Physical Therapy Protocols for Conditions of Shoulder Region

Red Flags for Potential Serious Conditions in Patients with Neck and Shoulder Problems

Red Flags for the Neck and Shoulder Region

Condition Red Flag

Data obtained during Interview/History

Red Flag Data obtained during

Physical Exam Cervical Fractures or Ligamentous Instabilities1-6

Major trauma such as a motor vehicle accident or a fall from a height with associated immediate onset of neck pain

Rheumatoid arthritis or Down’s syndrome

Midline cervical spine tenderness Positive ligamentous integrity tests:

Sharp-Purser test Alar ligament integrity test

Apprehension with or inability to actively rotate head < 45o

Cervical Central Cord Lesion7-9

Older age History of a trauma (esp. MVA or fall) Incontinence

Gait disturbances due to hyperreflexic lower extremities

Upper extremity (especially hand) sensory and motor deficits, and atrophy

Pancoast tumor10-12 Men over 50 with a history of cigarette

smoking. “Nagging” type pain in the shoulder and

along the vertebral border of the scapula – often progressing to burning pain down the arm into the ulnar nerve distribution.

Wheezing with auscultation when tumor obstructs bronchus

May have Horner’s syndrome Ptosis (drooping eyelid) Constricted pupil Sweating disturbances

Septic Arthritis (A-C Joint)13

Insidious onset of chest pain localized in the S-C joint

History of IV drug use, diabetes, trauma, infection (especially of central venous access)

Tender S-C joint Limited shoulder movement Swelling over S-C joint Fever

References: 1. Aspinall W. Clinical testing for the craniovertebral hypermobility syndrome. J Orthop Sports Phys Ther. 1990;12:47-54. 2. Panjabi M. (1992) in Swinkels R, Beeton K, Alltree J. Pathogenesis of upper cervical instability. Manual Therapy. 1996;

1:127-132. 3. Hoffman JR. Mower WR. Wolfson AB. Todd KH. Zucker MI. Validity of a set of clinical criteria to rule out injury to the

cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group.[erratum appears in N Engl J Med 2001 Feb 8;344(6):464]. N Engl J Med. 2003;343:94-99.

4. Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, et al. The Canadian C-Spine Rule versus the Nexus Low Risk Criteria in patients with trauma. N Engl J Med. 2003; 349:2510-2518.Niere KR, Torney SK. Clinicians” perception of minor cervical instability. Manual Therapy. 2004;9:144-150.Delfini R, Dorizzi A, Facchinetti G, et al. Delayed post-traumatic cervical instability. Surg Neurol. 1999; 51:588-95.

7. Newey MI, Sen PK, Fraser RD. The long-term outcome after central cord syndrome: a study of the natural history. J Bone Joint Surg Br. 2000;82:851-855.

8. Tow AM, Kong KH. Central cord syndrome: functional outcome after rehabilitation. Spinal Cord. 1998; 36:156-160. 9. Waters RL, Adkins RH, Sie IH, Yakura JS. Motor recovery following spinal cord injury associated with cervical

spondylosis: a collaborative study. Spinal Cord. 1996;34:711-715. 10. Spengler D, Kirsh M, Kaufer H. Orthopaedic aspects and early diagnosis of superior sulcus lung tumor. J Bone Joint Surg.

1973;55:1645-1650. 11. Jett J. Superior sulcus tumors and Pancoast’s syndrome. Lung Cancer. 2000;42:S17-S21. 12. Robinson D, Halperin N, Agar G, et al. Shoulder girdle neoplasms mimicking frozen shoulder syndrome. J Shoulder Elbow

Surg. 2003; 12:451-5. 13. Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine. 2004;83:139-148.

Joe Godges, DPT, MA, OCS KP So Cal Ortho PT Residency

NECK AND SHOULDER SCREENING QUESTIONNAIRE NAME: __________________________________________ DATE: _____________ Medical Record #: _________________________

Yes No

1. Have you recently experienced a blow to the head or a whiplash injury?

2. Do you have rheumatoid arthritis?

3. Are you currently taking steroids or have you been on prolonged

steroid therapy?

4. Have you noticed any recent weakness, tingling, or numbness in you

arms or legs?

5. Have you noticed a recent onset of difficulty with retaining your urine?

6. Do you now smoke or have you been a smoker in the past?

7. Do you administer medicine or drugs to yourself for which you need to

inject using a needle?

Joe Godges, DPT, MA, OCS KP So Cal Ortho PT Residency

Shoulder Mobility Deficits ICD-9-CM codes: 726.0 Adhesive capsulitis of the shoulder ICF codes: Activities and Participation Domain codes:

d4452 Reaching (Using the hands and arms to extend outwards and touch and grasp something, such as when reaching across a table or desk for a book.)

Body Structure code: s7201 Joints of shoulder region Body Functions code: b7100 Mobility of a single joint

Common Historical Findings

Lateral shoulder pain - worsens with positions or activities which put stretch on the glenohumeral joint

Progresses to stiffness Gradual, usually insidious, onset of symptoms

Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions:

ROM limitations - external rotation and abduction are most limited, flexion and internal rotation are least limited

Pain at end ranges--some motions are more painful than others (external rotation with abduction is typically the most painful)

Limited glenohumeral accessory movements Physical Examination Procedures:

Glenohumeral External Rotation ROM Measurement

Performance Cues:Remember that glenohumeral ROM is different than shoulder ROM (shoulder ROM is

the sum of glenohumeral and scapular ROM) Stand in patient’s axillary region Stabilize scapula with forearm Be precise with stabilization of humeral abduction (to 90 degrees if possible) and

horizontal abduction (maintain 0 degrees)

Joe Godges, DPT, MA, OCS KP So Cal Ortho PT Residency 1

If glenohumeral external rotation ROM is greater at 90 degrees of abduction than at 45 degrees of abduction, suspect a muscle flexibility deficit of the subscapularis

Normal glenohumeral external rotation ROM is 90 degrees

Glenohumeral Internal Rotation ROM Measurement Performance Cues: Stand above the patient Stabilize scapula in neutral - use forearm to prevent protraction Be precise with humeral abduction (90 degrees if possible) and horizontal abduction

(maintain 0 degrees) Normal is 60 degrees of isolated glenohumeral internal rotation ROM

Glenohumeral Flexion ROM Measurement

Performance Cues: Stabilize scapula - maintain lateral scapular border in a position that is parallel to the

tabletop Normal is 120 degrees of isolated glenohumeral flexion


Glenohumeral Abduction ROM Measurement

Performance Cues: Glenohumumeral (GH) abduction is difficult to assess in patients with adhesive capsulitis

because GH abduction requires GH external rotation Externally rotate humerus to the maximum of pain free motion - then abduct to

limitation. (Notate both: e.g., 70o of GH abduction with GH E/R at 30o) Stabilize scapular to prevent compensatory scapular elevation Normal is 120 degrees of isolated GH abduction (at 90 degrees of GH E/R)

Shoulder Mobility Deficits: Description, Etiology, Stages, and Intervention Strategies

The below description is consistent with descriptions of clinical patterns associated with shoulder Adhesive Capsulitis the vernacular term “Frozen Shoulder”

Description: Insidious onset of progressive stiffness and pain of the shoulder Etiology: The cause of this disorder is presumed to be due to repeated inflammatory reactions in the glenohumeral capsule and synovium, which lead to a thickened, fibrotic and inextensible glenohumeral joint capsule. The altered scapular and glenohumeral joint mechanics due to the glenohumeral capsular restrictions often lead to abnormal stress and subsequent inflammation of the rotator cuff tendons and subacromial bursa Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions codes: b7100.3 SEVERE impairments of mobility of a single joint

• Excessive scapular protraction • Excessive scapulothoracic joint motion – a common characteristic is excessive

scapular elevation with the scapular upward rotation that normally accompanies overhead activities

• Restricted active ROM – lateral rotation and abduction are commonly the most limited if overhead reaching is the reported functional limitation. Medial rotation is commonly limited if hand behind back movements are the reported functional limitation.


• Isolated glenohumeral motions are considerably limited – typically about 50% of normal (Normal glenohumeral PROM is 120o of flexion, 120o of abduction, 90o of lateral rotation and 70o of medial rotation when measured at 90o of glenohumeral abduction)

• Glenohumeral accessory movements and joint play movements are also considerable limited – especially humeral inferior, posterior and anterior glides

• Symptoms are worst with end-range positions that stretch the capsule • Rotator cuff muscles may weak and painful due to the tension transmitted to an

inflamed joint capsule by contracting musculotendinous units that attach to the capsule

• Pain around joint capsule (near axilla) Sub Acute / Moderate Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions codes: b7100.2 MODERATE impairments of mobility of a single joint

As above with the following differences:

• Resisted Tests are strong and relatively painless when the glenohumeral joint positioned in midrange (thus lessening tension on the capsule)

Now (when less acute) examine the patient for common coexisting upper quadrant impairments. For example:

• Segmental movement abnormalities cervical and upper thoracic spine • Limited glenohumeral physiologic and accessory movements • Muscle flexibility deficits – especially subscapularis, infraspinatus, pectoralis minor,

pectoralis major, latissimus dorsi, and teres major myofascia • Nerve mobility deficits – especially median, radial, and ulnar nerves in the common

thoracic outlet entrapment areas • Weak scapular upward rotator muscles – commonly lower trapezius, middle

trapezius, and serratus anterior • Excessive scapular elevation, abduction, downward rotation or winging with

overhead reaching Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions codes: b7100.1 MILD impairments of mobility of a single joint As above with the following differences:

• Pain with repetitive activities of the shoulder especially at end range • Painful only with overpressures at end ranges


Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Prevent movement induced inflammatory reactions

Avoid muscle guarding Painfree with daily activities that use shoulder within available range Painfree sleep

• Physical Agents:

Phonophoresis/iontophoresis or pulsed ultrasound to assist in reducing inflammation

Ice and/or TENS for relief of acute pain as well as to reduce muscle guarding

• External Devices (Taping/Splinting/Orthotics) Fit patient with a sling if pain relief requires temporary use of an external device

• Therapeutic Exercises

Painfree AROM or passive ROM exercises Pendulum (Codman’s) exercises

• Re-injury Prevention Instruction Temporarily limit end range motions or stretches, overhead or behind the back activities that aggravate the patient’s condition

Sub Acute Stage / Moderate Condition Goals: Improve glenohumeral ROM

Improve scapulohumeral rhythm Prevent re-injury to the joint capsule Restore strength of the muscles around shoulder and scapula

• Physical Agents:

May use ultrasound to the joint capsule prior to active or passive stretching procedures/exercises

• Manual Therapy

Soft tissue mobilization to adaptive shortened myofascia Joint mobilization to restricted accessory and joint play motions


Stretching exercises to enhance carryover of manual stretching procedures Strengthening exercises to weak scapular depressors, scapular upward rotators,

and rotator cuff motions


• Neuromuscular Reeducation

Facilitate neutral thoracic cage, scapular position, and shoulder proprioception

• Ergonomic Instruction: Promote efficient, painfree, motor control of the trunk, scapulae and arm with

overhead activities. Modify activities to prevent overuse and re-injury

Settled Stage / Mild Condition Goals: Normalize glenohumeral ROM

Normalize upper quarter posture, muscle flexibility and muscle strength Progress activity tolerance

• Approaches/ Strategies listed above

• Manual Therapy

Increase intensity and duration of soft tissue mobilization and myofascial stretching to the maximal tolerable level

Increase intensity and duration of joint mobilization procedures to the maximal tolerable


Maximize muscle performance of the relevant trunk, scapulae, shoulder flexion and shoulder girdle muscles required to perform the desired occupational or recreational activities.

• Ergonomic Instruction: as above

Add job or sport specific training Intervention for High Performance / High Demand Functioning in Workers and Athletes Goal: Return to desired occupational or sport activities

• Therapeutic Exercises Progress exercises focusing on job/sport specific training program based on individual needs of patient.


Selected References Deyle GD, Bang MD. Examination and treatment of the shoulder. Orthopaedic Physical Therapy Clinics of North America. 1999;8:83-115. Gross J, Fetto J, Rosen E. Musculoskeletal Examination. Blackwell Science, 1996. Hannifan JA, Chiaia TA. Adhesive capsulitis: a treatment approach. Clinical Orthop Rel Res. 2000; 372:95-109. Loyd JA. Adhesive capsulitis of the shoulder, diagnosis and treatment. South Medical Journal. 1993;76:879-883. Neviaser JS. Adhesive capsulitis and the stiff and painful shoulder. Orthop Clin of North Am. 1980;11:327-333. Nicholson GG. The effects of passive joint mobilization on pain and hypomobility associated with adhesive capsulitis of the shoulder. J Orthop Sports Phys Ther. 1985; 6(4): 238-246. Placzek J, Roubal P, Freeman C, et al. Long term effectiveness of translational manipulation for adhesive capsulitis. Clin Orthop and Rel Res. 1998;356:181-191. Rizk TE, Christopher RP, Pinals RS, et al. Adhesive capsulitis (frozen shoulder): a new approach to its management. Arch Phys Med Rehabil. 1983;64:29-33. Roubal PJ, Dobitt D, Placzek JD. Glenohumeral gliding manipulation following interscalene brachial plexus block in patients with adhesive capsulitis. J Orthop Sports Phys Ther. 1996;24:66-77. Tomberlin J, Saunders D. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders, 3rd ed., Vol. 2, (Extremities). Educational Opportunities, 1994. Vermeulen HM, Oberman WR, et. al. End-range mobilization techniques in adhesive capsulitis of the shoulder joint: a multiple subject case report. Phys Ther. 2000;80:1204-1213. Wadsworth T. Frozen shoulder. Phys Ther. 1986;66:1878-83.


SHOULDER MANUAL INTERVENTIONS

Patient Problem: LIMITED HUMERAL INTERNAL ROTATION ST MOB: Infraspinatus/Teres Minor/Posterior Deltoid JNT MOB: Posterior Glide (loose packed position)

Posterior Glide (combined movements) Distraction

RE-ED: Extension/Adduction/Internal Rotation PNF pattern (emphasize traction +

rotation) Contract/Relax to glenohumeral external rotators

MWM: Hand-Behind Back Maneuvers Patient Problem: LIMITED HUMERAL EXTERNAL ROTATION ST MOB: Pectoralis Minor

Subscapularis JNT MOB: Inferior Glide

Posterior Glide Anterior Glide

RE-ED: Contract/Relax of Extension/Adduction/Internal Rotation PNF pattern (emphasize

spiral/ diagonal) Flexion/Abduction/External Rotation PNF pattern (facilitate movement/traction)

MWM: Arm Overhead Maneuvers


Infraspinatus

Soft Tissue Mobilization

Subscapularis

Soft Tissue Mobilization


Impairment: Limited Shoulder Hand Behind Back Motions

Limited Glenohumeral Internal Rotation Limited Humeral Posterior Glide

Humeral Posterior Glide Cues: Position the patient supine with a wedge under the spine of the scapula (not under the

glenohumeral joint) A strap is handy to fixate the upper thorax and scapula - especially if you plan to add the

combined movement of humeral distraction Hug the arm Use a “flat” hand and padding (folded sheet) to prevent irritation of the anterior

humeral/bicipital groove area Consider adding combined movements of humeral distraction, abduction, and internal

rotation as well as cervical sidebending prior to the posterior glide

The following reference provides additional information regarding this procedure: Freddy Kaltenborn PT: Manual Mobilization of the Extremity Joints, p. 114, 1989


Impairment: Limited and Painful Shoulder Elevation

Shoulder Elevation MWM Cues: Position patient seated at the end of a raised treatment table

Stand to the side of the uninvolved shoulder Stabilize scapula with one hand Glide the humeral head posteriorly - parallel to the glenoid treatment plane Sustain the glide as the patient actively elevates his humerus Alter the amplitude and direction of the glide to achieve painfree active elevation Repeat several times (sets of 10) Progress the re-education with 1) lifting a weight during the MWM, or 2) overpressure at

end of available active range – one option is illustrated below

The following reference provides additional information regarding this procedure: Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 88-91, 1995

Shoulder Elevation MWM (with overpressure)


Impairment: Limited Shoulder Elevation

Limited Glenohumeral External Rotation Limited Humeral Anterior Glide

Humeral Anterior Glide Cues: Position the patient prone with the involved humerus off the side of the table – place a

towel pad under the coracoid process and clavicle A strap can be used to assist in stabilizing the scapula (especially when adding combined

movements) Hug the distal humerus into your thigh with one hand Apply an anterior glide to the proximal humerus with the other hand Use a soft flat hand Generate the anterior glide with a trunk lean or slight bend of the knees Consider adding combined movements of humeral distraction, abduction, horizontal

abduction, or external rotation prior to the anterior glide (an adjustable, rolling stool can be used to provide the external rotation)

The following reference provides additional information regarding this procedure: Freddy Kaltenborn PT: Manual Mobilization of the Extremity Joints, p. 112, 1989


Ext/Add/IR Contract-Relax

FLEX/ABD/ER facilitation


Shoulder Muscle Power Deficits

ICD-9-CM codes: 840.6 Supraspinatus strain 726.12 Bicipital tenosynovitis

ICF codes: Activities and Participation Domain codes:

d4452 Reaching (Using the hands and arms to extend outwards and touch and grasp something, such as when reaching across a table or desk for a book.) d4300 Lifting (Raising up an object in order to move it from a lower to a higher level, such as when lifting a glass from the table.)

Body Structure code: s7202 Muscles of shoulder region Body Functions code: b7300 Power of isolated muscles and muscle groups


Shoulder abductors/external rotators musculotendinous involvement: Pain in posterior-lateral shoulder Pain with overhead activities Midrange (about 90 degrees) catching sensation Symptoms developed from, or worsen with, repetitive overhead activities – or from an

acute strain such as a fall onto the shoulder

Shoulder flexors musculotendinous involvement: Pain in anterior-lateral shoulder Pain with shoulder flexion and lifting activities Painful arc Symptoms developed from, or worsen with, repetitive flexion and lifting activities

Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions:

Shoulder abductors/external rotators musculotendinous involvement: Painful arc with active elevation Supraspinatus manual resistive test: weak and painful (moderately painful) Infraspinatus manual resistive test: weak and painful (mildly painful) Palpable posteriolateral rotator cuff tenderness Shoulder girdle muscle flexibility, strength, and coordination deficits Shoulder flexors musculotendinous involvement: Painful arc with shoulder flexion Biceps brachii manual resistive test: weak and painful Palpable tenderness in bicipital groove Shoulder girdle muscle flexibility, strength, and coordination deficits


Physical Examination Procedures:

Normal Arm Elevation Painful Arc and Associated

Motor Control Deficits Performance Cues:Common muscle flexibility deficits include short pectoralis minor, levator scapulae, teres

major, and latissimus dorsi Common muscle strength deficits include weak supraspinatus, infraspinatus, lower

trapezius, and serratus anterior Common motor coordination deficits include excessive 1) thoracic spine flexion, 2)

contralateral weight shift of thorax, 3) scapular protraction and downward rotation, 4) scapular abduction during overhead activities

Supraspinatus Manual Resistive Test

Performance Cues: Elevate arm about 40 degrees in scapular plane “Thumb down” to internally rotate humerus Contact only dorsal surface of distal forearm Stabilize thorax - contact contralateral shoulder Remember - slow build-up of resistance, sustain peak, slow release of resistance If there is a grade III (complete) tear of the rotator cuff the patient will be unable to hold

the arm in this position (positive “Drop Arm Test”)


Infraspinatus Manual Resistive Test

Performance Cues: Contact only dorsal surface of distal wrist Stabilize ipsilateral elbow May test at differing degrees of humeral flexion and abduction

Biceps Manual Resistive Test

Supraspinatus and Infraspinatus Tendon

(Rotator Cuff) Palpation


Performance Cue:Placing the humerus in a position of internal rotation, extension, and adduction assists in gaining easier access to the tendons

Palpation of the Bicipital Groove

Shoulder Muscle Power Deficits: Description, Etiology, Stages, and Intervention Strategies

The below description is consistent with descriptions of clinical patterns associated with the vernacular term “Rotator Cuff Tendinitis”

Description: Repetitive strain injury to the deep tendons of the shoulder – most commonly the tendons of the supraspinatus of infraspinatus muscles. Etiology: The suspected cause of this disorder is the abnormal “impingement” of the tendons of the rotator cuff between the humeral head and the acromial arch due to deficits in the ability of the humeral head depressors (the “rotator cuff muscles”) or the scapular upward rotator muscles to function in a coordinated manner during overhead activities. Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions codes: b7300.3 SEVERE impairments of muscle power

• Accentuated thoracic kyphosis, scapular protraction, scapular abduction, and/or scapular downward tilt

• Excessive scapular elevation, abduction, downward rotation or winging with overhead reaching

• Midrange “arc” of pain with overhead movements (e.g., pain during 130o to 160o of shoulder flexion)

• Weak and painful supraspinatus and/or infraspinatus during manual muscle tests • Palpation of involved rotator cuff tendons reproduce the patient’s reported pain

complaint


Sub Acute / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b7300.2 MODERATE impairments of muscle power

As above, except:

• Strong and painful supraspinatus and/or infraspinatus Now (when less acute) assess thoracic and scapular malalignments, and muscle flexibility and strength deficits – for example:

• Shortened pectoralis minor, levator scapulae, teres major, and latissimus dorsi myofascia

• Weak scapular upward rotator muscles – commonly lower trapezius, middle trapezius, and serratus anterior

Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions codes: b7300.1 MILD impairments of muscle power As above, except:

• Strong and painful supraspinatus and/or infraspinatus muscles only with repeated contractions

• Midrange “arc” of pain only with repeated overhead movements • Overpressure, or passively forcing end range shoulder flexion (e.g., “impingement

tests”) reproduce the patients reported pain complaints

Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Alleviate pain with active arm elevation

Restore strength to supraspinatus and infraspinatus muscles

• Physical Agents Ultrasound, iontophoresis, and/or ice applied to the rotator cuff tendons

• Manual Therapy

Soft tissue mobilization to shortened pectoralis minor, levator scapulae, teres major, and latissimus dorsi myofascia


Facilitate neutral thoracic cage and scapular posture with overhead activities


• Therapeutic Exercises Strengthening exercises for the supraspinatus and/or infraspinatus

• External Devices (Taping/Splinting/Orthotics)

Taping procedures to promote scapular alignment and to facilitate contraction of the lower trapezius, middle trapezius, and/or serratus anterior

May consider a sling if necessary to temporarily limit painful active movements

• Re-injury Prevention Instruction Temporarily limit overhead activities

Sub Acute Stage / Moderate Condition Goals: Prevent re-injury of the rotator cuff

Improve strength of supraspinatus and infraspinatus Alleviate upper quarter malalignments and muscle flexibility and strength deficits

contributing to the mechanical “impingement” of the rotator cuff

• Approaches / Strategies listed above

• Manual Therapy If a localized area of tendon thickening is palpable – transverse friction massage may be indicated


Normalize scapulohumeral and scapulothoracic rhythm using verbal, manual, or biofeedback training


Stretching exercises for shortened pectoralis minor, levator scapulae, teres major, and latissimus dorsi myofascia

Strengthening exercises for weak lower trapezius, middle trapezius, and serratus anterior muscles

• Ergonomic Instruction

Promote efficient, pain free, motor control of the trunk, scapulae and arm with overhead activities

Modify activities to prevent overuse and re-injury Settled Stage / Mild Condition Goals: As above

Progress activity to improve tolerance with overhead arm use



• Therapeutic Exercises Provide muscularendurance exercises to improve muscle performance of the relevant trunk, scapulae, and glenohumeral muscles required to perform the desired occupational or recreational activities


Add job/sport specific training Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or leisure time activities

• Therapeutic Exercises Provide exercises to maximize muscle performance of the relevant trunk, scapulae, and glenohumeral muscles required to perform the desired occupational or recreational activities


Progress job/sport specific training to increase more mechanically demanding activities

Selected References Bang MD, Deyle GD. A comparison of the effectiveness of two physical therapy treatment approaches for impingement syndrome of the shoulder: supervised exercise versus supervised exercise combined with manual physical therapy. J Orthop Sports Phys Ther. 2000;30: Deyle GD, Bang MD. Examination and treatment of the shoulder. Orthopaedic Physical Therapy Clinics of North America. 1999;8:83-115. Godges JJ, Matson-Bell M, Shah D, Thorpe D. The immediate effects of soft tissue mobilization with PNF on shoulder external rotation and overhead reach. J Ortho Sports Phys Ther. 2003;33:713-718. Host, HH. Scapular taping in the treatment of anterior shoulder impingement. Phys Ther. 1995;75:803-812. Schmitt L, Snyder-Mackler L. Role of scapular stabilizers in etiology and treatment of impingement syndrome. J Orthop Sports Phys Ther. 1999;29:31-38.


Shoulder Muscle Power Deficits: Description, Etiology, Stages, and Intervention Strategies

The below description is consistent with descriptions of clinical patterns associated with the vernacular term “Bicipital Tendinitis”

Description: An inflammatory process involving both the tendon and its sheath within the intertubercular groove caused by repetitive strain injury to the long head of the biceps brachii tendon typically producing anterior shoulder pain. Etiology: The suspected cause of this disorder is abnormal friction or strain of biceps tendon against the medial wall of the bicipital (intertubercular) groove. The structure of the anatomy leaves the tendon relatively unprotected. It is very important to recall that the bicipital groove acts as a trochlea, causing the tendon and its overlying sheath to be susceptible to wear and injury in this region. Eventually, fraying and narrowing of the tendon may occur with dense adhesions if the repetitive activities precipitating the condition are not ceased. It is important to differentiate between primary and secondary bicipital tendonitis. With primary bicipital tendonitis, the tendonitis is specific to the intertubercular groove without associated shoulder pathology. When the condition occurs in association with other pathologic conditions, such as impingement syndrome or rotator cuff disease, it is termed secondary bicipital tendonitis. Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions codes: b7300.3 SEVERE impairments of muscle power

• Excessive scapular protraction • Pain with lifting objects • Pain with reaching and overhead activities • Pain with shoulder flexion, lateral rotation or extension • Weak and painful biceps brachii • Tenderness to palpation over bicipital groove

Sub Acute / Moderate Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions codes: b7300.2 MODERATE impairments of muscle power As above with the following differences:

• Strong and painful biceps brachii contraction – e.g., pain with resisted shoulder flexion with the elbow fully extended

• Pain with resisted shoulder horizontal adduction with the shoulder in 90o of glenohumeral lateral rotation

In conjunction with the above findings, it is appropriate to examine the patient for common coexisting upper quadrant impairments in this stage.

• Posterior glenohumeral capsular tightness • Coexisting upper thoracic or cervical disorders


• Upper limb nerve tension • Scapular malalignment • Muscle flexibility and strength deficits, e.g., shortened pectoralis major,

coracobrachialis, biceps brachii and weak middle and lower trapezius musculature Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions codes: b7300.1 MILD impairments of muscle power As above with the following differences: • Strong and painful biceps brachii only with repeated contractions • Pain with repetitive activities, such as lifting

It is important to rule out any rotator cuff disorders since these groups of muscles play a critical role in anterior shoulder stability. One of the most vulnerable positions for the shoulder complex is during extreme abduction and external rotation, as seen in the late cocking phase of pitching or throwing. Studies have shown that the glenohumeral joint (shoulder complex) can withstand higher and higher external rotational forces (torque) as the long head of the biceps muscle force is increased. In other words, the shoulder becomes torsionally stiffer with increasing biceps force. The greater the shoulder’s torsional stiffness or rigidity, the more force that would be required to externally rotate it to a state of dislocation. In one of the studies, it was discovered that while the shoulder was being stressed in the vulnerable abducted and externally rotated position with 100% predicted biceps force, the long head of the biceps muscle was able to increase the torsional rigidity of the glenohumeral joint by 32%. Further studies have provided evidence to support an additional significant stabilizing effect of the tendon of the long head of the biceps brachii against superior translation of the humeral head during abduction of the shoulder, contributing to a reduction in impingement. Other reasons as to why it is important to rule out pathologies of the shoulder lie in the possibility of pre-existing lesions or tears in the glenohumeral region, which may impair stability. In the case of a superior labral lesion, this can lead to disruption of the superior labrum’s firm attachment to the glenoid as well as a disruption of the origin of the long head of the biceps tendon, impairing shoulder stability.

Intervention Approaches / Strategies Acute Stage / Severe Condition Goal: Alleviate pain with active arm flexion

• Physical Agents Ultrasound, phonophoresis, iontophoresis or ice applied to the biceps tendon for pain relief and to decrease inflammation


• Manual Therapy Soft tissue mobilization and manual stretching to normalize the length of

pectoralis major and coracobrachialis Friction Massage to the long head of the biceps brachii may be used to reduce

adhesions of the retinaculum and tenosynovitic tissues in the intertubercular groove


May consider a sling if necessary to temporarily limit painful active movements Taping to reposition the scapula in order to promote normal scapulohumeral

rhythm when raising the arm.

• Neuromuscular Reeducation Facilitate neutral thoracic cage, scapular posture, and shoulder proprioception

exercises Taping may also be used to train the patient to use weak, elongated muscles (e.g.,

lower trapezius) to function in a normal position

• Therapeutic Exercises Normalize the strength of the muscles commonly found to be weak, namely lower trapezius, serratus anterior, and perhaps the biceps brachii and brachialis

• Re-injury Prevention Instruction

Temporarily limit shoulder flexion, lateral rotation, and overhead activities Sub Acute Stage / Moderate Condition Goals: Prevent re-injury of the biceps tendon

Normal length and strength of the shoulder girdle musculature


• Therapeutic Exercises Manual stretching procedures and home/gym stretching exercises to the trunk and

shoulder girdle muscles that have flexibility deficits Progressive resistive exercises to trunk and shoulder girdle muscles that have

strength deficits. (Depending on the patient’s strength deficits, this may include instructing the patient in isometric, isotonic (e.g., tubing or free weights), and/or glenohumeral/scapular stabilization exercises (e.g., seated press-ups, progressive push-ups, Swiss ball exercises)


Progression of strengthening exercises to regain normal coordination of rotator cuff and shoulder girdle musculature during functional activities. (Depending on the patient’s strength deficits, this may include instructing the patient in isometric,


isotonic exercises. For example, use of tubing or free weights for shoulder elevation, rows, scaption, curls and/or glenohumeral/scapular stabilization exercises such as seated press-ups, progressive push-ups, Swiss ball exercises)


Modification of jobsite or other environmental factors as well as ergonomic cuing (movement training) to promote efficient, painfree, motor control of the trunk, scapulae and arm with lifting, reaching and overhead activities

Modify activities to prevent overuse and re-injury Settled Stage / Mild Condition Goals: As above


• Therapeutic Exercises Progress activities to tolerance Maximize muscle performance of the relevant trunk, scapulae, shoulder flexion

and shoulder girdle muscles required to perform the desired occupational or recreational activities

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or leisure time activities

• Approaches/ Strategies listed above

• Ergonomic Instruction Progress job/sport specific training depending on the needs and desires and (impairments) of the worker or athlete


Selected References Bang MD, Deyle GD. A comparison of the effectiveness of two physical therapy treatment approaches for impingement syndrome of the shoulder: supervised exercise versus supervised exercise combined with manual physical therapy. J Orthop Sports Phys Ther. 2000; 30 Bonafede RP, Bennett RM. Shoulder Pain – Guidelines to diagnosis and management. Postgraduate Medicine. 1987 July; 82 (1): 185 – 193. Bang MD. Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop & Sports Phys Ther. 2000;30:126-137. 13a: Godges JJ, Matson-Bell M, Shah D, Thorpe D. The immediate effects of soft tissue mobilization with PNF on shoulder external rotation and overhead reach. J Ortho Sports Phys Ther. 2003;33:713-718. Gross J, Fetto J, Rosen E. Musculoskeletal Examination. Blackwell Science, 1996. Host, HH. Scapular taping in the treatment of anterior shoulder impingement. Physical Therapy. 1995; 75:803-812. Post M, Benca P. Primary Tendonitis of the Long Head of the Biceps. Clinical Orthopedics and Related Research. 1989 September; 246: 117 – 125. Rodosky MW, Harner CD, Fu FH. The Role of the Long Head of the Biceps Muscle and Superior Glenoid Labrum in Anterior Stability of the Shoulder. The American Journal of Sports Medicine. 1994; 22 (1): 121 – 130. Schmitt L, Snyder-Mackler L. Role of scapular stabilizers in etiology and treatment of impingement syndrome. J Orthop Sports Phys Ther. 1999; 29:31-38. Tomberlin J, Saunders D. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders, 3rd ed.,Vol. 2, (Extremities). Educational Opportunities, 1994. Wadsworth C. Manual Examination and Treatment of the Spine and Extremities. Williams & Wilkins, 1988. Warner JP, McMahon PJ. The Role of the Long Head of the Biceps Brachii in Superior Stability of the Glenohumeral Joint. The Journal of Bone and Joint Surgery. 1995 March; 77-A (3): 366 – 371.


Shoulder Movement Coordination Deficits ICD-9-CM codes: 840.2 Shoulder ligament sprain

840.0 Acromioclavicular joint sprain ICF codes: Activities and Participation Domain codes:

d4305 Putting down objects (Using hands, arms or other parts of the body to place an object down on a surface or place, such as when lowering a container of water to the ground.) d4451 Pushing (Using fingers, hands and arms to move something from oneself, or to move it from place to place, such as when pushing an animal away.) d4452 Reaching (Using the hands and arms to extend outwards and touch and grasp something, such as when reaching across a table or desk for a book.) d4300 Throwing (Using fingers, hands and arms to lift something and propel it with some force through the air, such as when tossing a ball.) d4550 Crawling (Moving the whole body in a prone position from one place to another on hands, or hands and arms, and knees.) d4551 Climbing (Moving the whole body upwards or downwards, over surfaces of objects, such as climbing steps, rocks, ladders of stairs, curbs or other objects.)

Body Structure code: s7203 Ligaments and fasciae of shoulder region Body Functions code: b7601 Control of complex voluntary movements


Glenohumeral ligaments and fasciae involvement: Shoulder pain during activity - aching afterwards Recurrent subluxations or dislocations with certain movements, positions, and activities Apprehension

Acromioclavicular ligaments and fasciae involvement: Trauma--a fall on the tip of the shoulder or a fall onto an outstretched arm Pain with reaching across body, with overhead activities and with weight bearing on

elbows or sleeping on the injured shoulder Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions:

Glenohumeral ligaments and fasciae involvement: Excessive glenohumeral accessory motion Apprehension at end range elevation, horizontal abduction, and external rotation (if

anterior instability)


Acromioclavicular ligaments and fasciae involvement: If Grade II or III sprain - palpable and observable displacement between the clavicular

and acromial articular surfaces Pain with accessory movement tests Pain with palpation/provocation of acromioclavicular ligament


Glenohumeral Accessory Movement Test

Humeral Posterior Glide

Performance Cues:Patient sits on end of table Ensure “loose packed position” Do not elevate scapula Allow the patient’s wrist to rest on your elbow Stabilize spine of scapula with palm Glide humerus (and thus, humeral head) posteriolaterally - in a direction parallel to the

plane of the glenoid fossa OK to use weight shift of thorax to produce glide

Glenohumeral Accessory Movement Test

Humeral Anterior Glide Glenohumeral Accessory Movement Test

Humeral Anterior Glide


Performance Cues: Glide humeral head anteriomedially - in line with the treatment plane Stabilize the clavicle with fingers or palm Normal is an excursion that is less than one half of the width of the humeral head

A/C Joint Accessory Movement Test

Clavicular Anterior Glide A/C Joint Accessory Movement Test

Clavicular Posterior Glide

Performance Cues: Stand behind patient Stabilize posteriorly via the spine of the scapula with you thumb and anteriorly via the

glenoid fossa (hugging the humeral head into the fossa) Grab the distal portion of the clavicle (it is OK to be somewhat medial to the A/C joint

line - which may be tender), glide the clavicle anteriorly and posteriorly Determine the amount of accessory motion and the patient’s response to this movement

provocation

Shoulder Stability Deficits: Description, Etiology, Stages, and Intervention Strategies

The below description is consistent with descriptions of clinical patterns associated with the vernacular term “Glenohumeral Instability”

Description: This condition is the excessive mobility in the glenohumeral joint in one direction or more, where the humeral head slips out of the glenoid cavity or the patient feels that it is about to dislocate. Etiology: The cause of glenohumeral instability could be due to traumatic or atraumatic (e.g., idiopathic glenohumeral ligament laxity or RA) causes that lead to dislocation of shoulder. The coracohumeral ligament is the primary restraint to inferior translation in adduction. The middle glenohumeral ligament is the primary restraint to anterior instability at 45o of abduction. The inferior glenohumeral ligament is the primary restraint to anterior instability from 45-90 o of abduction and secondary to posterior instability. The superior ligament prevents inferior dislocation and stabilizes the shoulder during dependent positions. Instabilities are labeled anterior, posterior, inferior, and superior depending on the direction of laxity. In addition,


dynamic stability is provided by the muscular action of the supraspinatus, infraspinatus, subscapularis, and deltoid muscles along with the tendon of the longhead of the biceps. Classification of Glenohumeral Instability is derived from four factors: 1. Frequency (acute, recurrent, chronic) 2. Causes (traumatic, atraumatic including voluntary, repeated micro trauma) 3. Direction (anterior, posterior, inferior, multidirectional) 4. Degree (subluxation, dislocation) Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions code: b7601.3 SEVERE impairment of motor control/coordination of complex voluntary movements

• Patients with a recent ligament injury typically try to support the arm with opposite

extremity and avoid using the injured arm • Active shoulder movements are restricted and painful • Passive and accessory movement testing reveals hypermobility of the glenohumeral

joint Note: The direction of laxity typically corresponds to the label given to the instability (e.g., excessive anterior glide corresponds with an anterior instability)

• Positive apprehension (Crank) test • Supraspinatus and infraspinatus weakness is common • Palpatory abnormalities may be present (e.g., with an anterior instability the humeral

head may palpable anteriorly and shows a hallow beneath the acromion posteriorly. • Axillary nerve injury is most commonly associated with an anterior shoulder

dislocation leading to altered sensation in an area of the lateral shoulder Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions code: b7601.2 MODERATE impairment of motor control/coordination of complex voluntary movements

As above with the following differences: • Weakness is common to the dynamic stabilizers such as scapular upward rotators

(trapezius, serratus anterior, rhomboids, and levator scapulae), and rotator cuff musculature (supraspinatus, infraspinatus, teres minor, and subscapularis) with contractions at end range of movement

• Now (when less acute) examine patient for co-existing upper quadrant impairments, such as upper thoracic and cervical pathologies, disorders of the acromioclavicular and sternoclavicular joints, muscle flexibility deficits such as tight pectoralis minor, pectoralis major, and/or serratus anterior and muscle strength deficits especially of the rotator cuff muscles and scapular upward rotators


ICF Body Functions code: b7601.1 MILD impairment of motor control/coordination of complex voluntary movements



• Shoulder symptoms are reproduced with repeated movements at end range

Intervention Approaches / Strategies Acute Stage / Severe Condition: Goals: Prevent further tissue damage

Re-establish non-painful mid-range mobility and avoid unstable positions with the involved shoulder

Retard muscle atrophy Decrease pain and inflammation

• Physical Agents

Ice pack or ice massage Electrical stimulation


Application of a shoulder sling may reduce pain, protect the joint from futher injury and prevent excessive muscle guarding following a glenohumeral ligament injury


Pendulum and wand exercises in painfree, mid ranges Isometric rotator cuff exercises in painfree, mid ranges

• Re-injury Prevention Instruction:

Temporarily limit abduction, flexion, lateral rotation and overhead activities or behind back activities that aggravate patient's symptoms.

Sub Acute Stage / Moderate Condition Goals: As above

Regain and improve muscular strength and endurance Regain and improve proprioception and neuromuscular control


Strengthening exercises for the dynamic stabilizers such as rotator cuff and scapular muscles in order to increase stability with pain free active movements at mid as well as end ranges

Upper body endurance can improved through use of mid range aerobic exercises such as rowing machines or upper body ergometers



Taping procedures may be used to 1) assist stabilization, 2) aid proprioception, and 3) promote scapular alignment

• Neuromuscular reeducation

Proprioceptive neuromuscular facilitation (PNF) patterns be used to facilitate neutral thoracic cage position, scapular posture, and shoulder proprioception Closed chain shoulder stabilization exercises can be used to facilitate co-ordination with rest of the shoulder girdle


Promote efficient, pain free, motor control of the trunk, scapulae and arm with overhead activities Modify activities to prevent repetitive strains or re-injury

Settled Stage / Mild Condition Goals: As above

Increase power (Reaching 90% strength in the injured shoulder) Progress activity tolerance and endurance Increase neuromuscular control Prepare individual for functional activities Normalize upper quadrant posture, muscle flexibility, and muscle strength Pain free AROM with increased stability with repeated active movements at end range



Stretching exercises for muscles that may have flexibility deficits, such pectoralis major, pectoralis minor, and latissimus dorsi

Strengthening exercises as above with using increased resistance Utilitize muscular endurance exercises to maximize muscle performance of the

relevant trunk, scapulae, shoulder girdle muscles required to perform the desired occupational or recreational activities

• Manual Therapy

Soft tissue mobilization for myofascia that may exhibit flexibility deficits, such pectoralis major, pectoralis minor, and latissimus dorsi


PNF techniques to increase shoulder control and stability with repeated movements at the end range



• Approaches / Strategies listed above Selected References Rockwood C., Masten III F., Fredrick A, The Shoulder 2nd ed. WBSaunders:Philadelphia, 1998. Donatelli R., Physical Therapy of the Shoulder 3ed ed. Churchill Livingston, London. 1997. Iannotti J, Williams G., Disorders of the Shoulder Diagnosis and Management, Lippincott: Philadelphia, 1999. Kessel L., Clinical Disorders of the Shoulder, Churchill Livingston, London. 1982. Kibler WB, McMullen J, Uhl T: Shoulder rehabilitation strategies, guidelines, and practice. Orthopedic Clinics of North America 2001;32:527-538. Rubin BD, Kibler WB: Fundamental principles of shoulder rehabilitation: Conservative to postoperative management. J Arthroscopic Related Surgery 2002:Suppl 2;18: 29-39. Burkhead WZ, Rockwood CA: Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg. 1992; 74-A: 890-896. Kibler WB: The role of the scapula in athletic shoulder function. Am J Sports Med 1998;26:325-37. Jobe Fw, Bradley JP: The diagnosis and nonoperative treatment of shoulder injuries in athletes. Clinics in Sports Medicine 1989 Jul; 8 (3): 419-437. Dines DM, Levinson M: The conservative management of the unstable shoulder including rehabilitation. Clinics in Sports Medicine 1995;14:797-814. Moseley JB, Jobe FW, Pink M, Perry J: EMG analysis of the scapular muscles during a shoulder rehabilitation program. Am J Sports Med 1992;20:128-134. NevasierRJ, Nevasier TJ, Nevasier JS: Anterior dislocation of the shoulder and rotator cuff rupture. Clinical Orthopaedic and Related Research 1993; 291:103-106. Hovelius L et al.: Recurrences after initial dislocation of the shoulder. J Bone Joint Surg. 1983;65A: 343-348. Gamulin A, Pizzolato G, Stern R: Anterior shoulder instability: histomorphometric study of the subscapularis and deltoid muscles. Clinical Orthopaedics 2002;398:121-126. Tibone JF, Lee TQ, Csintalan RP, Dettling J: Quantitative assessment of glenohumeral translation. Clinical Orthopaedics 2002;400: 93-97.


Shoulder Stability Deficits: Description, Etiology, Stages, and Intervention Strategies

The below description is consistent with descriptions of clinical patterns associated with the vernacular term

“Acromioclavicular Instability” Description: Disruption of the ligamentous integrity of the acromioclavicular (also called A/C) joint. The acromioclavicular ligament may be damaged with excessive posteriorly directed translatory or rotatory force. The coracoclavicular ligaments (conoid and trapezoid) may be damaged with excessive superiorly or anteriorly directed forces. Etiology: The cause of this injury is generally a traumatic incident such as a fall directly on the shoulder with the arm adducted or a fall on an outstretched hand. Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions codes: b7150.3 SEVERE impairments of stability of a single joint

• Protective posturing (e.g., cradling the arm and stabilizing it against the body) • Variable elevation of the distal clavicle relative to the acromion • Pain limited active shoulder flexion • Pain with reaching across the body (horizontal abduction) • Weak and painful with resisted shoulder flexion and shoulder abducton • Tenderness to palpation over the acromioclavicular joint • Symptoms reproduced with palpation or provocation of the A/C ligament • Localized swelling around the joint • Positive A/C compression or shear tests

Sub Acute / Moderate Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions codes: b7150.3 MODERATE impairments of stability of a single joint


• Pain with overhead activities • Resisted shoulder flexion and abduction are now strong and painful


ICF Body Functions codes: b7150.3 MILD impairments of stability of a single joint As above with the following differences:

• Resisted tests are now strong and painful only with repeated shoulder flexion and abduction

• Pain with repetitive activities of the shoulder especially at end range • Pain with sustained end ranges stresses to the A/C, such as with prone-on-elbows

positions


Intervention Approaches / Strategies

Acute Stage / Severe Condition Goals: Avoid movements that increase inflammatory reactions

Decrease pain with daily activities

• Physical Agents Ice


Taping may be used to assist in stabilization and to reduce pain A sling may be used – especially if splint immobilization aids pain relief and

limits aggravation of the injury Type II A/C sprains may benefit from a Kenny- Howard splint


Active or passive shoulder abduction to 90 degrees and external rotation to 30 degrees are initiated at 2 weeks if no internal fixation has been used

Sub-maximal isometric exercises to maintain scapular and glenohumeral strength

• Re-injury Prevention Instruction Temporarily limit end range ROM stretches, avoid vigorous work, avoid overhead activities

Sub Acute Stage / Moderate Condition Goals: Prevent re-injury of the AC joint

Restore full pain-free active and passive range of motion of the shoulder girdle Restore strength of the muscles around scapula and glenohumeral joint


Progress mobility exercises to regain full pain free range of motion Progress strengthening exercises (e.g., Rotator cuff strengthening, closed chain

exercises, progressive resistive exercises below 90 degree of flexion)

• Manual Therapy Joint mobilization of glenohumeral joint to prevent restrictions

Settled Stage / Mild Condition Goals: As above



• Re-injury Prevention Instruction Progress activities to tolerance

Intervention for High Performance / High Demand Functioning in Workers and Athletes Goal: Return to desired occupational or sport activities

• Therapeutic Exercises Progress exercises focusing on job/sport specific training program based on individual needs of patient.

Selected References Fukuda K, Craig KE, Kai-nan AN, Cofield RH Chao EYS. Biomechanical study of the ligamentous system of the acromioclavicular joint. J Bone Joint Surg. 1986; 68A:434-9. Urist MR, Complete dislocation of the acromioclavicular joint: the nature of the traumatic lesion and effective methods of treatment with an analysis of 41 cases. J Bone Joint Surg. 1946;28:813-37. Donatelli R, Wooden MJ. Orthopedic Physical Therapy. 2nd ed. 1994. Churchill Livingston Inc. Hulstyn MJ, Fadale PD. Shoulder Injuries in the athlete. Clinical Sports Medicine. 1997;16:663-679. Dias JJ, Gregg PJ. Acromioclavicular joint injuries in sport. Sports Medicine. 1991;11: 125-32. Bannister GC, Wallace WA, Stableforth PG, Hutson MA. The management of acute acromioclavicular dislocation. J Bone Joint Surg. 1989;71B:848-50. Larsen E, Bierg-Nielsen A, Christensen P. Conservative or surgical treatment of acromioclavicular dislocation. J Bone Joint Surg. 1986;68(4):552-5. Lemos MJ. The evaluation and treatment of the injured acromioclavicular joint in athletes. Am J Sports Medicine. 1998;26:137-44. Turnbull JR. Acromioclavicular joint disorders. Med Sci Sports Exercise. 1998;30(4 suppl.):526-32. Shamus JL, Shamus EC. A taping technique for the treatment of acromioclavicular joint sprains: a case study. J Orthop Sports Phys Ther. 1997;25:390-4. Kisner C, Colby LA. Therapeutic Exercises Foundations and Techniques. Third Edition. 1996 F.A. Davis Company. Philadelphia, PA.


Shoulder Pain

ICD-9-CM code: 726.19 Subacromial bursitis ICF codes: Activities and Participation Domain codes:

d4452 Reaching (Using the hands and arms to extend outwards and touch and grasp something, such as when reaching across a table or desk for a book.) d4300 Lifting (Raising up an object in order to move it from a lower to a higher level, such as when lifting a glass from the table.) d4305 Putting down objects (Using hands, arms or other parts of the body to place an object down on a surface or place, such as when lowering a container of water to the ground.) d4451 Pushing (Using fingers, hands and arms to move something from oneself, or to move it from place to place, such as when pushing an animal away.) d4452 Reaching (Using the hands and arms to extend outwards and touch and grasp something, such as when reaching across a table or desk for a book.) d4300 Throwing (Using fingers, hands and arms to lift something and propel it with some force through the air, such as when tossing a ball.) d4550 Crawling (Moving the whole body in a prone position from one place to another on hands, or hands and arms, and knees.) d4551 Climbing (Moving the whole body upwards or downwards, over surfaces of objects, such as climbing steps, rocks, ladders of stairs, curbs or other objects.)

Body Structure code: s7201 Joints of shoulder region Body Functions code: b28016 Pain in joints

Common Historical Findings:

Diffuse shoulder pain Pain at rest Recent unaccustomed repetitive use of upper extremity

Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: Pain with all shoulder movements Symptoms are reproduced/increased with palpation of subacromial bursa

Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency


Subacromial Bursa Palpation/Provocation Performance Cue: Slightly extend and internally rotate the humerus to improve access to the bursa

Shoulder Pain: Description, Etiology, Stages, and Intervention Strategies

The below description is consistent with descriptions of clinical patterns associated with “Subacromial Bursitis.”

Description: An inflammatory condition of the sub-deltoid bursa which develops due to recent unaccustomed overuse causing diffuse shoulder pain. A discriminating characteristic of acute subacromial bursitis is pain/aching at rest, which is aggravated by most all shoulder movements. Etiology: The subacromial bursa is a synovial-lined sac separating the superior surface of the supraspinatus tendon from coracoacromial arch and deep surface of deltoid muscle. The floor of the bursa is the supraspinatus tendon and the roof is the acromium. Inflammation of this bursa is most commonly the result of repetitive strain, or overuse, injury to other structures like the rotator cuff. Subacromial bursitis rarely occurs alone and is usually associated with supraspinatus tendonitis, or tenosynovitis of the rotator cuff, bicipital muscles, or glenohumeral arthritis. A detailed history is important to distinguish the bursa from a supraspinatus strain or involvement of other rotator cuff structures. Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions codes: b28016.3 SEVERE pain in joints

• Protection of the shoulder and avoidance of use of the injured arm • Unable to flex or abduct the shoulder or reach during overhead activities secondary to

pain • Apprehension with all shoulder movements • Symptoms are reproduced or increased with palpation of the subacromial bursa


Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b28016.2 MODERATE pain in joints


• Symptoms are provoked at end range of active abduction • Pain with resisted abduction/ flexion of the shoulder • Painful arc of ROM for subacromial bursitis is 70-110° of abduction • Resisted tests may be weak and painful due to the compression of an inflamed

subacromial bursa by a contracting deltoid muscle and involvement of rotator cuff muscles

• Impingement sign may help distinguish between bicipital tendonitis and bursitis. Lateral subacromial tenderness suggests bursitis or supraspinatus tendonitis, anterior subacromial tenderness suggests bicipital tendonitis

• Arthritis may cause osteophyte/calcium projections into the bursa (calcific bursitis) • Limitations in functional activities include difficulty in sleeping, grooming, dressing,

work and sports activities

Now (when less acute) examine the patient for common coexisting upper quadrant impairments. For example:

• Cervical and upper thoracic segmental movement abnormalities • Limited glenohumeral physiologic and accessory movements • Muscle flexibility deficits – especially subscapularis, infraspinatus, pectoralis minor,

pectoralis major, latissimus dorsi, and teres major myofascia • Nerve mobility deficits – especially median, radial, and ulnar nerves in the common

thoracic outlet entrapment areas • Weak scapular upward rotator muscles – commonly lower trapezius, middle

trapezius, and serratus anterior • Excessive scapular elevation, abduction, downward rotation or winging with

overhead reaching • Chronic Stage – radiographic findings show narrowing of acromiohumeral gap,

superior subluxation of the humeral head, erosive changes at the inferior aspect of the acromium


ICF Body Functions codes: b28016.1 MILD pain in joints


• Pain with repetitive activities of flexion/abduction such as overhead activities • Overpressure, or passively forcing end range shoulder flexion (e.g., “impingement

tests”) reproduces the patients reported pain complaint • Painfree resisted tests when performed in midrange shoulder positions • Pain only with repeated flexion and abduction contractions


Intervention Approaches / Strategies Acute Stage / Severe Condition Goal: Painfree at rest

• Physical Agents Phonophoresis/iontophoresis or pulsed ultrasound to assist in reducing inflammation (A random, controlled, double blind study suggests there is no evidence to support ultrasound having an important therapeutic effect over treatment with just ROM and non-steroidal anti-inflammatory drugs (NSAIDs) Ice and/or TENS for relief of acute pain as well as to decrease muscle guarding


May consider a sling if necessary to temporarily limit painful active movements

• Therapeutic Exercises Pendulum (Codman’s) exercises Painfree passive ROM, active assisted AROM, or AROM exercises once or twice

a day

• Re-injury Prevention Instruction Temporarily limit flexion, abduction, and, overhead activities

Sub Acute Stage / Moderate Condition Goal: Painfree with active movements


• Therapeutic Exercises Progress AROM exercises to painfree tolerance AROM exercises progress to weighted, supine and sitting shoulder flexion,

abduction and rotation strengthening program

• Manual Therapy Soft tissue mobilization to shortened subscapularis, infraspinatus, pectoralis

minor, pectoralis major, latissimus dorsi, and teres major myofascia Joint mobilization in an attempt to normalize the accessory mobility or

physiologic motion deficits believed to be associated with the patient’s complaints

Neuromuscular reeducation in an attempt to normalize the strength and coordination deficits believed to be associated with the patient’s complaints



Promote efficient, painfree, motor control of the trunk, scapulae and arm with overhead activities

Modify functional activities to prevent overuse and re-injury Patient education for prevention strategies

Settled Stage / Mild Condition Goal: Painfree with repeated active movements


• Therapeutic Exercises Attempt to normalize the strength and endurance deficits believed to be associated

with the patient’s complaints Maximize muscle performance of the relevant trunk, scapulae, and shoulder girdle

muscles required to perform the desired occupational or recreational activities

• Ergonomic Instruction Add job/sport specific training




Selected References Bonafede PR, Bennett RM. Shoulder pain: guidelines to diagnosis and management. Postgrad Med. 1987; 82:185-193 Deyle GD, Bang MD. Examination and treatment of the shoulder. Orthopaedic Physical Therapy Clinics of North America. 1999;8:83-115. Downing DS, Weinstein A. Ultrasound therapy of subacromial bursitis: a double blind trial. Phys Ther. 1986;66:194-199 Gorkiewicz R. Ultrasound for subacromial bursitis: a case report. Phys Ther. 1984;64:46-47 Gross J, Fetto J, Rosen E. Musculoskeletal Examination. Blackwell Science, 1996. Reveille JD. Soft-tissue rheumatism: diagnosis and treatment. Am J Med. 1997;102 (suppl 1A):1A-25S Salzman KL, Lilligard WA, Butcher JD. Upper extremity bursitis. American Family Physician. 1997;56(7) www.aafp.org Steinfeld R MD, Rock M MD, Younge D MD, Cofield R MD. Massive subacromial bursitis with rice bodies: report of three cases, one of which was bilateral. Clin Orthop. 1994;301:185-190 Tomberlin J, Saunders D. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders, Vol. 2. 3rd ed. (Extremities). Minneapolis MN. Educational Opportunities, 1994. Wadsworth C. Manual Examination and Treatment of the Spine and Extremities. Philadelphia. Williams & Wilkins, 1988.


Shoulder and Related Upper Extremity Radiating Pain ICD-9-CM codes: 723.3 Cervical brachial syndrome ICF codes: Activities and Participation Domain codes:

d4301 Carrying in the hands (Taking or transporting an object from one place to another using the hands, such as when carrying a drinking glass or a suitcase.) d4452 Reaching (Using the hands and arms to extend outwards and touch and grasp something, such as when reaching across a table or desk for a book.)

Body Structure code: s7208 Structure of shoulder region, other specified s7308 Structure of upper extremity, other specified

Body Functions code: b28014 Pain in upper limb b2804 Radiating pain in a segment or region


Paresthesias, pain, and numbness in upper extremity Symptoms aggravated by postures or activities that put stretch on neurovascular bundle

(e.g., reaching tasks, sleeping with arms overhead) Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions:

Symptoms reproduced with nerve tension test Symptoms reproduced with provocation of the peripheral entrapment site (e.g., scalenes,

clavipectoral fascia, pectoralis minor) Physical Examination Procedures:

Nerve Tension Test

Median Nerve Stretch Test

Performance Cues: Position patient with shoulder off edge of table and with the trunk and lower extremities

diagonally on the table


Establish baseline level of symptoms and determine the change in symptoms as the following components are moved toward end range:

Scapular depression Elbow extension Humeral external rotation Forearm supination Wrist, fingers, thumb extension Humeral abduction

Attempt to alter symptoms by moving a component two segments proximally or distally (e.g., alter elbow pain with cervical side bending; alter shoulder pain with wrist flexion and extension)

Nerve Tension Test

Radial Nerve Stretch Test Performance Cues: Components: Scapular depression

Elbow extension Humeral internal rotation Forearm pronation Wrist, finger, thumb flexion Humeral abduction

Nerve Tension Test Ulnar Stretch Test


Performance Cues: Components: Scapular depression

Elbow flexion (to 90 degrees) Humeral external rotation Forearm pronation Wrist, finger extension Elbow flexion (to available and range) Humeral abduction

Shoulder and Related Upper Extremity Radiating Pain: Description, Etiology, Stages, and Intervention Strategies

The below description is consistent with descriptions of clinical patterns associated with the vernacular term

“Thoracic Outlet Syndrome” Description: Thoracic outlet syndrome (TOS) is a complex of signs and symptoms caused by compression or stretching of the nerves and vessels (portions of the brachial plexus, subclavian artery, and subclavian vein) to the upper limb where they pass through the interval between the scalene muscles, over the first rib, and down into the axilla. Patient complains of numbness, tingling, weakness of hands and arms and pain in the upper chest, back and neck. The location of paresthesias, pain, numbness, and muscle weakness in the shoulder, arm, and hand depend on what nerve is vulnerable to compression. The patient with TOS may also report vascular symptoms such as swelling of the fingers and hands, heaviness of the upper extremities, clumsiness and coldness of hands, and tiredness, heaviness on elevation of arms. TOS symptoms are worst with postures and ADLs that stress the neurovascular bundle, such as combing hair, driving, or carrying bags with strap on sore shoulder. TOS symptoms are also reproduced with activities such as lifting heavy objects, looking up (neck extension), arm overstretched or reaching and overhead activities for extended periods of time. Etiology: The cause of this disorder may be due to tight muscles, ligaments, fibrous bands or bony abnormalities in the thoracic outlet area. The two common precipitating factors of TOS are trauma (such as auto accidents that cause whiplash) and excessive strains from repetitive activities. Other conditions that can lead to TOS are paradoxical breathing patterns, poor posture, an extra cervical rib from the neck at birth, and tumors (such as upper lobe lung cancer). Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions codes: b28014 SEVERE pain in upper limb

• Accentuated upper thoracic kyphosis and forward head posture leading to tightness around shoulder and neck musculature

• Excessive scapular abduction and medial rotation • Weak cervical flexors, upper thoracic extensors, and scapular depressors/retractors • Symptoms are reproduced with upper limb nerve tension testing


• Symptoms are reproduced with palpatory provocation of peripheral entrapment site (e.g., scalene muscles palpation will cause tingling down the arm)

• Sensory and motor deficits may be present Sub Acute / Moderate Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions codes: b28014 MODERATE pain in upper limb As above, except: Now (when less acute) examine patient for co-existing upper quadrant impairments such as cervical pathologies (extra cervical rib), assess scapular, thoracic malalignments and muscle flexibility and strength deficits – For example:

• Shortened anterior chest musculature such as pectoralis, serratus anterior • Shortened scalene muscles, and costoclavicular approximation • Tight muscles that are pressed against the nerves causing compression such as

subclavian artery or suprascapular nerve maybe affected. • Paradoxical breathing patterns in which the scalenes and pectorals are used as the

initiators of each breath, rather than assisting the diaphragm and lower intercostals during a deep inspiration


ICF Body Functions codes: b28014 MILD pain in upper limb As above, except:

• Pain with repetitive activities such as arm elevation, hyperextension of neck or with overhead activities

Intervention Approaches / Strategies

Acute Stage / Severe Condition Goal: Reduce neurological and vascular symptoms

• Re-injury Prevention Instruction Limit any activity that aggravates the symptoms – e.g., avoid sleeping on stomach with arms overhead

• Manual Therapy

Soft tissue mobilization to restricted myofascia or fascia adjacent to relevant nerve and vascular entrapment sites – e.g., scalene myofascia, clavipectoral fascia, subclavius myofascia


Joint mobilization to restricted joints adjacent to relevant nerve and vascular entrapment sites – e.g., cervical articulations adjacent to lateral foramina, 1st rib adjacent to C8 nerve root

Soft tissue mobilization and manual stretching to address shortened musculature such as pectoralis minor, serratus anterior, scalene, levator scapulae


Painfree, and symptom-free nerve mobility exercises Sub Acute Stage / Moderate Condition Goals: As above

Improve strength of weak upper quarter musculature


• Therapeutic Exercises Stretching exercises for shortened myofascia causing symptoms, such as

pectoralis minor, or anterior scalenes Strengthening exercises for upper thoracic extensors, scapular adductors and

depressors, and neck flexors Diaphragmatic and lateral costal breathing exercises to decrease paradoxical

breathing patterns

• Neuromuscular Reeducation Facilitate neutral thoracic cage and neutral scapular posture.


Promote efficient, painfree, motor control of the trunk, scapulae and arm with overhead activities

Modify activities to prevent re-injury Teach proper body mechanics and modify work-setting area as required to

prevent symptoms Settled Stage / Mild Condition Goals: As above

Progress activity tolerance Lessen predisposition to symptoms during active repeated movements




Muscular endurance exercises to maximize muscle performance of the relevant trunk, scapulae, shoulder girdle muscles required to perform the desired occupational or recreational activities

Aerobic conditioning exercises such as progressive walking program with emphasizing correct breathing techniques and posture


As above Add job/sport specific training


• Approaches / Strategies listed above Selected References Colby L, Kisner C. Foundations and Techniques of Therapeutic Exercise, 2nd ed. F. A. Davis Company, Philadelphia, PA 494-495, 1990 Daskalakis M. Thoracic outlet compression syndrome: current concepts and surgical experience. Int Surg. 68:337-344, 1983 Donatelli R. Orthopedic Physical Therapy. Churchill Livingstone Inc., Georgia, 1994 Donatelli R. Physical Therapy of the Shoulder, 3rd edition, pp. 153-178. New York: Churchill Livingstone, 1997 Kelly M, Clark W. Orthopedic Therapy of the Shoulder, pp. 144-148. Philadelphia: J.B. Lippincott Company, 1995 Kenny R, Traynor G, Withington D, Keegan D. Thoracic outlet syndrome: a useful exercise treatment option. Am J Surg. Feb 165:282-4, 1993 Lindgren K, Leino E, Hakola M, Hamberg J. Cervical spine rotation and lateral flexion combined motion in examination of the thoracic outlet. Arch Phys Med Rehabil 71:343-344, 1989 Lindgren K, Leino E, Manninen H. Cervical rotation lateral flexion test in brachialgia. Arch Phys Med Rehabil 73:735-7, 1992


Lindgren K. Conservative treatment of thoracic outlet syndrome: a 2-year follow – up. Arch Phys Med Rehabil Vol 78, April 1997 Magee D. Orthopedic Physical Assessment. W. B. Saunders Company, Philadelphia, PA. 90-142, 1992 Novak CB, Mackinnon SE. Thoracic outlet syndrome. Orthopedic Clinics of North America 1996 Oct; 27(4): 747-762 Rockwood C, Matsen F. The Shoulder, 2nd edition, volume 2, pp. 984. Philadelphia: WB Saunders Company, 1998 Saidoff D, McDonough A. Critical Pathways in Therapeutic Intervention: Extremities and Spine, pp. 189-202. Mosby, Missouri, 1998


Cervical and Shoulder Examination

Algorithm #1

Yes

No

Yes If Negative

If Negative

Suspect 1) Fracture or Loss of Connective Tissue Integrity Due to Trauma or Disease, and/or 2)

Abnormal/Hypermobile Cervical Segmental Mobility

Cervical Examination Algorithm #2

Consultation with Appropriate

Healthcare Provider

Screen for Potentially Serious Non-Musculoskeletal

Pathology

Medical Clearance and Negative Imaging

Stabilization Procedures

Emmanuel Yung PT, MA, OCS Skulpan Asavasopon MPT, OCS Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency

Cervical Examination and Intervention

Algorithm #2

Pain During Movement or Pain Does Not Limit Motion Pain Limits Motion in Available in Available Ranges and/or Ranges or Movement Produces Pain at End of Range Does Not Peripheral Symptoms Produce Peripheral Symptoms If Positive for Upper Motor Neuron Produces Lesions Vertebro- Basilar Insufficiency Produces Peripheral Symptoms Signs Does Not Produce If Safe to Proceed Peripheral Symptoms If Segmental Instability If Negative If Symptoms Unresolved If Positive If Negative

Neurological Status

Examination

Mobility Examination of • Upper Quarter Neural Elements • Peripheral Nerve Entrapment Sites

Nerve Entrapment Reduction Procedures

Cervical Stabilization Procedures

If Symptoms Resolve to the Point Where Pain Does Not Limit Motion in Available Range, Return to Single Plane

Active Mobility Examination

Pain Limited Nerve

Mobility

Consultation with Other Healthcare Providers

Cervical Spine Side Bending, and/or Combined Side

Bending/Rotation /Extension

Over Pressures

Vertebrobasilar Insufficiency Exam

Mobility Examination of: • Upper Thoracic and Cervical Spine • Upper Quarter Neural Elements

Mobilization of Upper Quarter Neural Elements

Mobilization of Cervical and Thoracic

Spinal Segments

Pain Limited Cervical Mobility

To Algorithm #3 Shoulder Examination

Resistance Limited Cervical Mobility

Resistance Limited Nerve

Mobility

Cervical and Upper Thoracic Single Plane

Active Mobility Examination


Shoulder Examination and Intervention Algorithm #3a

Active ROM Tests: 1) Elevation 2) 90/90 or Neutral External Rotation 3) Hand Behind Back

Passive ROM Tests: 1) Elevation with Over Pressure 2) Isolated Glenohumeral External Rotation\ 3) Isolated Glenohumeral Internal Rotation

To Algorithm #3b

Palpatory Examination of Suspected Enthesopathy

Resisted Tests: 1) External Rotation 2) Abduction Active Compression3) Flexion Test

Passive Accessory Motion Tests: 1) Posterior Humeral Translation 2) Anterior Humeral Translation 3) Inferior Humeral Translation (sulcus sign) 4) Acromioclavicular Accessory Movements


or continuum

If Symptoms Unresolved

Algorithm #3b • Night Pain • Weak External Rotators • Over 65 Years of Age

Medical/Surgical Consultation in Addition to PT

Intervention

Pain Limits Active and Passive Movements in

Mid Ranges

• Normal or Excessive Active and Passive Range of Motion

• Painful and/or Excessive Humeral Accessory Motions

• Positive Active Compression Tests

• Pain with Active Motions • Pain with Passive Over Pressure • Weak and/or Painful Resisted Tests

• Limited Active and Passive Range of Motion

• Limited Humeral Accessory Motions

Physical Agents and Ergonomic Counseling

Shoulder Strengthening Therapeutic Exercises

Shoulder Strengthening

Therapeutic Exercises

Shoulder Mobilization Procedures

If Symptoms Resolve, and Pain No Longer Limits Active and Passive

Movements in Mid Ranges, Return to Start of Algorithm #3

Associated Upper Quarter Impairment Examination

Algorithm #4

Suspect Rotator

Cuff Tear

Resistance Limited Shoulder Mobility

Impingement

Instability

• First Time Traumatic Dislocation

• Age ≤25 Years Old

Suspect Glenohumeral

Capsuloligamentous Labral Tear

Consultation with Other Healthcare Providers

• Dislocation • Over 40 Years of Age • Shoulder Elevation <90

degrees after 6 weeks

Medical/Surgical Consultation in Addition to PT

Intervention

Pain Limited Shoulder Mobility


Associated Upper Quarter Impairment Examination

Algorithm #4

Physical Agents and Ergonomic Instructions

Shoulder Strengthening Therapeutic Exercises

Shoulder Stabilization

Procedures and Therapeutic Exercises

Nerve Entrapment Reduction Procedures

Cervical Stabilization Procedures

Mobilization of Upper Quarter

Neural Elements

Mobilization of Cervical and

Thoracic Spinal Segments

Strength/Motor Control/Endurance Deficits Deep Neck Flexors Lower Trapezius Middle Trapezius Serratus Anterior

Shoulder Mobilization Procedures

Postural Deficits Excessive Capital Extension Protracted Scapulae Excessive Thoracic Kyphosis

Flexibility Deficits Levator Scapulae Pectoralis Major Pectoralis Minor Upper Trapezius Latissimus Dorsi Subscapularis Suboccipital Myofascia Teres Major Sternocleidomastoid


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SUMMARY OF SHOULDER DIAGNOSTIC CRITERIA AND PT MANAGEMENT STRATEGIES DISORDER HISTORY PHYSICAL EXAM PT MANAGEMENT “Supraspinatus Tendinitis” 840.6 onov* = 4 or less mnov** = 12

Post-Lat pain Pain w/overhead ADL Midrange “catch” Sx’s worse w/repetitive OH

ADL – or strains

Painful arc Weak and painful Supraspinitus MMT Post-Lat rotator cuff tenderness Shoulder girdle muscle flexibility, strength, and

coordination deficits

Reduce aggravating activities Physical agents (Ice, US) Address deficits in shoulder girdle strength,

flexibility, and coordination “Bicipital Tendinitis” 726.12 onov = 4 or less mnov = 12

Ant-Lat pain Pain w/flexion and lifting

ADL Sx’s worse w/repetitive

activities

Painful arc Weak and painful Biceps Brachii MMT Bicipital groove tenderness Shoulder girdle muscle flexibility, strength, and

coordination deficits

Reduce aggravating activities Physical agents (Ice, US) Address deficits in shoulder girdle strength,

flexibility, and coordination Subacromial Bursitis 726.19 onov = 4 or less mnov = 8

Diffuse pain Pain at rest Recent unaccustomed use

SR w/palpation or provocation of the subacromial bursa

Rest (i.e. sling) Physical agents (Ice, E.Stim.) Patient ed. (Prevent recurrence)

Adhesive Capsulitis 726.0 onov = 8 or less mnov = 16

Lat pain Sx’s worse w/end range

stretch positions Gradual prog. of stiffness

Glenohumeral ROM deficits – ER and ABD are the most limited

Pain at end of range Limited accessory movements

Patient education (Avoid aggravating positions/movements) Rx myofascial & joint ROM deficits (STM,

JM, MWM, C/R, Ther Ex) “Glenohumeral Instability” 840.2 onov = 4 or less mnov = 12

Recurrent subluxations or dislocations

Apprehension

Excessive GH accessory motion Apprehension w/passive end range movements

Patient education (Avoid unstable positions) Shld girdle & GH strengthening

Acromioclavicular Joint Sprain 840.0 onov = 4 or less mnov = 8

Fall on tip of shld or onto outstretched arm

Pain w/reaching across body, overhead, or weight bearing on elbows

Observable displacement of A/C joint Pain w/accessory movements SR w/palpation or provocation of A/C ligament

Patient education (Avoid positions of strain) Normalize ROM and strength deficits of

the scapulothoracic, GH and S/C articulations

“Thoracic Outlet Syndrome” 723.3 onov = 8 or less mnov = 16

UE paresthesias, pain, and numbness -- Sx’s worse w/postures or ADLs which stress NV bundle

SR: w/ULTT Provocation of peripheral entrapment site

Reduce entrapment neuropathy with applicable STM, Joint mob, Nerve mob, ergonomic cues, Ther Ex, Rx of Up ¼ muscle flexibility and strength deficits

“Myofascial Pain Syndrome” 726.2 onov = 8 or less mnov = 12

Persistent neck & shld girdle aching

Sx’s worse w/repeated, inefficient muscle use

SR w/provocation of trigger points Muscle flexibility and strength imbalances Ergonomic deficiencies

Rx trigger points (Inhibit, elongate, prevent) Rx muscle imbalances Provide ergonomic cuing

onov = optimal number of visits mnov = maximal number of visits SR = Symptom reproduction


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Acromioclavicular Joint Stabilization

Surgical Indications and Considerations: Anatomical Considerations: The acromioclavicular (AC) joint is a diarthroidal joint formed by the distal end of the clavicle and the medial facet of the acromion. A capsule consisting of anterior, posterior, superior, and inferior AC ligaments supports the joint. The posterior and superior ligaments are the strongest and are invested by the deltotrapezial fascia. The primary functions of the AC joint are to transmit force from the appendicular skeleton to the axial skeleton and to suspend the upper extremity. The coracoclavicular ligaments are extra-capsular and consist of two components: the medial conoid ligament, and the lateral trapezoid ligament. The AC joint is inherently unstable and relies heavily on these ligaments to maintain its integrity. So strong are the ligaments of the AC joint and the sternoclavicular (SC) joint, that the more frequent result of impact to the area is a fractured clavicle as opposed to rupturing of any ligaments. Pathogenesis: Injury to the AC joint is typically brought on by a force applied to the acromion with the arm adducted. A moderate force will injure the AC ligaments, and a more severe force will tear the coracoclavicular ligaments. A major trauma will involve all ligaments listed above as well as injury to the deltotrapezial fascia. Epidemiology: AC injuries are most common among athletes in contact sports, throwing sports, or people whose occupation requires a lot of overhead activities. Other possible mechanisms include falls and strength training. Males significantly outnumber females with this type of injury. Diagnosis:

• Anterior and superior shoulder pain • Visible and palpable deformity at the AC joint • Limitations in strength and range of motion, especially in abduction and flexion • Radiographs to rule out fracture and classify the injury (see below for scale) • MRI may be helpful in distinguishing extent of soft tissue damage

Classification is typically done using the Rockwood classification scale for acromioclavicular injuries, a scale with six levels of injury classification:

I. Mild injury of the AC ligaments II. AC ligaments disrupted, coracoclavicular ligaments are intact. III. AC and coracoclavicular ligaments disrupted. IV. Ligaments disrupted, posterior displacement of clavicle through trapezius. V. AC joint dislocation with extreme superior elevation of clavicle. VI. Clavicle displaced inferior to the acromion and coracoid processes.

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs Joe Godges DPT, MA, OCS

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Nonoperative Versus Operative Management: Patients who sustained Grade I or II AC injuries typically undergo conservative, nonoperative treatment. Most patients would rather deal with the cosmetic issue of a deformed AC joint than go under general anesthesia and surgery to repair their injury. Grades IV, V, and VI are all treated surgically for reduction and fixation of the dislocated AC joint. Grade III injuries are highly controversial regarding course of treatment. In the past, most Grade III injuries were treated surgically, but multiple recent studies have shown no benefit to from nonoperative management focusing on immobilization for a period of time followed by rehabilitation ro regain full strength, range of motion, and functional status. Several studies concluded that using a good splint, such as the Kenny-Howard splint, to immobilize the shoulder for several weeks was just as effective as surgical intervention at achieving restabilization. The number of complications associated with surgery are well documented. Infection and hardware malfunction were the primary concerns, and hardware has been known to migrate to the great vessels, heart and lungs. Surgical Procedure: Surgery typically occurs shortly after injury, one to two weeks at most. However, for Grade III injuries, sometimes surgery is put off to try nonoperative rehabilitation first. Several different surgical procedures have been described, including fixation across the AC joint using Kirschner wire or hook plate, dynamic muscle transfer, coracoclavicular fixation using Bosworth screw or synthetic augmentation, reconstruction of ligaments, and excision of the distal clavicle. Lemos prefers to do reconstruction using synthetic loop augmentation. Holes are drilled in the coracoid and clavicle, and synthetic fiber is used to tie the augmentation piece between the two.

POSTOPERATIVE REHABILITATION Note: The following rehabilitation progression is a summary of the guidelines provided by

Lemos. Refer to his publication for further information regarding criteria to progress from one phase to the next.

Phase I: Weeks 1-6 Goals: Control pain and swelling

Protect the repair Intervention:

• Sling for 4-6 weeks in with the shoulder in adduction and internal rotation • Patient permitted to use arm for activities of daily living • Restrict active elevation or abduction, and pushing, pulling, or carrying over 5 lbs.


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Phase II: Weeks 6-12 Goal: Regain full active range of motion and strength Intervention:

• Discontinue use of sling • Progressive range of motion exercises • Progressive strengthening regimen

Phase III: Weeks 12-24 Goal: Return to activities at prior level of function Intervention:

• Continue to progress strengthening, incorporating functional activities into treatment plan • Once patient has equal range of motion and strength bilaterally, he/she can return to pre-

injury activities, including contact sports at 24 weeks Selected References: Clarke H, McCann P. Acromioclavicular joint injuries. Orthop Clin North Am. 2000;31:177-187. Deerhake R, Olix M. Stabilization in acromioclavicular disruption. J Sports Med. 1976;3:218-227. Lemos M. The evaluation and treatment of the injured acromioclavicular joint in athletes. Am J Sports Med. 1998;26:137-144. Neviaser R. Injuries to the clavicle and acromioclavicular joint. Orthop Clin North Am. 1987;18:433-438. Taft T, Wilson F, Oglesby J. Dislocation of the acromioclavicular joint. J Bone Joint Surg. 1987;69-A:1045-1051.


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Acromioplasty

Surgical Indications and Considerations Anatomical Considerations: Any abnormality that disrupts the intricate relationship within the subacromial space may lead to impingement. Both intrinsic (intratendinous) and extrinsic (extratendinous) factors have been implicated as etiologies of the impingement process. The unique anatomy of the shoulder joint sandwiches the soft tissue structures of the subacromial space (rotator cuff tendons, coracoacromial ligament, long head of biceps, bursa) between the overlying anterior acromion, acromioclavicular joint, coracoid process, underlying greater tuberosity of the humeral head and the superior glenoid rim. Pathogenesis: When subacromial impingement is suspected it is necessary to differentiate primary from secondary impingement. This is essential for successful treatment. Primary subacromial impingement is the result of an abnormal mechanical relationship between the rotator cuff and the coracoacromial arch. Secondary impingement is a clinical phenomenon that results in “relative narrowing” of the subacomial space. This often results from glenohumeral or scapulothoracic joint instability. The loss of the stabilizing function of the rotator cuff also leads to an abnormal superior translation of the humeral head (decreased depression of the humeral head during overhead activity and less “clearance”) and mechanical impingement of the rotator cuff on the coracoacromial arch. In patients who have scapular instability, impingement results from improper positioning of the scapula with relation to the humerus. The instability leads to the insufficient retraction of the scapula, which allows for earlier contact of the coracoacromial arch on the underlying rotator cuff. Epidemiology: Patients with primary impingement are usually older than 40 years, complain of anterior shoulder and lateral upper arm pain, with an inability to sleep on the affected side. They have complaints of “shoulder weakness,” and difficulty performing overhead activities. Patients with secondary impingement are usually younger and often participate in overhead sporting activities such as baseball, swimming, volleyball, or tennis. They complain of pain and weakness with overhead motions and may even describe a feeling of the arm going “dead.” Diagnosis

• History and physical examination are crucial in diagnosing subacromial impingement syndrome because findings may be subtle and symptoms may overlap with various differential diagnoses

• Physical examination focuses on shoulder and cervical spine. Cervical spine must be cleared to rule out cervical radiculopathy, degenerative joint disease, and other disorders of the neck contributing to referred pain in the shoulder.

• Primary impingement: o (+) Hawkins sign o (+) Neer impingement sign o Possible associated AC joint arthritis (tenderness to palpation and increased pain

with horizontal adduction)


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• Secondary impingement: look for associated pathology o GH instability: (+) apprehension and relocation test, load and shift o Abnormal scapular function: scapular winging, scapular dyskinesia o Posterior capsule tightness: leads to an obligatory translation of the humeral head

and rotator cuff in an anterior and superior direction, which contributes to impingement problem.

• Radiographs are helpful in demonstrating acromial anatomy types, hypertrophic coracoacromial ligament spurring, acromioclavicular joint osteoarthritis, and calcific tendonitis.

• MRI can be helpful in revealing relationships in impingement syndrome, especially if rotator cuff tear and other internal derangement pathologies are suspected.

Nonoperative Versus Operative Management: Nonoperative treatment is very successful and the comprehensive rehabilitative protocols for primary and secondary impingement syndrome are similar and follow the postoperative rehabilitation plan for patients who have had a subacromial decompression with a normal rotator cuff. Initial goals of the rehabilitation process are to obtain pain relief and regain range of motion. Various modalities, oral medications and corticosteroid subacromial injections are helpful in the early stages to decrease the inflammatory process allowing for more successful advances in motion and strengthening. Strengthening exercises begin by avoiding impingement positions while performing the exercises. The focus is on closed kinetic chain exercises initially with open chain exercises to follow without aggravating shoulder discomfort. These exercises help to restore the ability of the rotator cuff to dynamically depress and stabilize the humeral head, resulting in a gradual relative increase in the subacromial space. Nonoperative treatment should be considered unsuccessful if the patient shows no improvement after 3 months of a comprehensive and coordinated medical and rehabilitative program. In addition, after 6 months of appropriate treatment, most patients have achieved maximal improvement from the nonoperative treatment program. The success of operative treatment is determined by the choice of an appropriate operative procedure and the skills of the surgeon. It is imperative to determine whether the patient has a primary or secondary impingement. For primary impingement the procedure of choice presently is arthroscopic subacromial decompression, although comparable long-term results can be obtained with a traditional open acromioplasty. Arthroscopic subacromial decompression has many advantages including the ability to evaluate the glenohumeral joint for associated labral, rotator cuff, and biceps pathology, as well as assessment of the acromioclavicular joint. Second, this technique produces less postoperative morbidity and is relatively noninvasive, minimizing deltoid muscle fiber detachment. However, arthroscopic subacromial decompression is a technically demanding procedure and the surgeon must be very skilled. When glenohumeral joint instability is the reason for secondary impingement, surgical treatment is a stabilization procedure. Surgical Procedure: Many different arthroscopic techniques have been described, but one that is often recommended is the modified technique initially described by Caspari and Thaw. Using standard posterior portal, the surgeon inserts the arthroscope into the glenohumeral joint and evaluates for pathology including biceps tendon, labrum and rotator cuff. Any incidental pathology can be addressed arthroscopically at this time prior to subacromial space arthroscopy being performed. Starting from the posterior portal and using an aggressive synovial resector with the inflow in the anterior portal, the surgeon uses the lateral portal to perform a bursectomy


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and debride the soft tissues of the subacromial space. This is done in a sequential manner, working from the lateral bursal area to the anterior and medial acromioclavicular regions. After the subacromial bursectomy and denudement of the undersurface of the acromion, the superior rotator cuff can be visualized along the acromioclavicular joint and anterior acromial anatomy is more easily defined. The surgeon must be careful not to disturb the coracoacromial ligament during the initial bursectomy procedure. Next the surgeon performs sequential acromioplasty with an acromionizer instrument with the therapeutic goal of a flat type I acromion and removal of the coracoacromial ligament from its bony attachment. In addition, the acromioclavicular joint may be assessed at this point and minimal inferior osteophytes may be excised. Lastly, dependent on preoperative evaluation the surgeon may choose to perform a distal clavicle excision (usually 1.5-2.0 cm). Surgical outcomes for arthroscopic subacromial decompression, partial acromioplasties, and distal clavical excisions have been favorable. Most surgical failures are associated with incomplete bone resection and not addressing acromioclavicular joint arthropathy.

POSTOPERATIVE REHABILITATION Note: The following rehabilitation progression is a summary of the guidelines provided by

Phillips and Tippet. Refer to their publication to obtain further information regarding criteria to progress from one phase to the next, anticipated impairments and functional limitations, interventions, goals, and rationales.

Postoperative rehabilitation can be divided into three phases:

1. Phase one emphasizes a return of range of motion 2. Phase two stresses regaining muscle strength 3. Phase three stresses endurance and functional progression

Phase I: Return of range of motion: Weeks 0-3 Goals: Days: 1-10

Control normal postoperative inflammation and pain Prevent infection Protect healing soft tissues Minimize effects of immobilization and activity restriction Days: 11-14 Flexion PROM to 150º External/internal rotation PROM to functional levels Supine AROM flexion to 120º


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Intervention: Phase I a & b (first 10 days post op)

• Cryotherapy • Grip strengthing exercises • Passive range of motion as indicated • Isometrics (Submaximal to maximal internal and external rotation) • Active range of motion (scapular retraction/protraction) • Joint mobilizations (sternoclavicular and acromioclavicular joints as indicated)

Phase I c (11-21 days post op) • Active range of motion:

o External rotation (at 60º-90º abduction) o Supine flexion, scapular protraction o Sidelying external rotation o Prone scapular retraction

• Cardiovascular exercise, pool therapy • Return to limited work duties (depending on job tasks)

Phase II: Regaining muscle strength: Weeks 3-8 Goals: Control any residual symptoms of inflammation and pain

Full PROM in all ranges Symmetric flexion AROM AROM flexion in standing to shoulder height without substitution Emphasis on muscle strengthening with continued work on rotator cuff musculature and scapula stabilizer strengthening Continue range of motion efforts if limited capsular extensibility detrimentally affects physiologic motion Restoration of normal arm strength ratios (involved/uninvolved) Return to previous levels of activities/sport Prevention of poor throwing mechanics

Intervention:

• Progressive resistance exercises for rotator cuff musculature and scapular stabilizers • Joint mobilizations as indicated • Proprioceptive neuromuscular retraining • Towards end of phase 2 begin progressive throwing program and gentle plyometrics


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Phase III: Endurance and Functional Progression: Weeks 9-12 Goals: Unrestricted overhead work and sporting activity

Focus on enhancing kinesthesia and joint position sense Muscular endurance Performing work-specific and sport-specific tasks

Intervention:

• Exercises to improve both passive detection of shoulder movement and active joint repositioning for enhanced kinethesia and joint positioning sense

• Decreased weight with increased repetitions during strengthening exercises of rotator cuff and scapular stabilizers.

• Emphasis on timing of muscle contraction and movement without substitution (proprioceptive neuromuscular facilitation)

• Functional progression program involving a series of sport or work-specific basic movement patterns graduated according to the difficulty of the skill and the patient’s tolerance.

Selected References: Caspari R: A technique for arthroscopic S.A.D., Arthroscopy. 1992;8:23. Gartsman GM et al: Arthroscopic subacromial decompression. an anatomical study, Am J Sports Med. 1988;16:48. Jobe FW: Impingement problems in the athlete. In Nicholas JA, Hershamann EB, eds. The Upper Extremity in Sports Medicine. St Louis, Mosby, 1990. Jobe FW, Jobe CM: Painful athletic injuries of the shoulder. Clin orthop., 1989; 173:117-124. Paulos LE, Franklin JC: Arthroscopic S.A.D. Development and application: a 5 year experience. Am J Sports Med. 1990; 18:235. Phillips P, Tippett S. Acromioplasty. In Maxey L, Magnusson J, eds, Rehabilitation for the Postsurgical Orthopedic Patient. St. Louis, Mosby, 2001. Wilk KE, Meister K, Andrews JR: Current concepts in the rehabilitation of the overhead throwing athlete. Am J Sports Med. 2002; 30:136-151. Wilk KE: The shoulder. In Malone TR, McPoil T, Nitz AJ, editors: Orthopaedic and sports physical therapy, ed 3, St Louis, Mosby, 1997.


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Arthroscopic Shoulder Stabilization and Rehabilitation

Surgical Indications and Considerations Anatomical Considerations: The concave surface of the glenoid is relatively less concave, and only 1/3 the size of the articulating surface of the much larger, more convex humeral head. However, the glenoid labrum accounts for the difference in concavity. In conjunction with the static and dynamic stabilizers of the shoulder, the labrum enables proper articulation to be possible in the non-pathologic shoulder, making up the difference between concavity/convexity of the glenoid and humeral head. However, when the stabilizing mechanisms of the joint are not sufficient, anatomic fit is compromised, causing excessive wear and tear on the joint, often resulting in pain with activity. Pathogenesis: While a certain amount of tissue laxity is required for proper articulation, a breakdown at any level: labral, static and/or dynamic stabilization, can result in excessive/pathologic laxity, termed instability. Breakdown at any level, static or dynamic, will place undue stress on the other, and lend itself toward more global effects. Resultant instability is often symptomatic by shoulder pain/discomfort with motions that cause excessive accessory joint motion. Epidemiology: While most common in overhead athletes and swimmers, glenohumeral capsular instability is not widely common/problematic among the general public. Among those affected, most are male. 86% male vs. 14% female. Diagnosis/Indications for Surgery

• Recurrent shoulder subluxation/dislocation • Acute traumatic dislocation • Pain or symptom associated with the above conditions.

Nonoperative Versus Operative Management: Conservative management of shoulder instability consists of strengthening for the dynamic stabilizers of the shoulder in effort to compensate for laxity in the static stabilizers. Dynamic stabilization of the rotator cuff and scapular stabilizers can sufficiently achieve glenohumeral stability for everyday activities in most patients. In those who participate in a high level of overhead activity, however (throwers, swimmers, etc.) surgical intervention may be required for future return to sport. However, from the physical therapist’s perspective, rehabilitation is quite similar for operative vs. nonoperative patients. Furthermore, there is no urgent need for surgical intervention to be immediate. In fact, most patient cases are those of chronic instability to begin with. Therefore, conservative management is often tried first, before resorting to surgical intervention when the instability is not related to rotator cuff or labral tears. Surgical Procedure: Among the newest and increasingly more common ways to increase shoulder stability is thermal-assisted capsular shrinkage. This is a process by which laser or


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radio-frequency sound waves are used to heat collagen tissues to temperatures above 60°C at which the collagen helix begins to unwind and cause resultant tissue shrinkage. This is a simple, yet very precise procedure in the sense that if the tissue is heated too rapidly, or too far, the desired effect is lost and tissue necrosis results instead. Due to the repetitive nature of the injuries that cause patients to require such a procedure, the majority of them (90%) have other reparative surgical procedures simultaneously with capsullorhaphy. Most commonly these include surgical repair and/or debridement of the labrum and/or rotator cuff as well as capsular suture repair in addition to laser. Even with that being the case, 87% of overhead athletes who undergo this procedure successfully return to competitive sport. Preoperative Rehabilitation

• None required • May include dynamic stabilization in attempt to manage nonoperatively.

POSTOPERATIVE REHABILITATION The greatest factor in post-operative rehabilitation is whether the patient’s shoulder instability is an acquired condition, or a congenital state of laxity, possibly worsened by lifestyle or activity. Those born inherently “loose” are most prone to capsular creep and thus eventual failure of the procedure, so their rehabilitation must be much more conservative so as to avoid any stretching to the capsular structures, especially during the critical early stages after surgery – when the collagen is most susceptible to stretch. Patients whose laxity is an acquired condition may be advanced more quickly. Acquired or congenital instability can be determined by examination of the uninvolved shoulder. Other considerations: Individuals prone to scar tissue deposition must be advanced through their rehabilitation more aggressively to prevent development of excessive capsular scarring and subsequent loss of range of motion (ie: frozen shoulder). For this reason, tissue end feel should be re-assessed on a weekly basis for all individuals post-surgery. Stretchy end feels indicate conservative treatment. Stiffer end feels indicate the need for more aggressive rehabilitation with stretching to maintain/gain range of motion as required. Note: The following rehabilitation progression is a synopsis of the guidelines provided by

Wilk, Reinold, Dugas, and Andrews. Refer to their publication for details regarding how to apply the progression effectively to individual patients.

Phase I for individuals with Acquired Laxity: Weeks 1-6 (Protection Phase) Goals: Tissue healing

Minimize pain and inflammation Initiate protected motion Retard muscular atrophy


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Weeks 0-2: • Sling use for 14 days • Wrist, elbow, and cervical ROM exercises • Passive and active-assisted shoulder ROM (no aggressive stretching) • Shoulder isometrics and rhythmic stabilization (7 days)

Weeks 3-4:

• Begin AROM at week 3, add 1 pound at week 4. • Emphasize strength of ER and scapular stabilization.

Weeks 5-6:

• Progress ROM to: o Elevation to 160o o ER at 90o ABD (75-80o) o IR at 90o ABD (60-65o)

• Initiate Thrower’s Ten strengthening program Phase II for individuals with Acquired Laxity: Weeks 7-12 (Intermediate Phase) Goals: Restore full ROM (week 8)

Restore functional ROM (weeks 10-11) Normalize arthrokinematics Improve dynamic stability, muscular strength

Weeks 7-8:

• Progress ROM o Elevation 180o o ER 90-100o o IR 60-65o

• May be more aggressive with ROM progression and stretching • May perform joint mobilization • Continue strengthening as above (Thrower’s Ten, dynamic stab, rhythmic stab) • Initiate plyometrics (2-handed drills)

Weeks 9-12:

• Progress ROM to specific athletic demand o ER 110-115o

• Generalized stretching • Strengthening

o Continue as above, with progressive resistance o Push-ups o Bench press (do not allow arm below body) o Single handed plyometric throwing o Plyoball wall drills


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Phase III for individuals with Acquired Laxity: Weeks 12-20 (Advanced Activity and Strengthening Phase) Goals: Improve strength, power, and endurance

Enhance neuromuscular control Functional activities

Weeks 12-16:

• Continue stretching/strengthening as above Weeks 16-22

• May resume normal training program Phase IV for individuals with Acquired Laxity: Weeks 26 (Return to Activity Phase) Goals: Gradual return to unrestricted activities

Maintain static and dynamic stability of shoulder joint Criteria: Full functional ROM

No pain or tenderness Satisfactory muscular strength Satisfactory clinical exam


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Phase I for individuals with Congenital Instability: Weeks 0-8 (Protection Phase) Goals: Allow healing of tightened capsule

Begin early protected motion of elbow, wrist and hand Decrease pain and inflammation Gradual increase in ROM after week 3

Weeks 0-2

• Active abduction after 10 days, but not to exceed 70o • Sleep in slign x 2 weeks • No overhead activity for 12 weeks

Weeks 2-4

• Pulley exercises (to 90o) • Isometric strengthening • Rhythmic stabilization

Weeks 4-6

• ROM exercises with cane o Flexion to 125o o ER to 25o o IR to 45o

• Continue strengthening as above o Add theratubing at week 5

• Gentle mobilization to reestablish normal arthrokinematics Phase II for individuals with Congenital Instability: Weeks 6-12 (Intermediate Phase) Goals: Full nonpainful ROM at weeks 10-12

Normalize arthrokinematics Increase strength Improve neuromuscular control

Weeks 6-12

• Gradually progress to 80% of full ROM • Isotonic dumbbell/tubing program – basic rotator cuff and scapular strengthening

program • Neuromuscular control exercises for scapulothoracic joint • Joint mobilization and self-capsular stretching after week 8


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Phase III for individuals with Congenital Instability: Weeks 12-20 (Dynamic Strengthening Phase) Goals: Improve strength, power, and endurance

Improve neuromuscular control Prepare the athlete to begin to throw

Exercises

• Continue strengthening as above • Gradually return to recreational activity

Phase IV for individuals with Congenital Instability: Weeks 20-28 (Return to Activity Phase) Goals: Progressively increase activities to prepare patient for full functional return Criteria:

• Full range of motion • No pain or tenderness • Isokinetic test that fulfills criteria • Satisfactory clinical exam

Exercises:

• Continue strengthening • Emphasize closed kinetic chain • Initiate recreational sport (physician clearance required)

Selected References: Cole BJ, Romeo AA. Arthroscopic shoulder stabilization with suture anchors: technique,

technology, and pitfalls. Clinical Ortho. 2001;390:17-30. Hayashi K, Markel MD. Thermal capsulorrhaphy treatment of shoulder instability. Clinical

Ortho. 2001;390:59-72 Nebelung W, Jaeger A, Wiedemann E. Rationales of arthroscopic shoulder stabilization. Arch

Orthop Trauma Surg. 2002;122:472-487. Reinold MM, Wilk KE, Hooks TR, Dugas JR, Andrews JR. Thermal-assisted capsular

shrinkage of theglenohumeral joint in overhead atheltes: a 15 to 47 month follow-up. JOSPT. 2003;33:455-467.

Stein DA, Jazrawi L, Bartolozzi AR. Arthroscopic stabilization of anterior shoulder instability: a review of the literature. Arthroscopy. 2002:912-924.

Wilk KE, Reinold MM, Dugas JF, Andrews JR. Rehabilitation Following Thermal-Assisted Capsular Shrinkage of the Glenohumeral Joint: Current Concepts. JOSPT. 2002;32:268- 292.


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Biceps Brachii Tendon Proximal Rupture

Surgical Indications and Considerations Anatomical Considerations: Biceps brachii, one of the dominant muscles of the arm, is involved in functional activities of the upper limb, both as a result of its size and its orientation about both the shoulder and elbow joints. At its proximal attachment, the biceps has two distinct tendinous insertions on the scapula from its long and short heads. The short head arises from the coracoid process with the coracobrachialis, while the long head originates from the supraglenoid tubercle and passes over the humeral head within the capsule of the glenohumeral joint. The biceps muscle then continues down the arm within the intertubercular groove covered by a synovial out pouching of the joint capsule. The two muscle bellies unite near the midshaft of the humerus and attach distally on the radial tuberosity. The distal tendon blends with the bicipital aponeurosis, which affords protection to structures of the cubital fossa, allowing distribution of forces across the elbow to lessen the pull on the radial tuberosity. The biceps receives innervation via the musculocutaneous nerve (C5, C6) from the lateral cord of the brachial plexus. Pathogenesis: The long head of the biceps is at risk of injury and degenerative changes because of its mechanical function and proximity to the rotator cuff, bicipital groove, and acromion. Most ruptures occur at the tendinous insertion to the bony anchor, both proximally and distally. The conditions that are most frequently associated with, and probably contribute to, ruptures of the long head of the biceps are rotator cuff pathology, spurs of the bicipital groove, and shoulder instability. Histological studies associated with tendon rupture repeatedly have revealed similar results. Nontraumatic tendon ruptures, including those of the biceps brachii, show evidence of advanced degeneration. Changes include hypoxic tendinopathy, mucoid degeneration, lipomatosis, and calcifying tendinopathy. In both symptomatic and asymptomatic patients with rupture (not limited to biceps alone), a healthy tendon composition rarely, if ever, has been encountered. In contrast, nonruptured (control) tendon samples have demonstrated much lower incidence of degenerative change in large study populations. Although the etiology of degenerative changes remains unclear, this group of subjects may be heterogeneous with multiple factors at work. Younger individuals may rupture the biceps tendon following a traumatic fall, during heavy weightlifting, or during sporting activities (e.g. snowboarding, football). Epidemiology: Biceps tendon ruptures are reported in the US with increasing frequency. A majority of biceps ruptures occur in males aged 40-60 years with a history of shoulder problems. The dominant arm is involved more commonly, probably related to its greater proportional use compared with the nondominant side. Ruptures of the long head account for 96% of all biceps brachii injuries, while distal tendon and short head ruptures account for 3% and 1% respectively.


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Diagnosis

• At the time of long head tendon rupture, patients often feel a pop. This is may be accompanied by a sudden, sharp pain in the anterior shoulder. Pain may actually diminish when a complete rupture occurs following chronic impingement and irritation.

• Most patients present with unusual bulging of the biceps (“Popeye” arm) muscle on the affected extremity.

• The bicipital groove may show indentation or hollowing when the tendon is absent following a rupture.

• Positive Ludington’s test: The patient supports the weight of the upper limbs by clasping both hands on top of the head and contracts and relaxes the biceps muscles of both arms. A ruptured long head tendon is demonstrated in two ways, 1) the biceps muscle of the injured extremity will show unusual bulging, and 2) the examiner will be unable to palpate the tendon on the injured side.

• Speed’s test: Weakness can be a sign of tendonitis or of tendon rupture. • Radiographs and MRI: Diagnosis can usually be made on the basis of the history and

physical exam, but imaging may help rule out other conditions. The biceps groove may demonstrate spurring of the groove, indicating chromic inflammation of the bicipital tendon. A supraspinatus outlet view may show evidence of supraspinatus outlet impingement syndrome.

• Differential diagnosis: Other diagnoses to consider include brachialis tendon rupture, biceps tendonitis, biceps tendon subluxation, and rotator cuff pathology.

Nonoperative Versus Operative Management: Treatment of biceps tendon ruptures is a topic of debate. Several reviews of surgical repair versus conservative (nonoperative) management report conflicting results; neither complete agreement nor general clinical consensus has been reached. Although no concrete evidence provides unconditional support for one treatment protocol, the results of these reviews ultimately may lend credence to the longstanding practice of individualizing treatment to each patient’s circumstances. Conservative management is considered appropriate for middle-aged or older patients and for those who do not require a high degree of supination strength in daily activities. Most studies have shown no significant deficits in forearm supination or elbow flexor strength in long-term follow-up of nonoperative management. The number of patients managed conservatively outweighs the number repaired surgically in most practice settings, and this therapy provides an effective and highly tolerable means of treatment. Generally accepted clinical guidelines advocate surgical repair consisting of tenodesis and subacromial decompression proximally for young or athletic patients or those who require maximum supination strength. Cosmetic concerns may prompt a surgical approach when appearance is unacceptable the patient following rupture. Surgical Procedure: Biceps tenodesis is a surgery to anchor the ruptured end of the biceps tendon. The best surgical results are achieved when the repair is performed within 3 to 4 weeks of the injury. A common method, called the keyhole technique, involves anchoring the ruptured


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end to the upper end of the humerus. The keyhole describes the shape of a small hole made by the surgeon in the humerus. The end of the tendon is slid into the top of the keyhole and pulled down to anchor it in place. The surgeon tests the stability of the attachment by bending and straightening the elbow. When the surgeon is satisfied with the repair, the skin incisions are closed, and the shoulder is placed in a protective sling.

NONOPERATIVE REHABILITATION Phase I for Immobilization and Rehabilitation: Weeks 1-4 Goals: Control edema and pain

Minimize deconditioning Intervention:

• Shoulder brace/immobilizer for 4 weeks. • Pendulums • Active-assisted ROM elbow 0-145 degrees with gentle ROM into extension. • Shoulder isometrics for 10-14 days. • Shoulder active-assisted ROM wand external and internal rotation in scapular plane. • Shoulder passive ROM: flexion, external and internal rotation. • Cryotherapy, other modalities as indicated to reduce edema or control pain

Phase II for Immobilization and Rehabilitation: Weeks 5-8 Goals: Control any residual symptoms of edema and pain

Minimize deconditioning Intervention:

• In addition to Phase I treatment, add light shoulder PREs. Phase III for Immobilization and Rehabilitation: Weeks 9-16 Goals: Limit scar tissue adhesions

Full range of motion (ROM) Improve strength of all shoulder girdle and elbow musculature

Intervention:

• Progress to isotonic exercise program including bench press and shoulder press.


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POSTOPERATIVE REHABILITATION

Phase I Immediate Postoperative phase-“Restrictive Motion”: Day 1 to Week 6 Goals: Protect the anatomic repair.

Prevent negative effects of immobilization Promote dynamic stability. Diminish pain and inflammation.

Intervention: Week 0-2

• Sling for 4 weeks • Sleep in immobilizer for 4 weeks • Elbow and hand ROM • Hand-gripping exercises • Passive and gentle active assisted ROM exercise

o Flexion to 60 degrees (week 2: flexion to 75 degrees). o Elevation in scapular plane to 60 degrees. o External and internal rotation with arm in scapular plane. o External rotation to 10-15 degrees. o Internal rotation to 45 degrees. o Note: No active external rotation or extension or abduction.

• Sub maximal isometrics for shoulder musculature. • NO isolated biceps contractions

Weeks 3-4

• Discontinue use of sling at 4 weeks. • Sleep in immobilizer until week 4. • Continue gentle ROM exercises (passive ROM and active assisted ROM)

o Flexion to 90 degrees o Abduction to 75-85 degrees o External rotation in scapular plane to 25-30 degrees. o Internal rotation in scapular plane to 55-60 degrees. o Internal rotation in scapular plane to 55-60 degrees. o Note: Rate of progression based on evaluation of the patient.

• No active external rotation, extension, or elevation. • Initiate rhythmic stabilization drills. • Initiate proprioception training. • Tubing external and internal rotation at 0 degrees abduction. • Continue use of cryotherapy


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Weeks 5-6 • Gradually improve ROM.

o Flexion to 145 degrees. o External rotation at 45 degrees abduction: 45-50 degrees. o Internal rotation at 45 degrees abduction: 55-60 degrees.

• May initiate stretching exercises. • May initiate light ROM at 90 degrees abduction • Continue tubing external and internal rotation (arm at side). • PNF manual resistance. • Initiate active shoulder abduction (without resistance). • Initiate full can exercise (weight of arm). • Initiate prone rowing, prone horizontal abduction. • NO biceps strengthening

Phase II Intermediate phase-Moderate Protection Phase: Weeks 7-9 Goals: Gradually restore full ROM (week 10)

Preserve the integrity of the surgical repair Restore muscular strength and balance.

Intervention:

• Gradually progress ROM o Flexion to 180 degrees o External rotation at 90 degrees abduction: 90-95 degrees. o Internal rotation at 90 degrees abduction: 70-75 degrees.

• Continue to progress isotonic strengthening program. • Continue PNF strengthening • Initiate “Thrower’s Ten” program.

Weeks 10-12

• May initiate slightly more aggressive strengthening. • Progress external rotation to thrower’s motion

o External rotation at 90 degrees abduction: 110-115 in throwers (week 10-12) • Progress isotonic strengthening exercises. • Continue all stretching exercises. Progress ROM to functional demands (i.e., overhead

athlete). • Continue all strengthening exercises.

Phase III Minimal Protection Phase: Weeks 14-20 Criteria for Progression to Phase III:

Full nonpainful ROM.


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Satisfactory stability. Muscular strength (good grade or better). No pain or tenderness.

Goals: Establish and maintain full ROM

Improve muscular strength, power, and endurance. Gradually initiate functional activities.

Intervention: Weeks 14-16

• Continue all stretching exercises (capsular stretches). • Maintain thrower’s motion (especially external rotation). • Continue strengthening exercises.

o “Thrower’s Ten” program or fundamental exercises. o PNF manual resistance. o Endurance training. o Initiate light plyometric program. o Restricted sport activities (light swimming, half golf swings).

Weeks 16-20

• Continue all exercises listed above. • Continue all stretching. • Continue “Thrower’s Ten” program. • Continue plyometric program. • Initiate interval sport program (e.g., throwing).

Phase IV Advanced Strengthening Phases: Weeks 20-26 Criteria for Progression to Phase IV: Full nonpainful ROM. Satisfactory static stability. Muscular strength 75-80% of contralateral side. No pain or tenderness. Goals: Enhanced muscular strength, power, and endurance.

Progress functional activities. Maintain shoulder mobility.

Weeks 20-26

• Continue flexibility exercises. • Continue isotonic strengthening program. • PNF manual resistance patterns. • Plyometric strengthening.


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• Progress interval sport programs. Phase V Return to Activity Phase: Months 6-9 Criteria for Progression to Phase V: Full functional ROM. Muscular performance isokinetic (fulfills criteria). Satisfactory shoulder stability. No pain or tenderness. Goals: Enhanced muscular strength, power, and endurance.

Progress functional activities. Maintain shoulder mobility. Gradual return to sport activities Maintain strength, mobility, and stability

Exercises

• Gradually progress sport activities to unrestrictive participation. • Continue stretching and strengthening program.

Selected References: Carter AM, Erickson SM. Proximal biceps tendon rupture, primarily an injury of middle age. Phys Sportsmed. 1999;27:95-101. Conrad MR, Nelms BA. Empty bicipital groove due to rupture and retraction of the biceps tendon. J Ultrasound Med. 1990;9:231-233. Curtis AS, Snyder SJ. Evaluation and treatment of biceps tendon pathology. Orthop Clin North Am. 1993;24:33-43. Jobe FW, Schwab DM, Wilk KE. Rehabilitation of the Shoulder. In Brotzman SB, Wilk, KE, eds., Clinical Orthopaedic Rehabilitation. Philadelphia, Mosby, 2003. Moorman CT, Silver SG, Potter HG, et al. Proximal rupture of the biceps brachii with slingshot displacement into the forearm. J Bone Joint Surg Am. 1996;78:1749-1752. Strauch RJ, Michelson H, Rosenwasser MP. Repair of rupture of the distal tendon of the biceps brachii: review of the literature and report of three cases treated with a single anterior incision and suture anchors. Am J Orthop. 1997;26:151-156.


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Shoulder Capsulolabral Reconstruction Surgical Indications and Considerations Anatomical Considerations: The function of the shoulder joint is described in terms of static and dynamic terms. There are several joints that affect the stability and function of the shoulder joint, such as the acromioclavicular (AC) joint, sternoclavicular (SC) joint, the glenohumeral (GH) joint and the scapulothoracic (ST) articulation. In regards to the GH joint, the capsule and labrum are intimately related to the stability of this joint. The labrum deepens the surface of the glenoid. One-third of the humeral head contacts the glenoid fossa at any given time. There is negative pressure in the GH joint that allows for optimal functioning. When the labrum is torn it interrupts this negative pressure seal and diminishes the glenohumeral joint stability. The capsule and the ligaments, which are thickenings of the capsule, provide static support of the GH joint. The major ligaments and their functions are the:

• Inferior glenohumeral ligament – preventing anterior and inferior translations • Middle glenohumeral ligament (attached to the labrum superiorly) – resists

external rotation and abduction • Superior glenohumeral ligament (attached to labrum and as well as the long head

of biceps) prevents superior translation The dynamic support of the GH joint is provided by the rotator cuff muscles. There are nearly 20 muscles that act on the shoulder joint complex. The major dynamic muscles and their function are as follows:

• Supraspinatus and the deltoid assist in abduction • Subscapularis assists in decreasing displacement during external rotation and

abduction • Infraspinatus decreases the anterior translation (along with the long head of the

biceps) Pathogenesis: The mobility of the shoulder complex occurs at the expense of stability. The superior/anterior part of the labrum is meniscal in nature and is loosely attached to the glenoid. If there is mobility of the inferior aspect of the labrum then there is a strong indicator of pathology. High repetitive forces generate degenerative changes in the capsule, rotator cuff, and labrum. This leads to abnormal humeral head translation, which leads to rotator cuff pathology. Many individuals with shoulder instabilities eventually require surgery. Epidemiology: Capsule and labral tears are frequent in the athletic population. Injuries that occur to the capsulolabral complex are many times multidirectional. Dislocations and subluxations are caused by falling on an outstretched arm, sliding into a base head/arm first, or having the arm jerked or pulled by a dog or during an athletic game. Repetitive motions also cause injury to the labrum and capsule, (e.g. in baseball and volleyball players). The labral detachment can occur in any of the above scenarios requiring intervention such as surgery and rehab. Therefore, capsulolabral reconstruction was developed to restore preinjury level of function.


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Diagnosis

• Pain with throwing or during activities requiring use of the arm in the overhead throwing position

• Palpatory tenderness anterior over long head biceps, rotator cuff insertions and bony landmarks of the AC, SC, ST and GH joints

• Normal or hypermobile GH internal and external rotation ROM • Load and shift test – clunk with axial loading with anterior and posterior shift • Apprehension test with combination of the relocation test • Positive sulcus sign • Rule out cervical spine and elbow conditions mimicking shoulder pathology • MRI can be helpful in demonstrating the presence, location, and severity of the tear(s) –

with and without contrast Nonoperative Versus Operative Management: Instability of the shoulder joint can be very painful and may continue to cause further complications if surgery is not performed, such as continued articular cartilage. Surgery can, ideally, repair and reconstruct the pathology. Even though surgery is warranted the person may have stability but be limited in mobility that could affect their career if they were a professional athlete, dancer, or muscian. Another challenge is open versus closed procedures. Open procedures are usually recommended for individuals with multiple dislocations and possible contact sports such as football and rugby. Arthroscopic procedures are usually used for the overhead athlete since it traditionally provides stability without compromising range of motion. Surgical Procedure: There are over 100 open surgical techniques described in the literature. They all have their goals of providing capsular tightening, bone block transfer or osteotomies. The two most common procedures, stated by Donatelli and Jobe et al, are the open Bankhart reconstruction and the anterior or posterior capsulolabral reconstruction. A Bankhart tear is located in the front lower part of the labrum and a SLAP tear occurs on the top part of the labrum – Superior Labrum from Anterior to Posterior. The Bankhart lesion specifically refers to an injury where part of the ligaments and capsule of the shoulder joint are pulled away from the bone. Donatelli states that the basic goal of the Bankhart procedure is repairing the capsular-periosteal separation at the anterior glenoid neck. It attempts to correct the inferior GH ligamentous complex. Jobe et al states that the goal of the capsulolabral reconstruction is to reduced the capsular shift by providing a double-thickness affect for the anterior or posterior capsule – thus, providing reinforcement at the site of the previous instability. Sutures and tacs/anchors are done according to the preference of the surgeon. During the capsular shift procedure in conjunction with the Bankhart procedure, it is important that the surgeon considers the placement of the sutures and the position of the flaps for reasons to protect the labrum as stated by Jobe et al. Before closing the site, passive motion must be performed to ensure at least 90◦ of abduction and 45◦ of external rotation. This capsular tightness observed will determine the safe zone for postoperative splinting and rehabilitation guidelines.


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Preoperative Rehabilitation (for 6 months)

• Rest (no throwing activities, etc.) • Nonsteroidal anti-inflammatory medications • Three steroid injections • Strengthening program for rotator cuff muscles and scapular muscles (trapezius,

rhomboids, and serratus anterior)

POSTOPERATIVE REHABILITATION Note: The following rehabilitation progression is a summary of the guidelines provided Jobe,

Giangarra, Kvitne and Glousman. As with all protocols your surgeon may have one that is specific to his or her surgical technique.

Phase I for Controlled Mobilization and Rehabilitation: Day one -2 weeks Goals: Control edema and pain

Maintain range of motion Protect repair (mainly by controlling excessive motion)

Intervention:

• Postoperative orthosis in a position of 90◦ of abduction, 45◦ external rotation and 30◦ of forward flexion.

• NMES and ice • Strengthening exercises to include elbow flexion and extension, isometric abduction,

active-assisted horizontal adduction and abduction • Passive range of motion of abduction, flexion and external rotation

NOTE: perform abduction and external rotation in the scapular plane with no forced motion (protect anterior capsule) NOTE: If a posterior repair occurred then perform no posterior glides, internal rotation and horizontal adductions will be limited initially

Phase II Rehabilitation: Weeks 2-6 Goals: Control any residual symptoms of edema and pain

Continue to protect repair Improve strength Improve range of motion


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Intervention:

• Discontinue orthosis – instead use abduction brace/pillow at about 20◦ abduction as needed

• Actively abduct from neutral to beyond 90◦ • Strengthening continued and progressed to add shoulder shrugs, and shoulder external

rotation • May use home over the door pulley or pool therapy for gentle range of motion

Phase III for Rehabilitation: 6 weeks - 5 months Goals: Improve strength of GH and ST muscles

Full active range of motion Begin synchronization of motor control

Intervention:

• Strengthening of the rotator cuff muscles, shoulder flexion, horizontal adduction beginning at 6-8 weeks post-op

• By week 9 add strengthening regimen for scapular rotators, biceps, coracobrachialis, pectoralis, and deltoid muscles (should be continued for minimum of 1 year)

• Upper extremity ergometer – low resistance • Progress to total body conditioning

Phase IV for Rehabilitation: 6-9 months Goals: Return to sport activity

Improving endurance of the sport specific musculature Re-established coordinated/synchrony of motion

Intervention:

• Isokinetic testing okay, progression of total body conditioning program • Progress sport specific activities, such as throwing • By 9th month patients should be performing sport specific activity 30 minutes each day


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Selected References: Donatelli RA. Instabilities. In Physical Therapy of the Shoulder. New York, Churchill Livingstone, 1997. Ferretti A, De Carli A, Calderaro M, Conteduca F. Open capsulorrhaphy with suture anchors for recurrent anterior dislocation of the shoulder. Am J Sports Med. 1998;26: 625-629 Jobe FW, Giangarra CE, Kvitne RS, Glousman RE. Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports. Am J Sports Med. 1991;19:428-434. Magarey ME, Jones MA, Grant ER. Biomedical considerations and clinical patterns related to disorders of the glenoid labrum in the predominantly stable glenohumeral joint. Manual Therapy. 1996;1:242-249 Ticker JB, Warner JJ. Selective capsular shift technique for anterior and anterior-inferior glenohumeral instability. Clinics in Sports Medicine. 2000;19:1-17.


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Proximal Humeral Fracture Repair and Rehabilitation

Surgical Indications and Considerations Anatomical Considerations: Numerous types of proximal humeral fractures can occur each of which have separate surgical indications and considerations. Proximal humeral fractures commonly occur along the physeal lines. Thus, fractures may involve the tubercles (greater and/or lesser), surgical neck, or anatomical neck of the humerus. The surgical neck lies between the tuberosities and the shaft while the anatomical neck is the junction between the humeral head and the tuberosities. Fortunately, surgical neck fractures are more common. Anatomical neck fractures typically have a less favorable prognosis due to their result in devascularization of the humeral head. Between the two tuberosities of humerus lies a groove in which the biceps tendon lies. It is through this groove that the terminal branches of the ascending division of the anterior humeral circumflex artery enter the humeral head. Fractures that split the tuberosities from the head disrupt this small arterial complex and can result in osteonecrosis of the humeral head. The most recognized and used standard for assessing proximal fractures is the 4-part Neer classification system. It is used for both treatment and prognosis. The 4-part classification: One-part fractures Eight of ten proximal humeral fractures are of this type and include all fractures of the proximal humerus, regardless of the level or number of fracture lines, in which no segment is displaced more than 1cm or angulated more than 45°. Two-part fractures The two-part fracture includes those proximal humeral fractures with a single displacement at the anatomic neck, surgical neck, lesser tuberosity, or greater tuberosity. The fracture is named by the structure that is displaced (Two-part surgical neck fracture). Three-part fractures The three-part fracture includes all proximal humeral fractures with a displaced surgical neck and either a greater or lesser tuberosity displacement fracture. Four-part fractures Four-part fractures are proximal humeral fractures with three displaced, fractured segments including both tuberosities and typically the surgical neck. Avascular necrosis is common in these types of fractures. The anatomical positioning of the neural and vascular structures of the arm can cause complications in these types of fractures. Severe displacement of the structures of the shoulder with these types of injury can cause damage to the brachial plexus (most commonly a traction injury of the axillary nerve) or vascular structures (commonly effecting the axillary artery). Avascular necrosis is also a complication causing bone cell death when the blood supply is cut off from a fractured region of bone as mentioned above.


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Pathogenesis: Bone fractures when the mechanical forces exceed the physiologic capacity of the bone. Intrinsic weakening of bone increases the risk of such pathology. Weakening of proximal humeral bone tissue may occur due to repetitive stress (as occurs in little leaguer’s shoulder and stress fractures), endocrine functioning (as is the case in osteoporosis), pathology (such as sickle cell anemia, tumors, or cancer), or nutritional deficits (as found in cases of Rickets and osteomalacia). External forces commonly leading to proximal humerus fractures include a fall on the outstretched arm, excessive rotation in the abducted position, a direct blow to the lateral aspect of the shoulder, dislocation leading to subsequent avulsion fracture(s), electrical shock, and muscular forces of seizures (subscapularis can avulse the lesser tuberosity). Biomechanically with a fall on the outstretched arm, the most common cause of proximal humeral fractures, the shoulder and limb remain medially rotated. Normally, to accomplish full abduction, the humerus must externally rotate. If external rotation is blocked, as in a fall, the proximal humerus becomes impinged against the acromion. The acromion acts as a fulcrum of a lever and the depending on the quality of the tissues of the shoulder complex the humerus may fracture, dislocate, or both dislocate and fracture. Epidemiology: Proximal humeral fractures are relatively common. They represent about 4% of all fractures seen in the average orthopedic clinic. These fractures occur in all ages but are most common in relatively fit elderly. The injury is more common in females and the highest age-specific incidence occurs in women between 80 and 89 years of age. Not surprisingly these injuries are more commonly caused by sport and road traffic accidents in younger generations, while over the age of 30 the chief cause of proximal humeral fractures is a “standing height” fall. ~49% of proximal humeral fractures are part-one, ~28% are part-two surgical neck fractures, ~9% are three-part greater tuberosity and surgical neck fractures. Four-part fractures and fracture dislocations account for ~3% of proximal humeral fractures. Diagnosis

• Mechanism of injury is usually consistent with a fall on an out stretched arm or blow to the shoulder during a traumatic or sports related event

• Severe point tenderness over the fracture site can be found with palpation, caution should be used to prevent further damage at the fracture site

• Swelling usually appears immediately about the shoulder and upper arm while ecchymosis generally appears 24-48 hrs later. Ecchymosis may spread to the chest wall, flank, and forearm.

• Confirmation of the fracture can be made with radiographic images. • CT scan is indicated in selected cases.

Non-operative Versus Operative Management: Treatment of proximal humeral fractures vary depending on the type and severity of the fracture as well as the activity level, health, age, quality of bone, and motivation of the patient. Generally, most unstable/displaced fractures or fractures with accompanying vascular insult require surgical intervention. Various methods of treatment include closed reduction, casts, splints, percutaneous pinning, external fixation, open reduction and internal fixation, and humeral head replacement.


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Non-operative: Non-displaced or minimally displaced fractures as well as patients with medical illnesses that preclude them from surgery should be treated conservatively. They can be managed non-surgically, by immobilizing the arm in a sling for comfort and instituting early range of motion exercises when pain permits. See protocol for treatment below. Operative: Isolated two-part fractures of the tuberosities are difficult to perform closed reduction on secondary to the forces created by the attached rotator cuff muscles. The greater tuberosity fracture is treated nonoperatively for fractures with less than .5 cm of superior displacement or 1cm of posterior displacement. If greater, these fractures are generally treated with open reduction internal fixation to prevent subacromial impingement and malunions. The rare isolated lesser trochanteric fracture is treated with open reduction internal fixation when the fragment is large and blocks medical rotation. Two-Part Surgical Neck Fractures are generally treated with open reduction internal fixation for younger patients with good bone quality and ability to comply with postoperative therapy. Rigid internal fixation devices often fail when applied to thin porous bone so hemiarthroplasty is often a better treatment choice for elderly patients. Percutaneous internal fixation is often chosen for displaced two-part fractures that can be reduced with closed manipulation. Intramedullary fixation has been completed successfully by some but concern of torsional rigidity, risk of displacement, and impingement by a prominent rod deters many from this technique. Three part fractures also have multiple treatment choices including internal fixation options of interfragmentary fixation with sutures or wire, percutaneous pinning, plate-and-screw fixation, and intramedullary fixation with and without suture supplementation. Reduction can be completed closed but are difficult to manage. Open reduction is the more common management. Rarely, prosthetic hemi-arthroplasty is used. Four-part fracture treatment options range from early mobilization to percutaneous reduction and internal fixation, open reduction and internal fixation, and hemiarthroplasty. Nonoperative treatment is typically reserved for those in which surgery is contraindicated secondary to the fact that this treatment often results in malunion and pain. There is conflicting evidence recorded on the most effective treatment for this injury.


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NONOPERATIVE AND POSTOPERATIVE REHABILITATION

Note: The following rehabilitation progression is a summary of the guidelines provided by Basti, Dionysian, Sherman, and Bigliani. Refer to their publication to obtain further information regarding criteria to progress from one phase to the next, anticipated impairments and functional limitations, interventions, goals, and rationales.

REHABILITATION FOR NON-OPERATIVE HUMERAL FRACTURES Early Passive Motion: (7-10 days post fracture) Goals: Control pain and edema

Protect fracture site Minimize deconditioning Maintain range in joints around the effected region (wrist, hand, and neck) Prevent glenohumeral adhesive capsulitis and muscle flexibility deficits

Intervention:

• Modalities, such as TENS and ice, for pain control • Splint/Sling as direct by MD • Monitor use and weight bearing instructions per MD • Cardiovascular conditioning • Gentle range of motion exercises of the neck, wrist, and hand • Pendulum exercises • Passive forward elevation of the shoulder • Passive external rotation of the shoulder

Early Passive Motion: (10 days to 3 weeks post fracture) When pain has diminished and the patient is less apprehensive. Goals: Same as above Intervention: in addition to above

• Active assistive forward elevation • Active assistive external rotation to 40°

Phase I: (3-6 weeks post fracture) Goals: Continue to control pain and edema as needed

Minimize deconditioning Regain full range of motion Prevent muscle atrophy


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Intervention:

• Pendulum • Active assistive forward elevation • Active assistive external rotation • Isometrics: Internal and external rotation, flexion, extension, and abduction in a neutral

position (at 4 weeks) • Active assistive hyper extension (at 6 weeks) • Gripping exercises

Phase II: (6-8 weeks post fracture) Goals: Regain full Range of motion

Actively work within newly gained range of motion Increase strength

Intervention:

• Active forward elevation in supine • Active forward elevation with weights in supine • Forward elevation in standing with stick • Pulleys with eccentric lowering of involved arm

Phase III: (8 weeks post fracture) Goals: Increase strength (especially at end range)

Gain adequate strength in the rotator cuff to allow for humeral head depression necessary to avoid impingement Strengthen scapular rotators to allow for proper scapulohumeral rhythm

Intervention:

• Resistive exercises: standing forward press, theraband resisted (flexion, internal rotation, external rotation and abduction) exercises, and rowing

• Self stretching: flexion/abduction combined, internal rotation, flexion, abduction/external rotation combined, bilateral hanging stretches

• Advanced internal rotation, shoulder flexion, external rotation and horizontal abduction stretching


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REHABILITATION FOR OPEN REDUCTION/INTERNAL FIXATION AND HUMERAL HEAD REPLACEMENT

Preoperative Rehabilitation

• Injury is protected with immobilization through casting, splinting and/or placed in a sling • Patient is instructed of post-operative rehabilitation goals and plan

Early Passive Motion: (3-5 days post op) Goals: Control pain and edema

Protect fracture site Minimize cardiovascular deconditioning Maintain range in joints around the effected region (wrist, hand, and neck) Prevent glenohumeral adhesive capsulitis and muscle flexibility deficies

Intervention:

• Modalities, such as TENS and ice, for pain control • Splint/Sling as direct by MD • Monitor use and weight bearing instructions per MD • Cardiovascular conditioning • Gentle range of motion exercises of the neck, wrist, and hand • Passive supine external rotation to 40° • Passive supine forward elevation

Phase Ia: (7-10 days post op) and Phase Ib: (3 weeks post op) Goals: Continue to control pain and edema as needed

Minimize deconditioning Regain full range of motion Prevent muscle atrophy

Intervention: Phase Ia

• Pendulum • Passive external rotation with stick or pulleys • Passive forward elevation with assist from non involved arm or pulleys • Passive internal rotation and hyperextension with stick (not to be done with tuberosity

fracture) • Cardiovascular conditioning


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Interventions: Phase Ib

• Isometrics: Internal rotation, external rotation, flexion, extension, abduction in a neutral position

Phase II: (4-6 weeks post op) Goals: Regain full Range of motion

Actively work within newly gained range of motion Increase strength

Intervention:

• Active forward elevation in supine • Active forward elevation with weights in supine • Forward elevation in standing with stick • Pulleys with eccentric lowering of involved arm

Phase III: (12 weeks post op) Goals: Increase strength (especially at end range)

Gain adequate strength in the rotator cuff to allow for humeral head depression necessary to avoid impingement Strengthen scapular rotators to allow for proper scapulohumeral rhythm

Intervention:

• Resistive exercises: Standing forward press, theraband resisted (flexion, internal rotation,

external rotation and abduction) exercises, and rowing • Self stretching: flexion/abduction combined, internal rotation, flexion, abduction/external

rotation combined, bilateral hanging stretches

• Advanced internal rotation, shoulder flexion, external rotation and horizontal abduction stretching


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Selected References: Basti JJ, Dionysian E, Sherman PW, Bigliani LU. Management of proximal humeral fractures. J Hand Ther. 1994;7:111-21. Cornell N, Schneider K. Proximal Humerus. In Koval K, Zuckerman J, eds., Fractures in the Elderly. Philadelphia, Lippincott-Raven 1998. Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand. 2001;72:365-371. Curwin S. Shoulder Injuries. In Zachazewski JE, Magee DJ, Quillen WS, eds. Athletic Injuries and Rehabilitation. Philadelphia, 1996, WB Saunders. Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD. Functional outcome after humeral head replacement for acute three- and four-part proximal humeral fractures. J Shoulder Elbow Surg. 1995;4:81-86. Green A, Izzi J. Isolated fractures of the greater tuberosity of the proximal humerus. J Shoulder Elbow Surg. 2003;12:641-649. Iannotti JP, Ramsey ML, Williams GR, Warner JP. Nonprosthetic management of proximal humeral fractures. J Bone Joint Surgery. 2003;8:1578-1593. Neer CS. Four-segment classification of proximal humeral fractures: purpose and reliable use. J Shoulder Elbow Surg. 2002;11:389-400. Visser C, et al. Nerve lesions in proximal humeral fractures. J Shoulder Elbow Surg. 2001;10:421-427. Zyto K, Wallace WA, Frostick SP, Preston BJ. Outcome after hemiarthroplasy for three-and four-part fractures of the proximal humerus. J Shoulder Elbow Surg. 1998;7:85-89.


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Repair of SLAP lesion

Surgical Indications and Considerations Anatomical Considerations: The rotator cuff is predisposed to tearing secondary to senescence of the tendon with age, including apoptosis of fibroblasts, loss of cellular activity, disorganization of the collagen, and decreased extracellular matrix synthesis. Furthermore the tearing of the rotator cuff can occur because of decreased vascularity within the shoulder, specifically, a centimeter of its insertion on the proximal humerus. Pathogenesis: A SLAP lesion is a lesion of the Superior aspect of the glenoid Labrum that extends Anteriorly and Posteriorly to the biceps insertion. There are four variations that include: 1) Type I, where the labrum is attached to the glenoid rim but fraying occurs at the leading edge of the labrum. 2) Type II lesion, where the superior labrum or biceps insertion is detached from the glenoid. 3) Type III, where the lesion is similar to Type II, but includes a bucket handle tear of the labrum. 4) Type IV has a longitudinal split in the biceps tendon. SLAP lesions are also common in patients with full-thickness rotator cuff tears or glenohumeral instability and shoulder pain. A variety of mechanisms can cause a SLAP lesion, including a fall on an outstretched arm, shoulder instability, and overhead work. Epidemiology: The incidence and etiology of SLAP lesions is uncertain. Research has indicated that pathologic shoulders that have been arthroscopically examined have revealed 6%-12% of those had SLAP lesions. The most common causes of SLAP lesions include falling on an outstretched arm, traction on the biceps tendon, and overhead athletic activity. Type I lesions are common in older patients, greater than forty years old, and usually associated with rotator cuff disease. Type II lesions are common in younger individuals, usually throwing athletes secondary to biceps insertion twisting as the arm is brought into abduction and external rotation causing a peeling back of the superior labrum. Approximately 81% of SLAP lesions in throwers are Type II. Type III and IV lesions are fairly rare and are associated with traumatic instability. Diagnosis: • Patient may complain of pain that is sharp, severe, and localized being deep within the joint • Symptoms may include intermittent catching or locking to the shoulder during overhead

sports or activities of daily living • Production of pain when the examiner applies compression to the abducted shoulder with

added rotation. Also pain with the internally rotated arm in adduction and having patient resist a downward force.

• Positive for these special tests: Speed test, apprehension test, active compression test, Hawkins impingement test, O’Brian test

• MRI with contrast material • Common with full-thickness rotator cuff tears or glenohumeral instability. • Arthroscopic visualization is the standard for diagnosis


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Nonoperative Versus Operative Management: Treatment for a patient with a suspected symptomatic SLAP lesion is initially nonoperative. For example, athletes involved with overhead sports with symptoms of a SLAP lesion often have symptoms of a rotator cuff pathology. The treatment consists of rest, rehabilitation, pain relief, and graduated return to a sport or activity. With throwing athletes being able to return to play, they must have full pre-injury full range of motion and be able to perform pain free. Recurrent episodes of pain that prevent full recovery may be an indication for surgery. Surgical Procedure: • Type I lesions: The minor fraying at the free edge of the labrum is considered an

abnormality and do not perform any debridement. • Type II lesions: An anterosuperior portal is created. A spinal needle is inserted at the

anterolateral acromial corner and enter the joint lateral to the biceps tendon. Then a burr is used to abrade the glenoid beneath the detached superior labrum to expose cancellous bone anterior to posterior margins of the superior labrum detachment. Holes are drilled for suture anchors. Then nylon sutures are used to suture the labrum.

• Type III lesions: If the bucket handle is less than one third the width of the labrum, then it is excised, and repair to the major portion to the superior labrum to the glenoid is performed as that of type II. If the bucket handle is one third of more the width of the labrum, then the detached portion is repaired with sutures.

• Type IV lesions: If the longitudinal tear in the biceps tendon is less than one third the diameter of the tendon, then the torn fragment is excised. If the fragment is one third or more the diameter of the tendon, then the torn fragment is repaired to the major portion of the bicep tendon. The superior labrum is repaired first as described in the Type II repair. Usually one or two sutures are sufficient to repair the torn fragment to the major portion of the biceps tendon.

POSTOPERATIVE REHABILITATION Phase I for Immobilization and Rehabilitation: Weeks 1-3 Goals: Increasing passive shoulder range of motion

Control inflammation Control pain/effusion

Intervention: • Shoulder immobilized immediately post-op in sling that is to be worn at all time except while

exercising or bathing for 4 weeks. • 2 weeks after surgery, passive range of motion is allowed in all planes except external

rotation and abduction • No shoulder rotation above 60° of glenohumeral abduction until week 3 • Modalities to reduce inflammation, pain, and edema


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Phase II for Mobilization and Rehabilitation: Weeks 3-6 Goals: Progressive passive range of motion

Increase scapulothoracic motor control Incorporate involved extremity with ADLs Pain control

Intervention: • Week 4, sling is no longer needed • Progressive passive range of motion is started, with emphasis placed on posterior capsule

stretching and internal rotation. • Begin passive and manual scapulothoracic mobility program • Begin external rotation in abduction • Allow use of operative extremity for light activities of daily living • Modalities Phase III for Immobilization and Rehabilitation: Weeks 6-12 to 7 months Goals: Increase shoulder active and passive range of motion

Increase scapular stabilizers strength Increase rotator cuff strength Increase trunk stability

Intervention: • At 6 weeks after surgery, external rotation and abduction is allowed with continued

stretching • Progressive strengthening program for the deltoid, rotator cuff, scapular stabilizers, biceps,

triceps, and trunk stability • 3 months after surgery - Patients engaged in sports that use upper extremities, such as

swimming and golf, are allowed • 4 months after surgery, throwing athletes can return, beginning with low-velocity, short

distance, throwing on level ground with emphasis on proper throwing mechanics. Continue stretching and strengthening regimen, with emphasis on posterior capsular stretching

• Distance and velocity are gradually increased until 7 months with continuation of progressive strengthening and posterior capsular stretching


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Selected References: Kim K, Queale W, Cosgariea A, McFarland E. Clinical features of the different types of SLAP lesions. J Bone and Joint Surgery. 2003; 85:66-71. Burkhart S, Morgan C. SLAP lesion in the overhead athlete. Orthopedic Clinics of North America. 2001;32:1-10. Conway J. Arthoscopid repair of partial-thickness rotator cuff tears and SLAP lesions in professional baseball players. Orthopedic Clinics of North America. 2001;32(3). Park H, Lin S, Yokota A, McFarland E. Return to play for rotator cuff injuries and superior labrum anterior posterior (SLAP) lesions. Clinics in Sports Med. 2004; 23(3). Garsman G., Hammerman S. Superior labrum, anterior and posterior lesions when and how to treat them. Clinics in Sports Med. 2000;19(1).


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Rotator Cuff Repair and Rehabilitation Surgical Indications and Considerations Anatomical Considerations: The rotator cuff “complex” is comprised of four tendons from four muscles: supraspinatus, infraspinatus, teres minor, and subscapularis, all originating from the scapula and attaching to the tuberosities of the humerus. The supraspinatus tendon lies superiorly along the scapula and under the coracoacromial arch of the scapula and has a hypovascular zone near its insertion. The primary function of the rotator cuff is to rotate and stabilize the humeral head in the glenoid socket against the upward pull of the deltoid with overhead activities. Pathogenesis: The supraspinatus tendon is the most commonly affected tendon in rotator cuff tears. An acute tear may occur in the case of a traumatic event to the shoulder, but more typically the tear occurs in progressive stages arising from glenohumeral instability and scapulothoracic dysfunction. Also playing a role is the natural aging process of gradual deterioration of tendon strength and flexibility, decreased use and vascularization, along with postural changes. A combination of any of these factors leads to an impingement problem in which the tendon is compressed between the acromion and the humeral head. These are generally classified as chronic tears, referring to repetitive microtrauma to the tendon which leads to inflammation, tendonitis, fibrosis, bone spurs, and eventually a partial thickness to complete tear. Complete tears are classified based on their size in square centimeters: small (0 - 1 cm²), medium (1 – 3 cm²), large (3 – 5 cm²), or massive (>5 cm²). Congenital bony abnormalities in which the acromion, coracoid, or greater tuberosity is thicker or protrudes into the subacromial space will also predispose a person to an impingement problem that eventually follows the same progressive course to a tear. Epidemiology: Rotator cuff tears are more often seen in individuals who perform frequent overhead lifting or reaching activities as well as athletes such as pitchers, swimmers, and tennis players who perform repetitive overhead activities. These activities cause fatigue and subsequent weakness in the rotator cuff muscles allowing superior and anterior migration of the humeral head, and also weakness of the scapular stabilizers creating a secondary cause of an impingement. A spontaneous tear may occur after a sudden movement or impact, and is seen in 80% of patients older than 60 years when a humeral head dislocation is involved. Diagnosis:

• Some evidence of atrophy may be seen in the supraspinatus fossa. • Possible atrophy in the infraspinatus fossa also, depending on size of tear • Passive motion usually maintained, but may be associated with subacromial crepitus.

However, if the injury is chronic, and the patient has been avoiding using the shoulder, adhesive capsulitis may be present

• Active motion is diminished, particularly abduction, and symptoms are reproduced when the arm is lowered from an overhead position. Loss of active external rotation present in


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massive tears • Muscle weakness is related to the size of the tear and muscles involved • Neer and Hawkins Impingement Signs may be positive, but are nonspecific because they

may be positive with other conditions as well (such as rotator cuff tendonitis or bursitis) • A subacromial injection of lidocaine would improve pain, but weakness would still be

present • It is important to rule out other potential etiologies such as patients with C5-6

radiculopathy as these patients may also have an insidious onset of shoulder pain, rotator cuff weakness, and similar muscular atrophy

• A “trauma shoulder series” of plain radiographs may show superior humeral migration and degenerative conditions or bone collapse.

• An MRI may help demonstrate the size and degree of retraction of a tear. Non-operative versus Operative Management: Surgical repair is indicated for patients who do not respond well to conservative treatment, active patients younger than 50 years with a full-thickness tear, or who have an acute tearing of a chronic injury. Conservative management will include nonsteroidal anti-inflammatory drugs (NSAIDs), cortisone injections, heat, ice, rest, and rehabilitation programs. The goals are to first restore normal range of motion, then strengthen the rotator cuff initially below shoulder level and gradually increase resistance to all functional planes and range of motion without aggravating symptoms. Normalizing scapulothoracic and glenohumeral rhythm may also be included. Approximately 50% of patients with rotator cuff tears improve to their satisfaction within 4 to 6 months of this treatment, but these results can deteriorate with time. Patients who do not progress, have pain even after regaining strength, or have significant weakness or posterior cuff involvement may also benefit from earlier surgery rather than waiting through the 4 to 6 month period of conservative treatment. This is particularly the case with younger patients with higher functional demands. Surgical Procedure: The primary goal of surgery is elimination or significant reduction of pain. Other goals are to improve shoulder range of motion, strength, and function. Surgical repair can be performed arthroscopically, partially open, or completely open. The type of procedure will depend on the size, type, and pattern of the tear as well as the surgeon’s preference. Generally the larger tears (3 to 5 cm) require more open techniques than the smaller tears (3 cm or less). Along with repair of the rotator cuff operative procedures also typically include an anteroinferior acromioplasty to decompress the subacromial space. The cuff tear is repaired using permanent sutures to the greater tuberosity with the goal of having minimal tension with the arm positioned at the side. A double layer fixation technique has been shown to provide greater initial fixation strength than single layer fixation. This is critical as the occurrence of rotator cuff repair failure is highest in the early postoperative phase before there has been time for sufficient tendon-to-bone healing. Clinical results for pain relief are satisfactory 85% to 95% of the time. This appears to correlate with the sufficiency of the acromioplasty and subacromial decompression. The integrity of the cuff repair, preoperative size of the tear, and quality of the tendon tissue influence the functional outcome. Acute tears with early repair may have a slightly greater susceptibility to develop stiffness, but it has also been noted that these patients progress with rehabilitation more rapidly than those with late repair.


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Preoperative Rehabilitation: The primary concerns preoperatively are to prevent loss of range of motion and further damage to the glenohumeral joint and rotator cuff tendons. This can be accomplished with passive range of motion and avoiding aggravating activities and positions. A sling may be provided briefly for pain management if needed, but caution must be taken to avoid adhesive capsulitis.

POSTOPERATIVE REHABILITATION Please note: Exercise progression is dependent upon the size of the tear and achievement of goals in previous phases of the rehabilitation protocol. Post-operative weeks indicated for each phase are guidelines. Larger tears will require longer healing and protection time, and therefore, delayed AROM and resistance exercises generally by 2 to 4 weeks. Small tears may be able to progress more rapidly and follow an accelerated protocol if the surgeon agrees. Precautions:

• Keep incision clean and dry • For at least the first 6 to 8 weeks:

Avoid shoulder adduction behind the back, extension, and horizontal adduction No lifting objects No excessive stretching or sudden jerking movements No supporting body weight by hands and arms

Phase I: Post-operative weeks 0 – 4 Goals: Decrease pain, including improved sleep patterns

Manage edema Well-healed incision Improve passive ROM and tolerance to movement Maintain ROM of cervical spine, elbow, wrist and hand Increase quality of muscle recruitment

Intervention:

• Immobilization of shoulder in sling or airplane splint except during exercise • Cryotherapy - 4 to 8 times/day during the first 1 to 2 weeks as needed for pain control • Pendulum exercises • Passive range of motion (PROM) • Elbow, wrist, and cervical spine active range of motion (AROM) • Submaximal isometrics (pain free) at 1 to 3 weeks • Rhythmic stabilization drills in balanced position (100º to 110º of elevation and 10º of

horizontal abduction) at 10 days to 3 weeks • Hand gripping with putty • Joint mobilizations – grades I and II to glenohumeral (GH) joint


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Phase II: Post-operative weeks 5 – 8 Goals: Passive ROM shoulder flexion/abduction = 140º – 165º, ext rot = 70º, int rot = 55º

Active-Assisted ROM (A/AROM) to reach above head height Pain management Re-establish dynamic shoulder stability (humeral head control) Improve scar mobility Improve fitness level

Intervention:

• Continue phase 1 exercises and progress as indicated • May use heat prior to exercises • May use pool for light AROM exercises • Shoulder proprioceptive neuromuscular facilitation (PNF) D1 and D2 patterns • Initiate AROM shoulder flexion in scapular plane and shoulder abduction up to 90º as

able without scapular hiking • Pulleys and wand exercises • AROM external and internal rotation at 0º abduction progressing from gravity-

eliminated to gravity-resisted positions to resistance tubing • Prone rowing and horizontal abduction • Bicep curls • Soft tissue mobilization • GH joint mobilizations as needed – Grades III- to III and IV • Cardiovascular conditioning (walking or stationary bicycle program)

Phase III: Post-operative weeks 8 – 12 Goals: Full AROM and PROM

Dynamic shoulder stability Gradual return to shoulder strength and power Gradual return to functional activities Minimal pain associated with overhead activities Increase exercises for performance at home (HEP)


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Intervention:

• Continue exercises and mobilizations from phases 1 and 2 as indicated • Progress AROM to full range, still avoiding scapular hiking with elevation movements • Progressive shoulder and elbow resistance exercises with tubing and light dumbbells • Manual resistance added to PNF patterns • Prone external rotation at 90º abduction • Modified military press • Body Blade exercises • Lower extremity and trunk strengthening if needed for preparation to return to strenuous

work or sport activities Phase IV: Post-operative weeks 13 – 16 Goals: Independent/self-management of HEP

Self-management of pain associated with overhead activities Able to reach in front and to the side with elbow extension for light-weight objects Carry light weight objects for short periods (e.g., groceries) Improve muscular strength and power Maintain full AROM

Intervention:

• Continue mobilizations and progress exercises from previous stages as indicated • Corner (anterior chest) and hand behind back stretches • Plyometrics if appropriate • Shoulder girdle depressions • Closed chain exercises • Self-capsular stretches • Joint mobilization to cervical and thoracic spine as appropriate

Phase V: Post-operative weeks 17 – 26 Goals: Pain-free with overhead activity

Gradual return to strenuous work activity or previous level of functioning Gradual return to recreational sport activity

Intervention:

• Continue mobilizations and progress Phase IV exercises as appropriate • Fundamental shoulder exercise program at least 4 times per week to include rotator cuff

and scapular stabilization exercises, bicep strengthening, and shoulder and chest stretches • Strengthen for sport-specific activities as appropriate


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• Initiate sport activity when appropriate Selected References:

Cohen BS, Romeo AA, Bach BR. Shoulder Injuries. In Brotzman SB, Wilk KE, 2nd ed., Clinical Orthopedic Rehabilitation. Philadelphia, Mosby, 2003. Holtby R, Razmjou H: Validity of the supraspinatus test as a single clinical test in diagnosing patients with rotator cuff pathology. J Orthop Sports Phys Ther. 2004;34:194-200. Kibler WB, Livingston B, Chandler TJ: Current concepts in shoulder rehabilitation. Adv Oper Orthop 3:249-301, 1996. Mandelbaum B, Gruber J, Zachazewski J. Rotator Cuff Repair and Rehabilitation. In Maxey L, Magnusson J, eds., Rehabilitation for the Postsurgical Orthopedic Patient. St. Louis, Mosby, 2001. Romeo AA, Hang DW, Bach BR, Shott S: Repair of full thickness rotator cuff tears: gender, age, and other factors affecting outcome. Clin Orthop 1999;367:243-255. Waltrip RL, Zheng N, Dugas JR, Andrews JR: Rotator cuff repair: a biomechanical comparison of three techniques. Am J Sports Med 31(4):493-497. Wilk KE, Crockett HC, Andrews JR: Rehabilitation after rotator cuff surgery. Tech Shoulder Elbow Surg. 2000;1(2):128-144, 2000.


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Total Shoulder Arthroplasty

Surgical indications and contraindications Anatomical Considerations: Total shoulder arthroplasty surgery involves the replacement of the humeral head and the glenoid articulating surfaces with artificial components. This procedure also involves precise placement and balancing or the muscles of the rotator cuff and the capsular ligaments, in addition to other related shoulder muscles. The muscles considered to be part of the shoulder include the Supraspinatus, Infraspinatus, Subscapularis, Teres Minor, Teres Major, Latissimus Dorsi, Pectoralis Major, Serratus Anterior, Deltoids, and the Trapezius musculature. Only the insertion of the subscapularis, at the lesser tubercle of the humerus, is affected during this procedure. None of the other muscular attachments are disrupted by this particular surgery. However, this procedure can alter the normal geometric mechanics of the shoulder, allowing only limited range of motion upon complete recovery time. Pathogenesis: Indication for a total shoulder arthroplasty involves a patient population with a medical diagnosis of rheumatoid arthritis, osteoarthritis, severe comminuted fractures of the humeral head, avascular necrosis, irradiation necrosis, ochronosis, and gout. The most common indications for this particular procedure are patients with either osteoarthritis or rheumatoid arthritis. With shoulder arthritis the joint surface is destroyed, by wear and tear, inflammation, injury, or previous surgery. This type of injury to the joint makes the shoulder stiff and painful. Total shoulder arthroplasty is indicated when the patient has a severe decreased ability to perform activities of daily living due to decreased range of motion, and decreased strength, both due to a rapid increase in pain. Epidemiology: Even though the first TSA surgery took place in 1892, advanced techniques of the total shoulder arthroplasty procedure began in the early 1970’s. However this procedure did not become a routine surgical procedure until years later. Beginning in the early 1990’s approximately 20,000 total shoulder arthroplasty’s are performed each year. It was difficult to ascertain specific genders, age groups, work groups or races that are more likely to undergo this procedure, however, within the last decade few patients have elected to have the procedure outside the age range of 18 to 75 years of age. Of those patients over 90% are either pain free or significantly improved after surgery. It is not uncommon for patients to plateau at a shoulder range of motion less then that of their previous range of motion. In fact, achieving only two-thirds of full mobility after a total shoulder arthroplasty procedure is not unheard of. This can be attributed to, but not limited to, disruption of the normal geometric mechanics of the shoulder during the surgical process. Non-operative vs. operative management: Most often osteoarthritis of the shoulder is treated with non-steroidal anti-inflammatory drugs, such as aspirin, ibuprofen, or cox-2 inhibitors. Physical modalities and exercise can be used in conjunction with these medications to offer greater pain relief and maintain function. Rheumatoid arthritis of the shoulder can also require conservative measures such as medication to relieve the effects of RA, and it may require


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exercise training to increase function and physical agents to offer limited pain relief. If and when non-operative treatments for arthritis of the shoulder fail to relieve pain or improve function, total shoulder arthroplasty may possibly yield more effective results. In general, this surgery is elective, and can be performed whenever conditions are optimal. Occasionally pain and stiffness from the shoulder osteoarthritis will plateau at a level that is acceptable to the patient. In such cases the patient can delay surgery without compromising the potential for future surgery. However, in cases of rheumatoid arthritis, excessive delay may result in loss of tendon and bone, making surgery more difficult for the patient and the surgeon. Surgical repair is typically recommended for patients who expect to eventually return to a relative prior level of function. Risks can include, but are not limited to: infection, injury to the nerves and/or blood vessels, fracture, stiffness or instability of the joint, loosening or wear of artificial components, and increased pain and need for additional surgical procedures. Surgical Procedure: There are several surgical techniques used in regard to the components used in a total shoulder arthroplasty procedure. The constrained component used to be one of the gold standards for this procedure used mainly in the 80’s and 90’s. It was designed for patients who had severe deterioration without a reconstructible rotator cuff, but with a functioning deltoid muscle. With technological advancements the semi-constrained or monospherical component was produced. With this component the humeral head is smaller and spherical with a head-neck angle of 60 degrees and reportedly permitted increased range of motion. The glenoid component was matched to the humeral head prosthesis to allow for constant surface contact. Today the most extensively used component is known as an unconstrained component. This is used with a polyethylene glenoid component that conforms to the radius of the glenoid articulating surface. The unconstrained components have replaced the semi-constrained and constrained due to the problem of loosening of the latter two.

Due to the shoulders dependence on soft tissues, great care must be taken during total shoulder arthroplasty to preserve and/or restore as much soft tissue integrity as possible. The most common approach in use today is the anterior deltopectoral approach. The most notable advantage of this approach is that it preserves the anterior deltoid, the primary flexor of the shoulder, as well as the axillary and musculocutaneous nerves. The initial incision begins at the superior aspect of the clavicle, traverses the coracoid process, and extends down the anterior aspect of the arm. The cephalic vein is then identified and retracted laterally with the deltoid. This is followed by release of the upper portion of the pectoralis major tendon as well as the subscapularis tendon, which lies beneath. Subsequently, the joint capsule is reflected, and the humeral head is dislocated anteriorly via external rotation and adduction of the arm. The rotator cuff is inspected, and if any tears are found they can be repaired. Then the humeral head is resected along the anatomic neck and the medullary canal is reamed. Prior to placement of the humeral component, the glenoid fossa is debrided, reamed and fitted with a solid polyethylene glenoid component that is cemented in place. Once the humerus has been reamed and sized, a trial reduction is performed with various humeral head and neck sizes to obtain the best fit and appropriate soft tissue tension to balance and stabilize the shoulder joint. Once the correct sizes are determined, the humeral component can be press-fit or cemented into the humeral canal, and the appropriate head and neck component impacted onto the humeral component. The newly-replaced humeral component is then reduced back into the glenoid fossa and taken through a final range of motion to assess stability. The subscapularis tendon is secured back into place, and the wound closed.


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Preoperative rehabilitation:

• Maintain shoulder range of motion as able either actively or active assisted in supine to eliminate gravity as a possible shoulder irritant

• Sleeping in supine is encouraged. Do not sleep on the affected shoulder to avoid increased pain and irritation to the shoulder

• Continue use of anti-inflammatory and pain medication to offer maximal relief • Instructions/review post-operative rehabilitation plan

POSTOPERATIVE REHABILITATION Phase I: Immediate Post Surgical (0-4 weeks) Goals: Allow healing of soft tissue

Maintain integrity of replaced joint Gradually increase PROM of shoulder; Restore AROM of elbow/wrist/hand Diminish pain and inflammation Prevent muscular inhibition Independent with ADL with modification while maintaining integrity of the replaced

joint Precautions: Sling should be worn for 3 weeks for comfort

Sling should be used for sleeping and removed gradually over course of 4 weeks periodically throughout the day

While lying in supine place a small pillow behind elbow to avoid shoulder hyperextension avoiding stretching the anterior capsule and subscapularis

tendon Avoid shoulder AROM No lifting of objects No excessive shoulder motion behind back No excessive stretching or sudden movements (especially ER) No supporting of body weight by hand of involved side Keep incision dry and clean (no soaking for 2 weeks) No driving for 3 weeks

Criteria for progression to the next phase:

• Tolerates PROM program • At least 90° PROM flexion • At least 90° PROM abduction • At least 45° PROM of ER in plane of scapula • At least 70° PROM of IR in plane of scapula • Be able to isometrically activate all shoulder, RC, and upper back musculature


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Postoperative Day #1 Interventions (in hospital):

• Passive forward flexion in supine to tolerance • ER in scapular plane to available gentle ROM (approx 30°) • Passive IR to chest • Active distal extremity exercise (Elbow/wrist/hand) • Pendulum exercise to tolerance • Frequent cryotherapy for pain, swelling, and inflammation • Patient education regarding proper positioning and joint protection

Postoperative Days 2-10 Interventions (out of hospital):

• Continue above exercises • Assisted flexion and abduction in scapular plane • Assisted external rotation • Begin submaximal, pain-free shoulder isometrics in neutral • Begin scapular musculature isometrics • Begin active assisted elbow ROM – Pulleys (flexion and abduction) – if patient can

achieve ≥ 90° of PROM • Continue cryotherapy to tolerance for pain, and inflammation management

Postoperative Days 10-21 Interventions:

• Continue previous exercises • Continue to progress PROM as tolerated • Gradually progress to AAROM in pain free ROM • Progress active distal extremity exercise to strengthening as able • Restore active elbow ROM

Phase II: Early Strengthening (Weeks 3-6) Goals: Continue PROM progression and gradually restore full PROM

Gradually restore AROM Control pain and inflammation Allow continued healing of soft tissue Re-establish dynamic shoulder stability

Precautions: Sling should be used as needed for sleeping and removed gradually over the course of

the next two weeks, periodically throughout the day While lying in supine place a small pillow behind elbow to avoid shoulder

hyperextension avoiding stretching the anterior capsule and subscapularis tendon Begin shoulder AROM against gravity


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No heavy lifting of objects (no heavier than coffee cup) No supporting of body weight by hands and arms No sudden jerking motions

Criteria for progression to next phase:

• Tolerates P/AAROM isometric program • Has achieved 140° PROM flexion • Has achieved 120° PROM abduction • Has achieved 60° PROM ER in scapular plane • Has achieved 70° PROM IR in scapular plane • Able to actively elevate shoulder against gravity to 100°

Week #3 Interventions:

• Continue with PROM, AAROM, and isometric exercises • Scapular strengthening • Begin assisted horizontal adduction • Progress distal extremity exercise with light resistance as appropriate • Gentle joint mobilizations as able • Initiate rhythmic stabilization • Continue use of cryotherapy for pain and inflammation as needed


• Begin active forward flexion, IR, ER, and Abd in supine (pain free ROM) • Progress scapular strengthening exercises • Wean from sling completely • Begin isometrics of rotator cuff and periscapular musculature

Phase III: Moderate strengthening (weeks 6-12) Goals: Gradual restoration of shoulder strength, power and endurance

Optimize neuromuscular contro Gradual return to functional activities with involved upper extremity

Precautions: No heavy lifting of objects (no heavier than 5lbs)

No sudden lifting or pushing activities No sudden jerking motions

Criteria for progression to the next phase:

• Tolerates AA/AROM • Has achieved 140° AROM flexion in supine • Has achieved 120° AROM abduction in supine • Has achieved 60° AROM ER in plane of scapula in supine


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• Has achieved 70° AROM IR in plane of scapula in supine • Able to actively elevate shoulder against gravity to 120°


• Increase antigravity forward flexion, abduction as appropriate • Active IR and ER in scapular plane • Advance PROM as tolerated, begin light stretching as appropriate • Continue PROM as needed to maintain ROM • Initiate assisted IR behind back • Begin light functional activities


• Begin progressive supine active elevation (anterior deltoid strengthening) with light weights (1-3 lbs) and variable degrees of elevation

Week #10 – 12 Interventions:

• Begin resisted flexion, abduction, ER (using theraband / sport cords) • Continue progressing IR and ER strengthening • Progress IR behind back from AAROM to AROM as able

Phase IV: Advanced Strengthening (weeks 12 to 6 months) Goals: Maintain full, non-painful AROM

Enhance functional use of involved UE Improve muscular strength, power, and endurance Gradual return to more advanced functional activities Progress closed chain exercises as appropriate

Precautions: Avoid exercise and functional activities that place stress on anterior capsule and

surrounding structures (example: no combined ER and abduction above 80° abd) Ensure gradual progression of strengthening

Criteria for discharge from skilled therapy:

• Patient able to maintain full non-painful AROM • Maximized functional use of involved UE • Maximized muscular strength power, and endurance • Patient has returned to more advanced functional activities


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Week #12+ Interventions: • Typically patient is on a HEP 3-4x/week • Gradually progress strengthening program • Gradual return to moderately challenging functional activities

Selected References: Brems JJ. Rehabilitation following total shoulder arthroplasty. Clin Orthop. 1994;307: 70-85. Brown D, Friedman RJ. Postoperative rehabilitation following total shoulder arthroplasty. Orthop Clin North Am. 1998;29:535-547. Fehringer E, Kopjar B, Boorman R. Characterizing the functional improvement after total shoulder arthroplasty for osteoarthritis. J Bone Joint Surg. 2002; 1349-1353. Iannotti J, Norris T. Influence of preoperative factors on outcomes of shoulder arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg. 2003; 251-258 Karduna A, Gerald W, Williams J. Glenohumeral joint translations before and after total shoulder arthroplasty. a study in cadavera. J Bone Joint Surg. 1997; 1166-1172. Sanchez J, Sperling J, Rowland C. Instability after shoulder arthroplasty: results of a surgical treatment. J Bone Joint Surg. 2003; 622-631. Sperling J, Antuna S, Schleck C, Cofield R. Shoulder arthroplasty for arthritis after instability surgery. J Bone Joint Surg. 2002; 1775-1781. Wallace A, Phillips R, MacDougal G. Resurfacing of the glenoid in total shoulder arthroplasty. J Bone Joint Surg. 1999; 510-518.


Documents

Physical Therapy Protocols for Conditions of Shoulder Region