1. PTA 130 Fundamentals of Treatment I
The Shoulder and Shoulder Girdle

2. Lesson Objectives
Identify key anatomical muscles and structures of the shoulder and arm.
Identify common tissue injuries, conditions and surgical interventions.
Analyze restorative interventions for common injuries.
Identify soft tissue specific mobilizations for the shoulder and arm.
Identify flexibility and ROM exercises.

3. Shoulder Factors
The shoulder girdle allows for mobility of the upper extremity in multiplanar directions
One of the primary functions of the shoulder is to position the hand
The shoulder girdle only has one bony attachment to the axial skeleton
Can you name the joint?
High injury risk because major shoulder stabilization comes from muscle strength and coordination

4. Shoulder Anatomy Review

5. Joints of the Shoulder Girdle Complex
The clavicle articulates with the sternum at the sternoclavicular joint
Stability is provided by muscles and joints
Three synovial joints:
Glenohumeral
Acromioclavicular
Sternoclavicular
Two functional articulations:
Scapulothoracic
Suprahumeral (subacromial space)

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Shoulder Stability
Structural stability provided by:
Ligaments
Capsule
Glenoid labrum
Dynamic stability provided by:
Muscular strength
Neuromuscular control
Proprioceptive input
Skilled motor response
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9. Scapulothoracic Articulation
Motions of the Scapula:
Elevation and depression
Protraction and retraction
Upward and downward rotation
What motion happens with flexion of the humerus?
Winging and tipping

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Scapular Stability
Scapular muscle stabilizers
Rhomboid major and minor
Serratus anterior
Middle and lower trapezius
Scapular stability provides platform for the glenohumeral (GH) joint
Poor scapular stabilization => unstable GH base
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12. Scapulohumeral Rhythm
Describes the timing of movement at these joints during shoulder elevation
First 60 degrees of shoulder elevation and/or 30 degrees of shoulder ABDuction involves a "setting phase":
The movement is primarily at the GH joint
Scapulothoracic movement is small and inconsistent
During the mid-range of humeral motion:
The scapula has greater motion
Typically at 1:1 ration with the humerus
The GH joint dominates the motion in end ranges
You can observe scapulohumeral rhythm by palpating the scapula's position as a person elevates the shoulder. Helpful scapular landmarks for palpation are the base of the spine and the inferior angle. - LR

13. Scapulohumeral Rhythm
Scapulohumeral rhythm serves at least two purposes.
It preserves the length-tension relationships of the muscles moving the humerus
It prevents impingement between the humerus and the acromion
the muscles do not shorten as much as they would without the scapula's upward rotation, and so can sustain their force production through a larger portion of the range of motion
2. . Because of the difference in size between the glenoid fossa and the humeral head, subacromial impingement can occur unless relative movement between the humerus and scapula is limited. Simultaneous movement of the humerus and scapula during shoulder elevation limits relative (arthrokinematic) movement between the two bones LR

14. Referred Pain Cervical Spine – Vertebral joints between Nerve Roots
C3, C4, C5
Nerve Roots
C4 or C5
Diaphragm
Pain perceived in the upper traps region
Heart
Pain perceived in the axilla and left pectoral region
Gallbladder irritation
Pain perceived at the tip of shoulder

15. Nerve Injury Brachial Plexus in the thoracic outlet
Compression of the brachial plexus nerves may occur under the coracoid process and pect minor
Suprascapular nerve compression
Direct compression or nerve stretch
May occur when carrying a heavy bag over the shoulder
Radial nerve compression
Continual pressure in axilla
Leaning on axillary crutches

16. What motions occur at the scapula while in this posture?
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17. Posture in Relationship to Shoulder
Correct posture is crucial to shoulder balance and function
Forward-head posture 
Round shoulder, rotator cuff impingement, and  shoulder flexion ROM
Scapula assumes protracted and anteriorly tilted posture
Causes internal rotation (IR) of GH joint
Tightness in anterior chest muscles
Weakness of posterior thoracic spine musculature
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18. Shoulder Joint Hypomobility
Restricted mobility at the glenohumeral (GH) joint may occur as a result of:
RA, OA
Traumatic arthritis
Prolonged immobilization
Idiopathic frozen shoulder (adhesive capsulitis)
Acromioclavicular Joint (AC)
Sternoclavicular Joint (SC)
AC and SC joints may become hypomobile due to arthritis, faulty postures, fractures, or dislocations

19. Common Shoulder Injuries
Rotator Cuff Tear
Rotator Cuff Tendonitis
Shoulder Impingement
Shoulder Bursitis
Shoulder Arthritis
Frozen Shoulder
Shoulder Dislocation or Separation
Bicep Tendonitis
Shoulder Instability
Labral tears, SLAP lesion, Bankart repair
Acromioclavicular Sprain

20. Rotator Cuff Tear
Commonly occur in both athletic and nonathletic patients
Symptoms include pain, weakness, and decreased range of motion
Early diagnosis is important for identifying causes, implementing effective treatment, and preventing further injury
The supraspinatus is the most commonly injured/torn rotator cuff muscle

21. Rotator Cuff 4 muscles and their tendons:
Supraspinatus muscle; Shoulder ABDuction
Infraspinatus muscle; Shoulder External Rotation
Teres minor muscle; Shoulder External Rotation
Subscapularis muscle; Shoulder Internal Rotation

22. Rotator Cuff Tear Stage 1- Stage 2- Stage 3- Treatment:
Partial tear less than 1 cm in size
Stage 2-
Partial tear > 1 cm, but < 5 cm in size
Stage 3-
Full tear greater than 5 cm
Treatment:
Stretching/ROM, isometrics, modalities, surgical intervention (if necessary)
Small, medium, large

23. Rotator Cuff Tendonitis
The most common rotator cuff injury
Caused by chronic overuse
Commonly occurs in the supraspinatus and infraspinatus tendons
Patient will most likely complain of pain with overhead motions
Patient will have pain with palpation over the tendon
Treatment:
Stretch/ROM, isometrics, Cross-Friction massage, and modalities

24. Shoulder Impingement
Occurs as a result of mechanical wear of the rotator cuff against the anteroinferior aspect of the acromion in the suprahumeral space
Vascular changes in the rotator cuff tendons and structural variations in the acromion often accompany this diagnosis
Faulty posture may also lead to shoulder impingement
Treatment:
Stretching, Soft tissue mobilization, Modalities, and possible surgical intervention

25. Shoulder Bursitis Inflammation of the subacromial bursa
May be caused by overuse of the shoulder and/or repetitive activities
Treatment:
Rest, Stretching, Soft tissue mobilization and Modalities

26. GH Joint Arthritis Acute Phase Subacute Phase Chronic Phase
Patient will present with pain and muscle guarding
ER and ABDuction are most limited
Subacute Phase
Patient will present with capsular tightness
Pain is elicited when shoulder is moved into end ranges
Chronic Phase
Progressive GH joint restriction
Significant loss of function

27. Frozen Shoulder (Adhesive Capsulitis)
Characterized by the development of adhesions, capsular thickening, and capsular restrictions
Onset may be insidious
Cause is idiopathic
Contributing factors may be: pain, restricted motion, arthritis, immobilization, trauma, etc.
Follows a pattern:
“Freezing”
“Frozen”
“Thawing”
Look at new literature- Demographics, trauma, self-limiting

28. Frozen Shoulder (Adhesive Capsulitis)
Common Impairments:
Night pain and disturbed sleep
Pain with motion
Decreased mobility
Muscle weakness
Substitution patterns
Functional limitations
Treatment:
Prevention, Stretch/ROM, joint mobilization, strengthening, and modalities

29. Shoulder Dislocation
The GH joint is the most commonly dislocated joint in the body
Usually caused by a severe blow to the arm with arm held in a position of external rotation and abduction
Anterior dislocations occur most frequently
Closed reduction-
Skilled technique to reduce the dislocation
Protection Phase, activity restriction for 6-8 weeks
Avoid position of dislocation
Protected ROM, isometrics

30. Shoulder Dislocation Controlled motion phase Return to function phase
Increase mobility
Increase stability and strength of RC and periscapular muscles
Return to function phase
Restore functional control; balance strength of shoulder and scapular musculature
Coordination
Endurance
Eccentric training
Increase speed and control
Simulate functional patterns
Need to Finish per K&C- kp

31. Bicipital Tendinitis
Lesion is typically located on the long head of the biceps tendon in the bicipital groove
Pain is elicited with resisted shoulder flexion while the arm is supinated
Tenderness to palpation of the bicipital groove
Treatment:
Isometric exercises, Stretching, Cross-Friction massage, and modalities

32. Normal on the left – biceps tendonitis on right - LR

33. Shoulder Instability Multidirectional Instability
Individuals have lax connective tissue which allows for mobility
The humeral head will translate to a greater degree than normal in all directions
Individuals involved in overhead throwing or lifting activities may be more prone to develop laxity of the shoulder capsule
Hypermobility may also lead to impingement, subluxation, dislocation, or tendinitis

34. Multi-directional InstabilityLR

35. Unidirectional Instability
May occur in one of the following directions:
Anterior
Posterior
Inferior
Usually the result of trauma
Typically involves rotator cuff tears
Damage to the glenoid labrum is also common

36. Shoulder Instability AMBRI: Usually initiated without trauma
Atraumatic,
Multidirectional,
often Bilateral,
requires Rehabilitation,
Inferior capsular shift is the best alternative surgical therapy
Usually initiated without trauma
Often multidirectional (anterior, inferior and posterior)
Occurring in patients with generalized joint laxity
An acronym for shoulder joint instability which is Atraumatic, Multidirectional, often Bilateral, requires Rehabilitation as first-line therapy, Inferior capsular shift as the best alternative (surgical) therapy. Cf Shoulder instability.

37. Shoulder Instability AMBRI Usually does not have surgery
Treatment consists of a program of shoulder strengthening and stabilization exercises

38. Shoulder Instability
TUBS (Traumatic, Unidirectional, Bankart, Surgery)
One of most common shoulder injuries in athletes
Most common in contact athletes
May present as traumatic dislocation/subluxation
Mechanism is a posteriorly directed force on an abducted and externally rotated arm
High recurrence rate that correlates directly with age at dislocation  
Up to 80-90% in teenagers LR

39. Traumatic Shoulder Dislocation

40. Glenoid Labral Tear - CAUSES
Falling on an outstretched arm
A direct blow to the shoulder
A sudden pull, such as when trying to lift a heavy object
A violent overhead reach
May occur while trying to stop a fall or slide
Throwing athletes or weightlifters may experience glenoid labrum tears as a result of repetitive shoulder motion LR

41. Labral Tear LR

42. SLAP Lesion Tear of the superior labrum
SLAP (Superior Labrum extending Anterior to Posterior)
Often associated with a tear of the proximal attachment of the long head of the biceps and recurrent anterior instability of the GH joint
Surgery involves debridement of the superior labrum and reattachment of the labrum and biceps tendon

43. Bankart Repair Bankart Lesion
Detachment of the capsulolabral complex from the anterior rim of the glenoid
Commonly occurs as a result of a traumatic anterior dislocation
The repair involves an anterior capsulolabral reconstruction to reattach the labrum to the surface of the glenoid lip

44. Acromioclavicular Sprain
Most AC sprains are NOT surgically repaired
Sometimes requires initial immobilization
Modalities used to relieve pain, swelling and muscle spasms
Early active and AAROM exercises to regain and maintain mobility
Isometric strengthening exercises

45. A-C Sprain / Dislocation

46. Common Surgical Procedures
Glenohumeral Arthroplasty
Arthrodesis of the Shoulder
RCR- Rotator Cuff Repair
SAD- Subacromial Decompression

47. Glenohumeral Arthroplasty
Total shoulder arthroplasty (TSA)
The glenoid and humeral surfaces are replaced
Hemireplacement arthroplasty
The humeral head is replaced
Both are open surgical procedures
Indications for surgery:
Persistent and incapacitating pain
Loss of shoulder mobility or stability
Inability to perform functional tasks

48. TSA Postoperative Management
Progression is influenced by the integrity of the rotator cuff musculature
Shoulder is typically immobilized
Maximum Protection Phase:
Day 1 post-op -> 6 weeks post-op
Control of pain and inflammation
Maintain mobility of adjacent joints
Restore shoulder mobility
Minimize muscle guarding and atrophy

49. TSA Postoperative Management
Moderate Protection/Controlled Motion Phase
6 weeks -> weeks post-op
Continue to increase PROM of the shoulder
Develop active control and dynamic stability
Improve muscle performance (strength and endurance)

50. TSA Postoperative Management
Minimum Protection/Return to Functional Activity Phase
Begins around weeks post-op
Extends for several more months
Continue to improve or maintain shoulder mobility
Continue to improve active control of the shoulder
Progress muscle strengthening and stabilization exercises
Return to functional activities

51. Arthrodesis of the Shoulder
The GH joint is fused with pins and bone grafts
Indications for surgery
Incapacitating pain
Gross instability of the GH joint
Complete paralysis of the deltoid and rotator cuff muscles
Severe joint destruction due to infection
Failed TSA

52. Arthrodesis of the Shoulder
Postoperative Management
Emphasis is placed on maintaining mobility of peripheral joints (wrist and hand) while the shoulder and elbow are immobilized
Following immobilization, begin active scapulothoracic ROM

53. Rotator Cuff Repair
May be appropriate for either partial-thickness tears or full-thickness tears
Indications for surgical repair are:
Pain
Impaired function
Surgical repair is not indicated for patients who are asymptomatic despite imaging reports confirming presence of a cuff tear
Surgical approach may be arthroscopic or open

54. Rotator Cuff Repair
Postoperative management depends upon many factors:
Size and location of tear
Onset of injury
Preoperative functional mobility and strength
Age of patient
Type of approach
Type of repair

55. RCR Postoperative Management
Maximum Protection Phase (up to 8 weeks)
Patient will most likely be immobilized
Protection of the repaired tendon(s) is the primary goal during this phase
Control pain and inflammation
AAROM exercises for elbow
AROM exercises for wrist and hand
Prevent shoulder stiffness
Restore shoulder mobility
Posture re-education
Scapular stabilization exercises
Gentle isometrics for GH joint musculature

56. RCR Postoperative Management
Moderate Protection Phase
Restore nearly full, nonpainful, passive mobility of the shoulder
Increase muscular strength and endurance of shoulder musculature
Re-establish dynamic stability of the shoulder
AROM is allowed in pain free ranges
Strengthening typically begins around 8 weeks post-op, but may begin as late as 12 weeks for larger repairs

57. RCR Postoperative Management
Minimum Protection/Return to Function Phase
Begins around weeks post-op, and lasts for 6 months to a year
Continue to work towards full ROM
Passive stretching of GH musculature
Joint mobilization
Advance task-specific exercises
Patients are not allowed to return to high demand activities for 6 months, up to 1 year

58. Subacromial Decompression
Designed to increase the volume of subacromial space and provide adequate gliding room for tendons
Indications for surgery:
Pain during overhead activities
Loss of shoulder functional mobility
Intact or minor rotator cuff tear
Impingement
Performed using an arthroscopic or open approach

59. Subacromial Decompression
Maximum Protection Phase (0-4 weeks)
Patient will have shoulder immobilized for 1-2 weeks
Pain control and inflammation control
ROM activities (PROM, AAROM, AROM)
Patient education
Postural re-education exercises
Isometric exercises

60. Subacromial Decompression
Moderate Protection Phase (4-8 weeks)
Joint mobilization
Stretching
Postural re-education
Isotonic strengthening exercises
Functional activities with light resistance
Minimum Protection Phase (8 weeks – 6 months)
Continued strengthening
Maintain full, pain-free AROM
Functional and activity-specific exercises

61. Exercise Interventions for the Shoulder Girdle

62. Early Glenohumeral Joint Motion
AAROM Wand Exercises
Flexion, ABDuction, ER, etc.
Ball rolling or Table top washing
Wall washing
Pendulums
Ensure that patient is performing this exercise correctly
Wall pulleys

63. Wand External Rotation

64. Wand Horizontal Abduction/Adduction

65. Wand Abduction

66. Wand Internal Rotation

67. Pendulum
Bend forward 90 degrees at the waist, using a table for support move body in a circular pattern to move arm

68. Self-stretching Techniques
Posterior Capsule Stretch
Table slides-
Flexion and ABDuction
Pect doorway stretch
“Sleeper Stretch”
Latissimus Stretch
K & C

69. Stretches - Latissimus

70. Latissimus Stretch

71. Exercises for Muscle Performance
Isometric exercises
Dynamic strengthening exercises—scapular muscles
Dynamic strengthening exercises—GH muscles
Functional activities

72. Isometric Strengthening
Isolated sustained submaximal muscle contraction without movement
Scapular isometrics
Shoulder flexion
Shoulder extension
Shoulder ABDuction ER IR
Shoulder Horizontal ABD/ADD

73. Stabilization/Dynamic Strengthening Exercises
Open and Closed Chain Stabilization
Dynamic Strengthening
Prone scapular retraction
Scapular retraction combined with Horizontal ABDuction
Scapular Retraction and Shoulder Horizontal Abduction Combined with External Rotation
Scapular Protraction
“Push-up with a Plus”

74. GH Dynamic Strengthening
Isotonic Strengthening
PNF Patterns
Isokinetic Training
Hand walking on a treadmill
ProFitter
UBE

75. Advanced Closed-Chain Stabilization and Balance
Quadruped with hands on unstable surface
Physioball
Push-up position walking stairs
BOSU Ball push-up, claps
Plyometrics

76. Functional Activities
Endurance Training
Eccentric Training
Plyometrics
Total Body Training

77. K&C 17.57

78. Shoulder stabilization and abdominal stabilization on ball

79. Orthopedic Special Tests

80. Anterior Instability Apprehension (Crank) Test
Positive test is indicated by a look or feeling of apprehension or alarm on the patient’s face and the patient’s resistance to further motion
This test is used to evaluate for anterior shoulder instability. This test may also be used to assess a labral tear.
The patient is lying supine. The examiner abducts the arm to 90° and laterally rotates the shoulder slowly. THIS TEST MUST BE DONE SLOWLY!!!

81. Tests for Muscle or Tendon Pathology
Speed’s Test
Test for tenosynovitis at the long head of biceps
Positive test elicits increased tenderness in the bicipital groove and in indicative of tendonitis
“The patient’s arm is forward flexed to 90 degrees and then the patient is asked to resist an eccentric movement into extension, first with the arm supinated, then pronated. A positive test elicits increased tenderness in the bicipital groove, especially with the arm supinated.”
More effective than Yergasons because the bone moves over the tendon during the test

82. Tests for Muscle or Tendon Pathology
Yergason’s Test
A positive result is tenderness in the bicipital groove (or the tendon may pop out of the groove) and is indicative of bicipital tendonitis
Patient sits while examiner stands in front. The patient’s elbow is flexed to 90 degrees and the forearm is in a pronated position while maintaining the upper arm at the side. Patient is instructed to supinate arm while examiner concurrently resists forearm supination at the wrist. Localized pain at the bicipital groove indicates a positive test

83. Tests for Muscle or Tendon Pathology
Supraspinatus “Empty Can” Test
The examiner looks for weakness or pain, reflecting a positive test result
A positive test result indicates a tear in the supraspinatus tendon or muscle, or neuropathy of the subscapular nerve
The patient’s shoulder is abducted to 90°with neutral rotation and resistance to abduction is provided by the examiner. The shoulder is then medially rotated and angled forward 30° so that the patient’s thumb is pointed toward the floor.

84. Tests for Muscle or Tendon Pathology
Drop Arm (Codman’s) Test
A positive test is indicated if the patient is unable to return the arm to the side slowly or has severe pain when attempting to do so.
A positive result indicates a tear in the rotator complex
Patient is seated with examiner to the front. Examiner grasps the patient’s wrist and passively abducts the patient’s shoulder to 90 degrees. Examiner releases the patient’s arm with instructions to slowly lower the arm. Test is positive if the patient is unable to lower his or her arm in a smooth, controlled fashion.

85. Tests for Impingement Neer Impingement Test
The patient’s face shows pain, reflecting a positive test result
The patient’s arm is forcibly elevated through forward flexion by the examiner causing a “jamming” of the greater tuberosity against the anteroinferior border of the acromion.

86. Tests for Impingement Hawkins-Kennedy Impingement Test
Pain indicates a positive test for supraspinatus tenditintis
The patient stands while the examiner forward flexes the arm to 90 degrees and then forcibly medially rotates the shoulder. The test may be performed in different degrees of forward flexion or horizontal adduction

87. Tests for Thoracic Outlet Syndrome
Roos Test
+ is unable to keep arms in starting position, ischemic pain, heaviness, profound weakness, numbness, tingling
The patient stands and abducts the arms to 90°, laterally rotates the shoulder and flexes the elbows to 90° so that the elbows are slightly behind the frontal plane. Then the patient opens and closes the hands slowly for 3 minutes.

88. Tests for Thoracic Outlet Syndrome
Adson Maneuver
Tests for subclavian artery compression or TOS
A disappearance in the pulse is a positive test.
The examiner locates the radial pulse. The patient’s head is rotated to face the test shoulder. The patient then extends the head while the examiner laterally rotates and extends the shoulder. The patient is instructed to take and deep breath and hold it

89. Questions