GP LECTURE SERIES 2013

THE SHOULDER

Assessment, treatment and functional considerations

Basic rotator cuff anatomy and function

Dynamic stability of the glenohumeral joint

The RC tendons blend together to become the joints capsule

Allows for increased mobility but compromises stability

Shallow glenoid fossa supported by a cartilaginous labrum cover

RC’s aim to maintain the HOH in optimal contact with the glenoid fossa throughout range

3D assessment• Upper and lower fibres of

trapezius work together to E/IR the scapula

• Serratus anterior keeps the medial border of the scapula in close contact with the thorax

• If 1 or more of these forces become under/over active abnormal shoulder, neck or back mechanics could result

Thoracic spine and shoulder function

Compensatory thoracic spine E, rot and LF to allows for more arm elevation

Hypomobile/stiff spinal and rib joints mean more movement needs to take place at the GHJ

Increase kyphosis protracts the scapula causing an imbalance throughout the shoulder girdle

Poor sitting posture & ergonomics

Looking at the bigger picture

The shoulder and thoracic spine can also be affected by structures way down the kinetic chain

Core strength and posture are very important and need to be addressed

Often diagnosing a shoulder condition is simply the symptom of a much bigger cause

Hawkins Kennedy TestTest for impingement

and bursal bunchingPosition for testing:

Arm abducted to 90 degrees the examiner administers a downward pressure on the forearm into internal rotation whilst stabilising the humerus.

Full/Empty can testTest for

supraspinatus/infraspinatus tear/tendonitis

Position for testing: Patient in standing or sitting abducts arms to 90 degrees.

- Supraspinatus; empty can

- Infraspinatus; full can

Apprehension Test Test for anterior instability or

recent shoulder dislocation/subluxation

Position for testing: patient lies in supine with shoulder abducted at 90 degrees and in maximal external rotation. The humerus is supported and overpressure into external rotation administered.

The anterior capsule should be supported and then overpressure released to confirm instability

Crank-pivot test• Designed to identify a

labral tear or SLAP lesion.

• Position for testing: Patient in supine, arm in external rotation, examiner compresses the humeral head into the glenoid fossa and pivots the arm back

and forth.

Frozen shoulderRelated to a loss of range throughout all degrees

of freedom in the shoulder – need to look at all AM’s

External rotation most affected followed by abduction and then flexion

Particular attention should be taken to look at the scapula - sometimes range may seem equal both sides, but this is only being achieved by excessive compensatory scapulothoracic joint movement rather than normal glenohumeral joint function

Physiotherapy and Shoulder Disorders

Analysis of the results and effectiveness of exercise across all available clinical trials demonstrates that Physiotherapy exercises for mixed shoulder disorders & rotator cuff diseases are effective at;

- Reducing pain- Improving muscle strength- Increasing function- Improving general well-being Unsurprisingly the longer the patients performed

the prescribed exercises the greater the reduction in their pain (Green, Buchbinder & Hetrick 2013)

Shoulder ImpingementManual therapy applied by experienced physical

therapists, combined with a supervised exercise programme was found to be better than exercise alone for patients with shoulder impingement syndrome in;

- Increasing strength- Decreasing pain- Improving function

(Bang & Deyle, 2000)

Frozen Shoulder No evidence that Physiotherapy, Pharmaceutical

intervention or corticosteriod injections change the outcome of idiopathic frozen shoulder (Brukner & Khan 2006)

However, early range of motion exercises and education on the pathway of frozen shoulder are effecting in restoring range, relieving pain and improving function (Brukner & Khan, 2006)

It is also important to correct secondary complications that may arise from having a stiff and painful GHJt