Week 11: Shoulder Part 3

What are key findings from the pt history (subjective exam that may lead you to lean towards gh instability as your primary hypothesis?

- apprehension w/ movements

- avoid end range positions

- trauma : FOOSH, blow to the shoulder

- general laxity

- previous dislocations

- scapular dyskinesia

- connective tissue disease

What type of dislocation is most common?

anterior

What position is typically most problematic for individuals with anterior instability?

abduction with external rotation

What feeling is usually described by the pt with anterior instability in the position of aBduction w/ ER?

feeling of apprehension/instability

What are the 3 classifications of instability?

1. traumatic

2. atraumatic

3. acquired

What are the key findings from the pt interview and physical exam that lead us to lean towards GH traumatic instability?

- presentation depends on Frequency, Etiology, Direction, Severity (FEDS)

- pain often generalized to shoulder, and to the particular tissues involved

- apprehension moving arm out away from the body

- increased mobility noted in the direction of the instability

What are the key findings from the pt interview and physical exam that lead us to lean towards GH atraumatic instability?

- pain generalized to the shoulder, and to the tissues that are aggravated by instability

- dysfunctional movement patterns

- often atrophy in shoulder

- general multi-joint hypermobility

What are the key findings from the pt interview and physical exam that lead us to lean towards GH acquired instability?

combination of traumatic and atraumatic findings

What is FEDS classification of shoulder instability?

- Frequency: how many episodes?

- Etiology: did you have an injury?

- Direction: what direction does the shoulder go out most of the time?

- Severity: have you ever needed help getting the shoulder back in the joint?

What are key findings from the physical exam that may lead you to lean towards GH instability as primary hypothesis?

- maintain protective posturing

- unable/unwilling to move into end-ranges

- weakness noted often in ABD/ER

- may have impaired sensation (axillary n. distribution)

- (+) instability tests

What is included in the test item cluster for anterior instability?

apprehension test, relocation test, surprise test

What is the most common position for a patient when sustaining a posterior shoulder dislocation?

IR, aDduction, flexion

What is a SLAP tear?

injury of the labrum at the attachment site of the LH of biceps

What are common MOI for SLAP tear?

FOOSH, shoulder dislocation, repetitive overhead activities

What is a common symptom for SLAP lesions?

painful clicking or popping

What is involved in a Type I SLAP tear?

fraying of the top limb of the labrum, but is still attached to the glenoid, symptoms may not be present

What is involved in a Type II SLAP tear?

labrum and biceps tendon detach from top of the glenoid

What is involved in a Type III SLAP tear?

bucket-handle tear, biceps tendon remains intact

What is involved in a Type IV SLAP tear?

bucket-handle tear to the top of the labrum with involvement of the biceps tendon

Which SLAP tear type is the most common?

Type II

Which SLAP tear type(s) are treated conservatively?

Type I, Type II (trending towards this approach)

Which SLAP tear type(s) are treated surgically?

Type II (trending away), III, IV

What is a Bankart lesion?

a tear that happens in the lower rim of the labrum

What is a Hill-Sachs lesion?

an indentation on the back of the humeral head

What is the most likely locations for a Bankart Lesion and Hill-Sachs Lesion following anterior dislocation of the GH joint?

anterior bankart, posterior Hill-Sachs

What is the most likely locations for a Bankart Lesion and Hill-Sachs Lesion following posterior dislocation of the GH joint?

Posterior Bankart, Anterior Hill-Sachs (reverse)

What is included in the posterior instability test?

Jerk Test

What is included in the labral tear tests?

Kim Test, Biceps Load Test II

Which two tests for posterior instability and labral tears combine to have a higher sensitivity?

Jerk and Kim test

What are the main goals of the acute phase of shoulder instability non-surgical rehab?

- reduce pain/inflammation

- promote healing, protect injured tissues

- prevent negative effects of immobilization

- re-establish baseline dynamic joint stability (motor control)

What are the interventions used for the acute phase of shoulder instability non-surgical rehab?

- immobilization

- PROM (protected range)

- submaximal pain-free isometrics

- dynamic stabilization (open and closed chain in protected positions

What are the main goals of the intermediate phase of shoulder instability non-surgical rehab?

- re-establish muscle balance and restore full AROM

- avoid apprehension

What are the interventions for the intermediate phase of shoulder instability non-surgical rehab?

- PROM and AROM to pt tolerance

- controlled strengthening early to mid-range

- advance closed chain activities

What are the criteria to enter the advanced phase of shoulder instability non-surgical rehab?

- full ROM all planes (90/90 w/o apprehension)

- minimal pain

- symmetrical capsular mobility

- 4/5 MMT throughout shoulder girdle

What are the main goals of the advanced phase of shoulder instability non-surgical rehab?

return to full activities, except higher level sports

What are the interventions for advanced phase of shoulder instability non-surgical rehab?

- low and high rep exercises

- incorporate co-contraction and dynamic stabilization to mimic higher level activities

- begin low intensity plyometrics

- ER near end-range movements

- advance closed chain activities

What are interventions for return to activity phase of shoulder instability non-surgical rehab?

- address specific needs to individual

- know the patient's goals

- sports and activity specific activities (ROM, strengthening, plyometrics)

A pt with shoulder pain presents with limited end.range shoulder IR. Assessment of GH Prom for IR reveals a hard end-feel. What should the normal end-feel be, and what plays a role in this end-feel?

Firm, posterior GH capsule

What manual therapy would you perform on a patient to increase GH IR?

posterior mobilizations

All shoulder end-feels are ________ due to capsule involvement

firm

How do you assess GH ROM?

stabilize the scapula

According to Reinold et al, which exercises are the best to activate the supraspinatus?

- full can

- prone full can

According to Reinold et al, which exercises are the best to activate the infraspinatus and teres minor?

- side-lying ER

- prone ER at 90° ABD

- ER w/ towel roll

According to Reinold et al, which exercises are the best to activate the subscapularis?

- IR at 0 and 90° ABD

- IR diagonal exercise

According to Reinold et al, which exercises are the best to activate the serratus anterior?

- push up w/ plus

- dynamic hug

- serratus punch 120°

According to Reinold et al, which exercises are the best to activate the lower trap?

- prone full can

- prone ER at 90° ABD

- prone horizontal ABD at 90° w/ ER

- bilateral ER

According to Reinold et al, which exercises are the best to activate the middle trap?

- prone row

- prone horizontal ABD at 90° w/ ER

According to Reinold et al, which exercises are the best to activate the upper trap?

- shrug

- prone row

- prone horizontal abd at 90° w/ ER

According to Reinold et al, which exercises are the best to activate the rhomboids and levator scap?

- prone row

- prone horizontal ABD at 90° w/ ER

- prone extension w/ ER

What is TUBS?

traumatic, unilateral, bankart, shoulder injury requires surgery

What is AMBRI?

atraumatic, multidirectional, bilateral, rehab, inferior

What is the current classification for shoulder surgery?

trauma, unidirectional

What type of surgery is performed for shoulder instability if needed?

capsulolabral repair

What are post-op management goals for anterior instability Phase 1?

- protect the repair

- decrease pain and inflammation

- minimize scapular dysfunction

- staged ROM goals

What are post-op management precautions for anterior instability Phase 1?

- do not exceed staged ROM recommendations

- no lifting

- immobilization for 4-6 weeks

What are post-op management goals for anterior instability Phase 2?

- decrease pain and inflammation

- staged ROM goals

- increase strength and endurance

What are post-op management precautions for anterior instability Phase 2?

- do not exceed staged ROM recommendations

- avoid activities in excessive ER

What are post-op management goals for anterior instability Phase 3?

- normal strength

- normal scapulohumeral rhythm

- staged return to activity

What are post-op management precautions for anterior instability Phase 3?

- continue to avoid unnecessary stress on the anterior capsule

- no plyos unless pt returning to this type of activity

What type of sling is used for posterior GH post-op management?

gunslinger position > prevents IR

What are post-op management goals for posterior instability POW 0-6?

AROM of distal extremity with arm in neutral

What are post-op management goals for posterior instability POW 6-12?

- IR w/ band from full ER to neutral

- ER w/ band from neutral to full ER

- prone horizontal ABD, limit to 45°

What are post-op management goals for posterior instability POW 13-18?

progress PRE's without limitations

What are post-op management goals for posterior instability POW > 18?

CKC (with body weight and sport specific strengthening

What are post-op management goals for posterior instability POW 4 months?

initiate interval throwing pattern to return to sport

What are post-op management goals for posterior instability POW 6 months?

return to play

What are main reasons for a Total Shoulder Arthroplasty?

- OA

- trauma

- humeral head fx

- severe rotator cuff arthropathy

- avascular necrosis

What is a shoulder hemi-arthroplasty?

only replace humeral head

What are main components for TSA post-op rehab Phase 1?

- wear sling for 3-4 weeks

- avoid stress on anterior capsule

- avoid extension, with IR and excessive ER

- avoid AROM, WB, lifting, or sudden movements

What are main components for TSA post-op rehab Phase 2?

- initiate AROM of flexion, IR, ER, ABD pain-free ROM

- begin submaximal shoulder isometrics in neutral

- scapular strengthening as appropriate

- initiate GH and ST stabilization

What are main components for TSA post-op rehab Phase 3?

- initiate assisted shoulder IR behind back stretch

- resisted shoulder IR, ER in scapular plane; flexion, ABD, extension

- begin light functional activities

What are main components for TSA post-op rehab Phase 4?

- AROM in all planes

- resistive exercises in pain free ranges

- perturbation training

- functional activities

What are TSA criteria for progression out of Phase 1?

- at least 90° PROM flexion ABD

- at least 45° PROM ER in scapular plane

- at least 70° PROM IR in scapular plane @30° of ABD

What are TSA criteria for progression out of Phase 2?

- tolerates PROM/AROM, isometric program

- PROM: 140° flex, 120° ABD, 60° ER in scapular plane, 70° PROM IR in scapular plane @30° ABD

- able to actively elevate shoulder against gravity with good mechanics to 100°

What are TSA criteria for progression out of Phase 3?

- tolerates AROM/AAROM/strengthening

- AROM: 140° flex, 120° ABD in supine, 60° AROM ER scapular plane supine, 70° IR in plane of scapula @30° ABD

- 120° active elevation against gravity

What are TSA criteria for progression out of Phase 4 and DC?

- independent w/ HEP

- 80% UE AROM non-painful

- full functional use of UE

- maximized muscular strength, power, and endurance

- patient returned to advanced functional activities

When is a shoulder reverse arthroplasty considered?

irreparable RC tear, complex fractures, failed TSA (especially when cuff is absent or deficient

What is different about the biomechanics of the shoulder after rTSA?

relies on increased moment arm of deltoid, less motion than TSA

What are main components of rTSA rehab early on?

- protect: sling 3-4 weeks, up to 6 weeks if revision for TSA

- no arm behind the back, no extension beyond neutral

- precautions often last about 12 weeks

- at 6 weeks, can initiate IR but w/ scapular elevation

What are main components of rTSA rehab POW 6-8?

- sumbax isometrics for rotation

- begin scapular and deltoid gentle strengthening and control

What factor influences regaining ROM in rTSA rehab?

ER strength (teres minor)

What amount of shoulder elevation and ER do you want to aim for during rTSA rehab?

120° elevation and 30° ER

What pre-disposing factor do all of the different shoulder repairs share in common?

arthritic changes

What are the differences in arthritic changes to help surgeons decide which shoulder arthroplasty to perform?

- rTSA: RC tissue integrity

- hemi: integrity of glenoid/humerus

- TSA: degenerative GH, but RC intact

What are the median nerve compression syndromes?

pronator teres, anterior interosseous nerve (AIN), carpal tunnel

What is pronator teres syndrome?

compression at ligament of Struthers, FDS arch or between 2 heads of pronator teres

What is presentation for pronator teres syndrome?

- pain and paresthesia in median nerve distribution including palmar branch

- non-localized forearm pain

- subjective complaints of weakness

- pain with activity, especially repetitive pronation/gripping

What clinically provokes pronator teres syndrome?

- resisted MF PIP flexion (FDS)

- resisted pronation with elbow extended and wrist flexed (PT)

- resisted elbow flexion at 12-135° of flexion (Ligament of Struther's)

What is AIN syndrome?

compression at the tendinous origin of the deep head of pronator teres

What are symptoms of AIN syndrome?

- no sensory complaints

- loss of FPL and FDP (2nd and 3rd digits)

- weak pronation: test with elbow in flexion (PQ)

What is carpal tunnel syndrome?

compression at the carpal tunnel

What are symptoms of carpal tunnel syndrome?

- pain and paresthesia in the distal median nerve distribution, spares the palmar branch

- nocturnal pain

- numbness in radial 3-5 digits (palmar side)

- atrophy of thenar muscles

- sensitivity to cold

What are the Wainner er all CTS rules?

- does shaking hands improve symptoms?

- Wrist Ratio Index > 0.67

- Symptom severity scale score > 1.9

- diminished median nerve distribution sensation of thumb

- age > 45

all 5+ = +LR of 18.3

4+ = +LR of 4.6

What are the ulnar nerve compression syndromes?

cubital tunnel, Guyon's canal

What is cubital tunnel syndrome

compression just posterior or distal to the medial epicondyle as ulnar n. passes through the 2 FCU heads, also compression may be at Arcade of Struthers

What are symptoms of cubital tunnel syndrome?

- sharp or aching pain at the medial side of the proximal forearm

- paresthesia's at the ulnar aspect of the hand

- provocation: elbow flexion for 1 minute

What is Zone 1 for Guyon's Canal Syndrome?

compression at wrist and proximal canal with both motor and sensory symptoms

What is Zone 2 for Guyon's Canal Syndrome?

compression at exit of the canal- only deep motor branch symptoms

What is Zone 3 for Guyon's Canal Syndrome?

compression at exit of the canal- only sensory branch symptoms

What are radial nerve compression syndromes?

Radial nerve palsy (Saturday night palsy), posterior interosseous (PIN), radial tunnel, Wartenburg