NAME- Swati Chokra. DATE OF BIRTH- 24th December 1985. NATIONALITY- Indian. ADDRESS- Rly Qr, RB/3/424, Block E, Ajni, Nagpur. CONTACT NUMBER- 9960619515. E-mail- capricron24@yahoo.com LANGUAGE KNOWN- English, Hindi, Marathi. EDUCATION QULIFICATION COURSE SSC HSSC BPTH 1st Year BPTH 2nd Year BPTH 3rd Year BPTH 4th Year AGGREGATE PERCENTAGE 60.66% 56.67% 65.78% 63% 70% 59.56% 64.1% BOARD/ UNIVERSITY Maharashtra State Board Maharashtra State Board PT. Ravishankar Shukla University PT. Ravishankar Shukla University PT. Ravishankar Shukla University PT. Ravishankar Shukla University PT. Ravishankar

Shukla University

PROJECT TOPIC OF 4thYEAR- Prevalence of Cervical and Lumbar Spine Discomfort in Bank Officials.

Joints People who are immobile have a higher tendency to suffer from muscular-skeletal problems such as malformed, inflamed or frozen joints (particularly if accompanied by Cerebral Palsy). Common muscular-skeletal problems include instability of the spine or cervical area, often due to kyphosis or scoliosis (curvature of the spine) from osteoporosis, or from having to stoop to use a walking frame; there may also be foot, ankle. knee, hip and shoulder problems due to arthritis, a recent fall or injury due to osteoporosis; Contracted tendons and ligaments are very common and can be damaged if handled incorrectly. Avoid the specific joints and areas of undiagnosed pain, but massage on the areas above and below can help to improve circulation and distract from any pain and aching. A knowledge of remedial massage may be required as well as seeking advice from the Physiotherapist. Make sure you have access to a manual-handling plan for your own safety and that of the client. Eucalyptus and peppermint are useful for passive muscle warming (Hong, et al. 1997).

OBJECTIVE To assess the efficacy of bipolar interferential electrotherapy (ET) and pulsed ultrasound (US) as adjuvants to exercise therapy for soft tissue shoulder disorders (SD). METHODS Randomised placebo controlled trial with a two by two factorial design plus an additional control group in 17 primary care physiotherapy practices in the south of the Netherlands. Patients with shoulder pain and/or restricted shoulder mobility, because of a soft tissue impairment without underlying specific or generalised condition, were enrolled if they had not recovered after six sessions of exercise therapy in two weeks. They were randomised to receive (1) active ET plus active US; (2) active ET plus dummy US; (3) dummy ET plus active US; (4) dummy ET plus dummy US; or (5) no adjuvants. Additionally, they received a maximum of 12 sessions of exercise therapy in six weeks. Measurements at baseline, 6 weeks and 3, 6, 9, and 12 months later were blinded for treatment. Outcome measures: recovery, functional status, chief complaint, pain, clinical status, and range of motion. RESULTS After written informed consent 180 patients were randomised: both the active treatments were given to 73 patients, both the dummy treatments to 72 patients, and 35 patients received no adjuvants. Prognosis of groups appeared similar at baseline. Blinding was successfully maintained. At six weeks seven patients (20%) without adjuvants reported very large improvement (including complete recovery), 17 (23%) and 16 (22%) with active and dummy ET, and 19 (26%) and 14 (19%) with active and dummy US. These proportions increased to about 40% at three months, but remained virtually stable thereafter. Up to 12 months follow up the 95% CI for differences between

groups for all outcomes include zero. CONCLUSION Neither ET nor US prove to be effective as adjuvants to exercise therapy for soft tissue SD.

No effect of bipolar interferential electrotherapy and pulsed ultrasound for soft tissue shoulder disorders: a randomised controlled trialG. J M G van der Heijden, P. Leffers, P. Wolters, J. Verheijden, H. van Mameren, J. Houben, L. Bouter, and P. KnipschildInstitute for Rehabilitation Research, Hoensbroek, The Netherlands.This article has been cited by other articles in PMC.

AbstractOBJECTIVETo assess the efficacy of bipolar interferential electrotherapy (ET) and pulsed ultrasound (US) as adjuvants to exercise therapy for soft tissue shoulder disorders (SD). METHODSRandomised placebo controlled trial with a two by two factorial design plus an additional control group in 17 primary care physiotherapy practices in the south of the Netherlands. Patients with shoulder pain and/or restricted shoulder mobility, because of a soft tissue impairment without underlying specific or generalised condition, were enrolled if they had not recovered after six sessions of exercise therapy in two weeks. They were randomised to receive (1) active ET plus active US; (2) active ET plus dummy US; (3) dummy ET plus active US; (4) dummy ET plus dummy US; or (5) no adjuvants. Additionally, they received a maximum of 12 sessions of exercise therapy in six weeks. Measurements at baseline, 6 weeks and 3, 6, 9, and 12 months later were blinded for treatment. Outcome measures: recovery, functional status, chief complaint, pain, clinical status, and range of motion. RESULTSAfter written informed consent 180 patients were randomised: both the active treatments were given to 73 patients, both the dummy treatments to 72 patients, and 35 patients received no adjuvants. Prognosis of groups appeared similar at baseline. Blinding was successfully maintained. At six weeks seven patients (20%) without adjuvants reported very large improvement (including complete recovery), 17 (23%) and 16 (22%) with active and dummy ET, and 19 (26%) and 14 (19%) with active and dummy US. These proportions increased to about 40% at three months, but remained virtually stable thereafter. Up to 12 months follow up the 95% CI for differences between groups for all outcomes include zero. CONCLUSIONNeither ET nor US prove to be effective as adjuvants to exercise therapy for soft tissue SD.

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These references are in PubMed. This may not be the complete list of references from this article.

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Written by:

DoctorNDTV team

What is frozen shoulder? What are the causes? Who is at risk? What are the symptoms? How is the diagnosis made? What is the treatment? What is frozen shoulder? Frozen shoulder or adhesive capsulitis is a painful condition in which the shoulder loses its range of movements. This condition is referred to as "frozen shoulder" because it becomes very difficult for a person to move his shoulder. The shoulder is not actually frozen, it is just stiff. It may follow an injury to the shoulder, but may also arise gradually without warning or injury. What are the causes? Adhesive capsulitis causes scar tissue to form in the shoulder region. This may occur as a result of injury. Other conditions like tendonitis (inflammation or irritation of a tendon) and bursitis (inflammation or irritation of a bursa). If the shoulder has been immobilized for a long period of time, adhesive capsulitis could develop as a result. The condition could also develop as a result of an autoimmune reaction. The body thinks it is under attack during an autoimmune reaction and will start to attack parts of itself causing an inflammatory reaction in the tissues. However, in most cases, the cause is unknown. Who is at risk? The usual age of onset begins between ages 40 and 65. It affects approximately 10% to 20% of diabetics. Other factors include: - a period of immobility, resulting from trauma, overuse injuries or surgery, hyperthyroidism, cardiovascular disease, clinical depression and Parkinsons disease.

What are the symptoms? Initially, the shoulder may feel stiff and ache and gradually becomes very painful. This stage can last up to eight months. The second stage is referred to as the adhesive stage and this is when the shoulder becomes stiffer. This stage usually lasts 4 to 6 months and is generally less painful than the first stage. The final stage lasts about one to three months. At this time, it usually becomes easier to move the shoulder. Pain may still persist and the full range of motion may still not be got with treatment. It hurts the patient regardless of whether he moves the shoulder or someone else is moving it for

him. The movement will simply stop if there was something preventing the shoulder from moving any further. The pain may increase at night. How is the diagnosis made? A doctor will examine the patient and ask for his medical history to be able to accurately diagnosis his condition. Other conditions have similar symptoms to adhesive capsulitis so the doctor may need to take an X-ray. The most common test used is the MRI scan. An MRI scan is used to create pictures that look like slices of the shoulder. This scan is used to create pictures that look like slices of the shoulder. It can show the tendons as well as the bones, and whether there has been a tear in those tendons. What is the treatment? Successful treatment of adhesive capsulitis include: Anti-inflammatory drugs Cortisone injections to the shoulder Physical therapy

Anti-inflammatory drugs and cortisone injections reduce the inflammation of the shoulder allowing the shoulder to be more easily stretched. Physical therapy is essential because it helps regain the range of motion in the shoulder. Treatment can be a long process. Initial treatment is aimed at reducing inflammation and pain and increasing the range of motion of the shoulder. Exercise is a very important part of the treatment. Exercises will help break up the scar tissue in the shoulder and should be done twice a day. The doctor or physical therapist will show the patient what kind of exercises should be performed. Since the exercises may be painful, using ice packs afterwards may help. With all exercises, the patient should warm up before attempting to do them. If progress is slow, the doctor may recommend a manipulation of the shoulder while the patient is under anaesthesia. This procedure allows the doctor to stretch the shoulder joint capsule, and break up the scar tissue. In most cases, a manipulation of the shoulder will increase the motion in the shoulder joint faster than allowing nature to take its course. It may be necessary to repeat this procedure several times. Arthroscopic surgery may also help break up the scar tissue.

A camera is inserted through a small incision allowing the doctor to access the damage to the joint and at the same time, aid in the healing process.Last updated: 29 January 2006This

disease goes through three distinct phases: Adhesive Capulitis is a condition that affects the lining of the shoulder joint, mostly affecting middle-aged Top people. The cause of this condition is unknown, though there is a fairly common theory that this is triggered from a viral infection. People with diabetes are more prone to this infection, and recovery time is longer in such cases.

The inflammatory phase - wherein the lining of the shoulder becomes heavily inflamed, typically becoming very painful especially during the nighttime. Ultrasound application in this stage is extremely helpful for reducing the inflammaton levels and alleviating pain.

After approximately six months, the inflammation reduces moving the patient into the scarring phase. The lining becomes scarred and when arm movement is attempted, sharp pains are experienced as the newly formed scar tissue is stretched. Ultrasound application in this stage will soften the scar tissue, helping minimize the sharp pains occuring during movement, and speeding the recovery process. This will last about six months as well. The recovery phase. In this phase, scarring is eventually broken down and movement slowly returns, usually taking about 12 months to complete.

Generally, the condition is considered to last over a 2 year span though there are times

when recovery lasts much longer.

The level of pain a person will experience in the inflammatory stage varies widely. Some people experience only small amounts of discomfort, while others experience a debilitating level of pain that alters their daily activities. If ultrasound application is begun quickly, the symptoms of the condition can be reduced, and recovery time shortened. Treatment will vary depending on the stage in which a suffer of adhesive capulitis will see a specialist, though physical therapy and steroid injections are common. As a last resort, surgery is also a good treatment.

Ultrasound therapy is also a helpful tool for recovery of adhesive capulitis, and having a portable ultrasound device at home can be a powerful and convenient treatment tool. If you have symptoms or are recovering from adhesive capulitis, using ultrasound on a regular basis before your activity or throughout the day will help relax your muscles, tendons and tissues, diminish pain and inflammation, soften scar tissue and contribute greatly to the healing of your condition.

If you suffer from mild inflammation or pain after certain activities or movements use ultrasound therapy when you complete the activity and then rest. Limit the application of ultrasound to a couple of treatments per day (the manual will recommend treatment frequency depending upon the injury or condition). In between ultrasound treatments, maximize your pain relief and injury recovery by using the Thermotex Personal Therapy System. When you're on the go, and not near an electrical outlet, take advantage of the "wear anywhere" concept of our hot/cold wraps - the highest rated wraps in the industry. Proven Performance, Proven Relief - only found at MendMeShop.com. If you have been given a treatment plan by your health professional, make sure you adhere to it to ensure pain free living. In general, people who are committed to their therapies and exercises will have the best medical outcomes.

. Frozen Shoulder (Adhesive Capsulitis)As the name implies, movement of the shoulder is severely restricted in people with a "frozen shoulder." This condition, which doctors call adhesive capsulitis, is frequently caused by injury that leads to lack of use due to pain. Rheumatic disease progression and recent shoulder surgery can also cause frozen shoulder. Intermittent periods of use may cause inflammation. Adhesions (abnormal bands of tissue) grow between the joint surfaces, restricting motion. There is also a lack of synovial fluid, which normally lubricates the gap between the arm bone and socket to help the shoulder joint move. It is this restricted space between the capsule and ball of the humerus that distinguishes adhesive capsulitis from a less complicated painful, stiff shoulder. People with diabetes, stroke, lung disease, rheumatoid arthritis, and heart disease, or those who have been in an accident, are at a higher risk for frozen shoulder. Frozen shoulder is more common among women than men. People between the ages of 40 and 70 are most likely to experience it. Signs and symptoms: With a frozen shoulder, the joint becomes so tight and stiff that it is nearly impossible to carry out simple movements, such as raising the arm. Stiffness and discomfort may worsen at night. Diagnosis: A doctor may suspect a frozen shoulder if a physical examination reveals limited shoulder movement. X rays usually appear normal. Treatment: Treatment of this disorder focuses on restoring joint movement and reducing shoulder pain. Usually, treatment begins with nonsteroidal anti-inflammatory drugs and the application of heat, followed by gentle stretching exercises. These stretching exercises, which may be performed in the home with the help of a therapist, are the treatment of choice. In some cases, transcutaneous electrical nerve stimulation (TENS) with a small battery-operated unit may be used to reduce pain by blocking nerve impulses. If these measures are unsuccessful, an intra-articular injection of steroids into the glenoid humeral joint can result in marked improvement of the frozen shoulder in a large percentage of cases. In those rare people who do not improve from nonoperative measures, manipulation of the shoulder under general anesthesia and an arthroscopic procedure to cut the remaining adhesions can be highly effective in most cases.

History of Presenting Complaint: As elsewhere accurate diagnosis depends on careful history, physical examination and appropriate investigations. Prior to assessment, it is necessary to obtain a detailed history of the onset(Acute or traumatic versus slow and insidious) and duration of the current, and any previous symptoms. Relating the stage of the pathology then gives an insight to the total management which is required. Information about the patient occupation, leisure interests and hand dominance is also obtained to form an accurate prognosis of the effect of treatment on lifestyle. The patient chosen for this study was a 52 year old lady with a history of left shoulder pain following a fall onto her left shoulder 1 month previously. The patient is a hair dresser by profession. Following the fall the patient was referred by her General Practitioner for radiological inverstigations. Nothing abnormal was seen on the radiograph. Non Steroidal medication was prescribed over a course of three weeks. Initially these reduced the pain. Approximatley 2 months later the patient reported increasing levels of pain and difficulty sleeping at night due to pain levels. At this point the patient was referred by the general Practitioner to attend for physiotherapy. Overall the patient was quite depressed about her shoulder pain, as it was interfering quite badly with her sleep. She works as a hairdresser and was fearful that she may be unable to continue working. Her hobbies included walking and golf. Subjective Examination: On attending the physiotherapy department a subjective examination was carried out to determine the site and nature of the symptoms, the level of pain experienced, the behaviour of pain over a 24 hour period and irritability of the condition. Information was obtained and recorded on the appropriate assessment form with the inclusion of the body chart,(Fig 1). The patient complained of pain: 1. Difficult to pinpoint, and felt deep in the shoulder and over the deltoid area.(P1) 2. Occasional pain along the posterior aspect of the arm to the elbow. P1 was described as an intermittent nagging pain and was made worse by shoulder flexion and abduction and relieved by rest. She reported experiencing increasing levels of pain while at work by day, which wakes her at night especially if she moves onto her left side. She complains that she can no longer tie her brassiere from behind, though she can perform most functional activities with her right dominant upper extremity. It was established that there were no other relevant symptoms to be considered. No vertebrobasilar symptoms No spinal cord symptoms No abnormal sympathetic symptoms No parasthesia

No diminished or loss of sensation Finally it was established that there were no other relevant current or past medical history that may affect treatment choice. The patients drug history consisted of distalgesic for pain relief. Objective Examination: The objective examination began with the patient standing undressed to the waist in a cubicle with a good light. The method for diagnosis of shoulder lesions as described by Cyriax was used during assessment. On examination of posture it was noted that the patient had a slightly forward head posture. Slight wasting of the bellies of the musculocutaneous cuff musculature was observed. Prior to examining the shoulder joint the Cervical Spine was assessed, as pathology of the cervical spine can have a major influence on shoulder pain. Assessment was carried out using six active movements as recommended by Cyriax. During these movements full range of motion in all directions at the cervical spine, without pain was noted. There was no provocation of the left shoulder pain during any of the cervical spine tests. The affected limb was then taken through a group of ten active, passive and resisted movements to determine which structure was at fault. During the active elevation tests pain, range and willingness to move were being observed. Active elevation was to 90 degrees and caused P1 at the end of range. Passive elevation was limited to 90 degrees with P1 and had a hard end feel. Active elevation through abduction was 80 degrees and caused P1 with a compensatory shoulder girdle elevation. Passive tests were then applied to the joint during which pain, range and end feel was observed. Passive lateral rotation was 45 degrees and caused P1 with a hard end feel. Passive abduction was limited to 80 degrees and caused P1 Passive medial rotation was 70 degrees and did not cause pain. Resisted tests were applied to examine the response in terms of pain and power to:the rotator cuff muscles, the adductors, and the biceps and triceps. The patient exhibited left shoulder weakness, with strength grades of 4/5 for the motions of abduction, external and internal rotation. A negative scarf test cleared involvement of the acromioclavicular joint and the lower fibres of subscapularis. Palpation revealed no focal point of tenderness. Clinical Diagnosis: From the assessment it was evident there was a capsular involvement (most limitation of lateral rotation, followed by abduction, followed by medial rotation).The presentation

correlated with the clinical signs and symptoms of adhesive capsulitis as reported by Cyriax: Pain sometime after initial minor trauma. Initial pain worsening and spreads further down the arm. Generally reduced ROM at the shoulder joint. Capsular Pattern at the shoulder: most limitation of lateral rotation, followed by abduction and medial rotation.

What causes a frozen shoulder?There are several different causes of a frozen shoulder. Some are obvious, whereas the others are difficult to find. A history of a fracture, a previous dislocated shoulder, or other trauma to the shoulder, can often aggravate the process of scar tissue formation. This is often made much worse by a period of prolonged immobilization in which the arm is held in a sling -- a measure that is often necessary as a fracture heals or because pain from the original trauma limits motion. Loss of motion can also commonly occur as the result of a prior shoulder surgery for the treatment of other conditions -such as fractures or a torn rotator cuff. CausesCLICK TO ENLARGE Frozen shoulder

Doctors don't know the precise cause of frozen shoulder. It can occur after an injury to your shoulder or prolonged immobilization of your shoulder, such as after surgery or an arm fracture. People who have diabetes have a greater risk of frozen shoulder. For this reason, frozen shoulder may have an autoimmune component, meaning your immune system may begin to attack the healthy parts of your body in this case, the capsule and connective tissue of your shoulder. People with other health conditions, including heart disease, lung disease and hyperthyroidism, also may have an increased risk of developing frozen shoulder. Your shoulder is a ball-and-socket joint. The round end of your upper arm bone (humerus) fits into a shallow groove on your shoulder blade (scapula), much like a golf ball rests on a tee. Tough connective tissue, called the shoulder capsule, surrounds the joint. When frozen shoulder occurs, the shoulder capsule becomes inflamed and stiff. The inflammation may cause bands of tissue (adhesions) to develop between your joint's surfaces. Synovial fluid, which helps to keep your joint lubricated and moving smoothly, may decrease. As a result, pain and subsequent loss of movement may occur. In some cases, mobility may decrease so much that performing everyday activities such as combing your hair,

brushing your teeth or reaching for your wallet in your back pocket is difficult or even impossible

Frozen shoulder, also known as Adhesive Capsulitis, is a condition that affects the shoulder joint capsule and results in stiffness and loss of movement in the shoulder joint. It is different to rotator cuff injury or shoulder tendonitis in that frozen shoulder affects the joint capsule, where as the other two conditions affect the muscles and tendons of the shoulder joint. Anatomy of the Shoulder Joint The shoulder joint is a truly remarkable creation. It's quite a complex formation of bones, muscles and tendons and provides a great range of motion for your arm. The only downside to this extensive range of motion is a lack of stability, which can make the shoulder joint vulnerable to injury. The shoulder is made up of three bones, and the tendons of four muscles. (Remember, tendons attach muscle to bone.) The bones are called the "Scapula," the "Humerus" and the "Clavicle." Or, in layman's terms, the shoulder blade, the upper arm bone and the collarbone, respectively. The four muscles which make up the shoulder joint are called, "Supraspinatus," "Infraspinatus," "Teres Minor" and "Subscapularis." It is the tendons of these muscles, which connect to the bones that help to move your arm.

Frozen shoulder occurs in the shoulder joint at the point where the humerus bone fits into the socket of the shoulder, (the glenohumeral joint). The supporting ligaments and surrounding capsule become inflamed causing stiffness and limited motion. Causes The exact cause of frozen shoulder is unknown, however in a number of cases, frozen shoulder occurs after another shoulder injury like rotator cuff tear, arthritis or shoulder surgery. Also, poor posture can cause a shortening of the ligaments around the shoulder joint, which can lead to frozen shoulder. Other theories have suggested that hormonal and genetic conditions like diabetes and hyperthyroidism can also contribute to frozen shoulder. Symptoms The most common symptoms of frozen shoulder are pain and stiffness. Pain usually takes the form of a persistent dull ache and stiffness prevents the full range of motion of the shoulder and upper arm. Patients are often unable to lift the arm above their head or rotate their arm inward. The normal progression of frozen shoulder has been described as having three stages. In stage one, (the freezing phase) the patient begins to develop mild pain and stiffness in the shoulder joint. This stage can last from a few weeks to a few months. In stage two, (the frozen phase) the stiffness remains but the pain begins to decline. This stage can last from a few months to nearly a year. In stage three, (the thawing phase) the full range of movement begins to return to the shoulder joint. This stage can also last a few months.

Most sufferers of frozen shoulder will be fully recovered within 4 to 6 months but some cases have lasted for up to three year, although these are extremely rare. Treatment Frozen shoulder treatment primarily consists of pain relief and physical therapy techniques. Pain relief usually takes the form of anti-inflammatory medication and the aim here is to reduce the pain enough so that physical therapy can be initiated. Two other forms of therapy should also be considered; heat and massage. Heat is extremely good for increasing blood flow to a particular area. Heat lamps and hot water bottles are the most effective way to increase blood flow; while heat based creams are distant second choices. Massage is one of the best ways to increase blood flow to an injured area, and of course the oxygen and nutrients that go with it. The other benefit of massage is that it helps to reduce the amount of scar tissue which is associated with all muscle, tendon and joint injuries.

During this period of pain relief treatments physical therapy should also be initiated. This is an extremely important part of the treatment process and full recovery will not occur without a dedicated approach to physical therapy treatments. Firstly, don't stop moving. Some doctors will often tell patients to keep the injured area still, and this is not always the best advice. Gentle movement will help to keep the blood flowing to the injured area. Of course, if pain is present, limit the amount of moving you do, but don't stop moving all together. Next, specific stretching and strengthening exercises should be started to help loosen up the shoulder joint and speed up the recovery process. A full description of appropriate stretching and strengthening exercises are included in the next section.

Prevention Mark my words, "Prevention is much better than Cure." Anything you can do to prevent an injury from occurring is worth it. The prevention of frozen shoulder and other shoulder injuries comes down the conditioning of the shoulder muscles, tendons and ligaments, which ultimately involves both stretching and strengthening of the shoulder joint.

Also, don't forget the common injury prevention techniques like, warming up properly and using a bit of old-fashioned common-sense. However, for the most part, stretching and strengthening are going to be your best defense against frozen shoulder. Even if you don't have a shoulder problem now, the following stretching and strengthening exercises could save you from a major headache in the future. Firstly, below you'll find two good stretches for the shoulder area. Although both are quite basic stretches, please be careful. If you haven't been stretching your shoulder joint, or your shoulders are normally very stiff, these stretches will put quite a lot of stress on the muscles and tendons. Be sure to warm-up first, then gently and slowly is the best way to proceed.

In the stretch to the left, simply stand upright and clasp you hands behind your back. Keep your arms straight and slowly lift your hands upwards. Hold this stretch for about 15 to 20 seconds and then repeat it 3 to 4 times.

In the stretch to the right, place one arm across your body, keeping it parallel to the ground. Then slowly pull your elbow towards your body. As above hold this stretch for about 15 to 20 seconds and then repeat it 3 to 4 times.

Stretching is one of the most under-utilized techniques for improving athletic performance, preventing sports injury and properly rehabilitating sprain and strain injury. Don't make the mistake of thinking that something as simple as stretching won't be effective.

Teach Patients to Treat With RICEIf a patient discloses a shoulder injury, offer

the following advice:

RestReduce activity or stop using the injured area for 48 hours. IcePut an ice pack on the injured area for 20 minutes, four to eight times/day. CompressionCompress the area with an elastic wrap or other bandage to stabilize the shoulder and help reduce swelling. ElevationKeep the injured area elevated above heart level.

HOW TO TREAT ADHESIVE CAPSULITISTreatment focuses on restoring joint movement and reducing shoulder pain. Usually, treatment begins with nonsteroidal anti-inflammatory drugs and the application of heat, followed by gentle stretching exercises. Stretching exercises can be performed in the home with the help of a physical therapist and are the treatment of choice. In some cases, transcutaneous electrical nerve stimulation (TENS) with a small battery-operated unit may be used to reduce pain by blocking nerve impulses. If these measures are unsuccessful, an intra-articular steroid injection into the glenoid humeral joint can result in marked improvement of adhesive capsulitis in a large percentage of cases. In rare cases where patients do not improve from nonoperative measures, manipulation of the shoulder under general anesthesia and arthroscopic procedure to cut remaining adhesions is usually highly effective.

WHAT IS PHYSICAL THERAPY? Physical Therapy is about helping people. Physical Therapy is also about helping people help themselves! Physical Therapy aims to restore movement and function, relieve pain, and prevent further injury. Physical Therapy is the evaluation and treatment of numerous physical conditions of all age groups. Physical Therapy treats people with musculoskeletal disorders such as back and neck strains or knee injuries; neurological deficits such as stroke patients or cerebral palsy children, and skin disorders such as wounds, burns or diabetic foot ulcers. Physical Therapy is provided in the hospital, for outpatients, in schools, in the home, and in nursing homes. Physical Therapy is about teaching people about their body, their disorder, and their health. Physical Therapy helps people lead more active and independent lives.Return To Top Of Page

WHAT DOES A PHYSICAL THERAPIST DO? A Physical Therapist will perform an evaluation of your problem or difficulty. This includes taking a history of a problem and then evaluating your problem by performing tests and measures to assess the problem. These tests include muscle strength tests, joint motion tests, sensory and neurological tests, coordination tests, balance tests, observation, palpation, flexibility tests, postural screening, movement analysis, and special tests designed for a particular problem. Also includes past medical history. A Physical Therapist will then develop a treatment plan and goals and then administer the appropriate treatment to aid in recovery of a problem or dysfunction. Physical Therapy treatments include patient education to teach you how deal with a current problem and how to prevent this problem from recurring in the future. Physical Therapy provides "hands on techniques" like massage or joint mobilization skills to restore joint motion or increase soft tissue flexibility. Physical Therapy aids in postural reeducation and movement awareness. Therapeutic exercise instructions will help restore strength, movement, balance, or coordination as a guide towards full functional recovery. Physical Therapy participates in functional training for work-related issues, and

home activities, and recreational or sports interests. Physical Therapy teaches basic mobility skills such as learning to move and get out of bed, transferring to a chair, walking with crutches or special devices on stairs or varied terrain. Physical Therapy can assist one in meeting special equipment needs such as wheelchairs or other adaptive equipment to improve function and independence. Physical Therapy often involves the use of modalities which include properties of heat, cold, air, light, water, electricity, ultrasound, and traction. These modalities are used to help decrease pain and increase movement and function. Examples of Physical Therapy modalities are: Hotpacks, Coldpacks, Whirlpools, TENS (Transcutaneous Electrical Nerve Stimulation), Ultrasound, Traction, Electrical Stimulation, Intermittent Compression Pumps, and Myofascial Release. This list is not all inclusive but should give you an idea of some of the modalities that are available. A Physical Therapist will monitor your progress and adjust treatments and treatment goals as appropriate. A Physical Therapist will consult with other health professionals to facilitate your recovery.Return To Top Of Page

WHEN SHOULD YOU SEE A PHYSICAL THERAPIST? You should see a physical therapist when: you have suffered an injury--to decrease pain and restore movement and function. Ask your Doctor for a referral to physical therapy. After surgery--to restore strength, range of motion, balance and function. If your illness or injury interferes with your daily normal tasks and your ability to function or if your child has had birth defects before accidents or injuries occur to prevent difficulties in the future.Return To Top Of Page

PHYSICAL THERAPY ASSISTIVE DEVICES A variety of implements or equipment used to aid patients in performing tasks or movements. Assistive devices include crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, and static and dynamic splints. Therapists will fit and instruct the patient in the use and care of the assistive device with the goal being optimal independence and safety .Return To Top Of Page

HOME EXERCISE PROGRAMS (HEP) Positive physical therapy results are largely dependent on a person's adherence to a specific exercise regime that is established by a Physical Therapist.

Individual home programs are written, taught, and monitored closely by the therapist through the duration of one's therapy with progressive modifications that are based on the individual's needs, progress and established goals.Return To Top Of Page

BALANCE / COORDINATION TRAINING Balance is the ability to maintain the body in equilibrium with gravity both statically (e.g. while stationary) and dynamically (e.g. while walking). Persons with balance / coordination deficits due to trauma, disease, stroke or other impairment are assisted through physical therapy in improving their balance by following individual treatment plans established by a physical therapist after a thorough evaluation. Treatment plans may include balance activities, sensory training, ambulation training possibly with an assistive device, therapeutic exercise and modalities as appropriate.Return To Top Of Page

SPINE CLINIC You don't have to live with the pain! Providing specialized treatment to control back and neck pain related to acute and chronic spine conditions. Involves intensive rehabilitation of the spine in order to return the patient to a maximum level of function. Rehabilitation will consist of individualized exercises, training in proper posture, body mechanics, lifting techniques, and pain management.Return To Top Of Page

PROSTHETIC AND ORTHOTIC TRAINING A prosthesis is an artificial device, often mechanical used to replace a missing part of the body. Prosthetic training involves working with an amputee on overall conditioning as well as specific stretching and strengthening of the involved limb and training in the use and wearing of the prosthesis. Therapy also emphasizes care of the amputation site, and performance of tasks of daily living with the prosthesis. An orthosis is a device that supports weak or ineffective joints or muscles, such as a splint, brace, shoe insert, or cast. Orthotic training concentrates on the increase of motion, function, and use of a limb that requires an orthosis for support. Therapy also emphasizes balance and coordination of activities.Return To Top Of Page

WHIRLPOOL Whirlpool is a water bath in which water is agitated by an electric turbine. Whirlpools come in various shapes and sizes, but all work on the same principles. Warm whirlpools are a source of moist heat and are used to increase local metabolism, promote muscle relaxation, sedate sensory nerve endings, and to increase cell permeability to aid with healing. The agitation in a whirlpool can increase lymphatic circulation, assist in the removal of debris and keeps the water at a constant temperature throughout the tank. Whirlpools are used to treat open wounds, burns, subacute and chronic traumatic or inflammatory conditions, and peripheral vascular disease or peripheral nerve injuries.

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THERAPEUTIC EXERCISE A broad range of activities intended to improve strength, range of motion (including muscle length), cardiovascular fitness, flexibility, or to otherwise increase a person's functional capacity. An individualized program is established, taught and monitored by a physical therapist/assistant that is based on an initial evaluation and aimed at achieving specific goals.Return To Top Of Page

REHABILITATION THERAPY PROGRAMS FOR POST SURGICAL / ACCIDENT / FRACTURE PATIENTS Therapy programs may follow specific protocols or individualized treatment plans with the aim of therapy being the return of strength, function and mobility. The programs may involve a variety of treatment options with goals set for the patient to resume normal activities of living as much as possible are established by a physical therapist after a thorough evaluation. In-hospital and skilled units may involve the inclusion of other therapeutic disciplines (i.e. speech therapy, occupational therapy, art therapy, etc.), depending on the patient's needs.Return To Top Of Page

TRACTION The therapeutic use of manual or mechanical tension created by a pulling force to produce a combination of distraction and gliding to relieve pain and increase tissue flexibility. Indications for traction therapy include, but are not limited to, decreased sensation that temporarily improves with manual traction, increased muscle tone that is reduced with manual traction, extremity pain or tingling that is temporarily relieved with manual traction, spinal nerve root impediment due to bulging, herniated or protruding disc, and muscle spasms that are causing nerve root impingement and general hypomobility of lumbar or cervical spine regions. Electric traction units exert a pulling force through a rope with various halters and straps.Return To Top Of Page

PARAFFIN BATH A superficial thermal modality using paraffin wax and mineral oil. Paraffin is a means of delivering heat, especially to areas that are difficult to heat with anything but a liquid medium, i.e. hands and feet. The effects of paraffin are: increase of local metabolism, increased local perspiration, promotion of muscle relaxation, sedation of sensory nerve endings reducing pain and softening of the skin. Paraffin bath can be used for subacute, chronic traumatic, and inflammatory conditions. All jewelry is removed prior to treatment. The area to be treated is washed and examined for temperature sensation and skin integrity then the patient dips the extremity into the paraffin. During the treatment, layers of paraffin build up on the area being treated and the paraffin is allowed to harden. At the conclusion of the treatment, the paraffin is pealed off and the therapist may do massage or have the patient do stretching exercises to the area that was treated.

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MODALITIES Modality is a term used to identify a broad group of agents that may include thermal acoustic, radiant, mechanical, or electric energy to produce physiological changes in tissues for therapeutic purposes.Return To Top Of Page

ULTRASOUND Ultrasound is a name given to sound waves that are of such high frequency that they are not detectable by the human ear. The sound waves when applied to human tissue are absorbed by the various tissues with the production of heat. Ultrasound does penetrate heat into human tissues deeper that any other heat modality, 4-6 cm. The benefits of heat from ultrasound include promotion of muscle relaxation, increased local metabolism, and reduction of pain by sedating nerve endings. Ultrasound waves also have non-thermal benefits resulting from vibration of molecules. These effects include increases in the flexibility of connective tissues such as joint capsules, ligaments, tendons, adhesions, scars and cellular membrane permeability that accelerates healing. Therapeutic ultrasound is a safe and effective tool for treating a variety of conditions that a physical therapist commonly encounters. Pulsed and continuous modes allow for ultrasound to be used for both acute and chronic cases, and ultrasound is most effective as part of an overall treatment plan, including stretching, therapeutic exercise, and mobilization.Return To Top Of Page

INTERMITTENT COMPRESSION PUMPS Intermittent compression pumps are pneumatic pumps designed to apply external pressure to a swollen body part. The amount of pressure and the time for which it is applied are adjustable according to condition and persons blood pressure. Some appliances have multiple compartments with separate tubes and controls. These chambers can be filled sequentially and in some cases to different pressures. External pressure, when applied to a swollen extremity, will help to reduce edema by moving the fluid in the extremity to sites of normal lymphatic or venous drainage. Intermittent compression pumps are used to treat post-mastectomy lymphedema, venous insufficiency, amputations and traumatic edema.Return To Top Of Page

ELECTRICAL STIMULATION Intervention through the application of electricity. Electrical stimulation of individual muscles is a means of providing exercise to muscles that the patient is unable to contract voluntarily. If the muscle has lost its physical connection with its nerve supply (is denervated), electrical stimulation can maintain nutrition of the muscle through promoting blood flow, decrease fibrotic changes and retard denervation atrophy. Electric stimulation used on muscles that have a nerve supply (are innervated) can strengthen healthy muscle, prevent or reverse disuse atrophy, maintain or improve mobility, promote peripheral circulation and

prevent fibrotic changes. There are various types of electrical stimulation in use today and the type used and its specific application depends on the goals of treatment.Return To Top Of Page

TENS UNITS Transcutaneous Electrical Nerve Stimulation is a generic name for a method of nerve stimulation designed to control pain. There are now a variety of TENS units designed for specific modes of application. The different modes are identified by their parameter ranges of amplitude, frequency and pulse width. The units are small, battery powered, and light weight weighing only a few ounces. Electrodes are placed on the skin near the area of pain and are attached to the TENS unit. A physical therapist/assistant instructs the patient on the positioning of the electrodes and the duration and frequency of the treatment and also sets the parameters for the amplitude, frequency and pulse width based on the patient's individual needs. The TENS unit is used at home by the patient for use as instructed as part of a comprehensive treatment program designed for the appropriate management of pain.Return To Top Of Page

MYOFASCIAL RELEASE Fascia is the interwoven connective tissue that surrounds our muscles and internal organs. Fascia shrinks when it is inflamed, is slow to heal because of poor blood supply, and painful when inflamed because of its rich nerve supply. Myofascial restrictions occur when the fascia is disrupted or stretched by any injury, no matter how minor. Myofascial release is a therapeutic stretching technique that relies entirely upon the feedback received by the therapist from the patient nonverbally through the patient's tissues. Myofascial release removes restrictions that impede efficient movement and use of energy for daily tasks. Myofascial release is often incorporated in a patient's therapeutic treatment plan along with other exercises and/or modalities.Return To Top Of Page

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AnatomyThe shoulder is a highly mobile joint, consisting of 3 bones, surrounded by ligaments, tendons, capsule and muscle. These soft tissues give the shoulder joint its stability, along with its mobility. The various muscles attach to the humerus or arm bone. (See diagram) In close proximity to the shoulder joint is the acromioclavicular joint, or A/C joint by which it is commonly known. This AC joint works in close relationship with the shoulder joint in order for the shoulder joint to do all of its actions.

Frozen Shoulder (Adhesive Capsulitis)

What Is a Frozen Shoulder? As the name implies, movement of the shoulder is severely restricted in people with a "frozen shoulder." This condition, which doctors call adhesive capsulitis, is frequently caused by injury that leads to lack of use due to pain. Rheumatic disease progression and recent shoulder surgery can also cause frozen shoulder. Intermittent periods of use may cause inflammation. Adhesions (abnormal bands of tissue) grow between the joint surfaces, restricting motion. There is also a lack of synovial fluid, which normally lubricates the gap between the arm bone and socket to help the shoulder joint move. It is this restricted space between the capsule and ball of the humerus that distinguishes adhesive capsulitis from a less complicated painful, stiff shoulder. People with diabetes, stroke, lung disease, rheumatoid arthritis, and heart disease, or who have been in an accident, are at a higher risk for frozen shoulder. The condition rarely appears in people under 40 years old. What Are the Signs of a Frozen Shoulder and How Is It Diagnosed? With a frozen shoulder, the joint becomes so tight and stiff that it is nearly impossible to carry out simple movements, such as raising the arm. People complain that the stiffness and discomfort worsen at night. A doctor may suspect the patient has a frozen shoulder if a physical examination reveals limited shoulder movement. An arthrogram may confirm the diagnosis. How Is a Frozen Shoulder Treated? Treatment of this disorder focuses on restoring joint movement and reducing shoulder pain. Usually, treatment begins with nonsteroidal anti-inflammatory drugs and the application of heat, followed by gentle stretching exercises. These stretching exercises, which may be performed in the home with the help of a therapist, are the treatment of choice. In some cases, transcutaneous electrical nerve stimulation (TENS) with a small battery-operated unit may be used to reduce pain by blocking nerve impulses. If these measures are unsuccessful, the doctor may recommend manipulation of the shoulder under general anaesthesia. Surgery to cut the adhesions is only necessary in some cases.Ultrasound is a therapeutic modality that has been used by physical therapists since the 1940s. Ultrasound is applied using a round-headed wand or probe that is put in direct contact with the patient's skin. Ultrasound gel is used on all surfaces of the head in order to reduce friction and assist in the transmission of the ultrasonic waves. Therapeutic ultrasound is in the frequency range of about 0.8-1.0 MHz. The waves are generated by a piezoelectric effect caused by the vibration of crystals within the head of the wand/probe. The sound waves that pass through the skin cause a vibration of the local tissues. This vibration or cavitation can cause a deep heating locally though usually no sensation of heat will be felt by the patient. In situations where a heating effect is not desirable, such as a fresh injury with acute inflammation, the ultrasound can be pulsed rather than continuously transmitted. Ultrasound can produce many effects other than just the potential heating effect. It has been shown to cause increases in tissue relaxation, local blood flow, and scar tissue breakdown. The effect of the increase in local blood flow can be used to help reduce local swelling and chronic inflammation, and, according to some studies, promote bone fracture healing. The intensity or power density of the ultrasound can be adjusted depending on the

desired effect. A greater power density (measured in watt/cm2 is often used in cases where scar tissue breakdown is the goal. Ultrasound can also be used to achieve phonophoresis. This is a non-invasive way of administering medications to tissues below the skin; perfect for patients who are uncomfortable with injections. With this technique, the ultrasonic energy forces the medication through the skin. Cortisone, used to reduce inflammation, is one of the more commonly used substances delivered in this way. A typical ultrasound treatment will take from 3-5 minutes. In cases where scar tissue breakdown is the goal, this treatment time can be much longer. During the treatment the head of the ultrasound probe is kept in constant motion. If kept in constant motion, the patient should feel no discomfort at all. If the probe is held in one place for more than just a few seconds, a build up of the sound energy can result which can become uncomfortable. Interestingly, if there is even a very minor break in a bone in the area that is close to the surface, a sharp pain may be felt. This occurs as the sound waves get trapped between the two parts of the break and build up until becoming painful. In this way ultrasound can often be used as a fairly accurate tool for diagnosing minor fractures that may not be obvious on x-ray. Some conditions treated with ultrasound include tendonitis (or tendinitis if you prefer), nonacute joint swelling, muscle spasm, and even Peyronie's Disease (to break down the scar tissue). Contraindications of ultrasound include local malignancy, metal implants below the area being treated, local acute infection, vascular abnormalities, and directly on the abdomen of pregnant women. It is also contraindicated to apply ultrasound directly over active epiphyseal regions (growth plates) in children, over the spinal cord in the area of a laminectomy, or over the eyes, skull, or testes.

What Are the Structures of the Shoulder and How Does the Shoulder Function The shoulder joint is composed of three bones: the clavicle (collarbone), the scapula (shoulder blade), and the humerus (upper arm bone) (see diagram). Two joints facilitate shoulder movement. The acromioclavicular (AC) joint is located between the acromion (part of the scapula that forms the highest point of the shoulder) and the clavicle. The glenohumeral joint, commonly called the shoulder joint, is a balland-socket type joint that helps move the shoulder forward and backward and allows the arm to rotate in a circular fashion or hinge out and up away from the body. (The "ball" is the top, rounded portion of the upper arm bone or humerus; the "socket," or glenoid, is a dish-shaped part of the outer edge of the scapula into which the ball fits.) The capsule is a soft tissue envelope that encircles the glenohumeral joint. It is lined by a thin, smooth synovial membrane. The bones of the shoulder are held in place by muscles, tendons, and ligaments. Tendons are tough cords of tissue that attach the shoulder muscles to bone and assist the muscles in moving the shoulder. Ligaments attach shoulder bones to each other, providing stability. For example, the front of the joint capsule is anchored by three glenohumeral ligaments. The rotator cuff is a structure composed of tendons that, with associated muscles, holds the ball at the top of the humerus in the glenoid socket and provides mobility

and strength to the shoulder joint. Two filmy sac-like structures called bursae permit smooth gliding between bone, muscle, and tendon. They cushion and protect the rotator cuff from the bony arch of the acromion. Causes The shoulder is the most movable joint in the body. However, it is an unstable joint because of the range of motion allowed. It is easily subject to injury because the ball of the upper arm is larger than the shoulder socket that holds it. To remain stable, the shoulder must be anchored by its muscles, tendons, and ligaments. Some shoulder problems arise from the disruption of these soft tissues as a result of injury or from overuse or underuse of the shoulder. Other problems arise from a degenerative process in which tissues break down and no longer function well. Shoulder pain may be localized or may be referred to areas around the shoulder or down the arm. Disease within the body (such as gallbladder, liver, or heart disease, or disease of the cervical spine of the neck) also may generate pain that travels along nerves to the shoulder. Diagnosis Following are some of the ways doctors diagnose shoulder problems: ? Medical history (the patient tells the doctor about an injury or other condition that might be causing the pain). ? Physical examination to feel for injury and discover the limits of movement, location of pain, and extent of joint instability. ? Tests to confirm the diagnosis of certain conditions. Some of these tests include: ? x ray ? arthrogram--Diagnostic record that can be seen on an x ray after injection of a contrast fluid into the shoulder joint to outline structures such as the rotator cuff. In disease or injury, this contrast fluid may either leak into an area where it does not belong, indicating a tear or opening, or be blocked from entering an area where there normally is an opening. ? MRI (magnetic resonance imaging)--A non-invasive procedure in which a machine

produces a series of cross-sectional images of the shoulder. ? Other diagnostic tests, such as injection of an anesthetic into and around the shoulder joint, are discussed in specific sections of this booklet.

THE SHOULDER GIRDLERequired Reading : pages 310 -329I. INTRODUCTIONA. The shoulder or pectoral girdle consists of articulations between the clavicle, scapula and the proximal end of the humerus. The sternoclavicular articulation is the only bony link between the upper limb and the axial skeleton. Movements at this joint are largely passive in that the occur as a result of active movements of the scapula. Through the acromioclavicular articulation, the clavicle can act as a strut maintaining the upper limb away from the thorax permitting a greater range of upper limb motion. This joint also helps provide static stability to the upper limb reducing the need to use muscle energy to keep the upper limb in its proper alignment. The glenohumeral articulation (shoulder joint) has the greatest range of motion of any joint in the body. The mobility of the shoulder joint is necessary for placement of the hand to maximize manipulation. The scapula is suspended on the thoracic wall by muscle forming a "functional joint" called the scapulothoracic joint. These muscles act to stabilize and/ or to actively move the scapula. Active movements of the scapula help increase the range of motion of the shoulder joint.

B.

The student will be asked to demonstrate their understanding of shoulder girdle anatomy by applying this information in the diagnosis of problems of these often injured joints

II. COMPONENTS OF THE SHOULDER GIRDLE (310 -317)A. Bones 1. Clavicle 2. Scapula 3. Proximal end of humerus B. Articulations 1. Acromioclavicular Joint a. Planar type joint between lateral portion of the clavicle and the acromion of the scapula. Sternoclavicular Joint a. Sellar joint between the medial end of the clavicle and the manubrium of the sternum. 3. Glenohumeral ( Shoulder ) Joint a. Ball and socket articulation between head of humerus and glenoid cavity. b. Favors mobility over stability Scapulothoracic "Joint" a. Scapula suspended on rib cage by muscles i. highly mobile b. capula movements increases range of motion at the shoulder joint

III. MUSCLES ACTING ON THE SHOULDER GIRDLE (pgs. 322-326)A. Extrinsic - Suspend scapula from the trunk .Stabilize and/or actively moves scapula 1. Trapezius 2. Levator Scapulae 3. Rhomboid Major and Minor 4. Serratus Anterior 5. Pectoralis minor B. Intrinsic - Attach scapula to humerus 1. Deltoid 2. Teres Major 3. Rotator Cuff (active stabilization of shoulder joint) a. Supraspinatus b. Infraspinatus c. Teres Minor

d. Subscapularis B. Attach trunk to humerus Latissimus dorsi Pectoralis Major C. Attachments and Functions (See Chart 1)

IV. STABILITY OF THE SHOULDER GIRDLE (pgs 318 -321)A. Acromioclavicular Joint 1. Ligaments a. Acromioclavicular b. Coracoclavicular c. Conoid d. Trapezoid 2. Functions a. Bind clavicle to scapula supporting weight of upper limb minimizing use of muscle energy 3. Shoulder Separation a. Tearing of acromioclavicular and /or coracoclavicular ligaments b. Clavicle overrides acromion c. Weight of upper limb pulls scapula and acromion inferiorly below clavicle B. Sternoclavicular Joint Ligaments a. Sternoclavicular b. ianterior and posterior c. Interclavicular d. Costoclavicular Fibrocartilage Disc a. Strengthens articulation B. Glenohumeral Joint Capsule a. Attaches from glenoid cavity to anatomical neck of humerus b. Least amount of support inferiorly Ligaments a. Coracoacromial i. Helps resist upward displacement of the head of the humerus

b. Coracohumeral

i.

Strengthens superior portion of capsule b. Transverse Humeral Ligament

ii. Some support during shoulder abduction i. holds long head of biceps in the groove b. Glenohumeral Ligaments - 3 parts all attach from upper margin of glenoid cavity and strengthen anterior portion of capsule i. Superior - over the humeral head to a depression above the lesser tuberosity

ii. Middle - in front of humerus to lower lesser tuberosity iii. Inferior - to lower part of the anatomical neck Rotator Cuff Muscles a. Active stabilizers of shoulder joint i. act throughout entire range of motion at shoulder b. Depress head of humerus in glenoid cavity when humerus moves i. Prevents compression of structures between humeral head and acromion b. Muscles also help rotate shoulder (See Chart: "Movements of Glenohumeral Joint" ) B. D.Scapulothoracic Articulation 1. Stability a. Dependent upon activity of extrinsic muscles b. Winged scapula 2. Alignment a. Upwardly rotated and elevated position of scapula at rest i. A. action of trapezius muscle

V. MOVEMENTS OF THE STERNOCLAVICULAR JOINTPassive movements. 1. Acromial end moves as consequence of movements of the scapula 2. Sternal end of clavicle moves in a direction opposite from that of the scapula. B. Types of Movements 1. Protraction - scapula is retracted causing the sternal end to move forward 2. Retraction - scapula is protracted causing the sternal end to move backward 3. Elevation - scapula is depressed causing the sternal end to move upward

4. Depression - scapula is elevated causing the sternal end to move downward C. Muscles Acting on Sternoclavicular Joint 1. The muscles acting on the Sternoclavicular joint are outlined in Chart 1. These are the same muscles that act on the scapula. 2. Movements of the Sternoclavicular joint and the muscles producing these movements are outlined in Chart 2. Remember the SC joint moves in a direction opposite from the way in which the scapula moves.

VI. MOVEMENTS OF THE SCAPULA ( pg 316)A. Types 1. Elevation - moving the superior border of the scapula and the acromion in an upward direction. 2. Depression - moving the superior border of the scapula and the acromion in an downward direction. 3. Upward Rotation - Moving the scapula so that the glenoid cavity faces upward. a. Increased the ranges of motion during abduction and/or flexion of the shoulder. Downward Rotation - moving the scapula so that the glenoid cavity faces inferiorly. a. Increases range of motion during extension and / or adduction of the shoulder. Protraction ( Abduction) - moving the scapula away from the midline Retraction (Adduction) - moving the scapula toward the midline B. Muscles Acting to Move Scapula Very mobile a. Muscles suspend scapula from vertebral column and chest wall b. Axis around which scapulae move changes c. Muscles attach to scapula obliquely i. Movements a. See chart Movements of the Scapula Muscle Synergy at the Shoulder Joint a. Retraction of the Scapula i. Trapezius -- retract and rotates upward b. Upward rotation of the Scapula i. Serratus anterior -- protracts and rotates upward ii. Trapezius -- Retract and rotates upward ii. Rhomboids -- retract and rotate downward Produce many motions

VII. MOVEMENTS OF THE GLENOHUMERAL JOINT ( pgs 322-323)A. Properties 1. Movements of the shoulder joint (glenohumeral joint) usually involve moving the humerus on the scapula. 2. All movements are to be studied starting from the ANATOMICAL POSITION 3. Axis of motion a. Flexion - Extension i. i. i. Coronal axis through head of humerus b. Abduction /Adduction Sagittal axis through humeral head b. Rotation Longitudinal axis through shaft of humerus B. Types of Movements Flexion moving the humerus forward and upward in the sagittal plane. Extension - bringing the arm down to the side in the sagittal plane. a. a. Hyperextension - moving the arm in the sagittal plane behind the body. Stages i. initiate -supraspinatus ii. 900 - deltoid iii. 1800 - deltoid with upward rotation of scapula Adduction - moving the arm in the coronal plane towards the midline. Inward Rotation - rotating the arm in a transverse plane so that the anterior surface of the bone turns inward. Outward Rotation - rotating the arm in a transverse plane so that the anterior surface of the bone turns outward. B. Scapulohumeral Rhythm Coordinated movements of the scapula and the humerus increasing the range of motion at the glenohumeral joint a. b. Most noticeable during complete flexion and abduction of the shoulder 2 - 30 of humeral abduction is associated with 1 - 20 of scapula rotation B. Movements of the Shoulder Joint Chart 3 - MOVEMENTS of the SHOULDER JOINT indicates which muscles interact to produce a given movements of the shoulder Abduction - moving the arm in the coronal plane away from the midline

VIII. CLINICAL ANATOMY OF THE SHOULDER JOINT ( pgs. 317,319,321)A. Dislocation 1. Weakness of rotator cuff tendons and / or trauma

2. Head of humerus subluxes (separated ) from glenoid cavity of humerus 3. Usually occurs when humerus is in position of abduction or flexion a. a. b. Least amount of contact between apposing bony surfaces Weakest region of capsule Humerus pulled either anterior to or posterior to shoulder joint depending upon which rotator cuff muscles are injured. Occurs in an inferior direction

Arm hangs limp at side with a prominent "step deformity" (space) between acromion and humeral head B. Impingement Syndrome Weakness or fatigue of rotator cuff muscles Activity of shoulder joint accompanied by intense pain a. b. Movements of abduction and flexion usually more painful Painful arc i. Very painful abducting from neutral position to horizontal. Then pain subsides

Compression of supraspinatus tendon between head of humerus and acromion. B. Nerve Lesions (pg 329) Lesions to components of the brachial plexus, especially those components associated with the C 5 and/or C 6 nerve roots, will have and major effect on the ability of the shoulder girdle to carry out normal functions. Often, the signs and symptoms concerning loss or reduction in function can be used to localize the site of the nerve lesion. The effects of various types of nerve lesions can have on the shoulder girdle is summarized below:

Accessory nerve - innervates the trapezius muscle. Paralysis of this muscle will result in a marked drooping and down turning of the affected shoulder at rest because of the loss of the ability of the trapezius to elevate and upwardly rotate the scapula. The latter loss will also prevent the patient from abducting their arm above the horizontal ( shoulder level). Dorsal Scapular nerve - innervates the rhomboideus muscles. Any attempt to retract the scapula will be accompanied by a marked upward rotation of the shoulder because the rhomboideus can no oppose the upward rotation on the scapula exerted by the trapezius. The patient will have difficulty retracting the scapula against resistance on the affected side. Long thoracic nerve - Innervates the serratus anterior muscle. Active contraction of this muscle results in scapula protraction and upward rotation. When the scapula is passively protracted by action of the pectoralis major muscle on the humerus , the serratus anterior acts to stabilize the scapula and keep it applied to the thoracic wall. Such action occur when a boxer throws a jab or a cross. Paralysis of the serratus anterior prevents the scapula from moving smoothly across the thoracic wall resulting in a bowing out of the medial border of the scapula. This condition is called "winged" scapula. In addition, the ability to actively upwardly rotate the

shoulder is diminished and the patient can not abduct the humerus above the horizontal. Suprascapular nerve - innervates the supraspinatus and infraspinatus muscles. Paralysis of this nerve will result is weakness of the rotator cuff muscles resulting in pain form impingement and an inability of the patient to begin shoulder abduction. Such patients tend to swing the affected limb away from their side in order to provide momentum to start abduction. Axillary nerve - innervates the deltoid and teres minor muscles. Since the deltoid plays a major role in movement of the glenohumeral joint, paralysis will cause a loss &/or weakness of most shoulder functions. Symptoms of deltoid paralysis include: a. b. c. d. e. loss or roundness to the shoulder and a very visible acromion process inability to abduct the glenohumeral joint more than a few degrees away from the side. inability to laterally rotate the humerus weakened movements of glenohumeral flexion and extension loss of sensation just below the point of the shoulder

C5, C6 root damage ( Erb's palsy) - axons from the C5 and C6 ventral rami innervate the following muscles acting on the shoulder girdle: deltoid, supraspinatus, infraspinatus , teres minor, subscapularis. Lesion to these roots will result in paralysis of these muscles. The symptoms of such a lesion are outlines in the chart below.

C5, C6 Nerve Root Lesion (Erb's Palsy)MOTOR DEFICITS SENSORY DEFICIT NERVES

Loss of Posterior and abduction, lateral aspect of flexion and arm - axillary n. rotation at shoulder ; Weak shoulder extension deltoid, rotator cuff Very weak elbow flexion and supination of radioulnar Radial side of Forearmmusculocutaneo us n. Thumb and 1st finger superficial br. of

Axillary, Suprascapular, Upper and Lower subscapular

Musculocutaneo us ; Radial N. brs. to supinator & brachioradialis muscles

jointbiceps brachii & brachialis Susceptible to shoulder dislocation - loss of rotator cuff muscles "Waiters Tip"position

radial; digital brs. - Median n.

Suprascapular, Upper and Lower subscapular

Chart 1 - Muscles Acting On The Shoulder Girdle MUSCLE PROXIMAL DISTAL NERVE FUNCTION S

Extrinsic: Attach scapula to neck and trunk Trapezius 1. Ext Occipital Protuberanc e 1. Lat. 1/3 Spinal Retracts of clavicle portion of XI and (upper) upwardly rotates 2. scapula Acromion

2. Lig . nuchae 3. Lower cervical & thoracic spinesLevator Scapulae Transverse processes of C 1 to or 4

(middle) 3. Spine of scapula (lower)Upper medial border of the scapula Medial border of Cervical Plexus Elevation and downward rotation of the scapula 1. Retraction,

C3&C4

Rhomboid Major &

1. Ligamentu

Dorsal Scapular

Minor

m nuchae,

2. spinous processes of C7 to T 5

the (Nerve to scapula; Rhomboids) from the C 4; (C5) root of the spine to the inferior angle Anterior Long surface of Thoracic the medial ( C 5,6,7) border of the scapula

downward rotation, some elevation of the scapula,

2. Fixes the scapula against the trunk1.Protractio n and upward rotation of scapula

Serratus Anterior

Outer surface of ribs

1-8

2. Fixes scapula against the thoracic wallProtract, downward rotation o f scapula

Pectoralis Minor

Ribs 3, 4, & Coracoid Medial 5 process of Pectoral scapula Nerve (C8,T1)

Intrinsic: Rotator Cuff ( Active stabilization of shoulder joint by preventing downward displacement of the humerus) Supraspinat Supraspino Superior Suprascapul Starts us us fossa of facet of ar shoulder scapula the abduction (C 5,6) greater tubercle of humerus Infraspinatu Infraspinous Middle Suprascapul Lateral s fossa of facet of ar shoulder scapula the rotation (C 5,6) greater tubercle of humerus Teres Minor Lateral border of scapula, Inferior Axillary (C fact of the 5,6) greater Lateral shoulder rotation

superior to tubercle of Teres Major the humerus MUSCLE PROXIMAL DISTAL NERVE FUNCTIO NS

Subscapula Subscapular Lesser ris fossa of the tubercle of scapula humerus Intrinsic: Attach humerus to scapula Deltoid 1. Lateral Deltoid one third of tuberosity clavicle on the

Subscapula 1. Medial r Nerves (C shoulder 5,6) rotation

Axillary (C 5,6)

2. Acromion 3. Spine of the scapula

humeral shaft

Anterior portion flexes, medially rotates shoulder

Middle portion abducts the shoulder Posterior Portion extends, laterally rotates the shoulder

Teres major

Dorsal Crest of the scapula near lesser inferior tubercle of angle humerus

Lower 1. Subscapula Adduction r and medial (C 5,6) rotation of the shoulder

2. Stabilizes shoulder during abduction 3. Extend shoulder

from flexed positionAttach humerus to trunk ( Act primarily on humerus; scapula moves passively in response to movement of humerus) Latissimus 1. Floor of Thoracodor 1.Extend, Dorsi Thoracolum bicipital sal Adduct, bar fascia groove (also (C 6,7,8) and called Medially 2. Sacrum, intertubercul rotate the iliac crest ar sulcus) shoulder

3. Spinous processes of T 6 to L5

2. Depress and downward rotation of scapulaLateral and Medial Pectoral nerves (C6T1) 1. Adduction , Flexion, Medial Rotation of the shoulder

Pectoralis Major

1. Medial 1/2 Lateral lip of of the the bicipital clavicle groove (also called the 2. Sternum, intertubercul costal cartilages of ar sulcus)

ribs 2 6

2. Horizontal Adduction 3. Protraction of scapula

Chart 2 - MOVEMENTS OF THE SCAPULA Motion Prime Movers Nerve Critical Segment

Elevation

Trapezius- upper Levator scapulae

Accessory N. to L. scapulae C 3,4

Rhomboideus major*

Dorsal scapular Dorsal scapular

C (4),5

Rhomboideus minor*

C (4),5

Depression

Latissimus dorsi1

Thoracodors C 7 al Pectoral Nerves Medial pectoral Long thoracic Accessory C 6, 7,8

Pectoralis major sternal head1 Pectoralis minor

C 8, T1

Upward Rotation

Serratus anterior

C 5, 6, 7

Trapezius-Upper & Lower Downward Rotation Latissimus dorsi1

Thoracodors C 7 al Pectoral Nerves Medial