The Shoulder

Introduction Components of the shoulder Most common joint pathology Rotator cuff Biceps Tendon Fractured neck of Femur Dislocation Adhesive Capsulitis

3 components The glenohumeral joint The acromiclavicular joint The scapular

Diagnosis History Range of Movement Palpation Pain Diagnostic tests (there are 65 that can be performed!)

Most common joint pathology Gh joint Ac joint Scapular Adhesive capsulitis OA (rare) Dislocation Tendonitis Impingement Instability

Shoulder or cervical nerve root? Is there loss of shoulder ROM? YES = SHOULDER Are the reflexes reduced? YES = CERVICAL

Rotator Cuff Stabilise the head of the humerus while the other major muscles around the shoulder are actively moving the arm. Eg. When deltoid is abducting. They also initiate most movements

3 main types of rotator cuff lesions Tendonitis Partial rupture Complete rupture

Tendonitis Infraspinatus and Teres Minor Laterally rotate humerus Supraspinatus Initiates abduction (Most commonly injured) Infraspinatus and Teres Minor Laterally rotate humerus Subscapularis Medically rotate humerus Painful arc at 90° abduction Toothache type, constant pain from acromion to deltoid insertion Reverse scapular pattern Painful arc at 90 abduction Resisted gh lateral rotation Thickened tendon posterior to ghjt Painful medial rotation

Treatment of tendonitis Early stages Later stages Frictions Ultrasound Strengthening exercises in pain free range Scapular control Shoulder taping to offload tendon Antiinflamatories Stretching exercises

Rotator cuff rupture Partial rupture Complete rupture Cause usually traumatic As tendonitis but pain is sharper Resisted abduction very painful Passive elevation not affected Cause fall onto point of shoulder with arm adducted/spontaneous due to degeneration Acute pain Inabiltiy to initiate abduction Full passive rom if helped through first 20-30º

Rotator Cuff strengthening Sidelying Lateral Rotation

Rotator Cuff strengthening Prone Horizontal Abduction

Rotator cuff strengthening Lateral rotator strengthening with resistance band

Biceps Tendon Tendonitis Rupture Pain in bicipital groove Pain on resisted forearm supination and elbow flextion Buldge in lower third of upper arm.

Fractured neck of femur Pain on early movement Upper arm swelling Need to be investigated early especially following a fall in the elderly Should be kept moving as much as possible

Ghjt disclocation Carries a very specific history of trauma - anterior dislocation (abduction, extension and lateral rotation) Usually involves tear of labrum Physio aims to strengthen rotator cuff After 3rd dislocation surgery is usually necessary

Adhesive Capsulitis/Frozen shoulder inflammation of the shoulder capsule and synovial membrane leading to adhesion formation. This causes a thickening in the capsule and constriction of the glenohumeral joint due to the scar tissue forming in the capsule

Diagnosis Age 40+ Cause ? Unknown Possible: trauma, wrench, dislocation. CVA, heart conditions, diabetes, viral. Can also be secondary to cx spondylosis or to tendonitis.

Clinical features

Clinical features Increasing dull ache over a few months duration. Sharp pain when reaching the end of pain free movement Loss of movement in a capsular pattern – lateral rotation – abduction - flexion Most reduced >>>>>>>>>Least reduced Elevation and protraction of shoulder girdle

Clinical features cont’ Pain over A/C joint and deltoid muscle – can spread to neck and/or elbow All G/H movement often painful, not specific planes Pain worse at night

Clincial features cont’ Muscle spasm in pectoralis major and latissimus dorsi Wasted deltoid  Associated posture Dowagers hump Poke chin

Prognosis 18 months to 3 years 3 phases Freezing –painful phase (worse at night and when lying on it) Frozen – stiff phase Thawing- stiffness gradually eases

Physiotherapy Reduce pain with electrotherapy, TENS and acupuncture until patient is able to sleep and function day to day Taping to rest the joint Static strengthening exercises for the shoulder Introduce stretching in sub acute phase

Exercises to increase rom

Other treatment Antiinflamatories Muscle relaxants Hydrocortisone injection Nerve block Surgery – Manipulation/Arthroscopic capsular release