Shoulder Management and Prognosis

Question 1

STAR Approach

Answer 1

Classification system/algorithm to guide treatment of shoulder disorders

Unknown if this improves treatment outcomes over other care

Simple approach, helps reduce novice clinicians getting lost in the weeds

Question 2

Step 1:

Answer 2

Classify based on impairments and available knowledge of pathoanatomy

loose
stiff
painful

Question 3

Step 2:

Answer 3

Classify based on tissue irritability levels

high pain >7/10
> consistent night pain
> pain before end of ROM
AROM < PROM

moderate pain 4-6/10
> intermittent night pain
> pain at end of ROM

low pain <3/10
> absent night pain
> minimal pain with overpressure
AROM = PROM

Question 4

Step 3:

Answer 4

Design a Plan of Care based on Impairment classification and Irritability level

Question 5

Step 4:

Answer 5

Continually re-assess impairments and irritability level and adjust the POC accordingly

> Always within the context of the patient’s function

> Toe the line: Don’t overtreat but don’t undertreat

Question 6

Painful Shoulder
Outcomes:

Answer 6

50% better within 8-12 weeks

40% can persist longer than a year

Surgery VS Rehab
> No differences in outcomes

Question 7

Painful Shoulder
Risk Factors:

Answer 7

Poorer outcomes associated with:

> Older age
Duration of symptoms
Concomitant neck pain
Patient expectations

Question 8

Painful Shoulder
Treatment Approach:

Answer 8

Subacromial Pain/Rotator Cuff related Pain = Overuse resulting in symptoms +/- degeneration:
> Reduce symptoms
> Relative rest
> Improve tissue capacity to loading

Rotator Cuff Strengthening

Manual Therapy

Joint mobilization is Effective at reducing pain, especially when combined with exercise

Question 9

Scapular stabilization programs

Answer 9

Effective at reducing shoulder pain

not effective at changing scapulothoracic biomechanics

Question 10

Painful Shoulder Management and Prognosis
Program should include the following:

Answer 10

> Rotator Cuff exercise (build load capacity

> Manual Therapy (pain)

> Include scapular exercises if impairments found and positive scap tests

> Sprinkle in adjuncts if needed

Question 11

Stiff Shoulder
Outcomes:

Answer 11

Adhesive Capsulitis

> Previously thought most patients recover in 12-18 months. New evidence:
At 4.4 years 41% still had symptoms although functional outcomes were good

Question 12

Stiff Shoulder
Risk Factors:

Answer 12

Adhesive Capsulitis
> Diabetes Mellitus 5x more likely
> Hyperlipidemia 1.5x more likely
> Hx of gout 1.7x

Question 13

Stiff Shoulder
Treatment Approach:

Answer 13

Use symptom irritability to guide treatment

Early referral for injection

Use knowledge of tissue biomechanics (e.g. Creep) to improve flexibility of fibrotic joint capsule

Stretching (joint mob & active) as part of a multimodal program can be effective but evidence is mixed

Question 14

Stiff Shoulder Management and Prognosis
Multimodal program including:

Answer 14

> Manual therapy
Active stretching
Rotator cuff exercise
Sprinkle in adjuncts as needed

Question 15

Adjuncts with little or poor evidence (stiff shoulder) =

Answer 15

> Ultrasound
E-stim
Diathermy

Question 16

Loose shoulder
Outcomes:
After primary dislocation:

Answer 16

Surgery VS Rehab
> Similar Improvements in Pain, function, and activity participation
> Recurrence after surgery: 21%
> Rehab: 43%

Recommendation: Both treatments effectively improve symptoms and function. Rehab first in general, consider early surgery in high-risk patients (collision athletes)

Question 17

Loose shoulder
Outcomes:
Multidirectional Instability:

Answer 17

Surgery VS Rehab
> Both Improvements in Pain, function, and activity participation

> Surgery: Better kinematics and RTS rates

> Rehab: Better pt satisfaction, better self report measures

Recommendation: progressive NM control and strengthening exercises

Question 18

Loose shoulder
Risk Factors
Children (18 and under) after primary dislocation:

Answer 18

Age 14-18: 24x more likely to have recurrence compared to 13 and under

Sex: Boys are 3.4x more likely to have recurrence

Concomitant injury: Hills-Sachs lesion presence 17x more likely to have recurrence

Question 19

Loose shoulder
Risk Factors
Adults (Over 18) after primary dislocation:

Answer 19

Age: Under 40 13.5x more likely to have recurrence compared to over 40

Sex: Men are 3.2x more likely to have recurrence

Laxity: Hyperlaxity are 2.7x more likely to have recurrence

Question 20

Loose shoulder
Treatment Approach
Immobilization:

Answer 20

Sling use 1 week vs 3 weeks = No differences in recurrent instability rates

Position: Internal vs External rotation = No differences in outcomes

Since the shoulder relies on muscles for dynamic stabilization, strengthening the rotator cuff will improve neuromuscular control and possibly reduce instability

Question 21

loose shoulder treatment goals - Early Phase: Protection

Answer 21

Avoid high-risk positions - Negative pressure restoration within a week

Reduce pain, carefully improve ROM, promote NM function (submax iso)

Gentle weightbearing to promote co-contraction

Question 22

loose shoulder treatment goals - Middle Phase:

Answer 22

Avoid high-risk positions
Rotator cuff strengthening
Scapular Exercises

Question 23

loose shoulder treatment goals - Late Phase:

Answer 23

Progress to overhead activities

Rotator cuff strengthening = Progress towards overhead depending on functional needs

Scapular Exercises

Question 24

Loose Shoulder Management and Prognosis

Answer 24

Rotator cuff strengthening with neuromuscular control

Avoid recurrence

Question 25

Shoulder Osteoarthritis:

Answer 25

Principle: Treat impairments to maintain/promote mobility, strength, and function without aggravating synovitis

Question 26

Shoulder AC joint injury

Answer 26

Principle: Treat impairments to maintain/promote mobility, strength, and function while protecting the AC joint during healing