Shoulder

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Author:
hgienau
ID:
100790
Filename:
Shoulder
Updated:
2011-09-11 18:44:54
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Ortho Fall 2011
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hg
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  1. Acute Joint Hypomobility Clincial Signs and Symptoms
    • pain and muscle guarding limit motion,
    • Pain frequently radiates below elbow and may distrub sleep
  2. Subactue Joint Hypomobility Clinical Signs and Symptoms
    • Capsular Tightness
    • Limited motion in capsular pattern (primary complaint)
    • Pain at the end of motion
    • Limited arthokinematics
  3. Chronic Joint Hypomobility Clinical Signs and Symptoms
    • Progressive restriction of glenohumeral joint capsule
    • significant loss of function
    • Aching localized to deltoid region
    • Pain referred to deltoid tuberosity
  4. Common impairments with Joint Hypomobility
    • Night pain and disturbed sleep
    • Pain with motion and often at rest during actue flare
    • Decreased joint play and ROM
    • Postural compensations - Protracted and anteriorly tipped scapula, rounded shoulder and elevated and protected shoulder
    • General Muscle Weakness and poor endurance in the glenohumeral muscles - overuse of the scapular muscles leading to paoin in the trapezius and posterior vervical muscles
  5. Common Functional Limitations for Hypomoble Shoulders
    • Inabilty to reach over head, behind head, out to the side and behind back
    • Trouble dressing, reaching hand into back pocket, reaching out of car window, self grooming
    • Difficulty lifting weighted objects
    • Limited ability so sustain repetitive activities
  6. Goals for the Max protection phase with Joint Hypomobility
    • 1. Control pain, edema and muscle guarding
    • 2. Maintain soft tisue and joint integrity and mobility
    • 3. Maintain integrity and function of associated areas - Pt educations
    • 4. Keep joints distal to injury site moble
  7. Goals for the Controlled Motion phase with Hypomobility
    • 1. Control Pain, edema and joint effusion
    • 2. Progressively increase soft tissue and joint mobility
    • 3. Correct faulty mechanics - Avoid compensation, reposition head of humerus caudally before proceeding with shoulder exercises
    • 4. Progressively increase strength
  8. Return to Function Goal with Joint Hypomobility
    • Progressively increase flexibility and strength
    • Progress stretching and strengthening as joint tissue tolerates
  9. Frozen Shoulder
    • Primary - idopathic in nature
    • Secondary - develops as a result of trauma or inflammation
    • the results stiffness can be due to soft tissue problems in the shoulder itseld or from an injury that is more distal
  10. Typical Clinical Presentation of a Frozen Shoulder
    • Passive ROM limitations in a capsular pattern
    • severly restricted funcion
    • Diabetic
    • Tyroid
    • can be bilateral - doesn't have to happen at the same time
  11. Prognosis of a Frozen shoulder
    • self-limiting condition in which the shoulder goes througth a cycle of "freezing", "Frozen", and "thawing"
    • Duration of each phase varies from person to person
    • Spontaneous reconvery occure within 1-3 yrs
  12. Considerations for a Frozen shoulder
    • Positioning - encourgae patients to avoid the adducted, internally roated shoulder positon
    • Do not permit the Pts to wear slings unless necessary to protect a surgicnal repair
    • Enougrage Pts to sleep in supine with a pollow under the affected arm in slighta abduction and in the plane of the scapula
    • NO SLINGS!!!
  13. Stage One of a Fronzen Shoulder
    • Painful phase
    • Goals - Pain control, maintain ROM
    • Pain cauased by edema or bad mechanics
    • PROM- within pain free range to minimize soft tissue inflammation (pullys or wands)
    • Isometrics
  14. Stage Two of a Frozen shoulder
    • Stiff phase
    • Goals - increase ROM, increase functional use
    • AROM and PROM exercises
    • Joint Mobs
    • Strtching
    • Strengthening
  15. Stage Three of a Frozen Shoulder
    • Goals - Increase end ROM and Increase Strength
    • Strengthening - progressive with tubing and weights
    • Should include: scapula and shouler musculature
  16. Total Shoulder Surgery
    • Subcapularis Tendon and anterior capsule are divided, other rotator cuff insertions on the greater tuberosity are presvered
    • NO IR / ER or EXT
    • Be careful for 6-8 wks
  17. Important Rehab considerations for a Total Shoulder
    • In the early weeks of recovery active internal roation and and passive ER are restricted
    • Pts MUST wear their immobilizer to avoid ER - regaining ER can be a challenge
  18. Total Shoulder Prognosis
    • Good to excellent results occur in 90%
    • Pt with OA usually progress more quickley than those with RA
    • Post-op care will vary PT to PT and depend on a variety of factors
    • The Average increase in shoulder flexion is 38 degrees and agerage of 124
    • The average ER increase is 29 with a total of 46 (normal 90)
    • Strength increases by one full grade ona manual muscle test to 4/5
    • 82-94% of Pts have no pain
    • 75 have no functional limitations
  19. Total Shoulder Complications
    • 14% of all cases
    • Includes:
    • INstability
    • Rotator Cuff tear
    • Intraoperative fracture
    • Axillary nerve injury
    • Loosening of Components
  20. Total Shoulder Goals during Maximum protection phase
    • Maintain mobity in adjacent joints (neck, scapula, elbow, hand) IR and ER with elbow flexed
    • Regain shoulder mobility
    • Minimize muscle atrophy - Isometrics
    • Control Pain
  21. Total Shouler Goals during Mobility Phase
    • Re-establish mobility and control of shoulder motions - If
    • Imporve strength, endurance and stability of the shoulder girdle
  22. Total Shoulder During Max Protection What ROM is ok
    • PROM of scapula
    • Limited IR and ER with elbow flexed
    • Position Pt lying supine with humerus slightly anterior to the midline of the body to avoid excessive stress to teh anterior capsule and sutrue line
  23. Total Shoulder
    How To re-establish mobility and control of shoulder motions
    • If rotator cuff in intact can being 2-3 weeks post-op if cuff repair 6wks
    • Transition from assisten to active ROM all planes and diagonal planes of motion
    • Avoid combined ER and abduction becuase they are stressful to the repair
    • Begin combining ER to neutral with forward flexion and scaption
  24. Total Shoulder Return to function phase
    • To be in this stage Pt must be Pain free ative shoulder ROM though functional range and 3-5 strength
    • Being no earlier than 6 weeks post-op for intact rotator cuff
    • Continue to improve mobility - Acitve or resistive ROM
    • Concinue to improve strength, stability and endurance of the shoulder
    • HEP
  25. Treatment Of Humeral Fracture
    • Stabilized for at least 6wks
    • Will be in an immobilizer
    • Aggressive therapy is NOT performed until sufficient healing is confirmed by x-ray
  26. Treatment During Immobilization of Humeral Fractures
    • Use ice to decrease Pain
    • Begin ROM exercises for elbow wrist and hand
    • Train balance and gait
    • Do not sue affected arm for ADls
  27. Treatment of a Humeral Fractures as teh Freacture Stabilizes
    • Discontinue the sling immobilization on MD orders
    • Begin Active scapula exercises
    • Debing active- assisted shoulder exercises
    • Begin using arm for daily activites to tolerance
  28. Treatment of a humeral fracture as the fracture heals
    • Discontinue to functiona brace on MD orders
    • Begin joint mobs and passive stretching
    • Retrain proper scapulohumeral ryhthm and coordination
    • usefull spectrum exercies to restroe strength and Rom
    • emphasize functional activites
  29. Humeral Head Fractures / Displaced fractures
    • Displaced fracture of the surgical neck and head require surgery to stabilize them properly
    • can be fixated witha variety of material
    • presently no accepted fixation of choice
    • Complication can include: avasular necrosis of humeral head - total shouler
    • Subacromial impingment
    • Never lesions
    • Vasular Damange
  30. Impportant Reatment Considerations for fractures
    • PROM and stretching are contraindicated in the early stages of healing for humeral head fractures
    • Clinican does know amount of stress put on the joint
    • Scapula or elbow ROM and Strenght is ok
  31. Humeral Head Fractures Postfracture 1-2wks
    • Pt is generally in excruciating pain despite pain meds
    • The arm is susallyy in a sling to immobilize it
    • Pt requires assistance with basic ADLs
    • Thearpy is limited at this time
    • Balance and Gait Training
  32. Humeral Head Fracture 3-6 wks
    Exercise progression is dependend on the stability of the fracture frgments and varies greatly from Pt to Pt
  33. What happens if a humeral head is Stable at 3-6wks
    • Pt removes the sling 3-5 tiems a day fro gentle ROM exerciese sme ME's DC sling at this time
    • Pendulum, AAROM elvenation activites, scapular motions, gentle isometrics
    • Slow progression
    • With MD approval can begin active GH motions in a very restricted range
  34. Humeral Head Fracture 6-12wks
    • AROM exercises progress in a pain-free range to the Pts tolerance
    • When the humerus is completely healed at approx 8wks therapy become more aggrssive
    • joint mob
    • passive ROM
    • Supervised pully work

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