A Physiotherapy approach for General Practitioners

Presenters: Jaquie Goldsack

and Linda Gomercic
Introduction
Anatomy
Review of movement terminology
Subjective Examination
Objective Examination
Practical component
Differential Diagnosis
When is Physio Indicated
When is a specialist referral required
Case Scenarios
Questions
Anatomy- Bone/Joint
Articulations:
1. Glenohumeral
2. Acromioclavicular
3. Sternoclavicular
4. functional articulation of
thorax and scapula

Shallow joint- deepened

by labrum
Lots of degrees of freedom
Large HoH, small fossa
Stability dependant on
non bony connections
Ligaments Major Ligaments
Anterior GHLs
Coracohumeral Ligament
Superior GHL
Middle GHL
Inferior GHL

Labrum
Narrow, wedged shaped
structure
Intimately associated with the
shld capsule
Blends with origin of LHB
Pain sensitive structure
Roles: deepens fossa, controls
translational movement of the
shld in mid range movements,
draws HoH into glenoid fossa.
Muscles Rotator Cuff
Made up of:
SS
IF
Sub scap
Teres minor

Other stabilisers
Upper, Middle and Lower traps
Post Deltoid

Other muscles that impact on

shoulder Position (global)
LS
Rhomboids
Pec Minor
Bursae
Subacromial
Decreases friction
Thickens with degeneration
and wear and tear
Can be site of acute
irritation or secondary
inflammatory response to
primary degenerative
pathology
Sub acromial space- true
site of classic impingement
Innervation of the RC
Supraspinatus: suprascapula nerve C4, C5, C6
Infraspinatus: suprascapula nerve C5, C6
Subscapularis: Upper and lower subscapula nerve C5,
C6, C7
Teres Minor: Axillary nerve C5, C6
Quick Review of Terminology
Flexion/extension

IR/ER

HF/HE
Abduction/ Adduction

Protraction/Retraction
Subjective Examination
Mechanism of injury
Pain area
Duration of pain (date of onset)
Irritability
24hr behaviour
Agg/easing factors
Previous History of shoulder problems (esp if gradual
onset)
Occupation
Sports, exercise, hobbies
Red flags (Hx cancer, bilateral P&N, pain levels exceeding
those expected, systemic S&S, non mechanical MOI)
Objective
Observation (scap levels, protraction, downward tilt,
depression, clavicle levels)

Normal resting position of the Scapula:

superior angle T2/3
inferior angle T6/7
upward rotation average 10 degrees
Anterior tilt 8 degrees
Internal Rotation 33-35 degrees
2-3 fingers off of the spinous process ??
Scapular Movements
Depressed Scapula
Protracted/Winging scap
Anterior Tilt
Kyphotic tx, Ant sitting HoH
Posture
Objective Examination cont
4 finger position of scap- superior and inferior angles
of the scapula, acromion and coracoid.
The claw position of HoH- Anterior and posterior
acromion compared to anterior and posterior HoH
(HoH sitting 1/3 anterior to acromion).
AROM
With scap repositioning
PROM
Repositioning of scap and Re-Ax
ROM
Special Tests- Hawkins and
Kennedy
Impingement testing
Full Can/Empty Can
Rotator cuff tear/inflammation
Subscap lift off and Press Belly
Tests
Speeds
Apprehension
Sulcus
Neural Tension tests
Median:
shoulder depression
90 deg shoulder abduction
Wrist, finger, thumb Extension
Supination
ER of shoulder
Elbow extension
Neural Tension Tests
Ulnar:
Wrist extension/ 4th and 5th finger ext
Pronation/ supination
Elbow flexion
ER of shoulder
Shoulder Abduction
Neural Tension Tests
Radial
Shoulder Depression
Elbow extension
Whole arm IR
Wrist flexion/ thumb flexion
Shoulder abduction
Practical- Groups
Observation
AROM
Scap repositioning
Hawkins + Kennedy
Full can/ Empty Can
Lift Off / press belly
Speeds
Apprehension Test
Sulcus
Imaging
When is it warranted?
Trauma
Very large loss in range of motion/severe shoulder
pathology
Red flags ie history of cancer, unexplained weight loss
Failed conservative management
Dislocation- can still be managed conservatively
Unclear diagnosis
Differential Diagnosis
Other Causes of pain in the shoulder
Referral from the neck
Thoracic outlet Syndrome
Peripheral nerve sensitisation
Thoracic spine pain
SLAP lesions

Refer to table
When are anti
inflammatories/Cortisone Warranted
Moderate-severe pain thats not improving (acute
rotator cuff tears)
Difficulties with sleep
Failure of over the counter anti inflammatorys to
provide relief
Frozen shoulder stage I and possibly II (pain relief)
Slow progress with conservative management
When is Physio Indicated
Rotator cuff pathology and impingement.
Dysfunctional scapula position
Significant symptom relief and improvement of range of motion from
scap repositioning
Post cortisone
Stiff shoulder
?Frozen shoulder. Especially stages II and III when pain has decreased
and shoulder is stiff. Physio essential to restore ROM and function.
There is also a role for physio with education and prevention of
secondary problems in stage I. Research also shows gains in the first 2
months of stage 1.
Hypermobile/unstable shoulder
Pre and post shoulder surgery
Unclear diagnosis for example pins and needles, multiple pathology,
referring pain into arm, headaches etc
Treatment Approach
Muscle release
Heat/ ice/ ultrasound/ tens/ acupuncture
Tape to offload structures/ promote optimal position
Mobilisations shoulder, cervical, thoracic or nerve
Stability exercises
Motor control exercises
Global muscle strengthening
Specialist Referral
Recurrent dislocations/subluxations
Rotator cuff tears >2cm, massive tears, full thickness
tears, partial thickness tears >50%
Frozen shoulder stage 1
If conservative management is not working
Unsure diagnosis
Case Study 1/Discussion
45y/o Female presents with acute onset right shoulder pain
after spending the weekend painting. She is unable to lift
her arm >90degrees due to pain.
Pain is at the deltoid insertion with some radiation down to
elbow when she uses her arm (ie brushing teeth, doing
hair)
Agg activities include: lifting arm, brushing hair, reaching,
doing up bra, lying on her right side
Easing activities include: supporting arm, rest, heat to
shoulder
Special Qs: nil Hx of cancer, no neural Sx,
What is your differential Dx?
What tests would you perform?
Case Study 2/Discussion
30 y/o male presents with right sided pain in his biceps and P&N &
numbness in his palm, onset 6 weeks ago, gradually worsening. Gets
pain at night time.
Works as a labourer. Hx of carrying a large sheet of metal. The other
person carrying dropped one side of it, causing a traction force through
his right arm.
Agg activities include arm hanging by side, carrying objects, lying on
right side. Gets headaches with prolonged sitting and driving
Ease activities: putting arm on head or resting thumb in belt, resting
arm on object
Mild decrease in range of motion. Catch at 90degrees of abduction but
can continue through ROM.
Observation: Depressed and protracted right scapula
Differential Dx?
What tests would you perform?
Case Study 3/Discussion
40 year old diabetic female presenting with gradual onset of pain and
restriction of the right GH joint over the last 3 months.
Constant ache with sharp pain upon movement
Agg all shoulder movements, sleeping, dressing herself
Worse at night sleeps only 3-4 hours per day
Ease nothing at the moment
Works full time as a secretary
Unaware of any previous injuries to the shoulder
Observation: Rounded shoulders and kyphotic; shoulder hike on affected side
AROM: 40deg flxn+ abduction; 10 deg ER; HBB = iliac crest
Differential Diagnosis: ?
What tests would you perform?
Any imaging?
Physio approach
Questions

Thank you for attending