Shoulder Orthopedic Considerations

Learning Outcomes

  • Understand anatomical and biomechanical considerations crucial for effective shoulder treatment.

  • Identify common shoulder orthopedic conditions and their general treatment approaches.

  • Learn assessment processes used in evaluating various shoulder conditions.

  • Recognize occupational therapy's unique role in managing shoulder conditions throughout rehabilitation.

  • Discuss intervention approaches and necessary precautions for post-surgical shoulder conditions.

Shoulder Anatomy and Biomechanics

  • Bones: 3 primary bones involved: the scapula (shoulder blade), humerus (upper arm bone), and clavicle (collarbone).

  • Joint types: The shoulder complex comprises 5 joints:

    • 3 Synovial Joints:

      • Glenohumeral (GH) Joint: Ball-and-socket joint between the humeral head and glenoid fossa; highly mobile but inherently unstable.

      • Acromioclavicular (AC) Joint: Connects the acromion of the scapula to the clavicle.

      • Sternoclavicular (SC) Joint: Connects the sternum and the clavicle; the only direct bony attachment of the upper extremity to the axial skeleton.

    • 2 Quasi-Joints (Functional Joints):

      • Scapulothoracic (ST) Joint: A physiological articulation between the scapula and the posterior thoracic wall, crucial for full shoulder motion.

      • Subacromial Space: Not a true joint but a critical space beneath the acromion containing the rotator cuff tendons, bursa, and biceps tendon.

  • Scapulohumeral Rhythm: A coordinated movement pattern between the glenohumeral joint and the scapulothoracic joint, typically a 2:1 ratio (for every 2 degrees of GH abduction/flexion, there is 1 degree of ST upward rotation).

    • Flexion: Involves protraction of the scapula with upward rotation, primarily driven by the Serratus anterior and Upper Trapezius.

    • Abduction: Initiated by the deltoid and supraspinatus, followed by synchronous upward rotation of the scapula (driven by Serratus anterior and Trapezius) to allow full range of motion while maintaining glenohumeral stability.

    • Extension: Involves retraction of the scapula with downward rotation.

Common Shoulder Conditions

  • Shoulder Instability: Occurs when the humeral head slips out of the glenoid fossa partly (subluxation) or completely (dislocation).

    • Causes: Can result from joint laxity (congenital or generalized), acute trauma (e.g., fall on an outstretched hand, sports injuries), repetitive microtrauma, or underlying rotator cuff or capsular pathology.

    • Types:

      • Unidirectional: Instability in one primary direction, often anterior (e.g., from abduction and external rotation trauma – TUBS: Traumatic, Unidirectional, Bankart, Surgery).

      • Multidirectional: Instability in multiple directions (anterior, posterior, inferior), often associated with generalized ligamentous laxity or capsular stretching (e.g., AMBRI: Atraumatic, Multidirectional, Bilateral, Rehabilitation, Inferior capsular shift).

      • Subluxation: Partial dislocation where the humeral head partially displaces but spontaneously reduces.

      • Dislocation: Complete separation of the humeral head from the glenoid cavity.

  • Impingement and Tears: Often related to compression of soft tissues within the subacromial space.

    • Causes:

      • Tendonitis and Bursitis: Inflammation of the rotator cuff tendons (e.g., supraspinatus) or subacromial bursa, often due to overuse or repetitive overhead activities.

      • Compression: Occurs during shoulder movements when structures like the Immobilization cuff tendons, long head of biceps, or bursa are pressed against the acromion and coracoacromial ligament.

    • Rotator Cuff Tears: Involve the four rotator cuff muscles (supraspinatus, infraspinatus, teres minor, subscapularis) and their tendons.

      • Acute vs. Chronic Causes: Acute tears often result from a single traumatic event (e.g., fall); chronic tears develop over time due to wear and tear, repetitive stress, and degenerative processes, often seen in older individuals or overhead athletes.

      • Partial vs. Full Thickness: Tears can be partial, affecting only a portion of the tendon, or full-thickness, extending through the entire tendon.

  • Adhesive Capsulitis (Frozen Shoulder): A condition characterized by significant pain and progressive loss of both active and passive range of motion due to inflammation and fibrosis of the joint capsule.

    • Stages:

      • Freezing Stage (Acute Inflammatory, typically 2-9 months): Gradual onset of pain, increasing with movement, and progressive loss of motion.

      • Frozen Stage (Proliferative, typically 4-12 months): Pain may decrease, but stiffness is significant, with severe restriction in all directions.

      • Thawing Stage (Resolution, typically 5-24 months): Gradual but often spontaneous improvement in range of motion.

    • Treatment: Varies significantly by stage, focusing on pain management and maintaining available ROM in the freezing stage, more aggressive mobilization in the frozen stage, and functional restoration in the thawing stage.

  • Fractures: Breaks in the bones of the shoulder joint.

    • Causes: Common causes include falls onto an outstretched hand (FOOSH), direct trauma, or high-energy impacts. Common fracture sites include the proximal humerus, clavicle, and scapula.

    • Rehab: Varies greatly depending on the stability of the fracture, location, displacement, and whether it's managed operatively or non-operatively.

    • Non-operative vs. Surgical Management: Non-operative management often involves immobilization (sling, cast) followed by gentle rehabilitation for stable, non-displaced fractures. Surgical options (e.g., Open Reduction Internal Fixation - ORIF, arthroplasty for complex proximal humerus fractures) are typically considered for displaced, unstable, or comminuted fractures to restore alignment and stability.

  • Brachial Plexus Injuries: Involve damage to the brachial plexus, a network of nerves (originating from cervical nerve roots C5-T1) that controls movement and sensation in the arm, hand, and wrist. Relates directly to the injury severity (neuropraxia, axonotmesis, neurotmesis) and location within the plexus.

  • Cervical Radiculopathy: Refers to arm pain, numbness, tingling, or weakness originating from compression or irritation of a nerve root in the cervical spine. May require referral to a neurologist or spinal specialist for diagnosis and treatment.

Medical and Surgical Management

  • Decision Factors: The choice between conservative and surgical management depends on multiple factors including:

    • Injury status: Type, severity, and chronicity of the injury.

    • Neurovascular involvement: Any compromise to nerves or blood vessels.

    • Recovery potential: Prognosis for return to desired activities.

    • Patient factors: Age, activity level, comorbidities, occupation, and patient preferences.

  • Conservative Treatment: Non-surgical approaches aimed at reducing pain and restoring function.

    • Education: Patient education on posture, body mechanics, and activity modification to prevent re-injury or aggravation.

    • Home Exercise Programs (HEP): Tailored exercises focusing on range of motion, stretching, and progressive strengthening.

    • Activity Modification: Adjusting daily activities, work tasks, and recreational pursuits to minimize stress on the shoulder.

    • Other options: Pharmacological management (NSAIDs), corticosteroid injections, physical therapy modalities (e.g., heat, ice, ultrasound).

  • Surgical Options: Invasive procedures to repair, reconstruct, or replace damaged shoulder structures.

    • Arthroscopy: Minimally invasive keyhole surgery using a small camera to visualize and repair intra-articular structures (e.g., rotator cuff repair, labral repair, debridement).

    • Arthroplasty: Joint replacement surgery, typically for severe arthritis or complex fractures (e.g., total shoulder arthroplasty, reverse total shoulder arthroplasty, hemiarthroplasty).

    • Open Repair: Traditional surgery with a larger incision for more complex repairs or reconstructions (e.g., extensive rotator cuff tears, complex fracture fixation).

    • Thermal Capsulorrhaphy: A technique using heat to shrink and tighten the joint capsule, primarily for shoulder instability (less common now).

OT Evaluation of the Shoulder

  • Components: A comprehensive evaluation includes:

    • History: Gathering information about the mechanism of injury, onset of symptoms, pain characteristics (type, location, intensity: 0-10 scale), prior medical history, medications, and functional limitations.

    • Clinical Observation: Assessing posture, signs of atrophy, symmetry, guarding, and compensatory movements during functional tasks.

    • Physical Examination: Includes palpation, active and passive range of motion (AROM, PROM), manual muscle testing (MMT) for strength, special tests to identify specific pathologies (e.g., Neer's, Hawkins-Kennedy for impingement; Empty Can for supraspinatus; Apprehension test for instability), and neurovascular screening.

  • Outcome Measures: Standardized tools used to quantify patient-reported outcomes.

    • DASH (Disabilities of the Arm, Shoulder, and Hand): A 30-item questionnaire assessing disability and symptoms in upper extremity conditions.

    • SPADI (Shoulder Pain and Disability Index): A 13-item questionnaire measuring shoulder pain and disability.

OT Interventions

  • Immobilization Phase (typically 0-6 weeks post-op/injury): Focus on protection and pain management.

    • Education: On precautions (e.g., no active ROM, lifting restrictions), sling use, and proper positioning.

    • Cryotherapy: Application of cold packs to reduce pain and inflammation.

    • Pendulum Exercises: Gravity-assisted, passive ROM exercises to maintain joint lubrication and prevent stiffness without actively engaging shoulder muscles.

    • Goal: Protect healing tissues, manage pain, prevent complications, and begin gentle passive ROM.

  • Mobilization Phase (typically 4-10 weeks post-op/injury): Gradual restoration of motion and initial strengthening.

    • Active Tasks: Progressing to active-assisted range of motion (AAROM) and active range of motion (AROM) exercises.

    • Passive Forward Flexion: Continued as appropriate.

    • Gentle strengthening: Isometrics, progression to light resistance bands for rotator cuff and scapular stabilizers.

    • Goal: Increase joint mobility, improve muscle activation, and enhance stability.

  • Reintegration Phase (typically 8-10+ weeks post-op/injury): Focus on advanced strengthening, endurance, and return to occupation/sport-specific activities.

    • Strengthening: Progressive resistive exercises (PREs) targeting all shoulder musculature, including eccentric exercises.

    • Endurance: Activities that challenge sustained muscle effort.

    • Advanced Activities: Sport-specific drills, overhead tasks, heavy lifting, and work simulation activities.

    • Goal: Achieve full functional return, optimize strength and endurance, and prevent re-injury.

  • OTA's Role: Occupational Therapy Assistants play a vital role in implementing intervention plans.

    • Psychological Impacts: Addressing psychosocial aspects such as fear-avoidance behaviors, anxiety, and depression related to injury/recovery; emotional support and education on coping strategies.

    • Compensatory Strategies: Teaching techniques and providing adaptive equipment to facilitate independent performance of daily activities while respecting precautions or limitations.

    • Collaboration with PT: Working closely with Physical Therapists to ensure a cohesive and comprehensive rehabilitation approach.

Knowledge Assessment

  • Questions to determine conditions' origins (e.g., overuse, trauma, acute vs. chronic onset) and guide appropriate recovery stages (e.g., initial ice therapy, progressing to resistive exercises in later stages).