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Ullswater Physio CPD


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Assessment & Management of the Shoulder in Private Physiotherapy Practice

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Ullswater Physio CPD

  1. 1. Assessment & Management of the Shoulder in Private Physiotherapy Practice Ullswater Physiotherapy & Sports Injuries Clinic CPD Mary McCance MSc. BSc (Hons). BSc (Hons). MCSP Sat 15th Feb 2020
  2. 2. Let’s learn more about the shoulder! • Shoulder pain / stiffness / instability is the second most common presentation I see in clinical practice after back pain • I see mainly sports / occupational injuries among active populations • Some of these people will have been seen by multiple practitioners often with varying diagnoses and treatments • Some will have Coaches / PTs • Some will be at first contact
  3. 3. Common presentations in clinical practice • Painful shoulder – Painful arc, pain with activities above shoulder height, pain with driving, pain lying on the affected side, pain with HBB (hand behind back) • Stiff shoulder Usually lacking range into flexion/extension, abduction and/or internal/external rotation • Unstable shoulder the patient will tell you it feels unstable, painful clunks and clicks • Weak shoulder muscle atrophy noted with weakness on resisted / functional tests possible possible winging of the scapula • Or a combination of these
  4. 4. Common Causes of Pain • The primary sources of pain are: • 1. Glenohumeral joint, including the articular labrum, the biceps and the capsule • 2. Subacromial area, rotator cuff, the bursa and the acromion • 3. AC joint, including the articular meniscus
  5. 5. Normal Shoulder Anatomy
  6. 6. Ligaments
  7. 7. Glenoid Labrum
  8. 8. Rotator Cuff Anatomy
  9. 9. Scapulothoracic anatomy
  10. 10. Anterior view
  11. 11. Force Couples of the Shoulder Two separate force couples are of particular importance in motion of the shoulder complex. The trapezius and serratus anterior act together to produce upward rotation of the scapula. If one or more of these muscles is weak or dysfunctional this can lead to impingement.
  12. 12. Force Couples The rotator cuff acts in concert with the deltoid to move the arm above head. One of the actions of the deltoid is to lift your arm over your head. One of the actions of the 4 rotator cuff muscles works to depress the humerus. The deltoid is bigger and stronger than the rotator cuff. With a weak rotator cuff, the deltoid can easily win this force battle and begin to elevate the humeral head too far. Leading to impingement.
  13. 13. Some possible underlying causes of pain • Rotator cuff pathology – painful arch / impingement – internal/external impingement • Bursitis – fluid filled sac • Glenohumeral instability - history of dislocations • Labral tears • Biceps related pathology - SLAP tears / tendinopathy • Posterior shoulder stiffness (GIRD) • Scapular pathology • Adhesive capsualitis (frozen shoulder) • Calcific Tendonitis • ACJ / SCJ
  14. 14. How I assess the shoulder • History taking o How / when did it start / mechanism of injury o Any history of trauma / red flags / yellow flags o Location of symptoms / body chart o Any pins and needles / numbness o Aggravating factors / what makes it worse o Easing factors / what makes it better o Sleep o Worse, better, staying the same o Any other injuries o Medical history / meds o Create Problem list o Assess goals
  15. 15. Objective Examination • Visual check deformity / bruising / swelling • Observe patient undressing for examination • Always check the neck first AROM / PROM • Active range of movement (AROM) include thoracic spine • Passive range of movement (PROM) • Resisted tests • Grip strength hand held dynamometry • Always assess the other arm • Special tests
  16. 16. Special Tests • The following tests are just a brief sample of the many tests of the shoulder • The various tests presented are not a sure fire way of diagnosing pathology • Multiple pathologies can and do coexist • It is impossible to isolate and test single structures • Findings must be seen in the context of a thorough history • Imaging of the shoulder may be required • The most accurate way to diagnose shoulder pathology is through arthroscopy
  17. 17. Special Tests • Posterior Capsular tightness GIRD Good Starting point. Often seen in overhead athletes / occupations. Posterior capsular tightness leads to anterosuperior translation of humeral head in flexion. Can lead to impingement of subacromial space •
  18. 18. Special Tests • Neer’s Impingement Test Designed to reproduce symptoms of rotator cuff impingement under the corocoacromial arch through flexing the shoulder and applying pressure. Symptoms should be reproduced if there is a problem with the supraspinatus or biceps. This test is also associated with the Hawkin’s Kennedy Test • A positive test may be due to other causes such as ACJ pathology
  19. 19. Special Tests Neer’s impingement sign is elicited when the rotator cuff tendons are pinched under the coracoacromial arch. The test is performed by placing the arm in forced flexion with the arm pronated. The scapula should be stabilised to prevent scapulothoracic motion. Pain is a sign of subacromial impingement. • Neer’s impingement Test
  20. 20. Special Tests • Hawkin’s Kennedy Test designed to reproduce patients symptoms and infers impingement. Less reliable than Neer’s Test. Indicative of impingement between the greater tuberosity of the humerus against the coraco- humeral ligament, trapping all those structures which intervene.
  21. 21. Special Tests • Apprehension Test. Testing anterior instability. Designed to recreate apprehension and the feeling that the joint is vulnerable. In supine or sitting the arm is positioned in 90° abduction and external rotation. With increasing external rotation the examiner watches for apprehension on the part of the patient.
  22. 22. Special Tests Apprehension Test Essentially this test must produce an apprehension response from the patient. Pain alone does not = a positive test. In the case of a positive test then proceed to the relocation test.
  23. 23. Special Tests • Jobe’s Relocation Test Most sensitive test to determine the presence of anterior instability especially in the face of secondary impingement. The examiner performs the apprehension test and notes the amount of external rotation before the onset of apprehension. They then return to the start position and apply a posterior stress over the humeral head. They then repeat external rotation and again note amount of external rotation at onset of apprehension.
  24. 24. Special Tests Jobe’s Relocation Test Jobe proposed that the anteriorly directed force tends to compress the rotator cuff tendon between the greater tuberosity and the posterior superior region of the glenoid rim; thus patients with minor instability will experience pain but not apprehension.
  25. 25. Special Tests • O’Brian’s Test For SLAP tears / ACJ. The patient is instructed to flex their arm to 90° with the elbow fully extended and then adduct the arm 10-15°medial to sagittal plane. The arm is then maximally internally rotated and the patient resists the examiner's downward force. The procedure is repeated in supination. The O'Brien Test is designed to maximally load and compress the ACJ and superior labrum. For maximal results the authors stress that the patient should resist the examiner's downward force rather than the examiner resisting forward flexion.
  26. 26. Special Tests • Scarf Test designed to test the ACJ the 90 degrees flexed arm on the affected side is forcibly adducted across the chest. It is essential that the patient reports the pain as being specifically over the AC joint with this test for a positive test. It is common to feel posterior capsule stretch pain with the test (false positive). An injury to the AC joint is typically sustained from a direct fall on the point of the shoulder. The injury may range from a torn meniscus of the joint to a complete dislocation .
  27. 27. Clinical Reasoning
  28. 28. Management of the Shoulder • Should we treat? When to refer • Exercise selection & Rehabilitation plan • Manual techniques acupuncture / massage / rock blades • Return to sports / previous activities • Monitor / adapt / progress goals • Liaise with other professionals. Private / NHS / PTs
  29. 29. Rehab Exercises • Passive mobility pulley work / cane • Auto assisted cane / stick / TRX • Active mobility work through all ranges • Resistance exercises isometrics / concentrics / eccentrics • Proprioception exercises • Closed chain / weight bearing • Open chain • Whole kinetic chain / functional rehab • Sport / work specific drills • Goal driven rehabilitation • See Physiotools sheet for rehab ideas
  30. 30. Rehab Exercises • Select exercises and reps/sets according to o Assessment findings o Patient’s ability / pain levels o Patient’s time constraints o Patients sport / occupation o Patient’s goals o Equipment available o Space available o Time available
  31. 31. Rehab Exercises • Resistance exercise is an important component of effective rehab programmes, but the optimal level of resistance remains unclear. Pain and/or fatigue can be used to guide treatment prescription, but whether pain should be produced or avoided during exercise is not clear. • Higher doses of exercises might confer superior outcomes, and should be maintained for at least 12 weeks before a decision regarding the potential for surgery is taken.
  32. 32. Shoulder Tendons • Some studies advocate surgery for tendinopathies after 3–6 months of conservative management. • Recent research has demonstrated that outcomes after tendon loading exercises both up to 12 months and longer term are as good as surgery, at least for shoulder tendinopathy. • It suggested healthcare professionals who treat patients with tendinopathies should reserve surgery for selected cases and only after a sufficiently long course (12 months) of evidence-based loading exercise has failed.
  33. 33. Outcome Measures • DASH / Quick DASH questionnaires • Functional measures HBB / driving / bench press • Hand Held Dynamometry grip strength • 10 rep max of a relevant exercise or anywhere • 1 rep max of a relevant exercise in between • Pain 0-10 scale • RPE scale • Sleep
  34. 34. To Close • The shoulder complex is complex but assessment, management and rehabilitation can follow some simple principles. o Treat the patient as a whole person both physically and mentally o Refer as required. Initially if concerned or other investigations are required, or If not improving after a month or so of good quality rehab refer the patient to their GP o Exercise is the corner stone of treatment for Physiotherapy / rehab o Work with other professionals where possible Consultant / GP / Physio / PT / Sports Therapist o Always listen to the patient how they are feeling / coping with exercises and rehab. Provide opportunities for discussion o Be progressive and goal driven o Expect setbacks
  35. 35. References • Brukner & Kahn (2017) Clinical Sports Medicine (5th edition). McGraw & Hill Education. Australia. • Challoumas et al (2019) How does surgery compare to sham surgery or physiotherapy as a treatment for tendinopathy? A systematic review of randomised trials. BMJ Open Sport Exer Medicine. doi:10.1136/bmjsem-2019-000528 • Funk et al (2020) Sports Injuries of the Shoulder. Springer. Switzerland. • Littlewood et al (2015) Therapeutic Exercise for Rotator Cuff tendinopaty: a Systematic Review of Contextual Factors and Prescription Parameters. International Journal of Rehabilitation Research. DOI: 10.1097/MRR.0000000000000113 • • • •
  36. 36. Abbreviations • ACJ Acromioclavicular Joint • AROM Active Range of Movement • PROM Passive Range of Movement • GHJ Glenohumeral Joint – ball & socket joint • GIRD Glenohumeral Internal Rotation Deficit • HBB Hand Behind Back • RPE Rating of Perceived Exertion • SLAP Superior Labrum Anterior Posterior lesions of the glenoid labrum. • STJ Sternoclavicular Joint • TRX Total Resistance eXercise suspension training