Shoulder Instability Definition: Pertaining to the Glenohumeral (GH) joint, a condition of excessive laxity or joint play associated with large translations of the proximal humerus relative to the glenoid. Shoulder instability can lead to subluxation or dislocation. Subluxation at the GH joint can be defined as an incomplete separation of articular surfaces, often followed by spontaneous realignment. Dislocation can be defined as a complete separation of articular surfaces without spontaneous realignment. Mechanism of Injury: Shoulder instability can often be classified into three types. 1) Posttraumatic Instability- example due to fall or forceful collision. Usually dislocations occur anteriorly when in position of abduction and external rotation. Involves overstretching or injuring rotator cuff muscles, middle and inferior GH ligaments, and anterior-inferior rim of glenoid labrum. Bankart lesions are tears or lesions of this part of the capsule or labrum that are detached from the rim of the glenoid fossa. Posttraumatic Instability frequently leads to future re-occurrences. Surgery is often needed to stabilize structures. 2) Atraumatic Instability- Persons that display generalized and excessive ligamentous laxity throughout their body. Not fully understood but considered congenital. Conservative therapy of strengthening and coordination is very successful in this type of instability. 3) Acquired Shoulder Instability-Wear and tear injuries related to overstretching and micro-trauma of the capsular ligaments within the GH joint. Associated with repetitive, high-velocity shoulder motions that involve extreme external rotation and abduction that are common in overhead sports like baseball, swimming, volleyball, tennis etc. Symptoms
Pain caused by shoulder injury
Repeated shoulder dislocations Repeated instances of the shoulder giving out A persistent sensation of the shoulder feeling loose, slipping in and out of the joint Numbness or tingling if nerve involvement Signs A positive Apprehension or Relocation Test (anterior GH stability) A positive posterior glide 90 degrees Flexion and internal Rotation (posterior instability) Multidirectional instability Test (multidirectional instability, especially inferior) Treatment Strategy Modalities/Pain Control: Cryotherapy can be used to reduce pain, swelling, and inflammation. IFC e-stim can be supplemented with cryotherapy for further pain relief. E-stim can be used for the muscular re-education of rotator cuff muscles. Manual Therapy: In the sub-acute phase restoring ROM is important. Restoring passive accessory movements keeping in mind what might be contra-indicated for dislocation. Posterior, Inferior, Anterior, and lateral glides of glenohumeral joint for pain control and increasing ROM. Assistive Devices: Shoulder sling for period of immobilization for healing Taping of glenohumeral joint for added stability
Education: It is important for the patient to be educated on the general normal anatomy of the shoulder joint and what their specific problem of shoulder instability is. The patient should be made aware of the likelihood of further dislocation/subluxation and what movements they should avoid. The patient should be made aware that with a good rehabilitation program of physical therapy that their shoulder joint will be properly strengthened and future problems can be resolved. Therapeutic Exercises: Phase I (0-3 weeks)- Usually period of immobilization. Cryotherapy and modalities Phase II (3-6 weeks) - PROM/AROM Shoulder flexion, abduction, adduction, internal/external rotation. Some strengthening exercises Phase III (6 weeks +) – Scapular stabilization exercises: elevation, depression, retraction, protraction Strengthen the rotator cuff muscles- supraspinatus, infraspinatus, subscapularis, teres minor Exercise examples: Shoulder Flexion (lying down) Shoulder blade squeeze Resisted Rows Internal and External Rotator Exercises
Home Exercise Program- Theraband can be given to patient to take home and perform exercises Flexion, Abduction, Adduction, Extension, External Rotation, Internal Rotation, Horizontal Adduction, Horizontal Abduction References: Hayes et al, Shoulder Instability: Management and Rehab. J Orthop. Sports Physical Therapy. Volume 32. Number 10. October 2002 Loudon, J., Swift, M., Bell, S. (2008). Knee. The clinical orthopedic assessment guide. (2nd ed., pp. 135-180). Champaign, IL: Human Kinetics Neumann, D. A. (2010). Upper Extremity. Kinesiology of the musculoskeletal system: Foundations for rehabilitation. (2nd ed., pp. 137-160). Mosby, Inc. OrthoInfo. (2009). Chronic Shoulder Instability. Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=a00529 Prentice, W. E., Quillen, W. S., & Underwood, F. (2011). Therapeutic modalities in rehabilitation. New York, NY: McGraw
Shoulder Impingement
Definition: Shoulder impingement refers to compression of the soft-tissue structures (rotator cuff muscles, subacromial bursa) causing pain with overhead activities. This syndrome can be classified as primary or secondary. It is common in athletes involved in throwing sports such as baseball, tennis, swimming, etc. as well as assorted occupations that involve keeping the shoulder in an elevated position for an extended period of time3.
MOI:
Primary – acromial abnormalities result in a narrower subacromial space 4. Some people are born with a curved (Type II) or hook-shaped acromion ( Type III)3. Aging adults may develop osteoarthritis of the AC joint or bone spurs, which would also contribute to the narrower space4.
Secondary – occurs without any acromial abnormality. This type is usually due to dysfunctional shoulder biomechanics and is exacerbated by repetitive use or long periods of compression3. Overuse or repetitive irritation of the rotator cuff can lead to inflammation of the rotator cuff tendons (rotator cuff tendonitis) and the bursa lying over them. Instability of the structures in the shoulder could allow the humeral head to migrate upwards, causing impingement. This is an especially common cause of impingement in young athletes4.
Signs/Symptoms:Patients experience intermittent, superficial pain typically in the anterior shoulder1. The pain usually starts off gradually and is aggravated with reaching, overhead activities, and lying on the affected side or at night4. Pain may radiate down the arm, but stops before the elbow. If pain travels to or beyond the elbow, a pinched nerve may be indicated. The patient may also have weakness and decreased range of motion2.
Tests/measures:
Primary – negative stability tests, positive impingement tests, painful arc between 60°-120°, abnormal scapulohumeral rhythm, restricted internal rotation and horizontal flexion because of tight posterior capsule
Hawkins-Kennedy Impingement Test – flex patient’s arm to 90° of shoulder flexion and 90° of elbow flexion. Clinician medially rotates patient’s shoulder. Reproduction of symptoms is a positive test for impingement of supraspinatus tendon. Hawkins-Kennedy video
Neer’s Test – clinician passively elevates patient’s arm overhead in the scapular plane with the arm medially rotated. Positive response for impingement of supraspinatus is pain. Neer's video
Crossover Impingement Test – clinician applies overpressure into horizontal adduction. Anterior pain is a positive response for impingement of subscapularis, supraspinatus, and long head of biceps brachii. Superior pain is a positive response for A/C joint impingement. Posterior pain is a positive response for impingement of infraspinatus, teres minor, posterior capsule.
Instability Tests: Glenohumeral Load and Shift (anterior and posterior stability of GH joint), Apprehension or Relocation Test (anterior GH stability), Posterior Glide 90° Flexion and Internal Rotation (posterior instability), Multidirectional Instability Test ( multidirectional, especially inferior instability)1.
Treatment Strategy:
Modalities/pain control – anti-inflammatory modalities are helpful in reducing swelling, inflammation, pain (ice, NSAIDS, cortisone injection)
Manual therapy – joint mobilization to posterior capsule if appropriate; deep friction massage
Exercise – Early in exercise, patients should begin stretching and range of motion exercises to promote pain-free ROM. Examples of these rotator cuff ROM increasing exercises/stretches might be: pendulum swings, corner stretch, horizontal adduction stretch, internal and external rotation stretches. The second phase will begin to include rotator cuff strengthening exercises beginning with a very low weight. Examples include: active shoulder flexion, abduction, prone extension, prone horizontal abduction, shrugs, bicep curls, empty can5.
Primary – normalize ROM (especially IR), rotator cuff strengthening and stretching (pec major, pec minor, rhomboids, upper trapezius)
Secondary – focus on dynamic stability (scapular and rotator cuff strengthening)
HEP – patient should rest, especially avoiding the offending sport if applicable. When appropriate, the patient will gradually begin a home exercise program including stretching and strengthening exercises.
Education – patient should be educated on the anatomy and nature of the injury. Educate the patient on importance of exercises and rest.
References:
1 Loudon, J, Swift, M. & Bell, S. (2008) The Clinical Orthopedic Assessment Guide (2nd ed). Champaign, IL: Human Kinetics.
Adhesive inflammation between the joint capsule and the peripheral articular cartilage of the shoulder, with obliteration of the subdeltoid bursa, characterized by increasing pain, stiffness, and limitation of motion. Signs and symptoms typically begin gradually, worsen over time and then resolve, usually within one or two years.
Adhesive capsulitis has been associated with several conditions. A higher incidence of frozen shoulder exists among patients with diabetes (10-20%) compared with the general population (2-5%). Incidence among patients with insulin-dependent diabetes is even higher (36%), with an increased frequency of bilateral shoulder involvement.Other diseases that increase the likelihood of developing frozen shoulder: hypothyroidism hyperthyroidism Parkinson's cardiac disease
Your risk of developing frozen shoulder increases if you're recovering from a medical condition or procedure that affects the mobility of your arm — such as a stroke or a mastectomy.
A few reported etiologic agents include the following:
Trauma
Surgery (including but not limited to shoulder surgery)
Inflammatory disease
Diabetes
Regional conditions
Various shoulder maladies
Signs/Symptoms
Most common names of the 3 phases:
Freezing (worsening)
Frozen (not as painful, very stiff)
Thawing (motion slowly improves)
Patients with primary frozen shoulder have no significant findings in the history, clinical examination, or radiographic evaluation to explain their motion loss and pain. Classically, symptoms of primary frozen shoulder have been divided into 3 phases: (1) the painful phase, (2) the stiffening phase, and (3) the thawing phase. In the initial painful phase, there is a gradual onset of diffuse shoulder pain lasting from weeks to months. The stiffening phase is characterized by a progressive loss of motion that may last up to 1 year. Most patients lose glenohumeral external rotation, internal rotation, and abduction during this phase. The final, thawing phase is measured in weeks to months and constitutes a period of gradual motion improvement. Once in this phase, the patient may require up to 9 months to regain a functional range of motion.
Can also be broken down like this:
Stage I: pain in and around the GH joint (no stiffness)
Stage II: deep pain or pain at deltoid insertion (deltoid tuberosity on the lateral aspect of the humerus); may radiate to elbow
Disturbs sleep, increased stiffness, perceived as weakness, inability to perform ADLs
Stage III: minimal pain at rest
Stage IV: gradual resolution of stiffness
Reminder: Capsular pattern for the shoulder is external rotation, abduction, internal rotation
People with frozen shoulder have limited active and passive ROM
Treatment Strategy
Sometimes spontaneous resolution
Therapeutic exercise
Stage I and II:
-exercise, massage, and forcible movements contraindicated
-risk humeral fracture, rupture of the joint capsule, and rupture of the subscapularis
Stage III and IV:
-stretching
External rotation — passive stretch. Stand in a doorway and bend your affected arm 90 degrees to reach the doorjamb. Keep your hand in place and rotate your body. Hold for 30 seconds. Relax and repeat.
Forward flexion — supine position. Lie on your back with your legs straight. Use your unaffected arm to lift your affected arm overhead until you feel a gentle stretch. Hold for 15 seconds and slowly lower to start position. Relax and repeat.
Crossover arm stretch. Gently pull one arm across your chest just below your chin as far as possible without causing pain. Hold for 30 seconds. Relax and repeat.
Patient education
In stages I and II, massage and forcible movements contraindicated
Assistive equipment
Stage I and II: Sling
Stage III and IV: None
Manual therapy
Stage I and II:
- Massage and forcible movements contraindicated
- Mobilizations for pain
Stage III and IV:
-mobilization and manipulation
From a study on standard PT stretching versus end-range mobilization/scapular mobilization treatment approach:
-insufficient external rotation of the humerus and limited posterior tipping and upward rotation of the scapula during arm elevation, exacerbate the condition of frozen shoulder symptoms, including impingement pain, limited range of motion (ROM), and muscle weakness
-specific end-range mobilization and scapular mobilization was shown to have greater positive effects than a standard protocol. -Shoulder kinematics, including humeral external rotation, scapular posterior tipping, and scapular upward rotation during arm elevation, are associated with treatment improvement -end-range intensive grade IV anterior-posterior mobilization techniques combined with scapula superior/inferior and upward/downward mobilization techniques can be advocated in subjects with frozen shoulder who have less than 8 degrees of scapular posterior tipping, 97 degrees of humeral elevation, and 39 degrees of humeral external rotation during arm elevation
Home instruction/HEP
Stage I and II:
-rest, positions that ease pain/discomfort
Stage III and IV:
-stretches listed above
Pain control/modalities
From a systematic review of non-operative options:
-intra-articular steroid injections for pain but not range of motion -steroid injections for pain in the medium term -No differences were found in ROM between steroid injections and manipulation -strong evidence in favor of laser therapy compared with placebo for reduced pain and disability -Most effects were shown in the short term, although physical therapy did show effects in the longer term -suprascapular nerve block -arthrographic distension (procedure where fluid is injected into the shoulder joint to break up the adhesions)
-The combination of a suprascapular nerve block and physical therapy improves pain, disability, and range of movement of the shoulders compared with intra-articular corticosteroid injection of the shoulder and/or physical therapy alone
-heat (before starting PT exercises)
Abdelshafi ME, Y. M.-S. (2011). Relief of chronic shoulder pain: a comparative study of three approaches. Middle East Journal of Anesthesiology, 83-92. Jing-lan Yang, M.-H. J. (2012). Effectiveness of the end-range mobilization and scapular mobilization approach in a subgroup of subjects with frozen shoulder syndrome: A randomized control trial. Manual Therapy, 47-52. Loudon, S. B. (2008). The Clinical Orthopedic Assessment Guide. Champaign, IL: Human Kinetics. RZ, T. (2012). The effectiveness of nonoperative treatment for frozen shoulder: a systematic review. Clin J Sport Med, 169-69.
Rotator Cuff Pathology**
(Rotator Cuff Tear, Tendinitis, or Tendinosis)
Definition:
Tendinosis: intrinsic tendon degeneration or failure of the tendon fibers
Tendonitis: acute irritation of the tendon and inflammation of the bursa
Supraspinatus
Infraspinatus
Biceps
Subscapularis
Mechanism of Injury:
Overuse or change in activity. Exacerbation and remission of symptoms can occur for many years
Symptoms:
Early Stages
Intermittent superficial pain present both during activity and rest
Sudden pain with lifting, reaching, or overhead movements
Deep, radiating, anterior shoulder pain, may move down the arm
Late Stage
Pain at night
Loss of strength and ROM
Inability to perform HBB activity
Signs:
Positive Hawkins-Kennedy Impingement test
Poor scapulohumeral rhythm
Pain with tendon palpation – thickening of tendon may also be present
Hand Behind Back (HBB) ROM – pain with over pressure (OP)
RROM will be STRONG and painful if minor, WEAK and painful if severe
Muscles of the rotator cuff, Deltoid, Serratus Anterior, Trapezius
Progression
Horizontal closed-chain
Vertical closed-chain
Horizontal open-chain
Diagonal closed-chain
Diagonal open-chain
Education
Postural instruction – anteriorly rolled shoulder
Home Instruction:
Activity modification – rest from aggravating factors
Instruction on sleeping position
Referral - Patient may require surgery
References:
1. Loudon, Janice, Marcie Swift, and Stephania Bell. The Clinical Orthopedic Assessment Guide. Champaign, IL: Human Kinetics, 2008. Print.
2. Neumann, Donald A. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. St. Louis, Mo: Mosby, 2010. Print
3. Gould, Barbara E., and Ruthanna Dyer. Pathophysiology for the Health Professions. St. Louis, MO: Saunders/Elsevier, 2011. Print.
4. Kibler, W. "Rehabilitation of Rotator Cuff Tendinopathy." Clinics in Sports Medicine 22.4 (2003): 837-47. Print.
Shoulder Labral Tears
Definition:
The glenoid labrum is the fibrocartilage rim around the glenoid fossa of the scapula. It acts to deepen the socket for the head of the humerous and increase the size of the articular surface. It also acts as an attachment site for the long tendon of the biceps brachii, the glenohumeral joint capsule, and some of the shoulder ligaments. Through trauma or repetitive motion the labrum can become injured and this is referred to as a tear.
Labral tears are classified by theirs locations, and can occur either superior or inferior to the middle of the glenoid cavity and are called SLAP lesions and Bankart lesions respectively.
SLAP (Superior Labrum Anterior and Posterior) lesions are labral tears above the middle of the glenoid cavity and may potentially have involvement of the long biceps tendon. This area of the tissue is more mobile and more prone to injury. Injuries in this area are common in baseball pitchers and other athletes who perform overhead motions.
Bankart lesions occur below the middle of the glenoid cavity and includes involvement of the inferior glenohumeral ligament.
Mechanism of Injury:
Acute Trauma – Falling on an outstretched arm Direct blow to the shoulder MVA Shoulder dislocation A forceful motion when the arm is above shoulder level Forceful pulling on the arm (catching a heavy object)
Repetitive motion – Throwing athletes Weightlifters Wearing down of the tissue with normal aging
Signs and Symptoms:
Symptoms – (Very similar to other shoulder injuries)
Pain in the shoulder (especially with overhead activities)
Catching, clicking, popping, or grinding,
Decreased range of motion,
Loss of strength,
Feeling that the shoulder is unstable
Potential pain at night and with ADLs
Signs – Arthroscopic imaging, and CT or MRI imaging (possibly with a contrast medium) may be used by the physician to confirm a labral tear. The following tests can also be used to help with diagnosis.
Labral (Clunk) test: Patient will experience pain, clunk, grinding, or pseudolocking when clinician applies compression, rotation and anterior force to the fully abducted humeral head.
Crank Test: Patient experiences a painful click when the clinician provides axial force on the humerus when it is at 160 degrees scaption and maximal internal or external rotation.
Speed’s Test: Patient will have pain in the bicipital groove with resisted shoulder flexion. The patient should be positioned in shoulder flexion and full external rotation, elbow extension, and supination.
Yergason’s Test: Patient will experience pain with resisted supination and shoulder external rotation with the elbow positioned at 90 degrees.
O’brien Test: A superior labral tear is indicated when patient experiences pain with resisted shoulder flexion when the patient’s arm is positioned starting in 90 degrees flexion, 10 degrees adduction, and maximal internal AND external rotation (this is a 2 part test and is to be performed with both IR and ER).
Anterior Slide Test: A superior labral tear is indicated if the patient experiences a reproduction of symptoms, a click or a pop, or pain in the anterosuperior shoulder area with this test. The patient is positioned standing with hands on hip and thumbs pointing backward. An anterior and superior force is applied by the clinician at the elbow while stabilizing the scapula and clavical, and the patient is instructed to resist this force.
Treatment: Non-Surgical Treatment: The physician may prescribe NSAIDs and rest for relief of symptoms. Physical Therapy is also initiated to stretch the joint capsule and strengthen the muscles supporting the shoulder. This can help with pain relief and prevention of further injury. Physical therapy with conservative treatment should concentrate on relief of patient symptoms and addressing instability and hypermobility of the shoulder with dynamic stabilization exercise.
Surgical Treatment: For SLAP lesions, the physician will determine the stability of the shoulder during surgery. If the injury only involves the labrum and the biceps tendon is unaffected, then the shoulder is still considered stable, and the doctor will repair or remove the injured tissue and fix any associated issues within the joint. However, if the biceps tendon is affected, then the shoulder is considered unstable, and the doctor will also need to repair or reattach the tendon as indicated by the severity of the injury.
Bankart lesions can also present with shoulder instability, in which case the doctor will repair the involved ligament and tighten the joint by “pleating” the tissues.
Therapeutic Exercise: Exercises for patients with labral tears can include, but are not limited to: ROM exercises of the glenohumeral joint Scapular stability exercises Closed chain exercises Open chain exercises PNF patterns Specific rotator cuff strengthening exercises Dynamic stability, neuromuscular coordination, and proprioceptive exercises
Education: The patient should be educated on shoulder anatomy, and the injury that occurred. Surgical procedures should also be explained if needed. The patient should be taught how to properly use a sling, and instructed to avoid any activities or positions that provoke symptoms.
Assistive Equipment: The patient will be instructed to keep their arm in a sling to restrict shoulder motion for 2-4 week after surgery while the labrum heals.
Manual Therapy:. Glenohumeral joint mobilizations may be indicated for pain or joint restriction, but the therapist should be cautious if instability if present.
Home Exercise Program: The HEP should include the exercises mentioned above, and should concentrate on regaining ROM and strength in the shoulder while staying in a pain free range.
Modalities/Pain Control: Cryotherapy, NSAIDs, and e-stim can be used for pain reduction along with rest and early immobilization.
References: Dutton, Mark. "Chapter 14." Orthopaedic Examination, Evaluation and Intervention. New York: McGraw-Hill Professional, 2004. 456+. Print.
Loudon, Janice, Marcie Swift, and Stephania Bell. "Special Tests." The Clinical Orthopedic Assessment Guide. 2nd ed. Champaign, IL: Human Kinetics, 2008. 151+. Print.
Neumann, Donald A. "Chapter 5." Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd ed. St. Louis, MO: Mosby/Elsevier, 2010. 139+. Print.
Prentice, William E., William S. Quillen, Frank B. Underwood, and William E. Prentice. Therapeutic Modalities in Rehabilitation. 3rd ed. New York: McGraw-Hill, Medical Pub. Division, 2005. Print.
There are three types of sprains/separation of the AC Joint, which is the joint between the acromion process and the clavicle. Type 1 is the incomplete tear of the acromioclavicular (AC) ligament. Type 2 tears are a tear of the AC ligament and a partial tear of the coracoclavicular (CC) ligament. Type 3 tears are complete tears of the AC and CC ligaments (1). http://www.youtube.com/watch?feature=player_embedded&v=4S3bkkjUaDg http://www.youtube.com/watch?v=OfcSvG-dgbY
Signs & Symptoms:
Point tenderness on the AC joint
Swelling, Bruising (2)
Pain with functional activities:
Lifting, coming hair, washing opposite axilla, reaching behind body
Widening of the AC joint with palpation (1)
Mechanism of Injury: Direct force applied to acromion with arm adducted. This force drives the acromion medially. (Falling directly on shoulder)(1) This separation can also occur when falling on an outstretched arm(3).
Treatment:
Therapeutic Exercise:
- Restore general shoulder ROM
- Regain shoulder strength (1)
Education:
Tell/show patient what is injured and possible MOI, so they can better understand the scope of their injury. Show the pt how to modify movements to not disturb the healing of the ligament(s). (1)
AssistiveEquipment:
Most patients will use a sling to partially immobilize the movement in the shoulder joints (3), this will also support the shoulder in a more comfortable position (1)
Modalities:
Ice, NSAIDS, US, MHP – goal to reduce the pain that may be limiting the patient’s ability to do exercises (1)
ManualTherapy:
- Joint mobilizations
Anterior AC Joint Glide
Posterior AC joint Glide
Home Exercise Program:
Patient should rest the joint/injury initially. Then, get back into exercise gradually.
Definition: Pertaining to the Glenohumeral (GH) joint, a condition of excessive laxity or joint play associated with large translations of the proximal humerus relative to the glenoid.
Shoulder instability can lead to subluxation or dislocation. Subluxation at the GH joint can be defined as an incomplete separation of articular surfaces, often followed by spontaneous realignment. Dislocation can be defined as a complete separation of articular surfaces without spontaneous realignment.
Mechanism of Injury: Shoulder instability can often be classified into three types.
1) Posttraumatic Instability- example due to fall or forceful collision. Usually dislocations occur anteriorly when in position of abduction and external rotation. Involves overstretching or injuring rotator cuff muscles, middle and inferior GH ligaments, and anterior-inferior rim of glenoid labrum. Bankart lesions are tears or lesions of this part of the capsule or labrum that are detached from the rim of the glenoid fossa. Posttraumatic Instability frequently leads to future re-occurrences. Surgery is often needed to stabilize structures.
2) Atraumatic Instability- Persons that display generalized and excessive ligamentous laxity throughout their body. Not fully understood but considered congenital. Conservative therapy of strengthening and coordination is very successful in this type of instability.
3) Acquired Shoulder Instability-Wear and tear injuries related to overstretching and micro-trauma of the capsular ligaments within the GH joint. Associated with repetitive, high-velocity shoulder motions that involve extreme external rotation and abduction that are common in overhead sports like baseball, swimming, volleyball, tennis etc.
Symptoms
Pain caused by shoulder injury
Repeated shoulder dislocationsRepeated instances of the shoulder giving out
A persistent sensation of the shoulder feeling loose, slipping in and out of the joint
Numbness or tingling if nerve involvement
Signs
A positive Apprehension or Relocation Test (anterior GH stability)
A positive posterior glide 90 degrees Flexion and internal Rotation (posterior instability)
Multidirectional instability Test (multidirectional instability, especially inferior)
Treatment Strategy
Modalities/Pain Control:
Cryotherapy can be used to reduce pain, swelling, and inflammation. IFC e-stim can be supplemented with cryotherapy for further pain relief. E-stim can be used for the muscular re-education of rotator cuff muscles.
Manual Therapy:
In the sub-acute phase restoring ROM is important. Restoring passive accessory movements keeping in mind what might be contra-indicated for dislocation.
Posterior, Inferior, Anterior, and lateral glides of glenohumeral joint for pain control and increasing ROM.
Assistive Devices:
Shoulder sling for period of immobilization for healing
Taping of glenohumeral joint for added stability
Education:
It is important for the patient to be educated on the general normal anatomy of the shoulder joint and what their specific problem of shoulder instability is. The patient should be made aware of the likelihood of further dislocation/subluxation and what movements they should avoid. The patient should be made aware that with a good rehabilitation program of physical therapy that their shoulder joint will be properly strengthened and future problems can be resolved.
Therapeutic Exercises:
Phase I (0-3 weeks)- Usually period of immobilization. Cryotherapy and modalities
Phase II (3-6 weeks) - PROM/AROM Shoulder flexion, abduction, adduction, internal/external rotation. Some strengthening exercises
Phase III (6 weeks +) – Scapular stabilization exercises: elevation, depression, retraction, protraction
Strengthen the rotator cuff muscles- supraspinatus, infraspinatus, subscapularis, teres minor
Exercise examples:
Shoulder Flexion (lying down)
Shoulder blade squeeze
Resisted Rows
Internal and External Rotator Exercises
Home Exercise Program-
Theraband can be given to patient to take home and perform exercises
Flexion, Abduction, Adduction, Extension, External Rotation, Internal Rotation,
Horizontal Adduction, Horizontal Abduction
References:
Hayes et al, Shoulder Instability: Management and Rehab. J Orthop. Sports Physical Therapy. Volume 32. Number 10. October 2002
Loudon, J., Swift, M., Bell, S. (2008). Knee. The clinical orthopedic assessment guide. (2nd ed., pp. 135-180). Champaign, IL: Human Kinetics
Neumann, D. A. (2010). Upper Extremity. Kinesiology of the musculoskeletal system: Foundations for rehabilitation. (2nd ed., pp. 137-160). Mosby, Inc.
OrthoInfo. (2009). Chronic Shoulder Instability. Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=a00529
Prentice, W. E., Quillen, W. S., & Underwood, F. (2011). Therapeutic modalities in rehabilitation. New York, NY: McGraw
Shoulder Impingement
Definition: Shoulder impingement refers to compression of the soft-tissue structures (rotator cuff muscles, subacromial bursa) causing pain with overhead activities. This syndrome can be classified as primary or secondary. It is common in athletes involved in throwing sports such as baseball, tennis, swimming, etc. as well as assorted occupations that involve keeping the shoulder in an elevated position for an extended period of time3.
MOI:
Primary – acromial abnormalities result in a narrower subacromial space 4. Some people are born with a curved (Type II) or hook-shaped acromion ( Type III)3. Aging adults may develop osteoarthritis of the AC joint or bone spurs, which would also contribute to the narrower space4.
(http://www.massagetoday.com/common/viewphoto.php?id=2153)
Secondary – occurs without any acromial abnormality. This type is usually due to dysfunctional shoulder biomechanics and is exacerbated by repetitive use or long periods of compression3. Overuse or repetitive irritation of the rotator cuff can lead to inflammation of the rotator cuff tendons (rotator cuff tendonitis) and the bursa lying over them. Instability of the structures in the shoulder could allow the humeral head to migrate upwards, causing impingement. This is an especially common cause of impingement in young athletes4.
Signs/Symptoms: Patients experience intermittent, superficial pain typically in the anterior shoulder1. The pain usually starts off gradually and is aggravated with reaching, overhead activities, and lying on the affected side or at night4. Pain may radiate down the arm, but stops before the elbow. If pain travels to or beyond the elbow, a pinched nerve may be indicated. The patient may also have weakness and decreased range of motion2.
Tests/measures:
Primary – negative stability tests, positive impingement tests, painful arc between 60°-120°, abnormal scapulohumeral rhythm, restricted internal rotation and horizontal flexion because of tight posterior capsule
Secondary – positive impingement tests and stability tests, increased external rotation, weak scapular muscles
Hawkins-Kennedy Impingement Test – flex patient’s arm to 90° of shoulder flexion and 90° of elbow flexion. Clinician medially rotates patient’s shoulder. Reproduction of symptoms is a positive test for impingement of supraspinatus tendon. Hawkins-Kennedy video
Neer’s Test – clinician passively elevates patient’s arm overhead in the scapular plane with the arm medially rotated. Positive response for impingement of supraspinatus is pain. Neer's video
Crossover Impingement Test – clinician applies overpressure into horizontal adduction. Anterior pain is a positive response for impingement of subscapularis, supraspinatus, and long head of biceps brachii. Superior pain is a positive response for A/C joint impingement. Posterior pain is a positive response for impingement of infraspinatus, teres minor, posterior capsule.
Instability Tests: Glenohumeral Load and Shift (anterior and posterior stability of GH joint), Apprehension or Relocation Test (anterior GH stability), Posterior Glide 90° Flexion and Internal Rotation (posterior instability), Multidirectional Instability Test ( multidirectional, especially inferior instability)1.
Treatment Strategy:
Modalities/pain control – anti-inflammatory modalities are helpful in reducing swelling, inflammation, pain (ice, NSAIDS, cortisone injection)
Manual therapy – joint mobilization to posterior capsule if appropriate; deep friction massage
Exercise – Early in exercise, patients should begin stretching and range of motion exercises to promote pain-free ROM. Examples of these rotator cuff ROM increasing exercises/stretches might be: pendulum swings, corner stretch, horizontal adduction stretch, internal and external rotation stretches. The second phase will begin to include rotator cuff strengthening exercises beginning with a very low weight. Examples include: active shoulder flexion, abduction, prone extension, prone horizontal abduction, shrugs, bicep curls, empty can5.
Primary – normalize ROM (especially IR), rotator cuff strengthening and stretching (pec major, pec minor, rhomboids, upper trapezius)
Secondary – focus on dynamic stability (scapular and rotator cuff strengthening)
HEP – patient should rest, especially avoiding the offending sport if applicable. When appropriate, the patient will gradually begin a home exercise program including stretching and strengthening exercises.
Education – patient should be educated on the anatomy and nature of the injury. Educate the patient on importance of exercises and rest.
References:
1 Loudon, J, Swift, M. & Bell, S. (2008) The Clinical Orthopedic Assessment Guide (2nd ed). Champaign, IL: Human Kinetics.
2 "Rotator cuff problems - PubMed Health." National Center for Biotechnology Information. N.p., n.d. Web. 11 Mar. 2012. <http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001474/>.
3 Lowe, Whitney (April, 2006). Shoulder Impingement. Massage Today, Vol. 06 Issue 04. <http://www.massagetoday.com/mpacms/mt/article.php?id=13403>.
4 Gotlin, Robert (2008). Shoulder impingement: causes, identification, treatment. Sports Injuries Guidebook. <http://www.humankinetics.com/excerpts/excerpts/shoulder-impingement-causes-identification-treatment->.
5 Edell, David. Shoulder Impingement Rehabilitation. The Sports Medicine Specialists. <http://www.peninsulaortho.com/downloads/Impingement.pdf>.
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Adhesive Capsulitis
Definition
“Frozen shoulder”
Adhesive inflammation between the joint capsule and the peripheral articular cartilage of the shoulder, with obliteration of the subdeltoid bursa, characterized by increasing pain, stiffness, and limitation of motion. Signs and symptoms typically begin gradually, worsen over time and then resolve, usually within one or two years.
Images:
http://www.google.com/imgres?um=1&hl=en&sa=N&rlz=1C1SKPL_enUS436US437&biw=1024&bih=509&tbm=isch&tbnid=LNC2dYI1JjQ_pM:&imgrefurl=http://orthoinfo.aaos.org/topic.cfm%3Ftopic%3Da00071&docid=b3HHnrHR3DHEDM&imgurl=http://orthoinfo.aaos.org/figures/A00071F02.jpg&w=500&h=214&ei=8HBZT43UNqXi0QHay8TWDw&zoom=1&iact=hc&vpx=176&vpy=77&dur=769&hovh=147&hovw=343&tx=227&ty=75&sig=103447308587300044840&page=1&tbnh=83&tbnw=195&start=0&ndsp=11&ved=1t:429,r:1,s:0
http://www.google.com/imgres?um=1&hl=en&sa=N&rlz=1C1SKPL_enUS436US437&biw=1024&bih=509&tbm=isch&tbnid=KWM1BuBJ3AkhJM:&imgrefurl=http://eliminatefrozenshoulder.com/&docid=FEtQWQUrvPP8yM&imgurl=http://eliminatefrozenshoulder.com/images/frozenshoulder.jpg&w=390&h=314&ei=8HBZT43UNqXi0QHay8TWDw&zoom=1&iact=hc&vpx=415&vpy=50&dur=828&hovh=201&hovw=250&tx=117&ty=97&sig=103447308587300044840&page=1&tbnh=125&tbnw=155&start=0&ndsp=11&ved=1t:429,r:2,s:0
Mechanism of Injury
Adhesive capsulitis has been associated with several conditions. A higher incidence of frozen shoulder exists among patients with diabetes (10-20%) compared with the general population (2-5%). Incidence among patients with insulin-dependent diabetes is even higher (36%), with an increased frequency of bilateral shoulder involvement.Other diseases that increase the likelihood of developing frozen shoulder:
hypothyroidism
hyperthyroidism
Parkinson's
cardiac disease
Your risk of developing frozen shoulder increases if you're recovering from a medical condition or procedure that affects the mobility of your arm — such as a stroke or a mastectomy.
A few reported etiologic agents include the following:
Signs/Symptoms
Most common names of the 3 phases:
Freezing (worsening)
Frozen (not as painful, very stiff)
Thawing (motion slowly improves)
Patients with primary frozen shoulder have no significant findings in the history, clinical examination, or radiographic evaluation to explain their motion loss and pain. Classically, symptoms of primary frozen shoulder have been divided into 3 phases: (1) the painful phase, (2) the stiffening phase, and (3) the thawing phase. In the initial painful phase, there is a gradual onset of diffuse shoulder pain lasting from weeks to months. The stiffening phase is characterized by a progressive loss of motion that may last up to 1 year. Most patients lose glenohumeral external rotation, internal rotation, and abduction during this phase. The final, thawing phase is measured in weeks to months and constitutes a period of gradual motion improvement. Once in this phase, the patient may require up to 9 months to regain a functional range of motion.
Can also be broken down like this:
Stage I: pain in and around the GH joint (no stiffness)
Stage II: deep pain or pain at deltoid insertion (deltoid tuberosity on the lateral aspect of the humerus); may radiate to elbow
Disturbs sleep, increased stiffness, perceived as weakness, inability to perform ADLs
Stage III: minimal pain at rest
Stage IV: gradual resolution of stiffness
Reminder: Capsular pattern for the shoulder is external rotation, abduction, internal rotation
People with frozen shoulder have limited active and passive ROM
Treatment Strategy
Sometimes spontaneous resolution
Therapeutic exercise
Stage I and II:
-exercise, massage, and forcible movements contraindicated
-risk humeral fracture, rupture of the joint capsule, and rupture of the subscapularis
Stage III and IV:
-stretching
External rotation — passive stretch. Stand in a doorway and bend your affected arm 90 degrees to reach the doorjamb. Keep your hand in place and rotate your body. Hold for 30 seconds. Relax and repeat.
Forward flexion — supine position. Lie on your back with your legs straight. Use your unaffected arm to lift your affected arm overhead until you feel a gentle stretch. Hold for 15 seconds and slowly lower to start position. Relax and repeat.
Crossover arm stretch. Gently pull one arm across your chest just below your chin as far as possible without causing pain. Hold for 30 seconds. Relax and repeat.
Patient education
In stages I and II, massage and forcible movements contraindicated
Assistive equipment
Stage I and II: Sling
Stage III and IV: None
Manual therapy
Stage I and II:
- Massage and forcible movements contraindicated
- Mobilizations for pain
Stage III and IV:
-mobilization and manipulation
From a study on standard PT stretching versus end-range mobilization/scapular mobilization treatment approach:
-insufficient external rotation of the humerus and limited posterior tipping and upward rotation of the scapula during arm elevation, exacerbate the condition of frozen shoulder symptoms, including impingement pain, limited range of motion (ROM), and muscle weakness
-specific end-range mobilization and scapular mobilization was shown to have greater positive effects than a standard protocol. -Shoulder kinematics, including humeral external rotation, scapular posterior tipping, and scapular upward rotation during arm elevation, are associated with treatment improvement
-end-range intensive grade IV anterior-posterior mobilization techniques combined with scapula superior/inferior and upward/downward mobilization techniques can be advocated in subjects with frozen shoulder who have less than 8 degrees of scapular posterior tipping, 97 degrees of humeral elevation, and 39 degrees of humeral external rotation during arm elevation
Home instruction/HEP
Stage I and II:
-rest, positions that ease pain/discomfort
Stage III and IV:
-stretches listed above
Pain control/modalities
From a systematic review of non-operative options:
-intra-articular steroid injections for pain but not range of motion
-steroid injections for pain in the medium term
-No differences were found in ROM between steroid injections and manipulation
-strong evidence in favor of laser therapy compared with placebo for reduced pain and disability
-Most effects were shown in the short term, although physical therapy did show effects in the longer term
-suprascapular nerve block
-arthrographic distension (procedure where fluid is injected into the shoulder joint to break up the adhesions)
-The combination of a suprascapular nerve block and physical therapy improves pain, disability, and range of movement of the shoulders compared with intra-articular corticosteroid injection of the shoulder and/or physical therapy alone
-heat (before starting PT exercises)
Abdelshafi ME, Y. M.-S. (2011). Relief of chronic shoulder pain: a comparative study of three approaches. Middle East Journal of Anesthesiology, 83-92.
Jing-lan Yang, M.-H. J. (2012). Effectiveness of the end-range mobilization and scapular mobilization approach in a subgroup of subjects with frozen shoulder syndrome: A randomized control trial. Manual Therapy, 47-52.
Loudon, S. B. (2008). The Clinical Orthopedic Assessment Guide. Champaign, IL: Human Kinetics.
RZ, T. (2012). The effectiveness of nonoperative treatment for frozen shoulder: a systematic review. Clin J Sport Med, 169-69.
Rotator Cuff Pathology**
(Rotator Cuff Tear, Tendinitis, or Tendinosis)
Definition:
Tendinosis: intrinsic tendon degeneration or failure of the tendon fibers
Tendonitis: acute irritation of the tendon and inflammation of the bursa
Supraspinatus
Infraspinatus
Biceps
Subscapularis
Mechanism of Injury:
Overuse or change in activity. Exacerbation and remission of symptoms can occur for many years
Symptoms:
Early Stages
Intermittent superficial pain present both during activity and rest
Sudden pain with lifting, reaching, or overhead movements
Deep, radiating, anterior shoulder pain, may move down the arm
Late Stage
Pain at night
Loss of strength and ROM
Inability to perform HBB activity
Signs:
Positive Hawkins-Kennedy Impingement test
Poor scapulohumeral rhythm
Pain with tendon palpation – thickening of tendon may also be present
Hand Behind Back (HBB) ROM – pain with over pressure (OP)
RROM will be STRONG and painful if minor, WEAK and painful if severe
Abduction = supraspinatus
External Rotation = Infraspinatus, Teres minor
Internal Rotation = Subscapularis, Biceps
Treatment Strategies:
Modalities
Ultrasound
Iontophoresis
NSAIDS
Manual Therapy
GH Inferior Glide (Grade I-IV)
GH Anterior Glide(Grade I-IV)
Lateral Glide (Grade I-IV)
Deep Friction Massage to affected tendon
Therapeutic Exercise:
Stretching
"Open Book"
Codman's exercise
http://www.youtube.com/watch?v=gn4LDOkWRHk
Horizontal Adduction
Strengthening
Muscles of the rotator cuff, Deltoid, Serratus Anterior, Trapezius
Progression
Horizontal closed-chain
Vertical closed-chain
Horizontal open-chain
Diagonal closed-chain
Diagonal open-chain
Education
Postural instruction – anteriorly rolled shoulder
Home Instruction:
Activity modification – rest from aggravating factors
Instruction on sleeping position
Referral - Patient may require surgery
References:
1. Loudon, Janice, Marcie Swift, and Stephania Bell. The Clinical Orthopedic Assessment Guide. Champaign, IL: Human Kinetics, 2008. Print.
2. Neumann, Donald A. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. St. Louis, Mo: Mosby, 2010. Print
3. Gould, Barbara E., and Ruthanna Dyer. Pathophysiology for the Health Professions. St. Louis, MO: Saunders/Elsevier, 2011. Print.
4. Kibler, W. "Rehabilitation of Rotator Cuff Tendinopathy." Clinics in Sports Medicine 22.4 (2003): 837-47. Print.
Shoulder Labral Tears
Definition:
The glenoid labrum is the fibrocartilage rim around the glenoid fossa of the scapula. It acts to deepen the socket for the head of the humerous and increase the size of the articular surface. It also acts as an attachment site for the long tendon of the biceps brachii, the glenohumeral joint capsule, and some of the shoulder ligaments. Through trauma or repetitive motion the labrum can become injured and this is referred to as a tear.
Labral tears are classified by theirs locations, and can occur either superior or inferior to the middle of the glenoid cavity and are called SLAP lesions and Bankart lesions respectively.
SLAP (Superior Labrum Anterior and Posterior) lesions are labral tears above the middle of the glenoid cavity and may potentially have involvement of the long biceps tendon. This area of the tissue is more mobile and more prone to injury. Injuries in this area are common in baseball pitchers and other athletes who perform overhead motions.
Bankart lesions occur below the middle of the glenoid cavity and includes involvement of the inferior glenohumeral ligament.
Mechanism of Injury:
Acute Trauma –
Falling on an outstretched arm
Direct blow to the shoulder
MVA
Shoulder dislocation
A forceful motion when the arm is above shoulder level
Forceful pulling on the arm (catching a heavy object)
Repetitive motion –
Throwing athletes
Weightlifters
Wearing down of the tissue with normal aging
Signs and Symptoms:
Symptoms – (Very similar to other shoulder injuries)
Pain in the shoulder (especially with overhead activities)
Catching, clicking, popping, or grinding,
Decreased range of motion,
Loss of strength,
Feeling that the shoulder is unstable
Potential pain at night and with ADLs
Signs – Arthroscopic imaging, and CT or MRI imaging (possibly with a contrast medium) may be used by the physician to confirm a labral tear. The following tests can also be used to help with diagnosis.
Labral (Clunk) test: Patient will experience pain, clunk, grinding, or pseudolocking when clinician applies compression, rotation and anterior force to the fully abducted humeral head.
Crank Test: Patient experiences a painful click when the clinician provides axial force on the humerus when it is at 160 degrees scaption and maximal internal or external rotation.
Speed’s Test: Patient will have pain in the bicipital groove with resisted shoulder flexion. The patient should be positioned in shoulder flexion and full external rotation, elbow extension, and supination.
Yergason’s Test: Patient will experience pain with resisted supination and shoulder external rotation with the elbow positioned at 90 degrees.
O’brien Test: A superior labral tear is indicated when patient experiences pain with resisted shoulder flexion when the patient’s arm is positioned starting in 90 degrees flexion, 10 degrees adduction, and maximal internal AND external rotation (this is a 2 part test and is to be performed with both IR and ER).
Anterior Slide Test: A superior labral tear is indicated if the patient experiences a reproduction of symptoms, a click or a pop, or pain in the anterosuperior shoulder area with this test. The patient is positioned standing with hands on hip and thumbs pointing backward. An anterior and superior force is applied by the clinician at the elbow while stabilizing the scapula and clavical, and the patient is instructed to resist this force.
Treatment:
Non-Surgical Treatment:
The physician may prescribe NSAIDs and rest for relief of symptoms. Physical Therapy is also initiated to stretch the joint capsule and strengthen the muscles supporting the shoulder. This can help with pain relief and prevention of further injury. Physical therapy with conservative treatment should concentrate on relief of patient symptoms and addressing instability and hypermobility of the shoulder with dynamic stabilization exercise.
Surgical Treatment:
For SLAP lesions, the physician will determine the stability of the shoulder during surgery. If the injury only involves the labrum and the biceps tendon is unaffected, then the shoulder is still considered stable, and the doctor will repair or remove the injured tissue and fix any associated issues within the joint. However, if the biceps tendon is affected, then the shoulder is considered unstable, and the doctor will also need to repair or reattach the tendon as indicated by the severity of the injury.
Bankart lesions can also present with shoulder instability, in which case the doctor will repair the involved ligament and tighten the joint by “pleating” the tissues.
Therapeutic Exercise:
Exercises for patients with labral tears can include, but are not limited to:
ROM exercises of the glenohumeral joint
Scapular stability exercises
Closed chain exercises
Open chain exercises
PNF patterns
Specific rotator cuff strengthening exercises
Dynamic stability, neuromuscular coordination, and proprioceptive exercises
Education:
The patient should be educated on shoulder anatomy, and the injury that occurred. Surgical procedures should also be explained if needed. The patient should be taught how to properly use a sling, and instructed to avoid any activities or positions that provoke symptoms.
Assistive Equipment:
The patient will be instructed to keep their arm in a sling to restrict shoulder motion for 2-4 week after surgery while the labrum heals.
Manual Therapy:.
Glenohumeral joint mobilizations may be indicated for pain or joint restriction, but the therapist should be cautious if instability if present.
Home Exercise Program:
The HEP should include the exercises mentioned above, and should concentrate on regaining ROM and strength in the shoulder while staying in a pain free range.
Modalities/Pain Control:
Cryotherapy, NSAIDs, and e-stim can be used for pain reduction along with rest and early immobilization.
References:
Dutton, Mark. "Chapter 14." Orthopaedic Examination, Evaluation and Intervention. New York: McGraw-Hill Professional, 2004. 456+. Print.
Loudon, Janice, Marcie Swift, and Stephania Bell. "Special Tests." The Clinical Orthopedic Assessment Guide. 2nd ed. Champaign, IL: Human Kinetics, 2008. 151+. Print.
Neumann, Donald A. "Chapter 5." Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd ed. St. Louis, MO: Mosby/Elsevier, 2010. 139+. Print.
Prentice, William E., William S. Quillen, Frank B. Underwood, and William E. Prentice. Therapeutic Modalities in Rehabilitation. 3rd ed. New York: McGraw-Hill, Medical Pub. Division, 2005. Print.
"Shoulder Joint Tear (Glenoid Labrum Tear) - OrthoInfo - AAOS." AAOS. Web. 12 Mar. 2012. <http://orthoinfo.aaos.org/topic.cfm?topic=A00426>.
Separated AC Joint
Definition:
There are three types of sprains/separation of the AC Joint, which is the joint between the acromion process and the clavicle. Type 1 is the incomplete tear of the acromioclavicular (AC) ligament. Type 2 tears are a tear of the AC ligament and a partial tear of the coracoclavicular (CC) ligament. Type 3 tears are complete tears of the AC and CC ligaments (1).
http://www.youtube.com/watch?feature=player_embedded&v=4S3bkkjUaDg
http://www.youtube.com/watch?v=OfcSvG-dgbY
Signs & Symptoms:
- Point tenderness on the AC joint
- Swelling, Bruising (2)
- Pain with functional activities:
- Lifting, coming hair, washing opposite axilla, reaching behind body
- Widening of the AC joint with palpation (1)
Mechanism of Injury:Direct force applied to acromion with arm adducted. This force drives the acromion medially. (Falling directly on shoulder)(1) This separation can also occur when falling on an outstretched arm(3).
Treatment:
Therapeutic Exercise:
- Restore general shoulder ROM
- Regain shoulder strength (1)
Education:
Tell/show patient what is injured and possible MOI, so they can better understand the scope of their injury. Show the pt how to modify movements to not disturb the healing of the ligament(s). (1)
AssistiveEquipment:
Most patients will use a sling to partially immobilize the movement in the shoulder joints (3), this will also support the shoulder in a more comfortable position (1)
Modalities:
Ice, NSAIDS, US, MHP – goal to reduce the pain that may be limiting the patient’s ability to do exercises (1)
ManualTherapy:
- Joint mobilizations
Anterior AC Joint Glide
Posterior AC joint Glide
Home Exercise Program:
Patient should rest the joint/injury initially. Then, get back into exercise gradually.
References:
1. Loudon, Janice, Swift, Marcie and Bell, Stephania. The Clinical Orthopedic Assessment Guide. Champaign : Human Kinetics, 2008.
2. Orthopod.Acromioclavicular Joint Separation. [Online] 2006. http://www.orthogate.org/patient-education/shoulder/acromioclavicular-joint-separation.html
3. American Academy of Orthopaedic Surgeons.Shoulder Separation. [Online] 2012. http://orthoinfo.aaos.org/topic.cfm?topic=a00033