Ther-EXII Chapter 17 Shoulder
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This stage of frozen shoulder has intense pain even at rest, last for 3-9 months, limited ROM in all directions
This stage of frozen shoulder has pain only with movement, significant adhesions, limited ROM, atrophy and lasts 9-15 months
This stage of frozen shoulder has minimal pain, significant capsular restrictions and last 15-24 months.
What are the two classifications of frozen shoulder
- primary - idiopathic
- secondary - s/p trauma, immobilization, RA
Compression in the scalene triangle will cause impingement of what nerve
Posterior shoulder pain and weakness of supraspinatus and infraspinatus is caused by compression or stretch of what nerve
Sensory deficit in the dorsum of the hand and weakness of tricep and wrist/finger extensors is caused by compression of what nerve
Anterior shoulder pain and deltoid weakness caused by compression on what nerve
An anterior glenohumeral dislocation or forced abduction will cause impingement of what nerve
The glenohumeral joint is supported by what structures
- rotator cuff tendons
- glenohumeral ligaments
- coracohumeral ligaments
- glenoid labrum
PROM in all joint ranges progressing to AAROM, muscle relaxation techniques, grade 1/2 mobs, Codmans Pendulum exercise, submaximal isometrics are used in what rehab stage of adhesive capsulitis
Emphasis on self-stretching, ROM up to not beyond point of pain, joint mobs 1-3, exercise to restore scapular stability, postural control and shoulder joint mechanics are all treatments in this stage of rehab for frozen shoulder
Progression of stretching and strengthening with correct mechanics in multiple planes including perturbations and dynamic exercise are used in what stage of frozen shoulder
Return to Function
A direct fall on joint or transmitted force from fall on an outstretched hand (FOOSH) will cause what injury
Subluxation/dislocation of the Acromioclavicular Joint
A dislocation between acromiom and clavicle where AC & coracoclavicular ligaments are ruptured & distal clavicle displaced superiorly, is what degree of dislocation
A complete rupture of AC ligament with partial tear of coracoclavicular ligament with abduction/adduction dysfunction and a visible and palpalable gapping between acromiom and clavicle is what degree of dislocation?
A partial tear of AC ligament with minimal or no laxity of ligament and minimum loss of function is what degree of subluxation/dislocation
What are the rehab treatments for Grade 1 AC Joint subluxation
symptom releif, protection from force to joint, 2 weeks rest
What are the max phase rehab treatments for Grade 2 AC Joint subluxation
- Symptom relief
- sub max isometrics to limit stress on AC joint encourage active/resistive for uninvolved joints
What are the Min phase rehab treatments for Grade 2 AC Joint subluxation
Progressive resistive exercises of the deltoid and rotator cuff musculature to include scapular stabilization
What are the mod phase(after immobilization) rehab treatments for Grade 2 AC Joint subluxation
- AROM with rope & pulley
- no downward displacement of scapula or distraction of humerus.
- no side weight carrying
There are two treatment categories for a
Grade III AC joint dislocation, what are they
Non-operative = 6-8 weeks immobilization delayed application of motion and resistance exercises
Operative = early rehab to maintain mobility and strength of distal joints
What are the four types of shoulder arthroplasty prosthetics
- Unconstrained = anatomical design, most frequent, greatest freedom no stabilityused when RC mechanism intact or can be repaired
- Semiconstrained = larger cupped/hooded glenoid component, some satbility, indicated with erosion to fossa
- Reverse ball and socket = some stability for RC deficient shoulder that cant be repaired
- Constrained = fixed fulcrum,
- greatest amount of joint stability with less mobility, rarely used, hardware loosening
What are exercise guidelines during the 3 phases after a TSA?
Max. protection = inflammation/pain control, mobility of adjacent joints, restore shoulder mobility (protocol from Dr.), minimize gaurding & atrophy
Mod protection = continue ROM, develop strength & endurance
Min Protection = end range stretching, passive resistive exercises, return to functional activities
What is the restrictive capsular pattern of the GH?
What is the open and closed pack position of the GH joint?
- open = ABD 55°, horizontal adduction 30°
- closed = full abduction, lateral rotation
What structures make up theses joints?
AC Joint = acromioclavicular & coracoclavicular ligaments
SC Joint = costoclavicular, sternoclavicular, and interclavicular ligaments.
What are the Neer classifications of shoulder impingement
Neer I <25 years, edema & hemorrhage, pain with abduction > 90°, reversible
Neer II 25-40 years, irreversible as tendons have become fibrotic, pain with ADLs and at night
Neer III >40 years, tendon degeneration, tears/ruptures, usually long history of shoulder dysfunction
What are the 4 Jobe groups of impingement?
Jobe's Group 1 = pure impingement, usually older recreational athlete with partial tear
Jobe's Group 2 = labral tear, secondary impingement
Jobe's Group 3 = hypermobility, multidirectional instability
Jobe's Group 4 = anterior instability due to trauma/dislocation
How is the Neer test performed
Patient flexes arm to 180° while internally rotated
A patient actively abducts arm slowly to 180°. What test is this and what does it test for?
Painful arc and it test for shoulder impingement
Patient's is placed in 90° of shoulder flexion and elbow flexed to 90° with arm internally rotated. Therapist then passively internally rotates shoulder and approximates the GH joint. What test is this
What is intrinsic impingement and how does it occur
Tissue degradation of inferior tendon being compressed and a tear developing which occurs inferior to superior, leads to articular side rotator cuff tear
What is extrinsic impingement and how does it occur
compression of the tendon under the coracoacromial arch and ligament, resulting in mechanical wear, stress and friction
There are two stages of extrinsic impingement
what are they.
Primary = mechanical compressionof RC tendon due to structural variance of acromiom or humeral head
Secondary = GH joint instability that creates reduced subacromial space, humeral head elevates and minimizes space
What postures can have an affect on shoulder impingement?
- Thoracic Kyphosis
- Forward head
- Protracted and forward tilted scapula
Tightness of what muscles have an affect on impingement or Rotator Cuff Disease (RCD)
Pec minor, levator scapulae, internal rotators
Overuse and fatigue of the rotator cuff can lead to
shoulder impingement and RCD
What will be done during the protection phase of rehab for shoulder impingement?
- control inflammation, modalities, isometrics and patient ed;
- no ABD >80-90° or Fwd Flex
- self stretch
- postural awareness and correction
What will be done during the controlled motion phase of rehab for shoulder impingement?
- PT Ed.
- Joint Mobs. if tightness is identified
- develop strong mobile tissue
- Strength Trng; external rotators scapular stabilizers emphasis on retraction/depression
- GH Joint stabilization closed chain (modified plantar grade)
What will be done during the return to function phase of rehab for shoulder impingement?
- endurance; 3-5 min. of repetitive loading
- specificity of training
- increase speed of exercise
A patient is in Mod phase after subacromial decompression, what can we work on during this phase?
- ROM and strengthening
- joint mobs; posterior & inferior
- self stretch Scapular - upward rotation restrictive muscles levator, rhomboid, traps, lats
- Deltoid - deltoid, posterior capsule
- pectorial muscles
What are the two categories of a rotator cuff tear?
Partial tear = extends from superior or inferior margins
Full thickness = extends through enitre depth of tissue
What are the different surgical repairs for a rotator cuff tear
arthroscopic, mini open, traditional open approach with deltoid detachment
can also include subacromial decompression, capsular tightening, labral repair
What are the MOI's for a posterior shoulder dislocation and a anterior dislocation
- Posterior = ABD, Flex, IR
- Anterior = ABD, Ext, ER
How are shoulder dislocations classified
Cause, direction, and degree of instability
What is a bankart lesion and Hill-Sachs lesion
it is an avulsion of the anterior capsule and glenoid labrum
compression fracture of posterior humeral head occasional axillary nerve or brachial plexus injury
What is done during protection phases after a shoulder dislocation
- avoid position of dislocation
- immobilize 6-8 weeks if young, 2 weeks if older
- intermittent sub maxinal muscle setting of rotator cuff, deltoid, and biceps
What is done during controlled motion phase after a shoulder dislocation
- avoid 90° ABD with ER
- sling use when shoulder is tired or for protection
- progressive isometrics in neutral position to incremental pain free ranges
- initiate close chain, partial WB activities (modified plantar grade)
- progress to dynamic resistance with ER <50°
- week 5 all shoulder motions are included except 90° ABD with ER
What are the tests for shoulder dislocation
anterior or posterior apprehension
During return to function phase what will be your rehab guidelines
- Develop balance between shoulder and scapula muscles
- work on endurance, coordination of tasks with speed
- simulation of functional patterns, return to previous task
- Patient Ed to recognize fatigue/self limitations
- must have negative apprehension task
What can be done to stabilize the glenohumeral joint surgically
Capsuloraphy - incise, overlap, secure
Electrothermally assisted capsuloraphy - radio frequency thermal energy shrinking
SLAP lesion repair
Reattachment of the long head of the bicep tendon and superior labrum to the superior glenoid is known as what type of surgery
SLAP lesion repair
a syndrome that includes a diagnosis involving UE neuro or vascular symptoms resulting from compression within the superior triangle opening of the thorax or
Thoracic outlet syndrome
compression of the subclavian artery, vein or brachial plexus between the clavicle and first rib is known as
thoracic outlet syndrome
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