Shoulder treatment Flashcards
Five Principles of Treatment of
the Shoulder Complex
1- Establish cortical potential for normal
movement. (Control the pain)
2- Establish mechanical potential for normal
movement. (Restore full passive movt)
3- Establish muscular potential for normal
movement. (Restore strength)
4- Establish normal movement. (Eradicate trick
movts/unlearn bad habits)
5- Re-enforce normal movement. (Practise)
Aims of treatment - Principle 1
To decrease pain and inflammation:
- selective rest
- a degree of painless movement is usually
possible – scapular plane; 20-50 deg movt
- injection
- surgery
Aims of treatment- Principle 2
To correct joint and soft tissue mobility:
- Posture
- Typical areas of capsuloligamentous restriction
include: post capsule; s-c jt; a-c jt; Tx; Lx; 1
scapulothoracic; anterior capsule
- Typical areas of muscular restriction include:
upper traps; pects maj/min; lat dorsi; serratus
anterior
Aims of treatment - Principle 3
To correct muscle strength, endurance + recruitment
Scapular muscles before RC.
Tonic muscles - initially low effort, sustained +inner range.
Phasic muscles - relax + inhibit; the body thinks in patterns - working stabilisers will normally inhibit mobilisers
Tx will encourage lower traps
Adduction will encourage humeral depressors.
Use scap plane asap
Be wary of too much eccentraic exercise until pain settled.
Normal progression - arc; resistance; WB; contraction; provactive.
Principle 4
To establish painless and functional pattern of movement
- scapular feedback – visual, tactile, mimicry
- mirror
- proprioception – weightbearing; gym ball
- reaction exs
- eccentric exs
- ‘correct’ pattern is an arbitrary concept
Principle 5
To re-enforce effective recruitment and pattern
of movement:
- Functional
- Occupational – use workplace items
- Sporting – use sporting implements
- Correct faulty technique
- Make it relevant
Adhsive capsulitis- pathophys
Pathophysiology poorly understood. General agreement it involves
initial inflam stage followed by restriction/contraction of g-h capsule
Adhesive capsulitis - History
Gradual onset ↑ pain + stiffness; can be precipitated by trauma, but usually idiopathic; most common atraumatically 45
75 yrs but any age is poss; pain on reaching up + back, doing up bra, back pocket; pattern of pain will depend upon stage of
condition
Adhesive Capsulitis - Exam
Characteristic pattern of limitation of the shoulder capsular pattern – ltd abd, less ltd flex, more ltd LR; if passive lateral rotation is full range, then it is NOT a frozen shoulder; if
passive lateral rotation is full range and painless, then there is nothing wrong with the capsule; -ve impingement tests
Adhesive Capsulitis - Frozen Shoulder
Stage I - Pain
Stage II - Pain and stiffness
Stage III - Stiffness and pain
Stage IV– Recovery
How long does it take for majoirty of frozen shoulders to heal
2 years
What can compound adhesive capsulitis problem
Diabetes, trauma and age and other comorbidities
What does Rx do to adhesive capsulitis
Either speeds up resolution or makes it less problematic.
No clinical imperative to treat in most cases.
No need for robust stretching at home.
Reverse scapulohumeral rhythm- adhesive capsulitis
Scapula moves more than the humerus, which can be seen in conditions like frozen shoulder.
Adhesive capsulitis - treatment (Stage 1-4)
Stage I and II – injection. Any other pain relieving modality - TENS, mobilisations, NSAIDS /analgesics, active movts
Stage III – time or physio. Mobs/manips give earlier increase in range and can be very useful, but are likely to lead to a short term increase in soreness. Injections unlikely to be effective.
Stage IV – Rx usually unnecessary. Sometimes exercises/mobilisations to increase hand-behind-back, which tends to be the last movt to return.
Types of impingment
Primary, secondary, primary inflammation/degenerative chnages
Primary impingment
Acromial morphology;
osteophytes; thickened cuff; calcific bursa/tendon;
fracture; a-c dislocation; OA/RA; bony
kyphosis/scoliosis
Secondary impingement
Posture; weakness;
instability; ergonomics; neuropathy; muscle
imbalance
Primary inflammation/degernative changes
Tendinitis/osis; bursitis; synovitis; capsulitis; cuff
tears; ageing
Treatment for impingement
Selective rest
Mobility– a-c jt; s-c jt; capsule esp posterior; Tx; posture
Rehabilitation – must be rational, appropriate and progressive; scap muscles before cuff. Also include correction of faulty technique/posture
Injection– proven short term success; long term results more equivocal; no unanimity of opinion re injection process or need for guidance
Surgery– subacromial decompression +/- acromioplasty; cuff repair. Subject of intense orthopaedic debate (Beard et
al, 2018; Kolk et al, 2017; Sealey and Lewis, 2016; Abdul Wahab et al, 2016)
Treatment of shoulder instability
Mobility– asymmetric capsular restriction; Tx;
posture
Rehabilitation – must be rational, appropriate and progressive; scap muscles before cuff muscles; emphasize function
Surgery– good for anterior, fair to good for
posterior, generally poor for inferior
Scapular muscles
Serratus anterior
Rhomboids
Trapezius
Levator Scapula
Pectoralis Major
Latisimuss Dorsi
Name exercises for the shoulder
Internal/external - seated, standing, prone lying, supine lying, banded
use of balls- on wall, ball above head
Push up positions
