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Rehabilitating Impairments of the Painful Shoulder. Chris Fjosne, PT, DPT, OCS. Objectives. Understanding the stages and treatment of Adhesive Capsulitis Understanding of the mechanism underlying rotator cuff disease Outlining the stages of primary and secondary impingement - PowerPoint PPT Presentation
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CHRIS FJOSNE, PT, DPT, OCS
Rehabilitating Impairments of the Painful Shoulder
Objectives
Understanding the stages and treatment of Adhesive Capsulitis
Understanding of the mechanism underlying rotator cuff disease
Outlining the stages of primary and secondary impingement
Facilitating the development of evidence-based strategies to treat rotator cuff impingement
Making the appropriate referral for treatment
Differential Diagnosis
Cervical RadiculitisFrozen ShoulderTendinopathy
Tendinosis/Tendinitis Full thickness RC tears Partial thickness tears Impingement Bursitis
Cervical Screen
Upper Limb Tension TestSpurlingsDistractionCervical rotation <60° to involved side
3 of 4 (+) tests demonstrates 94% specificity 4 of 4 (+) tests demonstrates 99% specificity
Frozen Shoulder
Adhesive CapsulitisRecognition-Classification
Adhesive capsulitis- Nevaiser defined it as “the inflamed and fibrotic condition of the capsuloligamentous tissue.Codman described frozen shoulder as “a condition difficult to define, difficult to treat, and difficult to explain from the point of view of pathology.”
Stiff and painful shoulder: painful condition with limited active and passive range of motion (ROM).
Primary vs. Secondary
Characteristics of Primary Frozen Shoulder
Patient age, 40-70 yearsInsidious or minimal trauma event resulting
in onsetSignificant night painSignificant limitations of active and passive
shoulder motion in more than 1 plane50% or greater than 30 degrees loss of
passive external rotationAll end ranges painfulSignificant pain and/or weakness of the
internal rotators
Etiology and Pathology
Although precise etiology remains unclear, evidence identifies elevated serum cytokine levels.
Cytokines and other growth factors facilitate tissue repair and remodeling as part of the inflammatory process.
The inflammatory healing response can lead to excess accumulation and production of fibroblasts releasing type 1 and type III collagen.
This exaggerated inflammatory response leads to arthrofibrosis
Studies report focal vascularity and synovial angiogenesis (increased papillary growth) rather then a synovitis.
Etiology and Pathology cont.
However, it is agreed that whether it is angiogenesis or synovitis that pain accompanies the change.
Open and arthroscopic examination demonstrated significant capsuloligamentous complex (CLC) fibrosis and contracture
Also contracture of the rotator cuff interval (RCI) is prevalent
Rotator Interval (RCI)
The RCI forms the triangular-shaped tissue between the anterior supraspinatus edge and upper subscapular border, and includes the superior glenohumeral ligament and the coracohumeral ligament.
Stages of Adhesive Capsulitis
Stage 1 0-3 months duration Pain with active and
passive ROM Limitation of forward
flexion, abduction, IR, ER Exam under anesthesia:
normal or minimal loss of ROM
Arthroscopy: GH synovitis (pronounced in anterosuperior capsule)
Hypervascular synovitis
Stage 2 3-9 months duration Chronic pain with active
and passive ROM Limitation of forward
flexion, abduction, IR, ER Exam under anesthesia:
ROM is identical to when patient is awake
Arthroscopy: diffuse pedunculated synovitis
Hypervascular synovitis, subsynovial scar, fibroplasias
Stages of Adhesive Capsulitis
Stage 3 9-15 months duration Minimal pain except at end
ROM Significant limitation of
ROM with rigid end feel Exam under anesthesia:
ROM identical to when patient awake
Arthroscopy: No hypervascularity, fibrotic synovium, diminished capsular volume
Capsule shows dense scar formation
Stage 4 15-24 months duration Minimal pain Progressive improvement
in ROM Minimal data available for
exam under anesthesia
Adhesive Capsulitis Diagnosis
Rule in if: Pt. age is between 40-65 years Pt. reports a gradual onset with progressive worsening
of pain and stiffness Pain and stiffness limit sleeping, grooming, dressing,
and reaching Glenohumeral passive ROM is limited in multiple
directions Glenohumeral ER or IR ROM decreases as arm is
abducted from 45 to 90 degrees Passive motions into the patient’s end ROM reproduce
the patient’s reported shoulder pain Joint glides/accessory motions are restricted in all
directions
Adhesive Capsulitis Diagnosis?
Rule out if: Passive ROM is normal Radiographic evidence of glenohumeral
arthritis is present Passive ROM for ER and IR increases as you
move from 45-90 degrees and the reported pain is reproduced with palpatory provacation of the subscapularis myofascia
Upper-limb nerve tension testing reproduces the reported shoulder pain
Shoulder pain is reproduced with palpatory provocation of the relevant peripheral nerve entrapment site
Nonoperative Interventions
Oral medicationsCorticosteriod injectionsExerciseJoint mobilizationDistensionAcupunctureManipulationNerve blocks
Phase 1 Treatment
Moist hot packs/electrical stimulation for painFrequent pain-free AAROM exercisesPendulum exercisesSingle plane mobilization (I, II)Soft tissue mobilizationStretchingHome program (10-12 times daily light
motion)Intra-articular corticosteriod injections
Phase 1 AAROM
Phase 2 Treatment
Active warm-upAAROM exercisesSingle plane near end range mobilizations
(III)StretchingEnd range submaximal isometricsSelf-capsular stretchingPostural programHome program (frequent sustained end
range stretches 5-7 minutes in duration)
Phase 3 Treatment
Active warm-upLow load long duration stretch (LLLDS) with
heatAggressive joint mobilizations (IV) single and
multi-planar and combined glidesStretchingStrengtheningHome program (4-6 times daily)
LLLDS is effective for improving Total End Range Time (TERT)
Lentell reported Time: 15-20 minutes Frequency: 3-4x/day Duration: 60min/day
Load added to stretch is (.5% BW)
What do we need to know about connective tissue?
In the absence of normal joint movement, the normal orientation of the connective tissue’s collagen fibers is lost.
Long-lasting or plastic elongation is produced by exposing connective tissue.
The effectiveness of a low-load long duration stretch (LLLDS) to promote long-lasting elongation of connective tissue is well documented.
Studies also support that the temperature of the connective tissue at the time of the stretch can significantly influence the long-lasting change that is produced.
Elevating the temperature of the tissue prior to the stretch and during the stretch produced greater changes and less tissue damage.
Joint mobilizations during Phase 3
High-grade joint mobilizations are used to promote elongation of shortened fibrotic soft tissue
Mobilizations should be performed at or near physiologic end range
Improved extensibility of the any portion of the CLC results in improved motion in all planes
Multi-planar mobilization techniques utilize rotational stress with concomitant translation which loads the collagen in multiple planes
Home Maintenance Program
Continue stretching program at least 3-4 times weekly
Prefer daily ROM stretchingSelf-capsular stretchesRotator cuff and scapular stabilization
program to begin once functional ROM restored
Activity modification
RCI Self Stretch
The patient’s hand remains fixed and the elbow is adducted toward the table.
Posterior Capsule stretch
Sleeper StretchCross Body Capsular Stretch
Summary of Adhesive Capsulitis
Stiff shoulder vs. adhesive capsulitisAssess and determine the stage of pathologyAssess classification to determine
appropriate treatment phaseUnderstanding and combining LLLDS, soft
tissue mobilizations and multi-planar mobilizations
PT appropriate at all stages but patient may need image guided intra-articular injection during painful phase 1 of treatment.
RC Tendinopathy
Seitz 2010
Extrinsic vs. Intrinsic Mechanisms
Extrinsic Mechanisms relates to external tendon compression or shear Impingement
(Subacromial and Internal)
Anatomical and Biomechanical Variants
Intrinsic Mechanisms relates to within the tendon Tendon Vascularity Tendon Biology Tendon Morphology Genetic Predisposition
Subacromial space
The acromiohumeral distance(AHD) is the linear measure to between the acromion and humeral head used to quantify the subacromial space
Acromial shapeAcromial shape
Subacromial spursAC joint spurs Acromial shape and
slope
Anatomical Factors
Biomechanical Factors
Abnormal scapular kinematics
Abnormal humeral kinematics
Postural abnormalities
RC and/or scapular muscle performance
Soft tissue tightness
Scapular motions
Patients with normal scapular mechanics show upward rotation, slight external rotation and posterior tilting of the scapula during shoulder elevation.
Factors leading to impingement
Mobility Deficits Capsular stiffness, Glenohumeral internal rotation
deficiency
Stability Deficits Scapular dyskinesis, Capsular laxity, Acquired anterior
instability
Neuromuscular control/Strength Deficits Scapular stability weakness, RC weakness, poor
recruitment patterns
Primary Impingement
Primary Impingement- compression of the RC tendons between the humeral head and overlying anterior third of the acromion, coracoacormial ligament, coracoid or AC joint.
Secondary Impingement
Attenuation of the static stabilizers of the GH joint, such as capsular ligaments and labrum, from the excessive demands incurred in throwing or overhead activities can lead to anterior instability
Internal Impingement
Internal impingement occurs when the shoulder is in a 90/90 position and the undersurface of the supra and infra tendons become compressed or pinched between the humeral head and the posterosuperior gleniod rim.
Rotator Cuff Tears
Incidence increases with ageResearch shows that tears are present in 50%
or more of the patient population greater than 60 years of age
Typically overuse injuries with compressive and shear forces
Ellenbecker & Cools 2012
Rehabilitating patients with impingement syndrome
Pec minor stretchingPosterior capsule
stretching and mobilization
Postural strengthening and education
RC and scapular muscle strengthening and retraining
Focus on modifiable factors
Summary
Adhesive capsulitis and RC tendinopathy are two of the most common diagnoses related to ongoing shoulder pain.
Research and evidence based practice demonstrates positive functional outcomes when treated conservatively with PT.
What if I need surgery?
Thank you and enjoy your next lecture!