with anti-inflammatories?
screening for systemic manifestations
what are examples of analgesics?
OTC: acetaminophen
prescription: opioids
they act on the CNS
who benefits from analgesics?
pt with pain that did not respond to NSAIDs
what are implications for PT treatment with analgesics?
screening for systemic manifestations
what are corticosteroid injections?
local administration of steroid into joint
greater pain relief than oral
can weaken bone or tendon
who benefits form corticosteroid injections?
pts with slow progress due to pain
PT + injection is better than either treatment alone
what are implications for PT treatment with corticosteroid injections?
avoid activity for 48 hrs then gradually return to activity
numbing agents may damped pain signals which results in overdoing
what is viscsupplementation?
sodium hyaluronate - glucosaminoglycan found in CT
series of 3-5 injections
brand names - supartz, hyalgan
who benefits from viscosupplementation?
pt with RC tear, adhesive capsulitis and OA
what are implications for PT treatment with viscosupplementation?
avoid strenuous activity for 48 hours
routine activity is ok
not as beneficial as cortisone or prolo
what is prolotherapy?
hypertonic dextrose injections create acute inflammation, leads to improved healing
what are some frequent injection sites of prolo in the shoulder?
corocoid process
subscapularis tendon
greater tuberosity
who benefits from prolotherapy?
after failed RC repair or with RC lesions
less evidence for AC and OA
what are implications for PT treatment with prolotherapy?
follow dr recommendation
possible activity restriction
has a relatively low risk
what is subacromial decompression?
arthroscopic removal of bony overgrowth of acromion
with or without bursectomy
who benefits from subacromial decompression?
pts not successful with conservative treatment
what are implications for PT treatment with subacromial decompression?
no structures require specific protection
based on tissue irritability
progress as quickly as pt tolerated
full return to function between 6 weeks to 3 months
what is a rotator cuff repair?
torn tendon reattached
open vs arthroscopic
open has higher risk, longer recovery, is for a more complicated case
who benefits from from rotator cuff repair?
younger pts with traumatic MOI or pts participating in high demand activities
what are implications for PT treatment with rotator cuff repair?
protocols
describe the surgical management of SLAP lesions
debridement
biceps tenotomy/tenodesis
SLAP repair
Bankart repair - 3:00-6:00
combined
who benefits from the surgical management of SLAP lesions?
pts who do not respond to conservative management
what are implications for PT treatment with surgical management of SLAP lesions?
protocols!
general protocol considerations for debridement
fastest recovery
ADLs as tolerated
fix biomechanical issues
general protocol considerations for biceps tenotomy/tenodesis
no resisted biceps work for 6 weeks
general protocol considerations for SLAP repair
early - immobilized, no shoulder AAROM/AROM, elbow AROM, WB on UE, or reaching behind back (IR)
intermediate - no resisted elbow flexion, lifting > 10 lbs
general protocol considerations for bankart repair
early - no shoulder AROM, WB on UE, lifting
intermediate - no lifting > 10 lbs
after 12 weeks, no limit
after 6 months, return to sport
what is a capsular shift/plication?
surgical technique to tighten the capsule
folding
can be arthroscopic or open
what is thermal capsulorrhaphy?
surgical technique to tighten the capsule
thermal or radiofrequency laser
heating to cause capsule to shrink in unilateral instability
who benefits from capsular shift/plication and thermal capsulorrhaphy?
pts with GH instability
what are implications for PT treatment with capsular shift/plication and thermal capsulorrhaphy?
ROM restriction initially post-op to reduce re-stretching of capsule
what is manipulation under anesthesia?
surgical procedure in which shoulder is moved through full ROM to tear adhesions
relatively quick procedure
what are the risks of manipulation under anesthesia?
fracture
dislocation
brachial plexus injury
who benefits from manipulation under anesthesia?
pt with AC who does not succeed with conservative treatment
what are implications for PT treatment with manipulation under anesthesia?
aggressive ROM post-op
daily for 1st week
what is an anatomical total shoulder arthroplasty?
implants preserve convex on concave relationship of shoulder joint
who benefits from anatomical total shoulder arthroplasty?
pt with primary OA and intact RC
what are implications for PT treatment with anatomical total shoulder arthroplasty?
immobilization for 2-8 weeks
protect the subscapularis
what is a reverse total shoulder arthroplasty?
implants change the convex on concave relationship of the shoulder to concave on convex
who benefits from a reverse total shoulder arthroplasty?
pt with OA without intact RC, fractures, tumors
what are implications for PT treatment with reverse total shoulder arthroplasty?
abduction sling initially, followed by regular sling for 4 weeks
now rely on delt when moving shoulder
dont have to protect RC
anatomic vs reverse total shoulder: which has less restrictions?
reverse
anatomic vs reverse total shoulder: biggest difference in rehab?
reverse has resistance earlier
