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PTA 130
Fundamentals of
Treatment I
The Shoulder and Shoulder Girdle
Lesson Objectives
 Identify key anatomical muscles and structures of
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the shoulder and arm.
Identify common tissue injuries, conditions and
surgical interventions.
Analyze restorative interventions for common
injuries.
Identify soft tissue specific mobilizations for the
shoulder and arm.
Identify flexibility and ROM exercises.
Shoulder Factors
 The shoulder girdle allows for mobility of the upper
extremity in multiplanar directions
 One of the primary functions of the shoulder is to
position the hand
 The shoulder girdle only has one bony attachment
to the axial skeleton
 Can you name the joint?
 High injury risk because major shoulder
stabilization comes from muscle strength and
coordination
Shoulder Anatomy Review
Joints of the Shoulder Girdle
Complex
 The clavicle articulates with the sternum at the
sternoclavicular joint
 Stability is provided by muscles and joints
 Three synovial joints:
 Glenohumeral
 Acromioclavicular
 Sternoclavicular
 Two functional articulations:
 Scapulothoracic
 Suprahumeral (subacromial space)
Shoulder Stability
 Structural stability provided by:
 Ligaments
 Capsule
 Glenoid labrum
 Dynamic stability provided by:
 Muscular strength
 Neuromuscular control
 Proprioceptive input
 Skilled motor response
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Scapulothoracic Articulation
 Motions of the Scapula:
 Elevation and depression
 Protraction and retraction
 Upward and downward rotation
• What motion happens with flexion of the humerus?
 Winging and tipping
Scapular Stability
 Scapular muscle stabilizers
 Rhomboid major and minor
 Serratus anterior
 Middle and lower trapezius
 Scapular stability provides platform for the
glenohumeral (GH) joint
 Poor scapular stabilization => unstable GH base
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Scapulohumeral Rhythm
 Describes the timing of movement at these joints
during shoulder elevation
 First 60 degrees of shoulder elevation and/or 30
degrees of shoulder ABDuction involves a "setting
phase":
 The movement is primarily at the GH joint
 Scapulothoracic movement is small and inconsistent
 During the mid-range of humeral motion:
 The scapula has greater motion
 Typically at 1:1 ration with the humerus
 The GH joint dominates the motion in end ranges
Scapulohumeral Rhythm
 Scapulohumeral rhythm serves at least two
purposes.
 It preserves the length-tension relationships of the
muscles moving the humerus
 It prevents impingement between the humerus and
the acromion
Referred Pain
 Cervical Spine – Vertebral joints between
 C3, C4, C5
 Nerve Roots
 C4 or C5
 Diaphragm
 Pain perceived in the upper traps region
 Heart
 Pain perceived in the axilla and left pectoral region
 Gallbladder irritation
 Pain perceived at the tip of shoulder
Nerve Injury
 Brachial Plexus in the thoracic outlet
 Compression of the brachial plexus nerves may
occur under the coracoid process and pect minor
 Suprascapular nerve compression
 Direct compression or nerve stretch
 May occur when carrying a heavy bag over the
shoulder
 Radial nerve compression
 Continual pressure in axilla
 Leaning on axillary crutches
What motions occur at the
scapula while in this posture?
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Posture in Relationship to
Shoulder
 Correct posture is crucial to shoulder balance and
function
 Forward-head posture 
 Round shoulder, rotator cuff impingement, and 
shoulder flexion ROM
 Scapula assumes protracted and anteriorly tilted
posture
• Causes internal rotation (IR) of GH joint
• Tightness in anterior chest muscles
• Weakness of posterior thoracic spine musculature
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Shoulder Joint Hypomobility
 Restricted mobility at the glenohumeral (GH) joint
may occur as a result of:
 RA, OA
 Traumatic arthritis
 Prolonged immobilization
 Idiopathic frozen shoulder (adhesive capsulitis)
 Acromioclavicular Joint (AC)
 Sternoclavicular Joint (SC)
 AC and SC joints may become hypomobile due to
arthritis, faulty postures, fractures, or dislocations
Common Shoulder Injuries
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Rotator Cuff Tear
Rotator Cuff Tendonitis
Shoulder Impingement
Shoulder Bursitis
Shoulder Arthritis
Frozen Shoulder
Shoulder Dislocation or Separation
Bicep Tendonitis
Shoulder Instability
Labral tears, SLAP lesion, Bankart repair
Acromioclavicular Sprain
Rotator Cuff Tear
 Commonly occur in both athletic and nonathletic
patients
 Symptoms include pain, weakness, and decreased
range of motion
 Early diagnosis is important for identifying causes,
implementing effective treatment, and preventing
further injury
 The supraspinatus is the most commonly
injured/torn rotator cuff muscle
Rotator Cuff
 4 muscles and their
tendons:
 Supraspinatus muscle;
Shoulder ABDuction
 Infraspinatus muscle;
Shoulder External Rotation
 Teres minor muscle; Shoulder
External Rotation
 Subscapularis muscle;
Shoulder Internal Rotation
Rotator Cuff Tear
 Stage 1 Partial tear less than 1 cm in size
 Stage 2 Partial tear > 1 cm, but < 5 cm in size
 Stage 3 Full tear greater than 5 cm
 Treatment:
 Stretching/ROM, isometrics, modalities, surgical
intervention (if necessary)
Rotator Cuff Tendonitis
 The most common rotator cuff injury
 Caused by chronic overuse
 Commonly occurs in the supraspinatus and
infraspinatus tendons
 Patient will most likely complain of pain with
overhead motions
 Patient will have pain with palpation over the
tendon
 Treatment:
 Stretch/ROM, isometrics, Cross-Friction massage,
and modalities
Shoulder Impingement
 Occurs as a result of mechanical wear of the
rotator cuff against the anteroinferior aspect of the
acromion in the suprahumeral space
 Vascular changes in the rotator cuff tendons and
structural variations in the acromion often
accompany this diagnosis
 Faulty posture may also lead to shoulder
impingement
 Treatment:
 Stretching, Soft tissue mobilization, Modalities, and
possible surgical intervention
Shoulder Bursitis
 Inflammation of the subacromial bursa
 May be caused by overuse of the shoulder and/or
repetitive activities
 Treatment:
 Rest, Stretching, Soft tissue mobilization and
Modalities
GH Joint Arthritis
 Acute Phase
 Patient will present with pain and muscle guarding
 ER and ABDuction are most limited
 Subacute Phase
 Patient will present with capsular tightness
 Pain is elicited when shoulder is moved into end
ranges
 Chronic Phase
 Progressive GH joint restriction
 Significant loss of function
Frozen Shoulder
(Adhesive Capsulitis)
 Characterized by the development of adhesions,
capsular thickening, and capsular restrictions
 Onset may be insidious
 Cause is idiopathic
 Contributing factors may be: pain, restricted motion,
arthritis, immobilization, trauma, etc.
 Follows a pattern:
 “Freezing”
 “Frozen”
 “Thawing”
Frozen Shoulder
(Adhesive Capsulitis)
 Common Impairments:
 Night pain and disturbed sleep
 Pain with motion
 Decreased mobility
 Muscle weakness
 Substitution patterns
 Functional limitations
 Treatment:
 Prevention, Stretch/ROM, joint mobilization,
strengthening, and modalities
Shoulder Dislocation
 The GH joint is the most commonly dislocated joint in
the body
 Usually caused by a severe blow to the arm with arm
held in a position of external rotation and abduction
 Anterior dislocations occur most frequently
 Closed reduction Skilled technique to reduce the dislocation
 Protection Phase, activity restriction for 6-8 weeks
 Avoid position of dislocation
 Protected ROM, isometrics
Shoulder Dislocation
 Controlled motion phase
 Increase mobility
 Increase stability and strength of RC and periscapular
muscles
 Return to function phase
 Restore functional control; balance strength of shoulder
and scapular musculature
 Coordination
 Endurance
 Eccentric training
 Increase speed and control
 Simulate functional patterns
Bicipital Tendinitis
 Lesion is typically located on the long head of the
biceps tendon in the bicipital groove
 Pain is elicited with resisted shoulder flexion while
the arm is supinated
 Tenderness to palpation of the bicipital groove
 Treatment:
 Isometric exercises, Stretching, Cross-Friction
massage, and modalities
Shoulder Instability
 Multidirectional Instability
 Individuals have lax connective tissue which allows
for mobility
 The humeral head will translate to a greater degree
than normal in all directions
 Individuals involved in overhead throwing or lifting
activities may be more prone to develop laxity of the
shoulder capsule
 Hypermobility may also lead to impingement,
subluxation, dislocation, or tendinitis
Multi-directional Instability
Unidirectional Instability
 May occur in one of the following directions:
 Anterior
 Posterior
 Inferior
 Usually the result of trauma
 Typically involves rotator cuff tears
 Damage to the glenoid labrum is also common
Shoulder Instability
 AMBRI:
 Atraumatic,
 Multidirectional,
 often Bilateral,
 requires Rehabilitation,
 Inferior capsular shift is the best alternative surgical
therapy
 Usually initiated without trauma
 Often multidirectional (anterior, inferior and posterior)
 Occurring in patients with generalized joint laxity
Shoulder Instability
 AMBRI
 Usually does not have surgery
 Treatment consists of a program of shoulder
strengthening and stabilization exercises
Shoulder Instability
 TUBS
(Traumatic, Unidirectional, Bankart, Surgery)
 One of most common shoulder injuries in athletes
• Most common in contact athletes
 May present as traumatic dislocation/subluxation
 Mechanism is a posteriorly directed force on an
abducted and externally rotated arm
 High recurrence rate that correlates directly
with age at dislocation
• Up to 80-90% in teenagers
Traumatic Shoulder Dislocation
Glenoid Labral Tear - CAUSES
 Falling on an outstretched arm
 A direct blow to the shoulder
 A sudden pull, such as when trying to lift a heavy
object
 A violent overhead reach
 May occur while trying to stop a fall or slide
 Throwing athletes or weightlifters may experience
glenoid labrum tears as a result of repetitive
shoulder motion
Labral Tear
SLAP Lesion
 Tear of the superior labrum
 SLAP (Superior Labrum extending Anterior to
Posterior)
 Often associated with a tear of the proximal
attachment of the long head of the biceps and
recurrent anterior instability of the GH joint
 Surgery involves debridement of the superior
labrum and reattachment of the labrum and biceps
tendon
Bankart Repair
 Bankart Lesion
 Detachment of the capsulolabral complex from the
anterior rim of the glenoid
 Commonly occurs as a result of a traumatic
anterior dislocation
 The repair involves an anterior capsulolabral
reconstruction to reattach the labrum to the surface
of the glenoid lip
Acromioclavicular Sprain
 Most AC sprains are NOT surgically repaired
 Sometimes requires initial immobilization
 Modalities used to relieve pain, swelling and
muscle spasms
 Early active and AAROM exercises to regain and
maintain mobility
 Isometric strengthening exercises
A-C Sprain / Dislocation
Common Surgical Procedures
 Glenohumeral Arthroplasty
 Arthrodesis of the Shoulder
 RCR- Rotator Cuff Repair
 SAD- Subacromial Decompression
Glenohumeral Arthroplasty
 Total shoulder arthroplasty (TSA)
 The glenoid and humeral surfaces are replaced
 Hemireplacement arthroplasty
 The humeral head is replaced
 Both are open surgical procedures
 Indications for surgery:
 Persistent and incapacitating pain
 Loss of shoulder mobility or stability
 Inability to perform functional tasks
TSA Postoperative Management
 Progression is influenced by the integrity of the
rotator cuff musculature
 Shoulder is typically immobilized
 Maximum Protection Phase:
 Day 1 post-op -> 6 weeks post-op
 Control of pain and inflammation
 Maintain mobility of adjacent joints
 Restore shoulder mobility
 Minimize muscle guarding and atrophy
TSA Postoperative Management
 Moderate Protection/Controlled Motion Phase
 6 weeks -> 12-16 weeks post-op
 Continue to increase PROM of the shoulder
 Develop active control and dynamic stability
 Improve muscle performance (strength and
endurance)
TSA Postoperative Management
 Minimum Protection/Return to Functional Activity
Phase
 Begins around 12-16 weeks post-op
 Extends for several more months
 Continue to improve or maintain shoulder mobility
 Continue to improve active control of the shoulder
 Progress muscle strengthening and stabilization
exercises
 Return to functional activities
Arthrodesis of the Shoulder
 The GH joint is fused with pins and bone grafts
 Indications for surgery
 Incapacitating pain
 Gross instability of the GH joint
 Complete paralysis of the deltoid and rotator cuff
muscles
 Severe joint destruction due to infection
 Failed TSA
Arthrodesis of the Shoulder
 Postoperative Management
 Emphasis is placed on maintaining mobility of
peripheral joints (wrist and hand) while the shoulder
and elbow are immobilized
 Following immobilization, begin active
scapulothoracic ROM
Rotator Cuff Repair
 May be appropriate for either partial-thickness
tears or full-thickness tears
 Indications for surgical repair are:
 Pain
 Impaired function
 Surgical repair is not indicated for patients who are
asymptomatic despite imaging reports confirming
presence of a cuff tear
 Surgical approach may be arthroscopic or open
Rotator Cuff Repair
 Postoperative management depends upon many
factors:
 Size and location of tear
 Onset of injury
 Preoperative functional mobility and strength
 Age of patient
 Type of approach
 Type of repair
RCR Postoperative Management
 Maximum Protection Phase (up to 8 weeks)
 Patient will most likely be immobilized
 Protection of the repaired tendon(s) is the primary goal
during this phase
 Control pain and inflammation
 AAROM exercises for elbow
 AROM exercises for wrist and hand
 Prevent shoulder stiffness
 Restore shoulder mobility
 Posture re-education
 Scapular stabilization exercises
 Gentle isometrics for GH joint musculature
RCR Postoperative Management
 Moderate Protection Phase
 Restore nearly full, nonpainful, passive mobility of
the shoulder
 Increase muscular strength and endurance of
shoulder musculature
 Re-establish dynamic stability of the shoulder
 AROM is allowed in pain free ranges
 Strengthening typically begins around 8 weeks postop, but may begin as late as 12 weeks for larger
repairs
RCR Postoperative Management
 Minimum Protection/Return to Function Phase
 Begins around 12-16 weeks post-op, and lasts for 6
months to a year
 Continue to work towards full ROM
• Passive stretching of GH musculature
• Joint mobilization
 Advance task-specific exercises
 Patients are not allowed to return to high demand
activities for 6 months, up to 1 year
Subacromial Decompression
 Designed to increase the volume of subacromial
space and provide adequate gliding room for
tendons
 Indications for surgery:
• Pain during overhead activities
• Loss of shoulder functional mobility
• Intact or minor rotator cuff tear
• Impingement
 Performed using an arthroscopic or open approach
Subacromial Decompression
 Maximum Protection Phase (0-4 weeks)
 Patient will have shoulder immobilized for 1-2 weeks
 Pain control and inflammation control
 ROM activities (PROM, AAROM, AROM)
 Patient education
 Postural re-education exercises
 Isometric exercises
Subacromial Decompression
 Moderate Protection Phase (4-8 weeks)
 Joint mobilization
 Stretching
 Postural re-education
 Isotonic strengthening exercises
 Functional activities with light resistance
 Minimum Protection Phase (8 weeks – 6 months)
 Continued strengthening
 Maintain full, pain-free AROM
 Functional and activity-specific exercises
Exercise Interventions
for the Shoulder Girdle
Early Glenohumeral Joint Motion
 AAROM Wand Exercises
 Flexion, ABDuction, ER, etc.
 Ball rolling or Table top washing
 Wall washing
 Pendulums
 Ensure that patient is performing this exercise
correctly
 Wall pulleys
Wand External Rotation
Wand Horizontal
Abduction/Adduction
Wand Abduction
Wand Internal Rotation
Pendulum
 Bend forward 90 degrees at the waist, using a
table for support move body in a circular pattern to
move arm
Self-stretching Techniques
 Posterior Capsule Stretch
 Table slides Flexion and ABDuction
 Pect doorway stretch
 “Sleeper Stretch”
 Latissimus Stretch
Stretches - Latissimus
Latissimus Stretch
Exercises for Muscle
Performance
 Isometric exercises
 Dynamic strengthening exercises—scapular
muscles
 Dynamic strengthening exercises—GH muscles
 Functional activities
Isometric Strengthening
 Isolated sustained submaximal
muscle contraction without
movement
 Scapular isometrics
 Shoulder flexion
 Shoulder extension
 Shoulder ABDuction
 ER
 IR
 Shoulder Horizontal ABD/ADD
Stabilization/Dynamic
Strengthening Exercises
 Open and Closed Chain Stabilization
 Dynamic Strengthening
 Prone scapular retraction
 Scapular retraction combined with Horizontal
ABDuction
 Scapular Retraction and Shoulder Horizontal
Abduction Combined with External Rotation
 Scapular Protraction
• “Push-up with a Plus”
GH Dynamic Strengthening
 Isotonic Strengthening
 PNF Patterns
 Isokinetic Training
 Hand walking on a treadmill
 ProFitter
 UBE
Advanced Closed-Chain
Stabilization and Balance
 Quadruped with hands on unstable surface
 Physioball
 Push-up position walking stairs
 BOSU Ball push-up, claps
 Plyometrics
Functional Activities
 Endurance Training
 Eccentric Training
 Plyometrics
 Total Body Training
Orthopedic Special
Tests
Anterior Instability
 Apprehension (Crank) Test
 Positive test is indicated by a
look or feeling of apprehension
or alarm on the patient’s face
and the patient’s resistance to
further motion
 This test is used to evaluate for
anterior shoulder instability. This
test may also be used to assess
a labral tear.
Tests for Muscle or Tendon
Pathology
 Speed’s Test
 Test for tenosynovitis at the long head of biceps
 Positive test elicits increased tenderness in the
bicipital groove and in indicative of tendonitis
Tests for Muscle or Tendon
Pathology
 Yergason’s Test
 A positive result is tenderness in the bicipital groove
(or the tendon may pop out of the groove) and is
indicative of bicipital tendonitis
Tests for Muscle or Tendon
Pathology
 Supraspinatus “Empty Can” Test
 The examiner looks for weakness or pain, reflecting
a positive test result
 A positive test result indicates a tear in the
supraspinatus tendon or muscle, or neuropathy of
the subscapular nerve
Tests for Muscle or Tendon
Pathology
 Drop Arm (Codman’s) Test
 A positive test is indicated if the patient is unable to
return the arm to the side slowly or has severe pain
when attempting to do so.
 A positive result indicates a tear in the rotator
complex
Tests for Impingement
 Neer Impingement Test
 The patient’s face shows pain, reflecting a positive
test result
Tests for Impingement
 Hawkins-Kennedy Impingement Test
 Pain indicates a positive test for supraspinatus
tenditintis
Tests for Thoracic Outlet
Syndrome
 Roos Test
 + is unable to keep arms in starting position,
ischemic pain, heaviness, profound weakness,
numbness, tingling
Tests for Thoracic Outlet
Syndrome
 Adson Maneuver
 Tests for subclavian artery compression or TOS
 A disappearance in the pulse is a positive test.
Questions