Shoulder Conditions and Considerations
PTA 104 Orthopedic Dysfunctions

Introduction

PTAs apply rehabilitation exercises and injury management and prevention principles to patient with shoulder complex dysfunction. In order to safely and effectively select appropriate interventions specific to the patient's rehab stage and treatment response, PTAs must demonstrate understanding of protection, controlled motion, and return to function phases of rehabilitation.

By understanding the signs/ symptoms, impairments and functional limitations, PTAs are able to prioritize exercise and other interventions based on the understanding how inflammation and the stages of tissue healing effect recovery.

PTAs provide patient education and monitor progress to maximize patient compliance with activity modifications, postural corrections, joint protection, and exercise progressions. PTAs apply knowledge of surgical approaches and special tests in prioritizing interventions specific to the patient's current condition while strictly complying with post-operative surgical precautions and contraindications where indicated.

Objectives

Recall structure and function of shoulder and shoulder girdle components
Recall the stages of tissue healing (acute, sub acute, chronic)
Describe therapeutic benefits of joint mobilization techniques
Define joint mobilization terminology for the shoulder complex
Describe the grades used in peripheral joint mobilization
Distinguish scope of practice guidelines for physical therapy techniques for restoring joint function
Identify and describe methods, management, and rehabilitation for shoulder dysfunctions encountered in orthopedic rehabilitation
Recognize precautions and contraindications in non-operative and operative shoulder conditions
Define the structures associated with special tests for the shoulder
Apply knowledge of tissue healing in prioritizing interventions for shoulder rehabilitation

Joint Mobilization

Peripheral joint mobilizations are manual techniques which use physiological motions or accessory joint motions to increase ROM, decrease pain, and facilitate neuromuscular re-education.

High velocity thrust manipulations (Grade V) are outside of the PTA scope of practice.

PTAs instruct patients in self-mobilization techniques to increase accessory joint motion, particularly in the shoulder region. PTAs also apply knowledge of postural factors on arthokinematics in order to progress toward return to function. PTAs may observe subluxations or other positional faults which may be impacting progress and, therefore, require further assessment from the PT.

Contraindications and precautions for joint mobilization are closely aligned with those for stretching.

The PT will select a joint mobilization technique based on the tissue healing stage and patient pain levels. Lower grades of joint mobilization are indicated for acute pain modulation and fluid mechanics in a joint and are performed in the available range without resistance. Higher grades of joint mobilization are indicated when it is safe to mobilize into and through tissue resistance.

PTAs should be able to describe and understand the grades of joint mobilization in order to safely progress mobility with therapeutic exercise and functional activities. PTAs should document response to the previous treatment(s), so the PT may use the data for clinical decision making regarding modifications or progressions to joint mobilization techniques.

Peripheral joint mobilization is described in detail in Chapter 6, Dutton. Key points are summarized in the Joint Mobilization Take Home Points handout (see sidebar on this page).

Shoulder dysfunction: Conservative management (non-operative)

Humeral fractures

are treated with casting (closed reduction) or hardware (open-reduction/external fixation). ROM to prevent contractures are the primary component of early rehabilitation. Progressive strengthening and stretching for improving post-fracture weakness and atrophy will depend on integrity of bone tissue during fracture healing. A significant complication of humeral fracture is avascular necrosis of the humeral head. Indications for joint replacement secondary to avascular necrosis are discussed further in the section on Surgical Management.

Scapula fracture

Incidence of scapular fracture is highly associated with trauma, therefore, patients will often present with other fractures, glenohumeral dislocations, pneumothorax, and/or neurovascular injuries. Scapular body fractures are the most common scapular fracture and are generally treated non-operatively. As pain and swelling subside (2-3 weeks of immobilization), patients may progress from isometric to active exercises.

Glenohumeral Hypomobility

Presentation	Associated conditions/etiology	Clinical signs and symptoms	Impairments	Functional Limitations
Joint is stiff, motion and muscle function is limited	OA/RA, trauma, immobilization, idiopathic adhesive capsulitis	limited external rotation>abduction, pain, limited functional motion	Pain during sleep/lying, pain and limited motion, scapular compensation, decreased arm swing during gait	Difficulty dressing, grooming, reaching and lifting; difficulty reaching behind back

Joint stiffness and pain can result from overuse of contractile and non-contractile structures. Arthritic changes to the humeral head, glenoid fossa, acromion, or sternum can all impact function. Joint stiffness can evolve during or following hospitalization due to illness or decline in function. Patients who are confined to bed or have extended periods of compromised cardiopulmonary endurance may develop stiff and painful shoulders in as little as 1-2 days. PTAs play a significant role in patient, family, and staff education in correct ROM techniques for the shoulder for contracture prevention and management.

Adhesive capsulitis ("frozen shoulder") has a greater incidence in women (40-60 years old) and may be associated with diabetes and other chronic inflammatory conditions. Significant functional limitations can present in as little as 24 hours following initial symptoms. Depending on pain, length of symptoms, and functional limitations, patients may undergo manipulation under anesthesia to manually break through adhesions in external rotation and abduction without an inhibitory guarding response. PROM immediately following manipulation and patient education in ROM techniques follows this procedure.

During the maximum protection phase, PTs will use mid-range joint mobilizations to increase mobility without increasing pain.

Stages of Adhesive Capsulitis

Acute "freezing" (10 wks to 3 months)

Subacute "frozen" ( from 4 months to 12 months)

Chronic "thawing" (2 months to 24 months)

Patient presents with pain at rest and with shoulder motion

Controlled pain-free motion and interventions to promote relaxation of muscle guarding of the glenohumeral joint, cervical area, and scapulothoracic muscles

Scapula stabilization exercises with correct technique

Joint mobilization

Frequent ROM (3-5 x) during day and stretching in end-range

Modalities for pain relief: ice, US, estim

Patients present with pain only with shoulder motions, scapula compensation with movement, and deltoid atrophy.

Exercise to restore glenohumeral and scapulothoracic motion and prevent scapula substitution; progressive strengthening of deltoid, scapula, rotator cuff and upper arm

Submaximal closed chain isometric shoulder strengthening

Patients present with little to no pain, joint stiffness, and decreased muscular endurance

PT to Increase strength, endurance and functional use; continue self-stretching

Precautions with Adhesive Capsulitis: Therapy is too aggressive if the patient reports increased pain or joint irritability

Contraindications with Adhesive Capsulitis: Stretching into end-range when there are signs and symptoms of active inflammation

Glenohumeral Hypermobility

Excessive motion at the glenohumeral joint can increase stress to bone, contractile and non-contractile tissue resulting in increased degeneration, instability with subluxation/dislocation, and overuse of static and dynamic stabilizers (sprain, tendinitis, etc.). Conditions which may result in hypermobility include:

History of trauma (fall on outstretched hand)
Generalized laxity (inherited, connective tissue disorders, history of previous dislocation)
Hemiparesis

loss of neuromuscular control results in an unopposed traction force on the upper extremity when upright. This can become quite painful as the nerve are traction and soft tissue structures are overstretched. A hemi-sling may be used permanently or temporarily for joint and soft tissue protection when there is neurological paresis or paralysis of the upper extremity

https://www.ncmedical.com/item_669.html

Non-traumatic Acromioclavicular (AC) Joint Dysfunction

Non-traumatic AC joint dysfunction is common in adults over 40. Correction of postural stressors and muscle imbalances can prevent or minimize progression of arthritis. Weight lifters and individuals who repetitively load the upper extremities are more likely to experience dysfunction in these smaller shoulder complex joints

http://upload.wikimedia.org/wikipedia/commons/e/ec/Gray328.png

Overuse

Subluxation or Dislocation of AC jt

Hypomobility

Impairments

Functional Limitations

Associated with repeated diagonal extension-adduction-internal rotation (tennis, volleyball)

and repetitive motion at waist level

Associated with direct fall onto shoulder and fall on outstretched arm

May include partial or complete tear of supporting ligaments

Associated with poor posture, especially scapular depression and retraction; OA common in AC joint after age 40

Localized pain; pain with shoulder elevation, horizontal adduction or abduction, hypomobility, neurovascular dysfunction

Difficulty with repetitive motion forward/backward; limited participation in volley sports; decreased overhead reaching

AC joint subluxations and dislocations can be graded by MDs and radiologists based on the amount of ligamentous damage. When reviewing the medical record, you may see reference to Grade I, II or III AC sprain. Higher grade sprains are less stable. AC joint disruption is also referred to as "shoulder separation"

Separated Shoulder

http://upload.wikimedia.org/wikipedia/commons/9/9e/Luxation_acromioclaviculaire.jpeg

Grades II and III A-C sprain benefit from a harness or sling for 3-6 weeks so that the torn ligaments can heal through superior pressure to clavicle. Clavicle braces are also prescribed following clavicle fracture

http://heritagemedical.typepad.com/heritage_medical/shoulder/

Subacromial Impingement Syndromes

Video is approximately 3 minutes

supraspinatus tendon is the most common structure involved in impingement, followed by infraspinatus, then subscapularis
may also present with inflammation of bursae (primarily subacromial bursa)
incidence is influenced by age of the patient and shape of the acromion (flat, curved, or hooked)
condition is associated with:

posterior capsule tightness
decreased control of rotator cuff muscles
faculty scapulothoracic posture
tear of structure in suprahumeral space
tendinitis (see Special tests)
sports-specific activities (racquet sports)

causes

overuse
trauma (fall on out-stretched hand)
exercise and movement form
muscle imbalance (tightness, over-development) and weakness; age-related changes

stages of impingement (Neer' stages) are based on patient age, pain level, and the degree of involvement of rotator cuff structures

Stage I: edema and hemorrhage in subacromial space, typically age 25 or less, pain with abduction > 90 degrees; reversible lesion
Stage II: fibrotic changes (RTC tendons, long head biceps, bursae); typically age 25-40, increased pain and pain at night with sidelying; irreversible lesion
Stage III: includes some RTC tear with chronic pain; generally includes weakness and atrophy of surrounding RTC structures; irreversible lesion

largely characterized by a painful arc of motion between 60 and 120 degrees of abduction, difficulty with overhead reach and lifting, difficulty with dressing and ADLs.
Special tests will help identify involved structures: palpation at musculotendinous junction of RTC muscles and associated structures should also be noted on PT evaluation

Positive (+) Impingement sign (aka 'Hawkins test'; pain with flexion to 90 degrees plus internal rotation) = supraspinatus tendinitis (Video is approximately 1.5 minutes)

Positive (+) Speed's test (resisted forearm supination while shoulder is flexing) = long head biceps tendinitis (Video is approximately 2 minutes)

Positive (+) Apprehension sign (patient refusal/avoidance of combined shoulder elevation, abduction, and ER) = GH anterior (Video is approximately 2 minutes)

instability
Positive (+) Anterior/Posterior drawer indicates anterior/posterior GH joint instability
Positive (+) Crossed arm adduction; pain may indicate AC joint involvement

Positive (+) Drop arm test; patients is unable to maintain isometric hold of 30 degrees abduction against gravity; indicates failure of supraspinatus (Video is approximately 2 minutes)

may be treated with cortisone injection(s) to decrease inflammation in subacromial space; modalities may be effective during acute tissue healing phases for pain control and edema management
progression to overhead motion is allowed once pain-free ROM (full or functional) is restored
PT interventions are based on tissue healing stages with an emphasis on maintaining as much motion in joints above and below the shoulder and continuing non-painful motions or activities involving the upper extremity

Impingement Syndrome Presentation

Impingement typically presents as subacromial impingement; however impingement can also occur between the glenoid, the glenoid labrum and the suprapinatus and infraspinatus

Associated condition/etiology

Clinical s/sxs

Impairments

Functional Limitations

Goals and Treatment(s)

Overuse from repetitive motion (overhead, throwing)

Overuse from repetitive eccentric loading (racquet sports, volleyball, etc.)

History of joint stiffness, OA, acromion shape precursors

History of fall on outstretched hand

History of MVA (holding steering wheel at impact)

Poor posture (thoracic kyphosis, ant-posterior muscle length-tension imbalances

Poor glenohumeral joint stability

Painful arc of motion (usually 60-120 degrees of abduction)

Pain with sidelying, reaching overhead, reaching behind back, lifting

Point tenderness at musculotendinous junction of involved structure

Pain, muscle guarding, posture, weakness, joint dysfunction

Decreased lifting, pushing, pulling, overhead reaching, dressing, grooming

Control pain and swelling, increase and maintain maximum pain-free range of motion, modify activities/ADLs, increase scapular control and stabilization, restore strength and timing of scapular and RTC during AROM, increase muscular endurance and postural control, progressive return to functional and sports-specific activities

Ice, NSAIDS, Iontophoresis, ultrasound, progressive strengthening, joint mobilization, stretching, postural education and re-education

Shoulder Dislocations

most often occurs due to trauma or history of previous shoulder dislocation
source of secondary impingement due to poor control of superior motion of humeral head into subacromial space during overhead shoulder motion
instability can be unidirectional or multidirectional (anterior, inferior, posterior) and may or may not involve rotator cuff tear
anterior dislocation is most common: blow to shoulder or arm while positioned in combined shoulder external rotation and abduction
posterior dislocation may occur following fall on outstretched hand
may also involve damage to rotator cuff, labrum, humeral head, glenohumeral ligaments, and neurovascular structures

Bankhart lesion = avulsion tear of anterior capsule at the anterior glenoid labrum
Hill-Sachs = posterior-lateral humeral head compression fracture resulting from anterior instability
Axillary or brachial plexopathy with sensorimotor changes from compression or over-stretch

Patients with a T traumatic U unidirectional injury and a B an kart lesion frequently require S surgery (TUBS). Patients with A traumatic M multidirectional B bilateral instability respond well to R habilitation, but occasionally require anI nferior capsular shift surgical procedure (AMBRI).
Immobilization for short term (1-2 weeks) is recommended to allow the capsular structures to stiffness post-injury; patient continues with distal UE use and isometric exercise in 0 degrees flexion and pain-free intensity.
Extension greater than 0 degrees is contraindicated until capsule is stabilized; caution with external rotation in positions greater than 55 degrees of shoulder abduction; no combined end-range abduction-external rotation motion until 3+ months post immobilization
Early exercises are gravity assisted pendulum motions, isometric with progressing through limited range. During progressive strengthening and return to function, modify exercises to protect anterior capsule: overhead press and chest press activities should be modified to limit abduction to the scapular plane

During the initial immobilization, the PT documents all limitations of specific joint motion. Each limitation is addressed as part of the rehabilitation program. However, if the PTA recognizes delayed restoration of motion, reduced motion, or increased pain during the rehabilitation program, then he or she immediately must communicate this to the PT.

Surgical Management of Shoulder Conditions

Adhesive Capsulitis

(Frozen Shoulder) may require surgical intervention to restore function. PTAs can help patients with post-operative education by understanding the structures involved and the expectations for post-operative recovery. Take a moment to review the Animation of Surgery for Adhesive Capsulitis (approximately 20 minutes) to reinforce information from your text book readings.

Glenohumeral Arthroplasty

Surgical techniques can include resurfacing of existing bone, replacement of the humeral head (hemiarthroplasty) or replacement of the humeral head and the glenoid fossa (total shoulder arthroplasty/replacement (TSR)). Traumatic fracture of the humeral head may lead to avascular necrosis and necessitate a TSR to restore arm function.

Choice in surgical procedure will depend on the involvement of articular surfaces and associated soft tissues.

Primary goals for TSR are

reduce pain
secondary outcomes may be

increased shoulder mobility
increased shoulder stability
restored or increase strength for functional use

Surgical approaches vary with patient condition and surgeon preference. Your text discusses general surgical procedures for a variety of shoulder prostheses. The take home message for the PTA is SURGEONS ESTABLISH ROM LIMITATIONS AND RESTRICTIONS FOR EACH CASE. If you are not sure of the ROM limitations for a post-operative TSR patient, consult with the supervising PT or contact the physician's office for clarification. Err on the side of caution and choose interventions which do not involve GH motion, such as pain management, postural instruction, activity modification, and alternatives for cardiovascular exercise.

In general, TSH without repair of the rotator cuff will have a maximum of 140 degrees of abduction range available. Patients who undergo a rotator cuff repair and TSH average 60 degrees of abduction post-operatively.

Arthrodesis of the Shoulder

Fusion of the shoulder is generally selected when there are no other non-operative or operative approaches which will minimize instability in the shoulder complex. PTAs should understand the significance of post-operative precautions and maintain mobility in distal joints during the recovery phase

Following fusion, ROM is generally limited to the following

15-30 degrees of flexion
15-30 degrees of abduction
35-45 degrees of external rotation

Functional use of the arm is achieved through scapular motion. Consider the muscle origin and insertions at the scapula: what overuse or secondary conditions may evolve with repetitive scapular motions?

Subacromial Decompression

The procedure is also referred to as acromioplasty and can be abbreviated 'SAD' in the medical record. SAD can uses arthoscopic techniques to remove bone spurs in the subacromial area and to remove debris associated with overuse. Surgical decisions to try SAD are based on patient symptoms and previous response to conservative treatment (PT, cortisone, meds, etc. ). Once the surgeon has visualized the RTC tendon during SAD, he/she can assess if a rotator cuff (RTC) repair is indicated.

Video of SAD arthroscopic surgery. Approximately 1.5 minutes

Recovery from SAD is typically 3-6 months. Rehabilitation processes are similar to management of impingement syndromes, with an emphasis on maintaining soft tissue mobility and preventing overuse. Patients may initiate RTC strengthening exercises soon after SAD as long as there has been no surgical repair of the RTC.

Rotator Cuff Tear

RTC tears can be due to repetitive motions or from trauma. Non-surgical and surgical management is largely driven by patient symptoms, surgical approach, and tissue healing times to allow repaired and/or fragile structure to heal. Too much too soon in these patient can result in total loss of RTC function.

Classifications of RTC tear

Partial thickness: partial thickness tears can be intraarticular, bursal, or intratendinous

Full thickness: tear extends through entire length of tendon (note: tutorial reinforces anatomy and includes a button for fully-torn rotator cuff tear

Major Surgical Approaches

arthroscopic: tendon is repaired with minimal disruption to supporting soft tissue structures; debridement approach is most often used for partial thickness tear
mini-open: deltoid muscle is split to allow surgical access to rotator cuff tendon group
traditional-open: deltoid is detached (taken down); includes a SAD; tendon is typically affixed to bone during repair; may also include a labral reconstruction or capsular tightening (aka capsular shift, capsulorhaphy)

Factors influencing RTC surgical approach include history of chronic impingement, size of RTC tear, associated pathologies in the shoulder, and general medical condition/stability.

Shoulder Instabilities

Video is approximately 1.5 minutes

Bankhart repair (Tutorial is approximately 1.5 minutes long)

labrum is reattached to glenoid
subscapularis is taken down or split at the humerus
capsulorhaphy: takes up slack in loose capsule

electrotherapy approaches use heat to shrink capsule and tightens capsular structures

SLAP: Superior Labrum Anterior Posterior (Tutorial is approximately 1 minute)

indicated when there is a tear of the superior aspect of the labrum which extends in an anterior-posterior direction
may also include a repair of the long head of the biceps

Special test for SLAP is the O'Briens (Video is approximately 2 minutes)

Bony block

A bone block can be placed anterior to the GH joint to prevent anterior translation motion and recurrent dislocation. This surgical procedure is performed infrequently.

Rehabilitation Principles for Shoulder Dysfunction

Rehabilitation protocols and progressions can vary from patient to patient and from surgeon to surgeon. In your text, you will find some guidelines for PT interventions based on the tissue healing phase. Note: most of the progressions are based on patient pain response, quality of shoulder motions (degree or absence of compensation), and surgical approach. All interventions consider pain levels and interventions to decrease pain and inflammation associated with exercises and functional use. Techniques to mobilize soft tissue (cross friction massage, joint mobilization) are introduced incrementally and respect pain limits and capsular barriers. Active exercises are generally progressed when there is no pain; resistive exercises are progressed (weights/bands) later in the rehabilitation stage when normal shoulder mechanics are restored. Proprioceptive activities in closed chain are only initiated when there is evidence of both increased strength and endurance in the rotator cuff (RTC) muscles without pain. Posture is ALWAYS included to prevent or minimize recurrence.

When referencing your text, formulate patterns for intervention based on the protection phase of the condition. For example, how does ROM exercise classification change as you progress the patient from maximal to moderate to minimal protection phases?

Posture

Forward head, kyphotic posture markedly increases risk of shoulder dysfunction due to altered mechanics and static compressive stresses
Faulty posture decreases the subacromial space, which can lead to impingement syndromes and progressive tearing of the RTC
External rotation motion is insufficient to allow adequate clearing of greater tubercle around the coracoacromial arch

performing AROM in scaption (scapular plane) does not require internal or external rotation motion to clear the greater tubercle

Postural re-education for correction of faulty mechanics can inhibit protective muscle spasm, increase circulation to subacromial space and increase length in scapular muscles
Specific components of kyphotic posture and postural muscle contributors include:

scapula

glenohumeral

tight

weak

forward tilt

downward rotation of glenoid

relative abduction

relative internal rotation

pectorals minor

levator scapula

scalenes

serratus anterior

trapezium

shoulder external rotators

Manual stretches for increasing flexibility are illustrated on pages 504-505 in your course text.

Joint Protection

Slings post-operatively to prevent active use and force of gravity on repaired or injured structures
Slings with neuromuscular conditions resulting in RTC insufficiency
Taping
PROM in allowable range for joint rehydration
Activity modification
Interventions are ALWAYS selected based on joint protection principles for the condition (maximum, moderate, minimal/return to function)
Adequate warm up; reinforcement of short, but frequent bouts of exercise in allowable range for progressive increased endurance without joint overuse

Early on in RTC repair rehabilitation, care must be taken to minimize anterior translation of the humeral head to avoid compression forces to the repaired structures. Techniques during PT include:

support the humerus on a folded towel when supine
for assisted shoulder extension rotation ROM, position the patient prone with arm hanging over bed/mat and work from 90 to 0 extension
for passive external rotation ROM, position the humerus in slight flexion and 45 degrees abduction

Scaption

Exercises in the scapular plane are preferred for rehabilitation and home exercise programs for rotator cuff dysfunction. In addition to greater tubercle clearance, scaption allows muscles to strengthen in the most functional position and produces less tension on the joint capsule compared to straight plane motions (e.g., flexion and abduction

Pain management

ice
rest (immobilization with progressive increased activity and regular rest intervals)
modalities (iontophoresis, ultrasound, TENS)

clinical tip: to maximize access to the supraspinatus tendon, position the patient with their arm behind their back. This will move the supraspinatus tendon anterior to the acromion

decompression (Pendulum exercises)
activity modification
patient instruction in self-massage
joint mobilization (primarily Grades I-II)

Restoring Combined Motion - Scapular Control

When progressing PROM to AAROM, continuously monitor for normal scapulohumeral rhythm; compensatory motions are an indicator of RTC insufficiency and care should be taken to instruct the patient in risks for reinjury/recurrence associated with abnormal mechanics

Scapular "setting" exercises are essential to restoring shoulder function. Consider these the "core strengthening" of the shoulder complex. Supine positioning can be used to assist with scapular setting during early ROM activities

During closed chain activities, monitor your patient for signs and symptoms of scapular muscle insufficiency. Scapular winging during wall push-ups or quadruped activities indicate poor stability of the scapula

Consider Entire Extremity

During the acute healing phase, ROM exercise for the forearm, wrist and hand can maintain mobility, provide pain relief and indirectly and gently mobilize recently injured and repaired structures.

Optional: Resources for Patients

In addition to ChoosePT, an extensive amount of patient resources for multiple shoulder conditions are available for downloading and printing through eOrthopod