Transcript Shoulder pathologies and Physiotherapy

Hampshire Community
Health Care
Contents
Anatomy
Pathologies and Treatment
Sources of referred pain
Exercises
Neural mobility exercises – sliders
Outcome measures
Anatomy – Shoulder joint complex
 Glenohumeral joint
 Acromioclavicular joint
Sternoclavicular joint
Scapulothoracic joint
Anatomy - Rotator Cuff Muscles
 Supraspinatus
 Infraspinatus
 Teres Minor
 Subscapularis
Anatomy - Rotator cuff posterior aspect
Pathologies
Impingement Syndrome
Rotator cuff tear
ACJ
Labral lesions
LHB
TOS
Referred Pain
Impingement
External
Internal
External impingement (Sub-acromial Impingement
Syndrome)
 Primary
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Bony abnormalities in the shape of the acromial arch
Bone spurs
Calcification
 Secondary
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Poor scapular stabilisation
Weakness of the rotator cuff
Muscular imbalance between deltoid and rotator cuff muscles.
Impingement
Internal Impingement
(Posterior Superior Glenoid
Impingement)
 Articular side of Supraspinatus
becomes impinged between
the greater tuberosity and the
posterosuperior labrum.
 Abduction and external
rotation are affected.
 Pain at the posterosuperior
aspect of the shoulder
Subacromial Impingement Syndrome (External)
 Subacromial space
 Space 9-10mm
 Arm elevation – superior head displacement
 Rotator Cuff muscles
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Provide dynamic stability
Work with deltoid
Prevent superior translation of HH
 RC – Deltoid balance
Sub-acromial space contents
 Supraspinatus tendon
 Long head biceps tendon
 Subacromial bursa
 Superior border of capsule
Causes of Impingement
 Instability/hypermobility
 RC overuse or tendinopathy
 Tight posterior GH capsule
 Poor scapular muscle control
 Poor Posture
Causes of impingement
 Poor Tx spine extension – reduced GH elevation
 Increased Tx kyphosis and FHP (forward head posture)
will cause:
 scapulae to abduct
 resulting in lengthening of rhomboids and LFT
 shortening of serratus anterior, latt dorsi, subscap – reduced
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scapular upward rotation
shortening of pect major and pect minor
pull the coracoid process downwards
bringing the acromion over the head of the humerus
causing a mechanical block to arm elevation
reduced subacromial space
Impingement tests
 SIS
Hawkins Kennedy – pushes supraspinatus tendon / RC/ against
coraco-acromial ligament
 Neer’s Impingement test
 Painful arc
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 Internal Impingement / PosteroSuperior
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Shoulder Abd, LR induce posterior pain, relieved by humeral head
relocation (AP glide of humeral head)
Treatment
Correct biomechanics of shoulder joint complex
Correct posture
Increase Tx mobility
Lengthen shortened muscles
Release tight posterior capsule or posterior cuff
Strengthen weaker muscles esp. RC and scapular
upward rotators – SA and LFT
RC Tear
 Partial or Full
 Overhead activity, trauma or
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recurrent impingement
If atraumatic - chronic diffuse
pain more than 3 months
Common in over 40’s Tendonosis, smoking, steroids,
RA, Diabetes
Affects 7% of elderly
Unable to sleep on effected
shoulder
Limited internal rotation,
passively painful
RC Tests
 SS
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Full can
Drop arm – eccentric control
 IFS
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LR at 45deg MR at GHJ to minimize SS, post deltoid
LR lag sign, Drop sign (Stop)
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Hornblower’s sign (LR in 90 scaption)
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 TM
 SbScap
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Gerber Lift off / Belly press
ACJ
Pain when lying on effected shoulder
Pain when reaching arm across body
Pain with passive or active arm
adduction
Tender on palpation over ACJ
Scarf test / Cross body adduction
Labral lesions
Superior – SLAP
Bankart lesion
Causes
 FOOSH
 Repetitive movements
 Strong biceps contraction
Symptoms of glenoid labrum tears
Clicking or catching with shoulder movements
Vague pain at front or top of shoulder
Pain is made worse by overhead activities or when
the arm is held behind the back.
Weakness and Instability in the shoulder.
Pain on resisted flexion of the biceps
Labral SLAP tests
 O’Brien Active Compression Test
Pt stdg, flexion 90°, adduction 15° with elbow extended
Full MR so thumb pointing down
Resist flexion
Pt laterally rotates arm so thumb pointing up
Resist flexion
Positive test = Pain or painful clicking elicited with thumb down and
decreased or eliminated with thumb up
 Crank test
Shoulder elevated to 160° in the scapular plane
A gentle axial load is applied through glenohumeral joint with one hand,
while other hand does IR and ER
Positive test = pain, catching, or clicking in the shoulder
Long Head Biceps
Yergason’s test
Elbow flexed 90. Resist supination of forearm.
Positive test if tenderness over bicipital groove
Speeds test
Resist forward flexion of extended and supinated arm
from 0 – 60 dg flexion
Thoracic Outlet Syndrome
 Abnormal compression of the neurovascular bundle
by bony, ligamentous or muscular structures at
thoracic outlet
 Neural symptoms:
Paraesthesia esp C8T1 dermatomal distribution
 Pain in upper limb and hand
 Numbness
 Muscle weakness and atrophy of hand muscles
 Difficulty with fine motor control of hand
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Thoracic Outlet Syndrome
 Vascular symptoms:
Deep pain at neck and shoulder, worse at night
 Feeling of heaviness in arm or hand
 Fatigue in arms and hands
 Swelling of hand
 Bluish discoloration
 Superficial vein distention in hand
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TOS
Interscalene
triangle
Costoclavicular
triangle
Subcoracoid
space
TOS Tests
 Adson’s test
Locate the radial pulse
Neck rotation toward the tested arm
Neck extension
PT extends the arm
Deep inspiration with hold
A positive test is indicated by a disappearance of the pulse.
 Allen’s test
Shoulder horizontal extension and lateral rotation
Palpate radial pulse
Neck rotation away from the tested arm
Positive if radial pulse disappears
Referred Pain : Cervical
Referred Pain: Gastro-Intestinal
 Liver : R shoulder
 Gall bladder: R shoulder and R scapula
 Diaphragm : unilateral / bilateral shoulder
pain
 Spleen: L shoulder + upper 1/3 arm
 Aortic Aneurysm: L scapula
 Cardiac: L shoulder + Scapula
 Post Laparoscopy: uni / bilateral shoulder
pain
Referred Pain: Pancoast Tumour
 Tumour of apex of lung
 Invade chest wall structures such as
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Lymphatics
Lower roots of brachial plexus (esp. C8, T1)
Intercostal nerves
Sympathetic chain and Stellate ganglion
Adjacent ribs
Initial symptom is pain in the shoulder and medial aspect of
scapula
Referred pain to C8, T1, T2 dermatomes
Horner’s syndrome later develops
Pt supports arm to relieve neural tension
Hand muscles later develop atrophy
Exercises
 Scaption instead of Abduction
Better joint congruence
 Reduced tensile forces on ligaments
 Optimal sub-acromial space and clearance
 Optimal alignment of RC muscles
 Increased proprioceptive feedback
 Increased activation of scapula upward rotators and RC muscles
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 Exercises for RC with minimization of deltoid and
Upper Fibres Trapezius activity
Exercises RC
Supraspinatus
 Full can in scaption +/- wt
 Empty can in scaption <90dg
Infraspinatus / Teres minor
 LR in varying degrees of abduction
Subscapularis
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MR in varying degrees of abduction
Diagonal exercise
Dynamic hug
Push up plus
Scapular exercises
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Side lying flexion +/- wt
Side lying lateral rotation +/- wt
LFT – prone arms overhead
MFT – prone 90 abd with LR
UFT – prone arms by side
Scapular setting progression in prone:
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Short lever arm, lateral rotation (wrist lift)
Short lever arm, medial rotation (elbow lift)
Short lever arm lift
Long lever arm lift
Long lever arm lift with wt
 Stability exs – active wall slide with towel, 4 point, and ball
press ups
Exercises
Serratus Anterior
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Knee Push up plus
Push up plus
Seated press up
Forward punch with TB attached behind
Scaption with wt
Dynamic hug
Posterior capsule tightness
STM of soft tissues at posterior shoulder
Medial rotation stretch (Sleeper’s stretch)
Horizontal adduction stretch
AP glide in neutral / medial rotation
AP axial glide in horizontal adduction
Corner stretch for pectoralis minor
Doorway stretch for pectoralis major
Neural mobility exercises
 Median nerve
 Radial nerve
 Ulnar nerve
Outcome measures - SPADI
Activity
Difficulty
1. Washing your hair?
2. Washing your back?
3. Putting on an undershirt or pullover sweater?
4. Putting on a shirt that buttons down the front?
5. Putting on your pants?
6. Placing an object on a high shelf?
7. Carrying a heavy object of 10 pounds?
8. Removing something from your back pocket?
Disability scale: How much difficulty do you have….
0 = no difficulty
10 = unable to do
NA = not applicable
Pain
DASH
(Disabilities
Arm
Shoulder
Hand)
Outcome measures – Simple shoulder test