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THE SHOULDER AND
SHOULDER GIRDLE
CH 17
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TOPICS TO BE COVERED
•Examination, evaluation and assessment of shoulder joint
•Referred pain and nerve injury
MANAGEMENT OF SHOULDER DISORDERS AND SURGERIES
•Joint Hypomobility: non-operative management
•Glenohumeral joint surgery and postoperative management
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Revision of shoulder anatomy and biomechanics
• Shoulder complex articulations
• Arthrokinematics/osteokinematics
• Static and dynamic constraints
• Scapulohumeral rhythm
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Winging and tipping
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Brief Glance on Surface Anatomy
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MANAGEMENT OF SHOULDER DISORDERS
AND SURGERIES
MANAGEMENT OF SHOULDER DISORDERS
AND SURGERIES
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Nerve Disorders in the Shoulder Girdle Region•Brachial plexus in the thoracic outlet
•Suprascapular nerve in the suprascapular notch
•Radial nerve in the axilla
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Joint Hypo mobility and post op management
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•RA and OA•Traumatic arthritis•Post-immobilization arthritis or stiffness
•Idiopathic frozen shoulder
Causes
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ACUTE PHASE SUBACUTE PHASE CHRONIC PHASE
Pain and muscle guardingRadiating below the elbowDisturb sleepTenderness (Deltoid)
Capsular tightnessLimited motion with a capsular patternPain at the end of the limited rangeLimited joint play
Limited motion in a capsular patternDecreased joint playLoss of function Inability to reach overhead, outward, or behind the back
Clinical Signs and symptoms
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STAGE IPRE-FREEZING (1-3
M )
STAGE IIFREEZING (3-9 M)
STAGE IIIFROZEN ( 9-14 M)
STAGE IVTHAWING ( 15-24
M)
GRADUAL ONSET OF PAIN , INCREASED WITH MOVEMENT, DISTURBS SLEEP, LOSS OF ER, INTACT RC STRENGTH
PERSISTENT AND INTENSE PAIN, AT REST, MOTION LIMITED IN ALL DIRECTIONS, CANT BE RESTORD WITH INTRA ARTICULAR INJECTIONS
PAIN ONLY WITH MOVEMENT, SIGNIFICANT ADHESIONS, LIMITED GH MOTIONS, SUBSTITUTE MOTIONS, ATROPHY OF DELTOID, BICEP, TRICEP AND RC
MINIMAL PAIN, NO SYNOVITIS,
SIGNIFICANT CAPSULAR
RESTRICTIONS, MOTION MAY GRADUALLY
IMPROVE, SOME PATIENTS NEVER
GAIN RANGE
IDIOPATHOC FROZEN SHOULDER
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IMPAIREMENTS AND FUNCTIONAL LIMITATIONS
IMPAIREMENTS
• Night pain and disturbed sleep
• Pain on motion and at rest
• Decreased ROM
• Faulty postural
• Gait disturbance
• Muscle weakness and poor endurance
• substitute scapular motions
FUNCTIONAL LIMITATIONS
• Difficulty in Putting on a jacket or coat
• women fastening undergarments
• Reaching hand into back pocket of pants (to retrieve wallet)
• Reaching out a car window (to use an ATM machine)
• Self-grooming (such as combing hair, brushing teeth, washing face)
• Bringing eating utensils to the mouth
• Difficulty lifting weighted objects
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Management—Protection Phase1. Control Pain, Edema, and Muscle Guarding
• Modalities
• Immobilization
• Grade I and II
• Cervical soft tissue
mobilization
• PROM/ AAROM
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Management—Protection Phase
2. Maintain Soft Tissue and Joint Integrity and Mobility• PROM
• Grade I and II distractions and
glides
• Pendulum (Codman’s )exercises
• Correct faulty posture
Be careful about
precautions and contra
indications
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Management—Protection Phase3. Maintain Integrity and Function of Associated Areas• Prevent CRPS – hand exercises• Edema in hand-elevate above heart• Elbow, forearm and wrist AROM
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Management—Controlled Motion Phase1. Control Pain, Edema, and Joint Effusion
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Management—Controlled Motion Phase
2. Progressively Increase Joint and Soft Tissue Mobility• Mobilization – grade III
sustained or grade III, IV
oscillations
• Self mobilization techniques
• Manual stretching
• Self stretching
Sling exercise for RC
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Self-mobilization techniques.
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Management—Controlled Motion Phase
•Inhibit Muscle Spasm and Correct Faulty Mechanics
•Improve Joint Tracking MWM•Improve Muscle Performance
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Management—Return to Function Phase
•Progressively Increase Flexibility and Strength
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Management—Return to Function Phase
•Prepare for Functional Demands
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Post manipulation under anaesthesia
•Following this procedure, there is an inflammatory reaction and the joint is treated as an acute lesion.
•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.
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Glenohumeral joint surgery and postoperative management
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Underlying pathologies
•RA , OA•AVN of head of humerus•An acute or nonunion fracture
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Indications
•Significant pain•Loss of upper Limb function
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Goals
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Designs of Prosthetic Implantsfor Total Shoulder Replacement
•Unconstrained
•Semiconstrained
•Reversed ball and socket (totally damaged RC)
•Constrained
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Complications of Glenohumeral ArthroplastyIntraoperative
Soft Tissue-Related
Implant-Related
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Postoperative Management: Special Considerations
•Integrity of the rotator cuff
•Intraoperative ROM ( greater ROM if unconstrained, less for more constrained)
•Posture (emphasize erect posture)
•Immobilization ( remove sling if no RC repair, sling worn up to 4-6 weeks with RC repair, removed for ecxercise)
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Positioning After Shoulder Arthroplasty•Supine
•Sitting
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POST OP MANAGEMENT
•Maximum protection phase – 4-6 weeks
•Moderate protection phase – up to 12-16 weeks
•Minimum protection/return to function phase – up to several months
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Exercise: Maximum Protection Phase•Control pain and inflammation.
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Exercise: Maximum Protection Phase•Maintain mobility of adjacent joints
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Exercise: Maximum Protection Phase•Restore shoulder mobility
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Exercise: Maximum Protection Phase•Minimize muscle inhibition, guarding, and atrophy
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Exercise: Moderate Protection/Controlled Motion Phase
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Exercise: Minimum Protection/Return to Functional Activity Phase
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Exercise: Minimum Protection/Return to Functional Activity Phase
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ASSIGNMENTResting and close packed positions
of Shoulder , elbow and wrist
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What is this condition?What is the cause?
• Paralysis of serratus Anterior leading to dynamic winging of scapula
• Active insufficiency of Deltoid during functional arm elevation when scapular UR are weak. • (reverse scapulohumeral rhythm)• Due to deltoid and supraspinatous
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Faulty posture
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MCQ• your patient is 65 years old female and she had a surgical repair of rotator cuff and TSR 5 weeks ago. which of the following exercises would not be appropriate for this patient?
a) Gentle manual resistance exb) Gentle pulley exc) Codman’sd) Passive ROM in pain free range
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THANK YOU