1. Copyright © 2013. F.A. Davis Company Part IV: Exercise Interventions by Body Region Chapter 17 The Shoulder and Shoulder Girdle

2. Copyright © 2013. F.A. Davis Company STRUCTURE AND FUNCTION OF THE SHOULDER GIRDLE

3. Copyright © 2013. F.A. Davis Company  Synovial Joints – Glenohumeral joint Arthrokinematics Stability – Acromioclavicular joint Arthrokinematics Stability – Sternoclavicular joint Arthrokinematics Stability Joints of the Shoulder Girdle Complex

4. Copyright © 2013. F.A. Davis Company  Functional Articulations – Scapulothoracic articulation Motions of the Scapula  Scapular Stability – Postural relationship – Active arm motions – Faulty posture – Suprahumeral (subacromial) space Joints of the Shoulder Girdle Complex (cont'd)

5. Copyright © 2013. F.A. Davis Company  Scapulohumeral Rhythm  Clavicular Elevation and Rotation With Humeral Motion  External Rotation of the Humerus With Full Elevation  Deltoid: Short Rotator Cuff and Supraspinatus Mechanisms Shoulder Girdle Function

6. Copyright © 2013. F.A. Davis Company  Common Sources of Referred Pain in the Shoulder Region – Cervical spine – Referred pain from related tissues  Nerve Disorders in the Shoulder Girdle Region – Brachial plexus in the thoracic outlet – Suprascapular nerve in the suprascapular notch – Radial nerve in the axilla Referred Pain and Nerve Injury

7. Copyright © 2013. F.A. Davis Company MANAGEMENT OF SHOULDER DISORDERS AND SURGERIES

8. Copyright © 2013. F.A. Davis Company  Glenohumeral Joint – Related pathologies and etiology of symptoms Rheumatoid arthritis and osteoarthritis Traumatic arthritis Post immobilization arthritis or stiff shoulder Idiopathic frozen shoulder Joint Hypomobility: Nonoperative Management

9. Copyright © 2013. F.A. Davis Company  Glenohumeral Joint (cont’d) – Clinical signs and symptoms – Common structural and functional impairments – Common activity limitations and participation restrictions Joint Hypomobility: Nonoperative Management (cont'd)

10. Copyright © 2013. F.A. Davis Company  Glenohumeral Joint Hypomobility: Management—Protection Phase – Maintain soft tissue and joint integrity and mobility – Maintain integrity and function of associated regions Joint Hypomobility: Nonoperative Management (cont'd)

11. Copyright © 2013. F.A. Davis Company  Glenohumeral Joint Hypomobility: Management—Controlled Motion Phase – Control pain, edema, and joint effusion – Progressively increase joint and soft tissue mobility – Inhibit muscle spasm and correct faulty mechanics – Improve joint tracking – Improve muscle performance Joint Hypomobility: Nonoperative Management (cont'd)

12. Copyright © 2013. F.A. Davis Company  Glenohumeral Joint Management: Return to Function Phase – Progressively increase flexibility and strength – Prepare for functional demands  Glenohumeral Joint Management: Postmanipulation Under Anesthesia Joint Hypomobility: Nonoperative Management (cont'd)

13. Copyright © 2013. F.A. Davis Company  Acromioclavicular and Sternoclavicular Joints – Related pathologies and etiology of symptoms Overuse syndromes Subluxations or dislocations Hypomobility – Common structural and functional impairments Joint Hypomobility: Nonoperative Management (cont'd)

14. Copyright © 2013. F.A. Davis Company  Acromioclavicular and Sternoclavicular Joints – Common activity limitations and participation restrictions – Nonoperative management of AC or SC joint strain or hypermobility – Nonoperative management of AC or SC joint hypomobility Joint Hypomobility: Nonoperative Management (cont'd)

15. Copyright © 2013. F.A. Davis Company  Glenohumeral Arthroplasty – Indications for surgery – Procedures Background – Implant design, materials, and fixation – Selection of procedure Operative procedures Complications Glenohumeral Joint Surgery and Postoperative Management

16. Copyright © 2013. F.A. Davis Company  Glenohumeral Arthroplasty – Postoperative management Special considerations – Integrity of the rotator cuff – Intraoperative ROM – Posture Immobilization and postoperative positioning Exercise – Maximum protection phase – Moderate protection/controlled motion phase – Minimum protection/return to function phase Glenohumeral Joint Surgery and Postoperative Management (cont'd)

17. Copyright © 2013. F.A. Davis Company  Glenohumeral Arthroplasty (cont’d) – Outcomes Pain relief ROM Functional use of the UE Glenohumeral Joint Surgery and Postoperative Management (cont'd)

18. Copyright © 2013. F.A. Davis Company  Related Pathologies and Etiology of Symptoms – Intrinsic impingement: rotator cuff disease – Extrinsic impingement: mechanical compression of tissues Primary extrinsic impingement Secondary extrinsic impingement Internal extrinsic impingement Painful Shoulder Syndromes (Rotator Cuff Disease, Impingement Syndromes): Nonoperative Management

19. Copyright © 2013. F.A. Davis Company  Related Pathologies and Etiology of Symptoms (cont’d) – Tendinitis/bursitis Supraspinatus tendinitis Infraspinatus tendinitis Bicipital tendinitis Bursitis (subdeltoid or subacromial) – Other impaired musculoskeletal tissues – Insidious (atraumatic) onset Painful Shoulder Syndromes: Nonoperative Management (cont'd)

20. Copyright © 2013. F.A. Davis Company  Common Structural and Functional Impairments – Impaired posture and muscle imbalances – Decreased thoracic ROM – Rotator cuff overuse and fatigue – Muscle weakness secondary to neuropathy – Hypomobile posterior GH joint capsule  Common Activity Limitations and Participation Restrictions Painful Shoulder Syndromes: Nonoperative Management (cont'd)

21. Copyright © 2013. F.A. Davis Company  Management: Protection Phase – Control inflammation and promote healing – Patient education – Maintain integrity and mobility of the soft tissues – Control pain and maintain joint integrity – Develop support in related regions Painful Shoulder Syndromes: Nonoperative Management (cont'd)

22. Copyright © 2013. F.A. Davis Company  Management: Controlled Motion Phase – Patient education – Develop strong, mobile tissues – Modify joint tracking and mobility – Develop balance in length and strength of shoulder girdle muscles – Develop muscular stabilization and endurance – Progress shoulder function Painful Shoulder Syndromes: Nonoperative Management (cont'd)

23. Copyright © 2013. F.A. Davis Company  Management: Return to Function Phase – Increase muscular endurance – Develop quick motor responses to imposed stresses – Progress functional training Painful Shoulder Syndromes: Nonoperative Management (cont'd)

24. Copyright © 2013. F.A. Davis Company  Subacromial Decompression – Indications for surgery – Procedures Surgical approach Component procedures Painful Shoulder Syndromes: Surgery and Postoperative Management

25. Copyright © 2013. F.A. Davis Company  Subacromial Decompression (cont’d) – Postoperative management Immobilization Exercise progression – Maximum protection phase – Moderate protection phase – Minimum protection/return to function phase – Outcomes Painful Shoulder Syndromes: Surgery and Postoperative Management (cont'd)

26. Copyright © 2013. F.A. Davis Company  Rotator Cuff Repair – Indications for surgery – Procedures Type of repair Components of a rotator cuff repair Selection of surgical procedures Painful Shoulder Syndromes: Surgery and Postoperative Management (cont'd)

27. Copyright © 2013. F.A. Davis Company  Rotator Cuff Repair (cont’d) – Postoperative management Immobilization Exercise – Maximum protection phase – Moderate protection phase – Minimum protection/return to function phase – Outcomes – Pain relief, ROM, strength, functional abilities Painful Shoulder Syndromes: Surgery and Postoperative Management (cont'd)

28. Copyright © 2013. F.A. Davis Company  Related Pathologies and Mechanisms of Injury – Atraumatic hypermobility – Unidirectional instability – Multidirectional instability Common structural and functional impairments Common activity limitations and participation restrictions Shoulder Instabilities: Nonoperative Management

29. Copyright © 2013. F.A. Davis Company  Related Pathologies and Mechanisms of Injury (cont’d) – Traumatic hypermobility Traumatic anterior shoulder dislocation Traumatic posterior shoulder dislocation – Recurrent dislocation Common structural and functional impairments Common activity limitations and participation restrictions Shoulder Instabilities: Nonoperative Management (cont'd)

30. Copyright © 2013. F.A. Davis Company  Closed Reduction of Anterior Dislocation – Management: protection phase Protect the healing tissue Promote tissue health – Management: controlled motion phase Provide protection Increase shoulder mobility Increase stability and strength of rotator cuff and scapular muscles Shoulder Instabilities: Nonoperative Management (cont'd)

31. Copyright © 2013. F.A. Davis Company  Closed Reduction of Anterior Dislocation (cont’d) – Management: return to function phase Restore functional control Return to full activity  Closed Reduction of Posterior Dislocation Shoulder Instabilities: Nonoperative Management

32. Copyright © 2013. F.A. Davis Company  Glenohumeral Joint Stabilization Procedures – Indications for surgery – Procedures Bankart repair Capsulorrhaphy (capsular shift) Electrothermally assisted capsulorrhaphy (ETAC) Posterior capsulorrhaphy Repair of a SLAP lesion Shoulder Instabilities: Surgery and Postoperative Management

33. Copyright © 2013. F.A. Davis Company  Glenohumeral Joint Stabilization Procedures (cont’d) – Postoperative management General considerations Immobilization Exercise progression – Maximum protection phase – Moderate protection phase – Minimum protection/return to function phase – Outcomes Recurrence of instability, ROM Shoulder Instabilities: Surgery and Postoperative Management (cont'd)

34. Copyright © 2013. F.A. Davis Company  Acromioclavicular Joint Stabilization  Sternoclavicular Joint Stabilization  Postoperative Management Acromioclavicular and Sternoclavicular Joint Stabilization: Procedures and Postoperative Management

35. Copyright © 2013. F.A. Davis Company EXERCISE INTERVENTIONS FOR THE SHOULDER GIRDLE

36. Copyright © 2013. F.A. Davis Company  Early Motion of the Glenohumeral Joint – Wand exercises – Ball rolling or table top dusting – Wall (window) washing – Pendulum (Codman’s) exercises – “Gear shift” exercises Exercise Techniques During Acute and Early Subacute Stages of Tissue Healing

37. Copyright © 2013. F.A. Davis Company  Early Motion of the Scapula  Early Neuromuscular Control – Multiple-angle muscle setting – Protected weight bearing Exercise Techniques During Acute and Early Subacute Stages of Tissue Healing (cont' d)

38. Copyright © 2013. F.A. Davis Company  Self-Stretching Techniques to Increase Shoulder ROM – To increase flexion and horizontal adduction – To increase flexion and elevation of the arm – To increase external (lateral) rotation – To increase internal rotation – To increase abduction and elevation of the arm – To increase extension of the arm Exercise Techniques to Increase Flexibility and Range of Motion

39. Copyright © 2013. F.A. Davis Company  Manual and Self-Stretching Exercises for Specific Muscles – To stretch the latissimus dorsi muscle – To stretch the pectoralis major muscles – To stretch the pectoralis minor muscle – To stretch the levator scapulae muscle – To stretch the upper trapezius muscle Exercise Techniques to Increase Flexibility and Range of Motion (cont'd)

40. Copyright © 2013. F.A. Davis Company  Isometric Exercises – Scapular muscles – Multiple-angle isometrics to the GH muscles – Self-applied multiple-angle isometrics Exercises to Develop and Improve Muscle Performance and Functional Control

41. Copyright © 2013. F.A. Davis Company  Stabilization Exercises – Open-chain stabilization exercises for the scapular muscles – Open-chain stabilization exercises for the shoulder girdle – Static closed-chain (weight-bearing) stabilization exercises – Dynamic closed-chain stabilization exercises Exercises to Develop and Improve Muscle Performance and Functional Control (cont'd)

42. Copyright © 2013. F.A. Davis Company  Dynamic Strengthening Exercises: Scapular Muscles  Dynamic Strengthening Exercises: Glenohumeral Muscles Exercises to Develop and Improve Muscle Performance and Functional Control (cont'd)

43. Copyright © 2013. F.A. Davis Company  Functional Progression for the Shoulder Girdle – Exercises using combined movement patterns with functional activities – Equipment – Integration of functional activities Exercises to Develop and Improve Muscle Performance and Functional Control (cont'd)

44. Copyright © 2013. F.A. Davis Company  Critical Thinking and Discussion  Laboratory Practice  Case Studies Independent Learning Activities