Therapeutic Exercise_ Foundations and Techniques PDF

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oup omegr Pth CHAPTER 17 The Shoulder and Shoulder Girdle 547 This chapter is divided into three main sections. The first Coracoclavicular section reviews the structure and function of the shoulder com- Acromioclavicular joint and ligament superior acromioclavicular Trapezoid Conoid plex. The second section describes common shoulder disorders ligament and provides guidelines for conservative and postsurgical man- ligament ligament agement. The last section describes exercise techniques com- Coracoacromial monly used to meet the goals of treatment during the stages of ligament tissue healing and phases of rehabilitation. Coracohumeral ligament Structure and Function Coracoid process of the Shoulder Girdle Superior Middle Glenohumeral The shoulder girdle has only one bony articulation with the ligament Inferior axial skeleton (Fig. 17.1). The clavicle articulates with the sternum via the small sternoclavicular (SC) joint, and this reduced articular contact area is an important reason for the considerable mobility of the upper extremity. Stability, how- ever, is hampered by this articular arrangement and relies on an intricate balance among the scapular and glenohumeral FIGURE 17.2 Ligaments of the glenohumeral (GH) and acromioclav- icular (AC) joints. (GH) muscles and the soft tissue structures of the joints in the shoulder complex. joint surface, the glenoid fossa, is located on the superior-lateral margin of the scapula. It faces primarily laterally, somewhat Acromioclavicular anteriorly, and slightly upward, providing minimal stability to the joint. A fibrocartilagenous lip, the glenoid labrum, Clavicle Glenohumeral deepens the fossa to increase joint congruity and stability and Sternoclavicular serves as the attachment site for the capsule. The convex joint surface is the hemispheric head of the humerus. Only a small Humerus portion of the head contacts the fossa at any time, allowing Scapula Manubrium for considerable joint movement but also the potential for instability.155 Arthrokinematics According to the convex-concave theory of joint motion (see Chapter 5), with motions of the humerus (physiological mo- tions), the convex head rolls in the same direction and slides FIGURE 17.1 Bones and joints of the shoulder girdle complex. in the opposite direction on the glenoid fossa. The arthrokine- matics of the GH joint are summarized in ONLINE Box 19.1 on the FA Davis website that supports this textbook. Joints of the Shoulder Stability Both static and dynamic restraints provide GH joint stability Complex (Table 17.1).28,44,180,218,221 The structural relationships among the joint morphology, ligaments, and glenoid labrum, along Three synovial joints (GH, acromioclavicular [AC], and SC) and with adhesive and cohesive forces in the joint, provide static two functional articulations (scapulothoracic and suprahumeral) stability. The tendons of the rotator cuff blend with the liga- make up the shoulder complex. ments and glenoid labrum at their sites of attachment, so mus- cle contractions provide dynamic stability by tightening the static restraints (Fig. 17.3). The coordinated response of the Synovial Joints muscles of the cuff and tension in the ligaments provide vary- Glenohumeral Joint ing degrees of support depending on the position and motion The GH joint is an incongruous, ball-and-socket (spheroidal) of the humerus.170,180,204 In addition, the long head of the bi- triaxial joint with a lax joint capsule. It is supported by the ceps and the long head of the triceps brachii reinforce the cap- tendons of the rotator cuff and the GH (superior, middle, sule with their attachments and provide superior and inferior inferior) and coracohumeral ligaments (Fig. 17.2). The concave shoulder joint support, respectively, when functioning with  oup omegr Pth 548 Joints of the Shoulder Complex TABLE 17.1 Static and Dynamic Stabilizers of the Scapula and Glenohumeral Joint Description Static Stabilizers Muscular Stabilizers Scapula Weight of upper extremity Cohesive forces of subscapular bursa, SC, Scapulothoracic musculature, creates downward rotation and AC joint ligaments especially upper, middle, and lower and protraction moment on Scapulothoracic fascia trapezius, serratus anterior, levator the scapula scapula, and rhomboids Glenohumeral joint In dependent position: Superior capsule, superior GH ligament, and Rotator cuff, deltoid, long head of if scapula is in normal coracohumeral ligament are taut biceps brachii, pectoralis major, alignment, weight of Adhesive and cohesive forces of synovial latissimus dorsi, and teres major arm creates an inferior fluid and negative joint pressure hold translation moment surfaces together on the humerus Slight upward inclination of glenoid and labrum deepens fossa and improves congruency; acts as inferior barrier When the humerus is Tension placed on static restraints by the Rotator cuff and deltoid; elbow elevating and the scapula rotator cuff action brings in two-joint muscle is rotating upward Glenohumeral ligaments limit excessive support translations of humeral head Long head of biceps stabilizes against humeral elevation Coracoacromial motor response, underlies coordination of the dynamic arch restraints.218,221 Acromion Coracoacromial ligament Supraspinatus Coracoid Acromioclavicular Joint process The AC joint is a plane, triaxial joint that may or may not have a disk. The weak capsule is reinforced by the superior Subacromial Coracohumeral ligament and inferior AC ligaments (see Fig. 17.2). The convex artic- bursa Biceps brachii ular surface is a facet on the lateral end of the clavicle and Infraspinatus tendon (long head) the concave articular surface is a facet on the acromion of Glenoid Middle the scapula. labrum glenohumeral ligament Arthrokinematics Glenoid Subscapularis With motions of the scapula, the concave acromial surface slides fossa Anterior in the same direction in which the scapula moves. Motions af- Teres minor band fecting this joint include upward rotation (the scapula turns so Axillary the glenoid fossa rotates upward), downward rotation, winging pouch Inferior Triceps glenohumeral of the vertebral border (also called internal/external rotation), (long head) Posterior ligament and tilting of the inferior angle. band Stability The AC ligaments are supported by the strong coracoclavic- FIGURE 17.3 Lateral aspect of the glenoid fossa (interior view), showing attachments of the glenoid labrum, capsule, and ligaments ular ligament. No muscles directly cross this joint for dynamic as well as their relationship to the rotator cuff and long head of the support. biceps brachii musculature. Sternoclavicular Joint The SC joint is an incongruent, triaxial, saddle-shaped joint elbow motions.105 The long head of the biceps, in particular, with a disk. The joint is supported by the anterior and poste- stabilizes against humeral elevation105 and contributes to an- rior SC ligaments and the interclavicular and costoclavicular terior stability of the GH joint by resisting torsional forces ligaments (Fig. 17.4). The medial end of the clavicle is convex when the shoulder is abducted and externally rotated.9,170 superior to inferior and concave anterior to posterior. The Neuromuscular control, including movement awareness and joint disk attaches superiorly. The superior-lateral portion of  oup omegr Pth CHAPTER 17 The Shoulder and Shoulder Girdle 549 Anterior sternoclavicular Interclavicular ligament ligament Articular disc Clavicle 1st rib Joint cavity Costoclavicular ligament Costal cartilage Manubrium A Elevation B Protraction Sternoclavicular joint FIGURE 17.4 Ligaments of the sternoclavicular (SC) joint. the manubrium and first costal cartilage is concave superior to inferior and convex anterior to posterior. Arthrokinematics The motions of the clavicle occur as a result of the scapular motions of elevation, depression, protraction (abduction), and retraction (adduction). Rotation of the clavicle occurs as an accessory motion when the humerus is elevated above the C Upward rotation D Forward tipping with horizontal position and the scapula upwardly rotates; it can- downward rotation not occur as an isolated voluntary motion. The arthrokine- FIGURE 17.5 Scapular motions. (A) Elevation occurs with clavicular matics of the SC joint are summarized in ONLINE Box 17.2 elevation at the SC joint when shrugging. (B) Protraction (abduction) occurs with clavicular abduction at the SC joint when reaching for- on the FA Davis website that supports this textbook. ward. (C) Upward rotation occurs with clavicular rotation at the SC and AC joints when flexing and abducting the shoulder. (D) Forward Stability tilting (along with downward rotation) occurs at the AC joint when The ligaments crossing the joint provide static stability. There extending and internally rotating the shoulder. are no muscles crossing the joint for dynamic stability.40 Functional Articulations Internal and external rotation and tilting: These motions are Scapulothoracic Articulation seen with motion at the AC joint concurrently with mo- Normally, there is considerable soft tissue flexibility, allowing tions of the humerus (Fig. 17.5 D). Internal and external the scapula to slide along the thorax and contribute to all rotations are transverse plane motions in which the medial upper extremity motions. border lifts away from (wings) or approximates the rib cage, respectively. Anterior tilting of the scapula occurs in Motions of the Scapula conjunction with internal rotation and extension of the Elevation, depression, protraction, and retraction: These humerus when reaching the hand behind the back, while motions are seen with clavicular motions at the SC joint posterior tilting occurs during humeral elevation.64,133 (Fig. 17.5 A and B). Elevation and depression occur in the frontal plane as the scapula moves upward and downward, respectively; protraction/retraction occur in the transverse Scapular Stability plane as the scapula moves away from or toward the spinal Postural relationship. In the dependent position, the scapula column. They are also component motions when the is stabilized primarily through a balance of forces. The weight humerus moves. of the arm creates a downward rotation, protraction, and for- Upward and downward rotation: These motions are seen ward tilting moment on the scapula. These moments are bal- with clavicular motions at the SC joint and rotation at the anced by the support of the upper trapezius, serratus anterior, AC joint and occur concurrently in various planes with mo- rhomboids, and middle trapezius116,181 (see Table 17.1). tions of the humerus (Fig. 17.5 C). Upward rotation along with posterior tilting and external rotation of the scapula are Active arm motions. With active arm motions, the muscles component motions that occur with full shoulder range of of the scapula function in synchrony to stabilize and control motion (ROM) of elevation (flexion, scapular plane abduc- the position of the scapula, so the scapulohumeral muscles tion, and frontal-plane abduction of the humerus).60,131 can maintain an effective length-tension relationship as they  oup omegr Pth 550 Shoulder Girdle Function function to stabilize and move the humerus. Without the po- individuals with a shorter pectoralis minor (n = 25) had sitional control of the scapula, the efficiency of the humeral greater scapular internal rotation (protraction) and less muscles decreases. The upper and lower trapezius along with posterior tilting during arm elevation in flexion, abduction, the serratus anterior upwardly rotate the scapula whenever and scapular plane than those with a longer pectoralis the arm elevates, and the serratus anterior protracts the minor (n = 25), thus providing evidence for altered pec- scapula on the thorax to align the scapula during flexion or toralis minor muscle length and altered scapular move- pushing activities. During arm extension or during pulling ment. In a related study by Borstad,16 a correlation between activities, the rhomboids function to downwardly rotate and the postural impairments of increased thoracic kyphosis, retract the scapula in synchrony with the latissimus dorsi, scapular internal rotation and forward tipping, and de- teres major, and rotator cuff muscles. These stabilizing mus- creased pectoralis minor length was found to be significant, cles also eccentrically control acceleration of upward rotation further supporting the relationship between muscle length and protraction of the scapula.157 and posture. Faulty posture. A slouched posture significantly alters scapular kinematics. Specifically, sitting or standing with in- creased thoracic kyphosis decreases posterior tilting and Suprahumeral (Subacromial) Space external rotation of the scapula during elevation of the arm.60 The coracoacromial arch, composed of the acromion and Furthermore, with faulty scapular alignment, muscle length coracoacromial ligament, overlies the subacromial/subdeltoid and strength imbalances occur not only in the scapular mus- bursa, the supraspinatus tendon, and a portion of the cles, but also in the humeral muscles, altering the mechanics muscle (Fig. 17.7).116 These structures allow for and par- of the GH joint. A forward tilt of the scapula (seen with a ticipate in normal shoulder function. Compromise of this forward head posture and increased thoracic kyphosis) is space from faulty muscle function, faulty postural relation- associated with decreased flexibility in the pectoralis minor, ships, faulty joint mechanics, injury to the soft tissue in levator scapulae, and scalenus muscles and weakness in the this region, or structural anomalies of the acromion lead to serratus anterior or trapezius muscles. This scapular posture impingement syndromes.15,101,109,114,130,233 After a rotator also changes the posture of the humerus in the glenoid, which cuff tear, the bursa may communicate with the GH joint assumes a relatively abducted and internally rotated position cavity.44 with respect to the scapula (Fig. 17.6). The GH internal rota- tors may become less flexible, and external rotators may weaken, affecting the mechanics of the joint. Supraspinatus Clavicle Acromion Subacromial/ subdeltoid bursa Scapula Deltoid Humerus Joint capsule X-section FIGURE 17.7 The supraspinatus and subacromial/subdeltoid bursa lie in the suprahumeral space. FIGURE 17.6 Faulty forward head, thoracic kyphosis, and shoulder girdle posture result in a forward tilt and downward rotation of the scapula with relative abduction and internal rotation of the humerus when the arm is in a dependent position. Shoulder Girdle Function FOCUS ON EVIDENCE Scapulohumeral Rhythm A study by Borstad and Ludewig,15 which looked at the effect Motion of the scapula, synchronous with motions of the of pectoralis minor resting length on scapular kinematics humerus, allows for 150° to 180° of shoulder ROM into flex- in subjects without shoulder pain, documented that those ion or abduction with elevation. The ratio has considerable  oup omegr Pth CHAPTER 17 The Shoulder and Shoulder Girdle 551 variation among individuals but is commonly accepted to 30 asymptomatic subjects and 9 individuals with shoulder average 2:1 (2° of GH motion to 1° of scapular rotation) at pathology documented 11° to 15° of clavicular elevation, 15° to the end of full arm elevation. During the setting phase (0° to 29° of retraction, and 15° to 31° of posterior long axis rota- 30° abduction, 0° to 60° flexion), motion is primarily at the tion, showing similar patterns but different ranges from GH joint, whereas the scapula seeks a stable position. During previously reported studies. Ranges of clavicular motion the midrange of humeral motion, the scapula has greater mo- above 115° were not reliable, owing to movement of the tion, approaching a 1:1 ratio with the humerus; later in the clavicle under the skin. range, the GH joint again dominates the motion.38,116,187 Early studies analyzed only upward rotation of the scapula. More recent three-dimensional research demonstrated com- External Rotation of the Humerus ponent scapular motions to be upward rotation, posterior tilting, and scapular external rotation with full shoulder el- With Elevation evation (flexion, scapular plane abduction, and frontal-plane During elevation of the arm, the humerus externally ro- abduction of the humerus).101,131 tates; this allows the greater tubercle of the humerus to clear During humeral elevation, the synchronous motion the coracoacromial arch. Weak infraspinatus and teres of the scapula allows the muscles moving the humerus minor muscles or inadequate external rotation may result to maintain an effective length-tension relationship in impingement of the soft tissues in the suprahumeral throughout the activity and helps maintain congruency space, causing pain, inflammation, and eventually loss of between the humeral head and fossa while decreasing function. shear forces.38,116,187 The upper and lower trapezius and the serratus anterior muscles create upward rotation of the scapula. Weakness or complete paralysis of these muscles results in the scapula ro- FOCUS ON EVIDENCE tating downward by the contracting deltoid and supraspina- An in vivo study of elevation in flexion, in the plane of the tus as abduction or flexion is attempted. These two muscles scapula, and in abduction demonstrated approximately 55° then reach active insufficiency, and functional elevation of external rotation in all planes.189 During abduction, external the arm cannot be reached, even though there may be rotation occurred up to 125° followed by some internal rotation; normal passive ROM and normal strength in the shoulder during forward flexion, external rotation occurred until 50° and abductor and flexor muscles.187 then plateaued. Lastly, external rotation occurred again from During elevation of the humerus, the pectoralis minor is 110° to 160°. During elevation in the scapular plane, external lengthened as the scapula upwardly rotates, retracts, and tips rotation occurred throughout. posteriorly. Restricted scapular movement during humeral elevation from a shortened pectoralis minor results in pat- terns similar to those seen in patients with impingement symptoms and could be a risk factor for development of the syndrome.15 Deltoid–Short Rotator Cuff and Supraspinatus Mechanisms Clavicular Elevation and Rotation Most of the force produced by the deltoid muscle causes up- With Humeral Motion ward translation of the humerus; if unopposed, it leads to impingement of the soft tissues in the suprahumeral space It is commonly accepted that the first 30° of upward rotation between the humeral head and the coracoacromial arch. of the scapula occurs with elevation of the clavicle at the SC joint. Then, as the coracoclavicular ligament becomes taut, The combined effect of the short rotator muscles (infra- the clavicle rotates 38° to 55° about its longitudinal axis, which spinatus, teres minor, and subscapularis) produces sta- elevates its acromial end (because it is crank shaped). This bilizing compression and downward translation of the motion allows the scapula to rotate an additional 30° at the humerus in the glenoid. AC joint.116 Loss of any of these functional components de- The combined actions of the deltoid and short rotators re- creases the amount of scapular rotation and thus the ROM sult in a balance of forces that elevate the humerus and of the upper extremity. control the humeral head. The supraspinatus muscle has a significant stabilizing, compressive, and slight upward translation effect on the humerus during arm elevation. It functions with the FOCUS ON EVIDENCE deltoid in humeral elevation. A three-dimensional study115 of clavicular motion during Interruption of the coordinated function of these mecha- humeral flexion, scapular plane elevation of the arm, and nisms may lead to tissue microtrauma and shoulder com- abduction to 115° using surface electromagnetic sensors on plex dysfunction.  oup omegr Pth 552 Joint Hypomobility: Nonoperative Management Referred Pain and Nerve Joint Hypomobility: Injury Nonoperative Management For a detailed description of referred pain patterns, peripheral Glenohumeral Joint nerve injuries in the shoulder, thoracic outlet syndrome Restricted mobility of the GH joint may occur as a result of (TOS), and complex regional pain syndromes and their man- pathology, such as rheumatoid arthritis (RA) or osteoarthritis agement, see Chapter 13. (OA); from prolonged immobilization; or from unknown causes (idiopathic frozen shoulder). Concurrent impairments in muscle performance and connective tissue mobility in the Common Sources of Referred Pain cervical and shoulder girdle region may also be present. in the Shoulder Region Cervical Spine Related Pathologies and Etiology of Symptoms Vertebral joints between C3 and C4 or between C4 and C5 RA and OA (degenerative arthritis). These disorders fol- Nerve roots C4 or C5 low the clinical pictures described in Chapter 11. Traumatic arthritis. This disorder occurs in response to a Referred Pain From Related Tissues fall or high force blow to the shoulder. Dermatome C4 is over the trapezius to the tip of the Postimmobilization arthritis or stiff shoulder. This disorder shoulder. occurs with lack of movement or as a secondary effect from Dermatome C5 is over the deltoid region and lateral arm. conditions such as heart disease, stroke, or diabetes mellitus. Diaphragm: pain perceived in the upper trapezius region. Heart: pain perceived in the left axilla and pectoral region. Idiopathic frozen shoulder. This disorder, which is also Gallbladder: pain perceived at the tip of shoulder and called adhesive capsulitis or periarthritis, is characterized by scapular region. the development of dense adhesions, capsular thickening, and capsular restrictions, especially in the dependent folds of the capsule, rather than arthritic changes in the cartilage and Nerve Disorders in the Shoulder bone, as seen with RA or OA. The onset is insidious and usu- ally occurs between the ages of 40 and 65 years; there is no Girdle Region known cause (primary frozen shoulder), although problems Brachial plexus in the thoracic outlet. Common sites for already mentioned in which there is a period of pain and/or compression are the scalene triangle and the costoclavicular restricted motion, such as with RA, OA, trauma, or immobi- space and under the coracoid process and pectoralis minor lization, may lead to a frozen shoulder (secondary frozen muscle.104 shoulder). With primary frozen shoulder, the pathogenesis may be a provoking chronic inflammation in musculotendi- Suprascapular nerve in the suprascapular notch. This nous or synovial tissue, such as the rotator cuff, biceps tendon, injury occurs from either direct compression or from nerve or joint capsule.40,70,100,145,148 Patients with diabetes mellitus stretch, such as when carrying a heavy book bag over the and thyroid disease are at increased risk for developing the shoulder. disorder.97 Radial nerve in the axilla. Compression occurs from con- tinual pressure, such as when leaning on axillary crutches. Clinical Signs and Symptoms GH joint arthritis. The following characteristics are typically associated with GH joint arthritis that leads to hypomobility. Acute phase. Pain and protective muscle guarding limit mo- Management of Shoulder tion, usually external rotation and abduction. Pain fre- Disorders and Surgeries quently radiates distal to the elbow and may disturb sleep. Owing to the depth of the GH capsule, joint swelling is not To make sound clinical decisions when managing patients detected, although tenderness can be elicited by palpating with shoulder disorders, it is necessary to understand the in the sulcus immediately below the edge of the acromion various pathologies, surgical procedures, and associated process between the attachments of the posterior and middle precautions and to identify impairments, functional limi- deltoid. tations, and possible disabilities. In this section, common Subacute phase. Capsular tightness, consistent with a cap- pathologies and surgeries are presented, and the conserva- sular pattern (external rotation and abduction are most tive and postoperative management of these conditions are limited, and internal rotation and flexion are least limited), described. often begins to develop. The patient may feel pain as the  oup omegr Pth CHAPTER 17 The Shoulder and Shoulder Girdle 553 end of the limited range is reached. Passive accessory mo- guarding the painful shoulder in a position of scapula tion testing reveals limited joint play. If the patient can be elevation and arm adduction treated as the acute condition begins to subside by gradu- Decreased arm swing during gait ally increasing shoulder motion and activity, the compli- Muscle performance: general muscle weakness and poor cation of joint and soft tissue contractures can usually be endurance in the GH muscles with overuse of the scapular minimized.139,145 muscles leading to pain in the trapezius, levator scapulae, Chronic phase. Progressive restriction of the GH joint capsule and posterior cervical muscles magnifies the signs of limited motion in a capsular pattern Increased scapulothoracic motion during arm movements and decreased joint play. There is significant loss of function to compensate for limited GH mobility with an inability to reach overhead, outward, or behind the back. Pain is often localized to the deltoid region. Common Activity Limitations and Participation Restrictions Idiopathic frozen shoulder. This clinical entity pro- Inability to reach overhead, behind head, out to the side, and gresses through a series of four stages following a classic behind back leading to difficulty dressing (putting on a jacket continuum.40,70,100,144,145,148 or coat or in the case of women, fastening undergarments be- Stage 1. Characterized by a gradual onset of pain that hind their back), reaching hand into back pocket of pants (to increases with movement and is present at night. Loss of retrieve wallet), reaching out a car window (to use an ATM external rotation motion with intact rotator cuff strength machine), self-grooming (combing hair, brushing teeth, is common. The duration of this stage is usually less than washing face), and bringing eating utensils to the mouth 3 months. Difficulty lifting heavy objects above shoulder level Stage 2 (Often referred to as the “Freezing” Stage). Charac- Limited ability to sustain repetitive activities terized by persistent and more intense pain even at rest. Motion is limited in all directions and cannot be fully GH Joint Hypomobility: Management— restored with an intra-articular injection. This stage is Protection Phase typically between 3 and 9 months after onset. See General Guidelines for Management When Symptoms Stage 3 (“Frozen” Stage). Characterized by pain only with Are Acute in Chapter 10 and Box 10.1. movement, significant adhesions, and limited GH motions. Educate the Patient Excessive scapulothoracic movement is a typical compen- Provide information about what to expect regarding the sation. Atrophy of the deltoid, rotator cuff, biceps, and tri- stages of healing. ceps brachii muscles may be noted. This stage occurs Instruct patient in safe motions and activity modifications between 9 and 15 months after onset. that minimize joint stress. Stage 4 (“Thawing” Stage). Characterized by minimal pain and no synovitis but significant capsular restrictions from Control Pain, Edema, and Muscle Guarding adhesions. Motion may gradually improve during this The joint may be immobilized in a sling to provide rest and stage. This stage lasts from 15 to 24 months after onset, minimize pain. although some patients never regain normal ROM. Intermittent periods of passive or assisted motion within the pain free/protected ROM and gentle joint oscillation Some references indicate that spontaneous recovery occurs, techniques to minimize further adhesions are initiated as on average, 2 years from onset,70 although others report long- soon as the patient tolerates movement. term limitations without spontaneous recovery.173 Inappropri- Gentle soft tissue mobilization of the cervical and periscapu- ately aggressive therapy at the wrong time may prolong the lar muscles may improve patient comfort and minimize symptoms.13 Management guidelines are progressed based protective guarding, as may cervical ROM and/or cervical on the continuum of stages100 and are the same as for acute grade I or II passive intervertebral mobilizations. (maximum protection during stages 1 and 2), subacute (con- trolled motion during stage 3), and chronic (return to function Maintain Soft Tissue and Joint Integrity during stage 4) joint pathology described in this section. and Mobility PRECAUTION: If there is increased pain or irritability in the Common Impairments of Structure joint after use of the following techniques, either the dosage was and Function too strong or the techniques should be modified by decreasing Night pain and disturbed sleep during acute flares the range of passive movement or delaying joint glides. Pain on motion and often at rest during acute flares CONTRAINDICATION: If there are mechanical restrictions Mobility: decreased joint play and ROM, usually limiting causing limited motion, appropriate tissue stretching should be external rotation and abduction with some limitation of initiated only after the inflammation subsides. internal rotation and flexion Posture: possible faulty postural compensations with pro- Passive ROM (PROM) in all ranges of pain-free motion tracted and anteriorly tilted scapula, rounded shoulders, or (see Chapter 3). As pain decreases, the patient is progressed  oup omegr Pth 554 Joint Hypomobility: Nonoperative Management to active ROM with or without assistance, using activities such as rolling a small ball or sliding a rag on a smooth CLINICAL TIP table top. Planar, multiplanar and circular motions can be For conditions in which there is potential for a prolonged given to move the shoulder to the end range of its available acute/inflammatory stage, such as with RA and during stages motions. Be sure the patient is taught proper mechanics I or II of idiopathic frozen shoulder, it is critical to teach the and to avoid faulty patterns, such as scapular elevation or patient active-assistive exercises to maintain muscle and joint a slumped posture. integrity and as much mobility as possible without exacer- Passive joint distraction and glides, grade I and II with the bating the symptoms. joint placed in a pain-free position (see Chapter 5). Pendulum (Codman’s) exercises are techniques that use the effects of gravity to distract the humerus from GH Joint Hypomobility: Management— the glenoid fossa.28,31 They help relieve pain through Controlled Motion Phase gentle traction and oscillating movements (grade II) and When symptoms are subacute, follow the guidelines as de- provide early motion of joint structures and synovial scribed in Chapter 10, Box 10.2, emphasizing joint mobility, fluid. No weight is used during this phase of treatment neuromuscular control, and instructions to the patient for (see Fig. 17.22). self-care. Control Pain, Edema, and Joint Effusion Functional activities. It is important to carefully monitor CLINICAL TIP activities. If the joint is immobilized, the amount of time Many patients perform pendulum exercises incorrectly by the shoulder is free to move each day is progressively using the GH muscles to initiate shoulder motion and by per- increased. forming large excursion of motion. The technique must be ROM. GH and scapula motions are progressed up to the taught as small, gentle pendular motions initiated with body point of pain. The patient is instructed in the use of self- swaying while keeping the shoulder muscles relaxed.113 assistive ROM techniques, such as wand exercises or hand slides on a table. Gentle muscle setting to all muscle groups of the shoulder and PRECAUTION: With increased pain or decreased motion after adjacent regions, including cervical and elbow muscles be- these techniques, the activity may be too intense or the patient cause of their close association with the shoulder complex. may be using faulty mechanics. Reassess the technique and Instructions are given to the patient to gently contract a modify it by restricting the joint to a safer ROM, correcting faulty group of muscles while slight manual resistance is applied— movements, or altering the intensity, frequency, and/or duration just enough to stimulate a muscle contraction without pro- of the technique. voking pain. The emphasis is on rhythmic contracting and Progressively Increase Joint and Soft Tissue relaxing of the muscles to stimulate blood flow and prevent Mobility circulatory stasis. Passive joint mobilization techniques. Grade III sustained or Maintain Integrity and Function of Associated grade III and IV oscillations that focus on the restricted Regions capsular tissue at the end of the available ROM are used Complex regional pain syndrome type I is a potential to increase joint capsule mobility94,207 (see Figs. 5.15 to complication after shoulder injury or immobility. There- 5.20 in Chapter 5 and ONLINE Box 17.1). End-of-range fore, additional exercises, such as having the patient repet- techniques include rotating the humerus and then applying itively squeeze a ball or other soft object, may be given for either a grade III distraction or a grade III glide to stretch the hand. the restrictive capsular tissue or adhesions (see Figs. 5.17, The patient is educated on the importance of keeping the 5.21, and 17.20). Use a grade I distraction with all gliding techniques. If joints distal to the shoulder complex as active and mobile as possible. The patient or family member is taught to the joint is irritable and gliding in the direction of re- perform ROM exercises of the elbow, forearm, wrist, and striction is not tolerated, glide in the opposite direction. fingers several times each day while the shoulder is im- As pain and irritability decrease, begin to glide in the mobilized. If tolerated, active or gentle resistive ROM is direction of restriction.94 preferred to passive ROM for a greater effect on circula- tion and muscle integrity. If edema is noted in the hand, instruct the patient to elevate FOCUS ON EVIDENCE the hand above the level of the heart whenever possible. Evidence supporting joint mobilization techniques is limited. A Cervical ROM (active and/or passive), intervertebral joint multiple-subject case study, using seven subjects with adhesive mobilizations, and soft tissue mobilization should also be capsulitis of the GH joint (mean disease duration 8.4 months, considered. range 3 to 12 months) treated with end-range mobilization