The Shoulder

Differential Diagnosis, Treatment and Rehabilitation

Capsular

LR>ABD>MR

Frozen Shoulder• Aka Capsulitis or adhesive capsulitis

• Vol of normal = 30mls• Vol of frozen = 3mls

• 2% of normal population• 20% go bilateral• 11% in diabetic pop (don’t know why)• W:M 60:40 Non dom gtr than dom• Risk factors – diabetes, hyperthyroid, immobilisation,

stroke

Frozen Shoulder

• Capsular pattern

Most loss of LR, then abd, then MR

• Insidious onset

• Self limiting 2-3 years

• 3 Stages – freezing, frozen and thawing

Stage 1

• Intermittent ache

• Not below the elbow

• Able to sleep on that side

• Elastic end feel

Stage 2

• Constant pain

• Below the elbow

• Unable to lie on that side at night

• Hard end feel

Stage 3

• As in stage 1

• Resolving problem

Treatment of frozen shoulders• Stage 1 – heat, gentle mobilisation grade A

and or injection

• Stretch into elev and release with distraction

• Distraction with sh elev and longitudinal distraction

Treatment of frozen shoulders cont.

• Stage 2 – injection combined with pain relief (and slow sustained stretching, as able)

• Stage 3 – heat + low load sustained stretching – LR, MR and elev

• 20 – 30 mins

Home Exercise Programme

Other Capsular Lesions

• OA

• Electro and Grade B mobs

• Steroid Sensitive Arthritis

• Intra-artic injection

Non - Capsular

Primary impingement

• Associated with anatomical changes in the sub-acromial space ? cause

• Acromial shape• Osteophytes

• Tendon changes – tendonitisOr tendinosis?• Ligamentous thickening• Bursal thickening

Secondary Impingement

• Posture, neck and thorax

• Tight muscle eg. Upper trapezius, pectoralis minor

• Weak muscles eg.lower trapezius, serratus anterior

• Poor timing, proprioception

Neer classification

• Stage 1 – under 25 years, oedema, inflammation, acute bursitis, tendonitis

• Stage 2 – 25-40 years, fibrosis, bursal thickening, fibre disruption in the tendons

• Stage 3 – over 40 years, bony spurs, compromised space, partial to full thickness tears

Sub-acromial bursitis• Aka sub-deltoid bursitis, SIS

• Sub-acromial space – supraspin. Tendon, bursa, sup aspect of GH capsule and long head of biceps

On examination

• Overuse

• Gradual onset

• C5 pain not usually below elbow

• Arc and pain EOR

• Non capsular pattern

• Resisted abd and LR painful esp on release

Treatment of Subacromial Bursitis

• Pain relief• Physio modalities eg acup, trig point, US, taping• Injection

• Posture • Postural stability work inc lower traps• Rotator cuff strengthening• Stretching upper traps, pec major, minor

Home Exercise Programme

Acromio-clavicular Joint

• O/E high painful arc • Localised pain C4• Scarf positive• EOR pain on passive movements

• Traumatic onset – RICE– Strapping– Mobs

• Gradual onset -mobs, frics and or inject

Contractile Lesions

• Strong + Painless = Normal• Strong + Painful = tendon or muscle local lesion I

or II• Weak + Painless = Rupture III or nerve damage• Weak + Painful = severe lesion eg #

• Pain during contraction – tendon• Pain on release - bursa

Supraspinatus Tendinitis• O/E resisted abd painful and painful arc = distal

end of tendon• Friction + electro + rest• All frics numb + 10mins • Or inject

• Resisted abd painful and no painful arc = MT junction

• Rotation Friction with arm in horizon abd, no injec

Subscapularis Tendinitis

• O/E resisted MR painful

+ painful arc = upper fibres

+ scarf test = lower fibres

Friction – may be painful due to bursa

Or inject

Infraspinatus Tendinitis

• O/E resisted LR painful

+ painful arc = distal end of tendon

+ no painful arc = body of tendon

• Friction or inject

Biceps Tendinitis

• O/E resisted flexion and supination of the elbow painful

• Long Head – rotation frics at bicipital groove or inject

• Belly – pinch grip frics or inject with LA only

When its not a shoulder

• Pins and needles / numbness

• Radiation to hand

• Neck movt aggravates pain

• Gastro– intestinal pathology

• Avascular necrosis