SHOULDER
Frozen Shoulder
AKA: Adhesive Capsulitis, Periatrithis
Age: 40-60 y/o
M<F
Development of adhesion, capsular
thickening, capsular restrictions
Chronic inflammation in synovial tissue &
musculotendinous tissue
MC: Rotator Cuffs, IR except subscapularis,
biceps tendon & joint capsule.
IMPINGEMENT
Compression in the subacromial space
Faulty posture, excessive IR contributes to
the impingement
Muscle strength imbalance
IDIOPATHIC FROZEN SHOULDER
1. FREEZING STAGE
Pain management, Hot/Cold Pack, PJM (Gr,
1&2)
2. FROZEN STAGE
Pain & Mobility (LOM)
3. THAWING STAGE
LOM, Excessive tightness, Mobility
Management,
PJM (Grade III&IV)
Common Structural & Functional Impairment
Night & Disturbed Sleep
Pain on motion & often at rest during acute
flares
Capsular Pattern: (ERABIR=Flexion)
Joint Play
LOM Capsular Pattern
Posture:
a. Anterior Tilted Scapula (Stretch
pectoralis minor to contract faulty
posture, strengthen ER (since naka IR)
b. Rounded shoulder
c. Elevated & Protected Shoulder
Gait:
a. Arm Swing
b. Pain upon movement
c. General muscle weakness
d. Poor endurance
e. Substitution for limited GH motion &
scapular motion especially elevation
Glenohumeral Joint Arthritis
1. Acute Phase
Pain & Muscle Guarding (limited ERAB)
2. Sub-acute
Capsular tightness & LOM
3. Chronic
Progressive Restriction
Common Activity Limitation & Participation
Restriction
Inability to reach overhead, behind head, out
to the side & behind back
Putting on undergarments
Retrieve Wallet
Self-Grooming
Difficulty in lifting weighted objects
Limited ability to sustain repetitive activities
GH Joint Surgery & Post-op Management
MC surgical procedure used to treat advanced
shoulder joint pathology is GH arthroplasty
Rare Condition: Arthrodesis (surgical
ankylosis)
GH Arthroplasty
1. Total Shoulder Arthroplasty
Bilateral
Glenoid & Humeral Surface
2. Hemishoulder Arthroplasty
One surface only
3. Reverse Total Shoulder Arthroplasty
Rotator cuff is integrated
Indications for Surgery
Persisting & Incapacitating Pain
LOM (Stability)
APPROACH
1. Deltopectoral Incision
Deltoids & Pectoralis Major
2. Release of Subscapularis tendon
AKA: Tenotomy
3. Anterior Capsulotomy
Anterior capsule repair
4. Humeral Osteotomy of Humeral canal
INTRAOPERATIVE COMPLICATIONS
 Insufficient Lengthening of a tight
subscapularis muscle-tendon unit
Intraoperative damage to
Axillary Nerve
Abduction, Flexion, extension (weak)
Suprascapular Nerve
Abduction & ER (weak)
Humeral Fracture
Soft-Tissue Related Post-Operative Complications
Re-tearing a repaired rotator cuff mechanism
Post-operative distribution of repaired
subscapularis
Chronic instability or dislocation of GH joint
Glenoid Articular Erosion
Implant-Related Complications
Aseptic Loosening
Fracture of Glenoid Implant
Positioning After shoulder arthroplasty: Early post-
operative (Maximum Protection Phase)
1. Supine
Arm is immobilized in sling that is worn
continuously
Elbow Flexed to 90
FA and hand resting on abdomen
Arm supported at the elbow in on a folded
blanket/pillow
Forward flexion (10-20), slight abduction &
IR of the shoulder
Head of bed elevated at 30
2. Sitting
Arm is supported in sling or pt. lap or arm
rest
3. Tenuous Rotator Cuff Repair
Abduction split
Low reps
Initally PROM/AAROM
Safe ROM
No end range stretching
Passive ERNeutral after rTSA or <30 after TSA
During PROM/AAROM of ROTshoulder rot.
slightly anterior to midline (lesser stress on
anterior capsule)
No Hyperextension stretching; Hyper horizontal
abduction, No combined EXADIR
Maintain Trunk Errect for Posture
No active anti-gravity dynamic exercises especially IR
ADLs
Avoid reaching behind the back
Avoid using operated limb
Use sling when going outside
No driving for 4-6 weeks
Painful Shoulder Syndromes (Rotator Cuff Disease &
Impingement (Non-operative Management)
Neer Classification of Rotator Cuff Disease
Stage I
- Edema & Hemorrhage
- 25 y/o
Stage 2
- Tendinitis, Bursitis, Fibrosis
- 25-40 y/o
Stage 3
- Bony Spurs, Tendon Rupture
- >40 y/o
Primary Impingement
- Anatomical & Shape of acromion
Secondary Impingement
- Other Factors & Instability
Based on Impaired Tissue
Supraspinatus: Empty Can
Infraspinatus: ER
Bicipital Tendinitis: Speeds Test & Yeargason
Superior Glenoid Labrum
Subdeltoid (Subacromial) Bursitis
Other Musculotendinous Strains
Anterior: Overuse & Racket sports
Inferior: Motor Vehicle Trauma
Based on Mechanical Disruption & Direction of
Instability/Subluxation
Multi-directional instability
Uni-directional instability (A, P, inferior)
Traumatic Injury with tear of capsule
Insidious (Atraumatic) onset from repetitive
microtrauma
 Inherent Laxity
Based on Progressive Microtrauma Jobes
Classification
Group I
- Pure impingement
Group II
- Impingement associated with labral tear/
capsular injury and secondary impingement
Group III
- Hyperelastic soft tissues anterior/multi-
directional instability & impingement
Group IV
- Anterior instability without associated
impingement
Common Impairments of Impingement
Pain at the musculotendinous junction of the
involve muscle with palpation, with resisted
muscle contraction & when stretched
Positive Impingement Sign
Impaired Posture
a. Thoracic Kyphosis
b. Cervical & Capital Extension Forward
Head
c. Forward/Anterior Tilting of the scapula
d. Thoracic Mobility
Muscle imbalances
a. Pectoralis Minor/Major
b. Levator Scapulae
c. IR of the shoulder
d. Weak serratus anterior & ER
Hypomobile posterior GH joint capsule
Faulty kinematics during humeral elevation
a. posterior tipping of scapula
b. Altered Scapulohumeral rhythm
With complete rotator cuff tear
Different eccentric abduction; drop arm
Acute pain, referred to C5-C6 reference zones
Painful Shoulder Syndromes
- (+) Pain & Loss of Functional Mobility
Secondary Impingement
- Resolve sufficiently with non-operative
management
1. Sub-acromial Decompression
- Increase volume of subacromial space
- Allows gliding of tendons
- AKA: Anterior acromioplasty/decompression
acromioplasty
Indications for Surgery
Pain during overhead activities
Loss of functional mobility due to primary
impingement even after conservative
treatment.
Stage II Neer Classification
Intact or minor tear of the rotator cuff
Component Procedures
Removal of subacromial bursa (bursectomy0
Release of coracoacromial ligament
Resection of anterior acromial protuberance
Rotator Cuff Repair & Post-op Management
Indications for Surgery
Partial thickness/Full thickness of tear of
rotator cuff
Tendons with irreversible degenerative
changes in soft tissues.
Neer Stage 2 & 3
Acute, traumatic rupture of the rotator cuff
tendons.
Arthroscopic Approach
- Small Incisions
MINI-OPEN (ARTHROSCOPICALLY ASSISTED)
APPROACH
Subacromial decompression
Deltoid splitting approach
Traditional Open Approach
- Anterolateral incision mid 1/3 of inferior
clavicle
- Anterior aspect of proximal humerus
GENERAL EXERCISE GUIDELINES & PRECAUTIONS
FOLLOWING REPAIR OF A FULL-THICKNESS
ROTATOR CUFF TEAR
Perform PROM/AAROMSafe & pain range
Passive & Non-assisted ROM for 6-8wks if
massive cuff tear or after traditional open
approach
Position humerus slightly anterior to midline
at rest in supine, support, distal humerus on
folded towel
 Initiating Passive/AAROM shoulder rotation
while supine, shoulder slightly flexed, 45
abduction
Maintain trunk posture
Supraspinatus & Infraspinatus: strengthen
shoulder flexion & abduction
Remove substitutions motion: shoulder hike
& trunk lateral flexion.
Strengthening Exercises
Isometric Resistance to ST muscle support
operated arm
Low exercise Load
It should not cause pain
No CKC for 6 weeks
Delay dynamic strengthening PRE, 8 weeks
for small; 3 months for large muscle
Precaution in the movement: Ex. Stretching
on supra/infraspinatus
Stretching Exercises
Avoid vigorous stretching or grade 3 PMJ
Use contract-relax procedures
Supra/Infra/Subscapularis was repaired
avoid ER/IR
ADLs
For light functional, wait until
a. Arthroscopic: 6 weeks
b. Traditional: 12 weeks
c. Heavy Functional: 6-12 months
INSTABILITY
Anterior Instability
- MOI: Abduction & ER
Posterior Instability
- MOI: FOOSH/FADIR
Inferior Instability
- Weakness/Paralysis on posterior deltoid &
supraspinatus
- Repetitively reach overhead (swimmers &
workers)
Common Activity Limitations & Participations
Restrictions (Functional Limitations/Disabilities)
Possibility of recurrence
Restricted ability in sports
Side-lying in unaffected side
Traumatic Anterior Shoulder Dislocation
- Prevented by long head of biceps,
subscapularis, inferior GH ligament, axillary
nerve (Most common injured)
Anterior Capsule & Glenoid Labrum
- Bankart Lesion
Compression Fracture at posterolateral of humeral
Head
- Hill-Sach Lesion
Traumatic Posterior Shoulder Dislocation
MOI: FADIR due to FOOSH
Common Structural & Functional Impairment
- Pain & Muscle guarding
- Inability to abduct humerus due to Rotator
cuff tear
- Asymmetrical joint restriction/hypomobility
- With recurrent dislocation, individual can
dislocate the shoulder at will.
Shoulder Instabilities: Surgery & Post-op Management
Indications for Surgery
Recurrent dislocation or subluxation
Uni/Multi-directional instability
Instability-related impingement
Joint Laxity resulting in recurrent involuntary
dislocation
Bankart Repair
- Attachment of capsulolabral complex from
anterior rim of glenoid
Repair of Slap Lesion
- Superior Labrum extending to anterior to
posterior
IMMOBILIZATION
Anterior/Inferior Instability
- Immobilized in a sling in adduction (arms at
side)
- Forearm across abdomen with arm slightly
anterior
Posterior/Posterior-Inferior Instability
 - UE in orthosis Ability to repair significant ligamentous
- Handshake damage
a. ER- neutral rotation 10-20 Early post-op motion permittable
b. Abduction 20-30
Disadvantage
c. Elbow Flexion
d. Slight Extension Extensive Soft Tissue Disruption &
Arthrotomy required
Precautions after anterior GH stabilization & or
Not amenable to nonreconstructible fracture
BANKART Repair
Arthroscopic/ Arthroscopically Assisted Reduction
- Limit ER, horizontal abduction & extension
and Internal Fixation
- Limit ER 5-10 with arm in slight abduction
- Stretching: Avoid Abduction & ER Advantage
- Avoid resisted & active unless permitted
- No resisted IR for 4-6 weeks Subscapularis Allows arthroscopic evaluation of the joint
Repair Debridement of fracture debris if fully
arthroscopic
Repair of SLAP lesion No arthrotomy, less soft tissue disturbance,
less post-op
- Long head of biceps is detached
- Limit Passive/Assisted elevation of arm to Disadvantage
a. 60 for first 2 weeks
b. 90 3-4 weeks post-op Limited reduction & fixation
- Avoid pain that create tension in the biceps, No more than 2 part displaced fracture
avoid shoulder & elbow extension Not appropriate for radial neck fracture; if
- Postpone Isotonic contraction: Elbow flexion fully arthroscopically
& supination Excision of Radial Head
Joint Hypomobility Advantage
- RA Only option if severely comminuted, non-
- JRA reconstructible fracture
- DJD Early ROM permissible
- After trauma, fracture, dislocation
- Post-immob, contractures & adhesions Disadvantage

Common Activity Limitations and Functional Requires arthrotomy; may compromise

Impairments Joint stability if a prosthetic implant is not
used
Difficulty turning a doorknob
Difficulty pushing & pulling Radial Head Excision
Restricted hand to mouth activities
Indication
Pushing up from chair
Inability to carry objects Severely Comminuted
Limited Reach Chronic synovitis, mild deterioration of
articular surface
Joint Surgery & Post-op
Contraindicated
Surgical Option for Displaced Fracture of Radial Head
ORIF In growing child
Active Infection
Advantage
Damaged lateral ulnar collateral ligament
Achieves stabilization & fixation of multiple
Total Elbow Arthroplasty
fracture fragments
Indication
 Debiliating pain, loss of functional UE due to Activity Limitation
severe pain
- Provoking activities
RA/DA/JRA
- Difficulty in repetitive activities
Gross Instability of Elbow
Acute comminuted, intra-articular fracture Students (Acute) Miners (Chronic)
Complication of Fracture Rheumatoid Arthritis
Non-Union Acute Stage
Malunion - 5 cardinal signs of inflammation
- Tissue proliferation, joints, bilateral
Delayed Union
- Inflammation (Tenosynovitis)
Complications - Synovial Proliferation in the extrinsic tendons
- Joint instability Advanced Stage
- Triceps insufficiency
- Joint Capsule Weakening
- Implant Loosening
- Cartilage destruction
Specific Precautions: Avoid early end-range of elbow - Bone erosion
flexion - Tendon rupture
- Instabilities, subluxations, deformities
ROM Exercises
OA
STRENGTHENING EXERCISES
Acute Stage
- Postpone resisted elbow extension for 6
weeks, if triceps reflecting approach was used - Achiness, feeling of stiffness
- Strengthening shoulder, apply resistance - 5 cardinal signs of inflammation
above the elbow, eliminated stresses across
Advanced Stage
the joints
- There is capsular laxity resulting
Myositis Ossificans
hypermobility instability
- MC: FCU (LE=QUADS) - Contractures
- Bone formation outside bone (mm/lig) - Muscle weakness
- Signs of inflammation - Grip Strength
- Muscle Endurance
Lateral Elbow Tendinopathy
JOINT SURGERY
- MC: ECRB
- Relief of pain
Medial Elbow Tendinopathy
- Restoration of Normal hand function
- MC: Pronator & flexors - Correction of deformity/instability
- Improvement of strength
Common Structural & Functional Impairments
Indications for surgery
pain in elbow region after wrist & hand
activity - Severe pain due to OA, RA & JRA
Pain when muscle is stretched/Contracts - Deformity & marked LOM
against resistance - Subluxation/Dislocation of Radiocarpal Joint
muscle strength & endurance for the - Low Demand UE functional needs
demand
WRIST/MCP/PIP IMPLANT ARTHROPLASTY
grip strength, limited by pain
Tenderness with palpation at site of Indications for surgery
inflammation
 Pain at joints of the hand & hand function
due to OA/RA
Instability
Stiffness & AROM
pinch & grip strength due to pain or
subluxation
TENDON RUPTURE ASSOCIATED WITH RA:
SURGICAL & POST-OP MANAGEMENT

Most common in patients with chronic

tenosynovitis associated with RA
With tendon ruptures & loss active
control digits
Rupture of a single/multiple tendons is
painless
Weak & Painful Fracture; break&
painless; nerve injury due to fracture
Ext>Flexor Tendons
Pre-cautions after extensor tendon transfers by
reconstruction in the RA of the hand
Do not initiate MCP extension from full
available MCP flexion to avoid excessive
stretch on separated tendons
Postpone Stretching to MCP flexion
Avoid finger & thumb flexion + adduction
with wrist flexion
Avoid weight-bearing on dorsum of the hand
Avoid vigorous gripping activities
Repetitive Trauma/Overused
Common Structural & Functional Impairment
Pain when related muscle contracts
There is movement that causes gliding of a
tendon sheath
Warmth & tenderness in palpation
RA, synovial proliferation & swelling in
affected tendon sheath
Imbalance in muscle strength & length
Pain at involved STH whenever a stretch
force is placed
Hypermobility/Instability