Painful Shoulder Syndromes (PTRP 2024) PDF

MODULE 2 THERAPEUTIC EXERCISE 2: ORTHOPEDIC PAINFUL SHOULDER SYNDROMES LECTURER: MR. JANSEN...

MODULE 2 THERAPEUTIC EXERCISE 2: ORTHOPEDIC PAINFUL SHOULDER SYNDROMES LECTURER: MR. JANSENN RAY D. DAVID, PTRP SOURCE: PPT PTRP 2024 IMPINGEMENT SYNDROMES Based on Progressive Microtrauma (Jobe’s Classification) Mechanical compression and irritation of the soft tissues Group 1. Pure impingement (usually in an older recreational (rotator cuff and subacromial bursa) in the suprahumeral space athlete with partial undersurface rotator cuff tear and Most common cause of shoulder pain subacromial bursitis) Pain with overhead reaching, a painful arc mid-range, and Group 2. Impingement associated with labral and/or Pain at a certain degree positive impingement tests capsular injury, instability, and secondary impingement Caused by excessive or repetitive overhead activities Group 3. Hyperelastic soft tissues resulting in anterior or SITS multidirectional instability and impingement (usually attenuated but intact labrum, undersurface rotator cuff tear) Group 4. Anterior instability without associated impingement (result of trauma; results in partial or complete dislocation) Based on Degree and Frequency Instability → subluxation → dislocation Acute, recurrent, fixed Categories of Painful Shoulder Syndromes Intrinsic Impingement (Rotator Cuff Disease) Based on Degree or Stage of Pathology of the Rotator Cuff (Neer’s Intrinsic factors are those that compromise the integrity of the Classification of Rotator Cuff Disease) **common*** musculotendinous structures: Vascular = blood supply Stage I. Edema, hemorrhage (patient usually 40 Extrinsic Impingement (Mechanical Compression of Tissues) years of age) Degenerative changes Extrinsic impingement is a result of mechanical wear of the rotator cuff against the anteroinferior one-third of the acromion in the Based on Impaired Tissue suprahumeral space during elevation activities of the humerus. Supraspinatus tendonitis Microtrauma – repetitive Infraspinatus tendonitis motions Bicipital tendonitis Superior glenoid labrum and/or biceps tendon instability Subdeltoid (subacromial) bursitis Other musculotendinous strains (specific to type of injury or trauma) Flexion and more of o Anterior – from overuse with racket sports (pectoralis abduction without ER minor, subscapularis, coracobrachialis, short head of biceps strain) o Inferior – from motor vehicle trauma (long head of triceps, serratus anterior strain) Primary Extrinsic Impingement Primary extrinsic impingement result from anatomical or Based on Mechanical Disruption and Direction of Instability or biomechanical factors. Subluxation 1. Anatomical factors: Bony spurs Multidirectional instability from lax capsule with or without Structural variations in the acromion or humeral head impingement Hyper trophic degenerative changes in the AC joint Unidirectional instability (anterior, posterior, or inferior) with Other trophic changes in the coracoacromial arch or or without impingement humeral head Traumatic injury with tears of capsule and/or labrum 2. Biomechanical factors: Insidious (atraumatic) onset from repetitive microtrauma Altered orientation of the clavicle or scapula during Inherent laxity movement Increased anterosuperior humeral head translation Special Tests May be d/t laxity of lig or atrophy or weakness 1. To confirm physician’s dx of mm 2. Rule out (prevent misdiagnosis) MARTINEZ, AMG. 1  Neer suggested that the size and shape of the structures that Anterior instability make up the coracoacromial arch are related to rotator cuff o occurs with force against the arm when it is in an impingement. abducted and externally rotated position, and it Variations of the acromion were identified and classified into frequently involves detachment of the anterior capsule three shapes: and glenoid labrum (Bankart lesion) o Type I: flat o Type II: curved > more common o Type III: hooked Posterior Instability o Result of a forceful thrust against a forward-flexed humerus or fall on an outstretched arm FOOSH Rotator cuff pathology is often associated with types II and III Secondary Extrinsic Impingement Mechanical compression of the suprahumeral tissues due to: o Hypermobility or instability of the GH joint – may be caused by laxity and sublaxation, weak musculatures o increased translation of the humeral head Internal Extrinsic Impingement Instability may be multidirectional or unidirectional and can Internal impingement occurs in a position of elevation, occur with: horizontal abduction, and maximum ER. o Compromised static restraints (GH ligaments) Mechanical entrapment of the posterior supraspinatus tendon o Dynamic rotator cuff insufficiency (force imbalances or between the humeral head and the labrum. fatigue) Associated with combination of posterior GH capsule § Imbalances brought by atrophy, tightness and scapula kinematic alterations. overworked/fatigued (training, etc.), tightness Mm imbalance = one is tight, one is weak 1. Multidirectional instability - athletes Physiologically increased connective tissue extensibility causing excessive joint mobility Increased extensibility allows larger than normal humeral head translations in all directions o Individuals involved in overhead activities develop laxity of the capsule from continually subjecting the joint to stretch forces Tendonitis Bursitis (Stage II Impingement Syndrome) A hypermobile GH joint may be supported by strong Supraspinatus Tendonitis rotator cuff muscles; but with muscle fatigue, poor Difficult to differentiate from subdeltoid bursitis humeral head stabilization leads to faulty humeral Painful arc with overhead reaching mechanics, trauma, and inflammation of the suprahumeral Pain with impingement tests and pain on palpation of the tissues. tendon Mechanical impingement of tissue in the suprahumeral Pain on palpation of the tendon space is a secondary effect of the increased humeral head translation. Secondary problems: o Impingement o Subluxation o Dislocation o Rotator cuff tendinitis o Bone spurs o Tendon rupture o Capsular restrictions and frozen shoulder Infraspinatus Tendonitis Instability - atrophy Painful arc with overhead, forward, or cross body motions 2. Unidirectional instability with or without Impingement (anything that involves horizontal adduction) Physiologically lax connective tissue It may present as a deceleration (eccentric) injury due to Result of trauma and usually involves rotator cuff tears overload during repetitive or forceful throwing activities Pain occurs with palpation of the tendon MARTINEZ, AMG. 2  Insidious Onset (Atraumatic Onset) No specific MOI Rupture/tear of tendon Rotator cuff tears à Stage III impingement syndrome Typically occurs in persons over age of 40 after repetitive microtrauma to the rotator cuff or long head of the biceps. Common Impairments Related to Painful Shoulder Syndromes 1. Impaired Posture and Muscle Imbalances Increased thoracic kyphosis, forward head, abducted and forward-tipped scapula à decreased suprahumeral space à irritation of rotator cuff tendons The pectoralis minor, levator scapulae, and shoulder Bicipital Tendonitis internal rotators are tight Long tendon of the biceps in the bicipital groove Lateral rotators of the shoulder and upward rotators of Pain occurs with Speed’s test and on palpation of the bicipital the scapula test weak Front mm – tight Back mm – weak groove 2. Decreased Thoracic ROM Decreased thoracic extension decreases the functional range of humeral elevation 3. Rotator Cuff Overuse and Fatigue Failure to provide the dynamic stabilizing, compressive, and translational forces that support the joint and control the normal joint mechanics 4. Neuropathies like long thoracic nerve palsy 5. Tight posterior capsule Increases anterior translation of the humeral head 6. Common Functional Limitations/Disabilities: When acute, pain may interfere with sleep Subacromial/Subdeltoid Bursitis Pain with overhead reaching, pushing, or pulling. When acute, the symptoms of bursitis are the same as those Difficulty lifting loads. seen with supraspinatus tendinitis Inability to sustain repetitive shoulder activities Once the inflammation is under control, there are no Difficulty with dressing, particularly putting a shirt on symptoms with resistance over the head. Other Impaired Musculotendinous Tissues Maximum Protection Phase Muscles subjected to microtrauma: Control Inflammation and Promote Healing 1. Pectoralis minor Patient Education on how to modify activities/motions that 2. Short head of biceps triggers pain/cause injuries; posture 3. Coracobrachialis Maintain Integrity and Mobility of the Soft Tissues o During racquet sports requiring a controlled Control Pain and Maintain Joint Integrity backward, then a rapid forward swinging of the arm. Develop Support in Related Regions 4. Scapular retractors (mid traps, rhomboids) o Functions to control forward motion of the scapula 1. Control inflammation and promote healing Modalities and low-intensity cross-fiber massage are Muscles that may be injured during MVA (motor vehicular applied to the site of the lesion. Prevents scar accidents) Not exercises < formation which could limits of motion d/t 1. Long head of the triceps inextensibility of the tissue 2. Scapular stabilizers (serratus ant, rhomboids, lev scap, trap) Immobilization using a sling. (not an exercise) o During MVA, the driver holds firmly to the steering wheel on impact 2. Maintain integrity and mobility of the soft tissues PROM, AAROM, Self-assisted ROM (pain-free range) Injury, overuse, or repetitive trauma can occur in any muscle Muscle setting à Multiple angle muscle setting (done being subjected to stress. in various ranges) Only to provide cxn to delay Pain occurs when the involved muscle is lengthened or when 6 SH x 10reps x 3 sets atrophy contracting against resistance. (mm isn’t fully healed yet) 3. Control pain and maintain joint integrity Palpation the site of the lesion causes the familiar pain. Pendulum exercises without weights (Codman’s Exercise) MARTINEZ, AMG. 3 4. Develop support in related regions 3. Develop Balance in Length and Strength if Shoulder Girdle Postural awareness and correction techniques (verbal Muscles cues ex. Paki-diretso po ang balikat, etc.) Stretching exercises for: Supportive techniques such as shoulder strapping or o Pectoralis major, Pectoralis minor scapular taping, tactile cues, and mirrors o Latissimus dorsi and Teres major o Subscapularis Management-Controlled Motion Phase o Levator scapulae Patient education à no signs of inflammation o Upper Trapezius à less pain To prevent hyperventilation Develop Strong, Mobile Tissues 15sh x 10 reps x 3 sets à to avoid disruption of healing Modify Joint Tracking and Mobility process “Active exercises” – with Develop Balance in Length and Strength if Shoulder Girdle breathing component Muscles Develop Muscular Stabilization and Endurance Progress Shoulder Function 1. Develop strong, mobile tissues Cross-fiber massage 6 SH x 10 reps x 3 sets Multiple angle isometrics Verbal and tactile cues to improve posture A. Clavicular Portion. B. Sternal Portion 2. Modify joint tracking and mobility Mobilization with movement Posterolateral glide upon shoulder elevation MARTINEZ, AMG. 4  For manual: 1. Ipsi hand at the back 2. Depress shoulder (ipsi of affected side) 3. Cervical rot to ipsi side 4. flex to contra side 15sh Stretching exercises for: o serratus anterior and lower trapezius o middle trapezius and rhomboids rotator cuff muscles c emphasis on shoulder ER Not usually w/ holds 4. Develop Muscular Stabilization and Endurance Progress Shoulder Function Closed chain stabilization Alternating isometrics of the scapular muscles in open- o Pt in weightbearing position while PT provides AI or chain positions All motions involved in the scapular mm RS Isometric or dynamic resistance to shoulder rotation Isometric resistance in scapular plane elevation Management-Return to Function Phase Open-chain stabilization exercises for the shoulder girdle Patient Instructions to Prevent Recurrences of Shoulder Pain Prior to exercise or work, massage the involved tendon or muscle; follow with isometric resistance and then with full ROM and stretching of the muscle. Take breaks from activities that are repetitive in nature. If possible, alternate the stressful, provoking activity with other activities or patterns of motion. Maintain good postural alignment; adapt seating or workstation to minimize stress. If sport related, seek coaching in proper techniques or adapt equipment for safe mechanics. Prior to initiating a new activity or returning to an activity for which not conditioned, begin a strengthening and training program. MARTINEZ, AMG. 5 1. Increase Muscular Endurance – more sets for endruance 2. Develop Quick Motor Reponses to Imposed Stresses 3. Progress to Functional Training 4. Progression of previous exercises Plyometric training, if possible For more advanced athletes Shoulder Dislocation Anterior Dislocation * Most common * MOI: Abd / ER INTEGRITY OF THE FOLLOWING STRUCTURES: o Subscapularis o GH ligament o Long head of biceps Posterior Dislocation MOI: Flexion, adduction, IR Inferior Dislocation – common for stroke pts Anterior Shoulder Dislocation (Management-Return to Function Rotator cuff weakness/paralysis No active mm cxn or atrophy Phase) (+) sulcus sign Strengthening exercises Because no stabilization from surrounding mms Coordination between scapular & arm motions Endurance exercises – increase sets Eccentric training Same approach for posterior dislocation except for: o the position avoided: FADIR o The joint glide avoided: posterior glide Recurrent Dislocation – pts with history of dislocation Anterior Shoulder Dislocation (Management-Protection Phase) Immobilization o > 3 Weeks for younger (6 to 8 weeks) o 2 weeks for older Protected ROM Muscle setting for rotator cuff, deltoid, biceps brachiI Grade II joint techniques*** Contraindication o Extension beyond zero degrees Protected ROM Anterior Shoulder Dislocation (Management-Controlled Motion Phase) MOBILIZATION techniques (except anterior glide) o Grade III distraction Isometric resistance exercises for IRs & ERs o Start with joint positioned at the side Partial weight-bearing and stabilization exercises Dynamic resistance exercise (dumbbells/ resistance bands) o Limit ER to 50º Isokinetic resistance exercise*** (machines eg. pulleys, etc.) MARTINEZ, AMG. 6