The Shoulder

Introduction

• Components of the shoulder• Most common joint pathology• Rotator cuff • Biceps Tendon• Fractured neck of Femur• Dislocation• Adhesive Capsulitis

3 components

• The glenohumeral joint

• The acromiclavicular joint

• The scapular

Diagnosis

• History• Range of Movement• Palpation• Pain• Diagnostic tests (there are 65 that

can be performed!)

Most common joint pathology

Gh joint Ac joint Scapular

Adhesive capsulitisOA (rare)Dislocation

TendonitisImpingement

Instability

Shoulder or cervical nerve root?

• Is there loss of shoulder ROM? YES = SHOULDER

• Are the reflexes reduced?YES = CERVICAL

Rotator Cuff

• Stabilise the head of the humerus while the other major muscles around the shoulder are actively moving the arm. Eg. When deltoid is abducting. They also initiate most movements

3 main types of rotator cuff lesions

•Tendonitis•Partial rupture•Complete rupture

TendonitisSupraspinatusInitiates abduction(Most commonly injured)

Infraspinatus and Teres MinorLaterally rotate humerus

SubscapularisMedically rotate humerus

•Painful arc at 90° abduction•Toothache type, constant pain from acromion to deltoid insertion•Reverse scapular pattern

• Painful arc at 90 abduction•Resisted gh lateral rotation•Thickened tendon posterior to ghjt

•Painful medial rotation

Treatment of tendonitis

Early stages Later stages

•Frictions•Ultrasound•Strengthening exercises in pain free range•Scapular control•Shoulder taping to offload tendon

•Antiinflamatories•Stretching exercises

Rotator cuff rupturePartial rupture Complete rupture

•Cause usually traumatic•As tendonitis but pain is sharper•Resisted abduction very painful•Passive elevation not affected

•Cause fall onto point of shoulder with arm adducted/spontaneous due to degeneration•Acute pain•Inabiltiy to initiate abduction•Full passive rom if helped through first 20-30º

Sidelying Lateral Rotation

Rotator Cuff strengthening

Rotator Cuff strengthening

Prone Horizontal Abduction

Rotator cuff strengthening

Lateral rotator strengthening with resistance band

Biceps TendonTendonitis Rupture

•Pain in bicipital groove•Pain on resisted forearm supination and elbow flextion

Buldge in lower third of upper arm.

Fractured neck of femur

• Pain on early movement• Upper arm swelling• Need to be investigated early

especially following a fall in the elderly

• Should be kept moving as much as possible

Ghjt disclocation

• Carries a very specific history of trauma

- anterior dislocation (abduction, extension and lateral rotation)

• Usually involves tear of labrum• Physio aims to strengthen rotator

cuff• After 3rd dislocation surgery is

usually necessary

Adhesive Capsulitis/Frozen

shoulder• inflammation of the shoulder

capsule and synovial membrane leading to adhesion formation. This causes a thickening in the capsule and constriction of the glenohumeral joint due to the scar tissue forming in the capsule

Diagnosis

• Age 40+• Cause ? UnknownPossible: trauma, wrench,

dislocation. CVA, heart conditions, diabetes, viral. Can also be secondary to cx spondylosis or to tendonitis.

Clinical features

Clinical features• Increasing dull ache over a few months

duration.• Sharp pain when reaching the end of

pain free movement• Loss of movement in a capsular

pattern – lateral rotation – abduction - flexion

Most reduced >>>>>>>>>Least reduced

• Elevation and protraction of shoulder girdle

Clinical features cont’

• Pain over A/C joint and deltoid muscle – can spread to neck and/or elbow

• All G/H movement often painful, not specific planes

• Pain worse at night

Clincial features cont’

• Muscle spasm in pectoralis major and latissimus dorsi

• Wasted deltoid • Associated posture• Dowagers hump• Poke chin

Prognosis• 18 months to 3 years

3 phases1. Freezing –painful phase (worse at

night and when lying on it)2. Frozen – stiff phase3. Thawing- stiffness gradually eases

Physiotherapy

• Reduce pain with electrotherapy, TENS and acupuncture until patient is able to sleep and function day to day

• Taping to rest the joint• Static strengthening exercises for the

shoulder• Introduce stretching in sub acute

phase

Exercises to increase rom

Other treatment

• Antiinflamatories• Muscle relaxants• Hydrocortisone injection• Nerve block• Surgery –

Manipulation/Arthroscopic capsular release