Upper Limb structures and
assessment
Learning Objectives
• Recognize different shoulder pathology
• Perform special test to identify different
shoulder pathology
• Justify PT treatment procedures for different
shoulder pathology
• Analyze the factors related to thoracic out let
syndrome
• Write treatment plan for 2 types of shoulder
pathology
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The shoulder Injuries and pathology
The Commonest cause of shoulder pain is
from the cervical in origin and mostly due
cervical spondylosis
There are many pathology affecting the
shoulder itself, some are needed to be
treated by Physical therapy.
• The rotator cuff and the sub deltoid bursa and
capsule may be compressed during sudden,
forceful glenohumeral abduction.
• The commonest site is subacromial bursa.
Causing a painful arc of movement between
70 and 120 degree of abduction
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Symptoms may occur acutely, or chronic,
particularly in the older patient. In this latter group
there are usually
1. degenerative changes in the acromiclavicular joint.
which leads to a reduction in size of the
supraspinatus tunnel,
2. Thickening of the subdeltoid bursa of the rotator
cuff tendons
Treatment
• Ice followed by US to the area
• AROM
• Trigger release with Shoulder PNF
a
1. Occurs in young athletes as a result of violent
traumatic incidents
2. Most commonly the supraspinatus region is involved
and the patient has difficulty in initiating abduction
of the arm
3. Other cases of torn cuff may cause impingement on
the acromion during abduction giving rise to a
painful arc of movement
4. It may require surgical intervention
1. Gross restriction of shoulder movements which is
associated with contraction and thickening of the
joint capsule (Inferior anterior part)
2. It is a condition that affects the middle-aged in
whose shoulder cuffs degenerative changes are
occurring.
3. Restriction of movement is often sever especially
rotation with abduction
4. Pain is often sever and may disturb sleep.
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5. In some cases the condition is initiated by a period of
immobilization of the shoulder by using a sling after
elbow or wrist fracture
6. Radiographs of the shoulder appears normal.
7. Pain may subside after a while, but restriction of
movement may be permanent unless treated
Treatment
• Ultrasound to the spot of restriction (the
lower part of the capsule)
• Stretching and mobilization exercise (inferior
glide, and anterior- posterior glide)
• Shoulder wheel
• AROM
1. Degenerative changes in the shoulder cuff may be
accompanied by the local deposition of calcium salts.
2. Calcified material may give rise to inflammatory
changes in the subdeltoid bursa, sudden sever
incapacitating pain results. The shoulder become
tender and is often swollen and warm to the touch
3. It may mix with Gout and infections symptoms,
4. Symptoms relieved by removing the calcified
material from the site of deposition
4
Dr. salameh al dajah
2014
Treatment
• Ice for 5 minutes followed by US on the
muscle insertion
• AROM
• Active exercise like pendulum exercise
• Acromioclavicular joint is exposed to a high
level of stress
• Results of fall or sport hitting
• Classified into 6 types
Dr. salameh al dajah
2014
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Shoulder may be affected by anterior,
posterior, or inferior instability. Anterior
stability is the commonest, and in many
cases.
It occurs most frequently in the 20-40 years
age group.
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The dislocation may occur by trauma for the first
time and then reoccur due laxity of ligaments and
shoulder tendons.
4. Depending on the mechanism of the trauma, the
anterior or posterior dislocation is occurring.
5. Shoulder recurrent dislocation is different from
habitual dislocation which occur as a results from
ligaments laxity, or psychological factors
Treatment
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Stabilize for 6-8 weeks
Mobility exercise (AROM and Active mobility)
Modalities to relieve pain
Strengthening exercise for deltoids, pectoralis,
scapular muscles, rotator cuff muscles
2
• Moderate swelling, painful, and decreased
mobility
• Affect the capsule and other inter articular
soft tissue
• Most of the pyogenic causes are
• Tuberculosis of the shoulder
• Gonococcal arthritis
2
Dr. salameh al dajah
2014
• Upper trunk region as a functional unit is
affected by common factors
• The first and second rib are attached to the
cervical spine and the clavicle by a group of
muscles
(Scalene muscles) and group of ligaments
• The subclavian artery bends over and passes through
a sulcus in the first rib.
• Brachial plexus lies stretched and lies tautly without
bony protection in this region.
• Anterior scalene syndrome and the costoclavicular
syndrome (cervical rib) compression are two
conditions recognized as thoracic outlet syndrome.
• X -ray is essential to determine the presence of the
cervical rib, but it is not a prove that it is the cause of
the symptoms.
h
• Adison’s test: Neurovascular compression of
the subclavian artery and brachial plexus
(cervical rib)
• Allen test: maneuver Thoracic outlet
syndrome
• Roos’ test: Thoracic outlet syndrome
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Procedure
The examiner locates the radial pulse of the involved
extremity
The patient’s head is rotated to the involved extremity
The patient extends the neck as the examiner externally
rotates and extends the shoulder
The patient takes a deep breath and holds it
Loss of the pulse is a positive test
If the test is negative, it is repeated having the patient
rotate the head to the uninvolved extremity
Dr. salameh al dajah
2014
 Procedure
 The patient’s elbow is flexed to 90 degree
 The shoulder is abducted and externally rotated
 As the examiner palpate the radial pulse, the patient
rotate the head away from the involved extremity
 If the pulse disappears when the head is rotated, it is
a positive test result for thoracic outlet syndrome
Dr. salameh al dajah
2014
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Procedure
While in the seated position, the patient
positions both arms at 90 degrees and
abducts and externally rotates them
• The patient repeatedly opens and closes the
fists for up to 3 minutes
If this maneuver reproduces the usual
symptoms of discomfort, the patient
probably has thoracic outlet syndrome
Treatment
• Modalities to relieve muscle spasm around
the shoulder
• Stretching and mobilization of the first rib to
relieve pressure on the artery
• Active shoulder ROM