PTA 130 Fundamentals of Treatment I The Shoulder and Shoulder Girdle

Lesson Objectives Identify key anatomical muscles and structures of the shoulder and arm. Identify common tissue injuries, conditions and surgical interventions. Analyze restorative interventions for common injuries. Identify soft tissue specific mobilizations for the shoulder and arm. Identify flexibility and ROM exercises.

Shoulder Factors The shoulder girdle allows for mobility of the upper extremity in multiplanar directions One of the primary functions of the shoulder is to position the hand The shoulder girdle only has one bony attachment to the axial skeleton Can you name the joint? High injury risk because major shoulder stabilization comes from muscle strength and coordination

Shoulder Anatomy Review

Joints of the Shoulder Girdle Complex The clavicle articulates with the sternum at the sternoclavicular joint Stability is provided by muscles and joints Three synovial joints: Glenohumeral Acromioclavicular Sternoclavicular Two functional articulations: Scapulothoracic Suprahumeral (subacromial space)

Concorde Career College Shoulder Stability Structural stability provided by: Ligaments Capsule Glenoid labrum Dynamic stability provided by: Muscular strength Neuromuscular control Proprioceptive input Skilled motor response Concorde Career College

Scapulothoracic Articulation Motions of the Scapula: Elevation and depression Protraction and retraction Upward and downward rotation What motion happens with flexion of the humerus? Winging and tipping

Concorde Career College Scapular Stability Scapular muscle stabilizers Rhomboid major and minor Serratus anterior Middle and lower trapezius Scapular stability provides platform for the glenohumeral (GH) joint Poor scapular stabilization => unstable GH base Concorde Career College

Scapulohumeral Rhythm Describes the timing of movement at these joints during shoulder elevation First 60 degrees of shoulder elevation and/or 30 degrees of shoulder ABDuction involves a "setting phase": The movement is primarily at the GH joint Scapulothoracic movement is small and inconsistent During the mid-range of humeral motion: The scapula has greater motion Typically at 1:1 ration with the humerus The GH joint dominates the motion in end ranges You can observe scapulohumeral rhythm by palpating the scapula's position as a person elevates the shoulder. Helpful scapular landmarks for palpation are the base of the spine and the inferior angle. - LR http://moon.ouhsc.edu/dthompso/namics/scapryme.htm

Scapulohumeral Rhythm Scapulohumeral rhythm serves at least two purposes. It preserves the length-tension relationships of the muscles moving the humerus It prevents impingement between the humerus and the acromion the muscles do not shorten as much as they would without the scapula's upward rotation, and so can sustain their force production through a larger portion of the range of motion 2. . Because of the difference in size between the glenoid fossa and the humeral head, subacromial impingement can occur unless relative movement between the humerus and scapula is limited. Simultaneous movement of the humerus and scapula during shoulder elevation limits relative (arthrokinematic) movement between the two bones. - http://moon.ouhsc.edu/dthompso/namics/scapryme.htm - LR

Referred Pain Cervical Spine – Vertebral joints between Nerve Roots C3, C4, C5 Nerve Roots C4 or C5 Diaphragm Pain perceived in the upper traps region Heart Pain perceived in the axilla and left pectoral region Gallbladder irritation Pain perceived at the tip of shoulder

Nerve Injury Brachial Plexus in the thoracic outlet Compression of the brachial plexus nerves may occur under the coracoid process and pect minor Suprascapular nerve compression Direct compression or nerve stretch May occur when carrying a heavy bag over the shoulder Radial nerve compression Continual pressure in axilla Leaning on axillary crutches

What motions occur at the scapula while in this posture? Concorde Career College

Posture in Relationship to Shoulder Correct posture is crucial to shoulder balance and function Forward-head posture  Round shoulder, rotator cuff impingement, and  shoulder flexion ROM Scapula assumes protracted and anteriorly tilted posture Causes internal rotation (IR) of GH joint Tightness in anterior chest muscles Weakness of posterior thoracic spine musculature Concorde Career College

Shoulder Joint Hypomobility Restricted mobility at the glenohumeral (GH) joint may occur as a result of: RA, OA Traumatic arthritis Prolonged immobilization Idiopathic frozen shoulder (adhesive capsulitis) Acromioclavicular Joint (AC) Sternoclavicular Joint (SC) AC and SC joints may become hypomobile due to arthritis, faulty postures, fractures, or dislocations

Common Shoulder Injuries Rotator Cuff Tear Rotator Cuff Tendonitis Shoulder Impingement Shoulder Bursitis Shoulder Arthritis Frozen Shoulder Shoulder Dislocation or Separation Bicep Tendonitis Shoulder Instability Labral tears, SLAP lesion, Bankart repair Acromioclavicular Sprain

Rotator Cuff Tear Commonly occur in both athletic and nonathletic patients Symptoms include pain, weakness, and decreased range of motion Early diagnosis is important for identifying causes, implementing effective treatment, and preventing further injury The supraspinatus is the most commonly injured/torn rotator cuff muscle

Rotator Cuff 4 muscles and their tendons: Supraspinatus muscle; Shoulder ABDuction Infraspinatus muscle; Shoulder External Rotation Teres minor muscle; Shoulder External Rotation Subscapularis muscle; Shoulder Internal Rotation

Rotator Cuff Tear Stage 1- Stage 2- Stage 3- Treatment: Partial tear less than 1 cm in size Stage 2- Partial tear > 1 cm, but < 5 cm in size Stage 3- Full tear greater than 5 cm Treatment: Stretching/ROM, isometrics, modalities, surgical intervention (if necessary) Small, medium, large

Rotator Cuff Tendonitis The most common rotator cuff injury Caused by chronic overuse Commonly occurs in the supraspinatus and infraspinatus tendons Patient will most likely complain of pain with overhead motions Patient will have pain with palpation over the tendon Treatment: Stretch/ROM, isometrics, Cross-Friction massage, and modalities

Shoulder Impingement Occurs as a result of mechanical wear of the rotator cuff against the anteroinferior aspect of the acromion in the suprahumeral space Vascular changes in the rotator cuff tendons and structural variations in the acromion often accompany this diagnosis Faulty posture may also lead to shoulder impingement Treatment: Stretching, Soft tissue mobilization, Modalities, and possible surgical intervention

Shoulder Bursitis Inflammation of the subacromial bursa May be caused by overuse of the shoulder and/or repetitive activities Treatment: Rest, Stretching, Soft tissue mobilization and Modalities

GH Joint Arthritis Acute Phase Subacute Phase Chronic Phase Patient will present with pain and muscle guarding ER and ABDuction are most limited Subacute Phase Patient will present with capsular tightness Pain is elicited when shoulder is moved into end ranges Chronic Phase Progressive GH joint restriction Significant loss of function

Frozen Shoulder (Adhesive Capsulitis) Characterized by the development of adhesions, capsular thickening, and capsular restrictions Onset may be insidious Cause is idiopathic Contributing factors may be: pain, restricted motion, arthritis, immobilization, trauma, etc. Follows a pattern: “Freezing” “Frozen” “Thawing” Look at new literature- Demographics, trauma, self-limiting

Frozen Shoulder (Adhesive Capsulitis) Common Impairments: Night pain and disturbed sleep Pain with motion Decreased mobility Muscle weakness Substitution patterns Functional limitations Treatment: Prevention, Stretch/ROM, joint mobilization, strengthening, and modalities

Shoulder Dislocation The GH joint is the most commonly dislocated joint in the body Usually caused by a severe blow to the arm with arm held in a position of external rotation and abduction Anterior dislocations occur most frequently Closed reduction- Skilled technique to reduce the dislocation Protection Phase, activity restriction for 6-8 weeks Avoid position of dislocation Protected ROM, isometrics

Shoulder Dislocation Controlled motion phase Return to function phase Increase mobility Increase stability and strength of RC and periscapular muscles Return to function phase Restore functional control; balance strength of shoulder and scapular musculature Coordination Endurance Eccentric training Increase speed and control Simulate functional patterns Need to Finish per K&C- kp

Bicipital Tendinitis Lesion is typically located on the long head of the biceps tendon in the bicipital groove Pain is elicited with resisted shoulder flexion while the arm is supinated Tenderness to palpation of the bicipital groove Treatment: Isometric exercises, Stretching, Cross-Friction massage, and modalities

Normal on the left – biceps tendonitis on right - LR

Shoulder Instability Multidirectional Instability Individuals have lax connective tissue which allows for mobility The humeral head will translate to a greater degree than normal in all directions Individuals involved in overhead throwing or lifting activities may be more prone to develop laxity of the shoulder capsule Hypermobility may also lead to impingement, subluxation, dislocation, or tendinitis

Multi-directional Instability LR

Unidirectional Instability May occur in one of the following directions: Anterior Posterior Inferior Usually the result of trauma Typically involves rotator cuff tears Damage to the glenoid labrum is also common

Shoulder Instability AMBRI: Usually initiated without trauma Atraumatic, Multidirectional, often Bilateral, requires Rehabilitation, Inferior capsular shift is the best alternative surgical therapy Usually initiated without trauma Often multidirectional (anterior, inferior and posterior) Occurring in patients with generalized joint laxity An acronym for shoulder joint instability which is Atraumatic, Multidirectional, often Bilateral, requires Rehabilitation as first-line therapy, Inferior capsular shift as the best alternative (surgical) therapy. Cf Shoulder instability.

Shoulder Instability AMBRI Usually does not have surgery Treatment consists of a program of shoulder strengthening and stabilization exercises

Shoulder Instability TUBS (Traumatic, Unidirectional, Bankart, Surgery) One of most common shoulder injuries in athletes Most common in contact athletes May present as traumatic dislocation/subluxation Mechanism is a posteriorly directed force on an abducted and externally rotated arm High recurrence rate that correlates directly with age at dislocation   Up to 80-90% in teenagers LR

Traumatic Shoulder Dislocation

Glenoid Labral Tear - CAUSES Falling on an outstretched arm A direct blow to the shoulder A sudden pull, such as when trying to lift a heavy object A violent overhead reach May occur while trying to stop a fall or slide Throwing athletes or weightlifters may experience glenoid labrum tears as a result of repetitive shoulder motion LR

Labral Tear LR

SLAP Lesion Tear of the superior labrum SLAP (Superior Labrum extending Anterior to Posterior) Often associated with a tear of the proximal attachment of the long head of the biceps and recurrent anterior instability of the GH joint Surgery involves debridement of the superior labrum and reattachment of the labrum and biceps tendon

Bankart Repair Bankart Lesion Detachment of the capsulolabral complex from the anterior rim of the glenoid Commonly occurs as a result of a traumatic anterior dislocation The repair involves an anterior capsulolabral reconstruction to reattach the labrum to the surface of the glenoid lip

Acromioclavicular Sprain Most AC sprains are NOT surgically repaired Sometimes requires initial immobilization Modalities used to relieve pain, swelling and muscle spasms Early active and AAROM exercises to regain and maintain mobility Isometric strengthening exercises

A-C Sprain / Dislocation

Common Surgical Procedures Glenohumeral Arthroplasty Arthrodesis of the Shoulder RCR- Rotator Cuff Repair SAD- Subacromial Decompression

Glenohumeral Arthroplasty Total shoulder arthroplasty (TSA) The glenoid and humeral surfaces are replaced Hemireplacement arthroplasty The humeral head is replaced Both are open surgical procedures Indications for surgery: Persistent and incapacitating pain Loss of shoulder mobility or stability Inability to perform functional tasks

TSA Postoperative Management Progression is influenced by the integrity of the rotator cuff musculature Shoulder is typically immobilized Maximum Protection Phase: Day 1 post-op -> 6 weeks post-op Control of pain and inflammation Maintain mobility of adjacent joints Restore shoulder mobility Minimize muscle guarding and atrophy

TSA Postoperative Management Moderate Protection/Controlled Motion Phase 6 weeks -> 12-16 weeks post-op Continue to increase PROM of the shoulder Develop active control and dynamic stability Improve muscle performance (strength and endurance)

TSA Postoperative Management Minimum Protection/Return to Functional Activity Phase Begins around 12-16 weeks post-op Extends for several more months Continue to improve or maintain shoulder mobility Continue to improve active control of the shoulder Progress muscle strengthening and stabilization exercises Return to functional activities

Arthrodesis of the Shoulder The GH joint is fused with pins and bone grafts Indications for surgery Incapacitating pain Gross instability of the GH joint Complete paralysis of the deltoid and rotator cuff muscles Severe joint destruction due to infection Failed TSA

Arthrodesis of the Shoulder Postoperative Management Emphasis is placed on maintaining mobility of peripheral joints (wrist and hand) while the shoulder and elbow are immobilized Following immobilization, begin active scapulothoracic ROM

Rotator Cuff Repair May be appropriate for either partial-thickness tears or full-thickness tears Indications for surgical repair are: Pain Impaired function Surgical repair is not indicated for patients who are asymptomatic despite imaging reports confirming presence of a cuff tear Surgical approach may be arthroscopic or open

Rotator Cuff Repair Postoperative management depends upon many factors: Size and location of tear Onset of injury Preoperative functional mobility and strength Age of patient Type of approach Type of repair

RCR Postoperative Management Maximum Protection Phase (up to 8 weeks) Patient will most likely be immobilized Protection of the repaired tendon(s) is the primary goal during this phase Control pain and inflammation AAROM exercises for elbow AROM exercises for wrist and hand Prevent shoulder stiffness Restore shoulder mobility Posture re-education Scapular stabilization exercises Gentle isometrics for GH joint musculature

RCR Postoperative Management Moderate Protection Phase Restore nearly full, nonpainful, passive mobility of the shoulder Increase muscular strength and endurance of shoulder musculature Re-establish dynamic stability of the shoulder AROM is allowed in pain free ranges Strengthening typically begins around 8 weeks post-op, but may begin as late as 12 weeks for larger repairs

RCR Postoperative Management Minimum Protection/Return to Function Phase Begins around 12-16 weeks post-op, and lasts for 6 months to a year Continue to work towards full ROM Passive stretching of GH musculature Joint mobilization Advance task-specific exercises Patients are not allowed to return to high demand activities for 6 months, up to 1 year

Subacromial Decompression Designed to increase the volume of subacromial space and provide adequate gliding room for tendons Indications for surgery: Pain during overhead activities Loss of shoulder functional mobility Intact or minor rotator cuff tear Impingement Performed using an arthroscopic or open approach

Subacromial Decompression Maximum Protection Phase (0-4 weeks) Patient will have shoulder immobilized for 1-2 weeks Pain control and inflammation control ROM activities (PROM, AAROM, AROM) Patient education Postural re-education exercises Isometric exercises

Subacromial Decompression Moderate Protection Phase (4-8 weeks) Joint mobilization Stretching Postural re-education Isotonic strengthening exercises Functional activities with light resistance Minimum Protection Phase (8 weeks – 6 months) Continued strengthening Maintain full, pain-free AROM Functional and activity-specific exercises

Exercise Interventions for the Shoulder Girdle

Early Glenohumeral Joint Motion AAROM Wand Exercises Flexion, ABDuction, ER, etc. Ball rolling or Table top washing Wall washing Pendulums Ensure that patient is performing this exercise correctly Wall pulleys

Wand External Rotation

Wand Horizontal Abduction/Adduction

Wand Abduction

Wand Internal Rotation

Pendulum Bend forward 90 degrees at the waist, using a table for support move body in a circular pattern to move arm

Self-stretching Techniques Posterior Capsule Stretch Table slides- Flexion and ABDuction Pect doorway stretch “Sleeper Stretch” Latissimus Stretch K & C

Stretches - Latissimus

Latissimus Stretch

Exercises for Muscle Performance Isometric exercises Dynamic strengthening exercises—scapular muscles Dynamic strengthening exercises—GH muscles Functional activities

Isometric Strengthening Isolated sustained submaximal muscle contraction without movement Scapular isometrics Shoulder flexion Shoulder extension Shoulder ABDuction ER IR Shoulder Horizontal ABD/ADD

Stabilization/Dynamic Strengthening Exercises Open and Closed Chain Stabilization Dynamic Strengthening Prone scapular retraction Scapular retraction combined with Horizontal ABDuction Scapular Retraction and Shoulder Horizontal Abduction Combined with External Rotation Scapular Protraction “Push-up with a Plus”

GH Dynamic Strengthening Isotonic Strengthening PNF Patterns Isokinetic Training Hand walking on a treadmill ProFitter UBE

Advanced Closed-Chain Stabilization and Balance Quadruped with hands on unstable surface Physioball Push-up position walking stairs BOSU Ball push-up, claps Plyometrics

Functional Activities Endurance Training Eccentric Training Plyometrics Total Body Training

K&C 17.57

Shoulder stabilization and abdominal stabilization on ball

Orthopedic Special Tests

Anterior Instability Apprehension (Crank) Test Positive test is indicated by a look or feeling of apprehension or alarm on the patient’s face and the patient’s resistance to further motion This test is used to evaluate for anterior shoulder instability. This test may also be used to assess a labral tear. The patient is lying supine. The examiner abducts the arm to 90° and laterally rotates the shoulder slowly. THIS TEST MUST BE DONE SLOWLY!!!

Tests for Muscle or Tendon Pathology Speed’s Test Test for tenosynovitis at the long head of biceps Positive test elicits increased tenderness in the bicipital groove and in indicative of tendonitis “The patient’s arm is forward flexed to 90 degrees and then the patient is asked to resist an eccentric movement into extension, first with the arm supinated, then pronated. A positive test elicits increased tenderness in the bicipital groove, especially with the arm supinated.” More effective than Yergasons because the bone moves over the tendon during the test

Tests for Muscle or Tendon Pathology Yergason’s Test A positive result is tenderness in the bicipital groove (or the tendon may pop out of the groove) and is indicative of bicipital tendonitis Patient sits while examiner stands in front. The patient’s elbow is flexed to 90 degrees and the forearm is in a pronated position while maintaining the upper arm at the side. Patient is instructed to supinate arm while examiner concurrently resists forearm supination at the wrist. Localized pain at the bicipital groove indicates a positive test

Tests for Muscle or Tendon Pathology Supraspinatus “Empty Can” Test The examiner looks for weakness or pain, reflecting a positive test result A positive test result indicates a tear in the supraspinatus tendon or muscle, or neuropathy of the subscapular nerve The patient’s shoulder is abducted to 90°with neutral rotation and resistance to abduction is provided by the examiner. The shoulder is then medially rotated and angled forward 30° so that the patient’s thumb is pointed toward the floor.

Tests for Muscle or Tendon Pathology Drop Arm (Codman’s) Test A positive test is indicated if the patient is unable to return the arm to the side slowly or has severe pain when attempting to do so. A positive result indicates a tear in the rotator complex Patient is seated with examiner to the front. Examiner grasps the patient’s wrist and passively abducts the patient’s shoulder to 90 degrees. Examiner releases the patient’s arm with instructions to slowly lower the arm. Test is positive if the patient is unable to lower his or her arm in a smooth, controlled fashion.

Tests for Impingement Neer Impingement Test The patient’s face shows pain, reflecting a positive test result The patient’s arm is forcibly elevated through forward flexion by the examiner causing a “jamming” of the greater tuberosity against the anteroinferior border of the acromion.

Tests for Impingement Hawkins-Kennedy Impingement Test Pain indicates a positive test for supraspinatus tenditintis The patient stands while the examiner forward flexes the arm to 90 degrees and then forcibly medially rotates the shoulder. The test may be performed in different degrees of forward flexion or horizontal adduction

Tests for Thoracic Outlet Syndrome Roos Test + is unable to keep arms in starting position, ischemic pain, heaviness, profound weakness, numbness, tingling The patient stands and abducts the arms to 90°, laterally rotates the shoulder and flexes the elbows to 90° so that the elbows are slightly behind the frontal plane. Then the patient opens and closes the hands slowly for 3 minutes.

Tests for Thoracic Outlet Syndrome Adson Maneuver Tests for subclavian artery compression or TOS A disappearance in the pulse is a positive test. The examiner locates the radial pulse. The patient’s head is rotated to face the test shoulder. The patient then extends the head while the examiner laterally rotates and extends the shoulder. The patient is instructed to take and deep breath and hold it

Questions