For physiotherapy student 3rd year msk

1. AC, SC and GH joint
disorders
Dechasa Imiru (BSc, MSc PT)
Physiotherapy Department
Jimma University
April, 2023

2. Acromioclavicular Joint Disorders
Acromioclavicular Joint Disorders
• Disorders is a general term to
cover a range of conditions.
• The two common conditions
affecting this joint are
–Dislocation / Subluxation
–Arthritis

3. Dislocation / Subluxation/separation
Mechanisms of Injury:
• Strain on the ligaments following a fall
–Onto the hand or
–Onto the Elbow or
–Onto the shoulder
• Direct hit or bump over the shoulder
(contact sports)
• Depending on the injury the joint
partially dislocates (subluxation)

4. Signs and symptoms
Signs and symptoms
• Severe pain is felt over the
shoulder
• Pain get worse by lifting arm up
or carry anything
• The injured area is usually very
tender

5. Associated risk factors
Associated risk factors
–American football
–Rugby
–Ice hockey
–Alpine skiing
–Snowboarding
–Bicycling

6. Note:
Note:
• When someone got fall or hit, not only
the ACJ, also other structures can be
involved
• Glenohumeral_Joint and/ SCJ
(dislocation)
• Labral lesion
• brachial plexus
• Fractures and others

7. Rockwood classification system
Rockwood classification system
Grade I
• Partial tear of the AC joint ligament
• No change in position of clavicle in
relation to the acromion
• No instability of joint

9. Grade II
• Rupture/tear of the AC ligament,
Partial tear of the coracoclavicular
ligament
• Displacement of clavicle (less than
the full width of the clavicle)

11. Grade III
• Rupture of AC and coracoclavicular
ligament
• Displacement of clavicle (more than
the full width of the clavicle)

13. INSTABILITY OF A-C Jt.
INSTABILITY OF A-C Jt.
Grade 1:
No instability of acromio-clavicular joint.
Grade 2:
Slight instability of A-C joint. ‘Springy’ clavicle.
Grade 3:
Total separation of A-C joint. The clavicle goes
superiorly

14. Diagnostic procedure
Diagnostic procedure
• Direct compression of the ACJ (the
Paxinos test) is a good clinical diagnostic
tool
• Imaging

15. ACTIVE MOVEMENTS TO ASSESS A-C Jt.
ACTIVE MOVEMENTS TO ASSESS A-C Jt.
Abduction
 Cross Flexion
CROSS FLEXION

16. Active Abduction of the Shoulder Joint
• Grade 1:
Full R.O.M. with pain at end of range.
• Grade 2:
Has over 45º of motion but not 90º.
• Grade 3:
less than 45º.

17. What is the initial treatment?
What is the initial treatment?
• Pain modalities and anti-inflammatory
medication to alleviate pain
• Sprains and majority of dislocations require a
sling to rest the joint
• It takes about 6 weeks for the discomfort to
settle down
• Grade III injuries may require stabilizing
surgery
• Severe dislocations require surgery to put the
joint back together and to repair the torn
ligaments (arthroscopic operation)

18. Physiotherapy Management
Physiotherapy Management
• The rehab is longer for a grade II injury
but the protocol is the same for grade I
• After pain easing it is important to
start as soon as possible with
–Movement
–Active exercises

19. Cont …
Active exercises:
• Moving the fingers, wrist and elbow
to prevent stiffness
• Progress with more targeted
shoulder exercises
Strengthening exercises:
• As pain is reduced more mobility and
strengthening is promoted

20. Sterno clavicular Joint Injuries
Sterno clavicular Joint Injuries
• It is a synovial joint, gaining the majority
of its strength from surrounding ligaments
• It can become relatively unstable if
subjected to trauma
–Due to the unreserved movement it provides
and
–the small part of the joint which actually
connects
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21. Signs and symptoms
Signs and symptoms
• Pain will be present if the joint is only
mildly sprained
• Straight away recognizable deformity will
be observed if the SCJ has been dislocated
• Pain is worsened when moving the arms
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22. Two types of SCJ dislocation
Two types of SCJ dislocation
• Anterior dislocations cause clavicle to poke out
of position
• Creating a readily visible bump on the chest
• Posterior dislocations can affect the throat,
limiting the ability to breath or swallow
properly

23. Causes
Causes
• Sporting activity, result of a falling and
accident
• The motor vehicle accident (MVA)
Mechanism of injury
• A hard strike to the shoulder
–(known as indirect force because it does not
hit the joint directly) e.g. contact sports

24. Treatment
Treatment
• Closed reduction or surgery (posterior
dislocation)
• Followed by immobilization for about 2 month
• Minor sprains should generally heal in a few
days on their own with suitable rest (sling)

25. Treatment …
Treatment …
• Cryotherapy a few times per day to reduce
pain and swelling, and anti-inflammatory pain
medication
• Avoid strenuous activities involving the arms
and shoulders
• Increasing motion of shoulder and build up
strength again using appropriate strategies

26. Shoulder Dislocation
anatomical predisposition to dislocation
–Glenoid Defects
– Labral Defects
– Neuromuscular Disorders
• Shoulder dislocations can occur in
two common directions:
–Anterior
–posterior

27. Types of dislocation
Types of dislocation
Traumatic
Atraumatic
Acquired

28. Anterior Shoulder Dislocation
• Accounts for 97% of recurrent or first
time dislocations
Causes;
– due to trauma from a direct posterolateral force
on the shoulder
– Due to an excessive amount of abduction and
external rotation direction force

29. • Supporting structures that may be
weaken in an anterior dislocation are:
–anterior capsule
–long head of biceps
–Subscapularis
–Superior and middle glenohumeral
ligaments

30. When an anterior dislocation results from a
traumatic event:
• loss of integrity of the anterior ligamentous
capsule
• Detachment of the anterior inferior labrum
• In severe cases, concurrent rotator cuff
injuries
• Fractures may occur

31. Anterior Dislocation Clinical
Presentation
• Arm held in abducted and ER position
• Loss of normal shape of the deltoid. M
• Acromion is prominent posteriorly and
laterally
• Humeral head palpable anteriorly
– Palpable fullness below the coracoid process and
towards the axilla
• All movements limited and painful

33. Cont …
Thorough examination is need to
check if there is;
–damage to rotator cuff musculature
–Bone fracture
–Vascular
–Nervous structures

35. Posterior Shoulder Dislocation
• Accounts for 3% of shoulder dislocations
• Caused by an external blow to the front of the
shoulder
• When force is applied to the humerus that
combines flexion, adduction, and internal
rotation
• Resulted from falling on an out stretched hand
(FOOSH injury)
• Traumatic mechanism of injury, posterior
dislocations may also have concurrent labral
or rotator cuff pathology or fracture

36. Posterior Dislocation
With acute posterior glenohumeral
dislocation:
– Arm is abducted and internal rotated (IR)
– May notice posterior prominence head of
humerus

37. Re-current dislocation
• Recurrence rate of dislocations in young active
individuals is as high as 92-96%
• In young patients , initial suggestions are to try
conservative rehabilitation because the risk of re-
dislocation is lower,
• Individuals whom are 40 and older also have a
low recurrence rate around less than 15%
• The recommended management is non operative
and to address associated injuries

38. Shoulder instability
• Instability can occur whenever the labrum is torn,
stretched or peeled back off the bone,
• This allows the head of the humerus to move
away from the glenoid
• This can occur after;
• a shoulder dislocation, shoulder trauma, or as a result of
repetitive motion
• Some patients also have a genetic predisposition
to develop shoulder instability

39. Continued …
• Patients with shoulder instability can suffer from
recurrent shoulder dislocations/subluxations or
shoulder pain
• Dislocations can cause fractures and rotator cuff
tears
• Osteoarthritis or wearing of the surface cartilage
of the shoulder joint can also occur as a result of
shoulder instability

40. Diagnostic Procedures
• Rule out a fracture if dislocation
is suspected
• Radiographs are necessary
• An MRI can be used to rule in or
rule out any soft tissue
pathologies

41. Management of sho. Dislocation
• Non surgical conservative management is
preferred, initially
• Surgical repair may be reasonable for fail
conservative care or
• Require extreme usage of the upper
extremity (i.e. elite level athletes)

42. Cont …
• Non-surgical intervention will be
a closed reduction by an
orthopedic surgeon
• Surgical intervention will be
surgical repairing by stabilization
procedures

43. Conservative management
Phase 1 (up to 6 weeks): Goal is to maintain
stability
Closed reduction
• Immobilization: by using sling (IR vs ER) for 2-
6 weeks
• Ice pack or pain medication (2-3 weeks)
To reduce stiffness:
• Gentle PROM of shoulder out of sling
• AROM for distal joint of the shoulder

44. Cont …
During the immobilization period
• Codman Exercises (pendulum exercises)
• AAROM for ER (0-30 degree) and FF (0-90
degree) & abduction
NB: Do each movt’s separately !!
• Static contraction can be incorporated for
the rotator cuff and biceps musculature
(end of this phase or the next)

46. Phase 2 (6-12 weeks)
Goal is to restore adequate motion
specifically in ER
• AAROM will continue to achieve full ROM
• Static strengthening for shoulder
(wall and towel exercises of FF, Ext, ER,
abd, add, IR)
• Passively stretch the posterior joint
capsule or self-stretching

47. Phase 3 (12-24 weeks)
Goal return to sports or physical activities of
daily living
Begin progressive strengthening exercises:
Strengthening exercise in a pain-free motion
(theraband exer.)
• Focusing on the rotator cuff musculature,
scapular stabilizers and then, progress to the
larger musculature
• Start focusing on functional exercises to
promote patient's activities and participation
in society

48. FF and ABD

49. EXT and IR

50. IR (Modified) and ER

51. ER and IR strengthening exercises

52. Extensor and flexors

53. Abductors

54. More advanced exercises
• Weight bearing exercises
–Push-ups against a wall
–Push-ups on four point kneeling
position
–Standard push-ups

55. Note !!
• Strengthening the structural support will
increase the joint stability and will reduce
the chance of re-dislocation
• Evidences shown that there is high
recurrence rate in the first 2 years of the
initial dislocation
• After three months patient can return to
normal ADL activities gradually
• Therefore high risk activities are not
advisable