Managing Shoulder Pain - Allied Health Ed

1

Treatment and Rehabilitation of Orthopedic Shoulder Conditions

Holt Physical Therapy & Performance [email protected]

Twitter: @HOLTPT1

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Biography

• East Carolina University

• BS Exercise Phys 1995

• MS Ad. Phys Ed. 1997

• MPT Physical Therapy 1999

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Biography

APTA Sports Certified

Specialist

NSCA Certified Strength and

Conditioning Specialist

Owner and Sports

Orthopaedic PT at Holt Physical Therapy &

Performance Training

PT Consultant NHL Carolina

Hurricanes 2007-2014

Mentors• Pete Friesen

• Doug Geiger

• Gary Gray

• Walt Jenkins

• Kevin Wilk

• Co-workers

• Patients

Outline• Etiology and Incidence of Shoulder Injuries

• Shoulder Anatomy

• Common Shoulder Injuries

• Shoulder Impingement

• Adhesive Capsulitis

• Bicipital Tendonosis

• Rotator Cuff Tendonitis

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Outline

• Rotator Cuff Repair Rehab

• Multidirectional Instability

• GIRDs

• Labral Repairs

• Non-operative Treatment

• Controlling Pain and Inflamation

Outline• Restoring Normal Motion

• Restoring Functional Strength

• Strengthening for the Overhead Athlete

• FUN: Ther Ex Videos

• Physical/Surgical Interventions

• Conclusion

Etiology and Incidence of Shoulder Injuries

• Traumatic injuries

• Chronic injuries

• Bony deformities

• Poor posture

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Etiology and Incidence of Shoulder Injuries

• Neer: 40% never performed

strenuous physical work

• 50% no recollection of

shoulder trauma

• 70% of defects occur in

sedetary people doing light work

• 2/3 of cases occur in males

The Cause of

Shoulder Pain?

• MRI of asymptomatic shoulders

• 4% incidence in 19-39 yo

• 26% in subjects > 60 yo

• So is the cuff tear causing the patient’s pain?

Shoulder Anatomy

Bony

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Shoulder Bony

Anatomy

Shoulder Anatomy

Shoulder Anatomy

Muscles

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Shoulder Anatomy

Rotator Cuff

Recent ResearchArthroscopic Capsulolabral Reconstruction for Posterior Shoulder Instability in Patients 18 years Old or Younger

• 22 athletes unidirectional instability treated with posterior capsulolabral reconstruction 63 mo follow up

• 92% of shoulders were still stable

• 67% return to sport at the same level

Recent ResearchFactors Affecting Satisfaction and Shoulder Function in

Patients With a Recurrent Rotator Cuff Tear: JBJS 1/2014

• It is widely accepted that most patients treated with rotator cuff repair do well regardless of the integrity of the repair

• 26% had a re-tear

• Three age groups: < 55 years, 55-65, > 65

• ASES and SST scores in re-tear group were significantly lower

• In patients with a re-tear, younger age, lower education

level and a workers comp claim were associated with poorer outcomes

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Recent ResearchEfficacy of a static progressive stretch device as an adjunct to

physical therapy in treating adhesive capsulitis of the shoulder: a

prospective, randomized study: Physiotherapy 9/2014

• Compared static progressive stretch device plus traditional

therapy with traditional therapy alone for treatment of adhesive capsulitis

• Each group had 3 sessions per week for 4 weeks

• Measured AROM/PROM abduction and PROM ER, DASH and pain scale

• Results continued to improve 12 months later in experimental group

Recent ResearchRehabilitation following rotator cuff repair: a systematic

review: Shoulder and Elbow January 2015

• Researched 12 studies

• Strong evidence that early initiation of rehabilitation does not

adversely affect clinical outcome

• Strong evidence that initiation of functional

loading early in the rehab program does not adversely affect clinical outcome

Role of the Rotator

Cuff• provide stability through force

couples and aid in motion of the GH joint

• humeral head depressing effect that counteracts the

superior pull of the deltoid

• maintain proper position of

the GH head within the glenoid

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Role of the Scapula

• Position glenoid fossa to

align with humeral head

• Fossa is at a 30 deg angle

• Advantageous length tension relationship of

muscles

• Stable base of support:

crucial to prevent injuries, improve performance

GEM

• Look for pec minor

tightness

• can cause protraction and

forward tipping of the scapula

• CFM to pec minor is very effective

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Attachments on ScapulaSubscapularisSupraspinatus

InfraspinatusTeres Minor

Teres MajorSerratus Anterior

Latissimus DorsiDeltoid

TrapeziusLevator Scapula

RhomboidsTriceps

Pec MinorCoracobrachialis

Biceps brachiiOmohyoid

Acromion Types

Born to Fail?

• Of patients with RTC tears:

• 70% have Type 3

• 27% have Type 2

• 3% have Type 1

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Common Shoulder

Injuries• Shoulder Impingement

• Adhesive Capsulitis

• Bicipital Tendonosis

• Rotator Cuff Tendonitis

• Rotator Cuff Tear

• Multi-directional Instability

• GIRDs

• Labral Repairs

Shoulder Impingement

• Subacromial Impingement

• Internal (posterior) Impingement

Subacromial

Impingement• Subacromial bursa and

supraspinatus tendon gets pinched between humeral

head and coracoacromial arch

• long biceps tendon may also be impinged

• increased pressures with increased shoulder elevation

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Painful Arc

• usually preceded and

followed by normal, painfree ROM

• arc usually between 70-120 degrees

• lessens as symptoms improve and ER strength

improves

Subacromial

Impingement (video)

• Treatment:

• Postural re-training

• Scapular re-positioning

• Posterior Cuff strengthening

• Sleeper Stretch

Prone Row

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Prone Row w/ ER

Prone T

Prone Extension

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Prone Y

Bentover Row

Bentover T

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Bentover Extension

Bentover Y

RTC Endurance (video)

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Subacromial

Impingement

• Surgical Options:

• Distal clavicle excision and subacromial decompression

• Very effective, easy rehab

• Usually performed on Type 2

and 3 acromions

Posterior Impingement

• also known as internal

impingement

• infraspinatus and teres minor

pinch between humeral head and posterior glenoid rim

during abduction and ER

• associated with posterior

capsular contracture (GIRDS)

Posterior Impingement

• Mainly seen in overhead

athletes but occurs in weight lifters as well due to poor

lifting technique

• MOI is shoulder extension,

abduction and ER

• ie. throwing a ball overhand

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S/S of Posterior

Impingement• Pain with excessive ER at

90deg abd

• excessive ER and limited IR

• Posterior shoulder tenderness

• ER and empty can weakness

• Scapular dyskinesia

• Hx of recurrent symptoms

Adhesive Capsulitis

• Effects more females than

males

• 2nd most common shoulder

condition in 40-60yo females

• Incidence among DM 10-

20%

• 15% will develop symptoms

in other shoulder within 1 year

Adhesive Capsulitis

• Abnormal Capsular

Thickening

• Produces stiffness and limits

motion

• Inflammation produces pain

with movement

• Usually insidious onset

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Stages of Adhesive

Capsulitis

• Early Painful Stage: (Freezing)

last 2 to 9 months

• Stiffening Stage: (Freezing) last 4

to 12 months

• Recovery Stage: (Thawing) lasts

5 to 24 months

The Cumulative Injury Cycle

Adhesive Capsulitis

Stretches• Cane Flexion

• Cane External Rotation

• Horizontal Adduction

• Towel IR Stretch

• 5-10 minutes 3x/day for 6-12

weeks

• symptoms improve in 90%

• Griggs et al JBJS 2000

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Cane Flexion

Cane ER

Horizontal Adduction

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Towel IR Stretch

Snow Angels

Non-op Results

• Levine et al JSES, 2007

• 105 shoulders

• only 10 required surgery

• All given NSAIDs

• 48% had steroid injection

• Flexion 118 to 164: External Rotation 26 to 59

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Manipulation Under

Anesthesia• Indication: Primary Frozen Shoulder

• Contraindications

• Post fracture

• Post Surgical

• Severe Osteopenia

• RSD

• Diabetes??

MUA Results

• Farrell et al, JSES, 2005

• 26 shoulders

• Min 15 year f/u

• Mean SST 9.5, ASES 80

• durable results at long term

follow up

Arthroscopic Capsular

Release

• Combined with manipulation

• manipulate before arthroscopic release

• may decrease risk of intra articular injury (Loew,

JSES, 2005)

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Capsular Release

Results• Not many new studies

indicating decreased usage

• due to medical costs??

• Ogilvie-Harris 1997 n=38

• 15/20 with capsular release

had excellent result compared with 7/18 with

manipulation alone

Treating the Stiff Shoulder

• Determine if capsular or muscular splinting

• Treat dominating problem first if both are present

• Control pain using cryotherapy

• Be patient, and encourage patient

• Can be frustrating for both patient and therapist

• Chronic pain is depressing

GEM

• Try PROM with EMPI 300PV

stim unit on TENS

• Turn it up to sensory

threshold (adjust as needed)

• Be careful and hand and pad

placement

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Bicipital Tendonosis(video)

• unless a traumatic event, it is

due to poor balance and mechanics of the rotator cuff

• Special Tests:

• MOI and palpation may be

best one!

Bicipital Tendonosis

• Pain in the “groove”

• Rarely a bicep tendon issue, usually secondary to another

condition

• Loss of dynamic stability

Biceps Tendonosis

• treatment: emphasize source

of the pain, not just the pain

• NSAIDs

• cuff strengthening

• modalities

• cross friction massage

• activity modification

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Rotator Cuff

Tendonitis

• usually develops over time

with poor RTC function

• possible spurring

• subacromial impingement and OH activities

• left untreated will result in a tear

Subacromial Spur

Types of RTC tears

• partial thickness

• full thickness

• undersurface

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Rotator Cuff Tears• 70% of RTC tears occur in sedentary individuals due to

degeneration

• Partial thickness tears can progress to full thickness tears withut

activity modification

• RTC is a tensile tissue

• Full thickness tears will retract with time and be more problematic in surgery and function

• Undersurface tears are on the surface of the cuff that attach to the tuberosity

Clinical Presentation

• PAIN

• night pain or pain w activity

• partial thickness more painful than full thickness

• STIFFNESS

• posterior capsule tightness

• WEAKNESS

• uncommon because adjacent cuff fibers pick up the load

Clinical Tests for RTC

Tear

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Clinical Tests for RTC

Tears

• According to Murrell and

Walton, 98% chance of RTC if:

• All 3 tests are positive

• or 2 out of 3 if 60+ yo

Classification of Cuff

Tears• Small: <1cm

• Medium: 1 to 3 cm

• Large: 3 to 5 cm

• Massive: >5cm\

• American Academy of

Orthopedic Surgeons

Rotator Cuff Repair

Rehab Factors

• COMMUNICATION WITH

MD IS CRITICAL!!

• This determines how

aggressive you can be

• All cuff repairs are not the

same

• surgical history

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Wolff’s Law

• a law according to which

biologic systems such as hard and soft tissues become

distorted in direct correlation to the amount of stress

imposed upon them.

• Jonas: Mosby's Dictionary of

Complementary and Alternative Medicine. (c)

2005, Elsevier.

Rotator Cuff Repair

Rehab Factors

• Type of Repair: scope vs mini open

• Tissue Quality: soft tissue, bony quality, fixation strength

• Size of Tear

• Location of Tear

• Surrounding Tissue Quality:

GEM

•The incision is a mirror image of what

type of healing is going on inside the

shoulder.

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Rotator Cuff Repair

Rehab Factors

• Mechanism of Failure: traumatic vs. gradual progression

• Patient Variables: activity level, motivation, worker’s comp

• Rehab Potiential: clinic vs. HEP

• MD Philosophy: conservative vs aggressive

• Type of Tear: horizontal vs. vertical vs. avulsion

Rotator Cuff Repair

Rehab

• Maintain Integrity of Repair

• Re-establish GH jt passive mobility

• Re-establish muscular balances

• Decrease pain and compensatory patterns

• Improve dynamic stability

Take Home Message

• Rehab must be based on type of surgery, tissue quality

and size of tear

• Communication between surgeon and PT is critical

• Gradual restoration of motion

• Resume dynamic stability via ER/IR ratios and scapula

• Do not exercise through shoulder shrug sign

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Take Home Message

• Muscular balance between ER/IR

• Be careful with “empty can” exercise

• Do not overstress healing tissues

• Marathon not a sprint!

GEM

• Increase 1 pound per week provided painless and no compensatory substitution patterns

Multidirectional

Instability

• What helps stabilize GH

joint?

• GHL complex is taught at

different shoulder positions

• depth of the fossa enhanced

by labrum, as much as 50%

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Multidirectional

Instability

• Common in swimmers,

dancers and gymnasts

• Size of RTC interval plays a

role as well

Shoulder Instability

• TUBS

• Traumatic

• Unidirectional

• Bankart Lesion

• Surgery

Shoulder Instability

• AMBRI

• Atraumatic Onset

• Multi-directional in nature

• Bilateral

• Rehabilitation

• Inferior Capsular Shift

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Shoulder Instability

• respond well to rehab

• technique is critical!

• strengthen scapular

stabilizers and RTC muscles to provide dynamic stability

• proprioception exercises

GEM

• Most people strengthen what they see in the mirror

• Must keep rotator cuff strength gains at the same

progression as power muscles

Rehab Principles

• Early CONTROLLED motion

• Regain static and dynamic stability

• Restore GH joint proprioception

• Stable and supportive scapula

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Rehab Principles

• Dynamic Functional Control

• Perturbation (Kevin Wilk)

• Increase Muscular Endurance

• Sport Specific Activities

Video

Surgical Options

• Bankart Repair

• Capsular Shift

• Putti-Platt

• Thermal capsulorrhaphy

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Gross Internal

Rotation Deficit

• Stabilize the scapula and

measure IR bilaterally

• Compare involved side wtih

uninvolved

Gross Internal

Rotation Deficit (GIRD)

• IR deficit compared to opposite

• greater than 20 degrees indicated shoulder at risk

• Burkhardt, Morgan, Kibler 1998

Gross Internal

Rotation Deficit• GIRD ROM data correlated to

shoulder and/or elbow injuries

• 3 year study on Tampa Bay

organization pitchers

• If greater than 20 deg diff, 5x

more likely to develop RTC injury

• Red flagged and put in daily PT

with IR stretching

• Wilk, Porterfield, Harker, Macrina,

2007

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Total Motion Concept

• Acceptable: 170-185

• Caution: 185-200

• Monitor Carefully: >200

Sleeper Stretch• Mike Reinhold: Controversial!

• similar to Hawkins Impingement Test

Sleeper Stretch (video)

• Bottom line is that it is a very

effective way to decrease posterior capsular tightness

• Must be done carefully to pain free end range and in

correct position

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SLAP Lesions

• superior labrum anterior and

posterior

• MOI: sudden downward force

on a supinated outstretched UE or repetitive microtrauma

(OH athlete)

• average time from onset of

sx to dx is 2.5 years

Special Tests• Speed’s Test

• Grind Test

• Clunk Test

• Crank Test

• Active Compression Test

• Biceps Load

• Pain Provocation

Classification of SLAP

• Type 1: Superior labrum frayed

• Type 2: Superior labrum frayed/detatched

• Type 3: Bucket handle tear, displaced

• Type 4: Bucket handle tear, biceps involvement

• Type 5: Ant/inf Bankart lesion w/ separation of biceps tendon

• Type 6: Unstable flap tear of labrum and biceps tendon separation

• Type 7: Superior labrum-biceps tnedon separation extends beneath MGH

ligament

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Treatment for SLAP

• NSAIDs, cortisone injection

• RTC and periscapular rehab

• limit strengthening to 90 deg

• Surgery

Type 1/3 Rehab

• Immediate ROM exercises

• Full PROM by 2 weeks

• Active ROM week 2

• Isotonics at 2 weeks

• Focus on dynamic stability

• Advance strength at weeks 4-6

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Type 2/4 Rehab

• Immobilizer for 3-4 weeks

• No motion above 90 deg 4 weeks

• Full ROM at Week 8

• No isolated biceps for 6-8 weeks

• Isotonics at Weeks 4-6

• Advance strength week 10-12

GEM

• Only thing worse than the patient not doing their HEP is them doing it incorrectly

Non-operative

Treatment

• Physical Therapy

• Controlling pain and inflammation

• Restoring normal range of motion

• Restoring functional strength

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Controlling Pain and

Inflammation

• Rest

• Ice

• Anti-inflammatories

• Therapeutic Ultrasound

• Ice and electrical stimulation

Restoring Normal

Motion• Joint mobilizations

• Soft tissue mobilizations

• Passive ROM

• Active assistive ROM

• Active ROM

• Resistive ROM

Joint Mobilizations (video)

Shoulder PROM (video)

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AAROM/AROM

Resisted ROM (video)

GEM

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Gem

• Can increase shoulder

flexion ROM by releasing the lats but also by releasing the

ispilateral psoas.

• body builder/cross fit type

athletes

Restoring Functional

Strength• Functional Training:

• ROM

• Strength

• Proprioception

• Endurance

• Stabilization

Restoring Functional

Strength

• Primary goal is to enhance

dynamic functional joint stability

• Periscapular strengthening

• Rotator cuff strengthening

• Best 3 RTC strengthening exercises

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Supraspinatus:

Standing Full Can

Sidelying External

Rotation

Subscapularis:Tband IR or belly press

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Normal Strength

Ratios

• Internal to External Rotation: 3 to 2

•Adduction to Abduction: 2 to 1

•Extension to Flexion: 5 to 4

Physician

Interventions

• Prescription anti-

inflammatories

• Cortisone injection

• Diagnostic tests

• Surgical interventions

Strengthening of the

Overhead Athlete• extraordinary demands on

the shoulder joint

• excessively high stresses are

applied

• tremendous angular

velocities

• GH joint must be lax enough

to allow for excessive ER

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Strengthening of the

Overhead Athlete

• Kevin Wilk Thrower’s Paradox: “Loose enough to throw but stable enough to prevent symptoms”

• ala Gary Gray’s “mostability” concept

• Mobility <---------------------------------> Stability

Core Strengthening

• Center of Kinetic Chain

• A strong core allows extremities to function unopposed

• Centripetal acceleration begins with trunk strength

• Maintaining appropriate spine angle allows for efficient use of extremities and injury prevention

Strengthening for the

Overhead Athlete

• Below shoulder level

• Above shoulder level

• Closed chain exercises

• Plyometrics

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Below Shoulder Level

• Need to make sure this is a

good solid base before we advance.

• Zero impingement or overhead symptoms before

progressing.

Prone Row

Prone Row w/ ER

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Prone T

Prone Y

Videos

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Bentover Row

Bentover T

Bentover Extension

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Bentover Y

Body Blade ER/IR

Body Blade Flexion

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Body Blade Add/Abd

Body Blade Abduction

CC Row

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CC Row

CC Pulldowns

CC Pulldowns

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Above Shoulder Level

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Video

Closed Chain

Exercises

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Video

Video

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Video

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Video

Plyometrics (video)

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Advanced UE Strength Exercises (video)

Videos

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Conclusion

• Most shoulder injuries can be rehabilitated

• MD communication critical!

• Strengthen posterior cuff

• Protect healing tissues

• Keep it interesting for you and your patient

Thank You!

• Jaime Holt, PT, MPT, SCS, CSCS

•[email protected]

•Twitter: @HOLTPT1