Shoulder Notes PDF

Shoulder – Notes 2025-01-10 8:31 AM Module Learning Objectives: Describe action of major muscles relevant to the joint; at a minimum, all muscles listed on the Anatomy Review Sheet for the module Perf...

Shoulder – Notes 2025-01-10 8:31 AM Module Learning Objectives: Describe action of major muscles relevant to the joint; at a minimum, all muscles listed on the Anatomy Review Sheet for the module Perform accurate anatomical palpation of major muscles relevant to the joint; at a minimum, all muscles listed on the Anatomy Review Sheet for the module Perform manual muscle test of major muscles relevant to the joint; at a minimum, all muscles listed on the Anatomy Review Sheet for the module Perform full range of motion assessment for the joint complex Describe closed pack position and capsular pattern of restriction of the joint(s) Describe arthrokinematics and understand joint mobilisation theory for the glenohumeral joint and the sternoclavicular joint Describe function of major structural ligaments (coracohumeral, transverse humeral, acromioclavicular ligs, coracoclavicular complex) Describe function of joint capsule and accessory structures (bursae, glenoid labrum) Describe scapulohumeral rhythm Describe scapula malposition and muscles responsible for malposition (see SICK scapula) Describe 3 force couples of shoulder function Describe passive stability of the GH joint Describe active stability and compromised stability of the GH joint Describe 3 ways to provoke musculotendinous tissue in assessment Describe all special tests (indication, procedure, positive finding, explanation of results) in special tests document Perform all special tests in special tests document using full NEER protocol Describe definition, affected tissue, signs and symptoms of tendonitis, bursitis, impingement, shoulder instability, AC separation, adhesive capsulitis Describe treatment plan (key questions, physical assessments, clinical impression and approach to treatment, precautions, and home care) for impingement syndrome, shoulder instability, adhesive capsulitis, general tendinopathy and general muscle strain through all stages of healing Perform indicated treatment (intake, treatment, home care) for impingement syndrome, shoulder instability, adhesive capsulitis, general tendinopathy and general muscle strain through all stages of healing Perform joint mobilisation for the sternoclavicular joint Section 1 - Anatomy: Glenohumeral Joint: Joint Type Synovial, ball & socket Articulating Surfaces Head of the humerus: Situated medial, slightly posterior, and superior Glenoid Fossa of Scapula: Laterally, forward, and superiorly – pear shaped – narrow superiorly and wider inferiorly Capsular Strength/Coaptation Weak and lax Inferiorly – at the inferior axillary pouch Ligaments 1. Superior/Middle/Inferior GH Ligament Anterior thickening/reinforcement - checks for External rotation Middle GH ligament limits lateral rotation up to 90 degrees abduction and important anterior stabilizer Inferior GH ligament thickest and strengthens anterior-inferior to prevent anterior subluxation & dislocation 2. Coracohumeral Ligament Strengthens superior capsule – checks gravity 3. Transverse Humeral Ligament Holds long biceps tendon in groove Rupture = unstable biceps tendon Extras The dynamic ligaments Tendons from the rotator cuff muscles blend w/ fibres of the joint capsule The Glenoid labrum surrounds and deepens the glenoid cavity of the scapula and allows for a better articulation Acromioclavicular Joint: Joint Type Synovial, modified gliding Articulating Surfaces Medial surface of acromion incomplete articular disc acromion facet of clavicle Due to its joint orientation a strong compression force = clavicle overrise acromion – AC separation Capsular Strength/Coaptation Weak and lax Ligaments 1. Superior/Inferior Acromioclavicular Ligament Prevents AC separation 2. Coracoclavicular Complex 1. Trapezoid Ligament (horizontal) - more LATERAL Checks excessive lateral movements 2. Conoid Ligament (vertical) - more MEDIAL Checks excessive superior movement and widening of scapuloclavicular angle Extras Incomplete intra-articular disc Dangling from superior part of inside the synovial joint capsule Sternoclavicular Joint: Joint Type Synovial, modified gliding Articulating Surfaces Clavicular notch of manubrium ---> sternal end of clavicle Capsular Strength/Coaptation Weak and lax – inferiorly Ligament 1. Anterior/Posterior Sternoclavicular Ligament Stabilizing 2. Interclavicular Ligament Checks excessive medial movement 3. Costoclavicular Ligament Checks elevation w/ medial movement & elevation w/ lateral movement Extras Complete intra-articular disc Helps prevent medial separation Glenohumeral Joint: Osteokinematics 3 degrees of freedom: Flexion – Extension Abduction – Adduction External rotation – Internal rotation Arthrokinematics Head of humerus – convex Glenoid fossa – concave Resting Position 55 – 70 degrees abduction & 30 degrees horizontal adduction Closed Packed Position Full abduction & external rotation Capsular Pattern of Restriction ER > AB > IR ROM & End feel Flexion – 180 degrees; firm Extension – 60 degrees; firm External rotation – 90 degrees; firm Internal rotation – 70 degrees; firm Abduction – 180; firm/hard Horizontal abduction – 45; firm Horizontal adduction – 135; firm/soft Acromioclavicular Joint: Osteokinematics 3 degrees of freedom: Elevation – Depression Protraction – Retraction Anterior rotation – Posterior rotation Arthrokinematics Acromion – concave Acromial end of clavicle – convex Resting Position Arm by side Closed Packed Position Arm abducted to 90 degrees Capsular Pattern of Restriction Full elevation with associated pain ROM & End feel Elevation/Depression - 30 degrees Protraction/Retraction - 50 degrees Rotation – 50 Degrees All motions have a capsular firm end feel Sternoclavicular Joint: Osteokinematics 3 degrees of freedom: Elevation – Depression Protraction – Retraction Anterior rotation – Posterior rotation Arthrokinematics Clavicular notch of manubrium Ant/Post - convex Sup/Inf - concave Sternal end of clavicle Ant/Post - concave Sup/Inf - convex Resting Position Arm by side Closed Packed Position Arm maximally elevated Capsular Pattern of Restriction Full elevation associated w/ pain ROM & End feel Elevation/Depression - 15 degrees Protraction/Retraction - 10 degrees Rotation – 50 degrees All motions have a capsular firm end feel Joint Mobilization: Sternoclavicular Joint Inferior/Superior Facets Convex on Concave Arthrokinesiology Roll SUPERIOR Glide INFERIOR Anterior/Posterior Facets Concave on Convex Arthrokinesiology Roll POSTERIOR Glide POSTERIOR Scapular Plane: Requires 20 degrees of horizontal adduction Scaption – Horizontal abduction in frontal plane Movement of the arm in scapular plane = scaption Really good area for muscle balance of all shoulder rotator cuff muscles Section 2 - Biomechanics: Joint Stabilization While the other joints of the body rely on their ligaments and joint capsules to maintain joint congruency and stabilization during movement, the shoulder joint capsule is relatively lax and must rely on muscles for active stabilization In addition, although minimal, the shoulder joint capsule does provide some passive stability if the joint is correctly oriented Shoulder Passive Stability When the arm hangs freely to the side (at neutral) 3 things that provide this stability: 1. Glenoid fossa – lip that faces superiorly, anteriorly, and laterally 2. Superior glenohumeral ligament – resist force of gravity on arm 3. Coracohumeral ligament – resist force of gravity on arm This is achieved b/c the superior joint capsule and coracohumeral ligament are usually taut creating an opposing force to the vertical weight of the humerus This causes the pull the head of the humerus against the upward facing glenoid cavity Shoulder Active Stability When the shoulder is raised in any plane away from the side of the body, the superior joint capsule becomes lax It is the responsibility of rotator cuff to maintain dynamic congruency and stabilization Compromised Stability: Two conditions 1. Excess Thoracic Kyphosis Situates the scapula in a downward rotation This takes away the stabilizing 'lip' of the glenoid fossa and places the humerus into a pseudo-abduction in reference to the newly positioned scapula The normally taut superior joint capsule and coracoacromial ligaments become lax Dynamic ligaments (rotator cuff) take over with ACTIVE stabilization This may lead to impingement syndrome because of the constant, increased tone in the rotator cuff group 2. Muscle Paresis Paresis – partial paralysis Weakness or imbalance may cause the scapular muscles to orient the scapula in the same forward rotation as thoracic kyphosis Depending on the severity of the muscle paresis, inferior dislocation or subluxation may occur if the rotator cuff muscles are affected Usually a neurological injury leading to this GH Joint Capsule & Movement: The fibers of the GH joint capsule face anteriorly and medially As the arm abducts this twist in the joint capsule increases and pulls the head of the humerus into the glenoid cavity This increasing tension furthers abduction b/c the medial fibers become taut This causes the capsule to pull the humerus into external rotation – untwisting of the joint capsule Allows for further abduction b/c the external rotation also helps to prevent the greater tubercle from colliding with the acromial arch The joint capsule is important in facilitating lateral rotation GH Force Couples: 1. Deltoid & Rotator Cuff Deltoid wants to pull up and out Rotator cuff pulls down and in This causes centration (correct alignment) of humeral head in glenoid fossa 2. Serratus Anterior & UT Work together to allow upward rotation of the scapular during abduction and other arm movements 3. Long Head of Biceps Tendon When the arm is laterally rotated acts as a pully that depresses the humeral head to keep it centrated in the glenoid fossa Abduction Biomechanics: 1. Scapulohumeral Rhythm 2. Clavicle – SC & AC – Movement 3. Axial Skeleton Movement Scapulohumeral Rhythm: Phase 1 0 – 30 degrees abduction First 30 degrees "scapular setting": is performed by the GH Scapula is stabilized against the thorax and has minimal or no movement – the scapula does not move; therefore, there is no ratio of scapulohumeral rhythm 0-5 degrees clavicular elevation Phase 2 30 – 90 degrees abduction Next 60 degrees of elevation At about 40 degrees of humeral angulation the scapula begins to rotate (20 degrees) and there is a 2:1 scapulohumeral rhythm The clavicle continues to elevate (15 degrees) Phase 3 90 – 180 degrees abduction Last 90 degrees of elevation There continues to be a 2:1 ratio of scapulohumeral movement In this final stage the clavicle elevates and rotates posteriorly (b/c of the pull on the conoid ligament) and the humerus laterally rotates 90 degrees to clear the acromial arch In addition to movements of the scapula, humerus, and clavicle, full 180 degrees abduction requires small movements from upper thoracic spine & lower thoracic spine vertebrae, the manubrium, and the first rib Reverse Scapulohumeral Rhythm: This is when the scapula moves more than the humerus with abduction The client tends to hike the shoulder upward to achieve movement This is often indicative of frozen shoulder If you observe the scapula move in the 1st 30 degrees of abduction, this too is often indicative of frozen shoulder When the shoulder capsule is inflamed or fibrosed, it loses its extensibility When the arm begins to move, instead of the capsule extending to allow the arm to move and the scapula to stay put, the fibrosed capsule drags the scapula upwards with the arm movement, even in the first 30 degrees Clavicle – SC & AC – Movement: The sternoclavicular joint is between the sternal facet of the clavicle and the clavicular notch of the manubrium The clavicle moves on the manubrium The sternal facet of the clavicle has an 'apple core' shape The anterior-posterior aspects are concave When the clavicle moves anterior or posterior – as happens in protraction/retraction - the joint is moving as concave on convex The arthrokinematic movement (glide) is the same direction as the osteokinematic movement Protraction requires anterior glide; retraction requires posterior glide The superior-inferior aspects are convex When the clavicle moves inferior or superior – as happens in abduction/adduction - the joint is moving as convex on concave The arthrokinematic movement (glide) is in the opposite direction as the osteokinematic movement Abduction requires inferior glide; adduction requires superior glide Axial Skeleton Movement For full abduction, you need to make sure the thorax (T-spine) is also functioning properly If patient has hyperkyphosis – they might not be able to fully abduct the arm Observation: Step Deformity At the distal end of clavicle Indicative of a separation Sulcus Sign A 'sagging'/'flattening' below the acromion process where a rounded deltoid muscle would be Indicative of a dislocation or deltoid paralysis/atrophy Mal-alignment of clavicle Often due to fractures Scapular 'winging' When the medial border moves away from the posterior chest wall (not away from the spine) Dynamic winging This is indicative of serratus anterior injury or a compromised long thoracic nerve, possible imbalance or strain to the rhomboids or upper trapezius Static winging This is indicative of structural deformity of the scapula, clavicle, spine, or ribs Scapular 'tilting' This is when the superior or inferior angles tilt away from the chest wall This is also indicative of weakness and instability (posterior muscles) or tightness of pec minor (very common) Painful Arc The first 45 – 60 degrees of abduction is painless b/c there is no pinching under the acromial arch Abduction of 60 – 120 degrees causes the structures to become pinched and abduction may cease or be painful If abduction continues, pain diminishes after 120 degrees because the pinched structures have passed under the acromion process and are no longer pinched The pain may return in the last 10 – 20 degrees of abduction indicating possible impingement (general pain) Indicating AC/SC joint involvement (specific pain) aka. acromioclavicular painful arc Apley's Scratch No really an orthopedic test, this is more like a quick function scan Section 3 - Common Conditions: Tendons Tendonitis (Tendinopathy) Definition This is an overuse injury that causes inflammation to the tendons involved in repetitive movements Etiology Commonly SITS muscles (though rarely teres minor) & biceps brachii MOI Repetitive upper limb (especially overhead) movements Swimming Throwing sports Volleyball Golf Occupations that require repetitive movements Dry walling Painting Signs & Symptoms In general, provoked by: Contraction against resistance (strengthen) - RROM/MMT of that muscle Stretch/elongation (lengthen) - AROM in opposite movement of that muscle Palpation – the site of tissue damage; the origin, the insertion Referral pain at lateral brachial region (supraspinatus) or anterior brachial region to the insertion of the biceps (bicipital, never supraspinatus) Note: pain referred below elbow is very rarely due to GH joint injury – more likely nerve entrapment Sleep disturbance if pt sleeps on affected side Soft tissue swelling, atrophy, redness Pain with palpation of the tendon Supraspinatus Tendinopathy The supraspinatus is a dynamic ligament and is therefore being constantly challenged to maintain stability and congruency of the joint It experiences repetitive movements and strain through: 1. Sports or other activities (abduction and flexion) 2. Postural changes (kyphosis) causing the rotator cuff to undergo fatigue & stress from constant use The rotator cuff has poor vascularity especially the supraspinatus and infraspinatus muscles Hypovascularity > poor nutrition and repair > degenerative changes > inflammation > scar tissue > calcification > tear Age, overuse & abuse may lead to impingement syndrome, bursitis, or adhesive capsulitis Bicipital Tendonitis The biceps acts as a humeral stabilizer and elbow decelerator Tenosynovitis may develop with continued compression of the biceps tendon in the bicipital groove Inflammation may adhere tendon to groove decreasing the gliding motion Continual cortisone injections may cause weakening of the tendon therefore if repetitive movements continue a rupture of the biceps long head may occur (usually proximal to distal) If the transverse humeral ligament is torn or if the bicipital groove is compromised – subluxation of tendon out of groove Calcific Tendonitis This occurs in the later stages of rotator cuff tendonitis (especially in the supraspinatus tendon) Fibroblasts change to chondrocyte and calcified deposits fill up the intercellular spaces of tendons causing an increase in size As the tendon grows bigger, this may lead to impingement under the acromial arch This condition is now though to be a self-healing mechanism The deposits are eventually reabsorbed (self-limiting) During this time there is increased circulation, inflammation, swelling and pain; may lead to complications like tendon rupture Bursitis may commence if the calcium deposits rupture into the bursa Calcific tendonitis is confirmed with an x-ray Don’t want to do any specific work on these areas – usually chronic when it shows up Lots of pain and if there is burning pain – red flag/bad sign Shoulder Tendinopathy – Special Tests: Speed's Testing the bicep tendon for bicipital tendonitis Positive – localized pain in the anterior shoulder where the bicep tendon is Empty Can Testing for supraspinatus (impingement) Do it in the scapular plane Positive – pain or pinchy sharp pain in the subacromial space Drop Arm Testing for supraspinatus strain Positive – if patient cant actively control the movement or the arm drops Lift off sign Testing for subscapularis strain Positive – notable weakness (unable to lift arm off of back) or pain Tendonitis-Bursitis Differentiation test Differential diagnosis for supraspinatus strain vs/ subacromial bursae Tendinopathy Treatment: Acute Rest and ice Decrease inflammation Reduce HT in affected mm's, TrPs Maintain available ROM Decrease pain Compensatory areas Chronic Break & build Decrease restrictions/adhesions Muscle tone, TrPs Friction therapy if needed Mobilize hypomobile joints Stretch to maintain new length of functional scar RROM to help realign fibers and return strength Increase circulation and decrease edema in the shoulder Strengthen Precautions and CI's: Calcific tendonitis to the supraspinatus tendon Tenosynovitis of the bicipital tendon Anti-inflammatory medication Common Conditions: Bursae Bursitis: This is the inflammation of the bursa In the shoulder there are 8 to 9 present but only 2 have clinical significance Subacromial (aka subdeltoid) bursa - this bursa is situated on top of the supraspinatus muscle (tendon and belly) and underneath the acromion and deltoid muscle As a result of this positioning, this bursa is susceptible to impingement by the acromial arch especially when inflamed or affected by a calcified supraspinatus tendon Subscapular bursa – this bursa lies over the anterior joint capsule and under the subscapularis tendon As a result of lying atop the articular joint capsule, joint effusion may be apparent because of inflammation of the bursa Etiology Usually secondary to other conditions like calcific tendonitis Overuse of the structures surrounding the bursa > excessive friction upon bursa > inflammation of bursa Contributing factors include: Repetitive movements Poor biomechanics/technique in sport Muscle imbalance Postural changes and a lack of flexibility Trauma (blunt force or FOOSH), infection (from a needle) Pathologies (arthritis) may also cause bursitis Signs & Symptoms Pain over the lateral brachial region (sometimes referred below elbow – acute) Pain may affect sleep especially if bursa is compressed Acute Inflammation, heat and swelling, pain is deep, constant, intense Burning and present at rest and with activity Onset is sudden over 12 – 72 hours and builds Severe debilitation lasting for 2 weeks Chronic Pain is more localized and expressed with activity or direct compression Other conditions may be present eg. - tendonitis Protected positioning and guarded movements With chronic inflammation – fibrosis and adhesions ROM: AROM All ROM restricted especially elevation (60 degrees), a painful arc may be present PROM Non-capsular pattern, empty end-feel (with pain or anticipation of it) RROM Most hesitation with abduction because of pain and the squeezing of the inflamed bursa *other movements may yield strong and painless contractions if performed carefully* Bursitis – Special Tests Painful arc Present – requires differentiation Neer impingement Present – requires differentiation Hawkins-Kennedy Present – requires differentiation Tendonitis-Bursitis Differentiation test Differential diagnosis – Supraspinatus vs. Subacromial bursa Bursitis – Treatment Treating bursitis is similar to tendonitis Manage inflammation first then address the structures contributing to the bursitis eg. - tendonitis Precautions & CI's Avoid compressing an inflamed bursa, therefore techniques should work around the affected area until inflammation subsides before performing onsite Avoid tissue drag around superficial bursae Hydro precautions If infected, refer to MD for medical attention Common Conditions: Impingement Impingement Syndrome This is an inflammatory condition that involves the coracoacromial arch and the space between the acromioclavicular and glenohumeral joints (subacromial space) Tissue is impinged in this space Rotator cuff (supraspinatus m/c) Long head biceps tendon Subacromial bursa Etiology Coracoacromial arch = 'roof' of the shoulder Coracoid process Coracoacromial and anterior acromioclavicular ligaments The rotator cuff tendons (especially the supraspinatus), biceps tendon and subacromial bursa undergo trauma and wear & tear when the head of the humerus is repeatedly being pushed up into the coracoacromial arch Factors that may cause this repeated trauma include: Failed muscled force-coupling Loss of passive stability Poor external rotation humerus Supraspinatus and bicipital tendonitis, subacromial bursitis, calcific tendonitis Poor vascularity in the rotator cuff muscles especially supraspinatus and infraspinatus Age and gender (more prevalent in 'older' >30 and females Sports w/ repeated upper limb movements or occupation/activities that require working w/ the arm in a horizontal or higher position Signs & Symptoms Insidious onset of toothache like pain over the lateral brachial region with sharp twinges felt on certain movements (ADLs involving abduction) AROM/PROM Earlier stages have a painful arc but relatively full range, this may decrease in the later stages Later stages may yield empty end feels b/c of pain or abnormal hard end feel b/c of bony changes RROM Pain when relevant muscles contract maximally Strong but painful with an intact tendon, weak and painful indicates a tear Holding patterns and postural changes may be present Impingement Syndrome – Special Tests Painful Arc Present – requires differentiation Neer impingement Present – requires differentiation Hawkins-Kennedy Present – requires differentiation Tendonitis-Bursitis differentiation test Differential diagnosis – supraspinatus vs subacromial bursa Empty can Supraspinatus tendon Speeds Long head biceps tendon Scapulohumeral rhythm Scapulothoracic function Precautions & CI's As for bursitis and tendonitis If there is bony changes, avoid joint mobilizations Possible corticosteroid injections to the shoulder Clinical Impression & Approach to Treatment: We can work with biceps tendonitis / supraspinatus tendonitis / subacromial bursitis with a similar approach to treatment 1. Improve subacromial space Humerus glides – inferior, distraction Scapula rotation – stimulate serratus anterior/decrease traps, lev scap, pec minor 2. Decrease affected tissue (muscle belly) Biceps Supraspinatus 3. Improve neuromuscular control – Home care Scapula rotation Scapula stability Muscular endurance Precautions Abduction / arm position Stage of healing / inflammation Common Conditions: GH Instability Shoulder Dislocation / Luxation Complete/partial dissociation of the articulating surfaces of the GH joint This occurs usually anteriorly (subcoracoid, subglenoid, subclavicular) and less often Posteriorly The body gives the shoulder stability by surrounding the socket with soft tissue The labrum The capsule The ligaments The rotator cuff The deltoid The pectoral muscle Etiology Anterior dislocation MOI – excessive abduction and external rotation of the humerus Either direct trauma with shoulder in this position (football) or indirect trauma (FOOSH) Posterior dislocation MOI – flexion, adduction and internal rotation (person breaking their forward fall on an outstretched hand/elbow) Inferior dislocation MOI – usually forced abduction with fixed hand Least common Signs & Symptoms Joint subluxed – reduction is usually needed Severity of injury depends on the extent of tissue damage (joint and muscle) Sulcus sign – visible deformity, loss of deltoid 'roundness' Acute Pain Severe bruising Protective mm spasm Joint effusion Possible hemarthrosis/tears/strains Holding pattern to protect joint Subacute Unstable joint – mm's provide stability TrP Decrease in ROM Adhesions develop around the joint Pain and edema slowly diminish Chronic Localized joint capsule pain Bruising gone Joint is a little more stable except of direction of injury (unless surgically repaired) Restricted ROM Matured adhesions HT and TrPs Weakness, disuse atrophy, decreased proprioception Protective posturing Sulcus sign Complications Rotator cuff tears Glenoid labrum tear Avulsion fracture (greater tubercle) Nerve and blood vessel injury Avascular necrosis Muscle atrophy (true or disuse) Adhesive capsulitis ROM Testing Apprehension in direction of injury Shoulder apprehension sign (AROM) Instruct patient to slowly move the arm and joint into the MOI (ABD + ER + EXT) Patient apprehension indicates unstable joint capsule *if present, do not perform PROM to avoid further injury to GH jt* Shoulder Instability – Special Tests Rockwood Anterior instability Push-Pull Posterior instability Feagin Inferior instability AC Shear AC joint sprain / shoulder separation Not a GH injury Shoulder Instability – Treatment Acute First 3 – 4 weeks the guest is usually immobilized Position for comfort and stability Reduce pain, decrease SNS firing, decrease edema, maintain local circulation, and address compensatory structures with GSM, petrissage, and MLD techniques Ice if needed Subacute As per acute stage Reduce but do not remove protective mm spasms Maintain available ROM (PROM) Prevent disuse atrophy (isometric contractions) Late Subacute/Chronic Prevent excess adhesion formation: begin cross-fibre frictions Reduce HT Restore ROM and strength CI's & Treatment Considerations Use only pain free AROM in the acute & subacute stages of healing Do not remove protective mm splinting in acute and subacute stages of healing Do not promote circulation at or distal to the joint in acute and subacute stages of healing Do not place back in MOI or at end-range or challenge the vulnerable part of the joint capsule Do not perform joint play or joint mobs if the joint remains unstable Make sure isometric, mid-range strength of the mm's crossing the joint is strong before taking the joint to end range in any movement If ligaments or the capsule were surgically repaired, do not restore full ROM in a way that challenged the repaired tissues Common Conditions: Shoulder Separation (AC) AC Separation or Sprain This is the sprain or rupture and possible displacement of the AC joint The structures involved are AC joint capsule and ligaments Coracoclavicular complex – trapezoid and conoid ligaments Etiology Direct trauma – downward force applied on top of AC joint Fall landing on the AC joint or FOOSH Grades Grade I Damage to AC joint (ligaments & joint capsule) with no clavicular displacement Coracoclavicular complex intact Mild inflammation Grade II Disruption to the AC joint (ligaments & joint capsule) Subluxation of the clavicle (partial or incomplete dislocation) - mild step deformity Some damage to the coracoclavicular complex More inflammation and edema Grade III Rupture of the AC and CCC ligaments Severe step deformity (clavicle rides superior to acromion) Severe inflammation Medical intervention needed Signs & Symptoms Step deformity observed with grade II and III Muscle spasms and guarding Holding pattern – IR and AD of shoulder, elbow flexed and hand rests against opposite shoulder, other hand supports AROM = limited and guarding, pain may or may not be present PROM = pain w/ ER, IR, horizontal AD, AB capsular pattern RROM = painful and weak Shoulder Separation (AC) – Special Tests Acromioclavicular shear test Integrity of AC joint AC horizontal adduction test Integrity of AC joint Not so much for a separation, more so for inflammation or perhaps mild grade 1 sprain w/out instability Shoulder Separation (AC) - Treatment Acute First 3 – 4 weeks the guest is usually immobilized Position for comfort and stability Reduce pain, decrease SNS firing, decrease edema, maintain local circulation, and address compensatory structures with GSM, petrissage, and MLD techniques Ice if needed Subacute Reduce but do not remove protective mm spasms Maintain available ROM (PROM) Prevent disuse atrophy (isometric contractions) Late subacute – prevent excess adhesion formation – begin cross-fibre frictions Chronic Prevent excess adhesion formation: begin cross-fibre frictions Maintain mobility between structures Reduce HT Restore ROM and strength Precautions & CI's In the acute stage, testing or challenging beyond available AROM should be avoided to prevent further damage If the AC joint has not been surgically reduced, joint play should be avoided in an unstable joint or until after surgical reduction Clinical Impression & Approach to Treatment: We can work with instability (hypermobility / fractures / dislocation / AC separation / post-immobilisation / disuse atrophy) conditions with a similar approach to treatment 1. Improve tissue health Muscle and joint 2. Stabilize and strengthen area Re-educate neuromuscular control of area Stimulate muscles Homecare 3. Prevent contractures/adhesions/dysfunctional scars MFR Precautions Position of injury Stretching Fragile tissue Stage of healing Hardware Surgical repair Common Conditions: Adhesive Capsulitis (Frozen Shoulder) Adhesive Capsulitis Self-limiting inflammation and fibrosis of the joint capsule Significant pain in early stages Significant reduction in ROM More that 1 range, normally in a capsular pattern – ER > ABD > IR A severe condition is with pain radiating below elbow Etiology Ages 40 to 70 – RA, DJD W>M High association with hyperkyphosis Contributing Factors: Arm not being used b/c of some painful condition (pain causes loss of motion) Disuse – immobilization Fibrosis of joint capsule Structures Affected Axillary Recess – inferior fold/pleat that stretches out during abduction. This is obliterated in frozen shoulder Inflammatory repair is said to be at the subsynovial layer (membranous layer) then at the synovial layer suggesting the easy tearing with Abduction and ER = inflammation Triangular area between subscapularis and biceps tendons is the initial area of adhesion; development spreads to surrounding rotator cuff muscles, glenoid rim, and coracohumeral ligament Types: Primary Frozen Shoulder Idiopathic Secondary Frozen Shoulder Impingement syndrome Subacromial bursitis Tendonitis or tears (rotator cuff or biceps) Trigger points in the subscapularis (decrease ER and influences satellite TPRs in surrounding muscles = decrease vascularity = inflammation = fibrosis of joint capsule Postural dysfunction – hyperkyphosis Disuse following shoulder injury or immobilization Extrinsic disorder: MI, hemiplegia, pulmonary disorders, breast surgery, bypass surgery, humeral fractures Systemic disease (diabetes – type II higher chance and hyperthyroidism) Stages/Phases These phases may be referred to as acute/subacute/chronic Phase 1 Freezing phase or painful phase Gradual onset of pain Severe pain at night and unable to lie on affected side Pain on the lateral brachial region is the main complaint Lasts several months: 3 – 9 months Phase 2 Frozen phase or Stiffening phase – blends with acute Severe pain diminishes but stiffness becomes primary complaint ADL's affected – Capsular pattern Disuse atrophy – deltoid and rotator cuff Lasts for 4 – 12 months Phase 3 Thawing phase or Resolution phase Pain begins to localize and continues to diminish Motion and function gradually return Full ROM isnt always regained Supposed to spontaneously resolve over 2 years however, symptoms may last for years: 5 – 10 years Length of painful phase corresponds to length of recovery time ROM AROM Decrease ROM – reverse scapulohumeral rhythm or 1:1 Substituted movements - "cheating" PROM Capsular pattern of restriction RROM Pain and strength depends on if there is a tear or tendonitis Strong/painless = no significant lesions Strong/painful = minor lesion Weak/painful = possible partial rupture or inhibition from a more serious lesion Weak/painless = complete rupture or neural compromise Adhesive Capsulitis – Special Tests ROM & Scapulohumeral rhythm What findings would make you consider the presence of adhesive capsulitis? Scapular mobility at the first 30 degrees of arm abduction Some authors advocate for an adhesive capsulitis abduction test Adhesive Capsulitis – Treatment Acute Help manage pain and inflammation Maintain available ROM Mobilize hypomobile joints (grade 1 and 2) Address muscle hypertonicity and fascial restrictions AAROM Subacute Continue to manage pain and inflammation Continue to address HT, fascial restrictions, and hypomobile joints (grade 3 or 4) Maintain and begin to increase ROM Chronic Maintain and increase ROM – capsular stretch Maintain and increase strength Re-educate movement and proprioception Adhesive Capsulitis – Standard of Care Medication – anti-inflammatories and pain-killers Steroid and anesthetic injections Saline injections to breakdown adhesions Manipulation under anesthesia – hematoma, fractures, dislocation ( NOT RECOMMENDED ) High grades of joint play too early in the condition can be damaging Clinical Impression & Approach to Tx 1. How much of this is neuromuscular (changeable) vs. Capsular (self-limiting) ? 2. Is it getting better on its own without pain? If no – all we can do is maintain tissue health, TrPs …. leave the capsule alone If yes – we can challenge the capsule gently to try and increase rate of healing Key Questions Has your range been improving on its own? Has your pain been improving, worse, or the same? Have you had or are you having pain below the elbow? Previous injuries or shoulder problems? How long was the painful phase (phase 1)? Sternoclavicular Joint Mobilizations: Anterior Glide To increase: 1. Shoulder Protraction 2. Reduce positional faults of the SC jt 3. Reduce SC pain Concave – convex Anterior roll, anterior glide Posterior Glide To increase: 1. Shoulder Retraction 2. Reduce an anterior positional faults of the SC jt 3. Reduce SC pain Concave – convex Posterior roll, posterior glide Inferior Glide To increase: 1. Shoulder elevation 2. Reduce a superior positional fault of the SC jt 3. Reduce SC pain Convex – concave Superior roll, inferior glide Superior Glide To increase 1. Shoulder depression 2. Reduce an inferior positional fault of the SC joint 3. Reduce SC pain Convex – concave Inferior roll, superior glide Section 4 – Home Care REMEX Principles: Programs must Not cause pain/inflammation Be progressive and gradual Start as early as possible (no inflammation) Stability is very important and requires endurance Exercise Selection Loaded exercises performed in mid-range Exercises which try to increase range performed unweighted In other words, we do not load at the end-range Passive before action Isometric before eccentric before concentric before plyometric Gravity removed (such as a theraband exercise like clamshells) before gravity added (such as squat) Bilateral before unilateral Signs that Program is too Challenging Discomfort post exercise lasting more than 2 hours in acute/subacute stage Discomfort post exercise lasting more that 4 hours in the chonic stage Need pain meds to control discomfort after activity or exercise Pain at rest Extreme fatigue Rebound muscle spasm Increased weakness Goals/Homecare Increase ROM Stretching Increase strength or stability Resistance exercises Decrease fibrosis Pain-free ROM/general movement Improve proprioception Remove vision Improve muscular endurance Isometric exercises against resistance Muscle Contraction Types: Acute stage – muscle setting (very gentle submaximal isometric contraction) Subacute stage – isometric exercises in mid-range Late subacute/chronic – progressive exercises both eccentric and concentric The main driver of choice is specificity/the functional movement you are rehabbing How to progress Submaximal to maximal Non-weight bearing to weight bearing (open chain to closed chain) Single plane to multi plane Single joint to multi joint Simple to complex Slow to fast Closed activity to open activity (closed not the same as closed chain) Why Eccentric before Concentric Eccentric has higher neural output and better effects for central sensorimotor mapping/recruitment Eccentric better at providing stability Eccentric specific to tendons is very well supported Eccentric we start with the muscle in its safest position before introducing load Why Concentric before Eccentric Concentric produces less tension in the muscle than eccentric for the same given weight Concentric before eccentric is a definite rule when doing isokinetic exercise (requiring specialised equipment) Early Stages: Exercise/Hydro Relevant Condition Self-distraction or self-mobilization Adhesive Capsulitis Impingement Manual PROM or AAROM Adhesive Capsulitis Impingement Dislocation AC separation Pendulum Swing Adhesive Capsulitis Finger Walking Adhesive Capsulitis Muscle setting or Isometric Adhesive Capsulitis Impingement Dislocation AC separation Tendonitis Later Stages: Exercise/Hydro Relevant Condition Eccentric Strengthening Tendonitis Co-contraction Impingement Dislocation AC separation Muscle stretch Adhesive capsulitis Impingement Tendonitis TERT stretch Adhesive capsulitis Proprioception Dislocation AC separation