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Diagnosis Rotator Cuff Impingement (Primary)

Rotator Cuff Impingement (Secondary)

Internal (Posterior) Impingement Rotatory Cuff Pathology

Signs and Symptoms Deep ache Poor posture Inadequate upward rotation of scapula Hypomobility of GHJ/capsule Weakness of depressors (subscap, teres minor & infraspinatus) Scapular dyskinesia (Type I,II,III) Impingement Sites: Greater tuberosity Ant/inf 1/3 of coracoacromial arch Soft tissue impingement: Supraspinatus tendon LH of biceps tendon Subacromial bursa Hypermobility of GHJ Joint capsule instability Weakness & overuse cycle o Stress to capsule/ligaments o Chronic inflammation o Thicker structures Pain post/sup portion of GHJ Repetitive microtrauma Acute vs. chronic Acute: less frequent and usually trauma Chronic: mechanical compression or tensile overload Intrinsic Causes: Vascularity of the RTC Extrinsic Causes: GH muscle imbalance ST muscle imbalance

Assessment Neer Hawkins-Kennedy Repeated movements (scapulohumeral rhythm creates painful arc) Mmt of supraspinatus (mid delt)& biceps AROM /PROM

Treatment Posture education STM stretch

See above

Rest (education) Stabilize scapular muscles and RTC muscles

See above

Rest (education)

Cyriax Palpation Lift off (subscap) Belly press (subscap) Full can/ empty can (supraspinatus) ER lag sign (infraspinatus &

Modalities (heat/cold) Active training of the periscapular muscles (rhomboids, serratus ant, traps, pec minor & RTC) EdUReP Strength & neuromuscular Control: Restore normal scapulohumeral rhythm Attention to humeral depressors Exercises: closed vs. open chain

Postural changes Capsular tightness Acromial type

teres minor)

Subscap exercises: o Push up plus o Diagonals Serratus anterior: o Push up plus o Dynamic hug o Wall slide above 90 o Upper cuts o Abd in scaption >120 o Abd in scaption <80 Upper Trap: o Unilateral shldr shrug o Abduction in scaption o Arm raise in line with low trap (prone) Middle Trap: o Arm raise in line with low trap (prone) o Horizontal extension (prone) o Unilateral row (prone) Low Trap: o Arm raise in line with low trap (prone) o ER with elbow supported (prone) o Horizontal ext (prone) Manual Therapy: STM Stretch Joint mobs (caudal glide or AP) Surgical intervention: (done after 6 months of failed conservative treatment) Arthrosopic evaluation

GH Instability

Potential hx of dislocation Excessive amount of motion with the presence of sx Glenoid retroversion Glenoid hypoplasia ( not fully developed glenoid) Muscular imbalance Lack of neuromuscular control Traumatic vs. Atraumatic Traumatic: Multidirectional or unidirectional (Anterior most common) Can result in bankart lesion

Assess posture Palpation MDI sulcus sign Load & shift Apprehension Jobes relocation MMT ROM with endfeels

Labral Pathology

Vague pain (with or without clicking, catching or locking) Worse with OH activities Pain in late cocking phase of throwing Instability with ant. labral/capsule involvement Weakness with RTC involvement Bankart: anterior dislocation SLAP: OH activities, pain in sup. Part of shldr

Obriens crank

Bursectomy with partial resection of the anteroinferior part of the acromian & the coracoacromial ligament MDI/UDI: tx based on direction of instability Strengthen scapular stabilizers (focus on serratus ant, low &mid trap) Wall angels Upper cuts Sunrise salutation PNF Strengthen RTC Theraband/sport cords Isotonic weights PNF Rhythmic stabilization Scapular Positioning STM (pec minor/major, subscap & post cuff) STJ mobs Surgical Intervention Capsular shift (open) Capsularplication (arthroscopic0 modalities STM Low grade jt mobs Normalize GHJ total arc of motion Post cuff stretches/STM Post GHJ glides Normalize scapular positioning o Scap mobs& strengthen o Pec min STM/stretch Posture

Adhesive Capsulitis frozen Shoulder

Females> males Self-limiting

Stage 1: Inflammatory 0-3 months Pain with AROM/PROM Decrease forward flexion, abd, IR, ER Diffuse synovitis No loss of motion with anesthesia Stage 2: Freezing 3-9 mos. Chronic pain with AROM/PROM Dec. flexion, abd, IR, ER Loss of motion with anesthesia Stage 3: Frozen 9-15 months Min. pain except at end ROM Dec. ROM with rigid end feel Loss of motion with anesthesia Capsular thickening/ scar formation Stage 4: Thawing 15-24 months Min. pain Progressive improvement in ROM

Posture Palpation of GHJ AROM PROM MMT (cyriax) Shoulder special tests are helpful if pt. can get into position

o T/S mobs Dynamic stability/proprioception o RTC strengthening o Scap stabilization o Rhythmic stabilization Core stabilization Do not push beyond pain tolerance Decrease Pain/ Inflammation Modalities STM Low grade Jt. Mobs Patient education (min. self immobilization) Normalize GHJ ROM as Irritability Dec. Progressive end range stretching High grade jt. Mobs STM Hold relax Normalize Scapular Positioning/ Mobility STM/ stretch to pect. Minor and subscap Scapular MWM Posture TS manip CT junction mobs Surgical: Manip/ mob under anesthesia Capsular release Know how much ROM in OR Communicate with surgeon Goals: Normalize motion Minimize pain