By-JOHNMEL-L.-FERMIN.pptx.pdf

TECHNIQUES AND PRINCIPLES OF EXERCISE FOR THE SHOULDER REGION BY: JOHNMEL L. FERMIN Structure and Function of the Shoulder Girdle It has only one bony articulation with the axial skeleton SC jt. Clavicle articulates to the sternum, this reduced articular contact area is an important reason for the considerable mobility of the upper extremity Stability relies on an intricate balance among the scapular and glenohumeral (GH) muscles and the soft tissue structures of the joints in the shoulder complex Shoulder complex GLENOHUMERAL JOINT Acromioclavicular joint Sternoclavicular joint Synovial joint GLENOHUMERAL JOINT (GH JT) Ball and socket Supported by the tendon of rotator cuff (SITS) Glenoid fossa ⚬ is the concave joint surface, and is located on the superior-lateral margin of the scapula ⚬ It faces primarily laterally, somewhat anteriorly, and slightly upward, providing minimal stability to the joint Glenoid labrum ⚬ is a fibrocartilagenous lip that deepens the fossa to increase joint congruity and stability and serves as the attachment site for the capsule Humeral head ⚬ Is the convex joint surface, with only a small portion of the head contacts to the fossa ⚬ Allowing considerable joint movement but also the potential for instability Synovial joint GLENOHUMERAL JOINT (GH JT) Arthrokinematics According to the convex-concave theory of joint motion, with motions of the humerus the convex head rolls in the same direction and slides in the opposite direction on the glenoid fossa. Stability Static stability was being provided by the structural relationships among the joint morphology, ligaments, and glenoid labrum, along with adhesive and cohesive forces in the joint Dynamic stability was being provided by blending of the rotator cuff ligaments and glenoid labrum in their sites of attachment with muscle contractions resulting in tightening the static restraints Long head of biceps and long head of triceps brachii reinforce the capsule with their attachments and provide sup and inf SH Joint support, ⚬ Long head of biceps stabilize Humeral elevation and contributes to ant. Stability of GH joint by resisting torsional forces when the shoulder is abducted and externally rotated Synovial joint ACROMIOCLAVICULAR JOINT (AC JT) Plane synovial joint Sup and inf AC lig gives reinforcement on weak capsule convex articular surface is a facet on the lateral end of the clavicle concave articular surface is a facet on the acromion of the scapula Arthrokinematics the concave acromial surface slides in the same direction in which the scapula moves Motions affecting this joint include upward rotation (the scapula turns so the glenoid fossa rotates upward), downward rotation, winging of the vertebral border (also called internal/external rotation), and tilting of the inferior angle. Stability Is supported by the strong coracoclavicular ligament. Synovial joint STERNOCLAVICULAR JOINT (SC JT) Saddle type synovial joint (function as ball and socket) It is supported by the anterior and posterior SC ligaments and the interclavicular and costoclavicular ligaments Joint disk attaches superiorly Medial end of the clavicle is convex superior to inferior Concave 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 horizontal position and the scapula upwardly rotates; it cannot occur as an isolated voluntary motion. Synovial joint STERNOCLAVICULAR JOINT (SC JT) Functional Articulations Scapulothoracic Articulation Motions of the Scapula Elevation, depression, protraction, and retraction Upward and downward rotation Internal and external rotation and tilting Functional Articulations Scapulothoracic Articulation Scapular Stability Postural relationship. In the dependent position, the scapula is stabilized primarily through a balance of forces By weight of the arm creates a downward rotation, protraction, and forward tilting moment on the scapula These moments are balanced by the support of the upper trapezius, serratus anterior, rhomboids, and middle trapezius Scapular Stability Active arm motions The muscles of the scapula function in synchrony to stabilize and control the position of the scapula Scapulohumeral muscles can maintain an effective length-tension relationship as they function to stabilize and move the humerus Without the positional control of the scapula, the efficiency of the humeral muscles decreases Upper and lower trapezius along with the serratus anterior upwardly rotate the scapula whenever the arm elevates Serratus anterior protracts the scapula on the thorax to align the scapula during flexion or pushing activities During arm extension or during pulling activities, the rhomboids function to downwardly rotate and retract the scapula in synchrony with the latissimus dorsi, teres major, and rotator cuff muscles. These stabilizing muscles also eccentrically control acceleration of upward rotation and protraction of the scapula Scapular Stability Faulty posture. A slouched posture significantly alters scapular kinematics. Sitting or standing with increased thoracic kyphosis decreases posterior tilting and external rotation of the scapula during elevation of the arm Muscle length and strength imbalances occur not only in the scapular muscles, but also in the humeral muscles, altering the mechanics of the GH joint A forward tilt of the scapula (seen with a forward head posture and increased thoracic kyphosis) is associated with decreased flexibility in the pectoralis minor, levator scapulae, and scalenus muscles and weakness in the serratus anterior or trapezius muscles Scapular Stability Suprahumeral (Subacromial) Space The coracoacromial arch, composed of the acromion and coracoacromial ligament overlies the subacromial/subdeltoid bursa, the supraspinatus tendon, and a portion of the muscle These structures allow for and participate in normal shoulder function Compromise of this space from faulty muscle function, faulty postural relationships, faulty joint mechanics, injury to the soft tissue in this region, or structural anomalies of the acromion lead to impingement syndromes After a rotator cuff tear, the bursa may communicate with the GH joint cavity Scapular Stability Suprahumeral (Subacromial) Space Shoulder Girdle Function Scapulohumeral Rhythm Motion of the scapula, synchronous with motions of the humerus, allows for 150° to 180° of shoulder ROM into flexion or abduction with elevation Ratio has considerable variation among individuals but is commonly accepted to average 2:1 (2° of GH motion to 1° of scapular rotation) at the end of full arm elevation During the setting phase (0° to 30° abduction, 0° to 60° flexion), motion is primarily at the GH joint, whereas the scapula seeks a stable position During the midrange of humeral motion, the scapula has greater motion, approaching a 1:1 ratio with the humerus; later in the range, the GH joint again dominates the motion Early studies analyzed only upward rotation of the scapula. More recent three-dimensional research demonstrated component scapular motions to be upward rotation, posterior tilting, and scapular external rotation with full shoulder elevation (flexion, scapular plane abduction, and frontal-plane abduction of the humerus) Shoulder Girdle Function Scapulohumeral Rhythm During humeral elevation, the synchronous motion of the scapula allows the muscles moving the humerus to maintain an effective length-tension relationship throughout the activity and helps maintain congruency between the humeral head and fossa while decreasing shear forces 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 rotating downward by the contracting deltoid and supraspinatus as abduction or flexion is attempted. These two muscles then reach active insufficiency, and functional elevation of the arm cannot be reached, even though there may be normal passive ROM and normal strength in the shoulder abductor and flexor muscles During elevation of the humerus, the pectoralis minor is lengthened as the scapula upwardly rotates, retracts, and tips posteriorly. Restricted scapular movement during humeral elevation from a shortened pectoralis minor results in patterns similar to those seen in patients with impingement symptoms and could be a risk factor for development of the syndrome Shoulder Girdle Function Clavicular Elevation and Rotation With Humeral Motion It is commonly accepted that the first 30° of upward rotation of the scapula occurs with elevation of the clavicle at the SC joint Then, as the coracoclavicular ligament becomes taut, the clavicle rotates 38° to 55° about its longitudinal axis, which elevates its acromial end (because it is crank shaped) This motion allows the scapula to rotate an additional 30° at the AC joint Loss of any of these functional components decreases the amount of scapular rotation and thus the ROM of the upper extremity Shoulder Girdle Function Deltoid–Short Rotator Cuff and Supraspinatus Mechanisms Most of the force produced by the deltoid muscle causes upward translation of the humerus; if unopposed, it leads to impingement of the soft tissues in the suprahumeral space between the humeral head and the coracoacromial arch. The combined effect of the short rotator muscles (infraspinatus, teres minor, and subscapularis) produces stabilizing compression and downward translation of the humerus in the glenoid The combined actions of the deltoid and short rotators result in a balance of forces that elevate the humerus and 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 deltoid in humeral elevation Interruption of the coordinated function of these mechanisms may lead to tissue microtrauma and shoulder complex dysfunction Referred Pain and Nerve Injury Common Sources of Referred Pain in the Shoulder Region Cervical Spine Vertebral joints between C3 and C4 or between C4 and C5 Nerve roots C4 or C5 Referred Pain From Related Tissues Dermatome C4 is over the trapezius to the tip of the shoulder Dermatome C5 is over the deltoid region and lateral arm Diaphragm: pain perceived in the upper trapezius region Heart: pain perceived in the left axilla and pectoral region Gallbladder: pain perceived at the tip of shoulder and scapular region Referred Pain and Nerve Injury Common Sources of Referred Pain in the Shoulder Region Referred Pain and Nerve Injury Common Sources of Referred Pain in the Shoulder Region Referred Pain and Nerve Injury Nerve Disorders in the Shoulder Girdle Region Brachial plexus in the thoracic outlet Common sites for compression are the scalene triangle and the costoclavicular space and under the coracoid process and pectoralis minor muscle Suprascapular nerve in the suprascapular notch This injury occurs from either direct compression or from nerve stretch, such as when carrying a heavy book bag over the shoulder Radial nerve in the axilla Compression occurs from continual pressure, such as when leaning on axillary crutches Joint Hypomobility: Nonoperative Management Glenohumeral Joint Hypomobility Related Pathologies and Etiology of Symptoms RA and OA (degenerative arthritis) arthritic changes in the cartilage and bone Traumatic arthritis This disorder occurs in response to a fall or high force blow to the shoulder. Postimmobilization arthritis or stiff shoulder. Occurs with lack of movement or as a secondary effect from conditions such as heart disease, stroke, or diabetes mellitus. Idiopathic frozen shoulder. Adhesive capsulitis or periarthritis characterized by the development of dense adhesions, capsular thickening, and capsular restrictions Onset is insidious and usually occurs between the ages of 40 and 65 years; there is no known cause (primary frozen shoulder), although problems already mentioned in which there is a period of pain and/or restricted motion, such as with RA, OA, trauma, or immobilization, may lead to a frozen shoulder (secondary frozen shoulder) With primary frozen shoulder, the pathogenesis may be a provoking chronic inflammation in musculotendinous or synovial tissue, such as the rotator cuff, biceps tendon, or joint capsule Clinical Signs and Symptoms GH joint arthritis Acute phase Pain and protective muscle guarding limit motion, usually external rotation and abduction. Pain frequently radiates distal to the elbow and may disturb sleep. Owing to the depth of the GH capsule, joint swelling is not detected, although tenderness can be elicited by palpating in the sulcus immediately below the edge of the acromion process between the attachments of the posterior and middle deltoid Clinical Signs and Symptoms GH joint arthritis Subacute phase Capsular tightness, consistent with a capsular pattern (external rotation and abduction are most limited, and internal rotation and flexion are least limited), often begins to develop. The patient may feel pain as the end of the limited range is reached. Passive accessory motion testing reveals limited joint play If the patient can be treated as the acute condition begins to subside by gradually increasing shoulder motion and activity, the complication of joint and soft tissue contractures can usually be minimized Clinical Signs and Symptoms GH joint arthritis Chronic phase Progressive restriction of the GH joint capsule magnifies the signs of limited motion in a capsular pattern and decreased joint play There is significant loss of function with an inability to reach overhead, outward, or behind the back. Pain is often localized to the deltoid region Clinical Signs and Symptoms Idiopathic frozen shoulder Stage 1 Characterized by a gradual onset of pain that increases with movement and is present at night. Loss of external rotation motion with intact rotator cuff strength is common. The duration of this stage is usually less than 3 months Stage 2 (Often referred to as the “Freezing” Stage) Characterized by persistent and more intense pain even at rest Motion is limited in all directions and cannot be fully restored with an intra-articular injection Clinical Signs and Symptoms Idiopathic frozen shoulder Stage 3 (“Frozen” Stage) Characterized by pain only with movement, significant adhesions, and limited GH motions Excessive scapulothoracic movement is a typical compensation Atrophy of the deltoid, rotator cuff, biceps, and triceps brachii muscles may be noted This stage occurs between 9 and 15 months after onset. Clinical Signs and Symptoms Idiopathic frozen shoulder Stage 4 (“Thawing” Stage) Characterized by minimal pain and no synovitis but significant capsular restrictions from adhesions Motion may gradually improve during this stage This stage lasts from 15 to 24 months after onset, although some patients never regain normal ROM Some references indicate that spontaneous recovery occurs, on average, 2 years from onset, although others report long term limitations without spontaneous recovery Inappropriately aggressive therapy at the wrong time may prolong the symptoms Management guidelines are progressed based on the continuum of stages the same as for acute (maximum protection during stages 1 and 2), subacute (controlled motion during stage 3), and chronic (return to function during stage 4) Common Impairments of Structure and Function Night pain and disturbed sleep during acute flares Pain on motion and often at rest during acute flares Mobility: decreased joint play and ROM, usually limiting external rotation and abduction with some limitation of internal rotation and flexion Posture: possible faulty postural compensations with protracted and anteriorly tilted scapula, rounded shoulders, or guarding the painful shoulder in a position of scapula elevation and arm adduction Decreased arm swing during gait Muscle performance: general muscle weakness and poor endurance in the GH muscles with overuse of the scapular muscles leading to pain in the trapezius, levator scapulae, and posterior cervical muscles Increased scapulothoracic motion during arm movements to compensate for limited GH mobility Common Activity Limitations and Participation Restrictions Inability to reach overhead, behind head, out to the side, and behind back leading to difficulty dressing (putting on a jacket or coat or in the case of women, fastening undergarments behind their back), reaching hand into back pocket of pants (to retrieve wallet), reaching out a car window (to use an ATM machine), self-grooming (combing hair, brushing teeth, washing face), and bringing eating utensils to the mouth Difficulty lifting heavy objects above shoulder level Limited ability to sustain repetitive activities GH Joint Hypomobility: Management Protection Phase Educate the Patient Provide information about what to expect regarding the stages of healing. Instruct patient in safe motions and activity modifications that minimize joint stress. Control Pain, Edema, and Muscle Guarding The joint may be immobilized in a sling to provide rest and minimize pain. Intermittent periods of passive or assisted motion within the pain free/protected ROM and gentle joint oscillation techniques to minimize further adhesions are initiated as soon as the patient tolerates movement Gentle soft tissue mobilization of the cervical and periscapular muscles may improve patient comfort and minimize protective guarding, as may cervical ROM and/or cervical grade I or II passive intervertebral mobilizations GH Joint Hypomobility: Management Protection Phase Maintain Soft Tissue and Joint Integrity and Mobility Passive ROM (PROM) in all ranges of pain-free motion. As pain decreases, the patient is progressed to active ROM with or without assistance, using activities such as rolling a small ball or sliding a rag on a smooth table top. Planar, multiplanar and circular motions can be given to move the shoulder to the end range of its available motions. Be sure the patient is taught proper mechanics and to avoid faulty patterns, such as scapular elevation or a slumped posture Passive joint distraction and glides, grade I and II with the joint placed in a pain-free position Pendulum (Codman’s) exercises are techniques that use the effects of gravity to distract the humerus from the glenoid fossa. They help relieve pain through gentle traction and oscillating movements (grade II) and provide early motion of joint structures and synovial fluid. No weight is used during this phase of treatment GH Joint Hypomobility: Management Protection Phase Maintain Soft Tissue and Joint Integrity and Mobility Gentle muscle setting to all muscle groups of the shoulder and adjacent regions, including cervical and elbow muscles because of their close association with the shoulder complex. Instructions are given to the patient to gently contract a group of muscles while slight manual resistance is applied— just enough to stimulate a muscle contraction without provoking pain. The emphasis is on rhythmic contracting and relaxing of the muscles to stimulate blood flow and prevent circulatory stasis PRECAUTION: If there is increased pain or irritability in the joint after use of the following techniques, either the dosage was too strong or the techniques should be modified by decreasing the range of passive movement or delaying joint glides CONTRAINDICATION: If there are mechanical restrictions causing limited motion, appropriate tissue stretching should be initiated only after the inflammation subsides GH Joint Hypomobility: Management Protection Phase Maintain Integrity and Function of Associated Regions Complex regional pain syndrome type I is a potential complication after shoulder injury or immobility. Therefore, additional exercises, such as having the patient repetitively squeeze a ball or other soft object, may be given for the hand The patient is educated on the importance of keeping the joints distal to the shoulder complex as active and mobile as possible. The patient or family member is taught to perform ROM exercises of the elbow, forearm, wrist, and fingers several times each day while the shoulder is immobilized. If tolerated, active or gentle resistive ROM is preferred to passive ROM for a greater effect on circulation and muscle integrity If edema is noted in the hand, instruct the patient to elevate the hand above the level of the heart whenever possible Cervical ROM (active and/or passive), intervertebral joint mobilizations, and soft tissue mobilization should also be considered GH Joint Hypomobility: Management Controlled Motion Phase Control Pain, Edema, and Joint Effusion Functional activities. It is important to carefully monitor activities. If the joint is immobilized, the amount of time the shoulder is free to move each day is progressively increased ROM. GH and scapula motions are progressed up to the point of pain. The patient is instructed in the use of selfassistive ROM techniques, such as wand exercises or hand slides on a table PRECAUTION: With increased pain or decreased motion after these techniques, the activity may be too intense or the patient may be using faulty mechanics. Reassess the technique and modify it by restricting the joint to a safer ROM, correcting faulty movements, or altering the intensity, frequency, and/or duration of the techniques GH Joint Hypomobility: Management Controlled Motion Phase Progressively Increase Joint and Soft Tissue Mobility Passive joint mobilization techniques. Grade III sustained or grade III and IV oscillations that focus on the restricted capsular tissue at the end of the available ROM are used to increase joint capsule mobility. End-of-range techniques include rotating the humerus and then applying either a grade III distraction or a grade III glide to stretch the restrictive capsular tissue or adhesions ⚬ Use a grade I distraction with all gliding techniques. If the joint is irritable and gliding in the direction of restriction is not tolerated, glide in the opposite direction. As pain and irritability decrease, begin to glide in the direction of restriction PRECAUTION: Carefully monitor the joint reaction to the mobilization stretches; if irritability increases, grade III or IV techniques should not be undertaken until the chronic stage of healing GH Joint Hypomobility: Management Controlled Motion Phase Progressively Increase Joint and Soft Tissue Mobility Self-mobilization techniques. The following self-mobilization techniques may be used for a home program. ⚬ CAUDAL GLIDE. Patient position and procedure: Sitting on a firm surface and grasping the fingers under the edge. The patient then leans the trunk away from the stabilized arm ⚬ ANTERIOR GLIDE. Patient position and procedure: Sitting with both arms behind the body or lying supine supported on a solid surface. The patient then leans the body weight between the arms ⚬ POSTERIOR GLIDE. Patient position and procedure: Prone, propped up on both elbows. The body weight shifts downward between the arm GH Joint Hypomobility: Management Controlled Motion Phase Inhibit Muscle Spasm and Correct Faulty Mechanics Muscle spasm may lead to a faulty deltoid-rotator cuff mechanism and altered scapulohumeral rhythm when the patient attempts arm elevation Greater relative deltoid activation may result in superior humeral head translation and impingement of the greater tuberosity on the coracoacromial arch, making it difficult and/or painful to elevate the arm. In this case, repositioning the humeral head with a caudal glide is necessary before proceeding with any other form of shoulder exercise. The patient must also learn to recognize and avoid “hiking the shoulder” when at rest or when elevating the arm GH Joint Hypomobility: Management Controlled Motion Phase Inhibit Muscle Spasm and Correct Faulty Mechanics The following techniques may address these problems ⚬ Gentle joint oscillation techniques (grade I or II) to help decrease the muscle spasm. ⚬ Sustained caudal glide joint techniques to reposition the humeral head in the glenoid fossa. ⚬ Protected weight bearing, such as leaning hands against a wall or on a table, to stimulate rotator cuff and scapula stabilizer co-contraction and improve synovial fluid movement through hyaline cartilage compression. Techniques are progressed by gentle rocking forward/backward and side to side, moving from bilateral to unilateral, increasing the angle of the joint, or adding perturbations. ⚬ GH internal/external rotation strengthening to facilitate stabilization of the humeral head GH Joint Hypomobility: Management Controlled Motion Phase Inhibit Muscle Spasm and Correct Faulty Mechanics The following techniques may address these problems ⚬ Movement retraining to minimize the substitution pattern of scapular elevation can be initiated by providing the visual feedback of a mirror or the tactile feedback of the opposite hand placed on the ipsilateral upper trapezius. ￭ Therapist position and procedure: Stand on the opposite side of the bed facing the patient and reach across the patient’s torso to cup the anteromedial aspect of the head of the humerus with reinforced hands. Apply a pain-free graded posterolateral glide of the humeral head on the glenoid. Instruct the patient to use the cane to push the affected arm into the previously restricted range of external rotation. Sustain the movement for 10 seconds and repeat in sets of 5 to 10. It is important to maintain the elbow near the side of the trunk and ensure that no pain is experienced during the procedure. Adjust the grade and direction of the glide as needed to achieve pain-free GH Joint Hypomobility: Management Controlled Motion Phase Inhibit Muscle Spasm and Correct Faulty Mechanics The following techniques may address these problems ⚬ Shoulder MWM for painful restriction of internal rotation and inability to reach the hand behind the back ￭ Patient position: Standing with a towel draped over the unaffected upper trapezius and affected hand at current range of maximum pain-free position behind back. The patient’s hand on the affected side grasps the towel behind the back. ￭ Therapist position and procedure: Stand facing the patient’s affected side. Place the hand closest to the patient’s back high up in the axilla with the palm facing outward to stabilize the scapula with an upward and inward pressure. With the hand closest to the patient’s abdomen, hook the thumb in the cubital fossa and grasp the lower humerus to provide an inferior glide. Your abdomen is in contact with the patient’s elbow to provide an adduction force to the arm. Have the patient pull on the towel with the unaffected hand to draw the affected hand up the back while the mobilization force is being applied in an inferior direction. Ensure that no pain is experienced during the procedure. Adjust the grade and direction of glide as needed to achieve painfree function. Maximal glide should be applied to achieve end-range loading GH Joint Hypomobility: Management Controlled Motion Phase Inhibit Muscle Spasm and Correct Faulty Mechanics Shoulder MWM for painful arc or impingement signs. If impingement signs are present in addition to the capsular restrictions, the MWM active elevation technique may be appropriate GH Joint Hypomobility: Management Controlled Motion Phase Improve Muscle Performance Faulty postures or shoulder girdle mechanics when moving the upper extremity, such as scapula elevation or protraction or excessive trunk movement, should first be identified and corrected. Manual techniques, stretches, and strengthening exercises are initiated to correct muscle length or strength imbalances, followed by an emphasis on developing active control of weak musculature. As the patient learns to activate the weak muscles, progress to strengthening in functional patterns Because faulty postures or shoulder girdle mechanics may be impacted by impaired trunk strength or control, an emphasis on trunk stability should also be considered. With active cervical retraction and thoracic extension especially important for shoulder function After proper mechanics are restored, the patient should perform active ROM of all shoulder motions daily and return to functional activities to the extent tolerated GH Joint Hypomobility: Management Return to Function Phase Progressively Increase Flexibility and Strength Stretching and strengthening exercises are progressed as the joint tissue tolerates. The patient should be actively involved in self-stretching and strengthening by this time, so emphasis during treatment is on maintaining correct mechanics, safe progressions, and exercise strategies for return to function. Progressions may include increasing resistance and repetitions, performing exercises through multiple planes, adding perturbations, and incorporating regional muscle groups (such as the trunk) into dynamic exercises If capsular tissue is still restricting ROM, vigorous manual stretching and joint mobilization techniques are applied Prepare for Functional Demands if the patient is involved in repetitive heavy lifting, pushing, pulling, carrying, or reaching, exercises are progressed to replicate these demand GH Joint Hypomobility: Management Postmanipulation Under Anesthesia The arm is kept elevated overhead in abduction and external rotation during the inflammatory reaction stage; treatment principles progress as with any joint lesion. Therapeutic exercises are initiated the same day while the patient is still in the recovery room, with emphasis on internal and external rotation in the 90° (or higher) abducted position. Joint mobilization procedures are used, particularly a caudal glide, to prevent re-adherence of the inferior capsular fold. When sleeping, the patient may be required to position the arm in abduction for up to 3 weeks after manipulation Acromioclavicular and Sternoclavicular Joints Related Pathologies and Etiology of Symptoms Overuse syndromes Overuse syndromes of the AC joint may result from repeated stressful joint movements with the arm at waist level, such as with grinding, packing assembly, and construction work, or repeated diagonal extension, adduction, and internal rotation motions, as when spiking a volleyball or serving in tennis. The AC joint is susceptible to overuse syndromes in conjunction with arthritis or following a traumatic injury Subluxation or dislocation Subluxation or dislocation of either the AC or SC joints is usually caused by falling on the shoulder or an outstretched arm. At the AC joint, the distal end of the clavicle often displaces posteriorly and superiorly on the acromion, and the ligaments supporting the AC joint may rupture. After trauma and associated overstretching of the capsules and ligaments of either joint, hypermobility is usually permanent because there are almost no muscles that provide direct stability to these joints Hypomobility Decreased clavicular mobility may occur with SC joint OA and may contribute to TOS by compromising the space available for the neuromuscular bundle as it courses between the clavicle and first rib Acromioclavicular and Sternoclavicular Joints Common Impairments of Structure and Function Pain localized to the involved joint or ligament Painful arc toward the end-range of shoulder elevation Pain with shoulder horizontal adduction or abduction Hypermobility if trauma or overuse is involved. Hypomobility if sustained posture, arthritis, or immobility is involved Common Activity Limitations and Participation Restrictions Limited ability to sustain repeated forceful movements of the arm, such as with grinding, packing, assembly, and construction work Inability to reach overhead or perform repetitive overhead activities without pain Acromioclavicular and Sternoclavicular Joints Nonoperative Management of AC or SC Joint Strain or Hypermobility Minimize joint loading by supporting the weight of the arm with a sling Cross-fiber massage to the capsule or ligaments Maintain ROM of the GH joint and scapulothoracic articulation Instruction in self-application of cross-fiber massage if joint symptoms occur after excessive activity Increase strength of shoulder complex, trunk, and legs Gradually return to functional activities Nonoperative Management of AC or SC Joint Hypomobility Joint mobilization techniques are used to increase joint mobility Painful Shoulder Syndromes (Rotator Cuff Disease and Tendinopathies): Nonoperative Management Related Pathologies and Etiology of Symptoms The cause of rotator cuff disease is often multifactorial, involving both structural and mechanical factors The term impingement syndrome and its recent variants has traditionally described a cluster of signs and symptoms that typically includes pain with overhead reaching, a painful arc in the mid-range of arm elevation, and positive provocation tests Patients also often report waking at night with pain. Symptoms from cuff tendinopathy are usually brought on by excessive or repetitive overhead activities that place a high demand on the shoulder joint. Insight into the multifactorial nature of rotator cuff disease can be appreciated by a classification system that describes impingement as intrinsic or extrinsic, with extrinsic further classified as primary, secondary, and internal types of musculotendinous strain in the shoulder region can occur from overuse, such as anterior pectoral region pain from playing racket sports, or from trauma such as a fall, traction on the arm, or an automobile accident Painful Shoulder Syndromes (Rotator Cuff Disease and Tendinopathies): Nonoperative Management Intrinsic Impingement: Rotator Cuff Disease Intrinsic factors are those that compromise the structural integrity of the musculotendinous structures and include vascular changes in the rotator cuff tendons, tissue tension overload, and collagen disorientation and degeneration Intrinsic conditions typically involve the deep articular side of the tendons and may progress to articular-side rotator cuff tears, seen most often in those older than 40 years of age Extrinsic Impingement: Mechanical Compression of Tissues Extrinsic impingement is believed to occur as a result of mechanical compression of the rotator cuff against the anteroinferior one-third of the acromion in the suprahumeral space during arm elevation Tendon compression is believed to result from anatomical or biomechanical factors that decrease the physical dimensions of the suprahumeral space Painful Shoulder Syndromes (Rotator Cuff Disease and Tendinopathies): Nonoperative Management Primary extrinsic impingement Primary extrinsic impingement can result from anatomical or biomechanical factors. Anatomical factors include structural variations in the acromion or humeral head, and hypertrophic degenerative changes of the AC joint and coracoacromial ligament Neer first suggested that the size and shape of the structures that make up the coracoacromial arch are related to rotator cuff impingement. In later studies, variations of the acromion were identified and classified into three shapes: type I (flat), type II (curved), and type III (hooked) Rotator cuff pathology may be associated with types II and III—but not type I—acromial shapes Anatomical factors that decrease the suprahumeral space often have to be managed surgically Biomechanical factors include altered orientation of the clavicle or scapula during movement, or increased anterosuperior humeral head translations as may occur with a tight posterior GH capsule Painful Shoulder Syndromes (Rotator Cuff Disease and Tendinopathies): Nonoperative Management Secondary extrinsic impingement Secondary impingement describes mechanical compression of the suprahumeral tissues due to hypermobility or instability of the GH joint leading to increased translation of the humeral head This instability may be multidirectional or unidirectional and can occur with compromised static (GH ligaments) and/or dynamic restraints (rotator cuff insufficiency) Multidirectional instability ⚬ Some individuals have physiologically increased connective tissue extensibility, causing excessive joint mobility. In the GH joint, this increased extensibility allows larger than normal humeral head translations in all directions ⚬ Many individuals, particularly those involved in overhead activities, develop laxity of the capsule from continually subjecting the joint to tensile forces ⚬ A hypermobile GH joint may be supported satisfactorily by strong rotator cuff muscles; but with muscle fatigue, poor humeral head stabilization may lead to faulty humeral mechanics, trauma, and inflammation of the suprahumeral tissues Painful Shoulder Syndromes (Rotator Cuff Disease and Tendinopathies): Nonoperative Management Secondary extrinsic impingement Unidirectional instability with or without impingement ⚬ Unidirectional instability (anterior, posterior, or inferior) may be the result of physiological laxity of the connective tissues, but is more often the result of trauma and usually involves rotator cuff tears ⚬ Often, there is damage to the glenoid labrum and tearing of some of the supporting ligaments associated with these traumas Internal extrinsic impingement Internal impingement is a type of extrinsic impingement that occurs in a position of elevation, horizontal abduction, and maximum external rotation, primarily in throwing athletes This position and a posterior-superior shift of the humeral head on the glenoid results in a mechanical entrapment of the posterior supraspinatus tendon between the humeral head and the labrum Internal impingement is associated with a combination of posterior GH capsule tightness and scapula kinematic alterations Painful Shoulder Syndromes (Rotator Cuff Disease and Tendinopathies): Nonoperative Management Tendonitis/Bursitis Neer categorizes tendonitis/bursitis as a stage II impingement syndrome In contrast to tendinopathy, these conditions are associated with active inflammatory processes and may be localized to one or more specific tissues Supraspinatus tendonitis lesion is usually near the musculotendinous junction, resulting in a painful arc with overhead reaching There is also pain with provocation tests and pain on palpation of the tendon just inferior to the anterior aspect of the acromion when the patient’s hand is placed behind the back difficult to differentiate tendonitis from subdeltoid bursitis because of the anatomical proximity of these two structures Painful Shoulder Syndromes (Rotator Cuff Disease and Tendinopathies): Nonoperative Management Infraspinatus tendonitis lesion is usually near the musculotendinous junction, resulting in a painful arc during overhead, forward, or cross body motions may present as a deceleration (eccentric) injury due to overload during repetitive or forceful throwing activities Pain occurs with palpation of the tendon just inferior to the posterior corner of the acromion when the patient horizontally adducts and externally rotates the humerus Bicipital tendonitis lesion involves the long tendon in the bicipital groove beneath or just distal to the transverse humeral ligament Swelling in the bony groove is restrictive and compounds and perpetuates the problem Pain occurs with Speed’s test and on palpation of the bicipital groove Rupture or dislocation of the biceps tendon may compromise its role as a humeral depressor during arm elevation, promoting impingement of tissues in the suprahumeral space Painful Shoulder Syndromes (Rotator Cuff Disease and Tendinopathies): Nonoperative Management Bursitis (subdeltoid or subacromial) symptoms of bursitis are the same as those seen with supraspinatus tendonitis Once the inflammation is reduced, there are no symptoms with resisted motions Other Impaired Musculotendinous Tissues pectoralis minor, short head of the biceps, and coracobrachialis are subject to microtrauma, particularly in racquet sports requiring a controlled backward, then a rapid forward swinging of the arm. The scapular stabilizers, particularly the retractors, are also susceptible to microtrauma as they function to control forward motion of the scapula long head of the triceps and scapular stabilizers may be injured in motor vehicle accidents, as the driver holds firmly to the steering wheel on impact Injury, overuse, or repetitive trauma can occur in any muscle being subjected to stress.151 Pain occurs when the involved muscle is lengthened or when contracting against resistance. Palpating the site of the lesion causes the familiar pain Painful Shoulder Syndromes (Rotator Cuff Disease and Tendinopathies): Nonoperative Management Insidious (Atraumatic) Onset Neer has identified rotator cuff tears as a stage III impingement syndrome a condition that typically occurs in persons over age 40 after repetitive microtrauma to the rotator cuff or long head of the biceps With aging, the distal portion of the supraspinatus tendon is particularly vulnerable to impingement or stress from overuse strain With degenerative changes, calcification and eventual tendon rupture may occur Chronic ischemia caused from tension on the tendon and decreased healing in the elderly are possible explanations although Neer stated that, in his experience, 95% of tears are initiated by impingement wear rather than by impaired circulation or trauma Painful Shoulder Syndromes (Rotator Cuff Disease and Tendinopathies): Nonoperative Management Common Impairments of Structure and Function Impaired Posture and Muscle Imbalances Increased thoracic kyphosis, forward head, and protracted and forward-tilted scapula are often identified as related to impingement syndrome Faulty scapular alignment may be one factor in decreasing the suprahumeral space and leading to irritation of the rotator cuff tendons with overhead activities Faulty upper quadrant posture may also lead to an imbalance in the length and strength of the scapulothoracic and GH musculature, decreasing the effectiveness of the dynamic and passive stabilizing structures of the GH joint With increased thoracic kyphosis, the scapula is often protracted and tilted forward and the GH joint is internally rotated pectoralis minor, levator scapulae, and shoulder internal rotators may become tight, and the external rotators of the shoulder and upward rotators of the scapula may test weak and have poor muscular endurance When reaching overhead, faulty scapular and humeral mechanics may result in alterations of scapular alignment and in the muscular control of the shoulder complex Painful Shoulder Syndromes (Rotator Cuff Disease and Tendinopathies): Nonoperative Management Common Impairments of Structure and Function Decreased Thoracic ROM Thoracic extension is a component motion that is needed for full overhead reaching Incomplete thoracic extension may decrease the functional range of humeral elevation Explanations for this regional interdependence include decreased thoracic spine mobility leading to faulty scapulothoracic mechanics and altered muscle activity Rotator Cuff Overuse and Fatigue the rotator cuff musculature or long head of the biceps fatigue from overuse, they no longer provide the dynamic stabilizing, compressive, and translational forces that support the joint and control healthy joint mechanics Fatigue is thought to be a precipitating factor in secondary impingement syndromes when capsular laxity is present and increased muscular effort is necessary for stability Without this dynamic stability, the tissues in the subacromial space may become impinged as a result of faulty joint mechanics There is also a relationship between muscle fatigue and joint position sense in the shoulder that may play a role in impaired performance in repetitive overhead activities Painful Shoulder Syndromes (Rotator Cuff Disease and Tendinopathies): Nonoperative Management Common Impairments of Structure and Function Muscle Weakness Secondary to Neuropathy may be related to compromised nerve function Long thoracic nerve palsy has been associated with faulty scapular mechanics due to serratus anterior muscle weakness a movement dysfunction that may lead to rotator cuff impingement in the suprahumeral region Hypomobile Posterior GH Joint Capsule Loss of extensibility in the posterior GH joint capsule may negatively alter humeral head translations Increased superior translations during arm elevation are reported in studies that have experimentally tightened the posterior capsule Painful Shoulder Syndromes (Rotator Cuff Disease and Tendinopathies): Nonoperative Management Common Activity Limitations and Participation Restrictions In the acute stages, pain may interfere with sleep, particularly when rolling onto the involved shoulder Pain with overhead reaching, pushing, or pulling Difficulty lifting heavy loads Inability to sustain repetitive shoulder activities (such as reaching, lifting, throwing, pushing, pulling, or swinging the arm) Difficulty with dressing, particularly putting a shirt on over the head Painful Shoulder Syndromes (Rotator Cuff Disease and Tendinopathies): Nonoperative Management Common Activity Limitations and Participation Restrictions In the acute stages, pain may interfere with sleep, particularly when rolling onto the involved shoulder Pain with overhead reaching, pushing, or pulling Difficulty lifting heavy loads Inability to sustain repetitive shoulder activities (such as reaching, lifting, throwing, pushing, pulling, or swinging the arm) Difficulty with dressing, particularly putting a shirt on over the head Painful shoulder syndrome: Management Protection Phase Control Inflammation and Promote Healing Modalities and low-intensity cross-fiber massage are applied to the site of the lesion. While applying the modalities, position the extremity to maximally expose the involved region.41,45 If necessary to rest the part, temporarily support the arm in a sling. Patient Education environment and habits that provoke the symptoms must be modified or avoided completely during this stage patient should be informed about the mechanics of the irritation and the anticipated recovery and be given guidelines regarding safe exercises at this stage of healing Painful shoulder syndrome: Management Protection Phase Maintain Integrity and Mobility of the Soft Tissues Passive, active-assistive, or self-assisted ROM is initiated in pain-free ranges Multiple-angle muscle setting and protected stabilization exercises are initiated. When exercising the shoulder, it is particularly important to stimulate the stabilizing function of the rotator cuff, biceps brachii, and scapular muscles at an intensity tolerated by the patient PRECAUTION: Exercises during this stage must avoid the impingement positions. Often, the midrange of abduction, with internal rotation, or an end-range position when the involved muscle is on a stretch (such as putting the hand behind the back) provokes a painful response Painful shoulder syndrome: Management Protection Phase Control Pain and Maintain Joint Integrity Pendulum exercises without weights can be used to cause pain-inhibiting grade II joint distraction and oscillation motions Develop Support in Related Regions Postural awareness and correction techniques are used Supportive techniques, such as shoulder strapping or scapular taping, tactile cues, and mirrors, can be used for reinforcement. Repetitive reminders and practice of correct posture are necessary throughout the day Painful shoulder syndrome: Management Controlled Motion Phase Patient Education Patient adherence to the program and protection of healing tissues are necessary in this stage home exercise program is progressed as the patient learns safe and effective execution of each exercise Continue to reinforce proper postural habits Develop Strong, Mobile Tissues Manual therapy techniques, such as cross-fiber or friction massage, can be used extremity is positioned so the tissue is on a stretch if it is a tendon or in the shortened position if it is in the muscle belly technique is applied using forces and durations that are to the tolerance of the patient patient is instructed to perform an isometric contraction of the muscle in several positions of their available range. Intensity of contraction should not cause pain patient should be taught how to self-administer the massage and isometric techniques Painful shoulder syndrome: Management Controlled Motion Phase Modify Joint Tracking and Mobility MWM Posterolateral glide with active elevation ⚬ Patient position: Sitting with the arm by the side and head in neutral retraction ⚬ Therapist position and procedure: Stand on the side opposite the affected arm and reach across the patient’s torso to stabilize the scapula with the palm of one hand. The other hand is placed over the anteromedial aspect of the head of the humerus ⚬ Apply a graded posterolateral glide of the humeral head on the glenoid. Request that the patient perform the previously painful elevation. Maintain the posterolateral glide mobilization throughout both elevation and return to neutral ⚬ Ensure that no pain is experienced during the procedure. Adjust the grade and direction of the glide as needed to achieve pain-free function ⚬ Add resistance in the form of elastic resistance or a cuff weight to load the muscle Self-Treatment. A mobilization belt provides the posterolateral glide while the patient actively elevates the affected Painful shoulder syndrome: Management Controlled Motion Phase Develop Balance in Length and Strength of Shoulder Girdle Muscles It is important to design a program that specifically addresses the patient’s impairments Typical interventions in the shoulder girdle include but are not limited to: ⚬ Stretch shortened muscles. Shortened muscles typically include the pectoralis major, pectoralis minor, latissimus dorsi, teres major, subscapularis, and levator scapulae ⚬ Strengthen and train the scapulothoracic muscles. Important scapular muscles typically include the serratus anterior and lower trapezius for posterior tilting and upward rotation of the scapula and the middle trapezius and rhomboids for scapular retraction. Because it is important that the patient avoid scapular elevation when raising the arm, emphasize maintaining scapular depression when abducting and flexing the humerus ⚬ Strengthen and train the rotator cuff muscles. Place emphasis on the shoulder external rotators Painful shoulder syndrome: Management Controlled Motion Phase Develop Muscular Stabilization and Endurance Alternating isometric resistance is applied to the scapular muscles in open-chain positions (side-lying, sitting, supine), including protraction/retraction, elevation/depression, and upward/downward rotation so the patient learns to stabilize the scapula against externally applied forces Scapular and GH patterns are combined using flexion, abduction, and rotation. Alternating isometric resistance is applied to the humerus while the patient holds against the changing directions of the external resistance force Painful shoulder syndrome: Management Controlled Motion Phase Develop Muscular Stabilization and Endurance Closed-chain stabilization is performed with the patient’s hands fixated against a wall, a table, or the floor (quadruped position) while the therapist provides graded, alternating isometric resistance or rhythmic stabilization. If abnormal scapular winging occurs during the applied resistance, the scapular stabilizers are not strong enough for the demand and the position should be modified to reduce the challenge. This can be accomplished by changing the patient’s body position relative to gravity or modifying joint angles Muscular endurance is progressed by increasing the amount of time the individual holds the pattern against the alternating resistance. The limit is reached when any one of the muscles in the pattern can no longer maintain the desired hold. The goal at this phase should be stabilization for approximately 3 minutes Painful shoulder syndrome: Management Controlled Motion Phase Progress Shoulder Function As the patient develops strength in the weakened muscles, it becomes important to develop a balance in strength of all shoulder and scapular muscles within the range and tolerance of each muscle. To increase coordination between scapular and arm motions, dynamically load the upper extremity with submaximal resistance as the patient maintains the synergy pattern. To improve muscular endurance, increase the length of time the patient controls the correct pattern up to 3 minutes Painful shoulder syndrome: Management Return to Function Phase Increase Muscular Endurance To increase muscular endurance, repetitive loading of the defined patterns is increased from 3 minutes to 5 minutes Develop Quick Motor Responses to Imposed Stresses Apply the stabilization exercises with increased speed with shorter durations and faster transitions between the applied forces Plyometric training in both open-chain and closed-chain patterns is initiated if power is a desired outcome Painful shoulder syndrome: Management Return to Function Phase Progress Functional Training Specificity of training progresses to an emphasis on timing and sequencing of events Eccentric training is progressed to maximum load Desired functional activities are simulated—first under controlled conditions, then under progressively challenging conditions using acceleration/deceleration drills The patient is involved in assessing performance in terms of safety, symptom provocation, postural control, and ease of execution and then practices adaptations to correct any identified problems Painful shoulder syndrome Painful shoulder syndrome Shoulder dislocation Traumatic anterior shoulder dislocation Anterior dislocation most frequently occurs when there is a posteriorly directed force to the arm while the humerus is in a position of elevation, external rotation, and horizontal abduction. In that position, stability is provided by the subscapularis, GH ligaments (particularly the anterior band of the inferior ligament), and long head of the biceps. A significant force to the arm may damage these structures, along with the attachment of the anterior capsule and glenoid labrum Traumatic anterior dislocation can be associated with complete rupture of the rotator cuff with the incidence increasing in those over 40 years of age There may also be a compression fracture at the posterolateral margin of the humeral head Neurological or vascular injuries may also occur during dislocations The axillary nerve is most commonly injured, but the brachial plexus or one of the peripheral nerves could be stretched or compressed Shoulder dislocation Traumatic posterior shoulder dislocation Traumatic posterior shoulder dislocation is less common mechanism of injury is usually a force applied to the arm when the humerus is positioned in flexion, adduction, and internal rotation such as falling on an outstretched arm (foosh injured person complains of symptoms when doing activities such as push-ups, a bench press, or follow-through on a golf swing Shoulder dislocation Recurrent Dislocations With significant ligamentous and capsular laxity, recurrent subluxations or dislocations may occur with any movement that reproduces the humerus positions and forces that caused the original instability These episodes result in significant pain and functional limitations. Some individuals can voluntarily dislocate the shoulder anteriorly or posteriorly without apprehension and with minimal discomfort rate of recurrence after the first traumatic dislocation is highest in the younger population (< 30 years) longer immobilization (> 3 weeks) is advocated after dislocation in patient’s less than 30-years old. A shorter immobilization (1 to 2 weeks) is recommended for older patients Shoulder dislocation Common Impairments of Structure and Function After an acute traumatic injury, symptoms resulting from tissue damage include pain and muscle guarding due to bleeding and inflammation When a dislocation is associated with a complete rotator cuff tear, there is an inability to abduct the humerus against gravity Asymmetrical joint restriction/hypermobility. With anterior instability, the posterior capsule may become tight; with posterior instability, the anterior capsule may become tight. After healing from a traumatic event, there may be capsular adhesions With recurrent dislocations, the individual can dislocate the shoulder at will, or the shoulder may dislocate during specific activities Shoulder dislocation Common Activity Limitations and Participation Restrictions With rotator cuff rupture, inability to perform all activities requiring humeral elevation Possibility of recurrence when replicating the dislocating position or with forces applied to the arm in the dislocating position With anterior dislocation, restricted ability in sports activities, such as throwing, swimming, overhead serving, and spiking ⚬ Restricted ability with dressing, such as putting on a shirt or jacket, and with self-grooming, such as combing the back of the hair ⚬ Discomfort or pain when sleeping on the involved side With posterior dislocation, restricted ability in sports activities, such as follow-through in pitching and golf; restricted ability in pushing activities, such as pushing open a heavy door or pushing one’s self up from a chair Closed Reduction of Anterior Dislocation Management: Protection Phase Protect the Healing Tissue Activity restriction is recommended for 6 to 8 weeks in a young patient. If a sling is used, the arm is removed from the sling only for controlled exercise. During the first week, the patient’s arm may be continuously immobilized because of pain and muscle guarding An older, less active patient (> 40 years of age) may require immobilization for only 2 weeks The position of dislocation must be avoided when exercising, dressing, or doing other daily activities Closed Reduction of Anterior Dislocation Management: Protection Phase Promote Tissue Health Protected ROM, intermittent muscle setting of the rotator cuff, deltoid, and biceps brachii muscles, and grade II joint mobilization techniques in safe directions (with the humerus at the side or in the resting position) are initiated as soon as the patient tolerates them PRECAUTIONS: In order not to disrupt healing of the capsule and other damaged tissues after anterior dislocation, ROM into external rotation is performed with the elbow at the patient’s side, with the shoulder flexed in the sagittal plane, and with the shoulder in the resting position (in the plane of the scapula, abducted 55° and 30° to 45° anterior to the frontal plane) but not in the 90° abducted position. The forearm is moved from maximal internal rotation to 0° or possibly 10° to 15° external rotation Closed Reduction of Anterior Dislocation Management: Controlled Motion Phase Provide Protection patient continues to protect the joint and delay full return to unrestricted activity. If a sling is being used, the patient increases the time the sling is off sling is used when the shoulder is tired or if protection from external forces is needed Increase Shoulder Mobility Mobilization techniques are initiated using all appropriate glides except the anterior glide. The anterior glide is contraindicated even though external rotation is necessary for functional elevation of the humerus. For a safe stretch to increase external rotation, place the shoulder in the resting position (abducted 55° and horizontally adducted 30°); then externally rotate the humerus to the limit of its range and apply a grade III distraction force perpendicular to the treatment plane in the glenoid fossa The posterior joint structures are passively stretched with horizontal adduction self-stretching techniques Closed Reduction of Anterior Dislocation Management: Controlled Motion Phase Increase Stability and Strength of Rotator Cuff and Scapular Muscles Isometric resistance exercises with the joint positioned at the side and progressed to various pain-free positions within the available ranges Partial weight-bearing and stabilization exercises Dynamic resistance, limiting external rotation to 50° and avoiding the position of dislocation At 3 weeks, supervised isokinetic resistance for internal rotation and adduction at speeds of 180° per second or higher may be used Position the patient standing with the arm at the side or in slight flexion and elbow flexed 90°. The patient performs internal rotation beginning at the zero position with the hand pointing anteriorly and moving across the front of the body Progress to positioning the shoulder at 90° flexion. Have the patient perform the exercise from zero to full internal rotation. Do not position in 90° abduction By 5 weeks, all shoulder motions are incorporated into exercises on isokinetic or other mechanical equipment except for the position of 90° abduction with external rotation Closed Reduction of Anterior Dislocation Management: Return to Function Phase Restore Functional Control The following are emphasized: A balance in strength of all shoulder and scapular muscles Coordinated scapulothoracic and arm motions Endurance for each previously described shoulder stability exercise As stability improves, progress to: ⚬ Eccentric training to maximum load ⚬ Increasing speed and control of combined motions ⚬ Simulating desired functional patterns for activity Return to Full Activity patient can return to normal activities when there is no muscle strength imbalance, good coordination is present during skilled movements, and the apprehension test is negative. Full rehabilitation takes 2.5 to 4 months It is important that the patient learns to recognize signs of fatigue and impingement and is educated about how to reduce the exercise load when these signs are noticed Closed Reduction of Posterior Dislocation The management approach is the same as for anterior dislocation with the exception of avoiding the position of humeral flexion with adduction and internal rotation during the acute and healing phases When mobilization is allowed, begin joint mobilization techniques using all appropriate glides except the posterior glide Posterior glide is contraindicated If adhesions develop that limit internal rotation, mobility can be regained safely by placing the shoulder in the resting position (abducted 55° and horizontally adducted 30°), internally rotating it to the limit of its range, and applying a grade III distraction force perpendicular to the treatment plane in the glenoid fossa THANK YOU

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