Exam

• - scap- spine of scap
• - manubrium (sternum)
• - humerus
• - Clavicle
• - upper thoracic vertebrae
• - upper ribs
• Note inability to elevate a rib can disable ROM of the shoulder jt
• 

• - sternoclavicular jt
• - acromioclavicular jt
• - scapulothoracic jt
• - glenohumeral jt

• - poorly congruous saddle jt
• - intervening intra- articular meniscus- allow clavicle to act as a hinge, prevents medial disslocation
• - acts as a hinge for the clavicle
• - prevents medial dislocation of the clavicle in the event of compression loading
• AC and SC jt stability

• - jt line is curved front to back allowing gliding of the acromion around the end of the clavicle
• - obliquely faces down laterally

• not a true anatomical jt
• - scapula makes an angle of 30* to the frontal plane and makes an angle of around 60* with the clavicle when viewed from above

• - provides up to 120* of elevation
• - in neutral, the humeral head faces medially, slightly posteriorly and superiorly angle of 45*
• - glenoid cavity faces superiorly, laterally and forward
• - glenohumeral jt is a mismatched apposition of the head of humerus and glenoid fossa
• 

• - glenoid labrum (fibro ring) provides expansion of the scapular articular surfaces
• - joint capsule is thin and lax with redundant folds sitting anterinferiorly- gives u range of elevation
• - capsular fibres are arranged into circular and radial fibres, which cross-link the shoulder capsule
• - during rot, the collagen fibre bundles tighten, contributing a compressive force, centring the humeral head and reducing translation
• - capsule receives some reinforcement from the tendons of the rotator cuff, which blend into the capsule
• - passive restraint mechanism of the GHJ are primarily anterior
• - more stability from the circular fibres around the capsule.
• - most likely to pop ant not post

• - 3
• - superior glenohumeral ligament- prevents displacement of head of humerus
• - middle glenohumeral ligament- control theshoulder in mid range abduction. And ext rot
• - inferior glenohumeral lig- higher range of abduction- this lig prevents dis
• 

• - deltoid
• - pec major
• - rotator cuff- supraspinatus, infrspinatus, teres minor and subscap - blend to form a a continuous 'cuff' surrounding the posterior, superior and ant aspects of the humeral head, blend with the capsule to provide dynamic stabilisation for the jt
• Subscap- youwill ant dis if not stable

• - subdeltoid or subacromial bursa- over suprspin tend etc
• - subscap bursa- sit under sub scap- it creates problems as it can communicate with other bursa

• - scap sits at about 30* to the coronal plane and the true movement description would be in this plane known as the scap plane
• - forward elevation is an average of 167* in men and 171* in women
• - extension averages around 60*

• - first 15-30* occurs at the glenohueral jt. Mm contolling the scap contract to stabilise the scap against the chest wall
• - after about 30*, the scap moves and contributes to the elevation by rotation in the frontal plane- 2* of glenohumeral rotation to 1* of scap rotation is considered normal

• - acting on scapular motion under the control of the upper and lower fibres of traps and serratus ant
• - rotates the scpula upward around the thoracic wall
• - takes place in the range of 30-100* abduction
• 

• - generated through the actions of deltoid and the roator cuff
• - subscapularis, teres minor and infraspinatus provide a downward and inward force vector to oppose the rotary component of deltoid
• 

• - glenohumeral jt- 55-70*, horizontal abduction and neutral rotation
• - acromioclavicular jt- arm resting by the side in the normal physiological position

• - glenohumeral jt- maximal abduction combined with ext rot
• - acromioclavicular jt- arm abducted to 90* with horizontally abduction
• as we abducted we ext rot. Thumb point behind

- greatest proportional loss of ext rot, followed by abduction, then int rot and then flexion

- loss of horizontal adduction and full ext

• - cervical spine
• - thoracic spine
• - diseased viscera in the chest and upper abdomen
• 

• - usually occurs from an impact to the point of the shoulder
• - angle o fthe AC jt drives the acromion beneath the clavicle with lig damade
• Grade 1- involves on the capsular lig of the AC jts
• Grade 2 tear- complete capsular disruption and partial tearing of the coracoacromial ligament
• Grade 3 tear- total tear- massive deformity- rupture- coracoclavicular lig
• 

• - conservatively
• - management of grade 2/3 sprains is aimed at achieving optimal re-alignmentand/or functional stability of AC jt
• grade 3 injuries are reduced with the use of strapping which should be worn day and night for at least 14 days

• - acute strains of the rotator cuff can occur during a fall, by wrenching the arm or in the even of a strong contraction of the cuff
• - complete ruptures of the cuff are possinle and tend to occur in older people with a long history or microtruma
• - diagnosis of cuff tears is by clinical examination and imaging techniques such as ultrasonography or MRI
• - degree of pain, disability and tenderness generally reflects the severity of a rotator cuff injury
• - specific mm test for rot cuff function will be painful and weak
• - impingement test

• - mehanism is usually a fall onto an outstretched arm accompanied by strong serratus ant activity
• - pain on scap motion, deep inspiration or coughing, resisted activity of the scapular mm and specific tenderness over the site of the injury
• - diagnosis is confirmed by xray
• - treatment consists of immobilisation of the arm in sling until the pain settles followed by gentle scapular mobilisation exercises. strength and faster movements are introduce after 3 weeks and full return to activity can occur after 5-6 weeks
• - # of the glenoid rim may accompany glenohumeral dislocation and usually requires open fixation
• glenoid rim can be broken- usually after disslocation

• - most common # around the shoulder
• - usually caused by a fall onto an outstretched arm or direct impact
• -severe pain with thept supporting the arm and and tilting head towards the # to ease mm tension on the clavicle. Deformitiy is likely, with tenderness and swelling
• - managed with figure- of eight strap and progressive exercise for range, then strength
• - activity restricted for 6 weeks

• - usually result from a fall onto the arm
• - if the displacement is minor, they are immobilised in a sling for 3-4 weeks. This is followed by mobilisation exercises and a graduated return to activity
• - management discussed more extensively in upper limb ortho lecture

• direct trauma to the shoulder region or indirect forces applied along the extended arm
• - can occur ant, post or inferiorly
• - arm is immobilised in a sling for 3 weeks
• - progressive mobilising and strengthening exercise program is then introduced
• Ant (most common- abd and ext rot)
• - post (fall forward out stretched arm)
• - inferior (rare- head of humerus dropped below shoulder)
• 1 time immobilise for 3 weeks, 2nd time- untilpain settle- shorter time

• - pain inhibition- mm cant stabilise the jt very well. Head can move up- impinge- cause pain and damage.
• Tendinitis
• 

• - occurs when the normal repain of any cross links damaged through activity or injury is repeated interrupted by further application of tensile forces beyond the load bearing limit of the injured tendon, estabilshing an environment of chronic inflammation
• 

• - repeated compression of the subacromial contents causes micropockets of damage, which eventually summate
• - ensuring inflammatory reaction involves vascular congestion and swelling into the tendon or bursa further reducing the space beneath the coracoacromial arch
• - test for impingement

- treatment involves unloading the subacromial compression through postural retraining, manual trherapy, massage and improving body mechanics and muscular reconditioning through exercise

• - can arise in 3 ways
• traumatically (dislocation or subluxation)
• insidiously (repeated microtruama of the lig and cuff)
• - congenitally (born with it)

- management is through correctly assessing the direction of instability and instituting and exercise program aimed at stabililising the glenohumeral jt

• - inflamatory lesion of the glenohumeral jt capsule that leads to thickening and contraction with consequent loss of jt volume
• - occurs most commonly in middle ages females and its aetiology is unknow
• - condition is often self limiting over a 12 month to 2yr period, although 20% of pt may be left with some degree of imapirment
• - describe in 4 stages
• - physiotherapy is normally used as an adjunct to medical management in this condition

• Long thoracic nerve
• Suprascapular nerve entrapment
• axillary nerve

- the space below the acromial arch (acromion, acromioclavicular ligament and ac joint) and is separated from the shoulder by the subacromial bursa and the rotator cuff

• - supraspinatus
• - infraspinatus
• - tere minor
• - subscapularis mm
• all from the scap and inserting on the humerus.

• -assist in the stability of the shoulder
• -rotate the shoulder
• - act as a humeral head depressor during shoulder elevation and abduction

- the encroachment of the acromion, coracoacromial ligament, coracoid rocess and/ or the a/c joint on the rotator cuff mechanism that passes between them as the glenohumeral jt is moved, partifcularly flexion and rotation

• - is the resection of the anteroinferior surface of the acromion
• - performed to remove the impingement
• - can be erformed in isolation or in conjuction with a rotator cuff debridement or repair

• - invovles suturing the torn rotator cuff
• - results of a surgical repain related tot he size of the tear and the duration of preoperative symptoms

• - wound healing, haemotoma, infection
• - adhesive capsulitis if the shoulder is immobilise post surgery
• - axillary nerve damage from reflecting deltoid in surgery

• - assessment
• - edu
• - control post op pain and swelling
• - sling- few days only following acromioplasty. Sling or an abduction aplint may be used for up to 6 weeks following reconstructive surgery

• - overall goal is the strengthening of the rot cuff and scap stabilisers
• - immediately post op:
• DVT prophylaxis, prevention of mm atrophy and jt stiffness of the elbow and hand, passive or active assisted flexion if acromioplasty only, passive for 6 weeks if rot cuff repair. A r rot cuff repair should never be placed under tension by active mm contraction or by extending or internally rot the shoulder in the first 6 weeks
• - pendular exercises, avoiding abduction if rot cuff repain
• - resisted static exercises if not rotcuff repain
• -shoulder girdle retraction and depression
• - postural re-education
• All post op exercises are dependdant on the individaul repair. asking surgeon is essential

- replacing articulating surfaces of the humeral head and the replacing of the articulating surfaces of the humeral head and glenoid

• - debilitating pain
• - limited ROM and strength

the aim of this op is function and pain relief

- replacement of both hueral and glenoid surfaces of the shoulder

- where the humeral head is replaced with a stemmed intramedullary implant that articulates with an unaffected and normal glenoid cavity

- replacement of only the humeral surface but the humeral prosthesis has 2 articulations

• - deltopectoral approach
• - short head of biceps, coracobrachialis are retracted
• - subscap andant shoulder capsule are divided to access the shoulder and repaired at the end of the procedure

• - pt with preserved bone stock
• - intact rotator cuff
• - pts who are well prep with exercises
• 10 yr implant survival in 75-90% of cases

• - edu
• - neer protocol
• An acute rehab protocol woll consist of
• - respiratory maintenance
• - DVT prophylaxis
• - passive or passive assisted exercises with external rot limited to allow subscap to heel
• - hand and elbow maintenance
• - scapula retraction and depression exercises
• - pendular exercises
• - resisted static contraction (abd, ext rot and flex) if there is no rot cuff repair
• - active exercises are commenced as soon as the repaired tissue tolerates. This is usually around two weeks. At this stage, active flexion, int rot and external rot and advanced muscle strengtheningand stretchingcan be commenced

• - glenoid loosening
• - inastability of dislocation
• - rotator cuff tears
• - periprosthetic fractures
• - infection
• - neurovascular injury

• - traumatic unidirectional associated with a bankart lesions requiring surgery (TUBS)
• - atraumatic multdirectional often Bilateral most requiring rehab and if surgery, then treated with an inferior capsular shift (AMBRI)

• - Bankart procedure
• - inferior capsular shift- the capsule is removed from the glenoid marin creating two flaps. The lower flap is raised and sutured high in the glenoid rim and the upper flap is attached over the top of this. This essentially tightens the anterior capsule

• Complications:
• - wound healing, infection and neurovascular injury are rare
• - recurrent dislocation in 5-10% of pts
• - functional restriction of ext rot

• - sling for 4-6 weeks
• - if subscap has been detached, shortened and reattached then it is important that the post operative protocol does not stretch or tighten the mm

• - hand andwrist maintenance exercises
• - strengthening exercises; static contractions of shoulder abduction, ext rotation, adduction, extension and flexion can be performed. Static internal rot should be avoided
• - pendular exercises in and out of the sling
• - active assisted flexion with pain limits
• - passive ext rot to neutral

Out pt physio is needed from 2 weeks post op

• - injury is commonl in the elderly and in adolescents
• - usual mechanism of injury is pt faling on outstretched hand

• - the arm is usually only immobilise in a sling. The weight of the arm tends to correct any displacement
• - union will occur in about 3 weks and consolidation in around 6 weeks

• - best outcomes have been demonstrated with early referral
• - pendular exercises of the shoulder are usually begun immediately
• - pt is encouraged to abduct the arm actively as soon as possible
• - main intervention is to reduce stiffness. Passive movements supporting the fracture site
• - static exercise in neutral progressed to strengthening through range

• - stiffness of shoulder
• - malunion
• - axillary nerve lesions

• - the greater tuberosity sustains a direct injury when the pt falls on an abducted arm and the tuberosity impinges against the acromion
• - common with dislocation of shoulder
• - is usually undisplaced, makng reduction unecessary
• - sling worn for 1-2 weeks

• - aimed to preventing stiffness
• - pendular exercises
• - activating the mm inseting into the greater tuberosity should be avoided in the early stages of repair
• Complication- ongoing impingement symptoms

• - most common fracture in people over 40yrof age esp women who may be osteoporotic
• - fall onto anoutstretched hand
• Fracture is easily recognised by its dinner fork deformity
• - fracture occurs transversely about 2 cm from about 2 cm from the lower articular surface of the radius
• - lower fragment is also driven upward and impacted into the upper fragment
• - lower fragment is displaced slightly backward and laterally and is tilted backward
• 

• - fracture is reduced and held in a plaster in a slightly flexe and ulnar deviated position
• - maintenance exercises of all unaffected jts, especially the fingers, begins immeiately
• - plaster for about 6 weeks

• - circulatory compromise of the plaster
• - compression of the median nerve in the carpal tunnel due to oedema
• - malunion, delayed union and non-union
• - stiffness of the shoulder from non use
• - stiffness of the wrist and fingers following removal of the plaster
• - rupture of the extensor pollicis longus tendon
• - CRPS

• - application and removal of plaster- plater care, manage swelling and non involved jts
• - control of swelling post plaster removal
• - exercises to improve range and strength
• - passive mobs techniques

• - common in young adults
• - usual mechanism is fall onto an outstretch arm with radial deviation
• - pt usually snuff box tenderness and impaired wrist movement
• - if displacement is present and substantia, a screw may be inserted across the fracture

• - complete plaster- in the holding glass position with thumb forward
• - plaster for 6 weeks

• - plaster
• - care of swelling
• -control of swelling
• - exercises to improve range and strength
• - passive mobs

• - avascular necrosis
• - jt stiffness post immobilisation
• - early non- union
• - OA

• - most common tendon injuries
• -considere a clinical specialty of its own