4 Anatomy Acromium Rotator interval Supraspinatus Posterior/ Superior ZoneInfraspinatusCorocoidAnteriorZoneTeres minorSubscapularisGlenoidNB: Subacromial Bursa not illustrated here but a critical element
5 Biomechanical Considerations DeltoidSuprasp.InfraspinSubscapTeres Minor
6 Cable Theory Posterior Pillar Anterior Pillar subscap Teres Minor LHBT Supra/infra sp.
8 Rotator Cuff Examination No test is absolute and definitiveTests are merely a provocation symptoms rather than a confirmation of diagnosis (Lewis, 2008)90% of diagnoses are made from the patient history (Malone, 2005)
10 Special Tests Supraspinatus Jobes Test 90 degrees scaption Internal rotation (thumb down)Without resistance then with resistancePain and or weaknessModification to start in thumbs up and run resistance testing through range to include rotator interval component.Initiation of Abduction testingArm by the patients sidePalpate the Humeral HeadAssess resisted abductionWeakness, pain, superior translation of humeral headare all indicative of a positive test
11 Subscapularis Gerber’s Lag sign Gerber’s lift off test As above but the therapist positions the hand ways from the spine and the patient must hold this position. (80% sensitivity for small tears)Gerber’s lift off testHand behind the back at 90 degrees elbow flexionThe patient must keep the arm away from the spineThe Therapist can add resistance(90% sensitivity for weakness or pain)LaFosse belly pressHand rests on belly with wrist at neutral away from the forearmHeld away from the body.The patient pulls the entire arm into the stomach (watch for drop of elbow or wrist), can also add therapist resistance to the outside of the elbowGood for patients with restrictions to movementRecruitment of P.major in 25% clouds the examination
12 Infraspinatus and Teres Minor Resisted testing1. External rot lag sign (ERLS) with arm at waist the therapist positions arm in full external rotation and the lets go while the patients attempts to hold this position. You can then add therapist resistance and required looking for pain/weakness.2. Patient Holds arms in 60 degrees scaption with elbows at 90 degrees. Patient must resist internal rotation movement against the therapist.Pain and or weakness can be indicative of posterior cuff insufficency.
13 Infraspinatus and Teres Minor Patte’s Test90 degrees of abduction and external rotation, the patient must hold against resistance.Watch for correct scapulo-thoracic alignmentCan test eccentric control elementHornblowers SignArm held in 90 degrees scaption with hand in front of the mouth (supination). Patient must move the arm out into external rotation against gravity, however the therapist can also look to add resistance.Hornblowers lag signArm is positioned at 90 degrees in scaption with full external rotation by the therapist. The Patient must the hold this position once the therapist lets the arm go. A positive drop sign is indicative of a massive posterior cuff tear.
14 Biceps tendon Check for Popeye sign (rupture of LBHT) Speeds test Patient holds straight arm in supination at 90 degrees flexion and tries to elevate the arm against the therapists resistance. Pain indicative of provocation.90% Sensitivity and 15 % specificity (Malone 2005)LaFosse AERS test (abduction, ext rot, supination)Arm is held at 90 degrees abduction and externally rotated with elbow at 90 degrees in pronation.The Therapist provides resistance as the patient supinates the armPain is indication of possible biceps irritation or SLAP tearYergason’s testarm by side and elbow at 90 degrees, the therapist holds the patients hand and resists the patient moving into supination while palpating the LHBT.Look for pain and or subluxation of tendon from bicepital groove
15 Shoulder Impingement Syndrome Extrinsic Primary Acromial shapeACJ pathologyHypertrophied CA ligChronic Synovitis of BursaSecondary Instability (micro and gross)Posterior capsule tightnessNeurogenicS/T dysrythmiaIntrinsic HypovascularityAge related degenerative changesOveruseCuff weakness/fatigue/cuff rupture
16 Impingement Tests Neer’s Test Hawkins (Kennedy) Test Therapist stands behind the patient and stabilizes the scapular. The holds the arm in ‘thumbs down’ in full elbow extension.The maneuver is to the elevate the arm into f.flexionProvocation of pain (80% specificity for bursa and cuff problems Malone et al)Hawkins (Kennedy) TestTherapist holds he arm in the plane of the scapular with the elbow at 90 degrees.The hand is put into a thumbs down position and then the arm is medially rotated, a positive test provokes pain/restriction of movement (90% sensitivity, Malone et al)
17 Acromioclavicular joint Pain on palpationPain at end range abduction, hand behind backScarf testPain provocation with horizontal adductionNB restriction of movement may be due to posterior capsular stiffness esp. if scapular is held in retraction
18 Innervation Suprascapular nerve Nerve to Subscapularis Axillary or Circumflex nerveLateral Pectoral NerveAutonomic Nervous System (LBHT)
19 Practical Session Basic Assessment Provocation Testing Where to Start Rehab?
26 Types of Shoulder Prosthesis Fully constrained = For severe arthritis of the shoulder and destruction of the rotator cuff. Basically a salvage procedure.Semi constrained = To prevent superior subluxation of the humeral prosthesis when the patient has joint arthritis and rotator cuff insufficiency.Un Constrained =Joint arthritis with good rotator cuff function.Surface replacement= one articular surface involved
27 Cemented or Uncemented? Reduced pain reportedIncreased mobilitySenior populationLess physically demanding lifestyleUncementedAvoid loosening of partsScope for revision in younger personActive lifestyleExtended recovery period
28 RNOH Philosophy Bone Stock & Rotator Cuff Good BS / good RC = unconstrained TSRGood BS / poor RC = ConstrainedPoor BS / good RC = CAD-CAM stemPoor BS / poor RC = CAD-CAM glenoid/stem
34 RNOH Rehabilitation guidelines Weak and smooth shoulderStiff shoulder
35 Post operation immobilisation Abduction pillowpolysling
36 Rehab Guidelines All of this will vary according to the individual Phase 1 – Initial RehabOptimise tissue healing (time specified)Pain control “SMOOTH AND WEAK”Use of slingNo ER>neutral/20 degreesA-A/Passive elevation<90 degreesNo active use of UL or strengtheningNo HBB or cross bodyEducationMilestones for next stageAchieved time specific goalsFor X-rays to show osseo-integrationAllowed ROM achievedReduced painAdequate scapula control
37 Early phase day 1 -6/52 exercise Active assisted GHJ FF 90ISOMETRIC ER IN NEUTRALCarer performing the exerciseISOMETRIC IR IN NEUTRAL
38 Early phase day 1 -6/52 exercise Start position with shoulder supportedCarer performing the exerciseEnd position of exerciseActive assisted GHJ ER to neutral start…
39 Phase 2 – Early Recovery (approx 6 weeks – 4 months) Decrease sling useStart light activity at waist levelIncrease ROMOptimise normal movement patternsNo exercises that increase painNo active anti-gravity work until RC rehabilitatedDeltoid Programme for Constrained TSRMilestones for next stageNo slingMinimal painPassive ROM: elevation>90 and ER>30RC stabilises within available ROMFunctional Triangle
40 Phase 3 – Late Recovery (approx 5 months – 12 months) Increase strength and endurance to functional level requiredNo exercises that increase painNo heavy lifting above shoulder levelMilestones for DischargeReduced pain from pre-op statusAchieved functional goalsExpected outcomesUnconstrained – Light to moderate use at waist, shoulder and above shoulder levelConstrained – Light use at waist level andtowards shoulder height if possibleMay take months to achieve
41 Rehabilitation Guidelines Follow link to CLINICAL SERVICESClick on PhysiotherapyClick on SHOULDER AND ELBOW UNITSelect Guideline for exercise information