Exploring Hand Therapy Manual

Shoulder Pathology:A Detailed Approach to

Examination & Treatment

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Exploring Hand Therapy, Corporationwww.exploringhandtherapy.com

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Shoulder Pathology

Paul J. Bonzani OTR/L CHT

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So Where do We Begin?????

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The Shoulder Complex:

• Shoulder movement results from the interaction of 4 joints– Sternoclavicular joint– Acromioclavicular joint– Glenohumeral joint– Scapulothoracic joint (physiological joint)

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Shoulder Movement:Osteokinematic Motion

• Forward flexion: sagittal plane elevation

• Abduction: frontal plane elevation• Scapula plane elevation: most

functional type of overhead motion• Rotation: internal/external rotation• Extension• Horizontal flexion/extension

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The Glenohumeral Joint 4 Axes of Motion

• Transverse axis.

• Anterior-posterior axis.

• Vertical axis.

• Long axis of the Humerus.

• Controls flexion & extension.

• Controls abduction & adduction.

• Controls horizontal flexion & extension.

• Controls internal and external rotation.

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ArthrokinematicsGlenohumeral Joint Motion

• Rolling

• Gliding

• Rotation

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The Scapulothoracic Joint

• Physiological joint > bone, muscle, bone articulation.

• Scapula lies 30 degrees anterior to the frontal plane.

• Combines with the 30 degrees humeral head retroversion to form the “scapula plane”.

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The Scapulothoracic JointPlanes of Motion

• Protraction-retraction.

• Elevation-depression.

• Upward rotation.

• Vertical axis.

• Frontal plane.

• Transverse axis in the sagittal plane.

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The Scapulothoracic JointFunctional Motions

• Upward rotation occurs around a transverse axis.

• Superior-inferior tilting occurs around a longitudinal axis.

• Scapulohumeral rhythm.

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Spinal Contributions

• Important for terminal elevation.• Orients the arm in relation to the body’s

center of mass.

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Force Couples• Deltoid-supraspinatus.• Serratus anterior-trapezius.• Rhomboids-teres major.• Triceps long head-latissimus dorsi.

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The Physiology of Abduction

3 phases of abduction• 1st phase > 0-90 degrees• 2nd phase > 90-150 degrees• 3rd phase > 150-180 degrees

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The Physiology of Flexion

3 phases of flexion.• 1st phase > 0-50/60 degrees.• 2nd phase > 60-120 degrees.• 3rd phase > 120-180 degrees.

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The Physiology of Rotation

• External rotators are 2/3 weaker than internal rotators.

• Shoulder rotation is augmented by periscapular motions to increase the range for the entire limb.

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Summary

• Shoulder motion is the result of 4 articulations.

• Each articulation contributes to smooth elevation of the extremity.

• The articulations and their motor are inter-related and balanced to provide functional extremity movement.

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Skeletal Injuries

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AC Joint Pathology

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AC Joint Compression Test

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Proximal Humerus Fractures

• 2-PART

• 3-PART

• 4-PART

• Conservative management

• Conservative/Surgical

• Surgical management

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Hills-Sachs Lesions

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Shoulder Osteoarthritis

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Arthritis

• Inspection- Possible disuse atrophy• Tenderness- May be anywhere • ▼ROM- Active and passive• Strength- variable

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Mid Shaft Humeral Fractures• Early AROM if rigidly

reduced.

• Mobilization can be delayed if other co-pathologies are noted.

• Concern is torque forces.

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Humeral Fracture Bracing

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Glenoid Fractures

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Glenoid Video 1

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Glenoid Video 2

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Glenoid Video 3k0j

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Soft Tissue Conditions

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Physical Examination of the Shoulder

• Subjective examination• Cervical spine screening• Objective examination

– Structural observation– Mobility testing– Strength testing– Special tests

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Subjective Examination• Helps plan the objective evaluation.• Document recent trauma.• Identify chronic contributions to the

problem.• Careful medical history.• Consider the results of objective tests.

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Cervical Spine Screening• Check cervical AROM

– Flexion/extension– Rotation– Side bending

• Provocative testing as indicated

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Cervical Motion Video

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Cervical Video 2

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Objective Evaluation:Structural

• Postural assessment.• Shoulder contours and heights.• Scapula winging.• Clavicluar abnormalities.

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Objective Assessment:Mobility

• Active mobility -physiological motions.

• Passive mobility.

• Accessory joint mobility.

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Objective Assessment:Palpation

• A/C and S/C joints.• Rotator cuff insertions.• Biceps tendon & Bicepital groove.• Scapula borders.• Levator scapulae & trapezius muscles.

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Objective Assessment:Strength/neurological Testing

• Manual muscle testing.

• “Functional testing”.

• Sensory testing: C4-T1 dermatomes.

• DTR’S: biceps (C5-6) Brachioradialis (C6-7) triceps (C7-8).

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Manual Muscle Testing

• Always assess periscapular strength.– Serratus anterior.– Rhomboids.– Levator scapula.

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Manual Muscle Testing

• Rotator cuff muscles by function.– Supraspinatus-abduction.– Infraspinatus-external rotation in adduction.– Teres minor-adduction and external rotation.– Supscapularis-adduction and internal rotation.

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Functional Testing

• Used in fracture rehabilitation.

• Neurogenic issues.

• Not indicated in muscle imbalance conditions. – Soft tissue dysfunction.

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Objective Assessment:Special Tests

• Neurological tests.• Impingement tests.• Biceps tests.• Rotator cuff test.• Instability tests.

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Neer Test Demo

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Hawkins Test Demo.

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External Rotation Resistance Demo

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Empty Can Versus Full Can Testing Demo.

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Physical Examination

• Anatomy and biomechanics improves examination skills.

• Practice improves technical aspects of performance.

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Impingement Syndrome

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Anatomical Considerations

• Shape of the acromion.– Curved.– Hooked.– Flat.

• Sub-acromial osteophytes.

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Factors Increasing Impingement• Thoracic kyphosis• Rotator cuff weakness/tear.• Acromioclavicular separation.• Posterior capsule tightness.• Biceps dysfunction (long head).

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Impingement Movie Quicktime.

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Bursitis Movie

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Therapy Intervention• Stop the offending activity!• Modality intervention?• Regain flexibility.• Improve strength.• Job or sport technique modification.• Aerobic exercise.

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Modality Intervention

• Ice

• PW ultrasound

• Iontophoresis

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Regaining Flexibility

• Posterior capsule stretching.

• Resolution of rhomboid/levator scapula tightness.

• Address thoracic kyphosis.

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Demo Horizontal Motion

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Demo Internal/External Rotation

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Strengthening Programs

• Scapular plane programs.

• Always address the periscapular muscles particularly Serratus anterior.

• External rotation strengthening.

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Strengthening Programs

• Consider PNF patterns with resistance.

– Should be based on regaining muscle balance.

– Avoid over strengthening anterior musculature.

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PNF Demo 1

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PNF Demo 2

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Resolution

• Patience is required!!

• Failure of 3 months of conservative care requires surgical assessment.

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Biceps Tendonitis

• Pain in anterior aspect of shoulder.

• Pain with forceful elbow and shoulder flexion.

• No pain radiation to deltoid insertion.

• May feel subluxation of the tendon.

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Biceps Tendonitis:Treatment

• Anti-inflammatory measures directed to the intertubecular groove region.– PW U.S.– Friction massage.– Icing.– Iontophoresis

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Exam Demo.

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Friction Massage

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Labral Tears

• Occurs with trauma.

• Can attritional and associated with arthritis.

• Rehabilitation goal is a flexible, strong should.

• Pain reduction may require surgery.

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Labral Tears (SLAP Lesions)

• Pain complaint is a deep, aching pain.

• Pain is increased with adduction movement.

• Pain occurs with passive motion and R.C. testing can be unimpressive.

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Assessment

• O’Brien test.

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Treatment

• Exercise to strengthen anterior/superior structures.

• Periscapular strengthening.

• Avoidance of horizontal adduction and internal rotation.

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Adhesive Capsulitis:Pathophysiology

• Capsular tightening of the G/H joint.

• Primarily idiopathic but can occur secondary to trauma.

• Self limiting condition.

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Adhesive Capsulitis

• 3 phases:– Acute inflammatory phase (freezing)– Sub acute phase (frozen)– Resolving phase (thawing)

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Anatomic Structures

• Anterior capsule.

• Inferior capsule.

• Posterior capsule.

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Clinical Presentation

• Primary finding is decreasing motion of the shoulder in “capsular pattern.”– External rotation>>>>abduction>>>>flexion.

• Severe night pain in acute phase.

• Disrupted scapulohumeral rhythm with over rotation of scapula.

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Treatment Approaches

• Acute, inflammatory disorder: (intense, continuous symptoms).– Correct resting position for sleep and sitting.– Grade 1 and 2 oscillations.– Gentile, active scapula stabilization exercises.– Modalities?

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Treatment Approaches

• Sub acute phase:– Continue resting positions.– Progress flexibility program.– Begin strengthening program.– Positional, postural exercises.

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Stretching Program

• Active to begin with.• Symptom free ranges.• Low level postures.

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Outcomes

• Generally prolonged with excellent recovery of motion.

• Some correlation between length of freezing phase and thawing phase.

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Rotator Cuff Tendinosis/tearsClinical presentation:

• Older patient.• Previous history of “tendonitis”. • Pain at night.• Disrupted scapulo-humeral rhythm.• Weakness in abduction and or flexion.• May have full PROM.

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Rotator Cuff Tear Movie

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Rotator Cuff TearsConservative treatment.

• Decrease inflammation and pain.• Identify underlying cause of the tear.• Rotator cuff strengthening.• Scapular stabilization exercises.• Posterior capsule stretching.• Activity assessment.

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Rotator Cuff Tears• Gentile isometrics -6 weeks.

• Progress to light resisted exercise.

• Eliminate strain during functional activities.

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Muscle Rebalancing

• Correction of faulty movement patterns.

• Dynamic/rhythmic stabilization of the periscapular region.

• Assessment and correction of faulty movement patterns.

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Instability

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Instability

• Anterior

• Posterior

• Inferior/Multidirectional

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History

• Does not have to be a traumatic event.

• Anterior in the athlete is usually related to dislocation.

• Multidirectional associated with general laxity.

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Subluxation Movie

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Assessment

• Apprehension sign.

• Relocation test.

• Load and Shift test.

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Apprehension sign

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Relocation Test

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Load and Shift Test

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Assessment

• Push/Pull test.

• Jerk test.

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Treatment

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Shoulder Pain

• Use systematic assessment for accurate conclusion.

• Treatment is little more than applied anatomy and biomechanics.

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Neurogenic Pain:The Thoracic Outlet

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Signs and Symptoms

• Vascular.

• Sympathetic

• Neurogenic

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Classic Assessment

• EAST assessment.• Wright’s maneuver.• Costoclavicular maneuver.• Pectoralis Minor loop.

Shoulder Course Reference List

1) The Interactive Shoulder. Primal Pictures Software

2) The Shoulder: Sport Injuries Series, 2nd edition: Primal Pictures Software

3) Krishnan, S.G., Hawkinns, R.J., Warren, R.F. (2004) The Shoulder and the Overhead Athlete.

a. Kuhn, J.E., Chapter 6 Resistance Training and Core Strengthening. b. Wilk, K.E. & Reinold, M.M. Chapter 7 Specific Exercise for the

Throwing Shoulder. c. Warren, R.F. & Prickett, W.D. Chapter 12 Unidirectional Anterior

Instability

4) Wilk, K.E. Arrigo, C. (1993) Current concepts in the rehabilitation of the Athletic shoulder. JSOPT 18 365-378

5) Davies, G.J., Dickoff-Hoffman, S. (1993) Neuromuscular testing and rehabilitation of the shoulder complex. JSOPT: 18 449-458

6) Harryman, D.T., Sidles, J.A., Clark, J.M. et al (1990) Translation of the humeral head on the glenoid with passive glenohumeral motion. J Bone Joint Surg (AM) 72:1334-1343

7) Bigliani, I.U., Ticker, J.B., Flatow, e.L., et al. (1991) The relationship of acromial architecture to rotator cuff disease. Clin Sports Med 10: 823-838

8) Jobe, C.M. (1997) Superior glenoid impingement. Orthop Clin North Am 28:137-143

9) Jobe, F.W., Bradley, J.P., Tibone, J.E., (1989) The diagnosis and nonoperative treatment of shoulder injuries in athletes. Clin Sports Med 8: 419-438

10) Wilk, K.E., Arrigio, C., Andrews, J.R., (1996) Closed and open kinetic chain exercises for the upper extremity. J Sports Rehabil 5:88-102.