Podcast
Questions and Answers
What is one consequence of unopposed deltoid activity on the humerus?
What is one consequence of unopposed deltoid activity on the humerus?
Which of the following muscles is NOT involved in the upward rotation of the scapula?
Which of the following muscles is NOT involved in the upward rotation of the scapula?
What is primarily responsible for inducing upward translation of the humerus during upper extremity elevation?
What is primarily responsible for inducing upward translation of the humerus during upper extremity elevation?
What happens when there is a failure in the deltoid-RTC coordination?
What happens when there is a failure in the deltoid-RTC coordination?
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Which of the following statements about the anterior/posterior RTC is true?
Which of the following statements about the anterior/posterior RTC is true?
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What ratio is generally observed in the scapulohumeral rhythm during shoulder elevation?
What ratio is generally observed in the scapulohumeral rhythm during shoulder elevation?
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Lack of proper functioning of the trapezius and serratus anterior can lead to what condition?
Lack of proper functioning of the trapezius and serratus anterior can lead to what condition?
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What effect does a slouched posture have on the mechanics of the glenohumeral (GH) joint?
What effect does a slouched posture have on the mechanics of the glenohumeral (GH) joint?
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Which of the following muscles is primarily weakened in individuals with forward head posture and increased thoracic kyphosis?
Which of the following muscles is primarily weakened in individuals with forward head posture and increased thoracic kyphosis?
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What is a principal cause of tendinopathy as mentioned in the content?
What is a principal cause of tendinopathy as mentioned in the content?
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Which statement about the healing phases of tendon injuries is accurate?
Which statement about the healing phases of tendon injuries is accurate?
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What consequence does forward head posture have on scapular positioning?
What consequence does forward head posture have on scapular positioning?
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What is an essential component when performing elbow-related shoulder exercises?
What is an essential component when performing elbow-related shoulder exercises?
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Which degree of shoulder abduction is used for self-stretching into external rotation?
Which degree of shoulder abduction is used for self-stretching into external rotation?
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In the controlled motion phase for GH joint hypomobility, which intervention aims to enhance joint tracking?
In the controlled motion phase for GH joint hypomobility, which intervention aims to enhance joint tracking?
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During the chronic phase of GH joint hypomobility management, the primary focus is on which aspect?
During the chronic phase of GH joint hypomobility management, the primary focus is on which aspect?
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What technique is emphasized during MUA (Manipulation Under Anesthesia) for GH joint hypomobility?
What technique is emphasized during MUA (Manipulation Under Anesthesia) for GH joint hypomobility?
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Which muscle is more active when using seated pulley systems for shoulder exercises?
Which muscle is more active when using seated pulley systems for shoulder exercises?
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Which stretching technique is recommended to stretch the posterior capsule of the shoulder?
Which stretching technique is recommended to stretch the posterior capsule of the shoulder?
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What type of glide is performed during the 'mobilization with movement' intervention?
What type of glide is performed during the 'mobilization with movement' intervention?
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What is a key goal of self-mobilization and manual stretching during the subacute phase of GH joint hypomobility management?
What is a key goal of self-mobilization and manual stretching during the subacute phase of GH joint hypomobility management?
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During interventions for GH joint hypomobility, which of the following should not be prioritized?
During interventions for GH joint hypomobility, which of the following should not be prioritized?
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Which stage of idiopathic frozen shoulder is characterized by thickened red synovitis and acute discomfort with painful end ranges of all motions?
Which stage of idiopathic frozen shoulder is characterized by thickened red synovitis and acute discomfort with painful end ranges of all motions?
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What is the average duration from the onset of idiopathic frozen shoulder to full recovery?
What is the average duration from the onset of idiopathic frozen shoulder to full recovery?
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Which stage of idiopathic frozen shoulder is associated with minimal pain but significant capsular restrictions?
Which stage of idiopathic frozen shoulder is associated with minimal pain but significant capsular restrictions?
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During which stage of idiopathic frozen shoulder does pain typically decrease, being experienced primarily with movement?
During which stage of idiopathic frozen shoulder does pain typically decrease, being experienced primarily with movement?
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Which treatment approach is recommended for managing acute phase symptoms of GH joint hypomobility?
Which treatment approach is recommended for managing acute phase symptoms of GH joint hypomobility?
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What symptom is NOT typically associated with the initial stages of idiopathic frozen shoulder?
What symptom is NOT typically associated with the initial stages of idiopathic frozen shoulder?
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Which exercise is classified as a passive range of motion technique used to relieve pain in the joint during the acute phase?
Which exercise is classified as a passive range of motion technique used to relieve pain in the joint during the acute phase?
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In idiopathic frozen shoulder, what characteristic suggests high likelihood for aggressive therapy to be detrimental?
In idiopathic frozen shoulder, what characteristic suggests high likelihood for aggressive therapy to be detrimental?
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Which of the following statements about joint mobilization in GH joint hypomobility is incorrect?
Which of the following statements about joint mobilization in GH joint hypomobility is incorrect?
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What is the procedure involved in SLAP repair?
What is the procedure involved in SLAP repair?
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Following a Bankart repair for anterior instability, which movement should be limited during the first six weeks?
Following a Bankart repair for anterior instability, which movement should be limited during the first six weeks?
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What is a common symptom of Subacromial Pain Syndrome?
What is a common symptom of Subacromial Pain Syndrome?
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Which type of instability requires the arm to be positioned in a 'handshake' position during immobilization?
Which type of instability requires the arm to be positioned in a 'handshake' position during immobilization?
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What intrinsic factor can compromise the integrity of the rotator cuff tendons?
What intrinsic factor can compromise the integrity of the rotator cuff tendons?
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Which shoulder movement should be avoided during Grade III or higher joint mobilizations after anterior stabilization?
Which shoulder movement should be avoided during Grade III or higher joint mobilizations after anterior stabilization?
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What is the key goal during the initial rehabilitation phase following capsule stabilization surgery?
What is the key goal during the initial rehabilitation phase following capsule stabilization surgery?
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What extrinsic factor involves wearing of the RTC against the acromion?
What extrinsic factor involves wearing of the RTC against the acromion?
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What is the common outcome of intrinsic impingement if not addressed?
What is the common outcome of intrinsic impingement if not addressed?
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What should be restricted during the first 8-12 weeks following an anterior capsular shift?
What should be restricted during the first 8-12 weeks following an anterior capsular shift?
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Study Notes
Therapeutic Exercise II: The Shoulder and Shoulder Girdle
- This course covers the anatomy and function of the shoulder girdle
- Students will learn about common shoulder pathologies that benefit from therapeutic exercise interventions.
- These interventions include hypomobility, hypermobility, and soft tissue overuse conditions.
- Students will learn how to create and modify therapeutic exercise programs for musculoskeletal, soft tissue, and joint lesions, based on the healing stages of tissue.
- The course will include common surgical procedures and precautions for conditions like hypomobility and instability.
- Students will learn about post-operative management goals and interventions for shoulder and shoulder girdle dysfunction at different rehabilitation phases.
- Students will learn how to demonstrate exercise progressions to improve range of motion (ROM), muscle performance, and functional use of the shoulder and shoulder girdle.
Outline of Topics
- Structure and function of the shoulder girdle
- Hypomobility: nonoperative management and TSA
- Hypermobility: instability of the GH joint
- Painful biomechanical shoulder syndromes
Structure and Function of the Shoulder Girdle
- Joints of the shoulder girdle: Glenohumeral (GH) joint, Acromioclavicular (AC) joint, Sternoclavicular (SC) joint
- Shoulder girdle function
- Force couples of shoulder complex: Balance, mobility, and stability, with diagrams showing angles and relationships
Shoulder Girdle Complex
- Synovial joints: Glenohumeral (GH) joint, Acromioclavicular (AC) joint, Sternoclavicular (SC) joint
- Functional articulations: Scapulothoracic articulation (ST), for greater shoulder mobility
Anatomy Review
- Glenohumeral joint structure (anatomical diagram)
- Acromioclavicular and sternoclavicular joint structures (anatomical diagram)
- Clavicle, scapula, humerus, sternum, and supporting structures
Glenohumeral Joint
- Incongruous ball and socket joint
- Tri-axial joint
- Lax joint capsule
- Supported by:
- rotator cuff (RTC)
- glenohumeral ligaments (superior, middle, inferior)
- coracohumeral ligaments
- Glenoid fossa: shallow, deepened by fibrocartilaginous lip
- Humeral head: 3-4x larger than glenoid fossa
- Glenoid labrum: a structure that deepens the glenoid fossa, providing stability, and an attachment site for the joint capsule
- Diagram of Glenoid Fossa (includes the muscles and ligaments)
Glenohumeral Joint: Stability
- Provided by static and dynamic restraints
- Static: bony anatomy, ligaments, glenoid labrum, and adhesive/cohesive forces
- Dynamic: RTC tendons blend with ligaments and glenoid labrum. Contraction tightens static restraints to enhance stability
- Coordinated response of the RTC muscles & biceps/triceps
- Long head of Biceps: Stabilizes against humeral elevation; resists torsion when in abduction & ER; contributes to humeral depression
- Long head of Triceps: Inferior shoulder support
Acromioclavicular Joint
- Plane, triaxial joint
- May or may not have AC disc
- Reinforced by superior and inferior AC ligaments
- Supported by coracoclavicular ligaments
- No dynamic support
Acromioclavicular Joint: Arthrokinematics
- Acromion: concave facet
- Clavicle: convex facet
- When scapula moves, acromial surfaces slide in same direction
- Motions affecting the AC joint
- Upward rotation
- Downward rotation
- Winging of vertebral border
- Tipping of inferior angle
Sternoclavicular Joint
- Incongruent, triaxial, saddle-shaped joint
- Has a disc
- Stability provided by
- Anterior and posterior SC ligaments
- Interclavicular ligaments
- Costoclavicular ligaments
Sternoclavicular Joint: Arthrokinematics
- Clavicle motions as a result of scapular motions.
- Elevation
- Depression
- Protraction
- Retraction
Clavicular Elevation and Rotation
- Posterior rotation of clavicle occurs as an accessory motion when humerus is elevated above 90 degrees.
- Cannot occur in isolation
- Coracoclavicular ligament taut for passive stability
Scapulothoracic Articulation
- Motions:
- Elevation, depression
- Adduction, abduction
- Upward, downward rotation
- Protraction
- Retraction
- Additional motions: tipping/tilting (anterior/posterior), winging (medial border lifts away from rib cage)
Subacromial Space/Suprahumeral Space
- Coracoacromial arch: acromion & coracoacromial ligament
- Structures: subacromial/subdeltoid bursa, supraspinatus tendon, long head of biceps tendon
Subacromial Space/Suprahumeral Space: Compromise
- Causes: faulty posture, muscle function, joint mechanics, structural abnormalities (Type I, II, III acromion), injury to soft tissue
- Outcome: Impingement syndrome
Shoulder Girdle Function
- Force couple review: deltoid-rotator cuff, trapezius/serratus anterior, anterior-posterior rotator cuff
- Important for balance and stability (diagram of forces)
Deltoid-RTC Relationship
- Deltoid leads to upward translation of humerus.
- Downward force/translation, and stabilizing producers:
- Infraspinatus
- Teres minor
- Subscapularis
- Supraspinatus: significant stabilizing, compressive, slight upward translation effect on humerus with UE elevation
- What is another humeral depressor? (See slide for answer)
Trapezius/Serratus Anterior
- Work together for scapular upward rotation (UT, LT, SA)
- Assists in elevation
- Lack of function leads to increased impingement due to lack of scapular rotation
Anterior/Posterior RTC
- Keeps humeral head properly positioned in glenoid
- Includes: subscapularis, infraspinatus, teres minor
- Opposes anterior-posterior glenohumeral joint translation
Shoulder Girdle Function: Failure
- Interruption of deltoid-RTC coordination
- Leads to tissue microtrauma, compression, or overuse of soft tissues causing shoulder dysfunction
Scapulohumeral Rhythm
- 3 phases where 180 degrees of elevation are assisted
- General 2:1 ratio (GH vs. scapula)
- Discrepancies in 1:1 vs 2:1 ratio in sources
- Phases:
- Phase 1: 0-30° abduction, 0-60° flexion. Primarily GH motion, scapula finding stability
- Phase 2: 30-90° degrees (depending on motion). Improved joint congruency as length-tension relationship of muscles is maintained (approaches 1:1 ratio)
- Phase 3: Last 90°. Dominated by glenohumeral motion. GH joint must ER to clear subacromial arch
Review (Questions)
- How does forward head and shoulder position affect the scapula and glenohumeral joint position?
- What are the various motions of the scapula?
- What are the major downward and upward rotators of the scapula?
- What is the importance of the long head of the biceps and triceps?
- Why is ER of the humerus with shoulder elevation important?
Shoulder Pathology and Management
- Joint Hypomobility: Non-operative management, surgery & post-operative management
- Glenohumeral Joint: Surgery & post-operative management
- Shoulder Instabilities: Non-operative, management; surgery & post-operative management
- Painful Shoulder Syndromes: Non-operative management (RTC, impingement syndromes); surgery & post-operative management
Shoulder Pathologies General Interventions
- Hypomobility: Restore Mobility/ROM
- Hypermobility: Restore Stability (strength)
- Painful disorders: Restore proper biomechanics
GH Joint Pathologies: Management
- Will initially be treated conservatively.
- Often involves pharmacology and active physical therapy.
- Includes therapeutic exercise
Joint Hypomobility: Non-operative Management
- Hypomobility can occur in any of the shoulder complex joints. - Glenohumeral (GH) joint - Acromioclavicular (AC) joint - Sternoclavicular (SC) joints
- Causes: rheumatoid arthritis, prolonged immobilization, traumatic arthritis, osteoarthritis, idiopathic frozen shoulder
GH Joint Hypomobility
- Restricted GH joint mobility due to: Rheumatoid arthritis, prolonged immobilisation, traumatic arthritis, Osteoarthritis, idiopathic frozen shoulder
Glenohumeral Osteoarthritis
- Description of the disease & characteristics
- Diagram/Images of the condition
GH Joint Arthritis: Clinical Signs & Symptoms
- Acute Phase: Pain, muscle guarding limits motion (ER, abduction), pain may radiate below elbow, disturb sleep
- Swelling usually not detectable
- Sub-acute Phase: Capsular tightness begins to develop, Limited motion pattern, pain at end of motion.
- Chronic Phase: Progressive restrictions in GH capsule, further limited motion and joint play. Significant loss of function (reaching overhead, out to side, behind back), aching in deltoid region
Idiopathic Frozen Shoulder/Adhesive Capsulitis
- Average age of onset: 40-65 years old
- Characterized by gradual onset of pain, restricted movement
- Synovial inflammation followed by fibrosis (capsuloligamentous complex)
- Self-limiting clinical entity, progresses through stages
- Primary (idiopathic): unknown cause
- Secondary: known cause (e.g., post-op, immobilisation)
- Stages: Pre-adhesive, Freezing, Frozen and Thawing (detailed clinical signs & symptoms of each) – Average time from onset to recovery
APTA Guidelines- Adhesive Capsulitis 2013
- Corticosteroid injections
- Patient education
- Stretching exercises
- Modalities
- Joint mobilization
- Translational manipulation (anesthesia)
GH Joint Hypomobility Impairments
- Night pain, disturbed sleep during acute flares
- Pain with motion; pain at rest during acute flares
- Decreased joint play and ROM in capsular pattern
- Decreased arm swing during gait
- Possible postural compensations: (protracted & anterior tilted scapula, elevated, protected shoulder)
- Excessive scapular motion
- Muscle performance:
- GH muscles: general muscle weakness and poor endurance
- overuse of scapular muscles
- Difficulty lifting weighted objects
- Inability to reach overhead, behind head, out to side, behind back
- Limited ability to sustain repetitive activities
GH Joint Hypomobility: Non-Operative Management
- Acute Phase (Protection):
- Control Pain, Edema, Muscle Guarding
- Maintain Soft Tissue and Joint Integrity and Mobility
- Pendulum (Codman's)
- PROM
- Passive joint distraction, Grade I, II joint mobilizations
- Gentle muscle setting
- Maintain Integrity and Function of Associated Regions
- Hand exercises
- Cervical ROM
PROM to Relieve pain and pressure in the joint: Pendulum (Codman) Exercises
- Passive motion
- Move your body/hips not your arm
- No weight: gentle distraction of GH joint
- With weight: Grade III (stretching) distraction force
Passive Exercises to AAROM
- External Rotation (elbow remains next to torso)
- AAROM: Only assist active motion necessary
Exercise Examples: PROM, AAROM: Flexion, Abduction
- Encouraging ER during shoulder elevation
S-Assisted Shoulder Elevation
- Supraspinatus is more active with seated pulley systems
- Performed when patient is released from PROM phase
- Ensure GH joint is in ER when moving overhead
GH Joint Hypomobility: Non-operative Management; Subacute Phase
- Control pain, edema, joint effusion
- Functional activities
- ROM: AAROM → AROM resistance
- Progressively increase joint and soft tissue mobility - Passive Joint Mobilization - Self-Mobilization - Manual Stretching - Self Stretching
GH Joint Hypomobility: Non-operative Management; Controlled Motion Phase
- Inhibit Muscle Spasm & Correct Faulty Mechanics
- Teach proper mechanics
- Gentle joint oscillation
- Sustained caudal glide
- GH IR and ER strengthening
- Protected WB
- Improve Joint Tracking (MWM)
- Improve Muscle Performance (Posture, trunk stability)
Interventions to Increase Motion: Mobilization with Movement: Posterior Lateral Glide
- Patient performs active elevation while a sustained posterior glide is performed.
Exercises to increase motion: Self Caudal Glide (GH Joint)
Exercises to increase motion: Self Anterior Glide
Exercises to increase motion: Self Posterior Glide
Self Stretching to Posterior Shoulder
- Stretch posterior capsule and external rotators, increase internal rotation
- Maintain proper spine posture
Exercises to increase motion: Subscapularis Stretch
- Stretching into ER
- Maintain correct abduction
- Chest up for proper positioning
Exercises to increase motion: Pectoralis Major Self Stretch
- Clavicular portion of pec major biased, sternal portion of pec major biased
Exercises to increase motion: Levator Scapulae Self Stretch
- Using upward rotation of the scapula to stretch.
- Using depression of the scapula to stretch
Exercises to increase motion: Sleeper Stretch
- To increase IR
GH Joint Hypomobility: Non-operative Management; Chronic Phase
- Progressively increase flexibility and strength
- Continue with strengthening
- Prepare for functional demands (sport & work specific training)
GH Joint Hypomobility: MUA
- Manipulation Under Anesthesia (used in cases with lack of improvement by non-operative treatments)
- Initially treated as an acute lesion
- Arm kept in overhead and ER position
- Immediate joint mobilization, PROM daily
- Emphasize inferior glide
- Emphasize abduction, ER
- Positioning: in ER and abduction (to avoid capsular pattern)
Review (Questions)
- What is the capsular pattern of motion loss for the glenohumeral joint?
- When does the capsular pattern of motion loss typically occur in a joint?
- What are 3 appropriate interventions for glenohumeral arthritis in the acute phase of healing?
- What are some causes of AC joint pathology?
- What motions of the shoulder will be limited in the acute phase of AC joint healing?
Glenohumeral Joint Pathology & Post-op Management
- Arthroplasty: Any joint procedure (with or without implant), used for pain relief and improved function.
- Excision Arthroplasty
- Excision Arthroplasty w/ implant
- Interposition Arthroplasty
- Joint Replacement Arthroplasty
Joint Replacement Arthroplasty
- Total Joint Replacement: Resection of both affected surfaces & replacement with artificial components.
- Hemi-replacement Arthroplasty: Resection of one surface, Indications include late-stage arthritis/femoral neck & proximal humeral fractures
Total Shoulder Arthroplasty (TSA)
- Surgical Procedures (description)
Glenohumeral Joint Surgery
- TSA, rTSA, Hemiarthroplasty (procedures & outcomes)
GH Arthroplasty: Post-Operative Management; Key Points
- ROM Goals for TSA* and rTSA (range differences)
GH Arthroplasty: Post-Operative Management—Exercise Progression
- Think about the anatomical structures involved in the surgery, and identify the surgical goals.
- What was cut?
- What was repaired?
- What is the post-operative time frame?
- What is the patient telling you?
- How is the patient responding to treatment?
- Use protocols to assist in guiding your exercise program
GH Arthroplasty: Post-Operative Management—Immobilization
- Sling or splint for reattached & repaired tissues
- Removed for exercise & bathing ASAP
- Immobilization time frame (usually 4-6 weeks, up to 8-12 weeks)
GH Arthroplasty: Post-Operative Management—Positioning
- Arm in slight flexion (10-20°) with slight abduction
- Elbow flexion at 90°
- Forearm & hand resting on abdomen/pillow
- Maintain scapula in a resting position
GH Arthroplasty: Post-Operative Management
- Correct faulty posture (will affect shoulder outcomes)
GH Arthroplasty: Post Operative Management: Table 17.2—TSA vs. rTSA
- (Table of comparison between TSA & rTSA in post-operative management)
GH Arthroplasty: Post Operative Management- Maximum Protection Phase
- Hospitalization (3-4 days), precautions, HEP
- Control pain & inflammation
- Maintain adjacent joint mobility
- Restore/maintain shoulder mobility (progression)
- Minimize muscle inhibition, guarding, and atrophy
Precautions: Maximum Protection Phase
- ROM (PROM, AAROM)
- No extension/horizontal abduction beyond neutral
- No lifting with involved arm
- No weight bearing
- No driving for 4-6 weeks
- Wear sling as indicated (Specific precautions for TSA and rTSA)
Gentle Post-op AAROM Exercise: Gear Shift Exercise
Criteria for Progression to Moderate Protection/Controlled Motion Phase (TSA)
- PROM, Elevation to 90, ER to 45, IR to 70 (in plane of the scapula), Minimal pain.
- No pain during resisted isometric IR
- Able to perform waist-level ADLs with no/minimal pain for rTSA
- Tolerance to AAROM, ability to isometrically activate deltoid and periscapular muscles while position in scapular plane.
Exercise: Moderate Protection/Controlled Motion Phase
- 4-6 weeks → 12-16 weeks
- Control pain and inflammation
- Progressively increased ROM
- Develop active control & dynamic stability (specific exercises noted for rTSA)
rTSA Special Considerations; Moderate Protection Phase
- No WB through arm until 12 weeks
- Pain-free submaximal isometrics to repaired muscles and subscapularis
- Dynamic low-resistance exercises for elbow, wrist, and hand
- Late in phase: RTC strengthening, strengthening scapula and shoulder muscles (progress supine→sitting)
Submaximal Isometrics: Flexion, Abduction and ER
- Exercises for isometric muscle activation
Isometric or Dynamic Manual Resistance to Scapular Muscles
- Exercises using manual resistance for scapular muscle activation
Dynamic Manual Resistance for ER/IR Muscles
- Exercises with manual resistance
Isometric Resistance in Scapular Plane
- Exercises for scapular muscle activation
- Can be performed at various angles with elevation depending on the symptoms and findings
Isometric Stabilization Exercise
- More advanced than "muscle setting"
- Apply resistance in varying sequence for flexion/extension, abduction, adduction, ER/IR.
- Can be performed for single arm without wand.
- Eyes open vs eyes closed for different challenges to the exercises
GH Arthroplasty: Post Operative Management; Criteria to Progress to Minimal Protection/Return to Function Phase
- Pain-free PROM/AAROM
- Flexion to at least 130-140 degrees
- Abduction to 120 degrees
- ER to 60, IR to 70 in plane of scapula
- Active elevation of UE against gravity to 100-120 degrees with proper mechanics, MMT: 4/5 for RTC and deltoid.
GH Arthroplasty: Post Operative Management; Minimum Protection/Return to Function Phase
- Continue to improve or maintain shoulder mobility, neuromuscular control & muscle performance.
- Return to most functional activities
CKC Scapular and GH Stabilization Exercises
(B) In minimal WB position, unilateral on less stable surface
Review (Questions)
- What is the difference between TSA and r-TSA?
- What muscle is retracted and reattached with a TSA?
- Based on the protocol in the Kisner, what exercises are appropriate for a patient s/p r-TSA at s/p post-op 6 weeks? Write them as you would in the objective section of a SOAP note.
Outline (recap of all previous outlined topics regarding shoulder girdle and instability)
Shoulder Instability (Hypermobility)
- Atraumatic hypermobility (due to generalized connective tissue laxity or microtrauma related to repetitive activities)
- Traumatic hypermobility (high force event(s) compromising stabilizing structures, often dislocating GH joint) - Unidirectional - Multi-directional
- Atraumatic Hypermobility: Unidirectional Instability
- Anterior, posterior or inferior
- Due to physiologic laxity of connective tissue, repetitive microtrauma
- Humeral head may continue to dislocate or sublux
- Can lead to progressive degeneration and subsequent tearing of supportive structures
GH Instability
- Anterior: Excessive anterior humeral head translation from forces against the arm when abducted/externally rotated
- Posterior: Can occur from repetitive or forceful forces against a forward flexed, adducted, internally rotated humerus
- Inferior: Typically results from RTC weakness or paralysis (hemiplegia)
- Multidirectional: Occurs when GH joint stability is compromised in more than one direction
Recurrent Dislocations
- With significant ligamentous and capsular laxity, one or multidirectional subluxations/dislocations occur, reproducing the forces causing instability.
- Voluntary dislocations (worse prognosis), can dislocate without apprehension & minimal discomfort.
- Highest rate of recurrence after 1st traumatic dislocation in younger populations (<30 years old).
Closed Reduction of Anterior Dislocations: Management
- Acute Phase (Protection): Protect healing tissue, promote tissue health
- Subacute Phase (Controlled Motion): Provide protection, Increase shoulder mobility, Increase stability/strength of RTC & scapular muscles
- Chronic Phase (Return to Function): Restore functional control, return to activity
Closed Reduction of Posterior Dislocations: Management
- Same general rehab as anterior/inferior dislocations, EXCEPT:
- Avoid humeral flexion with adduction and IR during acute & healing phases; posterior glide is contraindicated once mobilization is allowed.
External Rotation Evidence
- Infraspinatus activation greater at lower shoulder abduction angles
- Teres minor activation unaffected by shoulder angles
- Best exercise: Teres minor + infraspinatus = side-lying shoulder ER, Standing ER @ 45° Abd, Prone ER @ 90° - Adding towel roll between elbow & trunk increases ER muscle EMG 20-25%
Muscle Activation Evidence
- Use a towel roll to target the specific muscle being focused on in the exercises.
- Variety in exercise programs
Internal Rotation Evidence
- IR at 0 degrees abduction: very stable, add a towel roll for 20-25% increased activity
- IR at 90 degrees abduction: unstable position, less pectoralis activity, enhances scapular position, helps isolate subscapularis
- IR diagonal exercise—more functional (not PNF)
Abduction in Plane of the Scapula
- Standing “Full Can”: better than empty can for isolating supraspinatus from deltoid, improved GH mechanics, scapular plane: 30 degrees anterior to the frontal plane
- Prone full can: Greater EMG of posterior deltoid vs middle, decreases superior shear force, prone position activates scapular muscles
Deltoid Evidence
- Posterior deltoid: not a large roll; high activity with prone full can, 60º abduction: all deltoid muscles cause instability, 60º scaption: deltoid muscles contribute to stability
- Middle deltoid: most significant impact on superior head migration, high activity with empty can
- Anterior deltoid: effective abductor at start of full can, not effective abductor at start of empty can, large superior humeral migration pull
Serratus Anterior Evidence
- Serratus function: prevents scapular winging & anterior tilt, serratus + upper/lower traps = upward rot of scapula
- Top activation activities: push with plus, dynamic hug, supine punch
Lower Trapezius Evidence
- Top activation exercises: prone full can, prone ER at 90°, prone horizontal abduction at 90°
Rhomboids and Levator Scapulae Evidence
- Best exercises for activation: scapular abduction above 120° with ER, prone horizontal abduction at 90° abduction with IR and ER, prone rowing, prone extension from 90° flexion
Prone Scapular Retraction against resistance
- Scapular retraction (setting) towards spine should be initiated prior to horizontal abduction
Horizontal Abduction & Scapular Retraction
- Scapular retraction (setting) first.
- Thumbs facing ceiling: emphasize strengthening of the middle and lower trapezius.
Surgical Intervention for capsular instability
Capsule Stabilization & Reconstruction
- General rehab goals: restore balance of joint stability and functional motion while protecting repaired tissues, amount of immobilization and progression depend on surgery type, type of injured tissue, severity of injury, tissue fixation & quality.
- Restore ROM & Strengthening dynamic stabilizers.
Precautions following anterior GH stabilization
- Limit ER, horizontal abduction & extension during first 6 weeks
- No vigorous stretching to increase ER for 8-12 weeks.
Painful Shoulder Syndromes: Non-Operative Management
- Impingement, tendonitis/tendinopathy, Bursitis —Descriptions, causes & characteristics of various types of painful shoulder conditions; and management.
Painful Shoulder Syndrome: SPS/Impingement
- Subacromial pain syndrome/impingement: Subacromial space = mechanical compression and irritation of the RTC and subacromial bursa; within suprahumeral space.
- Pain with overhead reaching
- Painful arc (mid range elevation)
- Positive impingement tests
Intrinsic Impingement (RTC Disease)
- Intrinsic factors: compromise musculotendinous structures
- Vascular changes in RTC tendons, tissue tension overload, collagen disorientation and degeneration; in people over 40, may progress to RTC tears
Extrinsic Impingement
- Mechanical wearing of the RTC against the anterior/inferior 1/3 of the acromion, often caused by decreases in subacromial space due to anatomical and biomechanical factors
Acromion Shape
- Having an acromion shape of Type III would lead to extrinsic impingement
Faulty Posture
- Forward head, thoracic kyphosis, forward tilt & downward rotation of scapula, relative abduction, IR of the humerus (how it might lead to impingement) (diagram)
Scapular Stability & Posture
- Slouched posture alters the relationship of the scapula and humeral muscles, altering mechanics of the GH joint
Roundback/Forward Head Faulty Posture
- Summary diagram with various factors that influence this faulty posture.
Tendinopathy
- Function of tendons - transmitting muscle forces to bone
- Causes & phases of tendinopathy healing.
- Inflammatory phase (1-7 days);
- Repairing phase (Day 5 to 7-5 weeks);
- Remodeling phase (6 weeks -10 weeks)
- Maturation phase (10 wks-1 year)
- Supporting evidence lacking for eccentric exercises for shoulder
Painful Shoulder Syndromes; Tendonitis/Bursitis
- Supraspinatus tendonitis
- Infraspinatus tendonitis
- Bicipital tendonitis
- Subdeltoid bursitis
- Subacromial bursitis
Supraspinatus Tendonitis
- Usually at the musculotendinous junction
- Painful arc; impingement tests
- Pain with palpation (inferior to the acromion)
Infraspinatus Tendonitis
- Usually near musculotendinous junction
- Painful arc w/ overhead/forward/cross body motions
- May be due to deceleration injuries (throwing motions)
- Pain w/ palpation (inferior to posterior corner with horizontal add/ER)
Bicipital Tendonitis
- Lesion of long head of bicep tendon (within bicipital groove)
- Swelling in the bony groove
- Positive Speed's Test
- Pain with bicipital groove palpation - possible rupture or dislocation
Bursitis
- Subdeltoid/subacromial bursa inflammation
- Same acute phase symptoms as supraspinatus tendonitis
- No symptoms present with resisted movement (once acute phase subsides)
Other Musculo-tendinous Problems
- Injury, overuse or repetitive trauma that can occur in any muscle
- Pain with palpation of injured tissues, restricted motion and pain with muscle lengthening; pain & weakness during muscle contraction
- Pectoralis minor, short head of biceps, coracobrachialis (microtrauma in racquet sports)
Review (Questions)
- What are typical patient complaints with GH impingement?
- What are appropriate exercises to perform for subdeltoid bursitis, proximal bicipital tendonitis, or supraspinatus tendonitis in the acute phase of tissue healing? Subacute?
Studying That Suits You
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Description
Test your knowledge on shoulder mechanics, including the role of the deltoid and other muscles in shoulder movement and posture. This quiz explores the impact of muscle coordination, upward rotation of the scapula, and the effects of poor posture on shoulder function. Perfect for students or professionals in physical therapy or anatomy.
