THE SHOULDER AND

SHOULDER GIRDLE

CH 17

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

Revision of shoulder anatomy and biomechanics

• Shoulder complex articulations

• Arthrokinematics/osteokinematics

• Static and dynamic constraints

• Scapulohumeral rhythm

Winging and tipping

Brief Glance on Surface Anatomy

MANAGEMENT OF SHOULDER DISORDERS

AND SURGERIES

MANAGEMENT OF SHOULDER DISORDERS

AND SURGERIES

Nerve Disorders in the Shoulder Girdle Region•Brachial plexus in the thoracic outlet

•Suprascapular nerve in the suprascapular notch

•Radial nerve in the axilla

Joint Hypo mobility and post op management

•RA and OA•Traumatic arthritis•Post-immobilization arthritis or stiffness

•Idiopathic frozen shoulder

Causes

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

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

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

Management—Protection Phase1. Control Pain, Edema, and Muscle Guarding

• Modalities

• Immobilization

• Grade I and II

• Cervical soft tissue

mobilization

• PROM/ AAROM

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

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

Management—Controlled Motion Phase1. Control Pain, Edema, and Joint Effusion

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

Self-mobilization techniques.

Management—Controlled Motion Phase

•Inhibit Muscle Spasm and Correct Faulty Mechanics

•Improve Joint Tracking MWM•Improve Muscle Performance

Management—Return to Function Phase

•Progressively Increase Flexibility and Strength

Management—Return to Function Phase

•Prepare for Functional Demands

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.

Glenohumeral joint surgery and postoperative management

Underlying pathologies

•RA , OA•AVN of head of humerus•An acute or nonunion fracture

Indications

•Significant pain•Loss of upper Limb function

Goals

Designs of Prosthetic Implantsfor Total Shoulder Replacement

•Unconstrained

•Semiconstrained

•Reversed ball and socket (totally damaged RC)

•Constrained

Complications of Glenohumeral ArthroplastyIntraoperative

Soft Tissue-Related

Implant-Related

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)

Positioning After Shoulder Arthroplasty•Supine

•Sitting

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

Exercise: Maximum Protection Phase•Control pain and inflammation.

Exercise: Maximum Protection Phase•Maintain mobility of adjacent joints

Exercise: Maximum Protection Phase•Restore shoulder mobility

Exercise: Maximum Protection Phase•Minimize muscle inhibition, guarding, and atrophy

Exercise: Moderate Protection/Controlled Motion Phase

Exercise: Minimum Protection/Return to Functional Activity Phase

Exercise: Minimum Protection/Return to Functional Activity Phase

ASSIGNMENTResting and close packed positions

of Shoulder , elbow and wrist

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

Faulty posture

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

THANK YOU