The Shoulder Differential Diagnosis, Treatment and Rehabilitation.
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Transcript of The Shoulder Differential Diagnosis, Treatment and Rehabilitation.
The Shoulder
Differential Diagnosis, Treatment and Rehabilitation
Capsular
LR>ABD>MR
Frozen Shoulder• Aka Capsulitis or adhesive capsulitis
• Vol of normal = 30mls• Vol of frozen = 3mls
• 2% of normal population• 20% go bilateral• 11% in diabetic pop (don’t know why)• W:M 60:40 Non dom gtr than dom• Risk factors – diabetes, hyperthyroid, immobilisation,
stroke
Frozen Shoulder
• Capsular pattern
Most loss of LR, then abd, then MR
• Insidious onset
• Self limiting 2-3 years
• 3 Stages – freezing, frozen and thawing
Stage 1
• Intermittent ache
• Not below the elbow
• Able to sleep on that side
• Elastic end feel
Stage 2
• Constant pain
• Below the elbow
• Unable to lie on that side at night
• Hard end feel
Stage 3
• As in stage 1
• Resolving problem
Treatment of frozen shoulders• Stage 1 – heat, gentle mobilisation grade A
and or injection
• Stretch into elev and release with distraction
• Distraction with sh elev and longitudinal distraction
Treatment of frozen shoulders cont.
• Stage 2 – injection combined with pain relief (and slow sustained stretching, as able)
• Stage 3 – heat + low load sustained stretching – LR, MR and elev
• 20 – 30 mins
Home Exercise Programme
Other Capsular Lesions
• OA
• Electro and Grade B mobs
• Steroid Sensitive Arthritis
• Intra-artic injection
Non - Capsular
Primary impingement
• Associated with anatomical changes in the sub-acromial space ? cause
• Acromial shape• Osteophytes
• Tendon changes – tendonitisOr tendinosis?• Ligamentous thickening• Bursal thickening
Secondary Impingement
• Posture, neck and thorax
• Tight muscle eg. Upper trapezius, pectoralis minor
• Weak muscles eg.lower trapezius, serratus anterior
• Poor timing, proprioception
Neer classification
• Stage 1 – under 25 years, oedema, inflammation, acute bursitis, tendonitis
• Stage 2 – 25-40 years, fibrosis, bursal thickening, fibre disruption in the tendons
• Stage 3 – over 40 years, bony spurs, compromised space, partial to full thickness tears
Sub-acromial bursitis• Aka sub-deltoid bursitis, SIS
• Sub-acromial space – supraspin. Tendon, bursa, sup aspect of GH capsule and long head of biceps
On examination
• Overuse
• Gradual onset
• C5 pain not usually below elbow
• Arc and pain EOR
• Non capsular pattern
• Resisted abd and LR painful esp on release
Treatment of Subacromial Bursitis
• Pain relief• Physio modalities eg acup, trig point, US, taping• Injection
• Posture • Postural stability work inc lower traps• Rotator cuff strengthening• Stretching upper traps, pec major, minor
Home Exercise Programme
Acromio-clavicular Joint
• O/E high painful arc • Localised pain C4• Scarf positive• EOR pain on passive movements
• Traumatic onset – RICE– Strapping– Mobs
• Gradual onset -mobs, frics and or inject
Contractile Lesions
• Strong + Painless = Normal• Strong + Painful = tendon or muscle local lesion I
or II• Weak + Painless = Rupture III or nerve damage• Weak + Painful = severe lesion eg #
• Pain during contraction – tendon• Pain on release - bursa
Supraspinatus Tendinitis• O/E resisted abd painful and painful arc = distal
end of tendon• Friction + electro + rest• All frics numb + 10mins • Or inject
• Resisted abd painful and no painful arc = MT junction
• Rotation Friction with arm in horizon abd, no injec
Subscapularis Tendinitis
• O/E resisted MR painful
+ painful arc = upper fibres
+ scarf test = lower fibres
Friction – may be painful due to bursa
Or inject
Infraspinatus Tendinitis
• O/E resisted LR painful
+ painful arc = distal end of tendon
+ no painful arc = body of tendon
• Friction or inject
Biceps Tendinitis
• O/E resisted flexion and supination of the elbow painful
• Long Head – rotation frics at bicipital groove or inject
• Belly – pinch grip frics or inject with LA only
When its not a shoulder
• Pins and needles / numbness
• Radiation to hand
• Neck movt aggravates pain
• Gastro– intestinal pathology
• Avascular necrosis