Therapeutic Exercise II | The Shoulder part 2 PDF

Therapeutic Exercise II PTA 1010 The Shoulder part 2 of 2  Outline RTC tears: Other Joints of the nonsurgical & Shoulder: surgical management AC joint & SC joint Nerve Pathology in...

Therapeutic Exercise II PTA 1010 The Shoulder part 2 of 2  Outline RTC tears: Other Joints of the nonsurgical & Shoulder: surgical management AC joint & SC joint Nerve Pathology in Referred Pain the Shoulder © Stanbridge University 2022 2  Road Map By the end of this section the student should be able to: Understand RTC tear injuries, associated impairments, functional limitations disabilities Effectively teach and progress/regress a therapeutic exercise program to manage a RTC non surgically Understand the surgical interventions of decompression and RTC repair and how to manage the post-operative therapy Understand the pathology of the AC and SC joints, along with common management of the condition and potential surgical interventions Understand the common site of referred pain to the shoulder Understand common site of nerve pathology in the shoulder © Stanbridge University 2022 3  Painful Shoulder Syndromes: Atraumatic RTC Tear Insidious tear following repetitive micro-trauma to long head of biceps or RTC Usually over 40 years of age Age: increased vulnerability due to impaired circulation, degenerative changes, and calcification *hypovascular area →especially distal portion of supraspinatus tendon © Stanbridge University 2022 4  Painful Shoulder Syndromes: Atraumatic RTC Tear Common Impairments: Impaired Posture: increased T/S kyphosis, forward head, anteriorly tilted scapula Muscle imbalances: (tight anterior structures) -Hypo-mobile: pectoralis minor and major, levator scapula, GH IR’s -Weak: serratus anterior and GH ER’s Hypo-mobile posterior GH capsule —> its tight so it just shoves & sits higher up causing impingement © Stanbridge University 2022 5  Painful Shoulder Syndromes: Atraumatic RTC Tear Common Impairments, continued Hypomobile C/S, or T/S: decreased T/S extension mobility *happens with overhead throwing Faulty kinematics during humeral elevation - decreased posterior tipping of scapula -scapular elevation and overuse of the upper trapezius -altered scapulohumeral and scapulothoracic rhythms © Stanbridge University 2022 6  Painful Shoulder Syndromes: Atraumatic RTC Tear IF full thickness supraspinatus tear: unable to abduct humerus against gravity without compensations © Stanbridge University 2022 7  Painful Shoulder Syndromes: Functional Limitations & Disabilities Acute pain: interferes with sleep; often unable to lie on that shoulder Pain with overhead reaching, pushing, pulling (when RTC need to stabilize shoulder head) Difficulty lifting loads Difficulty sustaining repetitive shoulder activities (swinging, reaching, throwing, etc.) Difficulty with dressing or bathing, especially putting T-shirt on overhead, reaching behind back, etc. © Stanbridge University 2022 8  Painful Shoulder Syndromes: Acute Phase Management Acute Phase- Compare/Contrast Box 10.1 Control inflammation, promote healing Patient education Maintain integrity and mobility of the soft tissues Address dysfunctions in related regions (treating above & below the area of injury) Box 10.3- Review signs of excessive stress © Stanbridge University 2022 9  Subacute Phase Management Subacute Phase: Compare/contrast Box 10.2 Goal: progressive nondestructive movement with proper mechanics while tissues heal —> stops before the compensation happens Direct intervention based on evaluation findings: If mobility is restricted: mobilize If mobility is excessive: gain neuromuscular control, stabilize scapula and glenohumeral joint - side of body - pt position - name of exercise - parameters w/ load or no load, level of theraband resistance, reps, & sets © Stanbridge University 2022 10  Chronic Phase Management Patient education Develop strong, mobile tissues (strength & mobility) Modify joint tracking and mobility MWM - helps w/ tracking Develop balance in length and strength of shoulder girdle muscles Develop muscular stabilization and endurance Progress shoulder function © Stanbridge University 2022 11  Chronic Phase Management Plyometric Exercise —> write time based parameters Chronic Phase Increase muscular endurance Develop quick motor responses to imposed stresses Progress functional training – Progress eccentric training – Simulate functional activities – Prevention instructions (Box 17.7) © Stanbridge University 2022 12 Eccentric Shoulder strengthening Exercises: WWW.HEP2GO.COM © Stanbridge University 2022 13  Surgery & Postoperative Management Subacromial Decompression (SAD) and postoperative management Rotator Cuff Repair and postoperative management © Stanbridge University 2022 14  Subacromial Decompression Also called: anterior acromioplasty or decompression (cutting part of acromion to improve rooms for tendons to acromioplasty glide to decrease compression) Increases the volume of the subacromial space to provide adequate gliding room for the tendons www.sgsc.net © Stanbridge University 2022 15  Excision (Resection) Arthroplasty Removal of periarticular bone from one or both articular surfaces Resect the edge of the acromion to increase volume of subacromial space Kisner & Colby Fig. 17.19 © Stanbridge University 2022 16  Subacromial Decompression: Post-operative Management Considerations: *RTC has bigger limitation over acromion repair —> dont stretch or contract RTC repaired muscles Whether or not RTC was intact preoperatively Whether concomitant RTC repair was performed: follow RTC repair guidelines Type of approach: arthroscopic, open, mini-open What tissue was affected by surgery? This will guide the rehabilitation © Stanbridge University 2022 17  SAD: Post-operative Management of Arthroscopic Procedure Exercise: Maximum Protection Phase: Control pain and inflammation Prevent loss of mobility of adjacent regions Develop postural awareness and control Restore pain-Free shoulder mobility Prevent reflex inhibition and atrophy of the shoulder girdle musculature © Stanbridge University 2022 18  SAD: Post-operative Management of Arthroscopic Procedure Criteria to Progress to 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 to above shoulder level Pain free AROM ER to about 45 degrees Minimum of 3/5 muscle testing grades © Stanbridge University 2022 19  SAD: Post-operative Management of Arthroscopic Procedure Exercise: Moderate Protection Phase Often starts at 4-6 weeks following surgery, but may occur earlier Goals: 1. Full, pain free shoulder ROM passive ROM 2. Improve neuromuscular control 3. Improve strength and endurance © Stanbridge University 2022 20  SAD: Post-operative Management of Arthroscopic Procedure Exercise: Moderate Protection Phase Restore full pain-free PROM of the shoulder girdle and upper trunk Reinforce postural awareness and control Develop dynamic stability, strength, endurance, and control: Scapulothoracic and GH muscles © Stanbridge University 2022 21  SAD: Post-operative Management of Arthroscopic Procedure Criteria to Progress to Next Phase: Full pain free AROM without compensatory movement 75% strength of shoulder musculature compared to uninvolved side Negative Impingement tests —> retest impingement test If positive, there might still be swelling © Stanbridge University 2022 22  SAD: Post-operative Management of Arthroscopic Procedure Exercise: Minimal Protection Phase/Return to Function Phase: Same as final phase of non-operative management of primary impingement syndrome © Stanbridge University 2022 23 www.onsmd.com www.orthoneuro.com ROTATOR CUFF REPAIR © Stanbridge University 2022 24  General Surgical Considerations When a muscle/tendon has been repaired, reattached or resected at reattached initially you CANNOT: *no isometric exercise Stretch that muscle: pulls on attachment NO PASSIVE STRETCH opposite of the action of the muscle repaired Contract that muscle: also pulls the attachment NO ACTIVE motion of the muscle that was repaired © Stanbridge University 2022 25  Rotator Cuff Repair: Indications and Depth Pain, impaired function, failed conservative care Partial thickness tear:extends superiorly or inferiorly through only a portion of the tendon Full thickness tear: extends entire depth of tendon www.shoulderdoc.co.uk © Stanbridge University 2022 26  Rotator Cuff Tears: Size of width *would have different protocol based on the size of the tear Small: 1 cm or less Medium: 1-3 cm Large: 3-5 cm Massive: > 5 cm or full thickness tear © Stanbridge University 2022 27  Tendon Repair Location: Tendons tend to rupture at musculotendinous junctions or tendo-osseous junctions *where the change happen: insertion or origin Causes of tendon tear: Young person: usually due to trauma Older person: progressive deterioration of a tendon (i.e. with history of chronic impingement) Chronic tenosynovitis (RA) *both tendon & synovial lining have inflammation © Stanbridge University 2022 28  Tendon Repair- To operate or not operate? Rotator Cuff Disease Chronic FT-RCT Acute Tears Tendinopathy PT- >60 yo Chronic FT-RCT RCT- small tears Initial non-operative 20 kg 10 times/day; tools >1kg (2.2lbs) Repetitive movements >2hr/day Low job control and social support © Stanbridge University 2023 62 Lateral Elbow Tendinopathy (Tennis Elbow) Positive tests of provocation: TTP on or near lateral epicondyle Pain with resisted wrist extension with elbow extended Pain with resisted middle finger extension, performed with elbow extended Pain with passive wrist flexion with elbow extended and forearm pronated © Stanbridge University 2023 63 Medial Elbow Tendinopathy www.drgordongroh.com © Stanbridge University 2023 64 Medial Elbow Tendinopathy (Golfer’s Elbow) Involves the common flexor/pronator tendon near the medial epicondyle Associated with: Repetitive movements into wrist flexion: Swinging golf club Pitching a ball Work related- grasping shuffling papers Lifting heavy objects Ulnar neuropathy is often an associated finding © Stanbridge University 2023 65 Medial Elbow Tendinopathy (Golfer’s Elbow) Etiology van Rijn et al 2009 Handling loads >5kg (2x/min at min 2 hrs/day) (1kg = 2.2 lbs; 5kg x 2.2= 11lbs) Handling loads > 20 kg at least 10x/day High hand grip forces >1hr/day Repetitive movements >2 hr/day Working with vibrating tools > 2 hrs/day © Stanbridge University 2023 66  Golfer’s Elbow Excessive strain to the medial elbow with impact with the ball www.howardsgolf.com © Stanbridge University 2023 67  Pitching Excessive Stress to the Medial Elbow www.bostonglobe.com © Stanbridge University 2023 68 Tennis: Stress to the Medial Elbow www.improve-your-tennis.com www.woman.thenest.com © Stanbridge University 2023 69 Medial Elbow Tendinopathy (Golfer’s Elbow) Positive Tests of Provocation: TTP on or near medial epicondyle Pain with resisted wrist flexion performed with the elbow extended Pain with passive wrist extension performed with elbow extended © Stanbridge University 2023 70 Overuse Syndromes: Repetitive Trauma Syndromes Etiology of symptoms: Excessive repetitive use or eccentric strain of the wrist or forearm muscles (lateral or medial) Microdamage and partial tears near the MT junction where strain exceeds the strength of the tissues (OR) when demand exceeds the repair process © Stanbridge University 2023 71 Overuse Syndromes: Repetitive Trauma Syndromes Etiology of symptoms: Initially: inflammation followed by formation of granulation tissue and adhesions With continued trauma: fibroblastic activity and collagen weakening Recurring problems: immature scar is re-damaged due to too-early return to activity/insufficient healing © Stanbridge University 2023 72 Overuse Syndromes: Common Impairments Gradually increasing pain in the elbow after excessive activity of the wrist and hand Pain when the involved muscle is stretched or contracts against resistance Decreased muscle strength & endurance for the demand Decreased grip strength, limited by pain TTP at site of inflammation: lateral or medial epicondyle, head of radius, muscle belly, etc. © Stanbridge University 2023 73 Overuse Syndromes: Common Functional Limitations & Disabilities Inability to participate in provoking activities: racket sports, throwing, or golf Difficulty with repetitive forearm/wrist tasks: -sorting or assembling small pars -typing, use of computer mouse -gripping activities -using hammer, screwdriver -shuffling papers -playing an instrument © Stanbridge University 2023 74  Non-operative Management of Overuse Syndromes Acute Phase Decrease Pain, Inflammation, Edema, Spasm Immobilize: cock up splint- fingers & elbow free to move (if lateral tendinopathy) Corticosteroid injection Develop Soft Tissue & Joint Mobility Wrist isometrics starting in a shortened position, neuro-mobilization, cross friction massage Maintain Upper Extremity Function Resistive exercises: shoulder and scapula ROM and stabilization exercises with resistance applied proximal to the elbow © Stanbridge University 2023 75 Non-operative Management: Overuse Syndromes Subacute and Chronic Phases Increase Muscle Flexibility & Scar Mobility Restore Joint Tracking at the RU joint Improve Muscle Performance and Function Counterforce elbow sleeve or strap: for lateral epicondylitis Eccentric training Olaussen et al, 2013, Cullinane et al, 2013 Plyometrics Patient Education Reduction of overload forces and prevention/recognition of provoking factors © Stanbridge University 2023 76 Overuse Syndrome: Example of how to reload the muscle for lateral epicondylitis Initiate with Gentle Isometrics Start with muscle in shortened position: wrist in extension Progress into neutral and into further tension (flexion) Active ROM: full ROM Add weight slowly, isolated movement Progress into eccentric loads Progress into functional loads/patters © Stanbridge University 2023 77  Olecranon Bursitis “Liquid Elbow “; "elbow bump“; "student's elbow“; "Popeye elbow", or "baker's elbow Causes: Hard blow to tip of the elbow repeated leaning on the point of the elbow on a hard surface www.sciencedirect.com Treatment: ✓ RICE ✓ Cortisone ✓ Draining bursa ✓ Possible resection www.handandwristinstitute.com © Stanbridge University 2023 78 Example of Activities in the Subacute Phase © Stanbridge University 2023 79 Kisner & Colby Figure 18.7 A: Stretch to increase extension B: Self Stretch of biceps to increase elbow extension Forearm pronation is necessary to stretch the bicep © Stanbridge University 2023 80  Triceps Stretch to increase elbow flexion Two joint muscle, move one joint at the time: 1) Bring shoulder into end range flexion. 2) Next bring elbow into end range flexion to obtain a full stretch position © Stanbridge University 2023 81  Self Stretch: To Increase supination pressure must be on distal radius NOT hand Consider modification to include self distal RU joint mobilization © Stanbridge University 2023 82 Bicep Curl 2 joint muscles are strong in mid range Concurrent shoulder extension with elbow flexion improves optimal length tension throughout a greater ROM Consider needs of patient ▪ Do you want one end to remain stationary? ▪ What position of the forearm is important? © Stanbridge University 2023 83  Supination/Pronation Watch for shoulder IR/ER; wrist flexion/extension compensation Kisner & Colby Figure 18.13 © Stanbridge University 2023 84  Bar Roll Ups/Downs Wrist Flexion/Extension Consider compensation with upper traps Stabilize forearm with other hand © Stanbridge University 2023 85 Joint Hypomobility Non-operative Management: Chronic Phase Improve muscle performance Restore functional mobility of joints and soft tissues Promote joint protection Return to function- work, sport, etc. © Stanbridge University 2023 86 Closed Chain and Functional Strengthening Exercises © Stanbridge University 2023 87 Tennis Swing Simulation: Forehand and Backhand Swings © Stanbridge University 2023 88 Review What are the different overuse elbow and forearm pathologies? What is the difference between tendonosis and tendonitis? What are the common impairments associated with overuse pathologies of the elbow and forearm? What is the non operative management for each phase of tendinosis? © Stanbridge University 2023 89  PTA Lab II- TE II portion week 7- Elbow and forearm Lab activities: 1. Review billing and exercise (see attached document) as it applies to the case study 2. Review the shoulder and elbow case studies in an open thought process 3. Review exercises as they apply to the case studies Billing application: Margaret is a 45-year-old female who has had RA for 10 years. She presents to therapy for a HEP to help her with activities such as grooming her hair, opening a jar, and turning her key in her front door. Her left shoulder and right elbow have been affected by bouts of RA with hypomobility limiting her functional use of the UE’s for heavy and/or repetitive tasks. Her grip strength on the right is 15 lbs and on the left, 30 lbs. She has a mild swan neck deformity on the right 4th digit that started to develop about 6 months ago. The patient is in subacute phase when she sees the PTA for today’s visit. She has no pain at rest but has pain after 10 minutes of activity with the hands. POC: Treat 2x/wk. for 4 weeks. Treatment will include Ther. ex, therapeutic activities, neuromuscular re- education, manual therapy including manual stretching, STM, and Ice and Heat as needed. Goal is a treatment that totals 45-60 minutes. AROM/PROM Right Left Shoulder flexion 170°/170° elastic 145°/150° abnormal capsular Shoulder external rotation 80°/80° 65°/65° abnormal capsular Elbow flexion 120°/120° abnormal capsular 150°/150° Elbow extension -35°/-35° abnormal capsular -5°/-5° Forearm pronation 40°/40° elastic 75°/75° Forearm supination 40°/50° elastic 75°/75° Documentation: Pt. positioning Side of body: (R), (L), (B) Exercise/Activity Load Set + Reps Frequency (for HEP) Exercises (97110) à targeting impairment Activity Goal: Supine LLLD (L) GH flexion w/ 2# cuff wt. 1x5’ Seated (R) self-stretch into pronation & supination x60’ each Therapeutic Activities (97350) à functional activity Activity Goal: (B) standing forward cone reaching in eye level 1  PTA Lab II- TE II portion week 7- Elbow and forearm (R) seated level 2 putty power grip x3’ Manual treatment (STM, manual stretching, manual resistive exercise) (97140) Activity Goal: PNF HR to increase (R) supination x 3 cycles (last stretch 60”) AP GH jt. (L) gd. III 2x60” Neuromuscular re-education (97112) à Kinesthetic awareness, Proprioception, Balance, & Posture Education Activity Goal: Billing Codes: Can bill up to 4 codes 1 code = 8’ to 15’ 2 codes = 15 + 8 = 23’ + 7’ = 30’ o 23’ to 30’ Lab activity 2- open thought case studies Read each of the cases below. Highlight things that are notable in the paragraph and any impairments seen in the Rom chart. Write in the large box below all the thought that come to mind regarding treatment of this patient. What do you want to assess based on the statements found? What exercises do you want to do with the patient? What manual treatment would be appropriate? Case #1- shoulder à frozen phase Dustin is a 45-year-old male presents to the outpatient clinic with a diagnosis of adhesive capsulitis of the right shoulder. He reports stiffness in the shoulder, with a tight sensation at the end of range. He can perform most of his work functions, but he has difficulty reaching overhead. He reports that he no longer has pain with resting the arm at his side, but that with moving the arm (reaching, lifting) causes pain rated 5/10 and it will increase to 8/10 if he continues his activity. Observation revealed limited upward rotation of the scapula with the scapula resting in an anterior tilt à stretch pec minor bc inserts at the coracoid process of scapula when sitting with a moderate forward head posture. Dustin reports that he has started to get headaches after sitting at the desk at work. Left UE with full strength and ROM. Shoulder AROM/PROM Right Flexion 150°/155° *abnormal capsular Extension 48°/55° elastic Abduction 140°/145° *abnormal capsular Internal rotation at 90° abd. 55°/55° *abnormal capsular 2  PTA Lab II- TE II portion week 7- Elbow and forearm External rotation at 90° abd. 53°/53° *abnormal capsular *for patients that will need LLLD for multiple motions: do the most limited motion OR the most functionally needed *Gross MMT are listed/documented as the motion & body part (EX: Gross MMT shoulder flexion) Limited Upper Rot: Tight – Lev. Scap Weak – L.T & SA Anterior Scapular Tilting: Tight – Pec minor Weak- LT T/S Kyphosis: tight – pec major, UT, LS, Scalenes, SCM Weak -MT, Rhomboids, LT Forward Head: tight – Suboccipital, LS, UT, Scalenes weak – deep neck flexors Case #2- Elbow Vince is a 37-year-old avid golfer, playing 3x week and going to the range 1-2 other days of the week. He began experiencing left medial elbow pain after a full round of golf about 8 months ago. He took off 2 months from the sport and had relief of pain. He returned to golfing 2 months ago playing 2 x week and the pain returned. He loves the sport and does not want to stop playing, so he is now golfing 9 holes 1 a week and hitting a bucket of balls 1 other day a week. He does not have any swelling or pain at rest but has pain that increase to 4/10 after hitting the golf ball. He presents to physical therapy to address his restrictions and to find ways to manage his symptoms so he can continue to play. Motion AROM/PROM MMT Right Left Right Left Wrist flexion Full and pain free 70°/80° 5/5 4-/5 in avail ROM Wrist extension Full and pain free 58°/58° *elastic 5/5 4+/5 Pronation Full and pain free 80°/80° 5/5 4/5 Supination Full and pain free 70°/70° 5/5 5/5 Thoughts: 3