Presentation on theme: "Rehabilitating Impairments of the Painful Shoulder"— Presentation transcript:
1 Rehabilitating Impairments of the Painful Shoulder Chris Fjosne, PT, DPT, OCS
2 ObjectivesUnderstanding the stages and treatment of Adhesive CapsulitisUnderstanding of the mechanism underlying rotator cuff diseaseOutlining the stages of primary and secondary impingementFacilitating the development of evidence-based strategies to treat rotator cuff impingementMaking the appropriate referral for treatment
6 Adhesive Capsulitis Recognition-Classification Adhesive capsulitis- Nevaiser defined it as “the inflamed and fibrotic condition of the capsuloligamentous tissue.Codman described frozen shoulder as “a condition difficult to define, difficult to treat, and difficult to explain from the point of view of pathology.”Stiff and painful shoulder: painful condition with limited active and passive range of motion (ROM).
8 Characteristics of Primary Frozen Shoulder Patient age, yearsInsidious or minimal trauma event resulting in onsetSignificant night painSignificant limitations of active and passive shoulder motion in more than 1 plane50% or greater than 30 degrees loss of passive external rotationAll end ranges painfulSignificant pain and/or weakness of the internal rotators
9 Etiology and Pathology Although precise etiology remains unclear, evidence identifies elevated serum cytokine levels.Cytokines and other growth factors facilitate tissue repair and remodeling as part of the inflammatory process.The inflammatory healing response can lead to excess accumulation and production of fibroblasts releasing type 1 and type III collagen.This exaggerated inflammatory response leads to arthrofibrosisStudies report focal vascularity and synovial angiogenesis (increased papillary growth) rather then a synovitis.
10 Etiology and Pathology cont. However, it is agreed that whether it is angiogenesis or synovitis that pain accompanies the change.Open and arthroscopic examination demonstrated significant capsuloligamentous complex (CLC) fibrosis and contractureAlso contracture of the rotator cuff interval (RCI) is prevalent
11 Rotator Interval (RCI) The RCI forms the triangular-shaped tissue between the anterior supraspinatus edge and upper subscapular border, and includes the superior glenohumeral ligament and the coracohumeral ligament.
13 Stages of Adhesive Capsulitis 0-3 months durationPain with active and passive ROMLimitation of forward flexion, abduction, IR, ERExam under anesthesia: normal or minimal loss of ROMArthroscopy: GH synovitis (pronounced in anterosuperior capsule)Hypervascular synovitisStage 23-9 months durationChronic pain with active and passive ROMLimitation of forward flexion, abduction, IR, ERExam under anesthesia: ROM is identical to when patient is awakeArthroscopy: diffuse pedunculated synovitisHypervascular synovitis, subsynovial scar, fibroplasias
14 Stages of Adhesive Capsulitis 9-15 months durationMinimal pain except at end ROMSignificant limitation of ROM with rigid end feelExam under anesthesia: ROM identical to when patient awakeArthroscopy: No hypervascularity, fibrotic synovium, diminished capsular volumeCapsule shows dense scar formationStage 415-24 months durationMinimal painProgressive improvement in ROMMinimal data available for exam under anesthesia
15 Adhesive Capsulitis Diagnosis Rule in if:Pt. age is between yearsPt. reports a gradual onset with progressive worsening of pain and stiffnessPain and stiffness limit sleeping, grooming, dressing, and reachingGlenohumeral passive ROM is limited in multiple directionsGlenohumeral ER or IR ROM decreases as arm is abducted from 45 to 90 degreesPassive motions into the patient’s end ROM reproduce the patient’s reported shoulder painJoint glides/accessory motions are restricted in all directions
16 Adhesive Capsulitis Diagnosis? Rule out if:Passive ROM is normalRadiographic evidence of glenohumeral arthritis is presentPassive ROM for ER and IR increases as you move from degrees and the reported pain is reproduced with palpatory provacation of the subscapularis myofasciaUpper-limb nerve tension testing reproduces the reported shoulder painShoulder pain is reproduced with palpatory provocation of the relevant peripheral nerve entrapment site
20 Phase 2 Treatment Active warm-up AAROM exercises Single plane near end range mobilizations (III)StretchingEnd range submaximal isometricsSelf-capsular stretchingPostural programHome program (frequent sustained end range stretches 5-7 minutes in duration)
21 Phase 3 Treatment Active warm-up Low load long duration stretch (LLLDS) with heatAggressive joint mobilizations (IV) single and multi-planar and combined glidesStretchingStrengtheningHome program (4-6 times daily)
22 LLLDS is effective for improving Total End Range Time (TERT) Lentell reportedTime: minutesFrequency: 3-4x/dayDuration: 60min/dayLoad added to stretch is (.5% BW)
23 What do we need to know about connective tissue? In the absence of normal joint movement, the normal orientation of the connective tissue’s collagen fibers is lost.Long-lasting or plastic elongation is produced by exposing connective tissue.The effectiveness of a low-load long duration stretch (LLLDS) to promote long-lasting elongation of connective tissue is well documented.Studies also support that the temperature of the connective tissue at the time of the stretch can significantly influence the long-lasting change that is produced.Elevating the temperature of the tissue prior to the stretch and during the stretch produced greater changes and less tissue damage.
24 Joint mobilizations during Phase 3 High-grade joint mobilizations are used to promote elongation of shortened fibrotic soft tissueMobilizations should be performed at or near physiologic end rangeImproved extensibility of the any portion of the CLC results in improved motion in all planesMulti-planar mobilization techniques utilize rotational stress with concomitant translation which loads the collagen in multiple planes
25 Home Maintenance Program Continue stretching program at least 3-4 times weeklyPrefer daily ROM stretchingSelf-capsular stretchesRotator cuff and scapular stabilization program to begin once functional ROM restoredActivity modification
26 RCI Self StretchThe patient’s hand remains fixed and the elbow is adducted toward the table.
27 Posterior Capsule stretch Sleeper StretchCross Body Capsular Stretch
28 Summary of Adhesive Capsulitis Stiff shoulder vs. adhesive capsulitisAssess and determine the stage of pathologyAssess classification to determine appropriate treatment phaseUnderstanding and combining LLLDS, soft tissue mobilizations and multi-planar mobilizationsPT appropriate at all stages but patient may need image guided intra-articular injection during painful phase 1 of treatment.
30 Extrinsic vs. Intrinsic Mechanisms Extrinsic Mechanisms relates to external tendon compression or shearImpingement (Subacromial and Internal)Anatomical and Biomechanical VariantsIntrinsic Mechanisms relates to within the tendonTendon VascularityTendon BiologyTendon MorphologyGenetic Predisposition
31 Subacromial spaceThe acromiohumeral distance(AHD) is the linear measure to between the acromion and humeral head used to quantify the subacromial space
32 Anatomical Factors Subacromial spurs AC joint spurs Acromial shapeSubacromial spursAC joint spursAcromial shape and slope
36 Primary ImpingementPrimary Impingement- compression of the RC tendons between the humeral head and overlying anterior third of the acromion, coracoacormial ligament, coracoid or AC joint.
37 Secondary Impingement Attenuation of the static stabilizers of the GH joint, such as capsular ligaments and labrum, from the excessive demands incurred in throwing or overhead activities can lead to anterior instability
38 Internal ImpingementInternal impingement occurs when the shoulder is in a 90/90 position and the undersurface of the supra and infra tendons become compressed or pinched between the humeral head and the posterosuperior gleniod rim.
39 Rotator Cuff Tears Incidence increases with age Research shows that tears are present in 50% or more of the patient population greater than 60 years of ageTypically overuse injuries with compressive and shear forces
41 Rehabilitating patients with impingement syndrome Pec minor stretchingPosterior capsule stretching and mobilizationPostural strengthening and educationRC and scapular muscle strengthening and retrainingFocus on modifiable factors
42 SummaryAdhesive capsulitis and RC tendinopathy are two of the most common diagnoses related to ongoing shoulder pain.Research and evidence based practice demonstrates positive functional outcomes when treated conservatively with PT.
43 What if I need surgery?Thank you and enjoy your next lecture!