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The Shoulder

The Shoulder. Differential Diagnosis, Treatment and Rehabilitation. Capsular. LR>ABD>MR. Frozen Shoulder. Aka Capsulitis or adhesive capsulitis Vol of normal = 30mls Vol of frozen = 3mls 2% of normal population 20% go bilateral 11% in diabetic pop (don’t know why)

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The Shoulder

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  1. The Shoulder Differential Diagnosis, Treatment and Rehabilitation

  2. Capsular LR>ABD>MR

  3. Frozen Shoulder • Aka Capsulitis or adhesive capsulitis • Vol of normal = 30mls • Vol of frozen = 3mls • 2% of normal population • 20% go bilateral • 11% in diabetic pop (don’t know why) • W:M 60:40 Non dom gtr than dom • Risk factors – diabetes, hyperthyroid, immobilisation, stroke

  4. Frozen Shoulder • Capsular pattern Most loss of LR, then abd, then MR • Insidious onset • Self limiting 2-3 years • 3 Stages – freezing, frozen and thawing

  5. Stage 1 • Intermittent ache • Not below the elbow • Able to sleep on that side • Elastic end feel

  6. Stage 2 • Constant pain • Below the elbow • Unable to lie on that side at night • Hard end feel

  7. Stage 3 • As in stage 1 • Resolving problem

  8. Treatment of frozen shoulders • Stage 1 – heat, gentle mobilisation grade A and or injection • Stretch into elev and release with distraction • Distraction with sh elev and longitudinal distraction

  9. Treatment of frozen shoulders cont. • Stage 2 – injection combined with pain relief (and slow sustained stretching, as able) • Stage 3 – heat + low load sustained stretching – LR, MR and elev • 20 – 30 mins

  10. Home Exercise Programme

  11. Other Capsular Lesions • OA • Electro and Grade B mobs • Steroid Sensitive Arthritis • Intra-artic injection

  12. Non - Capsular

  13. Primary impingement • Associated with anatomical changes in the sub-acromial space ? cause • Acromial shape • Osteophytes • Tendon changes – tendonitis Or tendinosis? • Ligamentous thickening • Bursal thickening

  14. Secondary Impingement • Posture, neck and thorax • Tight muscle eg. Upper trapezius, pectoralis minor • Weak muscles eg.lower trapezius, serratus anterior • Poor timing, proprioception

  15. Neer classification • Stage 1 – under 25 years, oedema, inflammation, acute bursitis, tendonitis • Stage 2 – 25-40 years, fibrosis, bursal thickening, fibre disruption in the tendons • Stage 3 – over 40 years, bony spurs, compromised space, partial to full thickness tears

  16. Sub-acromial bursitis • Aka sub-deltoid bursitis, SIS • Sub-acromial space – supraspin. Tendon, bursa, sup aspect of GH capsule and long head of biceps

  17. On examination • Overuse • Gradual onset • C5 pain not usually below elbow • Arc and pain EOR • Non capsular pattern • Resisted abd and LR painful esp on release

  18. Treatment of Subacromial Bursitis • Pain relief • Physio modalities eg acup, trig point, US, taping • Injection • Posture • Postural stability work inc lower traps • Rotator cuff strengthening • Stretching upper traps, pec major, minor

  19. Home Exercise Programme

  20. Acromio-clavicular Joint • O/E high painful arc • Localised pain C4 • Scarf positive • EOR pain on passive movements • Traumatic onset – RICE • Strapping • Mobs • Gradual onset -mobs, frics and or inject

  21. Contractile Lesions • Strong + Painless = Normal • Strong + Painful = tendon or muscle local lesion I or II • Weak + Painless = Rupture III or nerve damage • Weak + Painful = severe lesion eg # • Pain during contraction – tendon • Pain on release - bursa

  22. Supraspinatus Tendinitis • O/E resisted abd painful and painful arc = distal end of tendon • Friction + electro + rest • All frics numb + 10mins • Or inject • Resisted abd painful and no painful arc = MT junction • Rotation Friction with arm in horizon abd, no injec

  23. Subscapularis Tendinitis • O/E resisted MR painful + painful arc = upper fibres + scarf test = lower fibres Friction – may be painful due to bursa Or inject

  24. Infraspinatus Tendinitis • O/E resisted LR painful + painful arc = distal end of tendon + no painful arc = body of tendon • Friction or inject

  25. Biceps Tendinitis • O/E resisted flexion and supination of the elbow painful • Long Head – rotation frics at bicipital groove or inject • Belly – pinch grip frics or inject with LA only

  26. When its not a shoulder • Pins and needles / numbness • Radiation to hand • Neck movt aggravates pain • Gastro– intestinal pathology • Avascular necrosis

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