Download Rehabilitation of Shoulder Injuries Presentation

Rehabilitation of Shoulder
Injuries
Adhesive Capsulitis/Frozen Shoulder
Rotator Cuff Strains
Jim Olds BHSc Dip RM
Member ANTA
Associate, Sports Medicine Australia
Muscles involved in movements of
the Glenohumeral Joint
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Flexion: 2 primary, 1 secondary
Extension: 3 primary, 2 secondary
Abduction: 2 primary, 3 secondary
Adduction: 2 primary, 1 secondary
External rotation: 2 primary, 1 secondary
Internal rotation: 4 primary, 1 secondary
• Total = 15 primary and 6 secondary
Common injuries of the shoulder
• With so many primary and secondary
muscles involved in the wide variety of
movements available at the shoulder, is it
surprising we see so many injuries and
conditions which affect this joint?
Stabilizers
• The glenohumeral joint is a ball and socket
joint.
• Unlike the hip joint the glenoid cavity is a
shallow socket which requires extra
stability.
• The main stabilizer of the shoulder is the
inferior glenohumeral ligament.
Additional stability
• Glenoid labrum and capsule
• Rotator cuff muscles: supraspinatus
infraspinatus
teres minor
subscapularis
• Other stabilisers consist of the teres major
and the serratous anterior, the latter via
location of the scapula.
Impingement and instability
• Most shoulder pathology relates to the
above two conditions in some way.
• Impingement occurs when the space
between the acromion, the coracoacromial
arch, the AC joint and the glenohumeral
joint is functionally narrowed. (Brukner&
Khan, 1993)
Impingement results from:
• Encroachment from above
• Swelling of rotator cuff tendons
• Excessive elevation of humeral head
Encroachment from above;
• This is usually due to abnormalities of the
surrounding structures.
• These are either congenital, such as “os
acromiale”, sloped acromion.
• Or due to osteophyte formation (spurring)
• Poor muscular stabilization of the scapula
is a common cause of encroachment of
the subacromial space in younger
athletes.
Swelling of rotator cuff tendons
The swelling of these tendons is another
cause of narrowing within the subacromial
space often due to an intrinsic overuse
tendinitis.
This condition is frequently associated with
poor biomechanics such as faulty
technique in throwing or other overhead
activities.
Instability
• The combination of congenital
abnormalities, osteophyte formation,
thickening of some structures through
aging, poor biomechanics and overuse
factors often lead to an instability of the
glenohumeral joint .
• This instability leads to rotator cuff fatigue
and may cause swelling of the tendons in
the subacromial space.
Overuse and misuse
• Ignoring the onset of early pain signals and a
resultant loss of power often results in a change
in technique.
• The poor biomechanics which occur as a result
of a continuation of training and competition
while compensating for a low grade injury are
common.
• This combination of continued activity, and poor
technique often result in further instability of a
compromised glenohumeral joint complex.
Elevation of the humeral head
• As a result of chronic instability the rotator
cuff tendons are likely to be weakened by
the excessive load being placed upon
them.
• Laxity of the anterior shoulder capsule
develops over time due to the repeated
stress placed on the static stabilizers at
the extremes of motion.
Understanding instability
• As the instability develops, continued use
of the shoulder will force the humeral head
up against the undersurface of the rotator
cuff tendons leading to ischemia and
further damage.
• Whenever assessing anyone with
impingement we must consider the
possibility of instability and its role in the
development of the condition.
Accurate assessment
• If the presence of instability is not
recognized and treated, the impingement
symptoms are likely to persist.
• Careful attention is paid to the person’s
description of any event leading to their
attendance at your clinic.
• If you suspect a dislocation, subluxation or
fracture, refer immediately to an
appropriate medical practitioner.
Step deformity
Clinical Assessment
• From a remedial therapists perspective
experience has shown we are more likely
to see chronic and acute on chronic injury
patterns.
• ROM testing is essential to gain an
accurate picture of painful arcs and loss of
function
Observation
• Viewing the client in each plane in the
standing position will also give an accurate
picture of shoulder function bilaterally and
highlight any other considerations, eg
upper crossed syndrome, which may be
relevant in establishing an accurate
prognosis for this client’s recovery.
ROM Testing
• The shoulder allows the following
movements:
• Flexion and extension
• Abduction and adduction
• Medial and lateral rotation
• Circumduction
• Initial testing should begin with a full
assessment of range of motion
Active Free or AF testing
• Active free testing describes how a client
would move their arm/shoulder through
the entire normal ROM described above.
• Both shoulders must be assessed for
comparison and what is normal for each
client.
• Scapulohumeral rhythm can easily be
assessed at this point.
Scapulohumeral Rhythm
Hoppenfeld: Physical
Examination of the Spine and
Extremities: RANGE OF
MOTION: Figure 51, p 22.
Passive movements
• Should you detect any loss of ROM you
should attempt to move the limb passively
through those painful arcs in an attempt to
establish any joint capsule pathology.
• This should be done with utmost care so
as not to exacerbate an existing condition
or increase the extent of an injury which
currently exists.
Special Tests
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Scapulohumeral Rhythm Test
impingement test
“empty can” test
instability test; posterior/anterior,
superior/inferior draw
• check quality of endfeel in each test
• Active Resisted tests in all ROM to
establish neuromuscular inhibition
X-ray and ultrasound
• Prior to beginning treatment, should you
have any doubt as to the extent of injury, it
is prudent to encourage your client to have
an x-ray of the shoulder. If this has already
been done and doubt prevails, an
ultrasound may detect any injured tendons
which may not have been detected by xray.
Cailliet: Soft Tissue Pain and Disability:
DROP SIGN; Figure 8-23, p 277
Active Trigger Points: TrPs
• Active trigger points may be detected during
routine Neuromuscular Technique, NMT
(Chaitow Soft Tissue Manipulation 1993)
• As shoulder pain may radiate proximally into the
neck, upper arm or even the forearm, wrist and
hand, a thorough evaluation needs to be made
via NMT and any trigger points deactivated
during this process.
Rotator Cuff TrPs
• NMT of both dorsal and ventral surfaces of
the scapula region on the affected side will
need to be applied to detect any active
TrPs of the infraspinatous, teres minor and
subscapularis muscles. NMT over the
superior border of the scapula will detect
any TrPs in the supraspinatus region.
Muscle energy technique
• Following a satisfactory palpatory
examination and TrP deactivation. A
warmup of the region should be
completed. Post isometric relaxation, PIR,
operator direct method may then be
attempted to release any residual tension
and discomfort in the region. Should this
prove too uncomfortable, alternating
between operator direct and patient direct
methods will often bring results.
Cervical considerations
• As active TrPs may arise within the
sternocleidomastoid, scalene and upper
trapezius regions concommitant with a shoulder
injury, NMT and PIR may also be employed to
obliterate any remaining TrPs and achieve
optimal ROM of these segments.
• This pressure and stretch approach has been
shown to be useful in clearing any residual
stiffness and pain in the region (Travell and
Simons 1982).
Adhesive Capsulitis
• Adhesive Capsulitis or Frozen Shoulder
occasionally occurs in the older
athlete/person.
• This is a painful condition which occurs as
a result of inflammation of the GH joint and
the surrounding capsule.
• The pain results in marked limitation of all
movements, these may be difficult to treat.
(Brukner&Khan 1993)
Cailliet: Soft Tissue Pain and Disability: SUBTLE SIGNS OF
ADHESIVE CAPSULITIS: Figure 8-25, p 278
Rattray & Ludwig: Clinical Massage Therapy:
GLENOHUMERAL JOINT ANATOMY: Figure 34.1, p
458.
Hoppenfeld: Physical Examination of the
Spine and Extremities: TEST FOR
ABDUCTION: Figure 52, p 23.
Hoppenfeld: Physical Examination of the Spine
and Extremities: FROZEN SHOULDER
SYNDROME: Figure 53, p 23
Rattray & Ludwig: Clinical Massage
Therapy: SHOULDER POSITION IN
HYPERKYPHOSIS: Figure 34.2. p 459.
Cailliet: Soft Tissue Pain and Disability: SUBTLE
SIGNS OF ADHESIVE CAPSULITIS: Figure 8-25, p
278.
Cailliet: Soft Tissue Pain and Disability:
ADHESIVE CAPSULITIS: Figure 8-26, p 279