Orthopedic Considerations of the Shoulder

ORTHOPEDIC CONSIDERATIONS: THE SHOULDER

CH 23: MUSCULOSKELETAL

SHOULDER

  • Functions of the Shoulder:

    • Reaching Tasks: Essential for activities requiring arm extension.

    • Support, Stabilizing, or Transporting Tasks: Involves the shoulder providing the base for arm movement and control.

    • Proximal Stabilization Allowing for Distal Movement: Stabilization of the shoulder girdle is crucial for effective distal (hand/arm) movements.

    • Funneling of Force to Accelerate and Project Limb: Necessary in activities such as throwing.

    • Supporting Body Weight: In activities such as leaning or rising from a seated position.

ANATOMY AND BIOMECHANICS

  • Shoulder Complex:

    • Consists of three bones: Clavicle, Scapula, and Humerus.

  • Synovial Joints:

    • Glenohumeral Joint (GHJ): The main shoulder joint allowing for a wide range of motion.

    • Acromioclavicular Joint (ACJ): Joint at the top of the shoulder.

    • Sternoclavicular Joint (SCJ): Connection between the sternum and clavicle.

  • Scapulohumeral Rhythm:

    • Describes the coordinated movement between the humeral movements at the GHJ and the scapular movements.

    • Important prime movers of scapular movements can be referenced in Table 23-2 Page 602.

MUSCLES OF ROTATOR CUFF - SITS

  • SITS Muscles:

    • Supraspinatus: Responsible for humeral abduction and is most active in the first 15 degrees of shoulder movement.

    • Infraspinatus: Contributes to external rotation and stability of the shoulder.

    • Teres Minor: Aids in external rotation of the arm.

    • Subscapularis: Facilitates internal rotation of the humerus.

COMMON SHOULDER CONDITIONS

  • **Pathologies of Shoulder:

    • Sudden Trauma

    • Repetitive Trauma (Overuse Injury)

    • Age-Related Deterioration

    • Disease-Related Degeneration**

SHOULDER INSTABILITY

  • Unstable GHJ (Glenohumeral Joint):

    • Instability arises from an imbalance of muscles around the joint.

    • Common in clients with hyperlax joints or loose ligaments.

    • Causes of Instability: Primarily due to trauma from falls, sports, or work-related incidents.

    • Ranges from Mild Slipping to Complete Dislocation: Known as subluxation.

    • Surgical Treatment: Involves tightening the GH capsule; occupational therapy assists in minimizing stress and promoting normal kinematics while preventing adhesions.

SHOULDER IMPINGEMENT

  • Condition characterized by: Mechanical stress on tissues that exceed tensile strength.

  • Effects can range from degenerative inflammation to partial or complete tears of tendons.

  • Repetitive Strain: Leads to microtears and inflammation (tendinitis).

  • Possible outcomes include Impingement Syndrome or Bursitis.

ROTATOR CUFF TEAR

  • Tears typically involve: Supraspinatus or Infraspinatus.

  • Acute or Chronic Presentation:

    • Types of tears include full or partial tears.

    • Microtears can progress to larger tears, which tend to be chronic.

    • Acute tears often result from specific trauma events (e.g., FOOSH - falling on outstretched hand).

CALCIFICATIONS/OSSIFICANS

  • Common Condition: Associated with tendons of Supraspinatus and Infraspinatus.

  • Symptoms and effects can mimic those of rotator cuff injuries or tears.

OTA INTERVENTIONS FOR ROTATOR CUFF

  • Acute Management of Inflammation:

    • Use of cryotherapy (ice) to reduce swelling and pain.

    • Treatment Protocols:

    • Passive Range of Motion (PROM) exercises:

      • Codman's Exercises (Pendulums): Gentle swinging motion for relaxation and pain relief.

    • Isometric Exercises: To maintain muscle strength without causing further injury.

    • Strengthening Exercises: Gradually reintroducing resistance training.

ADHESIVE CAPSULITIS

  • Often referred to as “Frozen Shoulder.”

  • Caused by inflammation of the synovium, leading to fibrous tissue development.

  • Treatment Options:

    • Modalities including heat.

    • PROM in all ranges to the client’s tolerance.

    • Surgery is a last resort.

    • Importance of keeping the joint moving.

SHOULDER FRACTURES

  • Most common type: Proximal Humerus Fracture.

  • Often results from FOOSH injury.

  • Treatment:

    • May require surgical intervention depending on the nature of the fracture (displaced vs. non-displaced).

    • ORIF (Open Reduction and Internal Fixation) may be necessary.

    • Rehabilitation Considerations:

    • Complex fractures may necessitate a sling for 4-6 weeks.

    • Non-displaced fractures may need 1-3 weeks of immobilization.

BRACHIAL PLEXUS INJURIES

  • Most Common Cause of Injury: Trauma affecting the brachial plexus originating from spinal nerves C5-T1.

  • Results in:

    • Paralysis of various arm/hand muscles.

    • Pain and sensory impairments.

CERVICAL RADICULOPATHY

  • Involves compression of spinal roots originating in the neck region.

  • Symptoms include:

    • Pain radiating from the neck down to the upper back or arm.

    • Weakness in shoulder and arm muscles.

    • Trigger points or tender spots may form.

    • Potential need for referral to specialists.

TOTAL SHOULDER ARTHROPLASTY

  • Types of Arthroplasty:

    • Total Shoulder Arthroplasty (TSA)

    • Reverse Total Shoulder Arthroplasty (RTSA)

  • Involves replacement of the humeral head and glenoid fossa.

  • Causes for Replacement:

    • Arthritic conditions or severe fractures.

MEDICAL AND SURGICAL MANAGEMENT OF SHOULDER CONDITIONS

  • Conservative Management: Used when benefits clearly outweigh risks of surgery.

    • Includes:

    • Home Exercise Programs (HEP)

    • Over-the-counter (OTC) medications

    • Therapy: Rest, immobilization, and modalities.

    • Range of Motion (ROM) exercises.

MEDICAL AND SURGICAL MANAGEMENT CONTINUED

  • Surgical Management Options:

    • Arthroscopy: Small incisions for tissue repair via scope.

    • Arthroplasty: Joint replacement (TSA, RTSA).

    • Open Repair: Open surgical correction, commonly following trauma.

    • Thermal Capsulorrhaphy: A procedure utilizing a thermal probe to shrink the GH capsule.

OCCUPATIONAL THERAPY ASSESSMENT

  • Evaluation Components:

    • History taking.

    • Screening tests (Orthopedic examination) - Refer to Table 23-4.

    • Observational assessments of daily activities.

    • Outcome Measures (DASH or Quick DASH).

    • Development of an Occupational Profile.

  • OTA Contributions: OTA may provide observational insights once service competent.

OT INTERVENTIONS: ACUTE PHASE

  • Acute Phase Duration: Typically lasts 4-6 weeks post incident/surgery.

  • Goals include:

    • Immobilization to support healing and integrity of repair while managing inflammation.

  • Characteristics: Pain, bruising, inflammation, and potential sensory deficits.

  • Intervention Strategies:

    • Education on care and movement restrictions.

    • Use of a sling or shoulder immobilizer with the option of an abduction pillow.

    • Cryotherapy: 20 minutes on, 20 minutes off for pain relief.

    • Exercises: Following physician’s protocols, including Codman's Pendulums and shoulder shrug exercises.

OT INTERVENTIONS CONTINUED: ACUTE PHASE

  • Occupations Involved:

    • Rest and sleep considerations include using an abductor sling and relaxation techniques.

    • Bathing: May require long-handled sponges to avoid twisting.

    • Toileting: Possible need for raised toilet seats or assistants.

    • Dressing Strategies: Don affected side first and doff the unaffected side first.

    • Adaptive Feeding Equipment: Required for tasks like opening jars.

    • Hygiene & Grooming Tips: Suggestions include flip-top caps for toothpaste and roll-on deodorant to minimize arm movement.

    • Leisure Activities: Should respect the prescribed weight-bearing restrictions.

    • Sexual Activities: Discussion and education on safe positioning, using pillows, and alternatives.

OT INTERVENTIONS FOR INTERMEDIATE PHASE OF REHABILITATION

  • Intermediate/Remodeling Phase Duration: Typically 4-10 weeks post-injury.

  • Focus during this phase includes:

    • Transitioning to increased activity levels as soft tissues heal and inflammation decreases.

  • Exercise Protocols: Refer to Table 23-5.

  • Modalities: May include thermal modalities if inflammation is controlled prior to exercises.

  • Aerobic Exercise: Recommended for 20-30 minutes of low intensity to improve fitness.

OT INTERVENTIONS CONTINUED: INTERMEDIATE PHASE

  • Involvement in daily occupations transitions:

    • Patients usually weaned off slings.

    • Performance of basic activities of daily living (BADLs) and light home management tasks, avoiding heavy lifting or jerking movements.

    • Driving may resume upon physician approval.

RTI (RETURN TO INTEGRATION) PHASE

  • Focus on Physical Activity:

    • Gradual transition to resistive exercises for strength.

    • Resumption of normal activities with an emphasis on increased range of motion exercises.

    • Use of resistive bands for rotator cuff strengthening and scapular stabilization exercises such as rolling a ball up a wall.

    • Emphasis on core strengthening throughout the rehabilitation process.

PSYCHOSOCIAL CONSIDERATIONS

  • Common issues encountered:

    • Pain

    • Depression

    • Feelings of hopelessness due to reliance on others for caregiving.

    • Steps toward restoring independence are crucial for recovery.

SUMMARY

  • The shoulder joint's functionality is vital for maintaining overall independence.

  • Occupational therapists must account for clients' occupations, body structures/functions, roles, routines, and the psychosocial impact of their shoulder conditions.