Shoulder

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Shoulder
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Anatomy Review

• 2 bones
• Scapula
• Humerus
• 4 joints
• Gleno-humeral
• Acromio-clavicular
• Sterno-clavicular
• Scapulo-thoracic

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• Rotator Cuff Muscles
• S
• I
• T
• S

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• Scapular Muscles
• Move Scapula / Greater ROM
• Fixate Scapula on thorax
• Rhomboid Major / Minor
• Levator Scapula
• Serratus Anterior
• Pectoralis Minor
• Trapezius
• Latissimus Dorsi
• Pectoralis Major

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General Rehab Considerations
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Mechanics of Activities

• Baseball throw
• Windup Cocking Acceleration Follow-through
• Tennis Serve
• Windup Cocking Acceleration Follow-through
• Tennis Backhand / Forehand
• Racket prep Acceleration Follow-through
• Swimming (Freestyle)
• Early pull-through Late pull-through Early
  recovery Late recovery
• Golf Swing
• Take-away Forward swing Acceleration
  Follow-through

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Stability

• Passive stabilizers
• Joint capsule, ligaments, labrum
• Active stabilizers
• Muscles
• Damage (Microtrauma / Macrotrauma) to passive
  stabilizers and weakness / dysfunction of active
  stabilizers ? Functional Instability

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Other Factors to Consider

• Posture
• Cervical Dysfunction
• Thoracic Dysfunction
• Scapular Plane (Scaption)
• Exercise Progression
• Stay below 90 until good strength in rotator cuff

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Flexibility / Range of Motion
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Range of Motion

• Pendulum Exercises (Codmans)
• Wand Exercises
• Supine
• Standing
• Pulley Exercises
• PROM

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Flexibility

• Capsular stretches
• Inferior (shoulder flexion)
• Anterior (horizontal ext / ext rotation)
• Posterior (horizontal flex / int rotation)

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• Active stretches
• Internal Rotation
• Rhomboid
• Supraspinatus

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• Assistive
• Supraspinatus
• Infraspinatus
• Subscapularis
• Teres Minor
• Teres Major
• Latissimus Dorsi

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Strengthening
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• Isometrics
• Rotator Cuff Isotonics
• MRE
• PRE
• Rubber bands
• Scapular Stabilizers
• Open Chain
• Closed Chain

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• Machines
• Deltoid
• Pectoralis Major
• Latissimus Dorsi
• Rhomboids
• Trapezius
• Isokinetics
• Flexion / Extension
• Internal / External Rotation

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Proprioception
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• Swiss Ball Stabilization
• Distal Segment Stabilization
• Rhythmic Stabilization
• PNF Patterns (D1 / D2)
• MRE
• Rubber Tubing

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Special Considerations
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Shoulder Instability

• TUBS
• Traumatic, Unilateral, Bankart, Surgery
• AMBRI
• Atraumatic, Multi-directional, Bilateral,
  Rehabilitation, Inferior capsular shift

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Shoulder Impingement

• Narrowing of subacromial space
• Primary
• Caused by structures within the SA space (RC
  tendons, biceps tendon, bursa)
• Secondary
• Caused by shoulder dysfunction due to instability
• Capsular laxity / tightness
• Postural deformity
• Rotator cuff weakness
• Muscular imbalance

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• Treatment options
• Pain / Inflammation Control
• Secondary Find the cause!!
• Tight capsule Joint Mobs
• Loose capsule Strengthen active stabilizers
• Avoid aggravating activities
• Gradual return to full activity

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Traumatic RC Conditions

• Acute strain
• Partial thickness tear vs. full thickness tear
• Post-surgical cases
• Conservative vs. Surgical Options

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Arthroscopic Decompression

• Surgical procedure to clean out the subacromial
  space
• Decompression
• Primary impingement
• May involve acromioplasty
• Debridement
• Chronic tendinitis / synovitis

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Glenoid Labral Tears

• Most common in high-velocity overhead activities
• SLAP (Superior Labrum Anterior and Posterior)
• Usually involves LH of Biceps
• Conservative vs. Surgical options
• Bankart repair
• Capsulolabral reconstruction

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Adhesive Capsulitis

• Frozen Shoulder
• Capsular pattern of restriction at GH jt.
• Most common in older adults
• Female gt male
• Stage I
• Shoulder pain, pain at EROM, sleeping
  difficulties, diminishing ROM (3-6 weeks of
  rehab)
• Stage II
• Very stiff shoulder, pain through available
  motion, elbow pain, unable to lay on affected
  shoulder (1-3 months of rehab)
• Stage III
• Pain at rest, hard-leathery end feel at EROM w/
  capsular pattern, loss of scapulo-humeral rhythm
  (3-6 months of rehab)
• No rehab ? 18 24 months to resolve

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AC Sprains

• Almost always treated conservatively
• Grade I
• No deformity, sling (1-2 days)
• Grade II
• AC ligament torn, mild deformity, sling (5-7
  days)
• Grade III
• AC / CC ligaments torn, deformity, sling (7-14
  days)
• Type IV, V, VI usually require surgery and
  involve severe damage to AC and surrounding
  tissues.

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Biceps Tendon Injuries

• Bicipital tendinitis
• Usually secondary to instability, impingement, RC
  pathology
• Biceps tendon ruptures
• More common in middle-aged adults especially with
  RC pathology
• Sudden muscle contraction while muscle on stretch
• Complete ruptures exhibit Popeye Sign
• Younger athletes will usually require surgery,
  older adults may be fine with out