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SHOULDER

Frozen Shoulder Glenohumeral Joint Arthritis

AKA: Adhesive Capsulitis, Periatrithis 1. Acute Phase


Age: 40-60 y/o Pain & Muscle Guarding (limited ERAB)
M<F 2. Sub-acute
Development of adhesion, capsular Capsular tightness & LOM
thickening, capsular restrictions 3. Chronic
Chronic inflammation in synovial tissue & Progressive Restriction
musculotendinous tissue
Common Activity Limitation & Participation
MC: Rotator Cuffs, IR except subscapularis,
Restriction
biceps tendon & joint capsule.
Inability to reach overhead, behind head, out
IMPINGEMENT
to the side & behind back
Compression in the subacromial space Putting on undergarments
Faulty posture, excessive IR contributes to Retrieve Wallet
the impingement Self-Grooming
Muscle strength imbalance Difficulty in lifting weighted objects
Limited ability to sustain repetitive activities
IDIOPATHIC FROZEN SHOULDER
GH Joint Surgery & Post-op Management
1. FREEZING STAGE
Pain management, Hot/Cold Pack, PJM (Gr, MC surgical procedure used to treat advanced
1&2) shoulder joint pathology is GH arthroplasty
2. FROZEN STAGE Rare Condition: Arthrodesis (surgical
Pain & Mobility (LOM) ankylosis)
3. THAWING STAGE
GH Arthroplasty
LOM, Excessive tightness, Mobility
Management, 1. Total Shoulder Arthroplasty
PJM (Grade III&IV) Bilateral
Glenoid & Humeral Surface
Common Structural & Functional Impairment
2. Hemishoulder Arthroplasty
Night & Disturbed Sleep One surface only
Pain on motion & often at rest during acute 3. Reverse Total Shoulder Arthroplasty
flares Rotator cuff is integrated
Capsular Pattern: (ERABIR=Flexion)
Indications for Surgery
Joint Play
LOM Capsular Pattern Persisting & Incapacitating Pain
Posture: LOM (Stability)
a. Anterior Tilted Scapula (Stretch
pectoralis minor to contract faulty APPROACH
posture, strengthen ER (since naka IR) 1. Deltopectoral Incision
b. Rounded shoulder Deltoids & Pectoralis Major
c. Elevated & Protected Shoulder 2. Release of Subscapularis tendon
Gait: AKA: Tenotomy
a. Arm Swing 3. Anterior Capsulotomy
b. Pain upon movement Anterior capsule repair
c. General muscle weakness 4. Humeral Osteotomy of Humeral canal
d. Poor endurance
e. Substitution for limited GH motion & INTRAOPERATIVE COMPLICATIONS
scapular motion especially elevation
Insufficient Lengthening of a tight Maintain Trunk Errect for Posture
subscapularis muscle-tendon unit
No active anti-gravity dynamic exercises especially IR
Intraoperative damage to
Axillary Nerve ADLs
Abduction, Flexion, extension (weak)
Suprascapular Nerve Avoid reaching behind the back
Abduction & ER (weak) Avoid using operated limb
Humeral Fracture Use sling when going outside
No driving for 4-6 weeks
Soft-Tissue Related Post-Operative Complications
Painful Shoulder Syndromes (Rotator Cuff Disease &
Re-tearing a repaired rotator cuff mechanism Impingement (Non-operative Management)
Post-operative distribution of repaired
subscapularis Neer Classification of Rotator Cuff Disease
Chronic instability or dislocation of GH joint Stage I
Glenoid Articular Erosion
- Edema & Hemorrhage
Implant-Related Complications - 25 y/o
Aseptic Loosening Stage 2
Fracture of Glenoid Implant
- Tendinitis, Bursitis, Fibrosis
Positioning After shoulder arthroplasty: Early post- - 25-40 y/o
operative (Maximum Protection Phase)
Stage 3
1. Supine
Arm is immobilized in sling that is worn - Bony Spurs, Tendon Rupture
continuously - >40 y/o
Elbow Flexed to 90
Primary Impingement
FA and hand resting on abdomen
Arm supported at the elbow in on a folded - Anatomical & Shape of acromion
blanket/pillow
Secondary Impingement
Forward flexion (10-20), slight abduction &
IR of the shoulder - Other Factors & Instability
Head of bed elevated at 30
2. Sitting Based on Impaired Tissue
Arm is supported in sling or pt. lap or arm Supraspinatus: Empty Can
rest Infraspinatus: ER
3. Tenuous Rotator Cuff Repair Bicipital Tendinitis: Speeds Test & Yeargason
Abduction split Superior Glenoid Labrum
Low reps Subdeltoid (Subacromial) Bursitis

Initally PROM/AAROM Other Musculotendinous Strains

Safe ROM Anterior: Overuse & Racket sports


Inferior: Motor Vehicle Trauma
No end range stretching
Based on Mechanical Disruption & Direction of
Passive ERNeutral after rTSA or <30 after TSA Instability/Subluxation
During PROM/AAROM of ROTshoulder rot. Multi-directional instability
slightly anterior to midline (lesser stress on Uni-directional instability (A, P, inferior)
anterior capsule) Traumatic Injury with tear of capsule
No Hyperextension stretching; Hyper horizontal Insidious (Atraumatic) onset from repetitive
abduction, No combined EXADIR microtrauma
Inherent Laxity - Allows gliding of tendons
- AKA: Anterior acromioplasty/decompression
Based on Progressive Microtrauma Jobes
acromioplasty
Classification
Indications for Surgery
Group I
Pain during overhead activities
- Pure impingement
Loss of functional mobility due to primary
Group II impingement even after conservative
treatment.
- Impingement associated with labral tear/ Stage II Neer Classification
capsular injury and secondary impingement Intact or minor tear of the rotator cuff
Group III Component Procedures
- Hyperelastic soft tissues anterior/multi- Removal of subacromial bursa (bursectomy0
directional instability & impingement Release of coracoacromial ligament
Group IV Resection of anterior acromial protuberance

- Anterior instability without associated Rotator Cuff Repair & Post-op Management
impingement Indications for Surgery
Common Impairments of Impingement Partial thickness/Full thickness of tear of
Pain at the musculotendinous junction of the rotator cuff
involve muscle with palpation, with resisted Tendons with irreversible degenerative
muscle contraction & when stretched changes in soft tissues.
Positive Impingement Sign Neer Stage 2 & 3
Impaired Posture Acute, traumatic rupture of the rotator cuff
a. Thoracic Kyphosis tendons.
b. Cervical & Capital Extension Forward Arthroscopic Approach
Head
c. Forward/Anterior Tilting of the scapula - Small Incisions
d. Thoracic Mobility
MINI-OPEN (ARTHROSCOPICALLY ASSISTED)
Muscle imbalances
APPROACH
a. Pectoralis Minor/Major
b. Levator Scapulae Subacromial decompression
c. IR of the shoulder Deltoid splitting approach
d. Weak serratus anterior & ER
Traditional Open Approach
Hypomobile posterior GH joint capsule
Faulty kinematics during humeral elevation - Anterolateral incision mid 1/3 of inferior
a. posterior tipping of scapula clavicle
b. Altered Scapulohumeral rhythm - Anterior aspect of proximal humerus
With complete rotator cuff tear
Different eccentric abduction; drop arm GENERAL EXERCISE GUIDELINES & PRECAUTIONS
Acute pain, referred to C5-C6 reference zones FOLLOWING REPAIR OF A FULL-THICKNESS
ROTATOR CUFF TEAR
Painful Shoulder Syndromes
Perform PROM/AAROMSafe & pain range
- (+) Pain & Loss of Functional Mobility Passive & Non-assisted ROM for 6-8wks if
Secondary Impingement massive cuff tear or after traditional open
- Resolve sufficiently with non-operative approach
management Position humerus slightly anterior to midline
1. Sub-acromial Decompression at rest in supine, support, distal humerus on
- Increase volume of subacromial space folded towel
Initiating Passive/AAROM shoulder rotation Side-lying in unaffected side
while supine, shoulder slightly flexed, 45
Traumatic Anterior Shoulder Dislocation
abduction
Maintain trunk posture - Prevented by long head of biceps,
Supraspinatus & Infraspinatus: strengthen subscapularis, inferior GH ligament, axillary
shoulder flexion & abduction nerve (Most common injured)
Remove substitutions motion: shoulder hike
& trunk lateral flexion. Anterior Capsule & Glenoid Labrum

Strengthening Exercises - Bankart Lesion

Isometric Resistance to ST muscle support Compression Fracture at posterolateral of humeral


operated arm Head
Low exercise Load - Hill-Sach Lesion
It should not cause pain
No CKC for 6 weeks Traumatic Posterior Shoulder Dislocation
Delay dynamic strengthening PRE, 8 weeks
MOI: FADIR due to FOOSH
for small; 3 months for large muscle
Precaution in the movement: Ex. Stretching Common Structural & Functional Impairment
on supra/infraspinatus
- Pain & Muscle guarding
Stretching Exercises - Inability to abduct humerus due to Rotator
cuff tear
Avoid vigorous stretching or grade 3 PMJ
- Asymmetrical joint restriction/hypomobility
Use contract-relax procedures
- With recurrent dislocation, individual can
Supra/Infra/Subscapularis was repaired
dislocate the shoulder at will.
avoid ER/IR
Shoulder Instabilities: Surgery & Post-op Management
ADLs
Indications for Surgery
For light functional, wait until
Recurrent dislocation or subluxation
a. Arthroscopic: 6 weeks
Uni/Multi-directional instability
b. Traditional: 12 weeks
Instability-related impingement
c. Heavy Functional: 6-12 months
Joint Laxity resulting in recurrent involuntary
INSTABILITY dislocation

Anterior Instability Bankart Repair

- MOI: Abduction & ER - Attachment of capsulolabral complex from


anterior rim of glenoid
Posterior Instability
Repair of Slap Lesion
- MOI: FOOSH/FADIR
- Superior Labrum extending to anterior to
Inferior Instability posterior
- Weakness/Paralysis on posterior deltoid & IMMOBILIZATION
supraspinatus
- Repetitively reach overhead (swimmers & Anterior/Inferior Instability
workers)
- Immobilized in a sling in adduction (arms at
Common Activity Limitations & Participations side)
Restrictions (Functional Limitations/Disabilities) - Forearm across abdomen with arm slightly
anterior
Possibility of recurrence
Restricted ability in sports Posterior/Posterior-Inferior Instability
- UE in orthosis Ability to repair significant ligamentous
- Handshake damage
a. ER- neutral rotation 10-20 Early post-op motion permittable
b. Abduction 20-30
Disadvantage
c. Elbow Flexion
d. Slight Extension Extensive Soft Tissue Disruption &
Arthrotomy required
Precautions after anterior GH stabilization & or
Not amenable to nonreconstructible fracture
BANKART Repair
Arthroscopic/ Arthroscopically Assisted Reduction
- Limit ER, horizontal abduction & extension
and Internal Fixation
- Limit ER 5-10 with arm in slight abduction
- Stretching: Avoid Abduction & ER Advantage
- Avoid resisted & active unless permitted
- No resisted IR for 4-6 weeks Subscapularis Allows arthroscopic evaluation of the joint
Repair Debridement of fracture debris if fully
arthroscopic
Repair of SLAP lesion No arthrotomy, less soft tissue disturbance,
less post-op
- Long head of biceps is detached
- Limit Passive/Assisted elevation of arm to Disadvantage
a. 60 for first 2 weeks
b. 90 3-4 weeks post-op Limited reduction & fixation
- Avoid pain that create tension in the biceps, No more than 2 part displaced fracture
avoid shoulder & elbow extension Not appropriate for radial neck fracture; if
- Postpone Isotonic contraction: Elbow flexion fully arthroscopically
& supination Excision of Radial Head
Joint Hypomobility Advantage
- RA Only option if severely comminuted, non-
- JRA reconstructible fracture
- DJD Early ROM permissible
- After trauma, fracture, dislocation
- Post-immob, contractures & adhesions Disadvantage

Common Activity Limitations and Functional Requires arthrotomy; may compromise


Impairments Joint stability if a prosthetic implant is not
used
Difficulty turning a doorknob
Difficulty pushing & pulling Radial Head Excision
Restricted hand to mouth activities
Indication
Pushing up from chair
Inability to carry objects Severely Comminuted
Limited Reach Chronic synovitis, mild deterioration of
articular surface
Joint Surgery & Post-op
Contraindicated
Surgical Option for Displaced Fracture of Radial Head
ORIF In growing child
Active Infection
Advantage
Damaged lateral ulnar collateral ligament
Achieves stabilization & fixation of multiple
Total Elbow Arthroplasty
fracture fragments
Indication
Debiliating pain, loss of functional UE due to Activity Limitation
severe pain
- Provoking activities
RA/DA/JRA
- Difficulty in repetitive activities
Gross Instability of Elbow
Acute comminuted, intra-articular fracture Students (Acute) Miners (Chronic)
Complication of Fracture Rheumatoid Arthritis
Non-Union Acute Stage
Malunion - 5 cardinal signs of inflammation
- Tissue proliferation, joints, bilateral
Delayed Union
- Inflammation (Tenosynovitis)
Complications - Synovial Proliferation in the extrinsic tendons
- Joint instability Advanced Stage
- Triceps insufficiency
- Joint Capsule Weakening
- Implant Loosening
- Cartilage destruction
Specific Precautions: Avoid early end-range of elbow - Bone erosion
flexion - Tendon rupture
- Instabilities, subluxations, deformities
ROM Exercises
OA
STRENGTHENING EXERCISES
Acute Stage
- Postpone resisted elbow extension for 6
weeks, if triceps reflecting approach was used - Achiness, feeling of stiffness
- Strengthening shoulder, apply resistance - 5 cardinal signs of inflammation
above the elbow, eliminated stresses across
Advanced Stage
the joints
- There is capsular laxity resulting
Myositis Ossificans
hypermobility instability
- MC: FCU (LE=QUADS) - Contractures
- Bone formation outside bone (mm/lig) - Muscle weakness
- Signs of inflammation - Grip Strength
- Muscle Endurance
Lateral Elbow Tendinopathy
JOINT SURGERY
- MC: ECRB
- Relief of pain
Medial Elbow Tendinopathy
- Restoration of Normal hand function
- MC: Pronator & flexors - Correction of deformity/instability
- Improvement of strength
Common Structural & Functional Impairments
Indications for surgery
pain in elbow region after wrist & hand
activity - Severe pain due to OA, RA & JRA
Pain when muscle is stretched/Contracts - Deformity & marked LOM
against resistance - Subluxation/Dislocation of Radiocarpal Joint
muscle strength & endurance for the - Low Demand UE functional needs
demand
WRIST/MCP/PIP IMPLANT ARTHROPLASTY
grip strength, limited by pain
Tenderness with palpation at site of Indications for surgery
inflammation
Pain at joints of the hand & hand function
due to OA/RA
Instability
Stiffness & AROM
pinch & grip strength due to pain or
subluxation
TENDON RUPTURE ASSOCIATED WITH RA:
SURGICAL & POST-OP MANAGEMENT

Most common in patients with chronic


tenosynovitis associated with RA
With tendon ruptures & loss active
control digits
Rupture of a single/multiple tendons is
painless
Weak & Painful Fracture; break&
painless; nerve injury due to fracture
Ext>Flexor Tendons
Pre-cautions after extensor tendon transfers by
reconstruction in the RA of the hand
Do not initiate MCP extension from full
available MCP flexion to avoid excessive
stretch on separated tendons
Postpone Stretching to MCP flexion
Avoid finger & thumb flexion + adduction
with wrist flexion
Avoid weight-bearing on dorsum of the hand
Avoid vigorous gripping activities
Repetitive Trauma/Overused
Common Structural & Functional Impairment
Pain when related muscle contracts
There is movement that causes gliding of a
tendon sheath
Warmth & tenderness in palpation
RA, synovial proliferation & swelling in
affected tendon sheath
Imbalance in muscle strength & length
Pain at involved STH whenever a stretch
force is placed
Hypermobility/Instability