This case study describes the physical therapy treatment of a 61-year-old male with a partially healed proximal humeral fracture and rotator cuff tear in his right shoulder. He had limited range of motion and pain with movement after 8 weeks of immobilization. The treatment plan involved joint mobilization techniques to increase shoulder range of motion, as well as strengthening exercises to improve muscular strength. The goals were to restore normal motion and strength without exacerbating pain.

1. Shoulder Mobilization Case Study Proximal Humeral Fracture

2. History 61 year old male Fractured the greater tuberosity of the right shoulder eight weeks ago Partially tore the rotator cuff muscle of the same shoulder. Patient was immobilized in a sling for eight weeks.

3. Clinical Presentation Sever limitation of right shoulder motions Demonstrates a capsular pattern External rotation, abduction , medial rotation Complains on a dull constant ache within the shoulder at rest. Rating the resting pain as a 6/10 on the pain scale. Experiences sharp pains with any motion of the shoulder . Pain is rated as a 8/10. X-rays and MRI indicates that the fracture is healed and the rotator cuff is partially healed.

4. Physical Therapy Referral Restore motion and normal strength to the right shoulder

5. Clinical Considerations Patient has moderate to sever pain with any movement. Shoulder restriction is due primarily to capsular and muscle shortening around the fracture site. Muscular strength of the right shoulder complex is weak due to the prolong immobilization.

6. Treatment Plan Modalities Mobilization techniques Strengthening exercises

7. Mobilization Joints to be mobilized Glenohumeral Sternoclaviclar Acromclavical Scapula Potential muscled that are shorten. Subscapularis Pectoral major & minor Infaspinatus & teres minor Lat Rhomboids Serrtaus Upper mid and lower trap

8. Goal Increase shoulder glenohumeral motion without exacerbation of pain.

9. Concepts To Remember In The Glenohumeral Joint Osteokinematic : There is 3 degrees of freedom Flexion/Extension, ABd /ADd, Internal/External Rot. Articulator surface anatomy Concave glenoid & convex humerus Loose pack position 20 degrees scapulohumeral abduction with 30 degrees elevation in the scapular plane.

10. Concepts To Remember In The Shoulder Complex Joint Accessory (C omponent ) Motions Arthokinematic movements that must occur in order for normal osteokinematic movement to take place Eg. Inferior Glide Joint Play Motion Those accessory that can be produced passively at a joint but not actively. Eg. Lateral Distraction

11. Physiological Movements Refer to Matiland CD

12. Shoulder Flexion Glenohumeral Lateral distaction Inferior glide Posteior glide Sternoclavicular Inferior gilde Anterior glide Scapula Distraction Upward rotation Elevation

13. Scapluar Plane Oscillations General technique Introductory Pain Lubication of tissues

14. Glenohumeral Lateral Distraction Often one of the first technique to use Good for general capsular tightness Pain control

15. Inferior Glide In Loose Pack For restriction in flexion and abduction Used to decreased pain with grade I & II oscillation

16. Inferior Glide At 90º of Abduction Increase mid-range flexion and abduction

17. Anterior Glide In Loose Pack The primary tissue affect by this technique is the anterior capsular region

18. Posterior Glide In Loose Pack Matiland Technique Indication for posterior capsular tightness Used in the early phases of the rehab to began To increase internal rotation

19. Posterior Glide At 90º Abduction Posterior Glide at 90 degrees abduction Increase flexion and internal rotation

20. Posterior Glide in Flexion Advance technique that gives a strong localized stretch to posterior capsule

21. Sternoclavicluar Inferior Glide Used to improve component motion for shoulder flexion.

22. Anterior & Posterior Glide of AC Joint Assist in improving shoulder flexion Used to decreased joint pain in the AC joint

23. Scapula Mobilizations The purpose of these techniques is to increase range of motion in scapular: Superior glide Inferior glide Medial rotation Lateral rotation

24. Advance Soft Tissue Stretching Latissmus Dorsi Patient supine Therapist at the head of patient One hand grips medial side of patient hand just above elbow and move it into flexion while laterally rotating the shoulder The other hand and forearm stabilizes the lower thorax Using the grip begin to stretch into flex and lateral rotation

25. Advance Soft Tissue Stretching Pectoralis Major Patient supine Therapist using both hands grips the medial side of the patient’s elbow and flexs and laterally rotate the arms Placing a stretch on the pectoral muscles

26. Subscapularis Stretch End Range

27. End Range Internal Rotation Use graded oscillations This technique may also be performed in prone