1. Assessment, treatment and functional considerations
GP LECTURE SERIES 2013
THE SHOULDER
Assessment, treatment and functional considerations

2. Basic rotator cuff anatomy and function
Dynamic stability of the glenohumeral joint
The RC tendons blend together to become the joints capsule
Allows for increased mobility but compromises stability
Shallow glenoid fossa supported by a cartilaginous labrum cover
RC’s aim to maintain the HOH in optimal contact with the glenoid fossa throughout range

3. 3D assessment
Upper and lower fibres of trapezius work together to E/IR the scapula
Serratus anterior keeps the medial border of the scapula in close contact with the thorax
If 1 or more of these forces become under/over active abnormal shoulder, neck or back mechanics could result

4. Thoracic spine and shoulder function
Compensatory thoracic spine E, rot and LF to allows for more arm elevation
Hypomobile/stiff spinal and rib joints mean more movement needs to take place at the GHJ
Increase kyphosis protracts the scapula causing an imbalance throughout the shoulder girdle

5. Poor sitting posture & ergonomics

6. Looking at the bigger picture
The shoulder and thoracic spine can also be affected by structures way down the kinetic chain
Core strength and posture are very important and need to be addressed
Often diagnosing a shoulder condition is simply the symptom of a much bigger cause

7. Hawkins Kennedy Test Test for impingement and bursal bunching
Position for testing: Arm abducted to 90 degrees the examiner administers a downward pressure on the forearm into internal rotation whilst stabilising the humerus.

8. Full/Empty can test
Test for supraspinatus/infraspinatu s tear/tendonitis
Position for testing: Patient in standing or sitting abducts arms to 90 degrees.
Supraspinatus; empty can
Infraspinatus; full can

9. Apprehension Test
Test for anterior instability or recent shoulder dislocation/subluxation
Position for testing: patient lies in supine with shoulder abducted at 90 degrees and in maximal external rotation. The humerus is supported and overpressure into external rotation administered.
The anterior capsule should be supported and then overpressure released to confirm instability

10. Crank-pivot test Designed to identify a labral tear or SLAP lesion.
Position for testing: Patient in supine, arm in external rotation, examiner compresses the humeral head into the glenoid fossa and pivots the arm back and forth.

11. Frozen shoulder
Related to a loss of range throughout all degrees of freedom in the shoulder – need to look at all AM’s
External rotation most affected followed by abduction and then flexion
Particular attention should be taken to look at the scapula - sometimes range may seem equal both sides, but this is only being achieved by excessive compensatory scapulothoracic joint movement rather than normal glenohumeral joint function

12. Physiotherapy and Shoulder Disorders
Analysis of the results and effectiveness of exercise across all available clinical trials demonstrates that Physiotherapy exercises for mixed shoulder disorders & rotator cuff diseases are effective at;
Reducing pain
Improving muscle strength
Increasing function
Improving general well-being
Unsurprisingly the longer the patients performed the prescribed exercises the greater the reduction in their pain (Green, Buchbinder & Hetrick 2013)
Green S, Buchbinder R, Hetrick SE, Physiothearpy and shoulder pain (review). The Cochrane Library, Issue 3

13. Shoulder Impingement Increasing strength Decreasing pain
Manual therapy applied by experienced physical therapists, combined with a supervised exercise programme was found to be better than exercise alone for patients with shoulder impingement syndrome in;
Increasing strength
Decreasing pain
Improving function
(Bang & Deyle, 2000)
Bang, M. & Deyle, G. (2000). Comparison of Supervised Exercise With and without manual Therapy for Patients With Shoulder Impingement Syndrome. Journal of Orthopaedic & Sports Physical Therapy ;30(3):

14. Frozen Shoulder
No evidence that Physiotherapy, Pharmaceutical intervention or corticosteriod injections change the outcome of idiopathic frozen shoulder (Brukner & Khan 2006)
However, early range of motion exercises and education on the pathway of frozen shoulder are effecting in restoring range, relieving pain and improving function (Brukner & Khan, 2006)
It is also important to correct secondary complications that may arise from having a stiff and painful GHJt