Stanbridge - T4 - TE2 - W7 - The Shoulder & Shoulder Girdle (Part 2)
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Questions and Answers

What is a common cause of an atraumatic RTC tear in individuals over 40 years of age?

  • Repetitive micro-trauma due to overuse (correct)
  • Direct impact during a fall
  • Acute trauma from sports injury
  • Sudden lifting of heavy weights

    • Which muscle is typically weak in someone with an atraumatic RTC tear?

  • Levator scapula
  • Serratus anterior (correct)
  • Upper trapezius
  • Pectoralis major

    • What factor contributes to the increased vulnerability to RTC tears in older adults?

  • Impaired circulation and degenerative changes (correct)
  • Higher intensity training
  • Greater muscle mass
  • Increased activity levels

    • Which condition is characterized by hypomobility in the posterior GH capsule?

    <p>RTC tear</p> Signup and view all the answers

    What is a common functional limitation experienced by individuals with an RTC tear?

    <p>Difficulty with overhead activities</p> Signup and view all the answers

    Which of the following reflects faulty kinematics associated with RTC tears?

    <p>Decreased posterior tipping of the scapula</p> Signup and view all the answers

    Which condition is often related to pain interfering with sleep in patients with RTC tears?

    <p>Atraumatic RTC tear</p> Signup and view all the answers

    What postural change is commonly observed in patients with an RTC tear?

    <p>Forward head posture</p> Signup and view all the answers

    Which of the following is NOT a common site of referred pain associated with shoulder pathologies?

    <p>Forearm</p> Signup and view all the answers

    What could be a consequence of a full-thickness supraspinatus tear?

    <p>Inability to abduct the humerus against gravity</p> Signup and view all the answers

    What is a primary goal during the Maximum Protection Phase after an arthroscopic procedure?

    <p>Restore pain-free shoulder mobility</p> Signup and view all the answers

    Which criterion indicates readiness to progress to the next phase of rehabilitation?

    <p>Symmetrical arm swing with gait</p> Signup and view all the answers

    What can occur during the Moderate Protection Phase of rehabilitation?

    <p>Improvement of neuromuscular control</p> Signup and view all the answers

    What is the primary focus during the Maximum Protection Phase regarding muscle condition?

    <p>Preventing reflex inhibition and atrophy of shoulder girdle musculature</p> Signup and view all the answers

    At what point may the Moderate Protection Phase typically start after surgery?

    <p>4-6 weeks post-operative</p> Signup and view all the answers

    What does achieving nearly full pain-free passive range of motion (PROM) signify?

    <p>Patient may be ready to progress to the next rehabilitation phase</p> Signup and view all the answers

    Which exercise focus is NOT part of the goals during the Maximum Protection Phase?

    <p>Restore overall upper body strength</p> Signup and view all the answers

    What does pain-free active range of motion (AROM) external rotation to about 45 degrees indicate?

    <p>A strong indication for advancing therapeutic exercises</p> Signup and view all the answers

    Which of the following is NOT a goal of the Moderate Protection Phase?

    <p>Preventing atrophy of the shoulder girdle musculature</p> Signup and view all the answers

    What defines the Maximum Protection Phase in post-operative management?

    <p>Focus on pain management and gentle mobilization</p> Signup and view all the answers

    What is the primary goal during the subacute phase of shoulder management?

    <p>Progressive nondestructive movement with proper mechanics</p> Signup and view all the answers

    In the chronic phase of shoulder management, which strategy is focused on improving muscle function?

    <p>Develop quick motor responses to imposed stresses</p> Signup and view all the answers

    What is a major consideration in the postoperative management of subacromial decompression?

    <p>Assessment of the rotator cuff's integrity preoperatively</p> Signup and view all the answers

    What is the primary purpose of subacromial decompression surgery?

    <p>To increase the volume of the subacromial space for tendon gliding</p> Signup and view all the answers

    Which of the following is NOT a goal during the acute phase of shoulder management?

    <p>Develop strong and mobile tissues</p> Signup and view all the answers

    During the chronic phase, which aspect is important for shoulder rehabilitation?

    <p>Prioritizing eccentric training and simulating functional activities</p> Signup and view all the answers

    What type of management is crucial for patients following excision arthroplasty?

    <p>Comprehensive evaluation of affected tissues post-surgery</p> Signup and view all the answers

    What best describes subacromial decompression?

    <p>It involves resecting part of the acromion to increase space.</p> Signup and view all the answers

    Which factor is essential when deciding postoperative management following rotator cuff repair?

    <p>Whether RTC was intact before the operation</p> Signup and view all the answers

    Which management strategy aims to stabilize the shoulder during the subacute phase?

    <p>Regain neuromuscular control and stabilize the scapula</p> Signup and view all the answers

    What is the primary goal during the Moderate Protection Phase after an arthroscopic procedure?

    <p>Achieving full range of motion without pain</p> Signup and view all the answers

    Which of the following criteria indicates readiness to progress to the next phase of rehabilitation?

    <p>Full pain-free active range of motion without compensatory movement</p> Signup and view all the answers

    What type of exercise is permitted during the Minimal Protection Phase of rotator cuff rehabilitation?

    <p>Exercises similar to non-operative management of primary impingement</p> Signup and view all the answers

    Which statement about post-operative management for muscle or tendon repair is true?

    <p>Stretching the repaired muscle is strictly prohibited</p> Signup and view all the answers

    What characterizes a full thickness rotator cuff tear?

    <p>It affects the entire depth of the tendon</p> Signup and view all the answers

    How is a small rotator cuff tear defined?

    <p>1 cm or less in width</p> Signup and view all the answers

    What is a common cause of tendon tears in younger individuals?

    <p>Traumatic incidents</p> Signup and view all the answers

    Where do tendons frequently rupture in the human body?

    <p>Musculotendinous junctions or tendo-osseous junctions</p> Signup and view all the answers

    Which condition would typically warrant a rotator cuff repair?

    <p>Pain and impaired function after conservative treatment has failed</p> Signup and view all the answers

    What level of shoulder musculature strength is required before progressing to the next rehabilitation phase?

    <p>75% compared to the uninvolved side</p> Signup and view all the answers

    Study Notes

    Therapeutic Exercise II: The Shoulder (Part 2 of 2)

    • Course: PTA 1010
    • Topics covered include: RTC tears (nonsurgical and surgical management), other shoulder joints (AC and SC joints), nerve pathology in the shoulder, and referred pain.

    Road Map

    • Students will be able to understand RTC tear injuries, associated impairments, and functional limitations.
    • Students will be able to effectively teach and progress/regress a therapeutic exercise program for non-surgical RTC management.
    • Students will understand surgical interventions (decompression and repair) and post-operative management.
    • Students will understand the pathology of the AC and SC joints, along with common management and potential surgical interventions.
    • Students will understand common sites of referred pain and nerve pathology in the shoulder.

    Painful Shoulder Syndromes: Atraumatic RTC Tear

    • Insidious tear following repetitive micro-trauma (e.g., long head of biceps, RTC).
    • Usually affects people over 40 due to impaired circulation, degenerative changes, and calcification.
    • Commonly affects the distal portion of the supraspinatus tendon.

    Common Impairments

    • Impaired Posture: increased thoracic kyphosis, forward head, anteriorly tilted scapula.
    • Muscle imbalances:
      • Hypo-mobile: pectoralis minor and major, levator scapula, glenohumeral internal rotators (GH IRs)
      • Weak: serratus anterior, glenohumeral external rotators (GH ERs)
    • Hypomobile posterior glenohumeral (GH) capsule.
    • Decreased posterior tipping of scapula during humeral elevation.
    • Scapular elevation and overuse of upper trapezius.
    • Altered scapulohumeral and scapulothoracic rhythms.
    • Decreased thoracic/lumbar extension mobility.

    IF full thickness supraspinatus tear: Inability to abduct humerus against gravity without compensatory movements.

    Functional Limitations & Disabilities

    • Acute pain interferes with sleep and lying on the affected shoulder.
    • Pain with overhead reaching, pushing, and pulling.
    • Difficulty lifting loads.
    • Difficulty sustaining repetitive shoulder activities (swinging, reaching, throwing).
    • Difficulty with dressing, bathing (especially putting on a T-shirt), overhead reaching, and reaching behind the back.

    Acute Phase Management

    • Control inflammation and promote healing.
    • Provide patient education.
    • Maintain soft tissue integrity and mobility.
    • Address related region dysfunctions.
    • Review signs of excessive stress (Box 10.3).

    Subacute Phase Management

    • Goal: progressive, non-destructive movement during tissue healing.
    • Direct intervention based on evaluation findings:
      • If mobility is restricted: mobilize
      • If mobility is excessive: gain neuromuscular control, stabilize scapula and glenohumeral joint.

    Chronic Phase Management

    • Patient education.
    • Develop strong, mobile tissues.
    • Modify joint tracking and mobility.
    • Develop balance in length and strength of shoulder girdle muscles.
    • Develop muscular stabilization and endurance.
    • Progress shoulder function.
    • Increase endurance.
    • Develop quick motor responses to imposed stresses.
    • Progress functional training, including eccentric training to simulate functional activities.
    • Follow prevention instructions (Box 17.7).

    Eccentric Shoulder Strengthening Exercises

    Surgery & Postoperative Management

    • Subacromial Decompression (SAD) and postoperative management.
    • Rotator Cuff Repair and postoperative management.

    Subacromial Decompression

    • Also known as anterior acromioplasty or decompression acromioplasty.
    • Increases the subacromial space to provide adequate gliding room for tendons.
    • Includes procedures like resection of periarticular bone from one or both articular surfaces and resection of the edge of the acromion.

    Subacromial Decompression: Post-Operative Management

    • Evaluate whether the RTC was intact pre-operatively.
    • Determine if concomitant RTC repair was performed; follow guidelines if so.
    • Note the type of surgical approach (arthroscopic, open, mini-open).
    • Identify the tissues affected by the surgery to guide rehabilitation.

    Post-operative Management of Arthroscopic Procedure: Maximum Protection Phase

    • Control pain and inflammation.
    • Prevent loss of mobility in adjacent regions.
    • Develop postural awareness and control.
    • Restore pain-free shoulder mobility.
    • Prevent reflex inhibition and atrophy of the shoulder girdle musculature.

    Post-operative Management of Arthroscopic Procedure: Criteria to Progress to the Next Phase

    • Minimal discomfort in unsupported positions
    • Symmetrical arm swing with gait
    • Nearly full pain-free PROM
    • Good scapular mobility
    • Pain-free supine active elevation above shoulder level
    • Pain-free active ROM ER to about 45 degrees
    • Minimum of 3/5 muscle testing grades

    Post-operative Management of Arthroscopic Procedure: Moderate Protection Phase

    • Often starts 4-6 weeks post-surgery (but can be earlier).
    • Full, pain-free shoulder ROM.
    • Improve neuromuscular control.
    • Improve strength and endurance.

    Post-operative Management of Arthroscopic Procedure: Moderate Protection Phase (Continued)

    • Restore full pain-free PROM of the shoulder girdle and upper trunk.
    • Reinforce postural awareness and control.
    • Develop dynamic stability, strength, endurance, and control of the scapulothoracic and glenohumeral muscles.

    Post-operative Management of Arthroscopic Procedure: Criteria Progress to Next Phase

    • Full pain-free AROM without compensatory movement.
    • 75% strength of shoulder musculature compared to the uninvolved side.
    • Negative impingement tests (all are important).

    Post-operative Management of Arthroscopic Procedure: Minimal Protection Phase/Return to Function Phase

    • Similar to the final phase of non-operative management of primary impingement syndrome.

    Rotator Cuff Repair: Procedures

    • Arthroscopic, Open, or Mini-Open; depends on:
      • Severity and location of the tear.
      • Number of tendons involved.
      • Additional lesions to be repaired
      • Type of onset (repetitive versus traumatic)
      • Tissue and bone quality
      • Patient age, health, activity level
      • Surgeon expertise and preference.

    Full Thickness RTC Repair (Arthroscopic/Mini-Open): Post-Operative Management

    • Immobilization
      • Small tear: sling 1-2 weeks
      • Medium/Large tear: sling with or without abduction pillow 3-6 weeks
      • Massive tear: sling with or without abduction pillow 4-8 weeks
    • Abduction Pillow: reduces tension on repaired tendon.

    Full Thickness RTC Repair: Post Operative Management

    • Protocols are general guidelines (Box 17.8).
    • Communicate with surgeon about their protocol and whether adequate repair was achieved.
    • Obtain the operative report.
    • Listen to the patient.
    • Adhere to precautions and contraindications.

    Full Thickness RTC Repair: Exercise: Maximum Protection Phase

    • Control pain and inflammation.
    • Prevent loss of mobility in adjacent regions.
    • Restore shoulder mobility.
    • Prevent or correct postural deviations.
    • Develop control of scapulothoracic stabilizers.
    • Prevent inhibition and atrophy of the GH musculature.

    Full Thickness RTC Repair: Criteria to Progress to the Next Phase

    • Well-healed incision
    • Minimal pain with PROM (and assisted if indicated).
    • Progressive improvement in ROM.

    Full Thickness RTC Repair: Exercise: Moderate Protection Phase

    • Restore nearly complete or full, pain-free passive mobility of the shoulder.
    • Increase strength and endurance and re-establish dynamic stability of the shoulder musculature (important).

    Full Thickness RTC Repair: Caution

    • Vigorous stretching is NOT considered safe for 3-4 months post-operatively.
    • End range ER stretching for repaired subscapularis.
    • End range IR stretching for repaired supraspinatus and infraspinatus.
    • If open procedure: Initially avoid end range extension, adduction, and horizontal adduction.

    Full Thickness RTC Repair: Moderate Protection Exercise Phase.

    • Strengthen and increase endurance of cuff and scapular stabilizers before dynamically strengthening shoulder abductors and flexors.
    • Restore Deltoid/RC force couple.

    Full Thickness RTC Repair: Criteria to Progress Next Phase

    • Full, pain-free ROM
    • Progressive improvement of shoulder strength and muscular endurance.
    • A stable glenohumeral (GH) joint.

    Full Thickness RTC Repair: Minimal Protection/Return to Function Phase

    • Same as non-operative chronic phase RC goals.

    Review

    • Typical patient complaints with GH impingement
    • Appropriate exercises for subdeltoid bursitis, proximal bicipital tendonitis, or supraspinatus tendonitis during acute and subacute phases of healing.
    • Different stages of NEER RCT disease
    • Difference between partial and full-thickness RCT tear
    • What are the appropriate activities, active and passive movements that are limited 3 weeks after infraspinatus repair
    • What would be observed when inspecting the skin after a mini open repair?

    Outline

    • Structure and function of the shoulder girdle
    • Hypomobility: Non-operative management and TSA
    • Hypermobility: Instability of the GH joint
    • Painful biomechanical shoulder syndromes
    • Other joints of the shoulder( AC and SC joint)
    • Nerve pathology and referred pain

    AC Joint Pathology

    • Repeated stressful movements (horizontal adduction/abduction, overhead motions, combined diagonal patterns)
    • Examples include spiking volleyball and tennis serves
    • AC joint susceptible to overuse syndromes in conjunction with arthritis following traumatic injury
    • Clavicular fracture: fall or high-force event
    • Motor vehicle accident (MVA) is an example of this.

    AC Joint Impairments

    • Localized pain in involved joint or ligament
    • Painful arc during shoulder elevation
    • Pain during horizontal adduction or abduction
    • Hypermobility of joints if trauma or overuse is involved.
    • Hypomobility if sustained posture, arthritis, or immobility is present.

    AC Joint Pathology: Functional Limitations & Disabilities

    • Limited ability to sustain repeated forceful arm movements (e.g., grinding, packing, assembly, construction).
    • Inability to reach overhead or perform repetitive overhead activities without pain.

    AC & SC Joint Pathology: AC Joint Subluxation or Dislocation

    • Causes:
      • Direct fall against the shoulder
      • Fall onto an outstretched arm (FOOSH)
    • After trauma, treat as instability pathology.
    • AC and SC joint separations rarely require surgery unless there's cardiovascular or neural compromise.
    • Surgical fixation using wires, screws, sutures, or soft tissue grafts.

    AC Joint Separation Classification

    • Type I: Intact
    • Type II: Disrupted; widened in the transverse plane
    • Type III: Dislocated; clavicle displaced superiorly relative to the acromion

    AC Joint Separation Classification (Type I, II, and III)

    • Type I: Injury without tearing

    • Type II: Incomplete tear (AC capsule and ligaments torn, but no coracoclavicular ligament injury)

    • Type III: Complete rupture of AC and coracoclavicular ligaments; visible "step-off" deformity due to acromion depression

    • Describe conservative management for Types I, II & III (immobilization , ice, rest, ROM exercises, and NSAIDS).

    AC Joint Separation Grade II Rehabilitation

    • Acute phase: immobilization, ice, AAROM (active assisted range of motion) as tolerated within scapular setting.
    • Subacute phase: Restore full ROM, add strengthening activities including bench and military overhead press as tolerated.
    • Chronic phase: Progress to sport and occupational-specific activities.

    AC Joint Reconstruction Rehabilitation

    • Maximum Protection Phase (0-4 weeks): Protect the injury using a sling and firm pillow.
    • Moderate Protection Phase (4-12 weeks): Gradual return to motion, increasing strength using active assisted ROM and resisted IR/ER (0-90 degrees of elevation)
    • Minimum Protection Phase (12-24 weeks): Functional activity focus on sports and vocation specific activities.

    Review (Various Topics)

    • How does the focus of conservative shoulder instability management differ from hypomobility (e.g., arthritis and frozen shoulder)?
    • Common position of GH joint during dislocation
    • Affected tissues during GH dislocation
    • Initial protected motions after repair and treatment.
    • General guidelines for treating Grade II AC joint sprain.
    • Various musculoskeletal structures may be sources of shoulder pain.
    • Structures include nerves, and other associated anatomical features

    Common Sources of Referred Pain: Shoulder Region

    • C3, C4, C5 nerve roots and C3/4, C4/5 joint
    • C4 dermatome (trapezius)
    • C5 dermatome (deltoid, lateral arm)
    • Diaphragm
    • Heart (axilla, left pectoral region)
    • Gallbladder (tip of shoulder, posterior scapula region)

    Referred Pain

    • Upper extremity pain not from referral (e.g musculoskeletal).
    • Discussion with primary PT and possible referral to physician

    Nerve Disorders in the Shoulder Girdle Region

    • Thoracic Outlet Syndrome (TOS), Brachial Plexus
    • Suprascapular nerve compression (e.g., heavy shoulder bag)
    • Radial nerve compression (e.g., from crutches)

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