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

PTA 130Fundamentals of

Treatment I

The Shoulder and Shoulder Girdle

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.

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 skeletonCan you name the joint?

High injury risk because major shoulder stabilization comes from muscle strength and coordination

Shoulder Anatomy Review

Joints of the Shoulder Girdle Complex

The clavicle articulates with the sternum at the sternoclavicular joint

Stability is provided by muscles and jointsThree synovial joints:

Glenohumeral AcromioclavicularSternoclavicular

Two functional articulations:ScapulothoracicSuprahumeral (subacromial space)

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Shoulder Stability

Structural stability provided by: LigamentsCapsuleGlenoid labrum

Dynamic stability provided by:Muscular strengthNeuromuscular controlProprioceptive input Skilled motor response

Scapulothoracic Articulation

Motions of the Scapula: Elevation and depressionProtraction and retractionUpward and downward rotation

• What motion happens with flexion of the humerus? Winging and tipping

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Scapular Stability

Scapular muscle stabilizersRhomboid major and minorSerratus anterior Middle and lower trapezius

Scapular stability provides platform for the glenohumeral (GH) joint

Poor scapular stabilization => unstable GH base

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 motionTypically at 1:1 ration with the humerus

The GH joint dominates the motion in end ranges

Scapulohumeral Rhythm

Scapulohumeral rhythm serves at least two purposes. It preserves the length-tension relationships of the

muscles moving the humerusIt prevents impingement between the humerus and

the acromion

Referred Pain

Cervical Spine – Vertebral joints betweenC3, C4, C5

Nerve RootsC4 or C5

DiaphragmPain perceived in the upper traps region

HeartPain perceived in the axilla and left pectoral region

Gallbladder irritationPain perceived at the tip of shoulder

Nerve Injury

Brachial Plexus in the thoracic outletCompression of the brachial plexus nerves may

occur under the coracoid process and pect minorSuprascapular nerve compression

Direct compression or nerve stretchMay occur when carrying a heavy bag over the

shoulderRadial nerve compression

Continual pressure in axillaLeaning on axillary crutches

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What motions occur at the scapula while in this posture?

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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

Shoulder Joint Hypomobility

Restricted mobility at the glenohumeral (GH) joint may occur as a result of: RA, OATraumatic arthritisProlonged immobilizationIdiopathic 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

Common Shoulder Injuries

Rotator Cuff TearRotator Cuff TendonitisShoulder ImpingementShoulder BursitisShoulder ArthritisFrozen ShoulderShoulder Dislocation or SeparationBicep TendonitisShoulder InstabilityLabral tears, SLAP lesion, Bankart repairAcromioclavicular Sprain

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

Rotator Cuff

4 muscles and their tendons:Supraspinatus muscle;

Shoulder ABDuctionInfraspinatus muscle;

Shoulder External Rotation Teres minor muscle; Shoulder

External Rotation Subscapularis muscle;

Shoulder Internal Rotation

Rotator Cuff Tear

Stage 1- 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)

Rotator Cuff Tendonitis

The most common rotator cuff injuryCaused by chronic overuseCommonly occurs in the supraspinatus and

infraspinatus tendonsPatient will most likely complain of pain with

overhead motionsPatient will have pain with palpation over the tendonTreatment:

Stretch/ROM, isometrics, Cross-Friction massage, and modalities

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

Shoulder Bursitis

Inflammation of the subacromial bursaMay be caused by overuse of the shoulder and/or

repetitive activitiesTreatment:

Rest, Stretching, Soft tissue mobilization and Modalities

GH Joint Arthritis

Acute PhasePatient will present with pain and muscle guardingER and ABDuction are most limited

Subacute PhasePatient will present with capsular tightnessPain is elicited when shoulder is moved into end

rangesChronic Phase

Progressive GH joint restrictionSignificant loss of function

Frozen Shoulder (Adhesive Capsulitis)

Characterized by the development of adhesions, capsular thickening, and capsular restrictions

Onset may be insidiousCause is idiopathic

Contributing factors may be: pain, restricted motion, arthritis, immobilization, trauma, etc.

Follows a pattern:“Freezing” “Frozen”“Thawing”

Frozen Shoulder (Adhesive Capsulitis)

Common Impairments: Night pain and disturbed sleepPain with motionDecreased mobilityMuscle weakness Substitution patternsFunctional limitations

Treatment: Prevention, Stretch/ROM, joint mobilization,

strengthening, and modalities

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 frequentlyClosed reduction-

Skilled technique to reduce the dislocationProtection Phase, activity restriction for 6-8 weeks

Avoid position of dislocationProtected ROM, isometrics

Shoulder Dislocation

Controlled motion phaseIncrease mobilityIncrease stability and strength of RC and periscapular

musclesReturn to function phase

Restore functional control; balance strength of shoulder and scapular musculature

CoordinationEnduranceEccentric trainingIncrease speed and controlSimulate functional patterns

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 grooveTreatment:

Isometric exercises, Stretching, Cross-Friction massage, and modalities

Shoulder Instability

Multidirectional InstabilityIndividuals have lax connective tissue which allows

for mobilityThe humeral head will translate to a greater degree

than normal in all directionsIndividuals 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

Multi-directional Instability

Unidirectional Instability

May occur in one of the following directions: AnteriorPosteriorInferior

Usually the result of traumaTypically involves rotator cuff tearsDamage to the glenoid labrum is also common

Shoulder Instability

AMBRI: Atraumatic, Multidirectional, often Bilateral, requires Rehabilitation, Inferior capsular shift is the best alternative surgical

therapyUsually initiated without traumaOften multidirectional (anterior, inferior and posterior)Occurring in patients with generalized joint laxity

Shoulder Instability

AMBRI Usually does not have surgeryTreatment consists of a program of shoulder

strengthening and stabilization exercises

Shoulder Instability

TUBS (Traumatic, Unidirectional, Bankart, Surgery) One of most common shoulder injuries in athletes

• Most common in contact athletesMay present as traumatic dislocation/subluxation Mechanism is a posteriorly directed force on an

abducted and externally rotated armHigh recurrence rate that correlates directly

with age at dislocation   • Up to 80-90% in teenagers

Traumatic Shoulder Dislocation

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

Labral Tear

SLAP Lesion

Tear of the superior labrumSLAP (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

Bankart Repair

Bankart LesionDetachment of the capsulolabral complex from the

anterior rim of the glenoidCommonly occurs as a result of a traumatic

anterior dislocationThe repair involves an anterior capsulolabral

reconstruction to reattach the labrum to the surface of the glenoid lip

Acromioclavicular Sprain

Most AC sprains are NOT surgically repairedSometimes requires initial immobilizationModalities used to relieve pain, swelling and

muscle spasmsEarly active and AAROM exercises to regain and

maintain mobilityIsometric strengthening exercises

A-C Sprain / Dislocation

Common Surgical Procedures

Glenohumeral Arthroplasty

Arthrodesis of the Shoulder

RCR- Rotator Cuff Repair

SAD- Subacromial Decompression

Glenohumeral Arthroplasty

Total shoulder arthroplasty (TSA)The glenoid and humeral surfaces are replaced

Hemireplacement arthroplastyThe humeral head is replaced

Both are open surgical proceduresIndications for surgery:

Persistent and incapacitating painLoss of shoulder mobility or stabilityInability to perform functional tasks

TSA Postoperative Management

Progression is influenced by the integrity of the rotator cuff musculature

Shoulder is typically immobilizedMaximum Protection Phase:

Day 1 post-op -> 6 weeks post-opControl of pain and inflammationMaintain mobility of adjacent jointsRestore shoulder mobilityMinimize muscle guarding and atrophy

TSA Postoperative Management

Moderate Protection/Controlled Motion Phase6 weeks -> 12-16 weeks post-opContinue to increase PROM of the shoulderDevelop active control and dynamic stabilityImprove muscle performance (strength and

endurance)

TSA Postoperative Management

Minimum Protection/Return to Functional Activity PhaseBegins around 12-16 weeks post-opExtends for several more monthsContinue to improve or maintain shoulder mobilityContinue to improve active control of the shoulderProgress muscle strengthening and stabilization

exercisesReturn to functional activities

Arthrodesis of the Shoulder

The GH joint is fused with pins and bone graftsIndications for surgery

Incapacitating painGross instability of the GH jointComplete paralysis of the deltoid and rotator cuff

musclesSevere joint destruction due to infectionFailed TSA

Arthrodesis of the Shoulder

Postoperative ManagementEmphasis is placed on maintaining mobility of

peripheral joints (wrist and hand) while the shoulder and elbow are immobilized

Following immobilization, begin active scapulothoracic ROM

Rotator Cuff Repair

May be appropriate for either partial-thickness tears or full-thickness tears

Indications for surgical repair are:PainImpaired 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

Rotator Cuff Repair

Postoperative management depends upon many factors: Size and location of tearOnset of injuryPreoperative functional mobility and strengthAge of patientType of approachType of repair

RCR Postoperative Management

Maximum Protection Phase (up to 8 weeks)Patient will most likely be immobilizedProtection of the repaired tendon(s) is the primary goal

during this phaseControl pain and inflammationAAROM exercises for elbowAROM exercises for wrist and handPrevent shoulder stiffness Restore shoulder mobilityPosture re-educationScapular stabilization exercisesGentle isometrics for GH joint musculature

RCR Postoperative Management

Moderate Protection PhaseRestore nearly full, nonpainful, passive mobility of

the shoulderIncrease muscular strength and endurance of

shoulder musculatureRe-establish dynamic stability of the shoulderAROM is allowed in pain free rangesStrengthening typically begins around 8 weeks post-

op, but may begin as late as 12 weeks for larger repairs

RCR Postoperative Management

Minimum Protection/Return to Function PhaseBegins around 12-16 weeks post-op, and lasts for 6

months to a yearContinue to work towards full ROM

• Passive stretching of GH musculature• Joint mobilization

Advance task-specific exercisesPatients are not allowed to return to high demand

activities for 6 months, up to 1 year

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

Subacromial Decompression

Maximum Protection Phase (0-4 weeks)Patient will have shoulder immobilized for 1-2 weeksPain control and inflammation controlROM activities (PROM, AAROM, AROM)Patient educationPostural re-education exercisesIsometric exercises

Subacromial Decompression

Moderate Protection Phase (4-8 weeks)Joint mobilizationStretchingPostural re-education Isotonic strengthening exercisesFunctional activities with light resistance

Minimum Protection Phase (8 weeks – 6 months)Continued strengtheningMaintain full, pain-free AROMFunctional and activity-specific exercises

Exercise Interventions for the Shoulder Girdle

Early Glenohumeral Joint Motion

AAROM Wand ExercisesFlexion, ABDuction, ER, etc.

Ball rolling or Table top washingWall washingPendulums

Ensure that patient is performing this exercise correctly

Wall pulleys

Wand External Rotation

Wand Horizontal Abduction/Adduction

Wand Abduction

Wand Internal Rotation

Pendulum

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

Self-stretching Techniques

Posterior Capsule StretchTable slides-

Flexion and ABDuctionPect doorway stretch“Sleeper Stretch”Latissimus Stretch

Stretches - Latissimus

Latissimus Stretch

Exercises for Muscle Performance

Isometric exercisesDynamic strengthening exercises—scapular

musclesDynamic strengthening exercises—GH musclesFunctional activities

Isometric Strengthening

Isolated sustained submaximal muscle contraction without movementScapular isometricsShoulder flexionShoulder extensionShoulder ABDuctionERIRShoulder Horizontal ABD/ADD

Stabilization/Dynamic Strengthening Exercises

Open and Closed Chain Stabilization Dynamic Strengthening

Prone scapular retractionScapular retraction combined with Horizontal

ABDuctionScapular Retraction and Shoulder Horizontal

Abduction Combined with External RotationScapular Protraction

• “Push-up with a Plus”

GH Dynamic Strengthening

Isotonic StrengtheningPNF PatternsIsokinetic TrainingHand walking on a treadmillProFitterUBE

Advanced Closed-Chain Stabilization and Balance

Quadruped with hands on unstable surfacePhysioball Push-up position walking stairsBOSU Ball push-up, clapsPlyometrics

Functional Activities

Endurance TrainingEccentric TrainingPlyometricsTotal Body Training

Orthopedic Special Tests

Anterior Instability

Apprehension (Crank) TestPositive 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.

Tests for Muscle or Tendon Pathology

Speed’s TestTest for tenosynovitis at the long head of bicepsPositive test elicits increased tenderness in the

bicipital groove and in indicative of tendonitis

Tests for Muscle or Tendon Pathology

Yergason’s TestA positive result is tenderness in the bicipital groove

(or the tendon may pop out of the groove) and is indicative of bicipital tendonitis

Tests for Muscle or Tendon Pathology

Supraspinatus “Empty Can” TestThe examiner looks for weakness or pain, reflecting

a positive test resultA positive test result indicates a tear in the

supraspinatus tendon or muscle, or neuropathy of the subscapular nerve

Tests for Muscle or Tendon Pathology

Drop Arm (Codman’s) TestA 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

Tests for Impingement

Neer Impingement TestThe patient’s face shows pain, reflecting a positive

test result

Tests for Impingement

Hawkins-Kennedy Impingement TestPain indicates a positive test for supraspinatus

tenditintis

Tests for Thoracic Outlet Syndrome

Roos Test+ is unable to keep arms in starting position,

ischemic pain, heaviness, profound weakness, numbness, tingling

Tests for Thoracic Outlet Syndrome

Adson ManeuverTests for subclavian artery compression or TOSA disappearance in the pulse is a positive test.

Questions