Therapeutic Exercise II: The Shoulder and Shoulder Girdle Part 1 of 2 PDF

Therapeutic Exercise II PTA 1010 The Shoulder and Shoulder Girdle Part 1 of 2  Road Map By the end of this section the student should be able to: Describe the anatomy and function of the various parts of the shoulder girdle Understand common...

Therapeutic Exercise II PTA 1010 The Shoulder and Shoulder Girdle Part 1 of 2  Road Map By the end of this section the student should be able to: Describe the anatomy and function of the various parts of the shoulder girdle Understand common shoulder pathologies that would benefit from Therapeutic Exercise Interventions including hypomobility, hypermobility and soft tissue overuse conditions Effectively teach and progress/regress a therapeutic exercise program to manage musculoskeletal lesions, soft tissue and joint lesions based on the stages of tissue healing © Stanbridge University 2022 2  Road Map List common surgical procedures and any special associated precautions for soft tissue and joint pathology of the shoulder for hypomobility & instability Explain the goals of & appropriate interventions for post operative management of shoulder & shoulder girdle dysfunction for each of the phases of rehabilitation Demonstrate exercise progressions to develop and improve ROM, muscle performance, and functional use of the shoulder and shoulder girdle © Stanbridge University 2022 3  Outline Hypomobility: Structure and Nonoperative Function of the management and Shoulder Girdle TSA Painful Hypermobility: Biomechanical Instability of the Shoulder GH joint Syndromes © Stanbridge University 2022 4  Structure and Function of the Shoulder Girdle Joints of the shoulder girdle complex Shoulder girdle function Force couples of the shoulder complex © Stanbridge University 2022 5 Structure and Function of the Shoulder Girdle Most important Balance Mobility and Stability gymnasticbodies.com © Stanbridge University 2022 6  Shoulder Girdle Complex Synovial Joints: Create the mobility Glenohumeral (GH) Joint Acromioclavicular (AC) Joint Sternoclavicular (SC) Joint Functional Articulations: Allows for greater mobility Scapulothoracic articulation (ST) © Stanbridge University 2022 7 Anatomy Review Sternum fadavispt.mhmedical.com © Stanbridge University 2022 8  Glenohumeral Joint Incongruous ball and socket joint Tri-axial Lax joint capsule Supported by: -rotator cuff (RTC) -glenohumeral ligaments (superior, middle, inferior) -coracohumeral ligaments scottsdalecc.edu © Stanbridge University 2022 9  Glenohumeral Joint Glenoid fossa: shallow deepened by fibrocartilagenous lip Humeral head is 3-4x larger than glenoid fossa Glenoid labrum: Function: deepens fossa for greater congruency of joint surfaces - Creates a negative intraarticular vacuum effect - Attachment site for capsule © Stanbridge University 2022 10 View of Glenoid Fossa Netter, 2019 © Stanbridge University 2022 11  Glenohumeral Joint: Stability Provided by static and dynamic restraints Static: bony anatomy, ligaments, glenoid labrum, adhesive & cohesive forces in the joint Dynamic: RTC tendons blend with ligaments and glenoid labrum → contraction leads to tightening of the static restraints, providing stability Coordinated response of the RTC muscles © Stanbridge University 2022 12  Glenohumeral Joint: Stability Dynamic Stability: Long head of the biceps and long head of the triceps reinforce the capsule with their attachments Long head of the biceps: – Stabilizes against humeral elevation – Contributes to anterior stability by resisting torsional forces when in abduction & ER – contributes to humeral depression in CKC Long head of the triceps: inferior shoulder support © Stanbridge University 2022 13  Acromioclavicular Joint Plane, triaxial joint May or may not have disc Reinforced by superior & inferior AC ligaments Stability: AC ligaments are supported by the coracoclavicular ligament No direct dynamic support © Stanbridge University 2022 14  Acromioclavicular Joint: Arthrokinematics Acromion: concave facet Clavicle: convex facet When the scapula moves the acromial surfaces slides in same direction in which the scapula moves Scapular motions affecting the AC joint: -upward rotation -downward rotation -winging of vertebral border -tipping of inferior angle © Stanbridge University 2022 15  Sternoclavicular Joint Incongruent, triaxial, saddle-shaped joint Has disk Stability provided by: -Anterior and posterior SC ligaments -Interclavicular ligaments -Costoclavicular ligaments © Stanbridge University 2022 16  Sternoclavicular Joint: Arthrokinematics Motions of the clavicle occur as a result of the following scapular motions: – elevation – depression – Protraction – retraction www.sideplayer.com © Stanbridge University 2022 17  Clavicular Elevation and Rotation POSTERIOR ROTATION of the clavicle occurs as an accessory motion when the humerus is elevated above 90 degrees and the scapula is upwardly rotating Cannot occur in isolation Coracoclavicular ligament becomes taut slideshare.com to provide passive stability © Stanbridge University 2022 18  Scapulothoracic Articulation Motions of the scapula: -Elevation, depression -Adduction, abduction -Upward, downward rotation -Protraction (combo of abd, elevation, upward rot) -Retraction (combo of add, depression, downward rot) © Stanbridge University 2022 19 Scapular Motions Fig 17.5 © Stanbridge University 2022 20  Additional Motions of the Scapula Tipping/Tilting (anterior, posterior) – Anterior tilting occurs when reaching behind the back – Posterior tilting occurs during humeral elevation Winging: medial boarder lifts away from rib cage © Stanbridge University 2022 21  Subacromial Space/Suprahumeral Space Coracoacromial arch: Includes the acromion & coracoacromial ligament Lies over: -Subacromial/subdeltoid bursa -Supraspinatus tendon & part of the muscle -Long head of the bicep tendon © Stanbridge University 2022 22  Suprahumeral/Subacromial Space Netter, 2019 Contents include Inferior Acromion, Subdeltoid and Subacromial Bursa, Supraspinatus tendon, Long head of biceps tendon © Stanbridge University 2022 23  Subacromial Space/Suprahumeral Space Compromise of this space due to: -faulty posture -faulty muscle function -faulty joint mechanics -structural abnormalities of the acromion (Type I, II, III acromion) -injury to soft tissue in the region Leads to impingement syndrome! © Stanbridge University 2022 24 Shoulder Girdle Function What occurs and what can fail?  Review Force Couples 3 force couples: 1. Deltoid -rotator cuff 2. Trapezius/ serratus anterior 3. Anterior-posterior rotator cuff Why is each important? What happens if there is an imbalance? © Stanbridge University 2022 26  Shoulder Girdle Function Deltoid- RTC Relationship: Deltoid leads to upward translation of the humerus; if unopposed: impingement within subacromial space Downward Force/ translation and stabilizing producers: – Infraspinatus – Teres minor – Subscapularis Anatomage table © Stanbridge University 2022 27  Shoulder Girdle Function Deltoid- RTC Relationship: Supraspinatus: significant stabilizing, compressive, and slight upward translation effect on humerus with UE elevation What is another humeral depressor not mentioned on the last two slides? © Stanbridge University 2022 28  Trapezius/ Serratus Anterior Work together to create upward rotation of the scapula (UT, LT, SA) Assists in elevation of the UE When not functioning increased impingement due to lack of rotation to open the anterior shoulder © Stanbridge University 2022 29  Anterior /Posterior RTC Helps to keep the humeral head properly positioned in the glenoid Includes subscapularis, infraspinatus, and teres minor Opposes anterior-posterior glenohumeral joint translation © Stanbridge University 2022 30  Shoulder Girdle Function What occurs when there is failure? Interruption of Deltoid-RTC Coordination Tissue microtrauma Compression or overuse of soft tissues Shoulder dysfunction © Stanbridge University 2022 31 Scapulohumeral Rhythm © 2017 by F. A. Davis Company © Stanbridge University 2022 32  Scapulohumeral Rhythm 3 phases Assists in a total of 180 degrees elevation In general, 2:1 ration (GH jt. vs scapula) Discrepancies in sources regarding when the ratio is 1:1 vs 2:1 © Stanbridge University 2022 33  Scapulohumeral Rhythm Phase 1: 0-30° of abduction, 0-60° flexion Primarily GH motion, scapula is finding place of stability Phase 2: 30-90° degrees (depending on motion) Improved joint congruency as length- tension relationship of muscles is maintained (approaches 1:1 ratio) Phase 3: last 90 ° Dominated by glenohumeral motion Glenohumeral joint must ER to clear subacromial arch © Stanbridge University 2022 34 Shoulder Girdle Function Scapulohumeral Rhythm https://youtu.be/H4nfQEeJmFo © Stanbridge University 2022 35  Review How does a forward head and shoulder position affect the scapula and glenohumeral joint position? What are the various motions of the scapula? What are the major downward and upward rotators of the scapula? The what is the importance of the long head of the biceps and triceps? Why is ER of the humerus with shoulder elevation important? © Stanbridge University 2022 36 SHOULDER PATHOLOGY AND MANAGEMENT © Stanbridge University 2022 37  Shoulder Disorders and Surgeries Joint Hypomobility: Non-operative management Glenohumeral Joint: Surgery and post-operative management Shoulder Instabilities: Non-operative ,management; surgery & post- operative management Painful Shoulder Syndromes: Non-operative management (RTC disease, impingement syndromes); surgery and post-operative management © Stanbridge University 2022 38  Shoulder Pathologies General Interventions Hypomobility Restore Mobility/ ROM Hypermobility Restore STABILITY (strength) PAINFUL DISORDERS Restore proper BIOMECHANICS © Stanbridge University 2022 39  GH Joint Pathologies: Management Will initially be treated conservatively with attempts to avoid surgical intervention Involves pharmacology and active Physical Therapy with THERAPEUTIC EXERCISE If symptoms worsen, progress or do not respond to conservative care Surgery will be considered © Stanbridge University 2022 40  Outline Hypomobility: Structure and Nonoperative Function of the management and Shoulder Girdle TSA Painful Hypermobility: Biomechanical Instability of the Shoulder GH joint Syndromes © Stanbridge University 2022 41  Joint Hypomobility: Nonoperative Management Hypomobility can occur in any of the shoulder complex joints: Glenohumeral (GH) joint Acromioclavicular (AC) Sternoclavicular (SC) joints © Stanbridge University 2022 42  GH Joint Hypomobility: Restricted GH Joint Mobility can be due to: Rheumatoid arthritis Prolonged immobilization Traumatic arthritis Osteoarthritis Idiopathic frozen shoulder © Stanbridge University 2022 43 GLENOHUMERAL OSTEOARTHRITIS www.arthritis-health.com www.orthobullets.com © Stanbridge University 2022 44  GH joint Arthritis: Clinical Signs & Symptoms: Acute phase: Pain, muscle guarding limits motion (ER, abduction) Pain may radiate below elbow, disturb sleep Swelling not detectable (depth of capsule) © Stanbridge University 2022 45  GH joint Arthritis: Clinical Signs & Symptoms: Sub-acute Phase: Capsular tightness begins to develop Limited motion in capsular pattern: – ER> Abd> IR – Pain at end of available motion Limited joint play w/ testing (joint mob) © Stanbridge University 2022 46  GH joint Arthritis: Clinical Signs & Symptoms: Chronic Phase: Progressive restrictions in GH capsule Further limited motion and joint play Significant loss of function: unable to reach overhead, out to side, behind back Pain: aching in deltoid region © Stanbridge University 2022 47  Idiopathic Frozen Shoulder/ Adhesive Capsulitis Ave age of onset 40-65 y/o Characterized by gradual onset of pain and restricted movement Synovial inflammation followed by fibrosis of GH joint capsuloligamentous complex Self-limiting clinical entity Progresses through a series of stages © Stanbridge University 2022 48  Types of Adhesive Capsulitis: Primary: Idiopathic: for no apparent reason, cause unknown Secondary: Cause is known such as other injury, period of immobility Ex. Post op and in a sling © Stanbridge University 2022 49  Idiopathic Frozen Shoulder Clinical Signs & Symptoms: Stage 1: Pre-adhesive stage Tissue changes: mild erythematous synovitis Gradual onset of pain that increases w/motion Achy pain at rest Sleep disturbance -Loss of ER ROM (capsular pattern) -Intact RTC strength -Duration: < 3 months © Stanbridge University 2022 50  Idiopathic Frozen Shoulder Clinical Signs & Symptoms: Stage 2 “Freezing Stage”: Tissue changes: thickened red synovitis Acute discomfort with very painful end ranges of all motions Persistent, intense pain, even at rest Motion limited in ALL directions –Motion cannot be restored w/ intra-articular injection Duration: 3-9 months © Stanbridge University 2022 51  Idiopathic Frozen Shoulder Clinical Signs & Symptoms: Stage 3 “Frozen Stage”: Tissue changes: more mature capsuloligamentous fibrosis (adhesions) Large decrease in pain- Pain only with movement Limited GH motion, excessive scapular substitutions Atrophy of deltoid, RTC, biceps, triceps Duration: 9-15 months © Stanbridge University 2022 52  Clinical Signs & Symptoms: Idiopathic Frozen Shoulder Stage 4 “Thawing Stage”: Tissue changes: significant adhesions without synovitis Minimal pain Significant capsular restrictions Motion may gradually improve during this phase Duration: 15-24 months Average time from onset to recovery: 2 years © Stanbridge University 2022 53  Ideopathic Frozen Shoulder Stages 1 and 2 treated as Acute Stage 3 treated as Subacute Stage 4 treated as Chronic Aggressive therapy at the wrong time may prolong symptoms © Stanbridge University 2022 54 APTA Guidelines- Adhesive Capsulitis 2013 A Corticosteroid injections B Patient education B Stretching exercises C Modalities C Joint mobilization C Translational manipulation (anesthesia) © Stanbridge University 2022 55  GH joint Hypomobility: The symptom presentation and functional limitations are the same for all types of hypomobility Does not change based on the underlying cause: Arthritis, immobilization, idiopathic adhesive capsulitis © Stanbridge University 2022 56  GH Joint Hypomobility: Impairments Night pain, disturbed sleep during acute flares Pain with motion; pain at rest during acute flares Decreased joint play and ROM in capsular pattern Decreased arm swing during gait Possible postural compensations: protracted & anterior tilted scapula, elevated, protected shoulder © Stanbridge University 2022 57  GH Joint Hypomobility: Impairments Excessive scapular motion Muscle performance: -GH muscles: general muscle weakness and poor endurance -overuse of scapular muscles Difficulty lifting weighted objects Inability to reach overhead, behind head, out to side, behind back Limited ability to sustain repetitive activities © Stanbridge University 2022 58  GH Joint Hypomobility: Non-operative Management Acute Phase (Protection): Control Pain, Edema, Muscle Guarding Maintain Soft Tissue and Joint Integrity and Mobility –Pendulum (Codman’s) –PROM –Passive joint distraction, Grade I, II joint mobilizations –Gentle muscle setting Maintain Integrity and Function of Associated Regions –Hand exercises –Cervical ROM © Stanbridge University 2022 59  PROM to Relieve pain and pressure in the joint: Pendulum (Codman) Exercises Passive motion Move your body/hips not your arm No weight: gentle distraction of GH joint With weight: Grade III (stretching) distraction force Fig 17.22 © Stanbridge University 2022 60 Passive Exercises will progress to AAROM: Example- External Rotation The elbow should not abduct or adduct away from originally placed spot I.e., if ER should be at 0 degrees abd. then the elbow should remain against the side of the torso AAROM: Only assist active motion when necessary through the range. Fig 17.21 © Stanbridge University 2022 61  Exercise Examples: PROM, AAROM: Flexion, Abduction ER of the humerus should be encouraged with all shoulder elevation techniques © Stanbridge University 2022 62  S-Assisted Shoulder Elevation Supraspinatus is active with both Supraspinatus is MORE active with seated pulley systems These should be performed when the www.HEP2go.com patient is released from PROM only (referral or protocol) Ensure the GH joint is in ER when moving overhead www.shoulderdoc.co.uk © Stanbridge University 2022 63  GH Joint Hypomobility: Non-operative Management Subacute Phase (Controlled Motion): Control pain, edema, joint effusion – Functional activities – ROM: AAROM→ AROM→ resistance Progressively increase joint and soft tissue mobility – Passive Joint Mobilization – Self-Mobilization – Manual Stretching – Self Stretching © Stanbridge University 2022 64  GH Joint Hypomobility: Non-operative Management Controlled Motion Phase (Sub-acute): Inhibit Muscle Spasm & Correct Faulty Mechanics – Teach proper mechanics – Gentle joint oscillation – Sustained caudal glide – GH IR and ER strengthening – Protected WB Improve Joint Tracking (MWM) Improve Muscle Performance- Posture, trunk stability © Stanbridge University 2022 65  Interventions to Increase Motion: Mobilization with Movement: Posterior Lateral Glide Patient performs active elevation while a sustained posterior glide is performed Kisner & Colby Fig. 17.17 © Stanbridge University 2022 66 Exercises to increase motion: Self Caudal Glide (GH Joint) © Stanbridge University 2022 67 Exercises to increase motion: Self Anterior Glide © Stanbridge University 2022 68 Exercises to increase motion: Self Posterior Glide © Stanbridge University 2022 69 Self Stretching to Posterior Shoulder Stretch posterior capsule and Maintain proper spine posture external rotators, increase internal rotation © Stanbridge University 2022 70  Exercises to increase motion Subscapularis Stretch or stretch to increase ER A: Stretch into ER at 0° of abduction with pressure through distal radius and ulna if possible; Elbow stays braced against patient’s trunk B: Seated ER- set up to maintain correct abduction ROM through out the exercise, chest up to maintain proper thoracic positioning © Stanbridge University 2022 71  Exercises to increase motion: Pectoralis Major Self Stretch Clavicular portion of Sternal portion of pec major biased pec major biased © Stanbridge University 2022 72 Exercises to increase motion Levator Scapulae Self Stretch A: using upward rotation of the scapula to stretch B: using depression of the scapula to stretch © Stanbridge University 2022 73 Exercises to increase motion: Sleeper Stretch: to increase IR © Stanbridge University 2022 74  GH Joint Hypomobility: Non-operative Management Chronic Phase (Return to Function): Progressively increase flexibility and strength –Continue with strengthening Prepare for functional demands – Sport & work specific training: replicate the necessary demands (SAID principle) © Stanbridge University 2022 75  GH Joint Hypomobility: MUA MUA: Manipulation Under Anesthesia Used if no progress with conservative care Initially treat as an acute lesion Arm is kept in overhead and ER position Immediate joint mobilization, PROM daily -emphasize inferior glide -emphasize abduction, ER Positioning (sleep, etc.): in ER and abduction (to avoid capsular pattern) © Stanbridge University 2022 76  Review What is the capsular pattern of motion loss for the glenohumeral joint? When does the capsular pattern of motion loss typically occur in a joint? What are 3 appropriate interventions for glenohumeral arthritis in the acute phase of healing? What are some of the causes of AC joint pathology? What motions of the shoulder will be limited in the acute phase of AC joint healing? © Stanbridge University 2022 77  www.hss.edu GLENOHUMERAL JOINT PATHOLOGY AND POST OP MANAGEMENT © Stanbridge University 2022 78  Arthroplasty Any reconstructive joint procedure, with or without a joint implant, used to relieve pain and improve function Types: -Excision Arthroplasty -Excision Arthroplasty w/ implant -Interposition Arthroplasty -Joint Replacement Arthroplasty Management: Follow PROTOCOL © Stanbridge University 2022 79  Joint Replacement Arthroplasty Total Joint Replacement: Resection of both affected articulating surfaces & replacement with artificial components relieve pain & improve function in those with severe joint degeneration associated w/ late-stage arthritis Hemi-replacement Arthroplasty: resection of just one of the articulating surfaces Indications: late-stage arthritis, femoral neck and proximal humeral fractures © Stanbridge University 2022 80 Total Shoulder Arthroplasty TSA rTSA www.hss.edu www.orthoinfo.aaos.org © Stanbridge University 2022 81  Glenohumeral Joint Surgery Glenohumeral arthroplasty – TSA= Total shoulder Arthroplasty – rTSA: Reverse TSA Used for RTC deficiency – Hemiarthroplasty Insufficient bone stock for fixation of a glenoid implant Arthrodesis of the shoulder: fusion of the joint © Stanbridge University 2022 82  rTSA, TSA, Hemiarthroplasty Surgical Procedures Deltopectoral incision from AC joint to deltoid insertion Subscapularis tendon release from lesser tuberosity Deltoid retraction and sometimes pec minor release Anterior capsulotomy Exposure of humeral head Preparation of humeral canal for insertion of the prosthetic implant Glenoid fossa debrided and contoured (TSA) © Stanbridge University 2022 83 GH Arthroplasty: Post operative Management Key Points ROM Goals TSA* -Elevation: 140-150 degrees -ER: 45-50 degrees * with sufficient postoperative static & dynamic stability rTSA -Elevation: 90-120 -ER: 0-20 © Stanbridge University 2022 84  GH Arthroplasty: Post operative Management: Exercise Progression Think about the anatomical structures involved in the surgery & goals -What was cut? -What was repaired? -What is the post-operative time frame? -What is the patient telling you? -How is the patient responding to treatment? -Use protocols to assist in guiding your exercise program © Stanbridge University 2022 85  GH Arthroplasty: Post operative Management- Immobilization Sling or Splint used post operatively to protect reattached & repaired tissues Removed only for exercise and bathing initially, then weaned from sling during the day ASAP Usually, 4-6 weeks but up to 8-12 weeks CHECK PROTOCOL for Immobilization timeframe This is part of the Maximum Protection Phase © Stanbridge University 2022 86  GH Arthroplasty: Post operative Management- Positioning In sling or when resting out of the sling: Box 17.3 Arm in slight flexion (10°-20°), slight abduction Elbow flexion- 90° Forearm and hand resting on abdomen Forearm/hand supported on pillow Scapula in resting position (i.e., not elevated towards ears) Consider how this promotes the capsular pattern of ROM loss after immobilization © Stanbridge University 2022 87  GH Arthroplasty: Post operative Management Correct Faulty Posture!! It will affect shoulder ROM outcomes © Stanbridge University 2022 88  GH Arthroplasty: Post operative Management Table 17.2 TSA vs rTSA © Stanbridge University 2022 89  GH Arthroplasty: Post operative Management Maximum Protection Phase: Day 1→4-6 weeks Hospitalization (3-4 days): review precautions, HEP Control pain & inflammation Maintain mobility of adjacent joints Restore (maintain) shoulder mobility (progression) Minimize muscle inhibition, guarding & atrophy: © Stanbridge University 2022 90  Precautions: Maximum Protection Phase: Shoulder Arthroplasty Precautions PROM, AAROM only rTSA: ER to neutral TSA: ER to < 30 degrees No extension or horizontal abduction beyond neutral No combined extension, adduction, IR No lifting of objects with involved arm No weight bearing i.e. getting up from chair, during bed mobility No driving for 4-6 weeks Wear sling as indicated Box 17.4- Precautions Box 17.3- Positioning after TSA © Stanbridge University 2022 91 Gentle Post-op AAROM Exercise: Gear Shift Exercise © Stanbridge University 2022 92  GH Arthroplasty: Post operative Management -TSA vs rTSA Maximum Protection Phase Considerations: see Table 17.2 TSA with RTC repair: follow RTC repair guidelines: PROM only through first phase of rehabilitation, different ROM restrictions, etc. rTSA: 1-pound lifting restriction x 6 weeks ER from 0-20 degrees for 3 months Elevation: 90-120 for 3 months No shoulder hyperextension No using shoulder to support body weight © Stanbridge University 2022 93  GH Arthroplasty: Post operative Management TSA Criteria for Progression to Moderate Protection/Controlled Motion Phase: PROM: Elevation to 90, ER to 45, IR to 70 in plane of scapula w/ Minimal Pain No pain during resisted isometric IR Able to perform midline, waist-level ADL’s with no/minimal pain For rTSA: tolerance to AAROM, ability to isometrically activate deltoid and periscapular muscles while positioned in scapular plane © Stanbridge University 2022 94  GH Arthroplasty: Post operative Management Exercise: Moderate Protection/Controlled Motion Phase 4-6 weeks→12-16 weeks Control pain & inflammation Progressively Increase ROM of the shoulder Develop Active Control & Dynamic Stability © Stanbridge University 2022 95  rTSA Special Considerations Moderate Protection Phase: 4-6 weeks→12-16 weeks No WB through arm until 12 weeks Pain free submaximal isometrics to repaired muscles and subscapularis Dynamic low-resistance exercises for elbow, wrist, and hand Late in phase: RTC strengthening, strengthening to scapula & shoulder muscles b/w 0-90 degrees with light weights/bands (progress: supine → sitting) © Stanbridge University 2022 96  Submaximal Isometrics: Flexion, Abduction and ER Kisner & Colby Fig. 17.19 © Stanbridge University 2022 97  Isometric or Dynamic Manual Resistance to Scapular Muscles A: scapular elevation and depression; pt’s arm is supported by therapist B: scapular protraction and retraction; can also do in side-lying position © Stanbridge University 2022 98  Dynamic Manual Resistance to ER/IR Muscles Manual: gauge force used Can do at various angles © Stanbridge University 2022 99 Isometric Resistance in Scapular Plane Can do at various angles of elevation depending on symptoms and objective findings © Stanbridge University 2022 100 Isometric Stabilization Exercise More advanced than “muscle setting” Apply resistance to shoulder girdle in varying sequence of flexion/extension, abduction, adduction, ER/IR Can do single arm without wand Eyes open vs. eyes closed © Stanbridge University 2022 101  GH Arthroplasty: Post operative Management Criteria to Progress to Minimal Protection/Return to Function Phase: Pain free PROM/AAROM: -flexion to at least 130-140 degrees -abduction to 120 -ER to 60, IR to 70 in plane of scapula Active elevation of the UE against gravity to 100-120 degrees with proper mechanics MMT: 4/5 for RTC and deltoid © Stanbridge University 2022 102  GH Arthroplasty: Post operative Management Minimum Protection/Return to Function Phase: 12-16 weeks (+) Continue to improve or maintain shoulder mobility Continue to improve neuromuscular control & muscle performance Return to most functional activities Box 17.2- Associated Complications © Stanbridge University 2022 103 CKC Scapular and GH Stabilization Exercises (B) In minimal WB position Unilateral on less stable surface © Stanbridge University 2022 104  Review What is the difference between TSA and r-TSA? What muscle is retracted and reattached with a TSA? Based on the protocol in the Kisner, what exercises are appropriate for a patient s/p R TSA at s/p post –op 6 weeks? Write them as you would in the objective section of a SOAP note. © Stanbridge University 2022 105  Outline Hypomobility: Structure and Nonoperative Function of the management and Shoulder Girdle TSA Painful Hypermobility: Biomechanical Instability of the Shoulder GH joint Syndromes © Stanbridge University 2022 106 www.sghs.org www.en.wikepedia.org SHOULDER INSTABILITY (HYPERMOBILITY) © Stanbridge University 2022 107  Shoulder Instabilities: Atraumatic hypermobility: due to generalized connective tissue laxity or microtrauma related to repetitive activities Traumatic hypermobility: high force event(s) compromise the integrity of the stabilizing structures, often dislocating the GH joint – Unidirectional – Multi-directional © Stanbridge University 2022 108 Atraumatic Hypermobility: Unidirectional Instability Anterior, posterior, OR inferior Due to: - physiologic laxity of connective tissue - repetitive microtrauma due to non-uniform loading of the joint Humeral head may continue to dislocate or sublux in the direction of the instability Can lead to progressive degeneration of tissue, & eventual tearing of the supportive structures © Stanbridge University 2022 109  GH Instability Anterior: Excessive anterior humeral head translation due to forces against the arm when it is in an abducted and externally rotated position Posterior: Can occur from repetitive or forceful forces against a forward flexed, adducted, Internally rotated humerus Inferior: Typically, the result of RTC weakness or paralysis (hemiplegia) Multidirectional: Occurs when stability of the GH joint is compromised in more than one direction © Stanbridge University 2022 110  Recurrent Dislocations With significant ligamentous and capsular laxity: one or multi- directional subluxations or dislocations may occur with any motion that reproduces the forces that caused the original instability Voluntary dislocations: worse prognosis Can dislocate without apprehension and with minimal discomfort Rate of recurrence after first traumatic dislocation is highest in younger populations (< 30 years old) © Stanbridge University 2022 111  Closed Reduction of Anterior Dislocations: Management Acute Phase (Protection): Protect healing tissue Promote tissue health Subacute Phase (Controlled Motion): Provide protection Increase shoulder mobility Increase stability & strength of the RTC and scapular muscles Chronic Phase (Return to Function): Restore functional control Return to activity © Stanbridge University 2022 112  Closed Reduction of Posterior Dislocations: Management Same general rehabilitation as anterior/inferior dislocation EXCEPT it is important to avoid: Humeral flexion with adduction, and IR during the acute and healing phases It is CONTRAINDICATED to to perform a posterior glide once mobilization is allowed © Stanbridge University 2022 113  External Rotation Evidence Reinold et al, JOSPT, 2009 Infraspinatus: activation greater at lower shoulder abduction angles Teres minor: activation unaffected by shoulder angle Best exercise: Teres minor + infraspinatus= side-lying shoulder ER Followed by: – Standing ER @ 45° Abd – Prone ER @90° Adding towel roll between elbow and trunk increases ER muscle EMG 20-25% © Stanbridge University 2022 114  Muscle Activation Evidence Reinold et al, JOSPT, 2009 Application of Research for ER USE a TOWEL ROLL Alter position based on the muscle you are trying to focus on Variety in your program © Stanbridge University 2022 115  Internal Rotation Evidence Reinold et al, JOSPT, 2009 IR at 0 degrees abduction- very stable, add a towel roll for 20-25% increased activity IR at 90 degrees abduction- unstable position for the shoulder, less pectoralis activity, enhances scapular position -> helps isolate subscapularis IR diagonal exercise- more functional (not PNF) © Stanbridge University 2022 116  Abduction in Plane of the Scapula Standing “Full Can”: Better than empty can for isolating supraspinatus from deltoid Improved GH mechanics Scapular plane: 30 degrees anterior from the frontal plane Reinold et al, JOSPT, 2009 © Stanbridge University 2022 117  Abduction in Plane of the Scapula Prone full can: Greater EMG of posterior deltoid vs middle Decreases superior sheer force Prone position activates scapular muscles © Stanbridge University 2022 118  Deltoid Evidence Reinold et al, JOSPT, 2009 Posterior deltoid: Not a large roll in abduction or superior humeral head migration High activity with prone full can Shoulder stability: 600 Abduction: All deltoid muscles cause instability via translation of humeral head anteriorly 600 Scaption: Deltoid muscles contribute to stability © Stanbridge University 2022 119  Deltoid Evidence Reinold et al, JOSPT, 2009 Middle deltoid: Most significant impact on superior head migration High activity with empty can Anterior deltoid: At start of FULL CAN: very effective abductor At start of EMPTY CAN: not effective abductor at all; large superior humeral migration pull © Stanbridge University 2022 120  Serratus Anterior Evidence Reinold et al, JOSPT, 2009 Serratus function Prevents scapular winging and anterior tilt Serratus + upper and lower trap= upward rot of scapula Top activation activities: – Push with plus – Dynamic hug – Supine punch © Stanbridge University 2022 121 Serratus Anterior Evidence Reinold et al, JOSPT, 2009 © Stanbridge University 2022 122  Lower Trapezius Evidence Reinold et al, JOSPT, 2009 Top activation exercises: Prone full can Prone ER at 900 Prone horizontal abduction at 900 © Stanbridge University 2022 123  Rhomboids and Levator Scapulae Evidence Reinold et al, JOSPT, 2009 The best exercises for activation of both are: Scapular abduction above 120° with ER Prone horizontal abduction at 90° abduction with IR and ER Prone rowing Prone extension from 90° flexion © Stanbridge University 2022 124 Prone Scapular Retraction against resistance Scapular retraction (setting) towards spine should be initiated prior to horizontal abduction of shoulder © Stanbridge University 2022 125 Horizontal Abduction & Scapular Retraction ✓ Scapular retraction (setting) first ✓ Thumbs facing ceiling (shoulder in ER): emphasize strengthening of the middle and lower trapezius © Stanbridge University 2022 126 Surgical Intervention for capsular instability © Stanbridge University 2022 127 Capsule Stabilization & Reconstruction Causes of Joint Instability: Congenital predisposition (Ehlers Danlos Syndrome) vs. Traumatic dislocation (fall) vs. Progressive joint laxity (due to repetitive stresses in extreme positions - pitchers) © Stanbridge University 2022 128  GH Joint Stabilization Procedures Procedures: Open stabilization or arthroscopic – Most common: recurrent anterior unidirectional stabilization surgery Capsulorrhaphy (Capsular Shift) Elecrothermally assisted Capsulorrhaphy Bankart repair Capsulolabral Reconstruction SLAP repair surgeries © Stanbridge University 2022 129  Capsule Stabilization & Reconstruction Common Surgical Procedures used for the shoulder: 1. Capsulorrhaphy (Capsular shift): portion of capsule is incised and tightened through imbrication/plication of the redundant tissue 2. Electrothermally assisted capsulorrhaphy: thermal energy (laser) used to shrink selective portions of capsule 3. Capsulo-labral Reconstruction: reattachment of labrum to glenoid, w/ stabilization of capsule © Stanbridge University 2022 130  GH Joint Stabilization Procedures & Postoperative Management CAPSULORRHAPHY/CAPSULAR SHIFT: Procedure is tailored to the direction (s) of instability -anterior -inferior -posterior -multidirectional (usually ant/inferior) Open or arthroscopic © Stanbridge University 2022 131 Bankart Repair www.drmillet.com © Stanbridge University 2022 132  GH Joint Stabilization Procedures & Postoperative Management BANKART REPAIR: Lesion: detachment of capsulolabral complex from anterior rim of the glenoid; often occurs with anterior dislocation May be accompanied by capsular shift procedure if there is capsular redundancy Open repair: subscapularis detached or split; tend to get more secure fixation; what tissue is affected? Arthroscopic: subscapularis not disturbed © Stanbridge University 2022 133  GH Joint Stabilization Procedures & Postoperative Management SLAP REPAIR: tear of the superior labrum Superior Labrum extending Anterior to Posterior May/May not be associated with tear of the long head of the biceps tendon Arthroscopic Repair: – Debridement of torn portion of labrum – Abrasion of the bony surface of the superior glenoid – Reattachment of the labrum and biceps tendon with tacks or suture anchors © Stanbridge University 2022 134  Shoulder Instability Surgery: Postoperative Management IMMOBILIZATION POSITION: determined by direction(s) of instability prior to surgery Anterior or anteroinferior instability: splint or sling with arm at side or varying degrees of abduction, with arm in IR , slightly anterior to the plane of the body Posterior or posteroinferior instability: orthosis with shoulder in “handshake” position: neutral to 20 degrees of ER, arm at side or in slight extension © Stanbridge University 2022 135  Capsule Stabilization & Reconstruction General Rehabilitation Goals & Management Restore balance of joint stability and functional motion while protecting the repaired tissues Amount of immobilization & progression depends on surgery type, type of injured tissue, severity of injury, tissue fixation, quality of injured tissue © Stanbridge University 2022 136  Capsule Stabilization & Reconstruction General Rehabilitation Goals & Management, cont.: Restore ROM, initially within protected range caution when stressing portions of capsule that were tightened or repaired Strengthen dynamic stabilizers of the joint once strengthening is permitted PROTOCOL © Stanbridge University 2022 137 PRECAUTIONS FOLLOWING ANTERIOR GH STABILIZATION ANTERIOR CAPSULAR SHIFT, BANKART REPAIR Limit ER, horizontal abduction, extension during first 6 weeks (anything placing stress on the anterior aspect of the capsule): ADL’s, exercise NO vigorous stretching to increase end range ER for 8-12 weeks (Check protocol) when permissible, avoid positioning the shoulder in abduction and ER during Grade III or higher joint mobilizations © Stanbridge University 2022 138  Outline Hypomobility: Structure and Nonoperative Function of the management and Shoulder Girdle TSA Painful Hypermobility: Biomechanical Instability of the Shoulder GH joint Syndromes © Stanbridge University 2022 139 PAINFUL SHOULDER SYNDROMES: NON-OPERATIVE MANAGEMENT Impingement Tendonitis/Tendinopathy Bursitis © Stanbridge University 2022 140  Painful Shoulder Syndromes: SPS/Impingement Subacromial Pain Syndrome/Impingement: mechanical compression and irritation of the RTC and subacromial bursa (SAB) within the suprahumeral space (subacromial space) – Pain with overhead reaching – Painful arc (pain at mid range elevation) – Positive impingement tests © Stanbridge University 2022 141  Intrinsic Impingement: Rotator Cuff Disease (RTC) Intrinsic Factors: those that compromise the integrity of the musculotendinous structures: -Vascular changes in RTC tendons -Tissue tension overload -Collagen disorientation and degeneration Often seen in those > 40 May progress to RTC tears © Stanbridge University 2022 142  Extrinsic Impingement: Mechanical Compression of Tissues Extrinsic Factors: (Less supported in literature as primary cause) Mechanical wearing of the RTC against the anterior/inferior 1/3 of the acromion Caused by decreased dimensions of the subacromial space due to anatomy biomechanical factors © Stanbridge University 2022 143  Acromion shape Kisner & Colby Figure 17.16 Having an acromion shape of type III would lead to which type of impingement? a. intrinsic b. extrinsic © Stanbridge University 2022 144  Faulty Posture How about assuming this posture? Forward head, thoracic kyphosis, forward tilt & downward rotation of the scapula, relative abduction, IR of the humerus Fig 17.6 © Stanbridge University 2022 145  Scapular Stability & Posture Slouched posture alters L/T relationship of the scapular and humeral muscles, altering mechanics of the GH joint! Impingement and pain!! © Stanbridge University 2022 146 Roundback/Forward Head Faulty Posture Increased thoracic kyphosis Weakness in serratus Round Anterior tipping anterior, back/Forward of scapula trapezius, and ERs Head Posture Decreased flexibility of pec minor, levator scap, scalenes and IRs © Stanbridge University 2022 147  Tendinopathy Camargo et al. 2014 What is the function of a tendon? – Transmitting muscle forces to bone. What is the cause of a tendinopathy? – Excessive mechanical loading Healing phases of tendon is longer than typical soft tissue. – Inflammatory phase: 1-7 days – Repairing phase: day 5 to 7-5 weeks – Remodeling phase: 6 weeks -10 weeks – Maturation phase: 10 wks-1 year Supportive evidence for eccentric exercise for shoulder tendinopathy is lacking © Stanbridge University 2022 148 Painful Shoulder Syndromes: Tendonitis/Bursitis Supraspinatus tendonitis Infraspinatus tendonitis Bicipital tendonitis Subdeltoid bursitis Subacromial bursitis Anatomage table © Stanbridge University 2022 149  Supraspinatus Tendonitis Lesion normally near musculotendinous junction Painful arc with overhead reaching + Impingement tests Pain with palpation= just inferior to the anterior aspect of the acromion when patient’s hand is behind the back www.enkiverywell.com © Stanbridge University 2022 150  Infraspinatus Tendonitis Lesion usually near the musculotendinous junction Painful arc with overhead, forward, or cross body motions May be due to a deceleration injury with throwing Pain with palpation (inferior to the posterior corner of the acromion with patient positioned in horizontal add, ER) www.painscience.com © Stanbridge University 2022 151  Bicipital Tendonitis Lesion of long head of bicep tendon within bicipital groove beneath or just distal to the transverse humeral ligament Swelling in bony groove is restrictive and compounds the problem +Speed’s Test Pain with palpation of bicipital groove Rupture or dislocation of this humeral depressor may escalate impingement in suprahumeral space www.coastalorthoteam.com © Stanbridge University 2022 152  Bursitis Subdeltoid or subacromial bursa Acute phase: same symptoms as supraspinatus tendonitis As acute phase subsides: no symptoms with resisted movement www.nielasher.com © Stanbridge University 2022 153  Painful Shoulder Syndromes Other Musculo-tendinous Problems: Injury, overuse, repetitive trauma can occur in any muscle subject to stress – Pain with palpation of injured tissue – Pain with limited motion with muscle lengthening – Pain and weakness with muscle contracting Pectoralis minor, short head of biceps coracobrachialis subject to microtrauma with racquet sports © Stanbridge University 2022 154  Review What are typical patient complaints with GH impingement? What are appropriate exercises to perform for subdeltoid bursitis, proximal bicipital tendonitis, or supraspinatus tendonitis in the acute phase of tissue healing? Subacute? © Stanbridge University 2022 155  Road Map By the end of this section the student should be able to: Describe the anatomy and function of the various parts of the shoulder girdle. Understand common shoulder pathologies that would benefit from Therapeutic Exercise Interventions including hypomobility, hypermobility and soft tissue overuse conditions Effectively teach and progress/regress a therapeutic exercise program to manage musculoskeletal lesions, soft tissue and joint lesions based on the stages of tissue healing. © Stanbridge University 2022 156  Road Map List common surgical procedures and any special associated precautions for soft tissue and joint pathology of the shoulder for hypomobility, instability and decompression. Explain the goals of & appropriate interventions for post operative management of shoulder & shoulder girdle dysfunction for each of the phases of rehabilitation. Demonstrate exercise progressions to develop and improve ROM, muscle performance, and functional use of the shoulder and shoulder girdle. © Stanbridge University 2022 157  References Michael Reinold, PT, DPT, ATC, CSCS, Rafael Escamilla, PT, PhD, CSCS, FACSM, Kevin Wilk, PT, DPT, Current concepts in the scientific and clinical rationale behind exercises for the glenohumeral and scapulothoracic musculature. JOSPT 2009; 39(2):105-117 Olivier van der Meijden, MD, Paul Westgard, PT, Zachary Chandler, PT, Trevor R Gaskill, MD, Dirk Kokmeyer, PT, Peter J Millett, MD, Rehabilitation after arthroscopic rotator cuff repair: Current concepts, review and evidence-based guidelines. IJSPT 2012; 7(2): 197-218 Paula Camargo, Francisco Alburquerque-Sendin, Tania F Salvini, Eccentric training as a new approach for rotator cuff tendonipathy: Review and Perspectives. World J Orthop 2014; 5(5): 634-644 © Stanbridge University 2022 158