Therapeutic Exercise II: The Shoulder (Part 2 of 2) PDF

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

Therapeutic Exercise II PTA 1010 The Shoulder part 2 of 2  Outline RTC tears: Other Joints of the nonsurgical & Shoulder: surgical management AC joint & SC joint Nerve Pathology in Referred Pain the Shoulder © Stanbridge University 2022 2  Road Map By the end of this section the student should be able to: Understand RTC tear injuries, associated impairments, functional limitations disabilities Effectively teach and progress/regress a therapeutic exercise program to manage a RTC non surgically Understand the surgical interventions of decompression and RTC repair and how to manage the post-operative therapy Understand the pathology of the AC and SC joints, along with common management of the condition and potential surgical interventions Understand the common site of referred pain to the shoulder Understand common site of nerve pathology in the shoulder © Stanbridge University 2022 3  Painful Shoulder Syndromes: Atraumatic RTC Tear Insidious tear following repetitive micro-trauma to long head of biceps or RTC Usually over 40 years of age Age: increased vulnerability due to impaired circulation, degenerative changes, and calcification →especially distal portion of supraspinatus tendon © Stanbridge University 2022 4  Painful Shoulder Syndromes: Atraumatic RTC Tear Common Impairments: Impaired Posture: increased T/S kyphosis, forward head, anteriorly tilted scapula Muscle imbalances: -Hypo-mobile: pectoralis minor and major, levator scapula, GH IR’s -Weak: serratus anterior and GH ER’s Hypo-mobile posterior GH capsule © Stanbridge University 2022 5  Painful Shoulder Syndromes: Atraumatic RTC Tear Common Impairments, continued Hypomobile C/S, or T/S: decreased T/S extension mobility Faulty kinematics during humeral elevation - decreased posterior tipping of scapula -scapular elevation and overuse of the upper trapezius -altered scapulohumeral and scapulothoracic rhythms © Stanbridge University 2022 6  Painful Shoulder Syndromes: Atraumatic RTC Tear IF full thickness supraspinatus tear: unable to abduct humerus against gravity without compensations © Stanbridge University 2022 7  Painful Shoulder Syndromes: Functional Limitations & Disabilities Acute pain: interferes with sleep; often unable to lie on that shoulder Pain with overhead reaching, pushing, pulling Difficulty lifting loads Difficulty sustaining repetitive shoulder activities (swinging, reaching, throwing, etc.) Difficulty with dressing or bathing, especially putting T-shirt on overhead, reaching behind back, etc. © Stanbridge University 2022 8  Painful Shoulder Syndromes: Acute Phase Management Acute Phase- Compare/Contrast Box 10.1 Control inflammation, promote healing Patient education Maintain integrity and mobility of the soft tissues Address dysfunctions in related regions Box 10.3- Review signs of excessive stress © Stanbridge University 2022 9  Subacute Phase Management Subacute Phase: Compare/contrast Box 10.2 Goal: progressive nondestructive movement with proper mechanics while tissues heal Direct intervention based on evaluation findings: If mobility is restricted: mobilize If mobility is excessive: gain neuromuscular control, stabilize scapula and glenohumeral joint © Stanbridge University 2022 10  Chronic Phase Management Patient education Develop strong, mobile tissues Modify joint tracking and mobility Develop balance in length and strength of shoulder girdle muscles Develop muscular stabilization and endurance Progress shoulder function © Stanbridge University 2022 11  Chronic Phase Management Chronic Phase Increase muscular endurance Develop quick motor responses to imposed stresses Progress functional training – Progress eccentric training – Simulate functional activities – Prevention instructions (Box 17.7) © Stanbridge University 2022 12 Eccentric Shoulder strengthening Exercises: WWW.HEP2GO.COM © Stanbridge University 2022 13  Surgery & Postoperative Management Subacromial Decompression (SAD) and postoperative management Rotator Cuff Repair and postoperative management © Stanbridge University 2022 14  Subacromial Decompression Also called: anterior acromioplasty or decompression acromioplasty Increases the volume of the subacromial space to provide adequate gliding room for the tendons www.sgsc.net © Stanbridge University 2022 15  Excision (Resection) Arthroplasty Removal of periarticular bone from one or both articular surfaces Resect the edge of the acromion to increase volume of subacromial space Kisner & Colby Fig. 17.19 © Stanbridge University 2022 16  Subacromial Decompression: Post-operative Management Considerations: Whether or not RTC was intact preoperatively Whether concomitant RTC repair was performed: follow RTC repair guidelines Type of approach: arthroscopic, open, mini-open What tissue was affected by surgery? This will guide the rehabilitation © Stanbridge University 2022 17  SAD: Post-operative Management of Arthroscopic Procedure Exercise: Maximum Protection Phase: Control pain and inflammation Prevent loss of mobility of adjacent regions Develop postural awareness and control Restore pain-Free shoulder mobility Prevent reflex inhibition and atrophy of the shoulder girdle musculature © Stanbridge University 2022 18  SAD: Post-operative Management of Arthroscopic Procedure Criteria to Progress to Next Phase Minimal discomfort in unsupported positions symmetrical arm swing with gait Nearly full pain free PROM Good scapular mobility Pain free supine active elevation to above shoulder level Pain free AROM ER to about 45 degrees Minimum of 3/5 muscle testing grades © Stanbridge University 2022 19  SAD: Post-operative Management of Arthroscopic Procedure Exercise: Moderate Protection Phase Often starts at 4-6 weeks following surgery, but may occur earlier Goals: 1. Full, pain free shoulder ROM 2. Improve neuromuscular control 3. Improve strength and endurance © Stanbridge University 2022 20  SAD: Post-operative Management of Arthroscopic Procedure Exercise: Moderate Protection Phase Restore full pain-free PROM of the shoulder girdle and upper trunk Reinforce postural awareness and control Develop dynamic stability, strength, endurance, and control: Scapulothoracic and GH muscles © Stanbridge University 2022 21  SAD: Post-operative Management of Arthroscopic Procedure Criteria to Progress to Next Phase: Full pain free AROM without compensatory movement 75% strength of shoulder musculature compared to uninvolved side Negative Impingement tests © Stanbridge University 2022 22  SAD: Post-operative Management of Arthroscopic Procedure Exercise: Minimal Protection Phase/Return to Function Phase: Same as final phase of non-operative management of primary impingement syndrome © Stanbridge University 2022 23 www.onsmd.com www.orthoneuro.com ROTATOR CUFF REPAIR © Stanbridge University 2022 24  General Surgical Considerations When a muscle/tendon has been repaired, reattached or resected at reattached initially you CANNOT: Stretch that muscle: pulls on attachment NO PASSIVE STRETCH opposite of the action of the muscle repaired Contract that muscle: also pulls the attachment NO ACTIVE motion of the muscle that was repaired © Stanbridge University 2022 25  Rotator Cuff Repair: Indications and Depth Pain, impaired function, failed conservative care Partial thickness tear:extends superiorly or inferiorly through only a portion of the tendon Full thickness tear: extends entire depth of tendon www.shoulderdoc.co.uk © Stanbridge University 2022 26  Rotator Cuff Tears: Size of width Small: 1 cm or less Medium: 1-3 cm Large: 3-5 cm Massive: > 5 cm or full thickness tear © Stanbridge University 2022 27  Tendon Repair Location: Tendons tend to rupture at musculotendinous junctions or tendo-osseous junctions Causes of tendon tear: Young person: usually due to trauma Older person: progressive deterioration of a tendon (i.e. with history of chronic impingement) Chronic tenosynovitis (RA) © Stanbridge University 2022 28  Tendon Repair- To operate or not operate? Rotator Cuff Disease Chronic FT-RCT Acute Tears Tendinopathy PT- >60 yo Chronic FT-RCT RCT- small tears Initial non-operative