A Physiotherapy approach for General Practitioners Presenters: Jaquie Goldsack and Linda Gomercic

A Physiotherapy approach for General Practitioners
Presenters: Jaquie Goldsack
and Linda Gomercic
Introduction










Anatomy
Review of movement terminology
Subjective Examination
Objective Examination
Practical component
Differential Diagnosis
When is Physio Indicated
When is a specialist referral required
Case Scenarios
Questions
Anatomy- Bone/Joint
Articulations:
1. Glenohumeral
2. Acromioclavicular
3. Sternoclavicular
4. ‘functional’ articulation of
thorax and scapula
•
•
•
•
Shallow joint- deepened
by labrum
Lots of degrees of freedom
Large HoH, small fossa
Stability dependant on
non bony connections
Ligaments
Major Ligaments
•Anterior GHL’s
•Coracohumeral Ligament
•Superior GHL
•Middle GHL
•Inferior GHL
Labrum
•Narrow, wedged shaped
structure
•Intimately associated with the
shld capsule
•Blends with origin of LHB
•Pain sensitive structure
•Roles: deepens fossa, controls
translational movement of the
shld in mid range movements,
draws HoH into glenoid fossa.
Muscles
Rotator Cuff
Made up of:
•SS
•IF
•Sub scap
•Teres minor
Other stabilisers
•Upper, Middle and Lower traps
•Post Deltoid
Other muscles that impact on
shoulder Position (global)
•LS
•Rhomboids
•Pec Minor
Bursae
 Subacromial
 Decreases friction
 Thickens with degeneration
and wear and tear
 Can be site of acute
irritation or secondary
inflammatory response to
primary degenerative
pathology
 Sub acromial space- true
site of classic impingement
Innervation of the RC
 Supraspinatus: suprascapula nerve C4, C5, C6
 Infraspinatus: suprascapula nerve C5, C6
 Subscapularis: Upper and lower subscapula nerve C5,
C6, C7
 Teres Minor: Axillary nerve C5, C6
Quick Review of Terminology
Flexion/extension
•IR/ER
•HF/HE
•Abduction/ Adduction
•Protraction/Retraction
Subjective Examination







Mechanism of injury
Pain area
Duration of pain (date of onset)
Irritability
24hr behaviour
Agg/easing factors
Previous History of shoulder problems (esp if gradual
onset)
 Occupation
 Sports, exercise, hobbies
 Red flags (Hx cancer, bilateral P&N, pain levels exceeding
those expected, systemic S&S, non mechanical MOI)
Objective
 Observation (scap levels, protraction, downward tilt,
depression, clavicle levels)
 Normal resting position of the Scapula:
 superior angle – T2/3
 inferior angle – T6/7
 upward rotation – average 10 degrees
 Anterior tilt – 8 degrees
 Internal Rotation – 33-35 degrees
 2-3 fingers off of the spinous process ??
Scapular Movements
Depressed Scapula
Protracted/Winging scap
Anterior Tilt
Kyphotic tx, Ant sitting HoH
Posture
Objective Examination cont
 4 finger position of scap- superior and inferior angles
of the scapula, acromion and coracoid.
 The ‘claw’ position of HoH- Anterior and posterior
acromion compared to anterior and posterior HoH
(HoH sitting 1/3 anterior to acromion).
 AROM
 With scap repositioning
 PROM
Repositioning of scap and Re-Ax
ROM
Special Tests- Hawkins and
Kennedy
 Impingement testing
Full Can/Empty Can
 Rotator cuff tear/inflammation
Subscap lift off and Press Belly
Tests
Speeds
Apprehension
Sulcus
Neural Tension tests
 Median:

shoulder depression
 90 deg shoulder abduction
 Wrist, finger, thumb Extension
 Supination
 ER of shoulder
 Elbow extension
Neural Tension Tests
 Ulnar:
 Wrist extension/ 4th and 5th finger ext
 Pronation/ supination
 Elbow flexion
 ER of shoulder
 Shoulder Abduction
Neural Tension Tests
 Radial –
 Shoulder Depression
 Elbow extension
 Whole arm IR
 Wrist flexion/ thumb flexion
 Shoulder abduction
Practical- Groups
 Observation
 AROM
 Scap repositioning
 Hawkins + Kennedy
 Full can/ Empty Can
 Lift Off / press belly
 Speeds
 Apprehension Test
 Sulcus
Imaging
When is it warranted?
 Trauma
 Very large loss in range of motion/severe shoulder
pathology
 Red flags ie history of cancer, unexplained weight loss
 Failed conservative management
 Dislocation- can still be managed conservatively
 Unclear diagnosis
Differential Diagnosis
Other Causes of pain in the shoulder
 Referral from the neck
 Thoracic outlet Syndrome
 Peripheral nerve sensitisation
 Thoracic spine pain
 SLAP lesions
Refer to table
When are anti
inflammatories/Cortisone Warranted
 Moderate-severe pain that’s not improving (acute
rotator cuff tears)
 Difficulties with sleep
 Failure of over the counter anti inflammatory’s to
provide relief
 Frozen shoulder stage I and possibly II (pain relief)
 Slow progress with conservative management
When is Physio Indicated
 Rotator cuff pathology and impingement.
 Dysfunctional scapula position
 Significant symptom relief and improvement of range of motion from
scap repositioning
 Post cortisone
 Stiff shoulder
 ?Frozen shoulder. Especially stages II and III when pain has decreased
and shoulder is stiff. Physio essential to restore ROM and function.
There is also a role for physio with education and prevention of
secondary problems in stage I. Research also shows gains in the first 2
months of stage 1.
 Hypermobile/unstable shoulder
 Pre and post shoulder surgery
 Unclear diagnosis for example pins and needles, multiple pathology,
referring pain into arm, headaches etc
Treatment Approach
 Muscle release
 Heat/ ice/ ultrasound/ tens/ acupuncture
 Tape to offload structures/ promote optimal position
 Mobilisations – shoulder, cervical, thoracic or nerve
 Stability exercises
 Motor control exercises
 Global muscle strengthening
Specialist Referral
 Recurrent dislocations/subluxations
 Rotator cuff tears >2cm, massive tears, full thickness
tears, partial thickness tears >50%
 Frozen shoulder stage 1
 If conservative management is not working
 Unsure diagnosis
Case Study 1/Discussion
 45y/o Female presents with acute onset right shoulder pain






after spending the weekend painting. She is unable to lift
her arm >90degrees due to pain.
Pain is at the deltoid insertion with some radiation down to
elbow when she uses her arm (ie brushing teeth, doing
hair)
Agg activities include: lifting arm, brushing hair, reaching,
doing up bra, lying on her right side
Easing activities include: supporting arm, rest, heat to
shoulder
Special Q’s: nil Hx of cancer, no neural Sx,
What is your differential Dx?
What tests would you perform?
Case Study 2/Discussion
 30 y/o male presents with right sided pain in his biceps and P&N &







numbness in his palm, onset 6 weeks ago, gradually worsening. Gets
pain at night time.
Works as a labourer. Hx of carrying a large sheet of metal. The other
person carrying dropped one side of it, causing a traction force through
his right arm.
Agg activities include arm hanging by side, carrying objects, lying on
right side. Gets headaches with prolonged sitting and driving
Ease activities: putting arm on head or resting thumb in belt, resting
arm on object
Mild decrease in range of motion. Catch at 90degrees of abduction but
can continue through ROM.
Observation: Depressed and protracted right scapula
Differential Dx?
What tests would you perform?
Case Study 3/Discussion
 40 year old diabetic female presenting with gradual onset of pain and
restriction of the right GH joint over the last 3 months.
 Constant ache with sharp pain upon movement
 Agg – all shoulder movements, sleeping, dressing herself
 Worse at night – sleeps only 3-4 hours per day
 Ease – nothing at the moment
 Works full time as a secretary
 Unaware of any previous injuries to the shoulder
 Observation: Rounded shoulders and kyphotic; shoulder hike on affected side
 AROM: 40deg flxn+ abduction; 10 deg ER; HBB = iliac crest
 Differential Diagnosis: ?
 What tests would you perform?
 Any imaging?
 Physio approach
Questions
Thank you for attending