1. The Shoulder and Shoulder Girdle

2. PAINFUL SHOULDER SYNDROMES, IMPINGEMENT SYNDROMES: NONOPERATIVE MANAGEMENT Ghurki Trust Teaching Hospital

3. Categories of Painful Shoulder Syndromes

4. Neer’s Classification of Rotator Cuff Disease

5. Stage I. Edema, hemorrhage (patient usually <25 years of age) Stage II. Tendonitis/bursitis and fibrosis (patient usually 25 to 40 years of age) Stage III. Bone spurs and tendon rupture (patient usually >40 years of age)

6. Jobe’s classification of impingement

7. Group 1. Pure impingement (usually in an older recreational athlete with partial undersurface rotator cuff tear and subacromial bursitis) Group 2. Impingement associated with labral and/or capsular injury, instability, and secondary impingement Group 3. Hyperelastic soft tissues resulting in anterior or multidirectional instability and impingement (usually attenuated but intact labrum, undersurface rotator cuff tear) Group 4. Anterior instability without associated impingement (result of trauma; results in partial or complete dislocation)

8. Etiology of Symptoms Primary impingement – Intrinsic factors Vascular changes in the rotator cuff tendons, tissue tension overload, and collagen disorientation and degeneration

9. Etiology of Symptoms Primary impingement – Extrinsic factors Tendinitis/Bursitis

10. Common Impairments Rotator Cuff Overuse and Fatigue Hypomobile Posterior GH Joint Capsule

11. Impaired posture Increased thoracic kyphosis, forward head, and protracted and forward-tilted scapula are often identified as related to impingement syndrome. Faulty scapular alignment may be one factor in decreasing the suprahumeral space and therefore leading to irritation of the rotator cuff tendons with overhead activities

12. Common Functional Limitations/Disabilities Pain in side lying Difficulty in – Lifting loads, reaching, lifting, throwing, pushing, pulling, or swinging the arm, dressing

13. Management: Painful Shoulder Syndromes (Without Dislocation)

14. Management: Protection Phase Massage Support

15. Management: Protection Phase PROM AROM AAROM Muscle Setting

16. Management: Controlled Motion Phase Mobile Scar Postural Awareness Joint Tracking and Mobility Stretching Muscular Stabilization and Endurance

17. Management: Return to Function Phase

18. PAINFUL SHOULDER SYNDROMES: SURGERY

19. Rotator Cuff Repair

20. Indications for Surgery Partial-thickness with irreversible degenerative changes Neer stage II lesions Neer stage III lesions Acute full-thickness tear

22. Type of Repair Arthroscopic approach Mini-open (arthroscopically assisted) approach Traditional open approach

23. Postoperative Management

24. Maximum Protection Phase Control pain and inflammation Prevent loss of mobility of peripheral joints Restore shoulder mobility Correct postural deviations Develop control of scapulothoracic stabilizers Prevent inhibition and atrophy

26. Exercise: Moderate Protection Phase

27. Exercise: Minimum Protection/Return to Function Phase

28. Shoulder Instabilities: Nonoperative Management Atraumatic Hypermobility It may be the result of physiological laxity of the connective tissues or repetitive non uniform loading of the joint. Anterior instability usually occurs with forces against the arm when it is in an abducted and externally rotated position, resulting in anterior humeral head translations. Posterior instability is much less common but can occur from repetitive forces against a forward-flexed humerus, translating the humeral head posteriorly Inferior instability is typically the result of rotator cuff weakness/paralysis and is frequently seen in patients with hemiplegia. It is also prevalent in patients who repetitively reach overhead (workers or swimmers, for example)

29. Traumatic Hypermobility Traumatic anterior shoulder dislocation In shoulder abducted and externally rotated position stability is provided by the subscapularis, GH ligaments (particularly the anterior band of the inferior ligament), and long head of the biceps. A significant force to the arm may damage these structures, along with the attachment of the anterior capsule and glenoid labrum (Bankart lesion)

31. Traumatic posterior shoulder dislocation. Traumatic posterior shoulder dislocation is less common. The mechanism of injury is usually a force applied to the arm when the humerus is positioned in flexion, adduction, and internal rotation, such as falling on an outstretched arm

32. Closed Reduction of Anterior Dislocation Management: Protection Phase Protect the Healing Tissue Activity restriction is recommended for 6 to 8 weeks in a young patient. If a sling is used, the arm is removed from the sling only for controlled exercise Promote Tissue Health Protected ROM, intermittent muscle setting of the rotator cuff, deltoid, and biceps brachii muscles, and grade II joint mobilization techniques

33. Management: Controlled Motion Phase Provide Protection The patient continues to protect the joint and delay full return to unrestricted activity. If a sling is being used, the patient increases the time the sling is off. The sling is used when the shoulder is tired or if protection is needed. Increase Shoulder Mobility Mobilization techniques are initiated using all appropriate glides except the anterior glide Increase Stability and Strength of Rotator Cuff and Scapular Muscles Both the internal and external rotators need to be strengthened as healing occurs Dynamic resistance, limiting external rotation to 50° and avoiding the position of dislocation.

34. Management: Return to Function Phase Restore Functional Control The following are emphasized. A balance in strength of all shoulder and scapular muscles Coordinated scapulothoracic and arm motions Endurance for each previously described shoulder instability exercise As stability improves, progress to: Eccentric training to maximum load. Increasing speed and control of combined motions. Simulating desired functional patterns for activity

35. Shoulder Instabilities: Surgery and Postoperative Management Bankart repair. A Bankart repair involves an open or arthroscopic repair of a Bankart lesion (detachment of the capsulolabral complex from the anterior rim of the glenoid) which commonly accompanies a traumatic anterior dislocation. During the repair an anterior capsulolabral reconstruction is performed to reattach the labrum to the surface of the glenoid lip

36. Exercise: Maximum Protection Phase The initial phase of rehabilitation extends for about 6 weeks after surgery. Control pain and inflammation. A sling for comfort when the arm is dependent. Cryotherapy and prescribed anti-inflammatory medication Shoulder relaxation exercises Prevent or correct posture impairments. Emphasis on spinal extension and scapular retraction; avoid excessive thoracic kyphosis Restore shoulder mobility while protecting tightened or repaired tissues. Pendulum exercises for the first 2 weeks postoperatively. Self-assisted ROM and wand exercises for the GH joint within protected ranges as early as 2 weeks or as late as 6 weeks postoperatively. Prevent reflex inhibition and atrophy of GH musculature. Multiple-angle, low-intensity isometric exercises of GH musculature as early as the first week or by 3 to 4 weeks postoperatively

38. Exercise: Moderate Protection Phase Regain nearly full, pain-free, active ROM of the shoulder. Continue active ROM with the goal of achieving nearly full ROM by 12 weeks Continue to increase strength and endurance of shoulder musculature. Alternating isometrics against increasing resistance with emphasis on the scapula and rotator cuff musculature.

39. Exercise: Minimum Protection/Return to Function Phase This phase usually begins around 12 weeks postoperatively or as late as 16 weeks, depending on individual characteristics of the patient and the surgical stabilization procedure. Stretching should continue until ROM consistent with functional needs has been attained

40. Exercise interventions for the shoulder Girdle Exercise Techniques During Acute And Early Subacute Stages of tissue healing Exercise techniques to increase flexibility and range of motion Exercises to develop and improve muscle performance and functional control.