CCSP Shoulder Review

1. CCSP Shoulder Review

2. Analyzing and Diagnosing Shoulder injuries for Rehabilitation • Inspection: thumbs forward abduction • 0-60 gleno humeral • 60-120 Scapular • 120-160 Impingment • 160-180 Thoracic and Lumbar extension • Thumbs back now extension • As arms go down look for speeds, SLAP, give way • Cross hands to opposite shoulder slight push down • Palm up 15 degrees biceps long head challenge • Sulcus press test • Sulcus abduction test • Cuff Challenge • Atrophy – big for cuff tears • Stability Challenge

3. All Rehabilitation Programs should have the following components • Stability • Manipulative • Rehabilitative • Surgical – most surgical intervention for instability • Flexibility • Of the soft tissue • Instability front need back stability • Range of motion • Global and functional range • shoulder manipulation • Little to manipulate from a subluxation position • AC, Scapular fixation • MUJA frozen shoulder • Must manipulate above and below • First rib, T3-T7, Lower CSP, opposite PSIS • Rehabilitation and Exercise

4. Rehabilitation Sequencing • Short Arc • Muscle integrations • Establish firing sequencing • Establish muscle segment altered firing pattern • EMG substantiate\ • Begin cat 1 • Long Arc • Complete range without subluxation • Different resistance banding load • Bow Flex • Begin cat 2 • Resistive Load • Controlled resistive load (not exercise prescription) • Do not pyramid load training • Compression loading at tendon insertions • Ballistic Loading • Torsional tendon lowing at origins

5. Scapular thoracic Motion /Function Scapular elevation and depression Shoulder shrugs Scapular Protraction and Retraction Motion can be distorted if performed at extremes Use a ball roll procedure (Basketball) Scapulothoracic lateral slide test Both sides are within 1 cm bilaterally

6. Scapular distances

7. Scapular Angles

8. Protraction distances in CM

9. Elevation and depression in CM

10. Scapular rotation

11. Clavicular motion in CM

12. Creating your MS3805 Exam form • Designed from class • Pain assessment questions: • Referral pain patterns (5 questions) • Segmental motion assessment • Regional motion assessment • Global motion assessment • Specific strength assessment • Special Test • Idea is to lead to a specific diagnosis and a Rehabilitation program

13. Painful Arc Testing • Even with frozen shoulder 40 degress of abduction is possible due to scapular thoracic motion • Pain between 80-120 degrees during palm down elevation • If thumb rotates then anterior humeral axis impingement • Above and below 120/ 80 degrees the A/C joint is involved. There is more room in the supraspinatus outlet as the cuff drops away from the elevated scapulae.

14. Painful Arc Testing • Between 80-120 degrees • The supraspinatus slides under the confines of the coracoacromial ligament, AC joint, distal clavicle and acromion. • If you cannot lift in this range then usually a full thickness tear of the cuff

15. Painful arc above 120 degrees • If the pain is above 120 degrees then the AC joint is the problem • Arthritis • Spurring • Acromiolysis

16. Painful arc testing in 80-120 range • If palm up pain > than palm down, in the mid range 80-120 then exam consistent with • Adhesive capsulitis • Bursal adhesions • Posterior capsule synovitis • These structures get caught in supraspinatus fossa behind the scapular spine or between the deltoid and the rotator cuff • Remember palm down is cuff tendonitis

17. Objective Clinical Testing • Laxity • SLAP • Strength • AC vs impingement • TOS • Scapular winging • Cervical spine • Remember the most missed shoulder DR comes from the cervical spine

18. Internal Laxity Testing • Seated Internal Apprehension testing • Internal Apprehension testing • 90 degrees arm at the square • Look for apprehension • Feel for shift of the Glenohumeral head forward • Bankart, capsular avulsion • Subluxation / Dislocation out of socket • Feel for grinding (bankart)

19. External Laxity Testing • Seated external laxity apprehension • with the arm at the square rotate from internal to external rotation of the arm • Clicking is usually associated with a Labral tear • Posterior capsular laxity • This test is similar to doing McMurray’s test of the knee and feel for the meniscus to click

20. Inferior Laxity • Downward traction apprehension test • With a downward traction force you will perform a pivot shift on the inferior labrum and the inferior capsule • AP Drawer sign with hands on clavicle and acrominon • With the production of a sulcus sign, multidirectional instability • If bilaterally then inherent laxity or progressive stress causing progressive laxity • Not uncommon in swimming • If painful then must be treated

21. Supine Laxity Testing • Internal and external rotation with the arm flexed at 30, 60 and 90 degrees respectively • Remember 50% glenohumeral translation is considered normal • Containment maneuver • Abducted 90 degree, internal apprehension test with containment pressure makes pain go away. • Identifies the chronic subluxation shoulder

22. TOS and 1st rib , 3 strike testing • Wrights • Hyperabduction • Adson’s • Down and extension • Roo’s • Open and closing hand • 3 strike • Costoclavicular • Supra Clavicular space • Posterior intercostal transverse

23. AC vs. Impingement Testing • Forced flexion and forced hyperabduction • Implies AC joint arthritis • Press down on the AC joint with abduction of arm first 0-15 degrees advocates AC spurring and initial supraspinatus tendon compression • Palpate the coracoid tip and feel for the coracoacromial ligament • Now perform a impingement test at 90 degree of forward flexion and internal rotation • If positive, then cuff is injured

24. SLAP Lesion Testing • Slap Test • With arm in 90 degrees of forward flexion • Abduct the arm 30 degrees more toward the midline • Now internally rotate the arm • Pain radiating down the biceps tendon of pain from the back of the joint, • Superior labrum is detached of loose • Capsular is caught because of laxity • Test also used for posterior subluxation • Pearl • Structure at the top of the shoulder joint are loose, or worn • Does or does not have to click…use pain

25. Global Strength & SITS Testing • General global strength testing • Patient is seated and elbow is flexed at 90 degrees • SITS testing all 4 head and try to assess the initial loading. • If the patient has good strength then “counting strength and comparing bilateral is important • 1001, 1002, 1003, etc