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