1. THE SHOULDER AND SHOULDER GIRDLE CH 17

2. TOPICS TO BE COVERED Examination, evaluation and assessment of shoulder joint Referred pain and nerve injury MANAGEMENT OF SHOULDER DISORDERS AND SURGERIES Joint Hypomobility: non-operative management Glenohumeral joint surgery and postoperative management

3. Revision of shoulder anatomy and biomechanics Shoulder complex articulations Arthrokinematics/osteokinematics Static and dynamic constraints Scapulohumeral rhythm

4. Winging and tipping

5. Brief Glance on Surface Anatomy

6. MANAGEMENT OF SHOULDER DISORDERS AND SURGERIES

7. Nerve Disorders in the Shoulder Girdle Region Brachial plexus in the thoracic outlet Suprascapular nerve in the suprascapular notch Radial nerve in the axilla

8. Joint Hypo mobility and post op management

9. RA and OA Traumatic arthritis Post-immobilization arthritis or stiffness Idiopathic frozen shoulder Causes

10. ACUTE PHASESUBACUTE PHASECHRONIC PHASE Pain and muscle guarding Radiating below the elbow Disturb sleep Tenderness (Deltoid) Capsular tightness Limited motion with a capsular pattern Pain at the end of the limited range Limited joint play Limited motion in a capsular pattern Decreased joint play Loss of function Inability to reach overhead, outward, or behind the back Clinical Signs and symptoms

11. STAGE I PRE-FREEZING (1-3 M ) STAGE II FREEZING (3-9 M) STAGE III FROZEN ( 9-14 M) STAGE IV THAWING ( 15-24 M) GRADUAL ONSET OF PAIN, INCREASED WITH MOVEMENT, DISTURBS SLEEP, LOSS OF ER, INTACT RC STRENGTH PERSISTENT AND INTENSE PAIN, AT REST, MOTION LIMITED IN ALL DIRECTIONS, CANT BE RESTORD WITH INTRA ARTICULAR INJECTIONS PAIN ONLY WITH MOVEMENT, SIGNIFICANT ADHESIONS, LIMITED GH MOTIONS, SUBSTITUTE MOTIONS, ATROPHY OF DELTOID, BICEP, TRICEP AND RC MINIMAL PAIN, NO SYNOVITIS, SIGNIFICANT CAPSULAR RESTRICTIONS, MOTION MAY GRADUALLY IMPROVE, SOME PATIENTS NEVER GAIN RANGE IDIOPATHOC FROZEN SHOULDER

12. IMPAIREMENTS AND FUNCTIONAL LIMITATIONS IMPAIREMENTS Night pain and disturbed sleep Pain on motion and at rest Decreased ROM Faulty postural Gait disturbance Muscle weakness and poor endurance substitute scapular motions FUNCTIONAL LIMITATIONS Difficulty in Putting on a jacket or coat women fastening undergarments Reaching hand into back pocket of pants (to retrieve wallet) Reaching out a car window (to use an ATM machine) Self-grooming (such as combing hair, brushing teeth, washing face) Bringing eating utensils to the mouth Difficulty lifting weighted objects

13. Management—Protection Phase 1. Control Pain, Edema, and Muscle Guarding Modalities Modalities Immobilization Immobilization Grade I and II Grade I and II Cervical soft tissue mobilization Cervical soft tissue mobilization PROM/ AAROM PROM/ AAROM

14. Management—Protection Phase 2. Maintain Soft Tissue and Joint Integrity and Mobility PROM PROM Grade I and II distractions and glides Grade I and II distractions and glides Pendulum (Codman’s )exercises Pendulum (Codman’s )exercises Correct faulty posture Correct faulty posture Be careful about precautions and contra indications

15. Management—Protection Phase 3. Maintain Integrity and Function of Associated Areas Prevent CRPS – hand exercises Prevent CRPS – hand exercises Edema in hand-elevate above heart Edema in hand-elevate above heart Elbow, forearm and wrist AROM Elbow, forearm and wrist AROM

16. Management— Controlled Motion Phase 1. Control Pain, Edema, and Joint Effusion

17. Management— Controlled Motion Phase 2. Progressively Increase Joint and Soft Tissue Mobility Mobilization – grade III sustained or grade III, IV oscillations Mobilization – grade III sustained or grade III, IV oscillations Self mobilization techniques Self mobilization techniques Manual stretching Manual stretching Self stretching Self stretching Sling exercise for RC

18. Self-mobilization techniques.

19. Management— Controlled Motion Phase Inhibit Muscle Spasm and Correct Faulty Mechanics Improve Joint Tracking MWM Improve Muscle Performance

20. Management— Return to Function Phase Progressively Increase Flexibility and Strength

21. Management— Return to Function Phase Prepare for Functional Demands

22. Post manipulation under anaesthesia Following this procedure, there is an inflammatory reaction and the joint is treated as an acute lesion. The arm is kept elevated overhead in abduction and external rotation during the inflammatory reaction stage; treatment principles progress as with any joint lesion. Therapeutic exercises are initiated the same day while the patient is still in the recovery room, with emphasis on internal and external rotation in the 90° (or higher) abducted position. Joint mobilization procedures are used, particularly a caudal glide, to prevent re adherence of the inferior capsular fold. When sleeping, the patient may be required to position the arm in abduction for up to 3 weeks after manipulation.

23. Glenohumeral joint surgery and postoperative management

24. Underlying pathologies RA, OA AVN of head of humerus An acute or nonunion fracture

25. Indications Significant pain Loss of upper Limb function

26. Goals

27. Designs of Prosthetic Implants for Total Shoulder Replacement Unconstrained Semiconstrained Reversed ball and socket (totally damaged RC) Constrained

28. Complications of Glenohumeral Arthroplasty Intraoperative Soft Tissue-Related Implant-Related

29. Postoperative Management: Special Considerations Integrity of the rotator cuff Intraoperative ROM ( greater ROM if unconstrained, less for more constrained) Posture (emphasize erect posture) Immobilization ( remove sling if no RC repair, sling worn up to 4-6 weeks with RC repair, removed for ecxercise)

30. Positioning After Shoulder Arthroplasty Supine Sitting

31. POST OP MANAGEMENT Maximum protection phase – 4-6 weeks Moderate protection phase – up to 12-16 weeks Minimum protection/return to function phase – up to several months

32. Exercise: Maximum Protection Phase Control pain and inflammation.

33. Exercise: Maximum Protection Phase Maintain mobility of adjacent joints

34. Exercise: Maximum Protection Phase Restore shoulder mobility

35. Exercise: Maximum Protection Phase Minimize muscle inhibition, guarding, and atrophy

36. Exercise: Moderate Protection/ Controlled Motion Phase

37. Exercise: Minimum Protection/ Return to Functional Activity Phase

39. ASSIGNMENT Resting and close packed positions of Shoulder, elbow and wrist

40. What is this condition? What is the cause? Paralysis of serratus Anterior leading to dynamic winging of scapula Active insufficiency of Deltoid during functional arm elevation when scapular UR are weak. (reverse scapulohumeral rhythm) Due to deltoid and supraspinatous

41. Faulty posture

42. MCQ your patient is 65 years old female and she had a surgical repair of rotator cuff and TSR 5 weeks ago. which of the following exercises would not be appropriate for this patient? a) Gentle manual resistance ex b) Gentle pulley ex c) Codman’s d) Passive ROM in pain free range

43. THANK YOU