Working with The Shoulder

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1 Working with The Shoulder Plus BONUS Stretching! Dr Bryan Hawley DC

2 Housekeeping Recording will be sent out tomorrow Certificates Questions All presented today is based off OUR OWN CLINIC system Lets begin copy right 2010 Dr Bryan Hawley

3 Shoulder pain is extremely common in fact it is the 2 nd most common complaint Difficult joint to examine Multi directional ROM Must make an accurate dx of the cause of the symptoms (look for the root cause) in order for it not to keep reoccurring

4 Anatomy Glenohumeral Joint- ball and socket synovial type of joint Highly dependent and guarded by muscles and ligaments When relaxed the head of the humerus is centered in the glenoid cavity Rotator Cuff mm plays vital role in stability and support

5 Pectoral/Shoulder girdle muscles from the back

6 Pectoral/Shoulder girdle muscles from the front

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9 Clinical Presentation Usually effects persons in the age from and mostly females Slight wasting of muscular tissue surrounding the joint with palpable tendernes Pain is gradual in onset External rotation is most inhibited of the ROM

10 Common Shoulder Injuries Impingement Syndrome Rotator Cuff Sprain Strain Rotator Cuff Tear Glenoid labral Tear Tendonitis Bursitis AC Separation Adhesive Capsulitis (Frozen Shoulder)

11 Shoulder Exam This topic is broken down into general shoulder exam inspection palpation ROM neurovascular exam impingement tests rotator cuff tests labral injury tests biceps injuries tests AC joint instability Other, Radiology

12 Acromioclavicular (AC) Joint Distraction Test Acromioclavicular (AC) Shear Test Adson s Maneuver Allen Test Anterior Drawer Test Apley s Scratch Test Apprehension Test Brachial Plexus Stretch Test Biceps Load Test Clunk Test Crank Test Cross-Over Impingement Test Drop Arm Test Empty Can (Supraspinatus) Test Feagin Test French Horn Test Gerber s Lift Off Test Grind Test Hawkins Test / Hawkins-Kennedy Impingement Test Jobe Relocation Test Load and Shift Test Orthopedic Special Tests for the Shoulder Girdle Ludington s Sign Neer Impingement Test O Brien s Test Pectoralis Major Contracture Test Piano Key Sign Posterior Drawer Test Roos Test Shoulder Abduction Test Speed s Test / Speed s Maneuver Sternoclavicular (SC) Joint Stress Test Sulcus Sign Yergason s Test Yocum Test

13 Impingement Tests Neer Impingement Sign indicative of impingement as well as many other causes of shoulder pain/focal abnormalities (stiffness, OA, instability, bone lesions); note you must have full range of motion for "positive" finding. technique use one hand to prevent motion of the scapula while raising the arm of the patient with the other hand in forced elevation (somewhere between flexion and abduction) eliciting pain (positive test) as the greater tuberosity impinges against the acromion (between ) Hawkins Sign positive with impingement technique performed by flexing shoulder to 90, flex elbow to 90, and forcibly internally rotate driving the greater tuberosity farther under the CA ligament. test for impingement. Jobe s Test positive with supraspinatus weakness and or impingement technique abduct arm to 90, angle forward 30 (bringing it into the scapular plane), and internally rotate (thumb pointing to floor). then press down on arm while patient attempts to maintain position testing for weakness or pain. Internal Impingement patient supine, abduct affected side to 90 and maximally externally rotate (throwing position-late cocking phase) with extension. If this maneuver reproduces pain experienced during throwing (posteriorly located) considered it is considered positive. Further confirmed with relief upon performing relocation test. Reperform test in Abduction/max. ER with elbow in front of plane of body and pain disappears.

14 Rotator Cuff Tests Subscapularis Strength is tested comparing both sides by having patient keep elbow at sides in 90 of flexion test ability to internally rotate against resistance. Internal Rotation Lag Sign this tests is the most sensitive and specific test for subscapularis pathology. technique stand behind patient, flex elbow to 90, hold shoulder at 20 elevation and 20 extension. Internally rotate shoulder to near maximum holding the wrist by passively lifting the dorsum of the hand away from the lumbar spine then supporting the elbow, tell patient to maintain position and release the wrist while looking for a lag. Increased Passive ER a person with a subscapularis tear may have increased Passive ER rotation when compared to contralateral side Lift Off Test more accurate for inferior portion of subscapularis. technique hand brought around back to region of lumbar spine, palm facing outward; Test patient s ability to lift hand away from back (internal rotation). Inability to do this indicates subscapularis pathology. Is confounded by other muscles. More accurate if the tested hand can reach the contralateral scapula. Belly Press test positive with subscapularis pathology more accurate for superior portion of subscapularis technique patient presses abdomen with palm of hand, maintaining shoulder in internal rotation. If elbow drops back (does not remain in front of trunk)

15 Supraspinatus tests Supraspinatus Strength Jobe s Test strength is assessed using Jobe s Test (see below) pain with this test is indicative of a subacromial bursitis/irritation not necessarily a supra tear. Only considered positive for tear with a true drop arm. i.e. arm is brought to 90 and literally falls down. tests for supraspinatus weakness and/or impingement technique abduct arm to 90, angle forward 30 (bringing it into the scapular plane), and internally rotate (thumb pointing to floor). Then press down on arm while patient attempts to maintain position testing for weakness or pain. Drop Sign tests for function/integrity of supraspinatus technique passively elevate arm in scapular plan to 90. Then ask the patient to slowly lower the arm. The test is positive when weakness or pain causes them to drop the arm to their side.

16 Infraspinatus Infraspinatus Strength external rotation strength tested while the arm is in neutral abduction/adduction External Rotation Lag Sign positive when the arm starts to drift into internal rotation technique passively flex the elbow to 90 degrees, holding wrist to rotate the shoulder to maximal external rotation. Tell the patient to hold the arm in that externally rotated position. If the arm starts to drift into internal rotation, it is positive.

17 Teres Minor Teres Minor Strength external rotation tested with the arm held in 90 degrees of abduction Hornblower's sign positive if the arm falls into internal rotation it may represent teres minor pathology technique bring the shoulder to 90 degrees of abduction, 90 degrees of external rotation and ask the patient to hold this position

18 AC joint Tests Acromioclavicular joint tenderness tenderness with palpation of the acromioclavicular joint Cross-Body Adduction positive when there is pain in the AC joint technique patient forward elevates the arm to 90 degrees and actively adducts the arm across the body. Obrien's Test (Active Compression test) positive when there is pain "superficial" over the AC joint while the forearm is pronated but not when the forearm is supinated Technique patient forward flexes the affected arm to 90 degrees while keeping the elbow fully extended. The arm is then adducted degrees across the body. The patient then pronates the forearm so the thumb is pointing down. The examiner applies downward force to the wrist while the arm is in this position while the patient resists. The patient then supinates the forearm so the palm is up and the examiner once again applies force to the wrist while the patient resists.

19 Drop-arm test Abduct the patient's shoulder to 90 and ask the patient to lower the arm side in the same arc of movement. Severe pain or inability of the patient to return the arm to the side slowly indicates a positive test result.a positive result indicates a rotator cuff tear.

20 Neer impingement test The shoulder is forcibly forward flexed and internally rotated, causing the greater tuberosity to jam against the anterior inferior surface of the acromion. Pain reflects a positive test result and indicates an overuse injury to the supraspinatus muscle and possibly to the biceps tendon indicative of impingement as well as many other causes of shoulder pain/focal abnormalities (stiffness, OA, instability, bone lesions); note you must have full range of motion for "positive" finding. technique use one hand to prevent motion of the scapula while raising the arm of the patient with the other hand in forced elevation (somewhere between flexion and abduction) eliciting pain (positive test) as the greater tuberosity impinges against the acromion (between )

21 Hawkins-Kennedy impingement test With force internally rotate the shoulder. Pain indicates a positive test result and is due to supraspinatus tendon and greater tuberosity impingement under the coracoacromial ligament and coracoid process.

22 Apprehension test Abduct the arm 90 and fully externally rotate while placing anteriorly directed force on the posterior humeral head from behind. The patient becomes apprehensive and resists further motion if chronic anterior instability is present.

23 Coracoid impingement syndrome is a less common cause of shoulder pain. Symptoms are presumed to occur when the subscapularis tendon impinges between the coracoid and lesser tuberosity of the humerus.

24 Where is the pain coming from? Rotator cuff? Bursa (bursitis) Glenohumeral disorders (capsulitis, frozen shoulder), arthritis Acromioclavicular pathology Trauma (minor dislocation) Referred, neck and upper back pain Fibromyalgia Internal disorders (lung malignancy cardiovascular)

25 Typical Gen Shoulder TPs

26 Adhesive Capsulitis Frozen Shoulder Syndrome Disorder in which the shoulder capsule becomes inflames and stiff greatly restricting the normal ROM Unless trauma is present the etiology is mostly unknown Progressive pain and increasing stiffness which sometimes will resolve spontaneously after 18 month Pain is worse at night and shoulder movement is severely restricted

27 Rehab of Frozen Shoulder Phase1 This phase is usually the most painful phase of frozen shoulder treatment and movement becomes gradually more and more difficult. The aim of the following treatments and exercises is to help control pain and maintain movement in the shoulder joint. Electrotherapy modalities such as ultrasound, TENS and laser treatment may all help reduce pain and inflammation. Massage and Trigger Point work for surrounding muscles combined w passive ROM Phase 2 Mobility exercises such as pendulums and wand exercises should be continued. Frozen shoulder stretching exercises for the chest muscles and muscles at the back of the shoulder should also be maintained. Strengthening exercises for frozen shoulder can be performed to maintain muscle strength. Isometric or static contractions are exercises needing no joint movement and can be done without worrying about movement in the shoulder. Phase 3 Mobility exercises and stretches can become more aggressive, but should still be within the boundaries of pain. Aim to restore full mobility in the shoulder joint. Strengthening exercises can progress from isometric or static contractions, to exercises using a resistance band, then eventually free weights or weight machines.

28 Impingement syndrome This occurs when the space between the humeral head and the acromion above becomes narrowed The three things that usually get pinched are 1. Joint capsule itself 2. Tendons of the rotator cuff muscles 3. Bursa sac This can create either a bursitis or tendonitis depending on the Structures involved. Overhead usage workers and athletes are more likely to have Issues such as this Approx 1/3 of shoulder problems are due to impingement

29 Rotator Cuff Muscles SITS

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31 Rotator Cuff Injuries Tendinitis: Tendons in your rotator cuff can become inflamed due to overuse or overload, especially in athletes who perform a lot of overhead activities. In some people, the space where the rotator cuff resides can be narrowed due to the shape of different shoulder bones, including the outside end of the collarbone or shoulder blade. Bursitis: The fluid-filled sac (bursa) between your shoulder joint and rotator cuff tendons can become irritated and Strain or tear: Left untreated, tendinitis can weaken a tendon and lead to chronic tendon degeneration or to a tendon tear. Stress from overuse also can cause a shoulder tendon or muscle to tear.

32 Rotator Cuff Tear A ripping of one or more of the tendons Result when a sudden eccentric force applied to the rotator cuff resulting in failure of the tendon. Uncommon under the age of 40 but strains do occur. In the population over 40 years of age, supraspinatus tears occur and less commonly, infraspinatus tears. Tears in the subscapularis tendon are uncommon and are often the result of a shoulder dislocation.

33 Rotator Cuff Tears YOUNG PERSON Usually is more due to a traumatic type injury from a hanging or falling on an outstretched arm A person can have a chronic injury such as a repetitive stress syndrome that can lead to a tear OLDER PERSON It is more likely due to loss of elasticity within the muscle and tendon which can result in A tear from doing basic everyday activities.

34 Causes of RT Tears Repetitive stress: Repetitive overhead movement of your arms can stress your rotator cuff muscles and tendons, causing inflammation and eventually tearing. This occurs often in athletes, especially baseball pitchers and tennis players. It's also common among people in the building trades, such as painters and carpenters Impingement: Falls or incorrect throwing techniques or arm movements and weak shoulder muscles may cause the arm bone to move up and trap the tendon. This may also happen in persons who over-train or have a sudden change in arm or shoulder activity. Normal wear and tear: The rotator cuff tendons can degenerate due to ages (starting around the age of 40). This can cause a breakdown of fibrous protein (collagen) in the cuff's tendons and muscles. Calcium deposits: Calcium may deposit in the tendons due to decreased oxygen and poor blood supply. These deposits may cause irritation and inflammation

35 Causes Cont. Poor posture: When you slouch your neck and shoulders forward, the space where the rotator cuff muscles reside can become smaller. This can allow a muscle or tendon to become pinched under your shoulder bones, including your collarbone, especially during overhead activities, Falling: Using your arm to break a fall or falling on your arm can bruise or tear a rotator cuff tendon or muscle. Lifting or Pulling: Lifting an object that's too heavy, or doing so improperly (especially overhead) can strain or tear your tendons or muscles. Pulling something, such as an archery bow of too heavy poundage, may cause an injury.

36 Rotator Cuff Tears Symptoms Atrophy of the muscles around the shoulder Pain when someone else lifts the arm Pain when lowering the arm from a fully raised position Weakness when moving the arm Crackling or grinding sensation when arm is passively moved With a partial tear the person will feel pain but still have normal ROM With a complete tear there is pain but not normal ROM Overhead motions are most difficult A shoulder shrugging motion is present

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39 Tendinitis of the Supraspinatus Sup Tendinitis is a common condition of the shoulder that causes anterior shoulder pain Present usually in abduction The painful arc is between 60 and 90 deg of abduction. Pt usually starts leaning body away from arc to avoid excessive abduction Pain sleeping on the affected side Catching of the shoulder during use Pain on BOTH AROM and PROM Palpable tenderness

40 Supraspinatous Tendinitis Test With pt seated abduct the arm to 90 deg against resistance POS pain or weakness over the insertion of the Supraspinatous tendon may indicate tendinitis or tear Pain over the deltoid mm may indicate a strained medial or anterior deltoid mm. Watch for pt leaning away sign as well. Always perform on the non involved side first to get a baseline ROM and resistance pressure Apley ScratchTest With pt seated place hand of affected shoulder behind head to touch the upper part of the back. POS indicates tendinitis of the tendons of the supraspinatous tendon

41 Bursitis The subacromial bursa overlies the rotator cuff tendons Bursitis is associated with tendinitis of the of the adjacent supraspinatus tendon Causes of bursitis are trauma, overuse, multiple traumas, improper executed activity Clinical Signs and Symptoms Anterloateral shoulder pain Pain sleeping on affected side Stiffness Pain on AROM and PROM

42 Glenoid Labrum The glenoid Labrum is a ring of cartilage attached to the margin of the Glenoid cavity of the scapula This labrum acts to keep the humeral head positioned on the glenoid by blocking Unwanted movement.

43 A SLAP tear is an injury to the labrum of the shoulder, which is the ring of cartilage that surrounds the socket of the shoulder joint. The term SLAP stands for Superior Labrum Anterior and Posterior. In a SLAP injury, the top (superior) part of the labrum is injured Injuries to the superior labrum can be caused by acute trauma or by repetitive shoulder motion. An acute SLAP injury may result from: A motor vehicle accident A fall onto an outstretched arm Forceful pulling on the arm, such as when trying to catch a heavy object Rapid or forceful movement of the arm when it is above the level of the shoulder Shoulder dislocation People who participate in repetitive overhead sports, such as throwing athletes or weightlifters, can experience labrum tears as a result of repeated shoulder motion.

44 3 Main types of instability 1.Anterior 2.Posterior 3.Multi Directional

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46 Posterior Instability 5% of cases Painful arc (PROM and AROM) if dislocated Feeling of shoulder slippage Apprehension on any movement Crepitus on movement Increase shoulder girth if dislocated TEST Pt is supine, forward flex and internally rotate the shoulder. Apply an ant-post pressure on the elbow POS Pain or apprehension on the pts face.

47 Shoulder Drawer Sign Manually assessing translation the examiner places hand on upper humeral while stabilizing at the distal end and checks for excessive movement. This can also be done sitting as well with placing hand on scapula and posterior shoulder for support while moving the humeral head. Apprehension test modified Pt arm is placed in abduction, extension, and external rotation while stressing it in anterior translocation. If patient becomes apprehensive or reports pain this is a pos finding.

48 What is Multidirectional Instability of the Shoulder? MDI of the shoulder is defined as generalized laxity (looseness) of the joint due to increased mobility and joint weakness. The shoulder joint may "slip" in and out of its socket in a forward (anterior), backward (posterior), or downward (inferior) direction. This "laxity" may be exaggerated in people who participate in activities that require repeated overhead movement of the arm, such as baseball pitchers or swimmers. The most common cause of MDI is overuse of the shoulder or repetitive stress.

49 At Home Exercises for shoulder instability Shoulder instability is relatively common condition characterized by loosening of the connective tissue (ligaments and joint capsule) surrounding the shoulder joint therefore enabling the bones forming the joint to move excessively on each other.

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57 Stretching the Sup.

58 The End, Thank you Recording will be sent out tomorrow Certificates Questions All presented today is based off OUR OWN CLINIC system Lets begin copy right 2010 Dr Bryan Hawley