Shoulder

• pain and muscle guarding limit motion,
• Pain frequently radiates below elbow and may distrub sleep

• Capsular Tightness
• Limited motion in capsular pattern (primary complaint)
• Pain at the end of motion
• Limited arthokinematics

• Progressive restriction of glenohumeral joint capsule
• significant loss of function
• Aching localized to deltoid region
• Pain referred to deltoid tuberosity

• Night pain and disturbed sleep
• Pain with motion and often at rest during actue flare
• Decreased joint play and ROM
• Postural compensations - Protracted and anteriorly tipped scapula, rounded shoulder and elevated and protected shoulder
• General Muscle Weakness and poor endurance in the glenohumeral muscles - overuse of the scapular muscles leading to paoin in the trapezius and posterior vervical muscles

• Inabilty to reach over head, behind head, out to the side and behind back
• Trouble dressing, reaching hand into back pocket, reaching out of car window, self grooming
• Difficulty lifting weighted objects
• Limited ability so sustain repetitive activities

• 1. Control pain, edema and muscle guarding
• 2. Maintain soft tisue and joint integrity and mobility
• 3. Maintain integrity and function of associated areas - Pt educations
• 4. Keep joints distal to injury site moble

• 1. Control Pain, edema and joint effusion
• 2. Progressively increase soft tissue and joint mobility
• 3. Correct faulty mechanics - Avoid compensation, reposition head of humerus caudally before proceeding with shoulder exercises
• 4. Progressively increase strength

• Progressively increase flexibility and strength
• Progress stretching and strengthening as joint tissue tolerates

• Primary - idopathic in nature
• Secondary - develops as a result of trauma or inflammation
• the results stiffness can be due to soft tissue problems in the shoulder itseld or from an injury that is more distal

• Passive ROM limitations in a capsular pattern
• severly restricted funcion
• Diabetic
• Tyroid
• can be bilateral - doesn't have to happen at the same time

• self-limiting condition in which the shoulder goes througth a cycle of "freezing", "Frozen", and "thawing"
• Duration of each phase varies from person to person
• Spontaneous reconvery occure within 1-3 yrs

• Positioning - encourgae patients to avoid the adducted, internally roated shoulder positon
• Do not permit the Pts to wear slings unless necessary to protect a surgicnal repair
• Enougrage Pts to sleep in supine with a pollow under the affected arm in slighta abduction and in the plane of the scapula
• NO SLINGS!!!

• Painful phase
• Goals - Pain control, maintain ROM
• Pain cauased by edema or bad mechanics
• PROM- within pain free range to minimize soft tissue inflammation (pullys or wands)
• Isometrics

• Stiff phase
• Goals - increase ROM, increase functional use
• AROM and PROM exercises
• Joint Mobs
• Strtching
• Strengthening

• Goals - Increase end ROM and Increase Strength
• Strengthening - progressive with tubing and weights
• Should include: scapula and shouler musculature

• Subcapularis Tendon and anterior capsule are divided, other rotator cuff insertions on the greater tuberosity are presvered
• NO IR / ER or EXT
• Be careful for 6-8 wks

• In the early weeks of recovery active internal roation and and passive ER are restricted
• Pts MUST wear their immobilizer to avoid ER - regaining ER can be a challenge

• Good to excellent results occur in 90%
• Pt with OA usually progress more quickley than those with RA
• Post-op care will vary PT to PT and depend on a variety of factors
• The Average increase in shoulder flexion is 38 degrees and agerage of 124
• The average ER increase is 29 with a total of 46 (normal 90)
• Strength increases by one full grade ona manual muscle test to 4/5
• 82-94% of Pts have no pain
• 75 have no functional limitations

• 14% of all cases
• Includes:
• INstability
• Rotator Cuff tear
• Intraoperative fracture
• Axillary nerve injury
• Loosening of Components

• Maintain mobity in adjacent joints (neck, scapula, elbow, hand) IR and ER with elbow flexed
• Regain shoulder mobility
• Minimize muscle atrophy - Isometrics
• Control Pain

• Re-establish mobility and control of shoulder motions - If
• Imporve strength, endurance and stability of the shoulder girdle

• PROM of scapula
• Limited IR and ER with elbow flexed
• Position Pt lying supine with humerus slightly anterior to the midline of the body to avoid excessive stress to teh anterior capsule and sutrue line

• If rotator cuff in intact can being 2-3 weeks post-op if cuff repair 6wks
• Transition from assisten to active ROM all planes and diagonal planes of motion
• Avoid combined ER and abduction becuase they are stressful to the repair
• Begin combining ER to neutral with forward flexion and scaption

• To be in this stage Pt must be Pain free ative shoulder ROM though functional range and 3-5 strength
• Being no earlier than 6 weeks post-op for intact rotator cuff
• Continue to improve mobility - Acitve or resistive ROM
• Concinue to improve strength, stability and endurance of the shoulder
• HEP

• Stabilized for at least 6wks
• Will be in an immobilizer
• Aggressive therapy is NOT performed until sufficient healing is confirmed by x-ray

• Use ice to decrease Pain
• Begin ROM exercises for elbow wrist and hand
• Train balance and gait
• Do not sue affected arm for ADls

• Discontinue the sling immobilization on MD orders
• Begin Active scapula exercises
• Debing active- assisted shoulder exercises
• Begin using arm for daily activites to tolerance

• Discontinue to functiona brace on MD orders
• Begin joint mobs and passive stretching
• Retrain proper scapulohumeral ryhthm and coordination
• usefull spectrum exercies to restroe strength and Rom
• emphasize functional activites

• Displaced fracture of the surgical neck and head require surgery to stabilize them properly
• can be fixated witha variety of material
• presently no accepted fixation of choice
• Complication can include: avasular necrosis of humeral head - total shouler
• Subacromial impingment
• Never lesions
• Vasular Damange

• PROM and stretching are contraindicated in the early stages of healing for humeral head fractures
• Clinican does know amount of stress put on the joint
• Scapula or elbow ROM and Strenght is ok

• Pt is generally in excruciating pain despite pain meds
• The arm is susallyy in a sling to immobilize it
• Pt requires assistance with basic ADLs
• Thearpy is limited at this time
• Balance and Gait Training

Exercise progression is dependend on the stability of the fracture frgments and varies greatly from Pt to Pt

• Pt removes the sling 3-5 tiems a day fro gentle ROM exerciese sme ME's DC sling at this time
• Pendulum, AAROM elvenation activites, scapular motions, gentle isometrics
• Slow progression
• With MD approval can begin active GH motions in a very restricted range

• AROM exercises progress in a pain-free range to the Pts tolerance
• When the humerus is completely healed at approx 8wks therapy become more aggrssive
• joint mob
• passive ROM
• Supervised pully work