EHR520 Weeks 11-13

Functional Anatomy of the Shoulder

• The shoulder is a complex structure designed to position the hand for function and allows for extensive mobility, but at the cost of greater instability.
• The shoulder is used for expansive motion and speed, reaching up to 7500°/s in pitching and 1500°/s in tennis.
• Injury risk occurs during deceleration in throwing, club, and racquet sports.

Influencing Factors

• Stability is influenced by both static and dynamic factors.
• Scapula muscles, force couples, trunk and hip strength, posture, and cervical and thoracic spines all play a role in shoulder stability.

Shoulder Joints

• The shoulder consists of four joints: sternoclavicular, acromioclavicular, scapulothoracic, and glenohumeral.
• Each joint has a unique structure and function, such as the saddle joint of the sternoclavicular joint and the gliding joint of the acromioclavicular joint.

Shoulder Ligaments

• No specific details about shoulder ligaments were mentioned.

Rotator Cuff

• The rotator cuff is a group of muscles that maintain glenohumeral alignment during all movements.
• The rotator cuff consists of four muscles: supraspinatus, infraspinatus, teres minor, and subscapularis.

Scapular Stabilisers

• Scapular stabilisers are muscles that help to stabilize the scapula during movement.

Scapular Plane

• The scapular plane is a 30° forward plane from the frontal plane, which is the functional plane of motion for the shoulder.
• Scaption is the elevation of the arm in the scapular plane.

Shoulder Rehabilitation Sequence

• The sequence of rehabilitation for the shoulder is:
  1. Find the cause of the problem.
  2. Relieve pain and promote healing.
  3. Restore range of motion and flexibility.
  4. Regain strength and endurance, starting with scapula muscles.
  5. Achieve proper movement patterns.
  6. Progress to functional activities.
  7. Perform performance-specific exercises.
  8. Return to optimal function.

Pathology of the Shoulder

• Scapular dyskinesis is a condition where the scapula has an abnormal position or movement, leading to increased risk of instability, impingement, and other injuries.
• Glenohumeral instability can occur due to damage to either static or dynamic structures, leading to a cycle of instability.
• Shoulder dislocation can occur due to traumatic or atraumatic injuries, and can be classified as either anterior or posterior.
• Shoulder impingement can occur due to either primary or secondary factors, and can lead to inflammation and further impingement.
• Rotator cuff tears can occur due to either traumatic or atraumatic injuries, and can be classified as either partial or full thickness.
• AC joint sprains can occur due to direct blows to the shoulder, and can be classified according to the Rockwood Classification.
• Adhesive capsulitis (frozen shoulder) is a condition where the shoulder capsule becomes inflamed and stiff, leading to greatly restricted movement and pain.

Special Tests for the Shoulder

• Neer's Test, Hawkins-Kennedy Test, and Painful Arc are used to diagnose shoulder impingement.
• Speed's Test is used to diagnose biceps tendinopathy or labral tears.
• Drop Arm Sign is used to diagnose full-thickness rotator cuff tears.
• Sulcus Sign and Load and Shift Test are used to diagnose shoulder instability.
• Apprehension Test is used to diagnose shoulder instability post-anterior GHJ dislocation.
• Full Can Test is used to diagnose rotator cuff pathology (supraspinatus).

Functional Anatomy of the Elbow, Wrist, and Hand

• Elbow anatomy: comprised of three joints (humeroradial, proximal radioulnar, and humeroulnar) that work together to provide a wide range of motion.
• Forearm anatomy: anterior and posterior compartments, with muscles and bones that facilitate flexion, extension, pronation, and supination.
• Wrist ligaments: provide stability and support to the wrist joints.

Functional Movements

• Elbow: flexion and extension
• PRUJ (proximal radioulnar joint) and DRUJ (distal radioulnar joint): pronation and supination
• Wrist: flexion and extension, radial deviation (abduction), and ulnar deviation (adduction)

Unique Elbow Characteristics

• Most muscles cross more than one joint, making it a complex system.
• Open chain: large velocities impart high forces on the joint, requiring deceleration forces to be applied to biceps, brachioradialis, and brachialis.
• Closed chain: compression and torsional stresses on the distal arm, with lateral elbow receiving compression stresses and medial elbow receiving distraction stresses.
• One capsule for three joints, with a weak anterior capsule.

Exercise for the Elbow, Wrist, and Hand

• Flexibility exercises: essential for maintaining range of motion and preventing injury.
• Exercise equipment: various devices can be used to target specific muscle groups and improve strength and function.
• Strength exercises: focus on strengthening the muscles of the elbow, forearm, and hand to improve overall function and prevent injury.
• Gripping strategies: important for maintaining grip strength and preventing injury.

Pathophysiology of the Elbow, Wrist, and Hand

• Epicondylopathy: a condition characterized by pain and inflammation at the elbow, with lateral epicondylopathy (tennis elbow) and medial epicondylopathy (golfer's elbow) being the two main types.
• Lateral epicondylopathy: caused by poor technique, overuse, or improper equipment, resulting in pain and inflammation on the lateral side of the elbow.
• Medial epicondylopathy: caused by overload, strain, or poor technique, resulting in pain and inflammation on the medial side of the elbow.
• Treatment: nonsurgical progression, including relieving pain, swelling, and spasm, and progressing to strength exercises and functional activities.

Tendinopathy

• Theories of aetiology: mechanical stresses, vascular supply, and neural basis.
• Factors contributing to tendinopathy: intrinsic (age, pathomechanics, structural abnormalities, and genetic or acquired systemic disease) and extrinsic (overtraining, poor equipment, excessive durations or distances, and excessive increases in speed).
• Management framework: identify the cause, correct the cause, and identify the level of tendinopathy.

Elbow Dislocation

• Common in sport, with most being simple dislocations.
• Mechanism: posterior and follow sudden hyperextension and abduction force applications.
• Signs and symptoms: intense pain, swelling, limited mobility, and deformity.
• Treatment: ice, splint, check blood and nerve supply, and bracing for 2-5 weeks.
• Complications: lengthy ligament healing time, damage to blood vessels and nerves, and recurrent dislocation.

Wrist Sprains

• Most common wrist injury, with poor management leading to chronic problems.
• Mechanism: falling onto hyperextended wrist, repeated flexion, extension, lateral or rotary movements, and any abnormal, violent torsion of the wrist.
• Signs and symptoms: generalized swelling, tenderness, and inability to flex wrist.
• Treatment: ice, supportive taping or bracing, and graduated exercise rehabilitation.

De Quervain's Tenosynovitis

• Inflammation of the synovium of the abductor pollicis longus and extensor pollicus brevis tendons.
• Common in racquet sports, golf, tenpin bowling, rowers, and kayakers.
• Signs and symptoms: local tenderness and swelling along the course of the tendons, crepitus, and positive Finkelstein's test.
• Treatment: splinting, stretches, and graduated strengthening.

Carpal Tunnel Syndrome

• Median nerve compression as it passes through the carpal tunnel.
• Signs and symptoms: anterior wrist pain, numbness, paraesthesia, and Tinel's sign.
• Treatment: mild cases treated conservatively, with persistent cases requiring surgery, and exercise rehabilitation.

Rheumatoid Arthritis

• Inflammatory disease caused by immune pathology, affecting the synovial membrane, articular cartilage, fibrous joint capsule, and surrounding ligaments and tendons.
• Signs and symptoms: fever, rash, poor circulation, and generalised aching and stiffness.
• Complications: excessive exudate in synovial cavity, cysts in articular cartilage or subchondral bone, and rupture with strenuous physical activity.

Effects of Rheumatoid Arthritis on Exercise Response

• Vigorous exercise is contraindicated in the presence of acute joint inflammation or uncontrolled systemic disease.
• People with RA are less active and deconditioned, with resting energy expenditure elevated, leading to fatigue and reduced exercise capacity.
• Pain, stiffness, biomechanical inefficiency, and gait abnormalities can increase the metabolic cost of physical activity.

Recommendations for Exercise Programming in RA

• Individualized programming, with low intensity and duration during the initial phase, and accumulation of exercise dose if necessary.
• Alternate exercise modes, interval or cross-training methods, and time vs. distance goals to encourage pacing.
• Include functional exercises, stretching, and warm-up daily, even on days when the disease flares.

Osteoarthritis and Rheumatoid Arthritis

• OA and RA commonly affect the wrist and hand, with significant impact on ADLs and QOL.
• Predictors of OA: older age, genetics, being female, menopausal, use of vibratory tools/equipment, high-impact PA, and repetitive use of the hands.
• RA: chronic, systemic inflammatory disease, with wrists and hands involved, and reduced grip strength.

Exercise Rehabilitation

• Maintain wrist and hand mobility and strength.
• Strength exercises are more important than flexibility exercises.
• Dose of exercise is individually-based on function and stage/severity of disease.

Elbow, Wrist, and Hand – Special Tests

• Mill's Test, Cozen's Test, and Medial epicondylalgia Test for lateral and medial epicondylalgia.
• Valgus Stress Test for ulnar collateral ligament.
• Varus Stress Test for radial collateral ligament.
• Tinel's Sign for carpal tunnel syndrome.
• Finkelstein Test for De Quervain's Tenosynovitis.

Total Body Considerations and Implications of Surgery and Medications

Principles of Water and Hydrodynamics

• Specific gravity: relative density of an object compared to water
• Archimedes' Principle of Buoyancy: an object in water experiences an upward thrust equal to the displaced water
• Centre of Buoyancy: the centre of gravity of the water an object displaces, which must be aligned with the object's centre of gravity for floating equilibrium

Hydrostatic Pressure

• Pascal's Law: pressure from a fluid is exerted equally on all surfaces of an immersed object at a given depth
• The deeper an object is immersed, the greater the pressure

Weight Bearing in Water

• The deeper a body is submerged in water, the less weight is going through the legs

Indications for Hydrotherapy

• Pain
• Oedema
• Muscle spasm
• Loss of range of motion (ROM)
• Weakness
• Limited endurance or restricted weight-bearing due to injury
• Maintenance of cardiovascular fitness (CRF)

Advantages of Hydrotherapy

• Can partially weight-bear in water due to reduced effect of gravity
• Warmth reduces muscle spasm and pain cycle
• Increased ROM and pain-free ROM
• Useful in re-training normal gait pattern, muscle tone, and activation

Hydrotherapy – Precautions and Contraindications

• Precautions: fear of water, medications affecting BP and heart rate, susceptible to ear infections, allergies, diabetes, cardiovascular disease, or seizure
• Contraindications: contagious illness, open wounds, advanced kidney disease, faecal incontinence

Hydrotherapy – Principles and Guidelines

• Include a warm-up and cool-down
• Begin with ROM and flexibility, progress to strength and endurance, then add coordination and agility before functional/performance-specific exercises
• Maintain hydration, as clients will sweat
• Adjust resistance by manipulating variables: longer lever arm, faster movements, larger or broader objects
• Cardiorespiratory training: deep water running, treading water, swimming

Therapeutic Exercise Equipment

• Large variety of equipment, uses, and prices
• Equipment selection determined by budget, client needs, and clinician preferences

Range of Motion Equipment

• Goniometers for objective measurement
• Stabilizing equipment for stretching: straps, belts, and ropes to support or apply stretch force

Resistive Applications

• Manual resistance
• Body weight resistance
• Rubber tubing and bands
• Free weights
• Isotonic machines

Swiss Balls

• Offer a new and different method of training for clients
• Can be used to develop flexibility, strength, endurance, balance, and coordination
• Progress from body weight exercises by adding resistance from cuff weights, resistance bands, free weights, and cable machine exercises

Foam Rollers

• Kinaesthetic awareness, balance, proprioception, flexibility, and strength
• Rolling + stretching = greater flexibility improvements than either one in isolation
• Efficacious as a warm-up tool and for reducing both the severity and duration of delayed onset muscle soreness (DOMS) post-exercise

Aquatic Equipment

• Assistive equipment: used to help position a client in the water (supine, prone, vertical)
• Resistive equipment: in addition to assistive equipment, use flippers, boots, gloves, paddles, and bells

Plyometric Equipment

• Hurdles
• Boxes
• Agility ladders
• Cones
• Sticks
• Medicine balls
• Trampolines

Total Body Considerations

• Geriatric physiological considerations: body changes with age, rehabilitation considerations
• Osteoporosis: loss of bone density, risk factors, common health issues, recommendations for exercise programming

Implications of Surgery

• Most MSK injuries resolve without surgery, but when needed, a well-planned individualized pre- and post-operative rehabilitation plan is required
• Indications for surgery: severe pain, chronic joint swelling, marked limitation of active or passive joint motion, gross instability of a joint or bony segment, joint deformity, and loss of function

Complications of Surgery

• Postoperative infection or poor wound healing
• Postoperative vascular disorders, such as thrombophlebitis and pulmonary embolism
• Delayed healing of soft tissue or bone
• Adhesions and contractures of soft tissue and joints
• Loosening of prosthetic implants leading to instability and pain
• Biomechanical breakdown of implants

Post-Operative Goals and Guidelines for Exercise

• Impairments/problems: postoperative pain, oedema, circulatory and pulmonary complications, joint stiffness, muscle atrophy, loss of strength, limitation of weight-bearing, and potential loss of strength and mobility in un-operated joints
• General postoperative treatment goals and plan of care during the maximum protection, controlled motion/protection, and minimum protection/return to function phases