The Shoulder
Introduction
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Components of the shoulder
Most common joint pathology
Rotator cuff
Biceps Tendon
Fractured neck of Femur
Dislocation
Adhesive Capsulitis
3 components
• The glenohumeral
joint
• The
acromiclavicular
joint
• The scapular
Diagnosis
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History
Range of Movement
Palpation
Pain
Diagnostic tests (there are 65 that can
be performed!)
Most common joint
pathology
Gh joint
Ac joint
Scapular
Adhesive
capsulitis
OA (rare)
Dislocation
Tendonitis
Impingement
Instability
Shoulder or cervical nerve
root?
• Is there loss of shoulder ROM?
YES = SHOULDER
• Are the reflexes reduced?
YES = CERVICAL
Rotator Cuff
• Stabilise the head of
the humerus while the
other major muscles
around the shoulder
are actively moving the
arm. Eg. When deltoid
is abducting. They also
initiate most
movements
3 main types of rotator cuff
lesions
• Tendonitis
• Partial rupture
• Complete rupture
Tendonitis
Supraspinatus
Initiates abduction
(Most commonly
injured)
Infraspinatus
and Teres Minor
Laterally rotate
humerus
•Painful arc at
90° abduction
•Toothache type,
constant pain
from acromion to
deltoid insertion
•Reverse scapular
pattern
• Painful arc at •Painful medial
90 abduction
rotation
•Resisted gh
lateral rotation
•Thickened
tendon posterior
to ghjt
Subscapularis
Medically rotate
humerus
Treatment of tendonitis
Early stages
Later stages
•Frictions
•Ultrasound
•Strengthening exercises
in pain free range
•Scapular control
•Shoulder taping to
offload tendon
•Antiinflamatories
•Stretching exercises
Rotator cuff rupture
Partial rupture
Complete rupture
•Cause usually traumatic
•As tendonitis but pain is
sharper
•Resisted abduction very
painful
•Passive elevation not
affected
•Cause fall onto point of
shoulder with arm
adducted/spontaneous
due to degeneration
•Acute pain
•Inabiltiy to initiate
abduction
•Full passive rom if
helped through first 2030º
Rotator Cuff strengthening
Sidelying Lateral Rotation
Rotator Cuff strengthening
Prone Horizontal Abduction
Rotator cuff strengthening
Lateral rotator strengthening with resistance band
Biceps Tendon
Tendonitis
Rupture
•Pain in
bicipital
groove
•Pain on
resisted
forearm
supination
and elbow
flextion
Buldge in
lower third
of upper
arm.
Fractured neck of femur
• Pain on early movement
• Upper arm swelling
• Need to be investigated early
especially following a fall in the
elderly
• Should be kept moving as much as
possible
Ghjt disclocation
• Carries a very specific history of
trauma
- anterior dislocation (abduction,
extension and lateral rotation)
• Usually involves tear of labrum
• Physio aims to strengthen rotator cuff
• After 3rd dislocation surgery is usually
necessary
Adhesive Capsulitis/Frozen
shoulder
• inflammation of the shoulder capsule
and synovial membrane leading to
adhesion formation. This causes a
thickening in the capsule and
constriction of the glenohumeral joint
due to the scar tissue forming in the
capsule
Diagnosis
• Age 40+
• Cause ? Unknown
Possible: trauma, wrench, dislocation.
CVA, heart conditions, diabetes, viral.
Can also be secondary to cx spondylosis
or to tendonitis.
Clinical features
Clinical features
• Increasing dull ache over a few months
duration.
• Sharp pain when reaching the end of
pain free movement
• Loss of movement in a capsular pattern
– lateral rotation – abduction - flexion
Most reduced >>>>>>>>>Least reduced
• Elevation and protraction of shoulder
girdle
Clinical features cont’
• Pain over A/C joint and deltoid muscle
– can spread to neck and/or elbow
• All G/H movement often painful, not
specific planes
• Pain worse at night
Clincial features cont’
• Muscle spasm in pectoralis major and
latissimus dorsi
• Wasted deltoid
• Associated posture
• Dowagers hump
• Poke chin
Prognosis
• 18 months to 3 years
3 phases
1. Freezing –painful phase (worse at night
and when lying on it)
2. Frozen – stiff phase
3. Thawing- stiffness gradually eases
Physiotherapy
• Reduce pain with electrotherapy, TENS
and acupuncture until patient is able
to sleep and function day to day
• Taping to rest the joint
• Static strengthening exercises for the
shoulder
• Introduce stretching in sub acute phase
Exercises to increase rom
Other treatment
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Antiinflamatories
Muscle relaxants
Hydrocortisone injection
Nerve block
Surgery – Manipulation/Arthroscopic
capsular release