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Rehabilitating Impairments of the Painful Shoulder

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1 Rehabilitating Impairments of the Painful Shoulder
Chris Fjosne, PT, DPT, OCS

2 Objectives Understanding the stages and treatment of Adhesive Capsulitis Understanding of the mechanism underlying rotator cuff disease Outlining the stages of primary and secondary impingement Facilitating the development of evidence-based strategies to treat rotator cuff impingement Making the appropriate referral for treatment

3 Differential Diagnosis
Cervical Radiculitis Frozen Shoulder Tendinopathy Tendinosis/Tendinitis Full thickness RC tears Partial thickness tears Impingement Bursitis

4 Cervical Screen Upper Limb Tension Test Spurlings Distraction
Cervical rotation <60° to involved side 3 of 4 (+) tests demonstrates 94% specificity 4 of 4 (+) tests demonstrates 99% specificity

5 Frozen Shoulder

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).

7 Primary vs. Secondary

8 Characteristics of Primary Frozen Shoulder
Patient age, years Insidious or minimal trauma event resulting in onset Significant night pain Significant limitations of active and passive shoulder motion in more than 1 plane 50% or greater than 30 degrees loss of passive external rotation All end ranges painful Significant 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 arthrofibrosis Studies 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 contracture Also 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 duration Pain with active and passive ROM Limitation of forward flexion, abduction, IR, ER Exam under anesthesia: normal or minimal loss of ROM Arthroscopy: GH synovitis (pronounced in anterosuperior capsule) Hypervascular synovitis Stage 2 3-9 months duration Chronic pain with active and passive ROM Limitation of forward flexion, abduction, IR, ER Exam under anesthesia: ROM is identical to when patient is awake Arthroscopy: diffuse pedunculated synovitis Hypervascular synovitis, subsynovial scar, fibroplasias

14 Stages of Adhesive Capsulitis
9-15 months duration Minimal pain except at end ROM Significant limitation of ROM with rigid end feel Exam under anesthesia: ROM identical to when patient awake Arthroscopy: No hypervascularity, fibrotic synovium, diminished capsular volume Capsule shows dense scar formation Stage 4 15-24 months duration Minimal pain Progressive improvement in ROM Minimal data available for exam under anesthesia

15 Adhesive Capsulitis Diagnosis
Rule in if: Pt. age is between years Pt. reports a gradual onset with progressive worsening of pain and stiffness Pain and stiffness limit sleeping, grooming, dressing, and reaching Glenohumeral passive ROM is limited in multiple directions Glenohumeral ER or IR ROM decreases as arm is abducted from 45 to 90 degrees Passive motions into the patient’s end ROM reproduce the patient’s reported shoulder pain Joint glides/accessory motions are restricted in all directions

16 Adhesive Capsulitis Diagnosis?
Rule out if: Passive ROM is normal Radiographic evidence of glenohumeral arthritis is present Passive ROM for ER and IR increases as you move from degrees and the reported pain is reproduced with palpatory provacation of the subscapularis myofascia Upper-limb nerve tension testing reproduces the reported shoulder pain Shoulder pain is reproduced with palpatory provocation of the relevant peripheral nerve entrapment site

17 Nonoperative Interventions
Oral medications Corticosteriod injections Exercise Joint mobilization Distension Acupuncture Manipulation Nerve blocks

18 Phase 1 Treatment Moist hot packs/electrical stimulation for pain
Frequent pain-free AAROM exercises Pendulum exercises Single plane mobilization (I, II) Soft tissue mobilization Stretching Home program (10-12 times daily light motion) Intra-articular corticosteriod injections

19 Phase 1 AAROM

20 Phase 2 Treatment Active warm-up AAROM exercises
Single plane near end range mobilizations (III) Stretching End range submaximal isometrics Self-capsular stretching Postural program Home 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 heat Aggressive joint mobilizations (IV) single and multi-planar and combined glides Stretching Strengthening Home program (4-6 times daily)

22 LLLDS is effective for improving Total End Range Time (TERT)
Lentell reported Time: minutes Frequency: 3-4x/day Duration: 60min/day Load 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 tissue Mobilizations should be performed at or near physiologic end range Improved extensibility of the any portion of the CLC results in improved motion in all planes Multi-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 weekly Prefer daily ROM stretching Self-capsular stretches Rotator cuff and scapular stabilization program to begin once functional ROM restored Activity modification

26 RCI Self Stretch The patient’s hand remains fixed and the elbow is adducted toward the table.

27 Posterior Capsule stretch
Sleeper Stretch Cross Body Capsular Stretch

28 Summary of Adhesive Capsulitis
Stiff shoulder vs. adhesive capsulitis Assess and determine the stage of pathology Assess classification to determine appropriate treatment phase Understanding and combining LLLDS, soft tissue mobilizations and multi-planar mobilizations PT appropriate at all stages but patient may need image guided intra-articular injection during painful phase 1 of treatment.

29 RC Tendinopathy Seitz 2010

30 Extrinsic vs. Intrinsic Mechanisms
Extrinsic Mechanisms relates to external tendon compression or shear Impingement (Subacromial and Internal) Anatomical and Biomechanical Variants Intrinsic Mechanisms relates to within the tendon Tendon Vascularity Tendon Biology Tendon Morphology Genetic Predisposition

31 Subacromial space The 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 shape Subacromial spurs AC joint spurs Acromial shape and slope

33 Biomechanical Factors
Abnormal scapular kinematics Abnormal humeral kinematics Postural abnormalities RC and/or scapular muscle performance Soft tissue tightness

34 Scapular motions Patients with normal scapular mechanics show upward rotation, slight external rotation and posterior tilting of the scapula during shoulder elevation.

35 Factors leading to impingement
Mobility Deficits Capsular stiffness, Glenohumeral internal rotation deficiency Stability Deficits Scapular dyskinesis, Capsular laxity, Acquired anterior instability Neuromuscular control/Strength Deficits Scapular stability weakness, RC weakness, poor recruitment patterns

36 Primary Impingement Primary 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 Impingement Internal 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 age Typically overuse injuries with compressive and shear forces

40 Ellenbecker & Cools 2012

41 Rehabilitating patients with impingement syndrome
Pec minor stretching Posterior capsule stretching and mobilization Postural strengthening and education RC and scapular muscle strengthening and retraining Focus on modifiable factors

42 Summary Adhesive 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!

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