SHOULDER REHABILITATION LATERAL, SUPERIOR, ANTERIOR

REHABILITATION PRINCIPLES FOR UE INJURY

• Complete diagnosis includes whether the injury is acute,
chronic, or an acute exacerbation
• Understanding the mechanism of injury
• Accurate diagnosis has been made with a thorough history,
physical examination and appropriate diagnostic test

CONDITIONS
• AC joint sprains
• Thoracic Outlet Syndrome
• Scapular Winging
• GH joint Instability
• Proximal Humeral Fracture
• Adhesive capsulitis
• Contusion and myositis
• Bicipital tendonitis
• Bursitis
• Rotator cuff tendonitis and impingement POSTERIOR, AXILLARY

SHOULDER REGION:
SUBJECTIVE INFORMATION
• Rotator Cuff Degeneration: 40-60 years old
• Rotator Cuff Tear: Any age or >65 years old)
• Rotator Cuff Impingement:
• Primary: > 35 years old
• Secondary: Late teens and twenties
• Calcium deposits: 20-40 years old
• Adhesive Capsulitis: 45-60 years old (Magee), 40-60 years
old (Braddom)
• AC sprain: third decade of life
• Proximal Humeral Fracture: Younger population

Gender: ADHESIVE CAPSULITIS

• M>F: AC sprain • An idiopathic disease wi 2 principal characteristics: PAIN
• 2-4x more common among Females: Adhesive Capsulitis & CONTRACTURES
Occupation: • A condition of uncertain etiology characterized by clinically
• Overhead Athletes: Rotator Cuff impingement (throwing significant restriction of active & passive shoulder motion
sports and swimmers); GH instability (baseball pitcher); labral occurs in the absence of a known intrinsic shoulder disorder
tear (throwing athletes) • Inability to sleep on affected side
• Restricted GH elevation and ER with unremarkable
CHIEF COMPLAINS: SHOULDER PAIN • radiographic findings
Shallow glenoid fossa AC SPRAIN
 Most mobile yet unstable joint in the body • Pain and Tenderness
 Extensive mobility: shoulder dislocation and ROTATOR CUFF TENDINITIS I IMPINGEMENT
degeneration •anterior or lateral shoulder pain that occurs with overhead
-3rd MCmusculoskeletal reason for GP consultation after neck activity and also at night while trying to sleep.
and back pain •stiffness, catching
-peaks at 50 y/o GH INSTABILITY
-categories: soft tissue disorders, arthritis, instability • shoulder instability include pain, popping, catching, locking,
an unstable sensation, stiffness and swelling
THORACIC OUTLEST IMPINGEMENT
• vague arm pain, numbness and tingling usually along the
medial aspect of the arm, pain along the neck and shoulder
region.
• deep, boring, toothache-like pain in the neck, shoulder
region
HISTORY OF PRESENT ILLNESS: MOI
• Direct trauma from a fall or blow to the acromion (AC
Sprain)
ROTATOR CUFF TENDONITIS AND IMPINGEMENT
• Macrotrauma can cause rotator cuff injuries
• Repetitive microtrauma*
• Outlet impingement between the acromion and greater
tuberosity of the humerus*

ROTATOR CUFF IMPINGEMENT (SUBACROMIAL, OR

"OUTLET," IMPINGEMENT)
• Primary - hooked acromion or a thick coracoacromial
INFERIOR GH DISLOCATION
ligament.
 joint instability include capsuloligamentous laxity or
• Secondary - glenohumeral joint instability, weak scapular
injury and absence of the glenoid fossa upward tilt
stabilizers, scapulothoracic dyskinesis, and instability
Impingement
POSTERIOR GH DISLOCATION
• Congenital glenoid hypoplasia or excessive glenoid or
humeral retroversion
• injury to the subscapularis tendon
• Reverse Bankart lesion vs Reverse Hill-Bach

ADHESIVE CAPSULITIS
MORPHOLOGY OF ACROMION PROCESS 1. Nighttime & end-range of motion >
2. Constant pain at rest (Aggravated by all movements,
repetitive UE moots, psychological stress, exposure
to cold or vibration, changes in weather) >
3. Relieves w/in 1-2years

PATHOLOGY & PATHOGENESIS

GH JOINT INSTABILITY
-Atraumatic
 voluntary and involuntary
 congenital capsular laxity or repetitive microtrauma.
-Acute instability vs Chronic instability
-Unidirectional:
 traumatic event resulting in disruption of the
glenohumeral joint
 The most frequent type of unidirectional instability is
traumatic anterior instability.
-Multidirectional
 congenital capsular laxity or chronic repetitive
microtrauma

ANTERIOR GH DISLOCATION
• frequently tears the anterior inferior glenohumeral joint
capsule
• avulses the anterior inferior glenoid labrum with or without
some underlying bone from the glenoid rim (Bankart lesion)
• associated with a compression fracture of the
posterolateral aspect of the humeral head (Hill-Bach Defect)
ADHESIVE CAPSULITIS

PAST MEDICAL HISTORY

GH INSTABILITY
• acute trauma or chronic, repetitive microtrauma, history of
GH joint dislocation
Adhesive Capsulitis
• diabetes mellitus (2-4x), inflammatory arthritis, trauma,
prolonged immobilization, thyroid disease, cerebrovascular
accident, myocardial infarction, or autoimmune disease

FAMILY MEDICAL HISTORY

GH INSTABILITY
• history of generalized ligamentous laxity or connective
tissue disorders (Marfan Syndrome)

CONTUSION ANCILLARY PROCEDURES

• result of blunt trauma to the soft tissue
• may be difficult to differentiate from tears because both
involve a significant amount of injury to the muscle fiber.
• Associated with Myositis ossificans is the invasion of
calcium and bony islands within the muscle
PROXIMAL HUMERAL FRACTURE
• Indirect Trauma (MC)
• FOOSH
• Direct Trauma (LC)
• Direct impact against proximal humerus
LABRAL TEAR
• FOOSH injury
• during deceleration when throwing, or arises when sudden
traction is applied to the biceps.
• SLAP vs Bankart lesion
• AC Sprain: Radiographic Imaging
• Rotator cuff pathology: US and MRI have higher levels of
sensitivity and specificity than radiographs
• Instability: X-ray
 anteroposterior view and Stryker Notch view : Hill-
Sachs defect
 Garth view and the West Point view: Bankart
fractures
 Magnetic resonance arthrography provides optimal
visualization of the labrum, cartilage, and joint
capsule
Adhesive Capsulitis
• Radiographic eval usually normal, but glenohumeral joint
arthrography typically shows a significant reduction in the
capsular volume

SHOULDER REGION: OBJECTIVE INFORMATION

PALPATION
- (+) Tenderness
• AC Sprain
• GH instability
• Rotator Cuff Pathology
• Bicipital Tendinitis: palpation of the tendon
- (+) Muscle spasm
• Thoracic Outlet Spasm
OCULAR INSPECTION GLENOHUMERAL JOINT
Step sign/ Step up sign
 AC joint Sprain
Sulcus Sign
 Inferior GH instability / Multidirectional Instability
Fountain Sign
 AC joint swelling ACROMIOCLAVICULAR JOINT
Swallow Tail sign
 Deltoid weakness
(+) Swelling over the transverse ligament
 Bicipital Tendinitis
STERNOCLAVICULAR JOINT

(+) Swelling and bruising

 Proximal humeral fracture
Sprengel's deformity
 leading to a high or undescended scapula
Popeye sign ADHESIVE CAPSULITIS
 Proximal Biceps rupture • progressive glenohumeral joint ROM restriction in forward
flexion, abduction, and internal and external rotation
BURSITIS
• painful and significantly limits abduction of the arm

APLEY'S SCRATCH TEST

• Abduction combined with flexion and lateral rotation
RANGE OF MOTION TESTING • Adduction combined with extension and medial rotation

APLEY'S SCRATCH TEST

Some examiners prefer doing the same motion in both arms
at the same time:
- neck reach (abduction, flexion, and lateral rotation at the
GH joint)
• back reach (adduction, extension, and medial rotation at
the GH joint).

MANUAL MUSCLE TESTING (MMT)

• Rotator Cuff Impingement/Tendinitis
 Weakness of RC muscles and Scapular stabilizers
• GH instability
 analysis of scapulothoracic kinesis, upper limb
strength
• Thoracic Outlet Syndrome
 weakness that is diffuse and does not follow a nerve
root distribution
SCAPULAR WINGING FAULTS GH INSTABILITY
• associated with a concomitant decrement in proprioception
• Sensory testing over the deltoid muscle is important to rule
out an associated axillary nerve injury.

FUNCTIONAL ASSESSMENT
SPECIAL TEST Scoring for Functional Shoulder Movements of the Arm
AC SPRAIN: Hand-To-Back of Neck (Test 1)
• AC crossover test / Horizontal adduction test* (SC and AC) 0 The fingers reach the posterior median line of the neck with
• Paxino's sign the shoulder in full abduction and lateral rotation. The wrist is
• Active test of O'Brien* (AC and Labral) not dorsally extended.
ROTATOR CUFF IMPINGEMENT / TENDINITIS: 1 The fingers reach the median line of the neck but do not
• Coracoid impingement sign* have full abduction and/or lateral rotation.
• Hawkins-Kennedy test* 2 The fingers reach the median line of the neck, but with
• Neer test compensation by adduction (over 200 in the horizontal plane)
• Yocum test or by shoulder elevation.
ROTATOR CUFF TEAR 3 The fingers touch the neck.
• Rent test — FOR RCT 4 The fingers do not reach the neck.
• Supraspinatus — Empty Can
• Infraspinatus - Infraspinatus test; Lateral rotation lag sign HAND- TO-SCAPULA (FROM BEHIND) (TEST 2)
• Teres Minor - Hornblower's sign 0 The hand reaches behind the trunk to the opposite scapula
• Subscapularis - Lift-off sign (Gerber's test) Medial rotation or 5 cm beneath it in full medial rotation.
lag or "spring back" test The wrist is not laterally deviated.
BICIPITAL TENDINITIS 1 The hand reaches the opposite scapula 6 cm to 15 cm
• Yergason test vs speeds test beneath it.
SCAPULAR DYSKINESIA 2 The hand reaches the opposite iliac crest.
• Scapular Load test 3 The hand reaches the buttock.
• Lennie test 4 Cannot move the hand behind the trunk.
SERRATUS ANTERIOR
• Punch out test HAND-TO-OPPOSITE SCAPULA (FROM IN FRONT) (TEST 3)
THORACIC OUTLET SYNDROME 0 The hand reaches the spine of the opposite scapula in full
• Adson Maneuver adduction without wrist flexion.
• Costoclavicular syndrome test. 1 The hand reaches the spine of the opposite scapula in full
• Halstead Maneuver. adduction.
• Roos Test* (Elevated Arm Stress Test) 2 The hand passes the midline of the trunk.
• Wright Test 3 The hand cannot pass the midline of the trunk.
• Allen Test
ANTERIOR INSTABILITY SHOULDER REGION: ASSESSMENT
Apprehension (Crank) Test CLASSIFICATION OF ACROMIOCLAVICULAR JOINT SPRAINS.
• Fulcrum test ROCKWOOD CLASSIFICATION
• Fowler sign/Jobe relocation sign
• Surprise test
POSTERIOR INSTABILITY
• Jerk Test
INFERIOR/MULTIDIRECTIONAL INSTABILITY
• Sulcus Sign

CORACOID PAIN TEST

 SHOULDER REGION: PLAN

SLAP LESION
Type 1 Superior labrum markedly frayed but attachments
intact
Type 2 Superior labrum has small tear; instability of the
labral-biceps complex (most common)
Type 3 Bucket-handle tear of labrum that may displace into
joint; labral biceps attachment intact
Type 4 Bucket-handle tear of labrum that extends to biceps
tendon; allowing tendon to sublux into joint
-Author's (Year)

4 TYPES OF SLAP TEARS

A. SURGICAL MX
1. Shoulder Manipulation
• Gentle manipulation of shoulder under GA
2. Hydrodilation
• Arthrographic distention
• using saline & steroid
SCAPULAR WINGING
3. Arthroscopic selective capsular release
Causes of Scapular Imbalance Patterns
4. Nerve blocks
5. Pain medications

B. PHARMACOLOGICAL MX
1. Oral steroid
• Rarely prescribed
• Mild short term benefit
2. Steroid injection
• Glenohumeral or subacromial injection

C. REHABILITATION MX
PATIENT'S PROGNOSIS
1. Therapeutic Exercise
For Adhesive Capsulitis:
Klintberg, L.H., et. al. (2015). Consensus for physiotherapy for
• Most patients will have restoration of normal function over
shoulder pain. International Orthopaedics (SICOT), 39:715-
a 12- to 14-month period
720.
2. Manual therapy
Page, M.J., Green, S., Kramer, S., Johnston, R.V., McBain, B.,
Chau, M. & Buchbinder, R. (2014). Manual therapy and
exercise for adhesive capsulitis (frozen shoulder). Cochrane
Database of Systematic Reviews, 8.
3. Electrotherapy modalities

Page, M.J., Green, S., Kramer, S., Johnston, R.V., McBain, B. &
Buchbinder, R. (2014). Electrotherapy modalities for adhesive
capsulitis (frozen shoulder). Cochrane Database of Systematic 3. ELECTROTHERAPY MODALITIES
Reviews, 10. •Low-level laser therapy for six days may be more effective
1. Therapeutic Exercise: General principles for prescribing than placebo
exercises •LLLT + Exercise better than exercise alone
• Exercises should not provoke the pain with which the
patient presented.
• Some mild to moderate pain (4/10 on VAS) due to the effort MAGEE- GRIP- SPECIAL TEST KAPLAN’S TEST
of doing the exercise can be tolerated but must have
subsided within 12 hours. POC
Strengthening
1. Therapeutic Exercise: General principles for prescribing Stretching
exercises -correct positioning and guarding
• The quality of the performance of exercises is crucial and
multimodal feedback (e.g. visual, biofeedback, taping) can be
used to achieve this. Exercises should be performed with
optimal scapular positioning and control without abnormal
compensatory trunk movement.

• START WITH:
 Unloaded proceeding to loaded exercises
 Simple exercises, e.g. targeting one force couple at a
time, proceeding to more complex movements
involving multiple force couples
 Slow proceeding to faster exercises
 Exercises performed in a conscious manner and
progress, by gradually decreasing feedback, to more
subconscious / automatic exercise performance

• The number of exercises should be limited to a maximum of

four
• Dose and progressions relate to the goal of each exercise
and should be adjusted in relation to the individual patient.

PENDULUM EXERCISES
ROM: 0' - 30 '
• Codman
• Chandler
• Sperry
• OHP: 30 ' - 60 °
• Sh Wheel: 60 ' - 90 '
• Finger ladder: 90 ° & above

2. MANUAL THERAPY: JOINT MOBILIZATION

• Combination of manual therapy and exercise may not be as
effective as glucocorticoid injection in the short-term