Shoulder Joint Stability - Chapter 17

Shoulder - Chapter 17

• The muscles that reinforce capsular stability of the Glenohumeral (GH) joint are the rotator cuff muscles, including the infraspinatus, supraspinatus, teres minor, and subscapularis.
• The joints that provide stability to the Acromioclavicular (AC) and Sternoclavicular (SC) joints.

Acromioclavicular (AC) Joint Stability

• The Acromioclavicular Ligament prevents horizontal displacement of the clavicle.
• The Coracoclavicular Ligament has two parts:
• The Trapezoid Ligament prevents shear forces.
• The Conoid Ligament provides vertical stability, preventing superior displacement.
• The Joint Capsule reinforces the AC joint.
• The Deltoid & Trapezius Muscles provide dynamic stabilization.

Sternoclavicular (SC) Joint Stability

• The Sternoclavicular Ligament provides anterior and posterior stability.
• The Interclavicular Ligament prevents clavicle depression and stabilizes both clavicles.
• The Costoclavicular Ligament limits clavicle elevation and excessive motion.
• The Joint Capsule adds reinforcement and protection.
• The Subclavius Muscle anchors the clavicle to the first rib, aiding in stabilization.

Scapulothoracic Articulation

• Retraction and protraction occur in the transverse plane.
• Elevation and depression occur in the frontal plane.
• Anterior tilt and downward rotation occur with full shoulder ROM.
• Posterior tilt and upward rotation occur with full shoulder ROM.

Postural Deviations

• Muscles that affect scapular stability due to postural deviations include the upper trap, middle trap, lower trap, serratus anterior, and rhomboids.

Subacromial Space

• Structures that are found in the subacromial space are the Supraspinatus Tendon, Subacromial Bursa, Long Head of the Biceps Tendon, Superior Joint Capsule, and Coracoacromial Ligament.

Supraspinatus Tendon

• Part of the rotator cuff and is most commonly affected by impingement.

Subacromial Bursa

• Reduces friction between the supraspinatus tendon and acromion.

Long Head of the Biceps Tendon

• Runs through the bicipital groove and passes under the acromion.

Superior Joint Capsule

• Encloses the glenohumeral (GH) joint, providing stability.

Coracoacromial Ligament

• Forms the coracoacromial arch, protecting structures beneath it.

Phases of Idiopathic Frozen Shoulder

• Stage 1 (0-3 months): Increasing pain with a gradual onset, slight ROM loss, and loss of ER being common.
• Stage 2 (3-9 months): Persistent pain, motion loss, freezing stage with more intense pain, ROM limited in all directions.
• Stage 3 (9-15 months): Pain only with movement, adhesions present, Frozen stage with limited GH motions.
• Stage 4 (15-24 months): Gradual ROM improvement, Thawing stage, and minimal pain with synovitis.

Stage 1 (0-3 months - Freezing Phase) Pain and ROM

• Gradually increasing, often exacerbated by movement, may be present even at rest.
• Slight loss of range of motion, with external rotation typically most affected.

Stage 2 (3-9 months - Frozen Phase) Pain and ROM

• Persistent and more intense pain, often present both at rest and with movement.
• Significant loss of active and passive range of motion in all directions; joint stiffness is marked.

Stage 3 (9-15 months - Frozen Stage) Pain and ROM

• Predominantly experienced during movement rather than at rest.
• Active range of motion is severely limited due to adhesions, though some passive motion may still be achievable.

Stage 4 (15-24 months - Thawing Phase) Pain and ROM

• Gradual reduction in pain; minimal pain associated with synovitis.
• Progressive improvement in range of motion as adhesions slowly resolve and function is restored.

Range of Motion

• External Rotation > Abduction > Internal Rotation are most limited secondary to frozen shoulder.

Total/Reverse Shoulder Arthroplasty

• Total Shoulder Arthroplasty (TSA) involves replacing both the glenoid and humeral head.
• Hemiarthroplasty involves replacing the Humeral head.
• Reverse TSA (rTSA) involves a Rotator cuff compromise, ball/socket positions reversed.
• Interpositional and Resurfacing arthroplasty- Involve less extensive removal of bone

Tendon Release

• The subscapularis tendon is released during a TSA procedure.

Restricted Motions (0-6 Weeks) POST TSA

• External Rotation (ER) Beyond Limits - Avoid ER >30°-45° to protect the subscapularis repair.
• Extension Beyond Neutral – Prevents excessive strain on the anterior capsule and subscapularis.
• Abduction with External Rotation – Places high stress on the anterior capsule and subscapularis tendon.

Motion to Avoid Post rTSA

• No active IR, ER, or resisted movements of the shoulder.
• Avoid reaching behind the back (internal rotation with extension).
• No weight-bearing through the surgical arm (e.g., pushing up from a chair).

Pendulum (Codman's) Exercises

• Uses gravity-assisted movement to create gentle traction in the glenohumeral joint.
• Reduces pain and stiffness by minimizing joint compression.

Early Passive Range of Motion (PROM)

• Allows gentle mobilization of the shoulder without active muscle engagement.
• Promotes joint mobility in the early rehab phase.

Minimizes Shoulder Stiffness & Adhesions

• Helps prevent frozen shoulder (adhesive capsulitis) by maintaining capsular mobility.

Enhances Circulation & Synovial Fluid Movement

• Improves joint lubrication and nutrient distribution to aid healing.

Reduces Muscle Guarding

• Encourages relaxation of surrounding muscles, decreasing protective spasms.

Rotator Cuff Impingement

• Intrinsic Impingement (vascular/tissue degeneration): Involves the deep articular side of the tendons and may progress to articular side
• Extrinsic Impingement (compression against acromion): Mechanical compression of the rotator cuff, Anteroinferior ½ of the acromion in the suprahumeral space

Impingement Activities

• Activities are contraindicated with impingement syndrome until pain free that involve Pain with overhead reaching, pushing, pulling

GH Strengthening for Impingement With Rounded Shoulders

• Strengthening the glenohumeral stabilizers is crucial for improving posture, shoulder mechanics, and preventing further impingement.
• Rotator Cuff Muscles (SITS) - Stabilize the humeral head in the glenoid fossa and prevent excessive superior migration:
• Supraspinatus - Assists with abduction and stabilizes the humeral head.
• Infraspinatus - Key external rotator, counteracting internal rotation dominance.
• Teres Minor - Aids in external rotation and posterior shoulder stability.
• Subscapularis - Provides anterior stability while balancing ER/IR forces.
• Posterior Shoulder Muscles: Helps with shoulder extension and external rotation to counteract rounded shoulders.
• Posterior Deltoid
• Long Head of the Biceps Aids in humeral head depression, preventing excessive upward translation
• Other Supporting Muscles:

Scapula Strengthening for Impingement

• Addresses shoulder impingement with rounded shoulders, focuses on strengthening the scapular stabilizers to improve posture, scapular positioning, and shoulder mechanics.
  • Key Muscles to Strengthen:
  • Lower Trapezius - Promotes scapular depression and upward rotation, counteracting excessive elevation.
  • Middle Trapezius - Aids scapular retraction, improving posture and reducing forward shoulder rounding.
  • Rhomboids - Assist in scapular retraction and downward rotation, helping stabilize the shoulder blade.
  • Serratus Anterior - Essential for scapular protraction and upward rotation, preventing winging and improving shoulder mechanics.

Neer's Classification of Rotator Cuff Pathology

• Stage 1: edema, hemorrhage: patient usually less than 25
• Stage 2: Tendonitis/bursistis and fibrosis: patient usually 25-40
• Stage 3: Bone spurs and tendon rupture: patient usually older than 40.

Indications of Subacromial Decompression Surgery

• Pain during overhead activities and loss of functional mobility for 3-6mo of longer and Stage 2: neer classification, Impingement
• Intact or minor tear of the rotator cuff

Speed of Progression After Subacromial Decompression Surgery

• If rotator cuff is in contact postoperatively: Rehab progresses quite rapidly because the shoulder musculature is not damaged during the procedure
• If rotator cuff is not intact postoperatively: Rehab progresses at a slower rate to allow the repaired shoulder musculature adequate time to heal

Full/Partial Rotator Cuff Tear Difference

• Partial thickness tear: Extends inferiorly or superiorly through only a portion of the tendon
• Full thickness tear: A complete tear extending between the superior and inferior surfaces of the tendon

Indications for Rotator Cuff Repair Surgery

• Partial thickness or full thickness tears of the rotator cuff tendons with irreversible, degenerative changes in soft tissues
• Some with neer stage 2 lesions and most with neer stage 3 lesions
• Acute, traumatic rupture of the rotator cuff tendons that may be combined with avulsion of the greater tuberosity, labral damage or acute dislocation of the GH joint

What are Glenoid and SLAP Lesions

• Glenoid labrum tear is bankart lesion
• injury to the cartilage in the shoulder joint

SLAP Lesion

• Superior labrum extending anterior and posterior
• Tear cartilage in the inner part of the shoulder
• Where the biceps tendons anchors the labrum

Exercise in Scapular Plane

• In an open pact positioning of the joint

Shoulder Special Tests

• Apprehension Test - dislocation

• Posterior: Pt is supine, Elbow 90 deg flex, should 90 degree flex, apply force at elbow then adduct and internally rotate

• Anterior: supine, should 90 abducted, elbow flex 90, and then externally rotate pts arm

• Sulcus Sign - inferior dislocation

• A inferior pull of the arm assessing the space between the acromion and humeral head

• Speeds Test - bicep tendonopthy -Pt standing, shoulder flex 90, forearm supinated, once in position add resistance to wrist

• Yergason's Test - bicep tendon pathology

• Pt sitting with elbow flexed at 90, pt will externally rotate and supinate at the same time while applying resistance once pt has correct motion

• Drop Arm Test - supraspinatus

• Abduct arm and hold then slowly return to midline

• Full Can Test - supraspinatus

• Place arm in scaption and have arm externally rotated slight resistance at wrist

• Empty Can Test

• Place arm in scaption and have arm internally rotated slight resistance at wrist

• Belly Press Test

• Bear Hug Test

• Hawkins-Kennedy Impingement Test

• Pt supine, 90 deg flex or elbow and shoulder, then load the joint with pressure and then adduct and internally rotate

• Neer Impingement Test

• Pt sitting passively raise their arm through flexion while stabilizing scapula

• O-Brien Test

• Standing, Shoulder flex 90, then horizontally adduct and then internally rotate.

• Therapist provides resistance at wrist

Elbow and Forearm Complex - Chapter 18

• Humeroulnar involves elbow/forearm function is one joint
• Humeroradial involves elbow/forearm function is one joint
• Proximal radioulnar involves elbow/forearm function is one joint
• Distal radia ulnar joint involves elbow/forearm function is one joint

Indications for Total Elbow Arthroplasty

• RA, severe OA, fractures, tumors, non-union fractures, failed conservative treatment.

Myositis Ossificans

• Bone formation in soft tissue after trauma (fractures, burns, TBI, SCI, CVA).
• Symptoms: Pain, swelling, warmth, restricted ROM.
• Management: NSAIDs, radiation therapy, surgical excision if functionally limiting.

Myositis Ossificans Post Elbow Fracture

• Supracondylar fracture of humerus
• Intercondylar fracture of humerus
  • High-risk due to:
  • Significant soft tissue trauma around the elbow.
  • Joint immobilization leading to abnormal bone formation.
  • Excessive stretching or aggressive rehab post-injury.

Lateral and Medial Epicondylitis

• Lateral Epicondyle: Extensors of forearm
• Medial Epicondyle: Flexors of forearm, pronator tendon

Tests for Lateral/Medial Epicondylitis

• Cozens Test - tennis elbow test, lateral epicondylitis
  • Palpate lateral epicondyle while stabilizing joint motion
  • Arm is supported in the table
  • Have Pt make fist with thumb tucked in and radial deviate then have pt go into extension and apply resistance
• Lateral epicondylitis Test - stresses extensor digitorum
  • Arm resting on table
  • Palpate lateral epicondyle while stabilizing joint motion
  • Have patient try to lift the 3 digit against light resistance and assess pain
• Medial Epicondylitis Test - golfer elbow
  • Passive supination of the pts arm
  • Then extend patients wrist while elbow is flexed then extend elbow
  • Positive if pain radiates to the medial epicondyle

Contraindications - Lateral Epicondylitis (Tennis Elbow)

• Avoid aggressive resisted or eccentric strengthening during the acute, painful phase.

Contraindications - Medial Epicondylitis (Golfers Elbow)

• Avoid resisted wrist flexion and forearm pronation exercises during acute inflammation.

  • Do not perform high-load activities that stress the medial elbow while pain and tenderness are prominent.
  • Radial Head Fracture:

• Contraindications - Radial Head Fracture

  • Avoid weight-bearing and resisted elbow/forearm exercises until proper healing is confirmed.
  • Refrain from active range of motion exercises that may destabilize the fracture site.
  • Do not engage in high-impact activities during the early healing phase.
  • Excessive pronation and supination early post injury
  • Olecranon Fracture:

Contraindications - Olecranon Fracture

• Avoid active elbow extension or resistance against the olecranon until bone healing is verified.
  • Do not load the elbow (e.g., pushing, weight-bearing through the arm) during the initial healing period.

Ulnar Collateral Ligament (UCL) Injury

• Contraindications- Ulnar Collateral Ligament (UCL) Injury
  • Avoid any activity or exercise that applies valgus stress (e.g., overhead throwing, aggressive resisted wrist flexion).
  • Do not perform motions that force the elbow into excessive abduction or external rotation until healed
  • Distal Biceps Tendon Rupture/Repair:

Contraindication - Distal Bicep Tendon Rupture/Repair

• Avoid forceful supination and resist elbow flexion until sufficient healing of the tendon repair has occurred.
  • Refrain from heavy lifting and high-intensity biceps activities in the early post-operative period.

Cubital Tunnel Syndrome

• Avoid prolonged elbow flexion and direct pressure over the cubital tunnel (e.g., leaning on elbows).
  • Do not perform aggressive manual therapy or mobilization that might further irritate the ulnar nerve

Forearm Compartment Syndrome

• Contraindicated for any exercise until after surgical decompression and complete healing.
  • Avoid compression or any intervention that might increase compartment pressure.

Pulled Elbow (Nursemaid's Elbow)

• Avoid vigorous or forceful reduction or pulling of arm maneuvers by untrained individuals.
  • Do not apply excessive force during reduction; once reduced, avoid heavy or repetitive activities until the joint stabilizes.

Contraindication - Myositis Ossificans

• Avoid aggressive stretching, high-intensity mobilizations, or forceful range-of-motion exercises in the affected area.
  • Do not perform deep massage or manipulative therapy that could exacerbate heterotopic bone formation in the early phases.

Total Elbow Arthroplasty (TEA)

• Avoid high-impact activities, heavy lifting, or resistance exercises that place undue stress on the prosthetic joint (especially in the early post-op period).
  • Do not engage in repetitive high-load activities that could compromise implant longevity or joint stability.

Goals for Elbow joint mobs

• Humeroulnar Distraction- general mobility
  • Humeroulnar Distal Glide - increased flexion

Purpose of Special Elbow Tests

• Varus stress Test - instability in the radial lateral ligament that hold the outside of the elbow together

• Sitting slightly flexed shoulder but relaxed position

• Hand on medial aspect of elbow pushing out while stabilizing wrist

• Valgus stress Test - damage to the ulnar collateral ligament on the medial side of elbow

• Sitting slightly flexed shoulder but relaxed position, elbow flexed 20-30

• Hand on lateral side of elbow applying force inward while stabilizing wrist

• Cozens Test - tennis elbow test, lateral epicondylitis

  • Palpate lateral epicondyle while stabilizing joint motion
  • Arm is supported in the table

Hand and Wrist Chapter 19

Types of Hand Grips

• Cylindrical Grip: Fingers wrap around the object, with the thumb providing counter-pressure. Used for holding tools or a glass.
• Spherical Grip: Fingers and thumb wrap around the object, with a slight spread of the fingers. Holding balls, fruits, or doorknobs.
• Hook Grip: Fingers curl around the object, but the thumb is not involved. Used for lifting bags, buckets, or suitcases.

Types of Precision Grips

• Pinch Grip: Thumb and index finger pinch the object. Used for picking up very asmall items such as coins or pins.
• Tripod Grip: Thumb, index finger, and middle finger. Used for writing, or drawing.
• Lumbrical grip : Thumb and the fingers. Used for holding cards, or objects with precision.

Defomities from RA of Hand

• Ulnar Deviation: Occurs when the fingers bend toward the ulnar side is one of the most characteristic deformities of RA.
• Swan Neck Deformity: In this deformity the fingers bend backward at the middle joint (PIP joint) and bend forward at the tip joint (DIP joint), resembling a swan’s neck.
• Boutonniere Deformity: In this condition, the middle joint of the finger (PIP joint) becomes bent inward, while the tip of the finger (DIP joint) is hyperextended, creating a “buttonhole” appearance.
• Z-Thumb Deformity: Develops a “Z” shape, where the MCP joint becomes hyperextended, and the interphalangeal joint flexes, leading to a loss of function in the thumb.
• Hammer Toe Deformity: This occurs when the toes are permanently bent in a claw-like position due to joint damage, often affecting the second and third toes.
• CMT (Claw-Mallet or Claw Deformity): In this deformity, the finger appears clawed, with the DIP joint drooping down and the PIP joint bent. This is due to tendon damage caused by RA.

Surgical/Non Surgical Deformity Treatment

• Boutonniere Deformity:
  • Post-op: Maintain PIP extension, early DIP flexion. Starts 10-14 days after procedure
  • Precautions: Avoid DIP hyperextension & PIP resistance and stretching for 6-8 weeks.
• Swan-Neck Deformity:
  • Post-op: Maintain PIP in slight flexion; Initiate AROM at the PIP and DIP joints several days post op, Stabilize the DIP joint in neutral during PIP ROM
  • Precautions: limit extreme DIP flexion/extension.

De Quervain's tenosynovitis

• Tendinopathy involving extensor pollicis brevis and abductor pollicis longus tendons

Diagnostics for De Quervain's tenosynovitis

• Finkelstein's test- thumb in fist and radial deviate

Trigger Finger

• Inability of the tendon to glide smoothly in the sheath surrounding it

Symptoms

• Finger Sticking: The finger may lock in a bent position and then suddenly pop straight.
• Pain: Pain or tenderness at the base of the finger or thumb, especially when trying to straighten the finger.
• Limited Movement: Difficulty straightening or bending the finger fully. Swelling: Swelling at the base of the affected finger may occur.
• Popping or Clicking: You might hear a popping or clicking sound when moving the finger.

Carpal Tunnel Syndrome

• Confined space between the carpal bones dorsally and the transverse carpal ligament
• Sensory loss and motor weakness that occurs when the median nerve is compromised is the carpal tunnel;

Expect to observe with Carpal Tunnel Syndrome

• Weakness and atrophy in the thenar muscles and first two lumbricals
• Decreased prehension in tip-to-tip, pad-to pad activities

Flexor tendon repair Surgery

• Zigzag approach is most common surgical approach Approach:

Most common approach

• Direct repair & Tendon graph surgical approach.
• Two rehab approaches: Early controlled motion - surgical approach.
• Prolonged immobilization and delayed motion - surgical approach.

Surgical Hand Wrist Flexion and Extension

• After a flexor tendon repair, what motions are initially protected (wrist/hand flexion or extension)
  • Wrist extension is protected after the procedure.
• After an extensor tendon repair, what motions are initially protected (wrist/hand flexion or extension)
  • Flexion after the procedure should be avoided.

Tendon Exercises

• Tendon Glide: Focuses on improving the smooth motion of tendons through their sheaths by performing full-range movements of the fingers and hand.
• Tendon Blocking: Involves isolating specific joints in the fingers to target specific tendons and improve their function, often used for strengthening or addressing tendon injuries or deformities.

Repairs/Injuries

• Place and hold exercises for flexor/tendon repairs.

Sensory Damage

• C6 (pattern)- Root
• C7 (pattern)- Root
• C8 (pattern)- Root
• Median, ulnar and radial nerves damage pattern.

Test of vascular nature of Hand

• Allen Test. Have pt open and close hand several times as quickly as possible then squeeze hand tightly
  • Therapist compresses radial and ulnar nerve
  • Then instruct pt to open hand, then release radial artery and repeat with ulnar artery
• Capillary Refill Test. Apply pressure to tip of finger and count how long until it returns

Test of neurological nature of Hand

• Froments Test - adductor pollicis
  • Ask pt to hold paper between thumb and index finger and try to pull the paper from the clinicians grip. Positive test: pt compensates by raising thumb
• Phalen's Test - carpal tunnel test Put pt in reverse prayer stretch and have them press the back of their hands together and hold for 30-60 sec
  • Positive sign: recreation of patients symptoms
• Tinel's Sign- carpal tunnel syndrome
• Tap on median nerve of the wrist Positive: Tingling in median innervated fingers
• De Quervain's Test
  • Finkelstein Test - Abductor pollicis and extensor pollicis brevis Have pt in neutral wrist tell them to tuck their thumb into fingers and have pt ulnar deviate Positive test: Pain over distal radius

Purpose of Wrist Mobilizations

• Radiocarpal Distraction improve general mobility in hand/wrist.
• Radiocarpal Dorsal Glide improve with extension.
• Radiocarpal Volar Glide improve with flexion.