Shoulder Conditions and Management

what is the STAR-shoulder framework?

subacromial px syndrome, adhesive capsulitis, instability, other

what does SPS = to with ICF language and guide interventions?

shoulder px and mm performance deficits

what does adhesive capsulitis = to with ICF language and guide interventions?

shoulder px and mobility deficits

what does instability = to with ICF language and guide interventions?

shoulder px and motor coordination deficits

what is subacromial px syndrome history and symptoms?

anterior/lateral shoulder px, px with motion > shoulder height, px with midrange AROM, hx of overuse, pain incr at night

what are the objective findings with subacromial px syndrome?

no apprehension/nosignificant loss of PROM, px with resisted ER, (+) special tests for long head of biceps tendon lesions, post shoulder tightness/GIRD, pec minor tight/short, scap stabilizer mm imbalances, associated T/S position/mobility deficits

what structures might be involved with subacromial px syndrome?

supraspinatus, infraspinatus, subscapularis, bursa, inf aspect of AC jt ligament, long head of biceps tendons, SLAP lesion

what is the SPS cluster?

neer, hawkins, jobe/empty can, px with resisted ER, painful arc

what are the SPS special tests designed to do?

reduce subacromial space

what are interventions for SPS?

gradual progressive resisted exer targeting RTC mm (post), scap stabilizers, pec minor length, manual therapy (STM, jt mobs to post shoulder)

when is surgery used for SPS?

when non-operative tx has been exhausted and ineffective

what is the rehab process for SPS arthroscopic subacromial decompression with acromioplasty?

non specific structures require protection, guided by tissue irritability, progress through AAROM/AROM/resisted, 6wks-3mo recovery

what does the treatment of RTC tears depend on?

mechanism and size

what population is atraumatic RTC tears more common in?

adults > 60 yo

t/f: atraumatic RTC tears are a red flag

false, traumatic RTC tears are (men = traumatic = red flags)

what are interventions for small/medium non-operative RTC tears?

same as SPS (work on post shoulder tightness, incr strength with focus on balance of forces or ERs and scap stabilizers)

what are interventions for large/massive non-operative RTC tears?

strengthen deltoid and remaining intact RTC muscles to gain functional elevation ROM

what is Phase I of RTC small/medium repair?

(0-8 wks) AAROM of shoulder begins 2-4 wks per tolerance, progress 0-90 elevation, 0-30 ER

what is Phase II of RTC small/medium repair?

(7-12 wks) active ROM, gradual progression AA to full ROM, gradual mm activation

what is Phase III of RTC small/medium repair?

(12-20 wks) endurance, progress to mm performance, AA to active against gravity, progress to full controlled AROM

what is Phase IV of RTC small/medium repair?

(>20 wks) strengthening, overhead work, sports, loading activities progressed cautiously, limit fatigue, monitor pain, motor control

what is Phase I of RTC large/massive repair?

(0-8 wks) passive/assisted, being shoulder ROM weeks 5-8 (0-90 elevation, 0-30 ER)

what is Phase II of RTC large/massive repair?

(7-12 wks) active, gradual progression of AA, active to full ROM beginning week 8

what is Phase III of RTC large/massive repair?

(12-20 wks) endurance, progress to mm performance; AA to active against gravity, progress to full controlled AROM

what is Phase IV of RTC large/massive repair?

strengthening, overhead work, sports, loading activities progressed cautiously, limit fatigue, monitor px, motor control

what is the hx and symptoms of long head biceps tendinopathy?

ant px isolated to long head of biceps in groove, px with shoulder flexion and arm supination, overuse

how is long head biceps tendinopathy managed?

same as SPS, ecc loading to biceps

what population is posterior internal impingement common in?

throwing athletes

what is the MOI of post internal impingement?

RC folds in on itself and gets caught between humeral head and post/sup aspect of glenoid rim

where is there pain with post internal impingement?

post shoulder px with shoulder aBD/ER

what test best detects post internal impingement?

neer

how is post internal impingement managed?

same as other SPS

what test offers relief with post internal impingement?

relocation test

where is there px with adhesive capsulitis?

anterior/lateral shoulder

what population is there a higher prevalence of adhesive capsulitis?

females 40-65, diabetes, hypothyroidism

what are the 4 stages of adhesive capsulitis?

prefreezing, freezing, frozen, thawing

what is secondary adhesive capsulitis d/t?

prolonged immobilization

what are the objective findings of adhesive capsulitis?

global and progressive loss of AROM and PROM; incr px with end range; capsular pattern ER>aBD>IR

what pathologies mimic adhesive capsulitis?

infections, septic arthritis, malignancy, inflammatory arthropathy (polymyalgia rhuematica)

what are interventions used for adhesive capsulitis?

px science ed, behavior change, activity mod, determine irritability, physical agents, jt mobs, PROM, ROM exer, intra-articular steroid injection

what are surgical options for adhesive capsulitis surgery?

releasing scarring through mechanical manip, injection of fluid, resection of scar

what are post-op considerations with adhesive capsulitis?

sling, frequent motion and activity, gain full ROM ASAP

what is the hx and symptoms of instability/labral tears?

age <40, hx of disloc/sublux, generalized systemic laxity, anterior shoulder px, apprehension/pain in end range, anterior/inferior trauma, joint clicking/clunking/locking, hx of dead arm syndrome

when there is apprehension/px with aBD/ER positions, where is there instability?

anterior

when there is apprehension/px with flex/aDD/IR positions, where is there instability?

posterior

what are SXS of a SLAP lesion?

deep ant px; clicking/clunking/locking, px with throwing, px with loading biceps, deceleration injury

what are the objective findings of instability/labral tears?

+ apprehension (ant/post) and relocation tests; GIRD, post shoulder tightness

what are common complications of instability/labral tears?

glenoid or greater tuberosity fx, RTC tear, brachial plexus involvement

what is a bankart lesion?

avulsion of anterior band of inferior GH ligament along with labrum

what is a bony bankart lesion?

avulsion of ant band of inf GH ligament along with labrum + avulsion fx of ant glenoid

what is the function of the inferior GH ligament?

main stabilizer resisting inferior translation and anterior translation at 90 aBD + ER

what are interventions for instability/labral tears?

depends on subgroup, px science ed, help pt identify safe ROM to improve confidence

what are specific interventions for traumatic labral tears/instability?

early activation of RTC/scap stab mm (isos), regain ROM as comfort permits, progress to midrange/more provocative positions, scapular setting, GHJ setting, GH proprioception, PNF, closed kinetic chain, dynamic stability

what are specific interventions for atraumatic labral tears/instability?

scap stabilizer neuromuscular control, RTC mm strengthening and neuromuscular control, breakdown movements/exer into parts and then put them together

what is a common theme with labral tear surgery?

limit ant capsule stretching first

what is Phase I of labral tear surgery intervention?

(0-6 wks) AA to AROM beginning 0-3 wks, progressing til wk 6 (flex 0-135, ER at side 0-30, wk 6: 90 aBD, max ER ROM = 45)

what is Phase II of labral tear surgery intervention?

(2-12 wks) AROM progressed to functional as tol, begin OKC and CKC scap stab and RTC exer, emphasize uniplanar, endurance, stability, motor control

what is Phase III of labral tear surgery intervention?

(12-24 wks) no limit to comfortable ROM, adv to multiplanar, con/ecc loading

what is Phase IV of labral tear surgery intervention?

(> 24 wks) loading gradually progressed to sport/work

what is the latarjet procedure used for?

instability combined with soft tissue pathology and bone loss → transfer bone off distal end of coracoid to ant glenoid

how long is someone immobilized with latarjet procedure?

1-4 wks

when does ROM begin with latarjet procedure?

wk 1 and focus of wks 0-6 for bone healing

how long is ER restricted with latarjet procedure?

6 wks

when is strengthening initiated with latarjet procedure?

wk 6-8, progressed to wk 12

what is the MOI of traumatic AC joint injury?

FOOSH, blow to top of shoulder or AC jt (fall to side)

what is the MOI of atraumatic AC joint injury?

OA

what is type I AC jt sprain?

ligament stretched, joint stable

what is type II AC jt sprain?

AC ligaments torn, coracoclavicular ligaments stretched

what is type III AC jt sprain?

all ligaments torn (separation of A&C)

what is type IV AC jt sprain?

posterior disloc of clavicle (clavicle goes through trapezius mm)

what is type V AC jt sprain?

greater displacement of clavicle

what is type VI AC jt sprain?

AC and CC ligament rupture with clavicular displacement (RARE)

what are the special tests for AC jt lesion?

obriens active compression, hor aDD

when is a step deformity seen?

grades III and up of AC jt sprain

what are the SXS of AC joint sprains?

px at end collar bone, swelling, difficulty with shoulder mobility

type I AC jt sprain intervention?

self limiting injury, resolution in 7-10 days

type II AC jt sprain intervention?

brief immobilization (1-3 wks), PROM/AROM, restore normal arthrokinematics, progressive resist

what are interventions for AC jt OA?

address mobility deficits in AC jt, progressive resistance

phase I AC jt reconstruction?

(0-4 wks) sling, reduce loading, promote healing

phase II AC jt reconstruction?

(4-12 wks) AAROM, strengthen ER/IR, flexion/aBD to 90

phase III AC jt reconstruction?

(12-24 wks) functional training, sport/occupational specific activities

GH OA hx/symptoms?

age > 60, px (esp with compression), stiffness, mild to mod ROM loss, hx of adhesive capsulitis

GH OA interventions?

pt ed on jt protection, activity mod, gentle ROM/stretching, general shoulder strengthening, scap stabilizers, corticosteroid injection, oral meds

what is GH OA surgery determined by?

degree/location, age, pt demand, underlying pathology, presence of intact RTC, adequate bone, surgeon experience, rehab expertise

when is a reverse shoulder arthroplasty (RSA) indicated?

massive or irreparable RTC/RTC deficiency

RSA improves ___ and decreases ___

function, pain

what is a common complication of RSA?

disloc secondary to massive RTC deficiency and lack of stability in GHJ

what is needed to get RSA?

deltoid function

phase I RSA/TSA?

(0-6wks) PROM, AAROM flex 0-90, ER 0-20; RSA → 120 by 4-6 wks

phase II RSA/TSA?

(6-12 wks) AAROM progressed 120-130, ER 0-30, IR hand to hip; RSA → AROM wk 4, deltoid isos

phase III RSA/TSA?

(12-16 wks) no ROM limits, low loading mm performance exer for TSA below 90, gradual progressing of light deltoid exer for RSA

phase IV RSA/TSA?

(16-20 wks) loading progressed cautiously; monitor motor control, px, return to fxn, full ROM, focus on endurance

what nerves are commonly involved with brachioplexus neuropathy?

thoracodorsal, axillary, musculocutaneous, suprascapular, long thoracic

SXS of brachioplexus neuropathy?

burning sensation UE, dead arm, no dermatomal/peripheral pattern, atrophy, dropping items, difficulty with overhead and cramping of hands with writing

what populations commonly have brachioplexus neuropathy?

athletes, post radiation breast CA

where does TOS occur?

region along pathway of brachial plexus from just distal to nerve roots exiting the intervertebral foramen to lower border of axilla

what structures are involved with TOS?

ant scalene, subclavian artery, posterior/med scalene, brachial plexus

t/f: if SXS do not follow dermatome/myotome or local nerve patterns, suspect TOS

true

what are itnerventions for TOS?

NSAIDs, avoid aggravating activities, resolve impairments, stretch structures that produce SX gently, strengthen scap stabilizing mm

what special tests are used for TOS?

adson's, costoclavicular