MSK 3: Shoulder Intervention

SAPS: is surgery indicated?

No- PT is just as effective

SAPS: interventions

1.) RTC and scapular strengthening/stabilization/endurance training

2.) GH posterior/inferior shoulder/thoracic manual

3.) stretching: pecs, lats

-address GIRD

-normalize scapulothoracic motion via stretching and thoracic extension/rotation ROM

-neuromuscular control of shoulder in neutral —> progressing to ABD+ER positions and core

-activity modification

-STM for posterior shoulder tightness superior to stretching alone

T/f passive modalities are not as helpful for SAPS

True

Why are ER resistance exercises for SAPS frequently done with a towel to bring arm into slight ABD?

-enhanced vascularity

-increased EMG of teres minor and infraspinatus

T/f a program with low load does not appear to be superior for SAPS

True

SAPS: purpose of injections

-facilitate adherence with exercise but do not improve SAPS outcomes

T/f STM for posterior shoulder tightness was superior to stretching alone in overhead athletes with SAPS

True

T/f there is low evidence for short-term effects of dry needling on SAPS posterior shoulder tightness

True

Is PT or surgery recommended for an atraumatic/degenerative small/medium full-thickness RTC tear?

-PT is effective; no difference between PT and surgery for pain and function at 2 years, but surgery is superior at 10 year follow up

-response to conservative treatment should occur in 1st year, otherwise patient could benefit from surgery

-surgery is favorable in young, active patients

-patient expectations were the greatest predictor of success with PT

T/f in patients with atraumatic/degenerative small/medium full-thickness RTC tear, patient expectations were the greatest predictor of good outcomes with PT

True

What PT tx is recommended for atraumatic/degenerative small-medium full-thickness RTC tear?

-same as SAPS- evaluate and treat impairments

-RTC and scapular strengthening/stabilization/endurance

-posterior/inferior GH shoulder mobility: manual therapy thrust/non-thrust, STM

-stretching: pecs, lats

-neuromuscular control in neutral —> ABD+ER, core

-activity modification

-consider towel at side for strengthening to enhance vascularity and TMinor EMG

Surgery vs. PT for atraumatic/degenerative large-massive full-thickness RTC tear

-PT is favored, evidence is growing

-rehab focus on strengthening deltoid and remainder of RTC (TMinor, subscap)

-goal is to be functional with ADLs, low demand activities

-if PT does not meet patient’s fxal goals, consider reverse TSA

What should you consider when determining if a patient with an atraumatic/degenerative large-massive full-thickness RTC tear should get a reverse TSA?

Does PT meet the patient's functional goals?

Adhesive capsulitis: stage I/II goals

-pain reduction, reduce fear avoidance, encourage movement

-4 key interventions: edu on clinical course, intra-articular steroid injection, exercise and manual (grade I-II), supervised neglect

Adhesive capsulitis: stage I/II treatment

1.) edu: positions of comfort for sleeping and iADLs, encourage to remain active, controlling A1C levels (DM), importance of sleep, nutrition, and stress reduction

2.) intra-articular injections: short-term improvement, PT+injection > injection > PT alone

3.) exercise (and supervised neglect): stretching matched to tissue irritability

4.) supervised neglect is an option, and encouragement to start PT once pain is reduced

-CBT if central sensitization/nociplastic

Examples of matched exercises for stage I/II adhesive capsulitis:

-low grade physiological P/AAROM within painfree ranges

-wand/cane/ball exercises

-Codman's Pendulum

T/f you can use CBT for patients with nociplastic adhesive capsulitis presentation

True

Adhesive capsulitis: stage III/IV goal

-ROM restoration

Adhesive capsulitis: stage III/IV interventions

-grade III/IV joint mobilization to GH to reduce pain and increase ROM

-stretching determined by P's irritability level

-neuromuscular/motor control to restore normal scapulothoracic motion

-strengthening in available pain-free ROM

First time anterior GH dislocation: intervention based on age

-<25 y/o: surgical repair of instability

-25-40 y/o: PT 1st (3-6 months), if symptoms persist refer to imaging

->40 y/o: rule out full thickness RTC tear

Why is surgery is the best option for young patients engaged in high demand activity who have a first time anterior GH dislocation?

High recurrent dislocation rate with PT; should get Bankart repair

Prognostic tools to assess risk of recurrent anterior GH dislocation:

-PRIS: recurrent instability following 1st time dislocation

-NSIS: successful non-operative management in HS athletes

First time anterior GH dislocation: intervention options

-first immobilize 7-10 days

-motor control exercises are best matched tx: including proprioception and neuromuscular control > just strengthening

-injury prevention and return to high demand activities: sport-specific strengthening and body mechanics, trunk and kinetic chain movements

-surgical repair of Bankart lesion 1st-line with recurrence (failed tx) or in young individuals involved in high-demand activity

First time anterior GH dislocation: recommended exercise progression (SINEX)

-phase 1: protect and WBing for co-contraction

-phase 2: progressive ROM and continued RTC strengthening in sx-free range (flexion —> scapular plane —> ABD)

-phase 3: restoration of fx (6-12 wks) via more challenging WB and strengthening RTC in higher risk positions, open chain

-phase 4: higher level functional progression, such as dynamic stability, plyo, and sport-specific exercises

Posterior GH dislocation: recommended tx

-same as First time anterior GH dislocation without immobilization phase

-1st strengthening and proprioception in loose pack positions / scapular plane avoiding end-ranges (safest to start in ABD/ER positions)

T/f surgical repair of Bankart lesion 1st-line with recurrence (failed tx) or in young individuals involved in high-demand activity

True

What position is safest to start strengthening in initially for anterior and posterior dislocations respectively?

-anterior: safe to start in flexion —> scapular plane —> ABD

-posterior: safe to start in ABD+ER

What is the recommended tx for multi-directional instability?

-research says surgery is no better than PT

-motor control program involving scapular positioning and training, consistent with anterior GH dislocation SINEX

Why is a strengthening + motor control program required for PT tx of multi-directional instability?

-requires a lot of strength and motor control to reduce instability d/t laxity

T/f PT is the preferred treatment for unidirectional and multidirectional atraumatic instability

True

T/f SLAP tears usually occur with atraumatic instability, and therefore usually in younger people

True

SLAP: PT vs. surgery

-rehab to address contributing impairments (GIRD, RTC weakness) is recommended at least 6 months- see intervention for anterior instability (SINEX)

-PT is just as good as surgery in mid-older patients (age 40)

-RTS outcomes similar surgery vs. rehab

T/f RTS outcomes are similar for SLAP tear surgery vs. rehab

True

SLAP: recommended interventions

Address patient-specific impairments:

-shoulder IR (GIRD), horiz. ADD ROM

-endurance for neuromuscular control

-scapular and RTC strength (consistent with anterior dislocation/instability)

GH OA: recommended intervention

-little/no evidence for PT, NSAIDs, injections

-may trial PT to increase mobility and reduce pain via manual, therex, activity modifications

-surgery: TSA

What surgery is recommended for RTC tear with GH OA?

Reverse TSA

AC Joint Sprain: recommended interventions

-ice to reduce pain/swelling

-rest and sling (1-2 wks) until pain subsides

-pain/anti-inflammatory meds

-weeks 1-4: restore normal resting posture by reducing scapular depression/protraction

-neural mobility

-manual for surrounding hypomobility and pain: thoracic, scapulothoracic, GH

-low grade exercise to restore normal motion and strength as soon as tolerated, then progress

T/f most grade I-III AC jt separations are successfully treated with non-operative mgmt

True

AC Joint Sprain: prognosis

-varies 2-3 months depending on grade

-grade 1: 2 wks

-grade 2: 6 wks

-grade 3: up to 12 wks

AC Joint OA: surgery vs. PT

-prefer conservative tx with injection, PT, activity modification

-if persistent pain despite PT, consider surgery for AC joint resection

AC Joint OA: recommended interventions

-injection

-activity modification

-PT to address AC and GH hypomobility (anterior, posterior, caudal AC mobilizations for pain/mobility)

-address individual impairments: consider GH ROM/strength deficits, scapulothoracic and kinetic chain impairments (ex. farmers carry)