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Ortho Shoulder 2009

Orthopedic Management of shoulder

Watershed effect is area of relative transient hypovascularity, pain w/abduction 60-120 deg forward flex, forced IR w/90 deg abd
causes of impingment muscular imbalance, faulty biomechanics, trauma (MVA), immobilization, poor posture (most often)
S.I.C.K. scapula Scapular malpostion, Inferior medial border prominence, Coracoid pain & malposition, Dyskinesis of scapular movement
symptoms of SICK impingment symptoms assoc w/decreased posterior tipping & dec upward rotation during humeral elevation
clinical manifistation - painful arc 60-120 deg of flex or abduction, pain w/resistance (to inflam tendons), pain w/stretch (of inflam tendons), tenderness to palpation at distal insertions, limited IR (MEASURE W/GON) SICK scapula
pain &/or weakness w/resistance to shoulder: flexed 90 deg, abd 45 deg horz. abd, & IR indicates? supraspinatus tendon is inflamed & impinged
Empty Can test tests supraspinatus stg in impingment position, may be + w/subacromial bursitis & inc tears
Full Can test integ of supraspinatus tendon, pain &/or weakness w/resistance to shoulder: flexed 90 deg, 45 deg horz abd, ER, indicates inflamed or torn
neer impingment to pinch LHB or supraspinatus tendon betw head of humerous & acromion. pain w/passive movement of shoulder above 90 deg flex w/slight over pressure
hawkins impingment, passive shoulder flex to 90 deg & shoulder IR, + if produces pain
painful arc to determine presence of impingment - presents w/pain while actively abd arm betw 60-120, if painful at end range, the AC jt may be involved as well
drop arm test clinician holds patient's arm out, if pt cannot actively descend & it drops, sign of probable tear of RC
Impingment, avoid what movements? abd below 45 deg (watershed effect), flex above 90 deg (Hawkins)
Impingment, what to strengthen? serratus anterior, trapezius, levator scapulae, rhomboid, shoulder blade squeezes
Impingment, what to stretch? external rotators, possibly internal rotators (w/good posture)
Impingment, when to start exercises? late max, so long as no further impingment inc symptoms
position for arm/bicep exercise seated, arm on plinth, put it at 45 deg, towel maybe under arm pit
to gain ROM in shoulder ER, you stretch____ internal rotators
MAX phase impingement PRICE, avoid motions above 90 deg, NSAIDS, Ionto/phono, estim, cross-friction msg, ice, PROM, tx w/shoulder support @ 45 deg abd (watershed), ALL MOTION (FLEX &/OR ABD) ABOVE 90 DEG S/B IN ER UNLESS OTHERWISE NOTED!!!!!!!, scapular stg if painfree
MOD phase impingement scap ex (rowing-rhomboids, scap plane eleva-scaption w/ER, seated press ups -upper & lower trap, pushups w/scap prot, at end, pushup plus -up & down w/o bending elbows -SA, RH, AROM lim to 90 deb abd, strtch to mntain ROM, restore IR 90 deg, start w/isom
MOD phase impingement strength trng start w/isom, (work towards isot, isok), Isotonics w/theraband, free wts, scaption: AVOID IR & SCAPTION ABOVE 45 DEG, isokinetics (UBE, IR/ER high speeds)
scaption plane is often preferable to the frontal or sagital plane because? less muscle effort is required to raise the arm in the scaption plane
MOD phase impingement, watch ..... POSTURE (very important), biomechanics, functional activities: activity modifictions
MIN phase impingement functional, return to activities, above 90 deg, concentrate on RC, supraspinatus, infraspinatus, teres mior, supscapularis ( concentric and eccentric), concentrate on scapular retractors & stablizers (rhomboids, Serratus anterior, trap, levator scap w/wts
MIN phase impingement stretching bilateral, strengthening in available range ASAP, work towards overhead strength as tolerated, wt machines pain-free, functional
two common bursitis to be painful subdeltoid, subacromial
characteristics of bursitis often 2 deg to RC lesion/impingment, constant dull, sometimes throbbing pain, all movements painful
site pain for bursitis lateral brachial area (deltoid area), might be referred distally, bursa has no neurons connecting so it is the structure that does & is affected
Bursitis restrictions AROM in all planes, especially in overhead motion, PROM restricted in non-capsular pattern, empty end feel
Bursitis - how to strengthen? resistance
Patient education for bursitis don't overwork w/o breaks, do not work when in pain or inflammed
Bursitis rehab splinting/immob to prevent irritation, modalities - ice or superficial heat, maintain painfree ROM, avoid shoulder elevation ( similar to impingement)
bursitis MAX phase PROM, below 80-90 deg, PRICE, theraband, modify ADL's
bursitis MOD phase early, strengthening, theraband (rhomboids), no under 45 deg abd, fex, ext, IR, ER
what structure is responsible for stabilization of humerous? bicipital tendon
How is the LHB affected by the RC? if the RC is weak, puts more stress on LHB.
bicipital tendonitis is secondary to what activity? overhead recurrent, repetitive
Speed's test apply resist to 90 deg of shlder flex w/ER & elbow ext & supinated, + if pain, indicates tendonitis or fraying of LHB
Yergason's test stablize pt's arm against body, flex elb to 90 deg, palpate bicipital tendon, have pt supinate & ER arm.....+ if pain or tester feels tendon slip out of groove
if someone has chronic pain, proximal area of shoulder, palpable tenderness in bicipital groove, pain w/resisted elbow flexion (flex after supination)....indicator of ? bicipital tendonitis
bicipital tendonitis rehab sometimes immob, bicep stretch, elbow & shoulder ext, ROM, isom, theraband, UBE, PNF patterns, isot, functional (throwing, swimming, work hardening, etc) in min prot use cable machine to bring up with both but lower w/involved arm (eccentric)
examiner holds pt's arm from behind in 90 flex, 40 deg horz add, max ir, if pain or popping? Patient horiz add & flexes their shldr against examiners manual resistance labral tear
pt supine, arm fully abducted. examiner places one hand on posterior aspect of head of humerous, while other hand holds arm above elbow. first hand pushes anteriorly while other rotates humerus laterally......clunk heard or felt indicates? capsular labrum integrity, labral tear
slap lesion superior labrum anterior to posterior.....(tendon peels Superior Labrum Anterior to Posterior of the LHB)
why does it take longer to heal? not vascularized
avoid in rehab for slap lesion avoid bicep strengthening & stretching, avoid supination (wrist stg)/AROM shldr flex
rehab slap lesion modalities to dec inflam & stimulate healing, maintain/gain ROM, strg ex to improve jt stability & restore jt biomechanics, proprioceptive ex (CKC), NSAIDS
shoulder capsular pattern ER, ABD, IR
causes of adhesive capsulitis? immob, trauma, insidious onset (most common), 70% female 40-60 y/o
Apleys scratch test for? adhesive capsulitis
Adh capsulitis rehab modalities? ice if constant pain, later heat to work to elongate
PT for adhesive capulitis Jt mobs (resting position = 55 deg abd, 30 deg horz add), PROM, stretches, AAROM, Home program!, strg available range is very important, functional (take glasses off shelf & put back on, wk full ROM available)
Bankart lesion tear in anteroinferior labrum, causes shoulder instability
shoulder instability more likely in what population? & what causes? younger, active patients, Bankart leasion, Slap lesion
GH dislocation abducted, ext rotation, extension......anterior dislocation most common position
what mm's offer stability to humerus subscapularis, GH ligament, LHB
what is the most commonly dislocated jt in body? GH (shoulder), often assoc w/RC tears (30-80%)
Anterior shoulder Apprehension test test for anterior instability, place jt in slow abd & ER, if pt has a feeling like the shldr will dislocate, indacates unstable shldr
Posterior shoulder apprehension test test by horizontally adducting the arm & IR while in 90 deg of flex
rehab for anterior dislocation sometimes immob 3-6 wks (remove from exer), ER w/elbow at side, shoulder in resting position, abd 55 deg, horz add 30 deg
AVOID w/anterior shoulder dislocation full ABD, ER, extension (worst position is 90 deg abd w/ER), don't ned to work on ROM, want them to tighten down
MAX phase, shldr dislocation ice, estim, NSAIDS, elbow, wrist & hand st/motion
MOD phase shldr dislocation pulleys, codman's, sub max isom first (add & IR), avoid stg in abd, ROM exercises, isom (0 deg of abd)
what to strengthen for anterior GH dislocation? anterior compartmet, IR & add's for stability, pec major, teres major, RC, coracobrachialis, biceps, latissmus dorsi, subscapularis, assess scapulothoracic/scapulohumeral motion & stg as necessary
MOD-MIN phase ant shld dislocation maintain jt play but avoid anterior glide, isot (focus s/b on pec major, adductors, internal rotators, theraband to begin shldr adduct & IR for ant dislo, UBE, CKC shldr st, LHB CREATES LOT OF STABILITY, BICEP CURLS
shoulder medial/internal rotators latissimus dorsi, teres major, subscapularis, pec major
shoulder external rotators supraspinatus, infraspinatus, teres minor
Created by: djbari
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