1. Orthopedic Management of the Shoulder
Chapter 22
p. 392

2. Anatomy Review (GH joint)
Glenohumeral Joint
Bones
Scapula
Glenoid fossa
Acromion process
Scapular spine
Axillary border
Vertebral border
Humerus
Humeral head
Surgical neck
Anatomic neck
Greater tubercle
Lesser tubercle
Intertubecular (bicepital groove)
Muscles
Deltoid
Anterior
Middle
Posterior
Rotator Cuff
S.upraspinatus
I.nfraspinatus
T.eres Minor
S.ubscapularis
Biceps
Triceps
Pectoralis Major
Latissimus Dorsi
Teres Major
Actions of these muscles?

3. Anatomy Review (GH Joint cont)
Bursa
Subacromial
Labrum
Function?
Ligaments (Capsule)
Superior Glenohumeral ligament
Middle Glenohumeral ligament
Inferior Glenohumeral ligament
Redundant folds
Coracohumeral ligament
Coracoacromial ligament
Provide Anterior Support
Provide Superior Support

4. Anatomy Review (GH joint cont.)
Motions?
Planes?
Axis?
Degrees of Freedom?
ROM estimates?

5. Anatomy Review (AC joint)
Acromioclavicular Joint
Bones
Scapula
Acromion process
Clavicle
Ligaments
AC ligament
Coracoacromial Ligament
Bifurcated
Conoid
Trapezoid
Motions?
Planes
Axis?
Degrees of Freedom?

6. Anatomy Review (SC Joint)
Sternoclavicular Joint
Bones
Sternum
Clavicle
Ligaments
Interclavicular ligament
Sternoclavicular ligament (2)
Anterior
Posterior
Motions?
Planes?
Axis?
Degrees of Freedom?

7. Anatomy Review (ScapuloThoracic Junction)
Bones?
Muscles?
Movements?
Scapulohumeral Rhythm?
Implications?

8. Common Pathologies Glenohumeral Joint Acromioclavicular Joint
Impingement syndrome
Rotator cuff tear
Adhesive capsulitis
Dislocation
Subluxation
Bankart Lesion
SLAP lesion
Hill-Sachs lesion
Multidirectional Instability (MDI)
Acromioclavicular Joint
Separation

9. Impingement Syndrome Very common Cause Laborers Athletes
Persons who do repetitive overhead motion
Cause
“the tendons of the rotator cuff (and subacromial bursa) are crowded, buttressed, or compressed under the coracromial arch, resulting in mechanical wear, stress, and friction” fig p. 393

10. 2 types of Impingement Primary Secondary
Mechanical compression of r/c tendons
Primarily which one?
Secondary
Related to GH instability that creates reduced subacromial space
Causes of GH instability?

11. Subacromial Space Causes for decreased subacromial space
Degenerative changes
Osteophyte formation
On Acromion process
Shape of acromion process
Straight
Slight hook
Hooked
Loss of scapular stabilization

12. Supraspinatus tendon Most common structure involved with impingement
Hypovascular just proximal to insertion point on humerus
“watershed zone”
“critical zone”
How damaged
Overhead activities
Mechanical wear
Stress
Friction
Can lead to
Impingement
Tendonitis
Tears

13. Stages of Rotator Cuff Impingement
Related to age and degenerative changes
Stage I
Younger patients
<25 y/o (can occur at any age)
Clinical features
Edema
Hemorrhage
Pain worse with >90 degrees abd.
Reversible lesion
Stage II
Middle age patients
25-40 y/o
Pain with ADL’s
PM pain
Fibrotic changes of
Supraspinatus tendon
Biceps tendon
Subacromial bursa
Irreversible because of long term repeated stress

14. Stages of Rotator Cuff Impingement
Stage III
>40 y/o
Long history of repeated shoulder pain and dysfunction
Characterized by
Tendon degeneration
R/C tears
R/C ruptures
Significant muscle weakness/atrophy

15. Rehabilitation of Primary and Secondary Rotator Cuff Impingement
Scapular Weakness
Affects humeral head stabilization
“functional scapular instability”
Affects
Scapular position during activities that causes
“relative decrease in subacromial space”
This can cause secondary impingement
Weak scapular muscles (serratus anterior, traps (3), levator scapula, rhomboid)
p nd paragraph

16. Rehabilitation of Primary and Secondary Rotator Cuff Impingement
Rehabilitation Program
Phase I
Pain/inflammation control
Modification of activities
Stretching
Phase II (recovery stage)
Criteria for moving to phase II
Improved motion without pain
ADL’s without pain
Scapular strengthening
R/C strengthening
Phase III (functional recovery)
Move slowly/cautiously
Overhead activities incrementally

17. Surgical Management of Shoulder Impingement
When used
PT fails
R/C tears
Neer’s stage III impingement
Tendon degeneration
Cuff tears
Management with no cuff tear
Subacromial decompression
Rehab
Same as before surgery

18. Surgical Management of Shoulder Impingement
Management with rotator cuff tear
3 types of cuff tear
Type I
<1cm
Type II
1-3cm
Type III
>5cm

19. Type I R/C Tear Rehabilitation
Active motion and pain-free exercise can begin as soon as patient tolerates
Same as before surgery

20. Type II/III Rehabilitation
Tissue protection must be longer to allow for soft-tissue healing
“rehabilitation must match surgical procedure”
Wilk and Mangine
Open procedure-anterior deltoid resection
Open procedure-lateral deltoid splitting
Arthroscopic
Larger cuff repairs take longer to heal

21. Rehab after decompression
Same as before decompression
3 phases
Phase I (early recovery) (acute stage) (maximal protective phase)
Approx 6 weeks
Pain/inflammation control
Protected motion (if applicable)
Type I cuff tears and less
Submaximal isometrics as soon as pain allows
Abductors, ER, IR, flexors, elbow flexors, gripping
PROM
AAROM
Performed pain free
ROM and strength gradually increase as pain decreases

22. Rehab after decompression
Phase II (intermediate) (fibroblastic phase) (moderate protective phase)
7-12 weeks
No flexion >90 degrees
Increase strength
Concentrics/eccentrics
Humeral head stabilization exercises (scapular stabilization)
Maintenance of pain control
Avoid repetitive motions

23. Rehab after decompression
Phase III (maturation) (tissue remodeling) (minimum protection phase)
Weeks 13-21
Begins when patient shows increased motion without symptoms
Gradual return to normal activites