Physio Charlie - shoulder

Shoulder Protocols

noreply@blogspirit.com (PhysioCharlie) — Tue, 08 Dec 2009 21:21:00 +0100

Yesterday I saw several post op shoulder patients at Kettering hospital.

http://www.shoulderdoc.co.uk/article.asp?article=77&section=206

Upper limb disorders Occupational aspects of management

noreply@blogspirit.com (PhysioCharlie) — Mon, 26 Oct 2009 16:29:10 +0100

Upper limb disorders Occupational aspects of management

This is a very up to date look at the evidence for the management of ULD's in the workplace. As with a lot of research, the only good evidence they have found is that multidisiplinary treatment with a biopsychosocial approach for non specific arm pain and changing a keyboard for carpal tunnel are better than usual care.

New website!!

noreply@blogspirit.com (PhysioCharlie) — Mon, 09 Mar 2009 19:22:00 +0100

I have a new website!!

http://physiocharlie.vpweb.co.uk

Shoulder course, Jeremy Lewis

noreply@blogspirit.com (PhysioCharlie) — Mon, 26 Jan 2009 15:01:00 +0100

I attended an excellent shoulder course yesterday by Dr Jeremy Lewis.

Things I learnt:

Common tests cannot diagnose R cuff problems as they all put pressure on the subacromial bursae causing pain. There is no way to differentiate between different muscles. Pec minor length test is not diagnostically specific, no need to use it.

There is not one "normal" posture and there is no correlation to shoulder pain.

Energy for shoulder mvt comes from the trunk and lower limbs (54%) so shoulder rehab should include general fitness, abs, glutes, hams and core. (Kibler 1995). Lower limb control is important, ie SLS.

Acromioplasty is not a good option for R cuff problems as it removes the bursae. This ends in increased r cuff tears. Also the cause of r cuff problems is not the acromion or a "Spur" it is more likely irritation of a bursae by oedema of the r cuff (not inflammation) due to overuse.

Imaging: there should be a 9-10mm subacromial space on X-ray. MRI and U/S; pts can have a tear and/or labral abnormalities but no symptoms. 40-60yrs = 28% have a r cuff tear. >60 yrs = 50% have a tear. WHY? "suspension bridge", the rotator cuff has a cable which holds the muscles onto the head of humerus.

Perceived weakness during testing may be better explained as occuring as a result of pain inhibition and not as a result of structural pathology, (Bronx et al 1997).

Oucome measures: www.oxfordshoulderandelbowclinic.org.uk He also uses inclinometers and tape from belly botton to ulnar styloid for lat rot ROM.

Shoulder Ax supervision

noreply@blogspirit.com (PhysioCharlie) — Mon, 15 Dec 2008 17:43:38 +0100

Shoulder Ax Supervision

Obs

Swelling, Asymmetry (ex. Squaring), Scars, muscle atropy; upper traps; Spinal accessory nerve, subscap, infrascap; suprascap nerve, deltoid; axillary nerve, Winging - scapula dyskinesis,

Posture – Increased Tx Kyphosis, chin poke posture increased risk of impingement, rounded shoulders, Tx scoliosis

Bony Alignment – no evidence to support ideal scapular position but acromion should be higher than spine of scapular, H of H should be 1/3rd ant 2/3rd posterior, if ant = tight post capsule/ subscapularis or weak infraspinatus

Test Tx and Cx- AROM, spurlings, beighton’s score - hypermobility

AROM

Watch Tx in elev. Elev needs 30 lat rot, upper traps is TA of shoulder, needs to fire before mvt in elev and protract. Good inferior translation of HH in abd. Watch scapula timing and ?winging. Abd with thumbs up.

Apley “Scratch” Test is the quickest way to evaluate: HBN: External rotation/ abduction, H.add: Internal rotation/ adduction (cross arm test), HBB: Internal rotation/ adduction, Ax of functional movement

PROM if above limited

L rot in sitting, Abd, Flx in supine, M rot - Gleno Humeral Internal rotation deficiency (GIRD) test; isolate GHjt movt in Med rot, Lat rot (aprehension and relocation test), pain less on relocation = secondary impingement

Resisted Muscle Tests – Ab, L rot, M rot in sitting, full can - supraspin, gerber’s/napoleon's - subscap

Special Tests

SIS - Empty can, Haw kennedy, Neers, relocation

Instability - sulcus, ant aprehension, Load shift

R/cuff tear see muscle tests, drop arm test

Biceps - Speeds

SLAP - O'briens, Crank, Yergason's

A/c jt - cross arm, A/c shear test

TOS - Adson's, Roos

Accessory Mvts

GHjt, Acjt, SCjt

Palpation

Sternoclavicular joint, Clavicle, Coracoid process, Acromion, supraspin, subscap tendons, Acromioclavicular joint, Scapula, biceps tendon in Bicipital Groove, Subacromial Bursa, infraspin, Cx, Tx

Visceral

Heart, diaphragm, Spleen - left shoulder

Gall bladder - R shoulder

Shoulder Anatomy, Ax and Impingement

noreply@blogspirit.com (PhysioCharlie) — Fri, 12 Dec 2008 11:48:00 +0100

I did this IST yesterday:

Shoulder Anatomy, Ax and Impingement, Charlie Cotterill, Senior II Physiotherapist, Dec 2008

Shoulder pain is a common problem with a reported prevalence of 6.9 to 34% in the general population and 21% in those over 70 years of age. It accounts for 1.2% of all general practice encounters, being third only to back and neck complaints as musculoskeletal reasons for primary care consultation

ANATOMY

Jarjavay (1867)

Neer (1972)

Subacromial space 10-15mm (Flatlow 1994)

Force couple to counteract downward pull of deltoid (Thompson et al 1996)

Function = scap: humeral rhythm, varies from 1:2 to 1: 4.5 (McQuade et al 1998)

Subacromial impingement syndrome was first recognised by Jarjavay in 1867.

Neer (1972) described it as the “Encroachment of the coracoacromial arch on the underlying mechanism of the rotator cuff”.

Force couple to counteract downward pull of deltoid Thompson et al (1996).

According to Neer, the entrapment syndrome is the result of anatomical variations in build, strain, and repetitive microtrauma. The terms 'impingement' and 'entrapment' refer to the presumed trapping of anatomical structures between the broad greater tuberosity of the humeral head and the acromion during abduction. This would cause a process of degeneration of the rotator cuff, coupled with oedema, bleeding, fibrosis, and calcification. Ultimately this could cause ruptures, osteophyte formation, and spur formation. The 'typical' clinical picture would be characterized by a painful arc during abduction, while other movements of the upper arm painless.

Differential Diagnosis?

Glenohumeral instability, Labrum tear; Bankart, Kim, SLAP lesion,

Avulsion of glenohumeral ligament (superior, middle, inferior), Posterior glenoid spur (a Bennett lesion), Cervical radiculopathy, Tx hypomobility, #, Humeral subluxation/ dislocation, Glenohumeral arthritis, Long thoracic nerve injury, Tumor/Malignancy, Post CVA, Ganglion cyst, Suprascapular nerve entrapment, Quadrilateral space syndrome, Scapulothoracic dysfunction, Impingement of R/C, R/C tear, glenoid erosion, glenoid retroversion, humeral head defects, capsular insufficiency, voluntary instability, hypermobility, RA, Bursitis, Polymyalgia Rheumatica, Biceps tendon rupture/tendinopathy, Calcific tendinitis, Adhesive capsulitis, AC arthritis, Glenohumeral arthritis, Septic arthritis, Gout, Lyme disease, Lupus erythematosus, AVN, Thoracic outlet syndrome, Brachial plexus neuropathy, Trigger points,

Visceral: PE, pleuritis, pericarditis, angina, MI, cholecystitis, pancreatitis, adnexitis.

Approx 57 differential diagnoses!!

Bankart = labrum avulsion from anterior glenoid rim

KIM = Incomplete and concealed avulsion of the postinferior aspect of capsule

SLAP = superior labral anterior-posterior

Aetiology of SIS

Primary/Secondary/ Primary Inflammation Degeneration

Intrinsic/Extrinsic

(Wilson 1999)

Primary – anatomical narrowing of the subacromial space, ie hooked acromion, tendon thickening

Secondary – functional narrowing of the subacromial space, ie muscle imbalance, posture, instability – physio can change

Primary Inflammation Degeneration – Tendon compression/tear, ageing, avascularity – Physio cannot change

Bigliani Classification (1991) Type III poor response to rehab, for surgery

Many causes have been proposed for subacromial impingement syndrome (Aoki M et al. 1986, Bigliani et al. 1986, Codman 1990, Bigliani et al. 1991, Edelson & Taitz 1992, Burns & Whipple 1993, Hutchinson & Veenstra 1993, Davidson et al. 1995). These factors can be broadly classified as intrinsic or intratendinous factors, which are related to the intrinsic theory on the origin of impingement, and extrinsic or extratendinous factors, which are related to the mechanical theory. They can be further characterised as primary or secondary. A primary aetiology — either intrinsic or extrinsic — causes the impingement process by decreasing the subacromial space or by causing a degenerative process of the rotator cuff tendons (Duke & Wallace 1997). A secondary aetiology is the result of another process, such as instability, neurological injury, tight posterior capsule of the glenohumeral joint and muscle dysfunction (Bigliani & Levine 1997, Duke & Wallace 1997). The net effect of secondary causes is usually an anterosuperior translation of the humeral head, which causes impingement of the cuff against the coracoacromial arch (Duke & Wallace 1997).

Aetiology

Aetiology of SIS is multifactoral (Lewis et al 2001).

Mechanical/Anatomical

Primary mechanical impingement (Neer 1972, 1983)

Acromial bone spurs (Neer 1972)

Os acromiale (Neer 1972, 1983)

Corocoacromial ligament (soslosky et al 1994)

Postereosuperior glenoid impingement (Jobe 1997, Riand et al 1998)

Rotator cuff

Overuse (Wickiewicz 1994) proximal migration of HH with fatigue

Weakness (Thompson 1996) loss of infra or subscap = > 400% increase in deltoid power. 1 in 10 cuff tear by 40

Instability/hypermobility

Secondary tensile disease (Meister and Andrews 1993)

Secondary compressive impingement (Warner et al 1990)

Aetiology of SIS is multifactoral, challenges Neer, Lewis et al (2001).

It has been suggested that an intrinsic contractile tension overload on the muscle rather than primary impingement is the major factor in the aetiology of rotator cuff tendinitis (Nirschl 1989). When the arm is in the overhead position, eccentric contraction of the supraspinatus decelerates internal rotation and adduction of the arm, causing an overload (Bigliani & Levine 1997). This phenomenon is most dramatic in persons who go in for overhead sports, and it may also occur in manual labourers who use overhead motions in their work (Bigliani & Levine 1997). The proximal migration of the humeral head has also been associated with muscle fatigue, injury and degenerative changes in the rotator cuff tendons (Jerosch et al. 1989, Leroux et al. 1994).

Decrease in proprioceptive sense with muscle fatigue may play a role in decreasing athletic performance and in fatigue-related shoulder dysfunction (Carpenter et al. 1998). Some functional analysis of rotator cuff muscles has shown disturbances in strength in different pathological conditions, including impingement syndrome (Nirschl 1989, Warner et al. 1990, Leroux et al. 1994). Imbalance of the rotator cuff muscles in athletes, who have developed it as a result of training or sport activities, has generally been found to be a predisposing factor or a consequence of impingement syndrome (McMaster et al. 1991, Burnham et al. 1993, Ticker et al. 1995).

The diagnosis of overuse syndrome can be made after possible extrinsic factors related to the coracoacromial arch that may contribute to the process has been ruled out (Bigliani & Levine 1997). This syndrome also occurs commonly in young competitive athletes and manual labourers who use overhead motions in their work (Bigliani & Levine 1997). Inflammation resulting from repetitive microtrauma increases the area occupied by soft tissues in the subacromial space and leads to friction and wear against the coracoacromial arch (Uhthoff et al. 1988, Jobe et al. 1989, Ark et al. 1992, McCann & Bigliani 1994). However, inflammation of the subacromial bursa may also result from a systemic disease, such as rheumatoid arthritis (Steinfeld et al. 1994, Reveille 1997). The findings of Soslowsky et al (Soslowsky et al. 2000) described in animal tendons changes that result from overuse activity, and they are believed to occur in rotator cuff tendons, too.

Aetiology

Restrictive processes

Restricted glenohumeral capsule (Harryman et al 1990, Matsen and Arntz 1990), restriction of post capsule = increased ant HH translation

Posture

Ayub 1991, Bowling et al 1986, Calliet 1991, Solem-Bertoft et al 1993, Greenfield 1995, Kibler 1998.

Functional scapular instability

Kibler 1991, 1998, 2002, 2003, Warner et al 1992, Lukasiewicz 1999, Ludewig and Cook 2000, Wandsworth, Bullock Saxton 1997)

Lateral Kibler slide test

Posture – Greenfield (1995) impingement had fwd head posture but no difference in Tx Kyphosis. Kibler found increased Tx kyphosis gave protraction and reduced subacromial space.

Kibler 1998 has described that a scapula positioned in excessive downward rotation due to poor muscular control would reduce acromial elevation which may lead to impingement. Weak lower traps or pec minor or levator scapula short.

Ludewig and Cook 2000 carried out an EMG study and found that the impingement group had more anterior tipping, less upward rotation and greater upper and lower traps activity than non impingement group. 9% reduction in serratus function.

Wandsworth, Bullock Saxton 1997 studied impingement in swimmers and found delayed serratus activity in impingement group. Upper traps and serratus activated prior to movement (similar to TA)

Lukasiewicz 1999, studied 3D movement with impingement and normals. Impingement 8-9% increase in anterior tipping of the scapula.

Lateral Kibler slide test – dist between the inferior point of the scapula and the corresponding spinal vertebrae in 3 different positions; neutral, hands on hips and 90 degrees of GHjt abduction. Hands on hips best reliability (McKenna 2004).

New Theories

Pathology not always = pain

Glutamate

Oxidative stress

Neovascularisation

Calcitonin gene related protein

Matrix substances

Substance P

Nitric Oxide

Bradykinin

1 in 10 cuff tear by 40 and no symptoms

Sher et al – subjects with large tears can have full function as long as rotator cable is intact (band of tissue that fibroses

Glutamate

Oxidative stress = tenocyte death

Neovascularisation = spiders web blood vessels

Calcitonin gene related protein

Matrix substances

Substance P = neurotransmitters increased in tendonopathy tissue

Nitric Oxide = decreased in tendonopathy tissue, vasodilator, found in GTN patches

Bradykinin

Muscle patterning

Inappropriate activation of torque producing muscles

Destabilising shear force across the joint.

Muscle patterning

Inappropriate activation of torque producing muscles ie; lat dorsi, pec major, ant post deltoid. Abnormal muscle patterning creates a destabilising shear force across the joint.

Malone (2004) in patients with anterior instability 58% had a primary problem with Pec major, posterior instability patients showed 74% had inappropriate activation of Lat dorsi or ant deltoid.

Patients can move around the triangle.

What causes muscle patterning? It has been suggested that shoulder dislocation leads to instability, proprioceptive deficits and mechanoreceptor damage Lephart et al (1994). Smith and Brunolli (1989) used a passive mechanical shoulder stimulation device and asked subjects when they detected movement. They found that patients with recurrent traumatic anterior instability demonstrated proprioceptive deficits. Rehab of instability should include re education of the kinaesthetic based neuromuscular control. Has been a specific concept in lower limb rehab but not in upper limb. Kibler (1998) abnormal biomechanics occuring after sports injury are result of alterations in the function of the scapula control muscles. Most efficient way to reorganise normal firing patterns for the scapula is with closed kinetic chain exercises (CKC).

Motor learning is key to establishing or restoring movement patterns.

Kibler (1998) describes the force development of a tennis serve, 54% comes from the legs and trunk. Injury to a distal segment can alter normal motor programmes. Kinetic chain rather than focus on the shoulder girdle.

Kinetic chain; For example sway back posture, increased flexion pattern in activation of GH jt muscles. Ie protraction through pectoralis activation. Links in with the myofascial sling, Myers (2001).

In presence of gluteal inhibition then lat dorsi works hard to compensate. Fixing to the affected side will take place, obs gait and arm swing.

Rx – Evidence - CSP Guidelines

7-21/7 of NSAIDs (A)

St Injections short term benefit (A)

Mobilisation Maitland (A)

HEP; ROM, strength, stability, scap/humeral rhythm (A)

U/S daily for 6/52 for calcification (A)

Isometric strength M & L rotation (B)

Correction of forward head position (B)

Capsular stretching at an early stage (B)

Closed Kinetic chain work (C)

Scapula stability (C)

Cold packs post exercise 10-30 mins(C)

Eccentric loading gives tenocyte repair (Khan & Cook 2004)

U/S daily for 6/52 for calcification (Philadelphia panel 2001)

Education, ?injection

Pain inhibition, rest, sleep, mobs

Scapula stability - serratus

Movement pattern correction

Kinetic chain

Proprioception/neuromuscular control

Humeral head control

Cuff function

Capsular tightness

Posture

Tx, Cx

Change in activity, "live in window"

Workplace modifications

Pain inhibition – selected rest, sleeping position (dressing gown cord and towel under arm) or (supine pillow under elbow), analgesia/NSAIDS, mobilisation, neural mobility, tape, injection (as long as no r/cuff tear), education

Scapula stability – scap setting in prone, weight in hand, elevation control with theraband, then lat rot whilst elevation, use pulleyabove head with theraband whilst work on scap, swiss ball up wall into elev whilst assist scap, elevate using hand first. Use Trp’s in pec minor, lev scap, mobilise, repetition. Kinetic chain, biofeedback, dynamic control of scap. facilitate serratus – press up on wall, forward punch, push up plus, dynamic hug

Humeral head control - Dynamic hug – all r/cuff muscles, subscap setting – slow scapation with med rot, push up plus, middle row, infraspin – T bar eccentric with theraband in supine, press ups, supraspin - T bar

Cuff function

Capsular tightness

Proprioception

Posture

Change in activity and workplace modifications

Scapula Rehab

Kibler2003

Rehabilitation should start at the base of the kinetic chain, which usually means correcting any strength or flexibility deficits in the low back and thoracic levels before starting on the scapular component. This phase includes exercises for flexibility, strengthening the trunk, and correction of postural abnormalities. Intermediate-stage scapular "clock" exercises (arrows indicate direction of scapular motion). A and B, Elevation and depression (12- and 6-o’clock positions, respectively). C and D, Retraction and protraction (9- and 3-o’clock positions).

"Wall washes" for scapular rehabilitation. The hand slides on a smooth-surfaced wall. Trunk extension and rotation and scapular motion are emphasized. Rotator cuff punches with weights. The weight should create a load but allow the arm to be extended. The exercise should start with hip and trunk extension and scapular retraction (B) and then proceed to arm punches at different levels of arm elevation

“Living within a window”

In addition to physical therapy and medications, activity and workplace modifications must be discussed. Patients should attempt to discontinue overhead activities until symptoms diminish. It may be helpful to discuss “living within a window” in which they consciously attempt to keep their hands within an area in front of their body during activity. The “window” should be from chest to waist and 2 to 3 feet wide, allowing the patient to avoid reaching overhead, away from the body, or behind the back, all of which will exacerbate their symptoms

Objective Ax

Posture

Bony Alignment

AROM/ PROM

Muscle Tests

Accessory Mvts

Palpation

Special Tests

Muscle length

Ax of functional movement

Posture – Increased Tx Kyphosis, chin poke posture increased risk of impingement, affected sh will be depressed?

AROM/ PROM – watch Tx in elev. Elev needs 30 lat rot, upper traps is TA of shoulder, needs to fire before mvt in elev and protract. Good inferior translation of HH in abd

Muscle Tests – gerber’s, ext rot, abd

Accessory Mvts; GHjt, Acjt, SCjt

Test Tx and Cx, beighton’s score

Palpation

Special Tests

Muscle length

Ax of functional movement

CONCLUSION

Primary – anatomical narrowing of the subacromial space, ie hooked acromion, tendon thickening

Secondary – functional narrowing of the subacromial space, ie muscle imbalance, posture, instability – physio can change

REFERENCES

Neer CS. Impingement lesions. Clin Orthop Rel Res. 1983;173:70 –77.

Neer, C. S. II. Anterior acromioplasty for the chronic impingement syndrome in the shoulder. J. Bone Joint Surg. 54A:41–50, 1972; 22.

Neer, C. S. II and R. P. Welsh. The shoulder in sports. Orthop. Clin. North Am. 8:583–591, 1977.

Hawkins RJ, Brock RM, Abrams JS, Hobeika P. Acromioplasty for impingement with an intact Rotator cuff. J Bone Joint Surg Br. 1988; 70:795–797.

Michael C. Koester, MD, Michael S. George, MD, John E. Kuhn, MD Shoulder impingement syndromeThe American Journal of Medicine (2005) 118, 452–455

Brox JI et al Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome) BMJ 1993 Oct 9; 307:899-903.

Blair B, Rokito AS, Cuomo F, Jarolem K, Zuckerman JD, Efficacy of injections of corticosteroids for subacromial impingement syndrome. J Bone Joint Surg Am. 1996 Nov;78(11):1685-9.

Downing DS, Weinstein A. Ultrasound therapy of subacromial bursitis. A double blind trial. Phys Ther1986;66:194–9.

Nykanen M. Pulsed ultrasound treatment of the shoulder. A randomised, double blind, placebo controlled trial. Scand J Rehabil Med1995;27:105–8.

Hasson S, Mundorf R, Barnes W, Williams J, Fujii M. Effect of pulsed ultrasound versus placebo on muscle soreness perception and muscular performance. Scand J Rehabil Med1990;22:199–205.

Green S, Buchbinder R, Glazier R, Forbes A. Systematic review of randomised controlled trials of interventions for painful shoulder: selection criteria, outcome assessment and efficacy. Br Med J1998;316:354–60.

Kibler, W. Ben MD a; Uhl, Tim L. PhD, ATC, PT b; Maddux, Jackson W. Q. MD c; Brooks, Paul V. MD a; Zeller, Brian MS, ATC d; McMullen, John MS, ATC 2002. a Qualitative clinical evaluation of scapular dysfunction: A reliability study. Journal of Shoulder & Elbow Surgery. 11(6):550-556,

W. Ben Kibler, MD and John McMullen, ATC , 2003 Scapular Dyskinesis and Its Relation to Shoulder Pain, J Am Acad Orthop Surg, Vol 11, No 2,, 142-151.

Lewis. J, Green. A, Dekel. S, The Aetiology of subacromial impingement syndrome, Physiotherapy Sept 2001, vol 87, No 9, pg 453-468.

McKenna et al (2004) Inter-tester reliability of scapular pposition in junior elite swimmers, Physical therapy in sport 5, 146-155.

Van der Heijden GJMG, van der Windt DAWM, de Winter AF. Physiotherapy for patients with shoulder disorders: a systematic review of randomised controlled clinical trials. Br Med J1997;315:25–30.

C. A. Speed, Rheumatology 2001; 40: 1331-1336, Therapeutic ultrasound in soft tissue lesions

P Frost and JH Andersen, shoulder impingement syndrome in relation to Shoulder intensive workOccup. Environ. Med. 1999;56;494-498

Cools et al (2008) Screening the athlete’s shoulder for impingement symptoms: a clinical reasoning algorithm for early detection of shoulder pathology,BMJ, 2008;42;628-635;

Takwale, Calvert, and Rattue (2000) Involuntary positional instability of the shoulder in adolescents and young adults: IS THERE ANY BENEFIT FROM TREATMENT? J Bone Joint Surg Br, 82-B: 719 - 723.

PA Dowdy and SW O'Driscoll (1993) Shoulder instability. An analysis of family history, J Bone Joint Surg Br, Sep 1993; 75-B: 782 - 784.

Gerber and Ganz (1984) Clinical assessment of instability of the shoulder. With special reference to anterior and posterior drawer tests, J Bone Joint Surg Br, Aug 1984; 66-B: 551 - 556.

Robinson M and Aderinto J (2005) Recurrent Posterior Shoulder Instability, Journal of Bone Joint Surg Am.

87:883-892.

Matsen FA 3rd, Titelman RM, Lippitt SB, Rockwood CA Jr, Wirth MA. (2004) Glenohumeral instability. In: Rockwood CA Jr, Matsen FA 3rd, Wirth MA, Lippitt SB, editors. The shoulder. Volume 2. 3rd ed. Philadelphia: Saunders;. p 655-794.

Falla D, Hess S and Richardson C (2003) Glenohumeral Joint Instability Strength In Baseball Players With Physical Signs Of Evaluation Of Shoulder Internal Rotator Muscle, Br. J. Sports Med.;37;430-432

Malone A, Jaggi A et al (2004) Muscle Patterning Instability – Classification and Prevalence in a Tertiary Referral Shoulder Service. Proceedings of the International Congress of Shoulder Surgery. Washington DC.

Lephart et al (1994) Proprioception of the shoulder joint in healthy, unstable and surgically repaired shoulders. Journal of Shoulder and Elbow Surgery, 3 (6), 371-380

Kibler B, Maddux J, Brooks P, Zeller B, McMullen J (2002). A Qualitative clinical evaluation of scapular dysfunction: A reliability study. Journal of Shoulder & Elbow Surgery. 11(6):550-556,

Kibler B, and McMullen J ( 2003) Scapular Dyskinesis and Its Relation to Shoulder Pain, J Am Acad Orthop Surg, Vol 11, No 2,, 142-151.

Kibler B (1998) The role of the Scapula in Athletic shoulder function. The American Journal of Sports Medicine, 26 (2), 325-337

Emery and Mullji (1991) Glenohumeral joint instability in normal adolescents, Journal of Bone Joint Surg, 73 (3) 406-408

Naughton et al (2005) Upper-body wobbleboard training effects on the post-dislocation shoulder, Physical Therapy in Sport, 6, 31-34

SLAP lesions

noreply@blogspirit.com (PhysioCharlie) — Thu, 04 Dec 2008 09:52:20 +0100

Identifying SLAP lesions: A meta-analysis of clinical tests and exercise in clinical reasoning, (2008) Walton et al, Physical Therapy in Sport 9 167–176

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WPB-4TFV947-1&_user=10&_coverDate=11/30/2008&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=3601a50a394ca47ec0d45470fdb7c5c5

Among the clinical tests for SLAP lesions that have been published to date, Yergason's test is the only one that shows a significant ability to influence clinical decision making, based on the results of the current analysis.

The shoulder Ax and Rx

noreply@blogspirit.com (PhysioCharlie) — Wed, 19 Nov 2008 17:35:01 +0100

http://www.ombregt.be/schouder/uk/schoud2.htm

Shoulder Kinetic chain

noreply@blogspirit.com (PhysioCharlie) — Tue, 21 Oct 2008 16:50:52 +0200

Shoulder Kinetic chain

http://www.gambetta.com/pdf/shoulderclearing.pdf

Labrum tear

noreply@blogspirit.com (PhysioCharlie) — Tue, 14 Oct 2008 10:54:00 +0200

I had a patient today who presented with a fall on to his right shoulder 3 months ago.

He has FROM and negative hawkins kennedy and Neers tests. He has pain on resisted Ab and Lat rot but full strength. Slightly more movement on Load shift test compared to the left, sulcus, relocation and apprehension were negative. He has a positive labral compression rotation test, reproducing his clicking and grinding.

He says that nothing showed up on the X-ray, but I explained that if it was a true labral tear only an MRI or arthroscopy would show a tear. See: http://www.myorthodoc.com/Shoulder_labral_injuries.htm

I gave him some strengthening and proprioceptive exercises and will see him in a week.

http://www.jankharia.com/newsletters/shoulder_viability_imaging_v2n3.pdf

"The best modality for diagnosing labral pathologies however is MRI arthrography. When the joint space is distended with fluid, the fluid separates out the labral tear from the underlying articular cartilage and glenoid rim leading to exquisite depiction of the tear. A tiny amount of gadolinium is introduced into the joint during injection. This allows highquality TIW images to be obtained. A plain MRI may miss upto 50% of labral pathologies, whereas MRI arthrography has a better than 90% accuracy rate for labral pathologies".

This gives a good over view of shoulder assessment:

http://jama.ama-assn.org/cgi/reprint/292/16/1989.pdf