shoulder joint replacement (exam 2), shoulder pathologies/ rotator cuff and adhesive capsulitis (exam 2), Snap/subacromial impingement syndrome (SAIS) (exam 2), Shoulder (EXAM 2) SLAP lesion, Low Back Pain

what can cause the shoulder to need replacement?

osteoarthritis

rheumatoid arthritis

humeral fractures

types of medical management

hemiarthoplasty

total shoulder replacement (TSR)

reverse total shoulder arthroplasty (RTSA)

hemiarthoplasty

replaces femoral head

total shoulder replacement (TSR)

The procedure involves replacing the head of the humerus (the "ball") and the glenoid (the "socket") with metal and plastic parts

reverse total shoulder arthroplasty (RTSA)

- reverses the normal anatomic relationship between the humerus head and the glenoid socket

- A ball is placed onto the socket & a cup or socket is placed on top of the humerus in place of the ball

postoperative considerations

1) soft tissue healing and proaction of the glenohumeral alignment are critical

2) pain, edema, and inflammation managed with physician-directed modalities

3) use of shoulder in sling or swathe for 3-4 weeks, weight bearing restricted 6-8 weeks

shoulder replacement PRECAUTIONS

-NO WEIGHT BEARING with surgical UE

-no lifting > 1-2 lbs

- avoid abduction past 45 degrees

- avoid ER past 30-60 degrees

-avoid IR past 60 degrees

- limit passive flexion 90-100

(not active just passive)

t/f OT can begin day 1 post if medically stable

true

OT goals

-restore safe occupational performance

- train ADLs/IADLs with adaptive strategies

- EDUCATE on PRECAUTIONS

-progressive UE functional mobility and strength

eval and intervention

1) asses motor, cognitive, and emotional factors

2) focus on ADLs, adaptive equipment, and compensatory methods (ex, dressing stick, one handed techniques)

3) progress AROM, strength, and activity tolerance

phase 1 (0-4 weeks) PP PHASE

-PROM only, pendulum exercise

goals: protect repair, manage pain and edema, and prevent stiffness.

(PROM ONLY within surgeon defined limits

Movements are restricted to the following ranges: shoulder flexion up to 90-100°, abduction up to 45°, and ER up to 30°. IR is limited to placing the hand on the abdomen only.

Once cleared by the surgeon, do Codman's pendulum exercises (gentle circular or lateral motions)

encourage (AROM) of distal joints (elbow, wrist, and hand) to support circulation and prevent edema.

During rest, the shoulder should be maintained in a neutral alignment

phase 2 (4-6 weeks) AAROM, light isometrics

Active-assisted range of motion (AAROM) and light isometric exercises

introduce AAROM - AROM transition

( table slides, dowel exercises, and incline board pushing)

flexion tolerance may increase to 70° and ER to 60°.

Begin active-assisted exercise: (Overhead pulleys, wall slides, and supine dowel movements)

Light isometric exercises, such as scapular retraction, can begin as tolerated;

IMPORTANT: lifting and weight-bearing activities remain restricted at this stage.

phase 3 (6-12 weeks) STRENGTHEN

Gradual strengthening, closed-chain activities.

- Progress to light strengthening:

- scapular stabilization (elevation, depression, retraction).

- shoulder adduction, flexion, and rotation with light weights.

-Closed-chain activities (e.g., wall push-ups, prone-on-elbows).

-Restore functional motion through all planes.

phase 4 (12+ weeks)

Full AROM, return to occupations

reverse total shoulder replacement protocol

Used for rotator cuff-deficient

shoulders.

PROM limited to 45°

flexion/abduction, neutral external

rotation.

Begin pendulum exercises ~day 1.

AAROM starts around 7-10 days if

stable.

Full AROM expected by 12 weeks if

healing progresses.

RTSR PHASE 1 (0-2 WKS)

PROM (Flex less than or equal to 90, abd less than or equal to 45)

codeman's pendulums only with surgeon approval

AVOID: ADD+IR

RTSR PHASE 2 (2-6 wks)

Gentle AAROM; light deltoid/scapular isometrics;

ER less than or equal to 30°

RTSR PHASE 3 (6-12 wks)

Controlled AROM, light resistance (deltoid focus);

avoid resisted IR or extension

what is rotator cuff tears

reversible inflammation and microtearing (tendinitis/tendinosis) to partial or full-thickness disruptions of the tendon

Supraspinatus

initiates abduction

infraspinatous

external rotation

teres minor

assists with ER and humeral head stabilization

subscapularis

internal rotation an anterior stability

rotator cuff tears epidemiology

- most frequent cause of shoulder pain in adults

-40-70 yrs

-dominant shoulder affected > 60% of cases

- degenerative tears> traumatic tears in individuals >50

injury spectrum rotator cuff tear

intrinsic degeneration

extrinsic impingement

overuse and repetitive overhead activity

acute trauma

intrinsic degeneration

age related collagen disorganization, reduced vascular supply

extrinsic impingement

mechanical compression beneath the coraco-acromial arch or acromial spurs

overuse and repetitive overhead activity

micro trauma exceeding repair capacity

acute trauma

falls on outstretch hand or lifting injury in younger patients

classification types

tendinopathy

partial thickness tear

full thickness tear

massive tear

tendinopathy

degenerative changes without discontinuity of fibers

-pain with overhead use; strength preserved

partial thickness tear

incomplete disruption of tendon fibers on articular or bursal side

(1-3 cm)

-pain> weakness

night pain common

plain will be greater than weakness

full thickness tear

complete discontinuity from tuberosity insertion

weakness and drop arm sign

crepitus

(3-5)

massive tear

>5 cm or 2 tendons involved

-loss of active elevation

pseudo paralysis (because not necessarily of a nerve it is just because it is so weak)

rotator cuff tear clinical presentation

dull aching pain in lateral (supraspinatous tension is there) shoulder

night pain when lying on affected side (compression in adduction)

weakness with abduction/externla rotation

difficulty with ADLs (grooming, reaching overhead)

neers/hawkins-kennedy test

purpose: impingement screening

positive finding: pain elicited near end range flex/IR

Drop arm test

purpose: full thickness tear

positive finding: inability to control slow lowering

empty can (Jobe)

purpose: supraspinatus weakness

positive finding: pain/weakness in scaption

lift-off test

purpose: subs cap tear

positive finding: inability to lift hand from back

RTC rehab primary goals

-protect surgical repairs

- prevent selective capsular hypo mobility

- gradually restore neuromuscular control and function

RTC evidenced based framework

-early passive motion minimizes adhesions (avoid aggressive stretching)

-progression based on TISSUE healing, not a timeline

-frequesnt reassessment for signs of overload (night, pain, inflammation)

RTC phase 1 (0-6 weeks) PROTECTIVE/PASSIVE MOTION PHASE

-PP PHASE

-immobilization: spring 4-6 weeks with intermittent pendulums and PROM in pain free range

- emphasize postural correction and scapular setting

-PROM: begin flexion/scaption - progress to 90/90 ER by 4 wks

-AROM: NONE!! avoid active contraction of repaired tendon

-mods: cryotherapy 3xday/ IRF (currents) PRN (as needed) for pain

-precautions: no behind the back or unsupported bicep activity

-TE: Pendulums, wrist/hand mobility, sub-max pain-

free isometrics (Flex, Abd, IR, ER at 4-6 weeks).

RTC phase 2 (6-12 weeks) ACTIVE

Active-assisted to active motion

-initiate AAROM-AROM with emphasis on scapular mechanism

- begin isometric and light isotonic as tolerated

- avoid compensatory upper trap dominance

RTC phase 3 (12 + weeks)

- strength and function restoration

-progressive resistance exercises for RTC (progress dumbbells, theraband) and scapular stabilization

-integrate CKC (WEIGHT BEARING) and task specific training

-pain free ROM and > 4/5 strength

RTC phase 3 (12 + weeks) TE focus:

Scapulothoracic + GH exercise

• Isotonic IR/ER in scaption.

• Sidelying ER, rhythmic stabilization, OKC/CKC progression.

• Emphasize lower trap and serratus anterior activation.

• Perturbation training, 8 weeks unsupported biceps, lower trap exercises,

unsupported triceps

rtc prognosis

-small tears respond well to conservative management

-full-thickness repairs regain greater than or equal to 80-90% ROM and strength with compliance

-POOR outcomes associated with non-compliance, re-tear or persistent pain syndrome

-

adhesive capsulitis

it is characterized by progressive pain and loss of A/PROM due to capsular fibrosis and thickening

Primary (idiopathic) adhesive capsulitis

no known precipitating event, spontaneous onset of pain and stiffness

common in Middle Aged women without trauma

secondary adhesive capsulitis

occurs after shoulder injury or surgery associated with systemic or neurologic condition

-post RTC repair, fracture, stroke, or prolonged immobilization.

Clinical presentation of adhesive capsulitis (symptoms)

- gradual, insidious onset, night pain, stiffness

-pain localized anteromedially or into long head of biceps

Clinical presentation of adhesive capsulitis (AROM/PROM)

-Restriction (capsular pattern, ER/ABD/IR/FLEXION)

-substitution with scapular elevation

Clinical presentation of adhesive capsulitis (All limitation )

reaching overhead, grooming, dressing, fastening bra, throwing activities

what is KEY symptom in adhesive capsulitis

equal loss of active and passive ROM in a capsular pattern

Assessment: AROM/PROM comparison

purpose: determine global restriction

positive finding: similar limitation in both

Assessment: ER at 0 and 90 ABD

purpose: identify capsular pattern

positive finding: markedly limited ER

Assessment: Scapulohumeral rhythm observation

purpose: assess compensation

positive finding: excessive scapular elevation

Stages freezing (painful) stage

time frame: 10-36 weeks

process: synovial inflammation, capsular distension

clinically: severe pain, night pain, progressive loss of ROM

frozen (adhesive) stage

time frame: 4-12 months

process: fibroplasia, thickened capsule (contracture of coracohumeral ligament)

clinically: marked stiffness, pain subsides

Thawing (Recovery) Stage

time frame: 5-24 months

process: remodeling of collagen fibers and gradual restoration of motion

clinically: minimal pain, slow ROM return

therapeutic management for the freezing stage

goals: reduce pain/inflammation

MAKE AVAILABLE ROM without provoking symptoms

you can use ultrasounds, cryotherapy, IFC. then you can do grade 1 and 2 joint mobs, oscillations. for exercises you can do pendulum, table slides, wand ER to tolerance

educate on sleeping position and activity mods.

therapeutic management for the frozen stage

goals: increase capsular extensibility

restore functional ROM gradually

you can do grade 3-4 joint inferior and posterior mobs. to stretch you can do wand flexion, ER/IR at 90 degrees, and, posterior capsular stretch (slow prolonged holds for these) (moist heat pre stretch)

for strengthening you can do Isometrics, light isotonic for RTC and scapular stabilizers (cryotherapy post)

therapeutic management for thawing stage (resolution)

goals: regain full ROM and restore strength and endurance

reinstate functional movement patterns and participation

grade 5 joint mobs

advanced therEx: PNF DS patterns, wall slides, theraband series (emphasize eccentric control)

Functional retraining: reaching tasks, dressing simulation, work conditions.

management approach for adhesive capsulitis (NSAIDs/Corticosteroids)

pain dominate phase (short term pain relief combined with therapy)

management approach for adhesive capsulitis (manipulation under anesthesia MUA)

severe ROM loss > 6 mo

with this there is rapid ROM gain but risk capsular tear/fracture

management approach for adhesive capsulitis (arthroscopic capsular release)

failed conservative tx > 9 mo

high success when followed by intensive rehab

Type 1 (Scapular dysfunction kibler classifciatdon)

Interior angle dysfunction

Type 2 (Scapular dysfunction kibler classifciatdon)

Medial border dysfunction

Type 3 (Scapular dysfunction kibler classifciatdon)

Superior dysfunction

Type 4 (Scapular dysfunction kibler classifciatdon)

normal

type 1 Scapular dyskinesia info

-scapula inferior angel tilts posteriorly in sagittal plane

- increased in the hands on hips position or during eccentric lowering/control

TREATMENT: strengthen lower traps, stretch pec minor

type 2 Scapular dyskinesia info

-entire medial border winging off thoracic walls

- increased in the hands on hips position or during eccentric lowering/control

TREATMENT: strengthen the serratus anterior

type 3 scapular dyskinesia info

-excessive elevation of the superior border of the scapula with arm elevation

TREATMENT: inhibit UPPER TRAPS, STRENGTHEN LOWER TRAPS.

TREAT CAUSE: treat GH hypo mobility

instability

-hypermobility is NOT instability

- instability causes SYMPTOMS

-laxity is not the same as instability

-WE DONT TREAT LAXITY, we treat instability

clinical instability

Patient's inability to keep the humeral head centered in the glenoid fossa

functional instability

can be due to capsular/ligamentous instability

Generalized Ligamentous Laxity

Test

Beighton Scale

1. Hyperflexion of CMC and MCP Joint (Thumb

to Volar Wrist)

2. Hyperextension of 2nd MCP joint

3. Hyperextension of Elbows

4. Hyperextension of Knees

RTC impingement

Age: >40

Mechanism of Injury (MOI): Repetitive overhead activities, overuse of arm in unaccustomed position

Pain- night

Pain- lateral shoulder

Pain- Palpation

Pain- overhead activities

Painful arc (0-45 degrees is painless, 45-120 degrees IMPINGEMENT SYNDROME)

note* 120-170 painless, 170-180 (acromio-clavicular joint arthritis)

types of impingement syndromes

-primary (hypo mobile)

-secondary (hypermobile)

-internal

subacromial space

space between the humeral head and coracoacromial arch

structures at risks- supraspinatus, long head of bicep, subacromial bursa

T/F upward rotation/posterior tilt protect the subacromial space

true

Primary (hypo mobile)

bursal side (superior surface/top)

typically older than 40 years old

-STRUCURAL NARROWING ( acromion type, osteophytes

TREAT cause: mobilize joint, restore posture, progressive exercise

The rotator cuff tendons (especially the supraspinatus) are mechanically compressed under the acromion, coracoacromial ligament, or acromioclavicular (AC) joint during arm elevation.

Usually due to bony changes or degenerative anatomy (degenerative changes).

Contributing factors:

Acromial shape (hooked or curved acromion)

Bone spurs

Thickened coracoacromial ligament

AC joint osteophytes

secondary (hypermobile)

articular side (age 15-40)

INSTABILITY and LAXITY

DO NOT stretch, focus on DYNAMIC stabilization and neuromuscular control

Description:

Occurs due to glenohumeral joint instability (excessive humeral head translation) that reduces the subacromial space during motion.

The issue is not bony but due to muscle imbalance, weakness, or poor motor control of the rotator cuff and scapular stabilizers

Common in: Younger, more active individuals or athletes.

Contributing factors:

Scapular dyskinesis

Weak rotator cuff or scapular stabilizers

Capsular laxity

Poor posture or repetitive overhead activities

internal impingement

articular side, posterior cuff contact with glenoid rim

Cause: Posterior impingement of rotator cuff tendons inside the joint.

Description:

The undersurface (articular side) of the supraspinatus and infraspinatus tendons are pinched between the humeral head and the posterior-superior glenoid rim during extreme abduction and external rotation (e.g., throwing motion).

Common in: Overhead athletes (e.g., baseball pitchers, swimmers).

type 1 acromion shape

flat- 91% success rate

type 2 acromion shape

smooth curve- 66% success rate

type 3 acromion shape

anterior hook- 50% success rate (posible surgical cases)

NEER classification (rotator cuff impingement stage) stage 1

edema and hemorrhage (good)

age less than 25

REVERSIBLE

pain with overhead activity

inflammation of bursa

NEER classification (rotator cuff impingement stage) stage 2

fibrosis and tendonitis (bad)

age 25-40

thickened bursa/tendon

recurrent pain

night pain

needs meds

inflammation of tendon

NEER classification (rotator cuff impingement stage) stage 3

bone spurs and ruptures (ugly)

greater than 40 years old

-not all full thickness require repair

rupture

t/f Subacromial pressure increase with IR, decrease with ER

true

Internal rotation (IR) rolls the greater tuberosity of the humerus upward and closer to the acromion.→ This narrows the subacromial space and increases pressure, compressing the supraspinatus tendon and bursa.

External rotation (ER) moves the greater tuberosity away from the acromion.→ This widens the subacromial space and reduces pressure, relieving impingement.

strengthening ER at __ degrees reduces pressure

0

SAIS clinical presentation

Painful arc: 60°-120° abduction

• Lateral shoulder pain; night pain

• Pain on palpation & overhead activity

• Weakness due to pain inhibition

• Functional impact: reaching, dressing, lifting, typing

• dentify if hypomobile (stiff/painful) or hypermobile (unstable/fatigued)

differential diagnosis

RTC tear - Weakness > pain

Biceps tendinopathy - Pain with

resisted supination

Adhesive capsulitis - Global

restriction

SAIS intervention phase 1

Goals: Decrease pain, maintain mobility

Modalities: Ice, ultrasound, kinesiotaping

Pendulum, gentle PROM

Postural correction & ergonomics

Avoid overhead/provocative tasks

Primary: gentle mobility

Secondary: stabilization only

SAIS intervention phase 2

Goals: Restore dynamic stability & strength

• Scapular stabilization: wall slides, serratus punches, prone retraction

• RTC strengthening: ER/IR with bands, sidelying ER

• Posterior capsule stretching

• Add rhythmic stabilization, proprioceptive drills

Isometric dynamic endurance progression

SAIS intervention phase 3

Goals: Reinforce coordinated functional movement

Combine core + scapular activation (planks, quadruped reaches)

Simulate occupational tasks (reaching, typing, lifting)

Ergonomic & joint protection education

Gradual overhead retraining

What is the purpose of the glenoid labrum?

it is a ring of tough fibrous cartilage that surrounds the glenoid fossa. it deepens it to create a more secure fit

and for stability

the biceps long head anchors at the?

superior labrum

Wha can detach the labrum

excessive traction or compression

A healthy labrum

supports overhead stability