Shoulder Pathology Flashcards
Frozen shoulder
condition characterized by functional restriction of both active and passive shoulder motion for which radiographs of the GH joint are essentially unremarkable except for the possible presence of osteopenia or calcific tendonitis
what pattern does frozen shoulder follow?
loss of ROM often in capsular pattern (Cyriax)
loss of ER > ABD > IR
capsular endfeel
frozen shoulder: shortening contracture of?
anterio-inferior capsule, rotator interval, coracohumeral ligament
frozen shoulder types
Primary: adhesive capsulitis (etiology unknown)
Secondary: linked cause
adhesive capsulitis
- etiology unknown
- regional ischemia of the shoulder soft tissues from autonomic sympathetic dysfunction?
- some genetic tendencies
- females>males
- peak incidence in early 50’s
defined clinical course of adhesive capsulitis
4 stages: 1=acute 2=freezing 3=frozen 4=thawing
- typically takes 1-3 years to run course
- important that tx be individualized according to stage
acute stage- adhesive capsulitis
0-3 months
- pathology=acute synovitis
- pain on AROM and PROM
- empty endfeel
- ROM is normal (anesthesia)
freezing stage- adhesive capsulitis
3-9 months
- pathology= hypertrophic hypervascular synovitis, proliferation of scar tissue
- pain on AROM and PROM
- empty end feel, pain before
- ROM becomes severely limited
*the shorter the acute & freezing (inflammatory) phase, the shorter the overall course
frozen stage- adhesive capsulitis
5-9 months
- pathology= dense mature scar tissue, decreased capsular volume (reduction of redundant fold), contractures of coracohumeral ligament, subscapularis, subacromial bursa
- no pain on AROM and PROM
- capsular end feel
- ROM severely limited
- prolonged loss of joint ROM causes changes in muscle- loss of sarcomeres
thawing stage- adhesive capsulitis
15-24 months
- pathology= restoration of capsular volume
- no pain on AROM and PROM
- capsular endfeel
- ROM gradually improving
stage 1 adhesive capsulitis treatment
GOAL: interrupt pain and inflammation, promote relaxation, educate
modalities: as needed for: pain, inflammation, relaxation
strengthening: early closed chain
ROM: AAROM, pain free ROM, gentle PROM, pendulum
stage 2 adhesive capsulitis treatment
goal: minimize pain, inflammation, capsular adhesions, and ROM restriction; posture HEP
modalities: as needed to: decrease pain & inflammation, improve tissue extensibility
strengthening: more advanced: scapular training- specific rotator cuff strengthening
ROM: AROM, PROM
stage 3 & 4 adhesive capsulitis treatment
Goal: increase ROM; posture HEP
modalities: to promote: relaxation, tissue extensibility, reduce tx discomfort
strengthening: more specific: scapular training to reestablish force couples, continued rotator cuff strengthening
ROM: more specific: AROM to reestablish scapular and GH mechanics; more aggressive stretching (PNF, STM, low load prolonged stretch)
secondary frozen shoulder
Loss of ROM: underlying or associated condition can be identified
Intrinsic
Extrinsic
Systemic
Intrinsic secondary frozen shoulder
related directly to the GH joint
rotator cuff disorders, bicep tendonopathy
extrinsic secondary frozen shoulder
remote from the GH joint
cervical radioculopathy, breast surgery, humeral or clavical fx, AC DJD
systemic secondary frozen shoulder
DM, hyper/hypothyroidism, hypoadrenalism
rotator cuff tears/impingement
Intrinsic/Primary
Extrinsic/Secondary
Intrinsic/Primary rotator cuff tears/impingement
=subacromial space issues
- abnormally shaped acromion (hook shaped); rough undersurface
- degenerative changes in the AC joint
- decreased vascularity (critical zone)
Extrinsic/Secondary rotator cuff tears/impingement
=stength/environment
- GH force couple dyskinesia
- ST force couple dyskinesia
- posture
- excessive overhead use of arm
- posterior capsule shortening
GH force couple
- deltoid elevates the arm but also produces superior translation of humeral head
- inferior & medial forces of rotator cuff offset superior translation of deltoid (specifically infraspinatus, teres minor and subscap)
- RC also assists in limiting anterior/posterior translation of humeral head
ST force couple
rotation of scapula is provided by trapezius force couple (upper, mid, lower) and serratus anterior
ST muscle balance
- efficient forces depend on stability of origins of the scapula
- scapular position affects length-tension properties of rotator cuff
- scapular upward rotation, posterior tilt, lateral rotation- NECESSARY to maximize subacromial space
integrated RC, GH, and ST force couples
scapular rotation during arm elevation adds to total ROM
lack of scapular rotation leads to impingement
- scapular rotation is necessary to keep acromion moving away from deltoid insertion
- lack of scapular rotation-head of humerus translates superiorly
failure of scapular adduction-head of humerus translates anteriorly
neer stage 1
- edema and hemorrhage
- minimal weakness
- excessive overhead use
- usually <25 y/o
neer stage 2
- fibrosis and tendonitis of cuff and bursa following repeated mechanical inflammation
- usually 25-40 y/o
neer stage 3
- bone spurs
- incomplete and complete tears of cuff and biceps tendon
- degeneration of remaining tendons
- usually >40 y/o
- common 5-40% > 60 y/o have evidence of full thickness tears
treatment principles for RC dysfunction
1: conservative rx for 6 months
2: surgery for RC pathology
conservative tx for RC dysfunction
- inflammation in acute phase
- manual therapy and exercise to address impairments in posture, weakness and stabilization
- DO NOT ignore the cervico-thoracic spine!
surgery for RC dysfunction
Primary impingement:
- subacromial decompression
- acromioplasty
Primary & secondary impingement:
-capsular repair
-post-op rehab:
modalities for pain relief, inflammation
initial protection from active & passive ms force
PROM->AAROM->AROM
gentle UE closed chain, stabilization ex at 3 wks
thoracic outlet syndrome
=mechanical, non-traumatic compression of the neurovascular bundle
- largest nerves affected first: sensory first, then motor
- poorly localized aching pain
- need to rule out CTS, radiculopathy, distal nerve compression
areas at risk for thoracic outlet syndrome
1: superior thoracic outlet
2: scalene groove
3: costoclavicular space
4: infracoracoid space
TOS: superior thoracic outlet
- cervical rib or long C7 TP
- often ulnar nerve distribution
- ^ symptoms with altered posture: forward head; protracted shoulders
TOS: scalene groove
- between ant & middle scalene
- scalene hypertrophy or tightness
- forward head posture
- symptoms ^ w/ overhead tasks and some cervical positions
**soft tissue release and posture correction
TOS: costoclavicular space
- between clavicle and 1st rib
- elevated ribs
- depressed, retracted shoulders
- backpacks, carrying heavy loads
- symptoms ^ with military postures
**1st rib, posture (scap elevation)
TOS: infracoracoid space
- beneath coracoid between pec minor and ribs
- tight pec minor
- symptoms ^ with overhead activity
**strengthen scap stabilizers, stretch pec minor
hypermobility/instability of GH joint
-GH stability involves articular geometry, the static capsulo-ligamentous complex, dynamix muscular stabilizers and NM control
most common abnormal GH motions
- excessive anterior translation during lateral rotation and abduction
- excessive anterior translation during medial rotation
- potential for axillary nerve damage
continuum of shoulder stability
Normal: normal congruity and loading
Lax/hypermobile: congruity maintained, but joint is unloaded
Subluxed: partial contact of articular surfaces- congruity lost
Dislocated: no contact of articular surfaces- congruity lost
contribution of shoulder musculature to joint stability
- passive muscle tension from bulk effect of rotator cuff
- rotator cuff contraction- compression of articular surfaces
- joint motion that secondarily tightens passive ligamentous restraints
- barrier or restrain effect of contracted rotator cuff muscle
- redirection of joint force to center of glenoid surface by coordination of forces from GH and ST joints
acute GH dislocation
up to 96% are trauma induced, TUBS injury, requiring surgery
- traumatic-unidirectional-Bankart-surgery
- > 20% successful without surgery: high re-dislocation rate
associated injuries:
- Bankart- injury to the glenoid
- Hill-sachs deformity- humeral head
in general, dislocations with HIll-sachs lesion and/or bankart lesion commonly experience chronic instability (commonly associated with traumatic dislocation)
Bankart
=injury to the glenoid
- Soft: avulsion of ant int GH ligament and labrum from anterior rim of glenoid
- Hard: fx of the glenoid rim
chronic GH dislocation
=progression from instability/subluxation
- usually due to increased passive laxity
- instability -> subluxation -> dislocation
- success rate w/out surgery >80%
- AMBRI: rarely requires inferior capsular shift
AMBRI
Atraumatic
Multidirectional
Bilateral
Rehabilitation Indicated
*rarely requires inferior capsular shift
GH dislocation presentation
Presentation (after reduction):
- (+)apprehension sign, anterior tenderness
- RTC weakness (if tear)
- deltoid weakness and/or lateral shoulder sensory loss if axillary nerve injured
- acute -> UE in ER with anterior prominence of humeral head
conservative treatment of GH dislocation
- improve dynamic stability/ proprioception of GH joint
- immobilize for up to 3 weeks? in IR or ER
- avoid forceful ER; no PROM/stretching
- focus on neuromuscular coordination/ re-education
surgical treatment for GH dislocation
anterior capsular shift or anterior capsulo-labral reconstruction if Bankart present
Predictors:
- if 40 y/o minimize immobilization, look for RTC tears if no response to tx after 2 wks
AC injury
trauma
disruption of AC ligs
no dynamic stability possible
AC trauma
- direct blow to lateral shoulder
- FOOSH driving humeral head into acromion
disruption of AC ligaments
1st deg: no instability
2nd deg: AP instability
3rd deg:: gross instability, distal clavicle high riding
AC joint treatment
- pain control, protected ROM, isometrics
- progress to strengthening ex, dynamic strengthening, sport/occupation specific activities
- perform ex sidelying, seated, or standing. avoid supine- scap pinned, results in greated clavicular rotation at AC
SC injury
- blunt force to sternum or clavicle
- lateral compression from clavicle
- usually dislocate anterior/inferior
- posterior more serious-can compromise NV, breathing/swallowing problems
- rare, less than 3% of shoulder injuries
labral tears
mechanism of injury
- FOOSH
- consequence of dislocation
- strong bicep contraction
- range from minor fraying to Bankart to SLAP lesions
- stable (pain but no locking/clicking) to unstable (pain with locking/clicking)
- symptoms often similar to AC joint pathology
SLAP lesions
4 types:
1: rough edge
2: labrum torn off glenoid (common)
3: bucket handle
4: tear includes bicep tendon
PT can treat symptoms and rebalance muscles
stable labral tears
stable=pain but no locking/clicking
- NSAID’s/ cortisone injection
- scapular stabilizer and RTC re-training
- limit strengthening to <90%
unstable labral tears
- conservative tx is rarely successful
- arthroscopic debridement and stabilization of unstable tears
subacromial bursitis
MECHANICAL:
- MOI= impingement- primary or secondar
- precurser to RC injury?
CHEMICAL:
-inflammation spread from RC injury
TX:
- rest, ice, gentle, pain-free AROM
- correct abnormal mechanics
- improve GH, ST control/conditioning
joint arthroplasties are indicated when..
- conservative management fails
- no other options to restore relatively pain-free joint function
destructive arthidities
OA RA ankyl spond marfan lyme
shoulder replacement
destructive arthidities
trauma/fx
avascular necrosis
shoulder replacement types
1: surface replacement
2: hemiarthroplasty
3: total
hemiarthroplasty
humeral component
- unipolar (old)
- bipolar: head moves in shell, shell moves in glenoid
total shoulder replacement
=both sides
CONSTRAINT= stability in plan of glenoid- usually refers to glenoid depth
constrained-ball in deep socket; increased stability, decreased mobility
REVERSED= semi-constrained cemented? -TSA type -soft tissue -bone block
humeral fracture
complete displaced- ORIF
- pins, wires, screws, plates
- soft tissue damage
- AVN
incomplete non-displaced-conservative
-sling
shoulder evaluation
1: intake and hx
2: systems review
3: pain rating
4: observation:
- posture: cervico-thoracic spine, shoulder girdle
- atrophy/edema/girth
- spasm/guarding
- skin condition/hair distribution
5: palpation (look for asymmetry)
- soft tissue tension
- joint lines, trigger/tender points
- temp/swelling
6: clear jt above and below
7: neuro: derma/myo/DTR/proprioception
8: AROM: ability/willingness
- scapulohumeral rhythm (con/ecc/slow/fast/weighted)
9: PROM w/ overpressure (endfeel)
10: isometric break tests (if deficit, do formal MMT)
11: accessory motion eval
12: special tests
13: outcomes/functional tests
- ADL
- simple shoulder test, SPADI, DASH
visceral referral to the shoulder
can’t change the pain with any positions or postures. if pain occurs upon contractions
-should be able to effect pain by movement of the musculoskeletal position
locking position
outside hand on elbow to control flexion/rotation
close hand protracts shoulder and cups palm over spine of scapula.
drop pt. arm into extension and abduction.
locking position when won’t abduct anymore w/o ER
- would not do for impingement, anterior instability or acute/freezing stages
- *would use for thawing stage and for limited ROM
quadrant position
once elbow goes over the “hill” to continue abduction from the locking position
general tests for impingement/tear
1: rent test
2: supine impingement
3: empty can test
Rent test
indicates rotator cuff tear and impingement
PT behind seated pt.
PT palpates anterior to anterior edge of acromion with 1 hand and other grasps pt’s relaxed flexed elbow with other
PT extends pt’s arm and slowly internally and externally rotates the shoulder
*for infraspinatus palpate posterior to acromion
positive test=eminence (prominent greater tuberosity) and a rent (depression of about 1 finger width) will be felt
supine impingement test
indicates rotator cuff tear and impingement
positive test=significant increase in shoulder pain
pt supine
PT grasps pt’s wrist and distal humerus and elevates arm to end range (close to ear)
PT moves pt’s arm into ER to IR
supraspinatus impingement tests
1: empty can test
2: drop arm test
3: neer’s test
4: Hawkins-kennedy
empty can test
indicates general impingement and rotator cuff tear (*most common supraspinatus)
positive test= pain, more weakness in empty can than in full can position
*cheating, if possible in PROM but not AROM
pt. standing, AROM test
abduction in scapular plane (30deg). pt “empties cans” while abducting
**thumbs pointed down
Drop arm test
indicates supraspinatus tear, subacromial impingement
positive test= inability of pt. to lower arm smoothly and controlled
pt standing.
passively lift pt’s arm to 90 deg abduction and release.
*can also apply pressure??
Subscapularis impingement tests
1: lift off test
2: IR lag sign
Lift-off test
indicates subscap tear, impingement
positive test=inability to lift arm off back
pt is seated with arm behind back; as them to lift off
IR lag sign
indicates subscapularis tear, impingement
positive test=inability to maintain arm off back
pt seated with arm behind back.
PT grasps elbow and wrist and passively lifts pt’s arm off their back and asks them to maintain the position
infraspinatus/teres minor impingement tests
1: ER lag sign
2: Hornblower’s sign
3: drop sign
ER lag sign
indicates supra/infra tear, impingement
positive test=inability to maintain arm near full ER
pt seated.
PT behind, grasps pt’s elbow and wrist.
PT places elbow is 90 flexion and shoulder in 20 deg scapular plane.
PT passively ER shoulder to NEAR end range and asks pt to maintain position
**overpressure at end range can causes false positives!!
Hornblower’s sign
indicates teres minor fatty degeneration and impingement
positive test=inability to maintain ER against resistance
pt seated.
PT supports pt’s shoulder in 90 deg flexion in the scapular plane and 90 deg elbow flexion while resisting ER
Drop sign
indicates infraspinatus tear or fatty degeneration, impingement
positive test=inability to maintain arm near full ER
pt seated.
PT behind, grasps elbow and wrist. places elbow in 90 deg flexion and shoulder in 90 deg abduction in scapular plane. PT passively ER shoulder to NEAR end range and asks pt to maintain position
painful ARC test
all stages of subacromial impingement
PT faces standing pt.
pt actively abducts involved shoulder
positive test=pt reports pain in the 60-120 degree range. pain outside of this range is considered a negative test
Posterior impingement sign
indicates: rotator cuff tear, post labral tear, impingement
positive test= complaints of pain in the deep post shoulder
pt supine. should in 90-110 deg abduction, 10-15 deg extension and max ER
- if pain in ant shoulder could be tight muscles
- *common in overhead throwing athletes
internal rotation resisted strength test
indicates internal impingement (subacromial) and impingement
pt standing.
PT stands behind. places pt’s shoulder in 90 deg abduction and 80 deg ER w/ 90deg elbow flexion
PT tests isometric ER and then IR
positive test=IR weaker than ER
labral tear special tests
1: Biceps load II test
2: Yergason’s test
3: crank test
4: kim test
5: jerk test
5: speed’s test
Apprehension position
supine shoulder in 120 degrees abduction elbow in 90 degrees flexion supinated end-range ER
biceps load II test
indicates SLAP lesion, labral tear
pt supine
PT sits at side of pt
PT places pt’s shoulder in apprehension position and resists elbow flexion
positive test= pain with resisted elbow flexion
yergason’s test
indicates subacromial impingement, SLAP lesion, any labral lesion, long head of biceps pathology
pt sitting or standing. shoulder neutral, elbow 90 deg flexion, pronated
PT resists supination
positive test=pain localized to bicipital groove
Crank test
Indicates SLAP lesion, labral tear
pt supine
PT passively abducts shoulder into 160 deg and 90 deg elbow flexion.
PT first applies a compression force to the humerus and then rotates repeatedly into IR and ER trying to pinch the torn labrum
positive test= production of pain, with or without clicking, catching
Kim test
indicates posterio-inferior labral lesion, labral tear
pt seated.
PT grasps elbow and mid humeral region. elevates pt’s arm to 90 degrees abduction.
simultaneously PT provides axial load to the humerus and a 45 degree diagonal elevation to the humerus (concurrent with a post-inf glide to the proximal humerus)
positive test=sudden onset of posterior shoulder pain
Jerk test
indicates posterio-inferior labral lesion
pt supine (to maintain position) PT grasps elbow and scapula. elevates pt's arm to 90 deg abduction and IR PT provides axial compression to humerus through elbow, maintaining horizontally abducted arm axial compression maintained as pt's arm is moved into horizontal adduction
positive test=sharp shoulder pain (possibly with clunk/click)
Speed’s test
indicates:
- subacromial impingement (all stages)
- SLAP lesion
- biceps pathology
- labral lesion
pt standing. elbow fully extended and supinated.
PT stands in front and resists shoulder flexion for 0-60deg. **stop at 60!
positive test=pain in bicipital groove
SLAP lesion
superior labral anterior to posterior lesion
instability special tests
1: anterior release/surprise test
2: apprehension test
3: apprehension/relocation test
4: load and shift test
Anterior release/surprise test
indicates anterior instability
pt supine
PT applies posterior force on humerus. maintains force while place arm in apprehension position and then release
positive test=sudden pain, increased pain, or reproduction of symptoms
apprehension test
indicates anterior shoulder instability (& SLAP)
pt supine.
PT grasps wrist and elbow. places shoulder in apprehension position.
PT then applies pressure to post aspect of humeral head (my examiner if standing, by table is supine)
positive test= show of apprehension by patient, reports of pain, muscle guarding, facial expression of concern
**move quickly, can use a block or fist to move head anteriorly. make sure to go to endrange ER!
Apprehension/relocation test
indicates anterior instability (also SLAP)
perform apprehension test.
if pain is felt then apply pressure anteriorly
positive test= decrease in pain or apprehension
- no change in pain symptoms indicates impingement
Load and shift test
indicates anterior, posterior instability
pt supine
PT grasps proximal humerus with one hand providing a compression force and loading the humerus into the glenoid fossa. other hand stabilizing the scapula
PT provides ant to post force nothing amount of translation.
PT then provides post to ant force
grade translation as 1 or 2
1: to the post/ant rim of glenoid OR
2: beyond the rim of the glenoid
positive test=translation beyond the glenoid rim, excessive translation
*do sulcus sign to assess inferior instability
sulcus sign
indicates inferior laxity, superior labral tear
pt seated.
PT stands behind. grasps elbow and pulls down causing inferior traction force. notes the distance between inferior surface of acromion and superior portion of humeral head
repeat the test in supine, 20 deg and
positive test=distance
AC joint special tests
check tender specific point
1: AC resisted extension
2: cross over sign
AC resisted extension
indicates AC joint abnormality
pt seated. shoulder in 90 flexion and IR. elbow flexed 90deg
PT resists horizontal abduction
positive test=pain at the AC joint
Cross over sign
indicates AC joint abnormality
passively flex shoulder to 90deg
passively horizontally adduct fully
positive test= pain in AC joint
Thoracic outlet syndrome special tests
1: hyperabduction test
2: Roos test
3: adson’s test
4: costoclavicular maneuver
Hyperabduction test
indicates TOS
pt sits up straight. both arms placed at sides for PT to assess radial pulse
pt then places arms above 90 deg and and full ER and held there for 1 minute
PT re-assesses radial pulse in abducted position.
pulse recorded as no chance, diminished, or occluded.
positive test=change in radial pulse and report of paresthesia
Roo’s test
indicates TOS (evaluates neural &vascular structures)
pt sits up straight with arms at sides.
pt brings arms up to 90deg abduction and ER. then rapidly opens and closes hands for a full minute
positive test=inability to maintain position, diminished motor function of hands, loss of sensation
**considered most accurate TOS test, often mistaken w/ fatigue
Adson’s test
indicates scalene tightness and TOS
pt sits straight with arms abducted 15deg.
PT palpates radial pulse.
pt inhales deeply, holds breath, tilts head back and rotate head to examine side
PT records radial pulse as diminished or occluded
positive test=absent or diminished radial pulse, paresthesias
Costoclavicular maneuver
indicates TOS
pt sits straight (exaggerated military position) both arms at sides
PT assesses radial pulse
pt retracts and depresses shoulders while protruding chest. holds for 1 minute
PT re-assesses radial pulse
positive test=absent or diminished radial pulse, paresthesias
GH joint mobs
GH traction: short axis, long axis caudal humeral glide dorsal humeral glide (in abd, or flex) ventral humeral glide lateral rotations dorsal- ventral humeral oscillations
SC joint mobs
craniodorsal clavicular glide
caudoventral clavicular glide
*thumbs or hypothenar eminence
AC joint mobs
ventral clavicular glide
dorsal clavicular glide
scapular mobilizations
not a synovial articulation, so more of a soft tissue stretch
dorsal tilt
medial/lateral
superior/inferior
up/down rotations
rotator cuff disorders include medical diagnoses such as:
- impingement syndrome
- rotatory cuff/glenoid labral tears
- posterior shoulder pain
- GH hypermobility/instability
therapeutic exercise intervention of rotator cuff disorders
- secondary disorders should consider impairments related to hyper mobility and stability related to impingement
- serratus anterior and trapezius strengthening is essential while monitoring GH movement!
- attention to “level” (difficulty) of intervention is important for dosage and success
treatment for primary rotator cuff disorders
- early stages- meds, rest, resting position, ice
- physical agents- for pain and inflammation
- ROM, muscle length, joint mobility exercises, and joint mobilization
- muscle performance exercises
- posture and movement training
- surgery-if conservative tx fails
- prevention- educate early recognition
specific therapeutic exercise intervention for rotator cuff disorder
- pain and inflammation: provide exercise for impairments contributing to cause of symptoms
- muscle length: passive manual stretch of rhomboids. self stretch to GH lateral rotators
- muscle performance: strengthen middle/lower trap, serratus anterior in short range. strengthen rotatory cuff
- posture and movement: ergonomic modifications. SEMG training for temporal relationships in scapular rotators. functional training
scapular upward rotator exercises
upper trap:
-shoulder shrug from arm-elevated position
Middle trap:
- prone arm lift with arm OH
- prone horizontal extension with ER
- *IT
Lower trap:
- prone arm lift with arm OH
- prone ER at 90 deg abduction
- prone horizontal extension w/ ER
- *ITYs
serratus anterior progressions- levels I, II, III
level I:
-supine, arm OH, gently but consistently push arm backward into pillow and hold for 10s
level II:
-sidelying with pillows in front of head and shoulders. bend hips and knees. grasp theraband attached to feet. slide arm up towards head on pillows and slowly lower back down.
level III:
- standing an inch from the wall. post tilt pelvis. head lying on wall… ?
therapeutic exercise intervention for common physiologic impairments- PAIN
differential dx of pain in this shoulder girdle is difficult due to interdependence of anatomy of shoulder, elbow, wrist, hand and cercivothoracic spine.
- tx can be directed toward the source of the pain (rotator cuff tendinopathy)
- tx must be directed toward the cause of the pain (scapula downward syndome)
**have to think “WHY is there pain there?”
Hypomobility
often coexists with hypermobility
tx:
-manual stretching with concurrent strengthening of weakened antagonist
-ex: stretch rhomboids while strengthening scapular upward rotators
(stretch rhomboids sidelying. strengthen lower trap and serratus anterior by facing wall and sliding ulnar side of hands in sagittal or scapular plane)
Hypermobility
to treat effectively- Hypomobility segments must be identified
- improve muscle performance, length-tension relationships, motor control of dynamic stabilizers
- Ex: anterior GH hypermobility due to inefficient properties of medial rotators (subscap)
- Goal- train subs cap to limit anterior GH movement. include functional activities
to strengthen subscap in short range- supine 90/90 with elbow hanging off. IR
impaired muscle performance
- neurologic patholoy
- muscle strain
- disuse, deconditioning, and reduced conditioning
muscle strain tx
can result from sudden and excessive tension or from gradual and continuous tension imposed on muscle
- initially- isometric contractions in pain free shortened range
- concentric-eccentric dynamic exercise can be slowly introduced
- low load muscle contractions in regeneration phase
- final phase of healing should include activity-specific exercises
disuse, deconditioning and reduced conditioning tx
- combined program aimed at restoring muscle force, endurance and coordination
- conditioning program should include exercises for all major muscle groups
- posture and movement technique should be closely monitored
- training depends on performance level (high level athletes, strenuous workers)
4 core scapular stabilization
- focus on movement CONTROL
- easy to overload/underload
- watch for substitutions!
- end at form fatigue
1: seated rows - post delt
2: push up with a plus (serratus)
3: press ups, with a plus
4: empty can (supraspinatus)- 90 deg max. only to point of pain, in scapular plane
shoulder girdle conditioning program
- bench press (flat, incline, decline)
- prone middle and lower trapezius
- lat pulldown
- lateral deltoid raise-frontal or scapular plane (through full ROM)
- front deltoid raise (through full ROM)
- biceps curl
- triceps extension
posture treatment
- education of habitual postures (cervical, thoracic, lumbar, and pelvic) standing, sitting and sleeping
- ergonomic/workstation education and modification
- support via bracing, taping, etc to reduce strain on lengthened muscles
movement treatment
- restore “normal” scapulohumeral rhythm during active motion
- use of SEMG and cinematography can be helpful
treatment of GH instability/hypermobility
- specific joint mobilization (post capsule)
- immobilization (max 3 wks) if subluxation is diagnosed
- AROM against gravity as pt regains strength and motor control
- main target muscle tends to be subscap as well as gradually resisted exercises for pectoralis major, lats, teres major
- infraspinatous and teres minor are also often targeted
**must have stable scapula for rotator cuff function to be effective!
tx principles for post-op rotator cuff disorders- four phases
**educate pt- tendinous repair may take 1 year
1: protective phase
2: early intermediate phase
3: later intermediate phase
4: advanced rehabilitation
protective phase
1-6 wks
- sling protection
- pendelum exercises
- self assisted ROM
early intermediate phase
6 wks-3 months
- additional self assisted ROM
- PROM
later intermediate phase
3-5 months
- isometrics and progress to dynamics if possible
- swimming at 5 months
advanced rehabilitation
5 months-1 year
- submax activity-specific training
- progress to max training by end of year
tx of stage 1 adhesive capsulitis
- type and intensity dependon pt’s specific strength, ROM, joint mobility, motor control, and level or irritability
- NSAIDS, steroid, and local analgesics can be helpful
- postural training to discourage FHP and kyphosis
- therapeutic modalities to control pain, inflammation and promote relaxation (pendulums, scap mobs, protect GH jt but everything else can move!)
- grade 1 &2 jt mobs and movements within pain free range
- closed chain exercises to promote GH stabilization
- scapular exercises in pain free position
- taping can be used to augment stability
tx of stage 2 adhesive capsulitis
- continue to decrease pain and inflammation
- passive stretching of post capsule (in pain free range)
- active exercises against gravity MAY be introduced
- careful isolated strengthening of rotator cuff, serratus anterior, middle and lower trap
- taping of ST jt for stabilization
tx of stage 3& 4 adhesive capsulitis
- improve GH mobility
- restore SH rhythm
- aggressive stretching and jt mobilization
- heat may be used for relaxation of tissues
- strengthening of rotator cuff and SH muscles
adjunctive interventions: taping
scapular taping can improve resting alignment of the scapula on the thorax
goals &benefits of taping
- improve initial alignment
- alter length0tension properties
- provide support and reduce stress to myofascial tissues
- provides kinesthetic awareness of scapular position during rest and movement
taping scapula into elevation
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tapin scapula into upward rotation
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scap re-education exercise
- make a fist and reach up, supine
- grab inf/med scap border
- pt squeezes down and back “hold it there” try to pull and check to make sure not upper trap
- try to pull arm up “don’t let me move you”
- push up into me
- try to move arm back and forth
- hold a shoe/kettle bell and try to rotate IR/ER
- or rotate head back and forth
- knees up-trunk rotation
