shoulder lecture

Shoulder Mobilization Case Study

Proximal Humeral Fracture

History

• 61 year old male• Fractured the greater tuberosity of the right shoulder eight weeks ago

• Partially tore the rotator cuff muscle of the same shoulder.

• Patient was immobilized in a sling for eight weeks.

Clinical Presentation

• Sever limitation of right shoulder motions• Demonstrates a capsular pattern

– External rotation, abduction , medial rotation

• Complains on a dull constant ache within the shoulder at rest. Rating the resting pain as a 6/10 on the pain scale.

• Experiences sharp pains with any motion of the shoulder . Pain is rated as a 8/10.

• X-rays and MRI indicates that the fracture is healed and the rotator cuff is partially healed.

Physical Therapy Referral

•Restore motion and normal strength to the right shoulder

Clinical Considerations

• Patient has moderate to sever pain with any movement.

• Shoulder restriction is due primarily to capsular and muscle shortening around the fracture site.

• Muscular strength of the right shoulder complex is weak due to the prolong immobilization.

Treatment Plan

• Modalities• Mobilization techniques

• Strengthening exercises

Mobilization

• Joints to be mobilized– Glenohumeral– Sternoclaviclar– Acromclavical– Scapula

• Potential muscled that are shorten.– Subscapularis– Pectoral major & minor

– Infaspinatus & teres minor

– Lat– Rhomboids – Serrtaus– Upper mid and lower trap

Goal

Increase shoulder glenohumeral motion without exacerbation of

pain.

Concepts To Remember In The Glenohumeral

Joint• Osteokinematic : There is 3 degrees of freedom– Flexion/Extension, ABd /ADd, Internal/External Rot.

• Articulator surface anatomy– Concave glenoid & convex humerus– Loose pack position 20 degrees scapulohumeral abduction with 30 degrees elevation in the scapular plane.

Concepts To Remember In The Shoulder Complex Joint

• Accessory (Component) Motions– Arthokinematic movements that must occur in order for normal osteokinematic movement to take place •Eg. Inferior Glide

• Joint Play Motion– Those accessory that can be produced passively at a joint but not actively.•Eg. Lateral Distraction

Physiological Movements

Refer to Matiland CD

Shoulder Flexion

• Glenohumeral – Lateral distaction

– Inferior glide– Posteior glide

• Sternoclavicular– Inferior gilde– Anterior glide

• Scapula– Distraction

• Upward rotation• Elevation

Scapluar Plane Oscillations

• General technique– Introductory– Pain– Lubication of tissues

Glenohumeral Lateral Distraction

• Often one of the first technique to use

• Good for general capsular tightness

• Pain control

Inferior Glide In Loose Pack

• For restriction in flexion and abduction

• Used to decreased pain – with grade I & II oscillation

Inferior Glide At 90º of Abduction

• Increase mid-range– flexion and abduction

Anterior Glide In Loose Pack

• The primary tissue affect by this technique is the anterior capsular region

Posterior Glide In Loose Pack

Matiland Technique• Indication for posterior capsular tightness

• Used in the early phases of the rehab to began

• To increase internal rotation

Posterior Glide At 90º Abduction

• Posterior Glide at 90 degrees abduction

• Increase flexion and internal rotation

Posterior Glide in Flexion

• Advance technique that gives a strong localized stretch to posterior capsule

Sternoclavicluar Inferior Glide

• Used to improve component motion for shoulder flexion.

Anterior & Posterior Glide of AC Joint

• Assist in improving shoulder flexion

• Used to decreased joint pain in the AC joint

Scapula Mobilizations

• The purpose of these techniques is to increase range of motion in scapular:– Superior glide– Inferior glide – Medial rotation– Lateral rotation

Advance Soft Tissue Stretching Latissmus

Dorsi• Patient supine • Therapist at the head of patient

• One hand grips medial side of patient hand just above elbow and move it into flexion while laterally rotating the shoulder

• The other hand and forearm stabilizes the lower thorax

• Using the grip begin to stretch into flex and lateral rotation

Advance Soft Tissue Stretching

Pectoralis Major• Patient supine• Therapist using both hands grips the medial side of the patient’s elbow and flexs and laterally rotate the arms

• Placing a stretch on the pectoral muscles

Subscapularis Stretch End Range

End Range Internal Rotation

• Use graded oscillations

• This technique may also be performed in prone