Adhesive Capsulitis. Presented by Mary Ewers-Dennison, Sara Hamilton, Cynthia Watkins, Barbara Woolston, Donna Tiley, Marydel Delmar, Marc Tanner, M.

Transcription

1 Adhesive Capsulitis Presented by Mary Ewers-Dennison, Sara Hamilton, Cynthia Watkins, Barbara Woolston, Donna Tiley, Marydel Delmar, Marc Tanner, M.D

2 Adhesive Capsulitis Definition: Decreased ROM in all planes secondary to inflammation of the shoulder capsule Self Limiting Pain Therapeutic intervention varies

3 Adhesive Capsulitis Primary = idiopathic May not respond well to therapy Good candidate for intra-articular injection Secondary = due to trauma or immobilization In patients > 45 years Responds well to therapeutic intervention

4 Adhesive Capsulitis Operative Treatment After failed therapeutic intervention Manipulation under Anesthesia Anterior Capsular Release Rotator Interval Release Non-operative Treatment Intra-articular injection (hydroplasty saline vs. cortisone) PT/OT

5 Anatomy: Ligaments

6 Anatomy: Ligamentous Stuctures

7 Anatomy: Ligaments

8 Anatomy: Ligaments

9 Anatomy: Rotator Cuff (supraspinatus)

10 Anatomy: Pectoralis Minor

11 Anatomy: Rotator Cuff Interval

12 Anatomy: Serratus Anterior

13 Anatomy: Rotator Cuff (subscapularis)

14 Anatomy: Rotator Cuff Interval

15 Anatomy: A-C Joint, Coracoid process

16 Evaluation Ideas Observe posture Assess Shoulder ROM (ER/Abduction, IR) Strength, MMT Neurological/sensory Special Tests (decreased ROM active and passive in all planes)

17 Therapeutic Intervention Modalities Hot packs with stretch IFC/TENS Ultrasound with ROM

18 Therapeutic Intervention Exercise Joint mobilization with emphasis on the coracohumeral ligament, subscapularis, teres major, pec minor. CPM Strengthening, PRE/RRE

19 Research: Intervention Arthroscopic release for chronic, refractory adhesive capsulitis of the shoulder End-Range Mobilization Techniques in Adhesive Capsulitis of the Shoulder Joint: A Multiple-Subject Case Report PHYS THER Vol. 80, No. 12, December 2000, pp

20 Plan of Care Surgical Inter-scalene nerve block 5x week x 1 week PROM post-op day 1 2x a week x 4 weeks followup/ out-patient for OT/PT Non-surgical 2-3 times per week OT/PT mins in clinic Home Exercise Program 2-3 times per day for 30 mins. Home Exercise Program Pulleys, cane ex. In Pulleys, cane ex. Swimming

21 Questions

22 2010 Teton Hand and Upper Extremity Conference: Clinical Workshop The Elbow: Elbow Instability Group members: Sara Hamilton, Donna Tiley, Marydel Delmar, Mary Ewers-Dennison and Barbara Woolston

23 Elbow Instability Posterior Lateral Rotatory Instability (PLRI) Medial Collateral Ligament Instability

24

25 Elbow Instability Causes Osseus Dislocation/Fracture Vascular Ischemia Iatrogenic Surgery Soft Tissue Ligament, laxity, avulsion/disruption Steroid injections (too many)

26 Lateral Collateral Ligament Complex

27 Annular Ligament

28 Lateral Collateral Ligaments Radial Collateral Annular Ligament Lateral Ulnar Collateral Origin: Capitellum of the Humerus Insertion: Supinator Crest of the Ulna

29 Etiology Elbow Dislocation Elbow Fractures Post Lateral Epicondylitis Surgery Radial Head Exposure

30 Posterior Lateral Rotatory Instability Laxity of the ulnar part of the lateral collateral ligament, which allows a transient rotatory subluxation of the ulnohumeral joint and a secondary dislocation of the radio- humeral joint. The annular ligament remains intact, so the radio-ulnar joint does not dislocate. O Driscoll (JBJS 1991)

31 Research: Evaluation O Driscoll, S.W., Bell, D. F., & Morrey, B. F. (1991). Posterolateral rotatory instability of the elbow. Journal of Bone & Joint Surgery. 73:

32 Pivot Shift Test This test involves supination of the forearm and application of a valgus moment and an axial compression force to the elbow while it is flexed from full extension. The elbow is reduced in full extension and must be subluxated as it is flexed in order to obtain a positive test result.

33 Pivot Shift Test

34 Posterior Elbow Dislocation

35 Surgical Repair Ligament Reconstruction with Tendon graft, allograft, or graft jacket

36 Postoperative Treatment Splint elbow 90 degrees flex, pronation x 1 week (post op splint) Brace 30 degrees ext block allow full flexion and full pronation x 4 weeks Protect x 3 months for full healing PRE s 4 months High level activity 6 months

37 Ulnar Collateral Ligament Complex

38 Ulnar Collateral Ligament Complex Anterior Bundle Posterior Bundle Transverse Ligament

39 Etiology Throwing Trauma

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41 Valgus Stress Test

42 Milking Test Valgus stress demonstrating instability of the anterior bundle of the UCL complex

43 Intervention Conservative OT/PT Bracing

44 Intervention Surgical Tommy John Surgery Donor Tendon is used to reconstruct a damaged anterior bundle of the UCL complex.

45 Tommy John Surgery

46 Therapeutic Intervention Ideas Splinting Modalities ROM Scar Massage Strengthening

47 Research: Therapeutic Interventions carlykreps.tripod.com/tommyjohn/id6.html

48 Plan of Care Tommy John Surgery rotocol.pdf

49 Questions?

50 2010 Teton Hand and Upper Extremity Conference: Clinical Workshop The Hand/Wrist: Ulnar-sided Wrist Pain Group members:

51 Purpose To provide all attendees the opportunity to discuss, interact, organize, and assimilate clinical thought, evidence based literature, and specific treatment ideas as a cohort.

52 Clinical Workshop Outline Roles/person 1. Anatomist 2. Researcher: Evaluation 3. Researcher: Therapeutic Intervention 4. Evaluator/Antagonist 5. Therapeutic Exercise contributor 6. Plan of care contributor Timeline (90 minutes) 5 min: discuss roles/organize responsibilities 25 min: review/discuss anatomy slides 10 min: evaluator suggests assessment ideas 10 min: research evaluator suggests literature ideas 10 min: therapeutic interventionist suggests ideas 10 min: research therapeutic interventionist suggests ideas from literature 10 min: antidotal clinical treatment ideas 10 min: plan of care clinician suggests ideas for continuum of care 7. Antidotal clinician/scribe

53 Objectives 1. Each group member will take an active role with their given responsibility. 2. The antagonist in the group will offer directed, thoughtful, and founded argument to presented ideas (devils advocate in a constructive, resourceful manner). The antagonist will also keep the time, ensure flow, and completion of the project. 3. The anatomist will pre-dissect the shoulder specimen and present work in power point format. 4. The anatomist will replace the sample illustrations in the power point with their own photos of the suggested structures (suggested structures are illustrated as examples in this power point presentation). 5. The evaluator will suggest/discuss evaluation thoughts specific adhesive capsulitis.

54 Objectives 6. The research evaluator will search, review and present evaluation thoughts from the literature. 7. The therapeutic interventionist will suggest/discuss treatment thoughts specific to adhesive capsulitis based on his/her clinical expreince. 8. The research therapeutic interventionist will search, review and present treatment thoughts from the literature. 9. The antidotal clinician will offer and lead a group discussion treatment ideas specific to adhesive capsulitis based on their own clinical reservoir of knowledge and clinical experience (this person will be a senior therapist). 10. The plan of care clinician will discuss the frequency, duration and continuum of care specific to adhesive capsulitis. 11. All groups members will end the workshop with their own copy of power point presentation they helped to create. 12. All groups will also receive copies of other group presentations

55 Objectives 6. The research evaluator will search, review and present evaluation thoughts from the literature. 7. The therapeutic interventionist will suggest/discuss treatment thoughts specific to adhesive capsulitis based on his/her clinical expreince. 8. The research therapeutic interventionist will search, review and present treatment thoughts from the literature. 9. The antidotal clinician will offer and lead a group discussion treatment ideas specific to adhesive capsulitis based on their own clinical reservoir of knowledge and clinical experience (this person will be a senior therapist). 10. The plan of care clinician will discuss the frequency, duration and continuum of care specific to adhesive capsulitis. 11. All groups members will end the workshop with their own copy of power point presentation they helped to create. 12. All groups will also receive copies of other group presentations

56 Gross Dissection Outline & Examples Remember: the goal is for your group to complete your workshop session with a uniform power point presentation for each group member. Each group may have different presentations.

57 Wrist/Hand Dissection Outline (discuss clinical relevance) 1. FDS/FDP origin & insertion 2. Carpal tunnel 3. Extensor carpi ulnaris sheath 4. Extensor compartments 5. Triangular fiibrocartilage complex (TFCC) 6. Distal radial ulnar joint (DRUJ) 7. Superficial radial nerve 8. Arcade of Frohse 9. Guyan s canal 10. Motor recurrent branch of median nerve 11. Juncutrea tendinum 12. Sagittal bands 13. Lumbricals/interoussei 14. Pulley system 15. Extensor hood 16. Lateral bands 17. Volar plate 18. Terminal extensor tendon 19. Triangular ligament 20. Neurovasucular bundle

58 Distal FDS/FDP

59 Carpal Tunnel

60 Extensor Carpi Ulnaris Sheath

61 Extensor Compartments

62 TFCC

63 DRUJ

64 Superficial Radial Nerve

65 Arcade of Froshe (radial nerve)

66 Guyan s Canal

67 Motor Recurrent Branch of Median Nerve

68 Juncturea Tendonium

69 Sagittal Bands

70 Intrinsics

71 Pulley System

72 Extensor Hood

73 Lateral Bands

74 Volar Plate

75 Terminal Extensor Tendon

76 Triangular Ligament

77 Neurovascular Bundle

78 Evaluation Ideas ROM, strength, special tests, history, observation, posture, etc

79 Evaluation Ideas

80 Research: Evaluation List supporting references/discuss implications Search ideas: google scholar, University of Florida Health Science Library, PubMed, etc.

81 Therapeutic Intervention Ideas Examples: mobilizations, splinting, exercise, activities, etc.

82 Therapeutic Intervention Ideas

83 Research: Therapeutic Interventions List supporting references/discuss implications Search ideas: google scholar, University of Florida Health Science Library, PubMed, hard copy articles provided

84 Plan of Care Outline the frequency, duration, and scope of treatment.

85 Summary Thoughts