Shoulder (Orthopedic)

Posture: including scapulae position
Rule out cervical involvement: ROM, compression
Special Tests
ROM: including scapulae mobility during arm elevation
MMT
Joint mobility
Palpation
Passive scapular mobility

Labral Lesions

Labrum lesions often occur as a result of a traumatic incident, including a fall on outstretched hand (FOOSH), direct blow to or fall on the shoulder, a sudden pull or other overhead motion (trying to lift an object or trying to grab/hang from something to prevent a fall). Participation in certain activities may increase the risk of a labrum lesion, including weight lifting, throwing sports, sports with overhead activities (e.g., swimming), contact sports, rock climbing/bouldering. Many patients have experienced direct shoulder trauma, but onset may be insidious secondary to repetitive overuse of the shoulder.

Surgical management: If patient fails to improve with conservative therapy (usually a trial of 6–12 weeks), labral repairs (including Bankart/SLAP repairs, biceps tenodesis/tenotomy), labral debridement, and glenohumeral stabilization may be required.

Physical Examination
-Joint integrity and mobility: Anterior, posterior, and inferior drawer.
-Muscle Strength: MMT
-Palpation: Assess for RTC tendon tenderness to rule out impingement/tendonitis, assess AC, ST, SC joint. Following acute injury, mild, generalized edema of the shoulder may be present. 
-Pain: Assess for provocation of pain with active ROM, resisted movements, and exacerbating activities. Pain with end range flexion and overhead movements is common. Movements that cause the humeral head to compress the labral lesion will also be painful (for example, supine bench pressing in an individual with a posterior labrum lesion). Pain can be reported using visual analog scales (VAS).
-Posture: Assess the cervical and thoracic spine, clavicles, scapulae, and shoulders for bilateral symmetry and general posture.
-ROM: Measure (goniometric measurements) active and passive ROM to assess function of the rotator cuff and shoulder joint. Assess scapular and clavicular mobility. ROM following a labrum lesion usually is within normal limits.
-Special Tests: 
O’Brian’s Test/Active compression: 90 deg of shoulder flex and 15 deg of horizontal ADD. Performed in full pronation then neutral. Positive is pain and/or clicking during pronation and absent with neutral. 
Yeargaon’s Test (resisted supination): tests for bicipital tendon involvement
Speed’s Test: shoulder flex while ER, full elbow ext, and supination. Tests for bicipital involvement.
Bicipital Load test: Supine, shoulder 120 deg ABD, full ER, elbow 90 deg flex, supination. 
Crank/Compression Rotation Test: For anterior instability or labral tears. Supine or seated, elevate patient's arm to approximately 120 deg in scapular plane. Provide axial load through humerus while IR and ER GH joint. Positive if pain or clicking.

Interventions

Generally, labral lesions do not heal. Therapy may be utilized to increase rotator cuff and periscapular strength to compensate for the instability secondary to the labral tear. However, inability to participate in overhead activities/sports, contact sports, and other activities due to pain or apprehension often leads to surgical intervention. Following surgery, most patients are able to return to sports and prior level of function

-Pain: rest, ice, heat
-Shoulder instability: RTC and scapular strengthening. 
-ROM deficits: stretching of tightened muscles, joint mobilization. Moist heat prior to help with tissue elasticity.
-Postural abnormalities: cervical, shoulder girdle, scapular
-Neuromuscular: perturbations, balance strategies (bosu)

Subacromial Impingement

Physical Examination
-Joint integrity and mobility: Anterior, posterior, and inferior drawer.
-Muscle Strength: MMT
-Palpation: Assess for RTC tendon tenderness to help rule-in impingement/tendonitis, assess AC, ST, SC joint. Following acute injury, mild, generalized edema of the shoulder may be present. 
-Pain: Assess for provocation of pain with active ROM, resisted movements, and exacerbating activities. 
-Posture: Assess the cervical and thoracic spine, clavicles, scapulae, and shoulders for bilateral symmetry and general posture.
-Syndromes of humerus and/or scapula
-ROM: Measure (goniometric measurements) active and passive ROM to assess function of the rotator cuff and shoulder joint. Assess scapular and clavicular mobility. ROM following a labrum lesion usually is within normal limits.
-Special Tests: 
Painful Arc: pain reported b/t 60-120 deg 
Neer Impingement: while seated, block  the scapula and place shoulder into passive end-range flexion. Variation would be to perform with GH IR.
Empty Can: shoulder in 90 deg in scapular plane and full IR (thumbs down) while providing downward resistance at elbow. Perform again with ER (thumbs up). Positive with pain and/or weakness for supraspinatus tendon/muscle if thumbs down is more painful.
Hawkin's Kennedy: passively place patient's GH at 90 deg in scapular plane and IR. Positive is pain. 

Interventions

Scapular mobility, cervical strengthening for posture, shoulder mobilization (particularly posterior and inferior capsule), rotator cuff strengthening while the scapula is set, pec stretching, AROM, AROM IR while the shoulder is set in supine (driving posterior shoulder into mat table while AROM IR), serratus strengthening, arm bike with correct posture (neck and thoracic as well as setting scapula in place), proprioception with scapula in place (plank on bosu).

RTC Tendinopathy

More common in older individuals. 

Physical Examination
-Palpation for tenderness
-Special Tests: 
External Rotation Lag Sign: 90 deg elbow flexion, 20 deg scaption, place shoulder in full range ER. If inability to maintain position actively, positive for supraspinatus and/or infraspinatus.
Internal Rotation Lag Sign: Take patient’s arm off back and see if they can hold it there. Positive for subscapular tear if unable.
Belly  Press Test: Tell the patient to place hand on belly and lift elbow forward while maintain hand position. Positive for subscapular tear if elbow drops into extension.

Interventions

-Manual therapy for pain relief: Grade 1 mobilization, soft tissue mobilization.
-Focus on eccentrics. 

 

Adhesive Capsulitis

Women>men, 5th and 6th decades of life. Risk factors: DM (5-6x more likely), thyroid disease, Hx of frozen shoulder in contralateral shoulder. Normal function regained: 2 years following onset. 
Stages:
1. "Pre-Adhesive". Can last up to 3 months. Early loss of ER ROM with intact strength. Sharp pain at end range achy pain at rest, and sleep disturbance. 
2. "Freezing Stage". 3-9 months. Gradual loss of motion in all directions due to pain. 
3. "Frozen Stage" or "Stage of Maturation". 9-15 months. Pain and loss of motion. Synovitis/angiogenesis is starting to lessen. Loss of axillary fold. 
4. "Thawing Stage" or "Chronic Stage". 15-24 months. Pain resolution. Gradual return in ROM. Mild symptoms may persist for years.

Physical Examination
-The common capsular pattern of limitation has historically been described as diminishing motions with external shoulder rotation being the most limited, followed closely by shoulder flexion, and internal rotation.

Interventions
-Corticosteroid injections combined with shoulder mobility and stretching are more effective in providing short-term (4-6 weeks) pain relief compared to mobility and stretching alone. 
-Short-wave diathermy, US, E-stim combined with mobility and stretching to reduce pain and improve ROM.
-Joint Mobilization to reduce pain and increase motion. 
-Stretching exercises 
-Stage 1: ROM maintenance, pain management.
-Stage 2: ROM maintenance, pain management, compensation training, muscle performance.
-Stage 3: ROM maintenance, pain management, compensation training, muscle performance.
-Stage 4. Strengthening, improve ROM, joint mobilization.
Irritability:
-High: heat for pain, E-stim for pain, low-intensity joint mobs for pain relief, pain-free passive ROM, pain-free AAROM.
-Moderate: heat for pain, E-stim for pain, moderate-intensity joint mobilization into resistance without producing post-treatment pain, gentle to moderate stretching with tissue resistance without producing post-treatment pain, neuro re-ed to integrate gains in mobility into normal scapulohumeral movement while performing reaching activities.
-Low: end-range joint mobilization high amplitude and long duration into tissue resistance, stretching long duration with tissue resistance without post-treatment pain, neuro re-ed to integrate gains in mobility into normal scapulohumeral movement during performance of activities performed by the patient during his/her functional and/or recreational activities.
Surgical open release of capsule to increase mobility. Evidently, not too effective.
Manipulation under anesthesia.
Joint mobilization consisting of: GHJ, SCJ, ACJ, STJ, C-Spine, T-Spine
Soft tissue mobilization
Stretching: upper trapezius, pec major and minor, levator scap, SCM, posterior joint capsule 

Subacromial Decompression (SAD) Surgery

Usually performed on patient's with fibrosis/tendonitis of supraspinatus usually found in middle-aged individuals that have intrinsic anatomical factors that have not responded favorably to conservative treatment. Having a curved (type 2) or hooked (type 3) acromion may be resected during surgery as it can cause the impingement. Os acromiale (developmental defect) or spurring of the underside of coracoacromial ligament can cause compression. SAD can be performed as an open or arthroscopic procedure. 90% satisfaction with partial tear and 70% satisfaction with full thickness tears.

Week 0-3 (Inflammatory Phase)
Following arthroscopic procedure: typically there aren't any restrictions to PT evaluation for patients with arthroscopic SAD. You can assess ROM, strength and functional tests while accounting for their irritability and severity. 
Focus on managing inflammation, pain, ROM, and patient education. 
-Education regarding support of pillows during sleeping.
-Restoring normal ROM is main goal during this phase. Perform manual therapy joint mobilization and STM to restore motion. Caudal mobilization can be helpful. 
-HEP for ROM such as table slides (shoulder flexion). 
-Patient may or may not be in a sling following surgery. Educate regarding bolster between arm and thorax if discomfort is present.

Following open SAD. Defer deltoid muscle testing due to deltoid being split during surgery.

Week 3-6+ (Reparative Phase)
Focus on muscle strengthening and re-education.
-Continue ROM until full range is achieved.
-Begin resistive exercises for addressing imbalances. 
-Motor control exercises to ensure proper biomechanics of shoulder girdle. Strengthen scapular muscles and ensure proper function before progressing to RTC muscles. Target serratus anterior. Full can exercise for supraspinatus. Replicate functional activities. 

Understand that the patient may have the same pain as before the surgery and they may ask, "did the surgery work?" Many patients had these imbalances and weaknesses before the surgery and contributing to the impingement initially. As they get stronger and mechanics improve, the pain will diminish. Also, time for healing for the irritated tendon is needed for reduction in pain.

Week 9-12 (Remodeling Phase)
Should have full ROM and significantly reduced pain. 
-Progress strengthening based on their activity level. Sports specific and work specific training. High reps and low weight to address endurance. Continue scapular stabilization. 

Rotator Cuff Surgical Repair

Surgery may be appropriate for patients younger than 50 with acute tear or for patients where conservative management has not been affective. Usually caused by compression of rotator cuff between acromion and humeral head (usually in older population from compression). Dislocation or trauma, such as a fall, can cause tears. Overhead athletes may experience a tear. 

Week 0-4 (Inflammatory Phase)
Patient will start PT between 1-6 weeks after surgery. Some wait until 4-6 weeks. Because of the slow rate of healing of the tendon-bone interphase, full PROM during this phase is not the goal. The goal is to protect the repair and prevent stiffness.
Typically patient will be in an abduction sling during day and night and only removed during self-care activities.
During evaluation, strength testing, AROM, and PROM of horizontal adduction, IR, and extension should be deferred to protect surgical site.
-Focus on ROM, decrease inflammation and pain, patient education.
-Address cervical, elbow, wrist impairments. Educate patient to periodically moving elbow and wrist while in sling.
-Cryotherapy and electrotherapy can be used for pain and inflammation.
-Joint mobilization may be used to control pain,  reduce guarding, and improve joint nutrition. 

Week 5-8 (Reparative Phase)
Continue to treat any relevant cervical spine, elbow or wrist impairments. Continue with pain and inflammation control. Continue protecting the surgical site. Progress ROM activities. Strength testing and resistive exercise are still contraindicated until week 8 and patient should still avoid using the arm for reaching overhead or lifting. The abduction sling is typically discharged during this phase. At approx. 
-ROM activities. AAROM flexion with dowel while hooklying. AROM activities can begin at this phase. PROM can be progressed including horizontal adduction, shoulder extension, and IR. Avoid overstretching and going to end-range.
-Encourage cardiovascular exercise to increase blood flow for healing. Stationary recumbent bike or brisk walking are appropriate. Avoid running as arm swinging can stress the shoulder. 
-After discharge of sling, education regarding pillows between elbow and thorax during sleeping for comfort.

Week 8-13 (Remodeling Phase)
At the 8 week mark, patient will follow-up with surgeon and allow strengthening to be implemented as appropriate based on the integrity of the repair. 
Focus on restoring full ROM, increase strength, and improve function.
-Scar mobilization if wound healing is completely healed. This will improve mobility of the scar and underlying tissue. This may be implemented earlier than this time frame based on patient presentation.
-Work towards full PROM using soft tissue mobilization, joint mobilization with capsular stretch, manual stretching, etc. For soft tissue mobilization to allow the glenohumeral head to sit more center onto the glenoid fossa which will aid in full IR and aid in reducing guarding, have patient sidelying, apply STM to posterior cuff and follow up with posterior glides of GH joint.
-Proper shoulder mechanics should occur before adding resistance. They should not be hiking shoulder as they attempt to elevate arm. There should not be pain with resistive exercises. Post-exercise soreness is okay, but sharp pain should be avoided. Add biceps strengthening and scapular stabilization exercises as indicated. If scapular stability is not addressed, it will be difficult to strengthen rotator cuff musculature with good mechanics. 

Week 13-22+ (Remodeling Phase)
Focus on maintaining full ROM, increase strength and endurance, and improve function. Remodeling is still occurring and can take up to 26 weeks for full healing of tendon to bone. Understand that it will never have the same pre-surgical or pre-injury properties. This means that all structures surrounding the shoulder should be improved for proper support. Patient will be discharged from therapy during this phase. Provide good HEP as the RTC will always be more vulnerable than prior to repair/injury.
-Strengthening. Can implement diagonals. Focus on endurance (high reps, lower resistance), If difficulty achieving full ROM against gravity, implement supine/gravity eliminated shoulder abduction to full range. 
-Full ROM should be achieved by this time. If not, more aggressive joint mobilization and mobility interventions can be used. 
-Functional exercises that mimic sport/work activities should be implemented. Eventually, implement plyometrics, higher speed exercises as appropriate based on patient's functional requirements.

Outcome Measures
-FIM (Functional Independence Measure)
-DASH (Disability of the Arm, Shoulder, Hand)
-pVAS
-ROM via goniometer
-MMT

Protocols: https://medicine.osu.edu/departments/sports-medicine/education/medical-professionals/rehabilitation-protocols