shoulder pathology: a detailed approach to examination ... · a detailed approach to examination...
TRANSCRIPT
Exploring Hand Therapy Manual
Shoulder Pathology:A Detailed Approach to
Examination & Treatment
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Exploring Hand Therapy, Corporationwww.exploringhandtherapy.com
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Shoulder Pathology
Paul J. Bonzani OTR/L CHT
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So Where do We Begin?????
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The Shoulder Complex:
• Shoulder movement results from the interaction of 4 joints– Sternoclavicular joint– Acromioclavicular joint– Glenohumeral joint– Scapulothoracic joint (physiological joint)
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Shoulder Movement:Osteokinematic Motion
• Forward flexion: sagittal plane elevation
• Abduction: frontal plane elevation• Scapula plane elevation: most
functional type of overhead motion• Rotation: internal/external rotation• Extension• Horizontal flexion/extension
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The Glenohumeral Joint 4 Axes of Motion
• Transverse axis.
• Anterior-posterior axis.
• Vertical axis.
• Long axis of the Humerus.
• Controls flexion & extension.
• Controls abduction & adduction.
• Controls horizontal flexion & extension.
• Controls internal and external rotation.
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ArthrokinematicsGlenohumeral Joint Motion
• Rolling
• Gliding
• Rotation
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The Scapulothoracic Joint
• Physiological joint > bone, muscle, bone articulation.
• Scapula lies 30 degrees anterior to the frontal plane.
• Combines with the 30 degrees humeral head retroversion to form the “scapula plane”.
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The Scapulothoracic JointPlanes of Motion
• Protraction-retraction.
• Elevation-depression.
• Upward rotation.
• Vertical axis.
• Frontal plane.
• Transverse axis in the sagittal plane.
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The Scapulothoracic JointFunctional Motions
• Upward rotation occurs around a transverse axis.
• Superior-inferior tilting occurs around a longitudinal axis.
• Scapulohumeral rhythm.
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Spinal Contributions
• Important for terminal elevation.• Orients the arm in relation to the body’s
center of mass.
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Force Couples• Deltoid-supraspinatus.• Serratus anterior-trapezius.• Rhomboids-teres major.• Triceps long head-latissimus dorsi.
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The Physiology of Abduction
3 phases of abduction• 1st phase > 0-90 degrees• 2nd phase > 90-150 degrees• 3rd phase > 150-180 degrees
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The Physiology of Flexion
3 phases of flexion.• 1st phase > 0-50/60 degrees.• 2nd phase > 60-120 degrees.• 3rd phase > 120-180 degrees.
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The Physiology of Rotation
• External rotators are 2/3 weaker than internal rotators.
• Shoulder rotation is augmented by periscapular motions to increase the range for the entire limb.
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Summary
• Shoulder motion is the result of 4 articulations.
• Each articulation contributes to smooth elevation of the extremity.
• The articulations and their motor are inter-related and balanced to provide functional extremity movement.
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Skeletal Injuries
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AC Joint Pathology
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AC Joint Compression Test
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Proximal Humerus Fractures
• 2-PART
• 3-PART
• 4-PART
• Conservative management
• Conservative/Surgical
• Surgical management
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Hills-Sachs Lesions
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Shoulder Osteoarthritis
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Arthritis
• Inspection- Possible disuse atrophy• Tenderness- May be anywhere • ▼ROM- Active and passive• Strength- variable
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Mid Shaft Humeral Fractures• Early AROM if rigidly
reduced.
• Mobilization can be delayed if other co-pathologies are noted.
• Concern is torque forces.
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Humeral Fracture Bracing
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Glenoid Fractures
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Glenoid Video 1
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Glenoid Video 2
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Glenoid Video 3k0j
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Soft Tissue Conditions
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Physical Examination of the Shoulder
• Subjective examination• Cervical spine screening• Objective examination
– Structural observation– Mobility testing– Strength testing– Special tests
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Subjective Examination• Helps plan the objective evaluation.• Document recent trauma.• Identify chronic contributions to the
problem.• Careful medical history.• Consider the results of objective tests.
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Cervical Spine Screening• Check cervical AROM
– Flexion/extension– Rotation– Side bending
• Provocative testing as indicated
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Cervical Motion Video
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Cervical Video 2
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Objective Evaluation:Structural
• Postural assessment.• Shoulder contours and heights.• Scapula winging.• Clavicluar abnormalities.
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Objective Assessment:Mobility
• Active mobility -physiological motions.
• Passive mobility.
• Accessory joint mobility.
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Objective Assessment:Palpation
• A/C and S/C joints.• Rotator cuff insertions.• Biceps tendon & Bicepital groove.• Scapula borders.• Levator scapulae & trapezius muscles.
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Objective Assessment:Strength/neurological Testing
• Manual muscle testing.
• “Functional testing”.
• Sensory testing: C4-T1 dermatomes.
• DTR’S: biceps (C5-6) Brachioradialis (C6-7) triceps (C7-8).
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Manual Muscle Testing
• Always assess periscapular strength.– Serratus anterior.– Rhomboids.– Levator scapula.
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Manual Muscle Testing
• Rotator cuff muscles by function.– Supraspinatus-abduction.– Infraspinatus-external rotation in adduction.– Teres minor-adduction and external rotation.– Supscapularis-adduction and internal rotation.
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Functional Testing
• Used in fracture rehabilitation.
• Neurogenic issues.
• Not indicated in muscle imbalance conditions. – Soft tissue dysfunction.
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Objective Assessment:Special Tests
• Neurological tests.• Impingement tests.• Biceps tests.• Rotator cuff test.• Instability tests.
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Neer Test Demo
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Hawkins Test Demo.
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External Rotation Resistance Demo
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Empty Can Versus Full Can Testing Demo.
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Physical Examination
• Anatomy and biomechanics improves examination skills.
• Practice improves technical aspects of performance.
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Impingement Syndrome
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Anatomical Considerations
• Shape of the acromion.– Curved.– Hooked.– Flat.
• Sub-acromial osteophytes.
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Factors Increasing Impingement• Thoracic kyphosis• Rotator cuff weakness/tear.• Acromioclavicular separation.• Posterior capsule tightness.• Biceps dysfunction (long head).
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Impingement Movie Quicktime.
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Bursitis Movie
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Therapy Intervention• Stop the offending activity!• Modality intervention?• Regain flexibility.• Improve strength.• Job or sport technique modification.• Aerobic exercise.
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Modality Intervention
• Ice
• PW ultrasound
• Iontophoresis
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Regaining Flexibility
• Posterior capsule stretching.
• Resolution of rhomboid/levator scapula tightness.
• Address thoracic kyphosis.
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Demo Horizontal Motion
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Demo Internal/External Rotation
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Strengthening Programs
• Scapular plane programs.
• Always address the periscapular muscles particularly Serratus anterior.
• External rotation strengthening.
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Strengthening Programs
• Consider PNF patterns with resistance.
– Should be based on regaining muscle balance.
– Avoid over strengthening anterior musculature.
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PNF Demo 1
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PNF Demo 2
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Resolution
• Patience is required!!
• Failure of 3 months of conservative care requires surgical assessment.
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Biceps Tendonitis
• Pain in anterior aspect of shoulder.
• Pain with forceful elbow and shoulder flexion.
• No pain radiation to deltoid insertion.
• May feel subluxation of the tendon.
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Biceps Tendonitis:Treatment
• Anti-inflammatory measures directed to the intertubecular groove region.– PW U.S.– Friction massage.– Icing.– Iontophoresis
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Exam Demo.
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Friction Massage
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Labral Tears
• Occurs with trauma.
• Can attritional and associated with arthritis.
• Rehabilitation goal is a flexible, strong should.
• Pain reduction may require surgery.
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Labral Tears (SLAP Lesions)
• Pain complaint is a deep, aching pain.
• Pain is increased with adduction movement.
• Pain occurs with passive motion and R.C. testing can be unimpressive.
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Assessment
• O’Brien test.
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Treatment
• Exercise to strengthen anterior/superior structures.
• Periscapular strengthening.
• Avoidance of horizontal adduction and internal rotation.
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Adhesive Capsulitis:Pathophysiology
• Capsular tightening of the G/H joint.
• Primarily idiopathic but can occur secondary to trauma.
• Self limiting condition.
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Adhesive Capsulitis
• 3 phases:– Acute inflammatory phase (freezing)– Sub acute phase (frozen)– Resolving phase (thawing)
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Anatomic Structures
• Anterior capsule.
• Inferior capsule.
• Posterior capsule.
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Clinical Presentation
• Primary finding is decreasing motion of the shoulder in “capsular pattern.”– External rotation>>>>abduction>>>>flexion.
• Severe night pain in acute phase.
• Disrupted scapulohumeral rhythm with over rotation of scapula.
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Treatment Approaches
• Acute, inflammatory disorder: (intense, continuous symptoms).– Correct resting position for sleep and sitting.– Grade 1 and 2 oscillations.– Gentile, active scapula stabilization exercises.– Modalities?
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Treatment Approaches
• Sub acute phase:– Continue resting positions.– Progress flexibility program.– Begin strengthening program.– Positional, postural exercises.
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Stretching Program
• Active to begin with.• Symptom free ranges.• Low level postures.
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Outcomes
• Generally prolonged with excellent recovery of motion.
• Some correlation between length of freezing phase and thawing phase.
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Rotator Cuff Tendinosis/tearsClinical presentation:
• Older patient.• Previous history of “tendonitis”. • Pain at night.• Disrupted scapulo-humeral rhythm.• Weakness in abduction and or flexion.• May have full PROM.
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Rotator Cuff Tear Movie
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Rotator Cuff TearsConservative treatment.
• Decrease inflammation and pain.• Identify underlying cause of the tear.• Rotator cuff strengthening.• Scapular stabilization exercises.• Posterior capsule stretching.• Activity assessment.
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Rotator Cuff Tears• Gentile isometrics -6 weeks.
• Progress to light resisted exercise.
• Eliminate strain during functional activities.
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Muscle Rebalancing
• Correction of faulty movement patterns.
• Dynamic/rhythmic stabilization of the periscapular region.
• Assessment and correction of faulty movement patterns.
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Instability
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Instability
• Anterior
• Posterior
• Inferior/Multidirectional
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History
• Does not have to be a traumatic event.
• Anterior in the athlete is usually related to dislocation.
• Multidirectional associated with general laxity.
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Subluxation Movie
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Assessment
• Apprehension sign.
• Relocation test.
• Load and Shift test.
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Apprehension sign
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Relocation Test
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Load and Shift Test
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Assessment
• Push/Pull test.
• Jerk test.
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Treatment
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Shoulder Pain
• Use systematic assessment for accurate conclusion.
• Treatment is little more than applied anatomy and biomechanics.
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Neurogenic Pain:The Thoracic Outlet
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Signs and Symptoms
• Vascular.
• Sympathetic
• Neurogenic
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Classic Assessment
• EAST assessment.• Wright’s maneuver.• Costoclavicular maneuver.• Pectoralis Minor loop.
Shoulder Course Reference List
1) The Interactive Shoulder. Primal Pictures Software
2) The Shoulder: Sport Injuries Series, 2nd edition: Primal Pictures Software
3) Krishnan, S.G., Hawkinns, R.J., Warren, R.F. (2004) The Shoulder and the Overhead Athlete.
a. Kuhn, J.E., Chapter 6 Resistance Training and Core Strengthening. b. Wilk, K.E. & Reinold, M.M. Chapter 7 Specific Exercise for the
Throwing Shoulder. c. Warren, R.F. & Prickett, W.D. Chapter 12 Unidirectional Anterior
Instability
4) Wilk, K.E. Arrigo, C. (1993) Current concepts in the rehabilitation of the Athletic shoulder. JSOPT 18 365-378
5) Davies, G.J., Dickoff-Hoffman, S. (1993) Neuromuscular testing and rehabilitation of the shoulder complex. JSOPT: 18 449-458
6) Harryman, D.T., Sidles, J.A., Clark, J.M. et al (1990) Translation of the humeral head on the glenoid with passive glenohumeral motion. J Bone Joint Surg (AM) 72:1334-1343
7) Bigliani, I.U., Ticker, J.B., Flatow, e.L., et al. (1991) The relationship of acromial architecture to rotator cuff disease. Clin Sports Med 10: 823-838
8) Jobe, C.M. (1997) Superior glenoid impingement. Orthop Clin North Am 28:137-143
9) Jobe, F.W., Bradley, J.P., Tibone, J.E., (1989) The diagnosis and nonoperative treatment of shoulder injuries in athletes. Clin Sports Med 8: 419-438
10) Wilk, K.E., Arrigio, C., Andrews, J.R., (1996) Closed and open kinetic chain exercises for the upper extremity. J Sports Rehabil 5:88-102.