1. The Shoulder

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

3. 3 components The glenohumeral joint The acromiclavicular joint
The scapular

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

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

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

7. 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

8. 3 main types of rotator cuff lesions
Tendonitis
Partial rupture
Complete rupture

9. 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

10. 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

11. 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

12. Rotator Cuff strengthening
Sidelying Lateral Rotation

13. Rotator Cuff strengthening
Prone Horizontal Abduction

14. Rotator cuff strengthening
Lateral rotator strengthening with resistance band

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

16. 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

17. 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

18. 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

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

20. Clinical features

21. 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

22. 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

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

24. 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

25. 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

26. Exercises to increase rom

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