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The Shoulder & Shoulder Girdle

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Ashley Ambrosio

on 5 March 2014

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Transcript of The Shoulder & Shoulder Girdle

The Shoulder & Shoulder Girdle
PTA 105B
Describe the importance of shoulder stabilization as it affects the biomechanics of the joint.
Discuss the ramifications of surgical procedures upon function and early mobilization of the shoulder joint.
Review the physiology of the “Idiopathic Frozen Shoulder”.
Describe the non-operative intervention for impingement syndromes of the shoulder.
Review other common acute & chronic conditions associated with the shoulder and shoulder girdle.
Shoulder Rehabilitation
Learning Objectives
Scapulothoracic Articulation

Shoulder & Shoulder Girdle
Structure and Function
Glenohumeral Joint
Acromioclavicular Joint
Sternoclavicular Joint

Horiz add
GHJ arthrokinematics
Physiological mvmt
Horiz AB
Upper trap
Serratus anterior
Middle trap

Cohesive forces of subscapular bursa
Static & Dynamic Stabilizers of the Scapula

Rotator cuff

Synovial fluid and negative jt pressure hold surfaces together.
Static & Dynamic Stabilizers of the GHJ

Capsule, ligaments
Glenoid labrum deepens fossa & improves congruency
Long head of biceps
Winging (occurs w/ horiz add of humerus)

Motions of the scapula
With Abduction or flexion: upper/lower traps + serratus anterior upwardly rotates, protracts the scapula.
Active arm motions
Upward rotation (ab arms), Downward rot.
Tipping (occurs HBB)
Scapular muscles try to stabilize and control scap position.
Eccentric control of acceleration provided by these muscles in the opposite direction.
Extension or pulling; downward rotation & adduction created by rhomboids, lats, teres m, & RC.
Flexion or pushing activity serratus ant. Protracts scapula.
Changes position of the humerus in the glenoid: abducted.internally rotated position
Result is shortened internal rotators & stretched or weakened external rotators.

Muscle imbalances
Muscle length
Strength imbalances
Forward tilt of scapula results from tight Pec. Major & weak Serratus Ant. or Trapezius.

Faulty Posture
Faulty scapular mechanics due to:
During mid-range, the scapula has greater motion, approaching a 1:1 ration w/ humerus.
If scap is in synch w/humerus, the humerus moves 150-180 degrees of shoulder ROM into flexion or abduction w/ elevation.
Scapulohumeral Rhythm
Setting phase: 1st 60* of flexion or 1st 30* of AB = motion is primarily at the GH joint.
There is considerable variation amongst pts.
It is commonly accepted that there is a 2:1 ratio of GH/Sc rotation.
This synchronous motion decreases shear forces and maintains congruency.
After this the GH joint dominates the motion.
Pec minor is lengthened as scap upwardly rotates, retracts, tips posterior
A tight pec minor restricts scapular mvmt which could = impingement syndrome

Rehab Tidbit
During elevation
What should we do with these patients and why?
Loss of any of these components will result in loss of ROM

Coracoclavicular ligament becomes tight and rotates the clavicle 38-50° around it’s longitudinal axis.

Clavicular Elevation & Rotation
In order for the greater tubercle of the humerus to clear the coracoacromial arch, the humerus must externally rotate as it elevates above horizontal.

External Rotation w/Abduction
Motion in this plane is described as “scaption”.
This motion allows the scapula to rotate an additional 30° at the AC joint.
Initially w/ upward rotation of the scapula, 30 degrees of elevation of the clavicle occurs at the SC joint.
Inadequate ER will result in impingement in the suprahumeral space.
More functional ADL’s/mvmts are performed in scaption
There is less tension on the capsule and greater elevation is possible than w/ pure frontal or saggital plane elevation.
Scaption = plane of the scapula is described as 30° anterior to the frontal plane.
Deltoid causes upward translation; leads to impingement if unchecked.

Infraspinatus, teres minor & subscapularis stabilize and pull down on the humerus.
Result is abduction & control humeral head.
Supraspinatus stabilizes and has slight upward translation of the humerus.
These effects combined lead to abduction of the arm.

Deltoid-RC mechanism
Vertebral joints – C3-4, C4-5 w/ nerve roots C4-5.
C4 over the trap to the tip of the shoulder.
C5 over the deltoid and lateral arm.
Diaphragm: pain perceived in the upper trapezius.
Heart: pain perceived in the axilla and left pectoral area.
Gall bladder: pain perceived at tip of shoulder and posterior scapular region.

Referred Pain
Common Nerve Injury Sites
Primary IFS:
w/o known cause. Adhesions in the inferior capsule. Consistent with faulty posture.

Lack of mvmt=stiffness

Joint Hypomobility/Non-surgical

Secondary IFS:
when there is a known possibility,i.e. arthritis, immobilization
Idiopathic Frozen Shoulder
Adhesive capsulitis
Dense adhesions; capsular restrictions.
40-60 y/o
Traumatic arthritis
From fall/blow or faulty posture micro trauma
Muscle guarding/pain
Limit ROM, especially ER & AB
Difficult to detect jt swelling due to depth of capsule
Clinical signs/sx GHJ arthritis
Progressive restriction of capsule continues
Capsular pattern & decreased jt play
Significant loss of function
Inability to reach overhead, outward, or behind the back
Aching is localized over deltoid region
Capsular tightness begins do develop
Capsular pattern develops (ER>AB>IR>flx)
Pt feels pain at end of range available to them
Acute phase
Sub-Acute phase
Chronic Phase
=pain only w/ movement. Sig. Adhesions, limited GH motion, substitute muscle patterns. Atrophy of deltoid, RC, bicep, triceps. Lasts 4-12 months

Classic Pattern of IFS

= no pain, or synovitis but significant capsular restriction from adhesions. Lasts 2-24 months. Some never recover full ROM
= intense pain @ rest/limited ROM by 2-3 weeks post onset. Acute symptoms may last 10-36 weeks.
Maintain function (educate pt.)

Control pain:Grade 1 jt. Mobs, modalities
Intervention:Max Protection Phase
Maintain soft tissue integrity:
Passive joint traction & glides
Pendulum (Codman’s) Exercise
Muscle setting

If edema is noted have pt. elevate hand.
Watch for RSD symptoms( to avoid it, have pt do ex with hands)
Correct faulty mechanics

Control pain, edema, joint effusion.

AAROM, AROM, Neuro re education

Joint Mobs

Teach Self Mob Techniques:
Caudal glide
Anterior glide
Posterior glide

Intervention: Controlled Motion Phase
Self mobilization techniques
Posterior Mobilization/Inferior Mobilization
Mobilization with Movement (MWM) techniques(550,551,556)
External Rotation (17.12 pp 550)
Internal Rotation( 17.13 pp551)
Painful Arc or Impingement (17.17 pp 556)

Progress to self stretching and strengthening.

Muscle relaxation techniques

End Range Jt. Mobs

Prepare for functional movements. Make exercises functional and specific to PLOF tasks.

Intervention: Return to Function
Manipulation Under Anesthesia



Overuse syndromes
Arthritic, post-trauma
Work with arm at waist level
Diagonal extension,adduction, internal rotation (VB/Tennis)


Fractured clavicle

Joint Lesions of the AC/SC joints

Use sling or resting positions to support the weight of the arm

XFM to capsule or ligaments

Shoulder ROM
Gr II mobilizations to minimize loss of ROM @ GHJ

Non operative mgmnt of AC/SC jt strain or hypomobility

Surgical Goals
Relieve pain
Improve mobility or stability
Restore or improve functional use & strength

Types of surgeries:
GH joint arthroplasty (total shoulder replacement)
Hemiarthroplasty (hum head replaced)
Arthrodesis (fusion) not common

GH Joint Surgery – Postop Mgmt.

Most common
Least stable
Greatest freedom of shoulder motion
Pt depends on RC muscles for dynamic stability post op

Reversed ball/socket
Used for RC deficient shoulders that cannot be repaired
Sm humeral socket on larger ball shaped glenoid.

Types of prosthetic implants
Operative Procedures
Anterior approach
Incision extends from AC joint to deltoid insertion
Subscap is released/anterior capsulotomy performed.
GH joint dislocated
Humeral osteotomy performed.
Glenoid fossa is debrided
PROM under anesthesia determines possibilities

Glenohumeral Arthroplasty
Elbow flexed to 90°
Forearm/hand rest on abdomen
Arm at side with slight abduction on pillow
Forward flexion 10-20°; internal rotation
Head of bed elevated 30°
Arm supported as above
Tenuous Rotator Cuff Repair:
Abduction splint might be warranted

Positioning p/ Arthroplasty
(Max Protection Phase)
Short but frequent ex sessions (4-5x/day) w low reps
Limit PROM ER to neutral to 30* (WHY?)
No resisted IR or resisted ANYTHING
During passive or assisted shoulder rotation with the patient supine, position the humerus slightly anterior to midline by placing a towel under the arm (avoids stress to anterior capsule) Why does this matter?
Have pt face doorway if using pulley (why?)
In sitting and standing avoid thoracic kyphosis. Emphasize extension & scapular retraction
ADL’s avoid WB on the operated extremity.
Avoid lifting heavy objects; no reaching HBB
Use sling; even while sleeping; avoid driving

Post-op Management Precautions up to 6 weeks

Restore shldr mobility
PROM w/in limits
Codmans w elbow flxd (not a fan)
AAROM supine progressed to sitting
AAROM touching nose/forehead etc
Functional activites w elbow at waist level ie writing

May last 2-3 weeks; 6 wks w/tenuous RC repair.

Maintain mobility of adjacent joints
Keep shoulder, neck & upper trunk relaxed via gentle massage, AROM.
AROM of hand, wrist and elbow when arm can be removed from the sling.

Intervention – Max Protect Phase
Criteria for progression to this phase includes
ROM: at least 90* PROM flexion; 45* ER; 75* IR all in scapular plane.
No pain with resisted test to subscap
Ability to perform waist level ADL’s w/o pain
Moderate protection phase

Improve strength, endurance, stability of the shoulder girdle.
Scapular Stability
Dynamic strength to 90° w/light weights & bands
If RC is intact, may start in 2-3 weeks. If tenuous RC repair may have to wait 6 weeks.

Re-establish mobility and control of shoulder motions.
Transition to AROM
Table slides/Wall climbing
Wand exercises
Wall stretching flx/ER
Towel stretch for IR
Intervention-Mod Protect Phase
Improve Mobility
Self stretching
Assisted end-range stretching
Grade III mobs

Improve strength, stability and endurance.
Low load, hi rep PRE’s, PNF
Closed chain/WB ex.
Light carrying, lifting, etc
Modified recreational act; make the prosthetic last
Full PROM or at least 140* flx, 120* AB; 70* IR; 60* ER
AROM to 120 scaption with good mvmt quality
Greater than Good (4/5) for RC & deltoid
Return to use in light ADL’s and modified recreational use you should be (4/5)
Intervention-Min Protect Phase

Almost all patients report decrease in shoulder pain, improvement in functional use.

Continue to avoid heavy lifting and high-impact activities.



May expect to achieve 90-130° of active elevation due to scapular mobility.

Pt.s can bring had to mouth, behind the head and to the hip.

May wind up stressing the AC joint resulting in hypermobility and pain.
Incapacitating pain
Gross instability of GH jt.
Complete paralysis of deltoid and RC muscles
Joint destruction from infection
Failed joint arthroplasty in young, active patients.

Primary – tissues under the suprahumeral space become congested 2° to hypertrophic degenerative changes in the AC joint.

Secondary – tissues become impinged 2° to hypermobility. “Multi-directional” instability.

Painful Shoulder Syndromes
No matter if the cause is primary or secondary, impingement is usually brought on by excessive or repetitive overhead activities that load the shoulder in mid range.
Impingement Syndrome
Neer’s classifications

Stage 1 – edema and hemorrhage; typically occurs in pt.s below 25 yrs of age.

Stage 2 – Fibrosis and tendonitis: typically in pts. between 25-40

Stage 3 – Bone spurs, RC tears and biceps rupture. Seen in pt.s over 40 years of age.

Primary Impingement/RC Disease

Defined by Neer as stage II impingement

Supraspinatus – palpable pain over insertion.
Pain with impingement test

Infraspinatus – near musculotendinous junction, results in a painful arc. Pain inferior to the posterior corner of the AC joint w/ horizontal adduction and lateral rotation of the humerus. From continued deceleration in throwing athletes.

Bicipital tendonitis – Swelling in bicipital groove. Pain with resisted elbow flexion and supination.

Bursitis – symptoms same as supraspinatus tendonitis.
Pt has lax connective tissues
= excess mobility

RC has to work overtime to stabilize
When its fatigued, that’s when injury happens

Rehab considerations
Approximation;stablity ex
Endurance training of RC and scap stabilizers ( prone on ball)
Neuro re education/ PNF/ correct movement patterns; rhythmic stabilization open to closed chain.
Avoid position of dislocation

Secondary impingement: instability
Impaired posture
Increased thoracic kyphosis
Scapula is now tilted fwd (how does this change mechanics of shoulder? )
Increased humeral IR
Weak (stretched) ER ms

Decreased T/S ROM
Lack of thoracic extension
Necessary for fwd flexion

RC overuse & fatigue
No longer able to provide stabilizing/compressive forces to control motion

Muscle weakness secondary to neuropathy
Long thoracic n palsy
Serratus anterior is weakened

Hypomobile posterior capsule
Anteriorly translates & IR humeral head
Common impairments leading to impingement
Control inflammation

Patient education

Maintain mobility of soft tissue
Muscle setting of RC, bicep, scapular ms.

Avoid impingement positions (what are they?)

Control pain
Gr I II jt mobs, pendulums

Posture awareness

Management of painful shoulder syndromes Protection phase
Progress after acute symptoms calm down

Patient education

Promote strong mobile scar

Postural awareness reinforcement

Mobilization w movement

Develop muscle balance in length & strength
Stretch: pec minor/major, lats, teres mj, subscap, levator scap
Strengthen scap stabilizers
Prone on ball
Strengthen RC ms
Especially ER

Develop muscular stabilization/endurance
Rhythmic stab
Closed/open chain
PNF patterns scap & GHJ
Endurance of RC/scap stab
Have them hold positions
Plank, ER, IR, protraction, wall p/u, x3min

Management of painful shoulder syndromes: controlled motion
Increase ms endurance
Progress from 3-5 min

Develop quick motor responses to imposed stresses
Stab exercises are done w increased speed
Potential plyo training

Progress functional training
Lifting, etc.

Management of painful shoulder syndromes: return to function
Three approaches:


Mini-open incision from AC down through the deltoid. Proximal insertion remains intact.

Open repair is an antero-lateral incision, proximal insertion of the deltoid is detached and reflected to expose RC.

Surgical Repair of RC injuries

Rehab considerations?
What is it?
C-A lig resected
AC jt resection (sometimes)

Sub acromial decompression
Just because its torn doesn’t mean surgery

Full thickness tears
Torn all the way through tendon
From repetitive microtrauma & impingement

Partial thickness tears
Not torn all the way through
From repetitive microtrauma & impingement

Types of surgery
Mini open repair
Have to cut through deltoid
Longer rehab
Usually means tear is larger and/or muscle/tendon has retracted and purchase is poor.

Rotator Cuff Repair & Mgmt

Each surgeon may have their own protocol

Early shoulder motion guidelines
ONLY PROM for 6-8 wks after traditional open or massive tear
PROM done in supine initially to maintain scap stability
Minimize anterior translation of hum head
Put towel roll under elbow in supine
Emphasize good posture w ex.
No AG flexion until pt can do it w/o hiking

General Rehab Guidelines for Rotator Cuff Repair
Strengthening exercise
Low loads and
No CKC ex for at least 6 weeks
No PRE’s for 8 weeks for sm repairs
No PRE’s for 3 months for lg tears
No Isom to deltoid or cuff ms for at least 6-8 weeks.

Stretching Exercises
Avoid vigorous stretching
No contract relax or Gr III jt mobilization for at least 6-12 weeks.
If Ss was repaired avoid stretching into IR
If Subscap was repaired avoid stretching into ER
Mini open/arthroscopic- wait 6 weeks for light functional act
12 weeks for larger tears

Repair of a detachment of labrum from anterior rim of glenoid

Commonly accompanies dislocation

Debridement is performed of the labrum and it is attached back to glenoid with tacks.

Sometimes anterior capsular shift is performed if needed.

Generally done arthroscopically so there is not a disturbance of the subscap.

Be careful with ER

Bankart repair
Also called capsulorrhaphy
Done when there is capsular laxity
Multiple dislocations
Capsule is folded over itself and sutured
Surgery is done in the direction of instability

Thermal capsular shift
Not very successful
Capsule is shrunk thermally
Capsular shift

Tear of the Superior Labrum Anterior to Posterior
Some are associated with tear of proximal attachment of long head of bicep.

Rehab notes
Be careful with resisted shldr and elbow flexion. WHY?

Bankart repair/anterior stabilization
Limit ER, Horiz AB, Ext (ant cap stress) x 6wk
Only 5-10* x 2 wks
Then progress to 45* in 4 wks
No vigorous PROM stretching in ER for 12 wk
Avoid pos of dislocation (AB&ER)
If subscap is involved, avoid resisted IR or ER stretching x wks

Rehab considerations
Thermal asst. capsular tightening
Use caution with ROM ex for 6wks. Thermal treated tissue is actually more extensible during this time. Then the collagen tightens up.
Sling during sleep x2wks
ROM precautions based on instability

When bicep tendon is detached= progress more cautiously
PROM in scapular plane for first 2 wks
Avoid elbow extension with shldr ext or any pos that creates tension on biceps X 12 wks
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