ShoulderClassification impairments at Shoulder, Elbow, Wrist, and Hand

1. Pain (ex-Systemic sources: Cervical spine, dermatomes, diaphragm, heart, gallbladder, myofascial trigger points or non-systemic/localized pain)

2. Postural (muscle imbalances)3. Mobility (hypo and hyper)4. Muscle (neurological, misuse, strain)

Adhesive Capsulitiso Joint capsule becomes inflamed, fibrotic, shrunkeno Adhesions formo RC and biceps tendon shorten/changePROMo Decreased classical PROM in the capsular pattern: (ER>ABD>FLEX>IR)o Decreased accessory PROM in the capsular pattern: (P/A>inf> A/P)Muscle Lengtho Tight muscles may include: Pec minor and major, teres major, lats, subscap (Interal Rotators/Adductors)GH joint precautions

o Acutely, oscillations may irritate patient Use only to decrease pain

o Do not perform grade III, IV manips until inflammation is goneo Careful of pt dizziness after Codman’so Watch for scapular substitutions during ROM and exercises

Acute stage – focus to decrease pain and inflammation Modalities Grade I manips Codman’s Sub-max isometrics (to decrease swelling not strengthen)

Subacute Restore PROM AAROM Grade II & III mobs

Settled/chronic Focus on AROM (PROM & jt mobility should be restored)

Impairment Treatment during ACUTE stagePostural May/may not be able to improve w/exercise…depends on age

Don’t sleep on involved armRest in loose pack position

Mobility AROM – pain/limited – reduce inflammationPROM – capsular pattern, perform in painfree rangeCodman’sGrade I mobsMLT – defer

Muscle- Strength Sub-max isometrics (to decrease swelling not strengthen)

Impairment Treatment during SUBACUTE stagePostural Postural exercises to decrease forward head, rounded

shouldersLook at LB positioning (lumbar roll)

Mobility ROM – restore PROM 1st, then work on AROM in new rangeProgress to AAROM to AROM (include wand exercises)Start ER early!Muscle length – as ROM improves, begin gentle manual stretching

Muscle- Strength As PROM improves, work on AROM

Sub-max isometrics isotonics (as tolerated)Emphasize good mechanics, no substitutions

Impairment Treatment during SETTLED/CHRONIC stagePostural Progress postural exercisesMobility Grade III/IV mobs, grade III distractions

AROM progresses as PROM improvesProgress stretching to end-range w/overpressure

Strength May need to strengthen to improve scap mech to enhance alignment & proper functioning & improved posture

AC (acromioclavicular) Injury: MOI- Direct blow to areaInjury Type AC ligament CC ligament Delt-trap fascia Direction Treatment

Grade I Sprain Intact Intact Non-displaced ROMGrade II Complete Sprain Intact <25% superior Protect, no

activities until painfree

Grade III Complete Complete Injury 25-100% sup. Surgery, slingGrade VI Complete Complete Detached Post trapGrade V Complete Complete Detached 1-3x superiorGrade VI Complete Complete Detached Inferior to

acromion

AC osteoarthritis- Result of repetitive minor stresses, grade I, II separations, clavicular fractures- Symptoms

o Minor ache with throw or resisted exercise to pain with all activitieso Pain with lying on sideo Painful or painless crepituso Horizontal flexion test positive

Tendonitis (supraspinatus and biceps common)Impairment Treatment during ACUTE stagePostural Educate on proper sitting/standing postureMobility AROM defer

PROM in pain free range; Codman’sGrade I & II mobsMLT – defer

Strength Decrease inflammationStrengthening deferred

Functional limits Avoid sleeping on involved sideRest arm in ABD position to improve vascularity

Impairment Treatment during SUBACUTE stagePostural Stretch tight anterior structuresMobility PROM – Codman’s

AAROM to AROM in painfree rangeGrade II & III mobs (inferior glide)ML – use AC or gentle stretching of mm that cross GH jointTFM w/ tendon in short position to lengthened position

Strength Gentle strength to RC musclesLight MRE IR/ER w/slight distraction to decrease joint compression

Functional limits Teach pt. to function in proper planeICE after treatment

Impairment Treatment during SETTLED/CHRONIC stagePostural Further stretch anterior

Strengthen scap mm to maintain position (include SA)Mobility AROM resisted ROM (as tolerated)

Grade III & IV jt. mobs, stabilize hypermobilityML – passive stretch or active inhibition (pecs, IR, ER, Lats, teres maj, rhomboids)

Strength MSTT – increase load as pain decreasesTFMBegin strength 0-90 to avoid impingement to full ROM

Bursitis- Subacromial and subdeltoid are the most common- Acute

o Spontaneous, rapid onseto Severe debilitating paino Resolves rapidlyo Exam

All motions limited Empty end-feel Tender over bursa

- Chronico Associated with impingemento Exam

Impingement signs Painless restricted motions May have mild capsular restrictions due to disuse

Categorizing shoulder pathology>35 – degenerative aging process

Factors includeo Overuseo Postureo Acromion shape; ACJ, DJD

o Post &/or inf capsule tightnesso RC/biceps weakness or fatigueo SH rhythm

<35 – microtrauma to muscle, tendon, capsule & ligamentous tissue (often due to laxity)

Shoulder instability/laxity – dislocationsContraindications with Shoulder Instability:• Anything that increases mobility of GH jt– Contraindicated therapeutic interventions: • Joint manipulation (for mechanical effects) • Manual passive stretching • End range of motion activities

Classification of impingement groups (for impingement syndrome)Group 1(Greater than age >35)

Pure impingementNo instability-Due to: overuse, posture, acromion shape, posterior and/or inferiorcapsule tightness, RC or biceps weakness, SH rhythm-Impingement Syndrome-Impingement of the RC, bursa, or biceps tendon under the CA arch (anterior portion)

-Often in the area of hypovascularity of the Supraspinatus and bicepstendonExam:-ROM: lack IR, ER, HADD-RC imbalance: dominant Supraspinatus-Radiology: hooked acromion, AC DJD

Group 2(Less than age <35- microtrauma due to laxity)

Primary instability due to microtrauma with impingement IIA – internal impingement IIB – subacromial impingement

Exam:-Laxity tests-Relocation test most sensitive-ROM: increased with external rotation

Group 3(AMBRI- Atraumatic, Multidirectional, Bilateral, Rehabilitation- Inferior capsule shift recommended)

Primary instability due to hyperelasticity with impingement IIIA – internal impingement IIIB – subacromial impingement

Multidirectional Laxity: AMBRI Patients

Group 4(TUBS- Traumatic Unidirectional, Bankart, Surgery recommended)

Pure instability (traumatic)No impingement-Can occur at any age but usually in younger people-Unidirectional laxity : TUBS Patients

Neer’s classification for impingement syndromeStage I Edema & inflammation

<25 yrs old painful arc btw 60-120 deg +/- decreased ROM

significant subacromial inflamm reversible treatment – conservative

Stage II Fibrosis & tendinitis 25-40 yrs old crepitus due to subacromial scarring catching sensation limitation of AROM & PROM not reversible w/activity mods may need bursectomy or CA lig resection

Stage III Bone spurs & tendon ruptures >40 yrs old decreased ROM; AROM worse than PROM atrophy weakness of ABD/ER Biceps tendon involved Not reversible (prog disability) Treatment – acromioplasty or RC repair

RC tears & repairsStage Impairment TreatmentACUTEMAX protection0-6 weeks post-op

Surgical healingSwelling

Ice, E-stimPossibly gentle massage

ACUTEMAX protection0-6 weeks post-op

Mobility ROM – decreased & painfulCodman’s & PROM (painfree range)Grade I & II mobs

ACUTEMAX protection0-6 weeks post-op

Strength Deferred

ACUTEMAX protection0-6 weeks post-op

Functional limitation

Educate about resting in ABD positionEducate about precautions based on protocol ROM limitations

Stage Impairment TreatmentSUBACUTEMod Protection6-12 weeks post-op

Mobility AAROM, begin AROM when MD ok’edGrade II & III mobs, as needed

SUBACUTEMod Protection6-12 weeks post-op

Strength AAROM to AROMLight isometricsMRE ~8 weeks, if ok w/MD

SUBACUTEMod Protection6-12 weeks post-op

Functional limits Out of slingEducate to avoid/reaching overhead

Stage Impairment TreatmentSETTLED/CHRONICMin protection12wks – 1 yr post-op

Mobility Begin passive stretching to end-range where limitedGrade III & IV mobs

SETTLED/CHRONIC Strength Strengthen IR/ER 1st specific

Min protection12wks – 1 yr post-op

deltoid & RC exercisesBe cautious w/eccentrics

SETTLED/CHRONICMin protection12wks – 1 yr post-op

Functional limits Progress back to functional activity

Thoracic outlet syndromeSigns

Forward head, rounded shoulders Hypertrophied scalenes Upper respiratory breather Raised/limited 1st rib Restricted upper thoracic mobility Tight pec minor/major Hypertrophied pec minor

Symptoms Deep aching, not well defined Raynaud’s Pallor, coldness, claudication Intermittent edema, venous

engorgement Cyanoses Dorsal scapular pain Parasthesias into the hand

Peripheral nerve injuries Long thoracic N.

Exam step Finding/impairmentStructural inspectionAROM

PROM

Scapular wingingScap winging w/FLEX, ABD, SCAP (20-30 deg limited)Decreased AROM bc weak SA

May/may not = hyper/hypomobileMay have impingement bc lack of scap movement

Muscle strength SA = 0/5Shoulder Flex = 4/5Other mm = WNL w/scap manually stabilize

P for T Negative or possible tender subacromion area

Suprascapular N. Exam step Finding/impairmentPain assessment Pain at posterior, lateral shoulderStructural inspection May see atrophy of innervated mmAROM

PROM

Possible decreased ABD & ER

Examine for hyper/hypomobilityMuscle strength Weak ER & ABD

Pain if impingement developed

Axillary N. ****same as above****ElbowCapsular pattern for the elbow flexion > extension, pronation= supination

Nerve disorders at the elbow- Ulnar Nerve

o Cubital tunnel syndrome Referred to: Ulnar side of the hand and 4th and 5th phalanx

- Radial Nerve (Motor Only)o Deep radial compressed by ECRB or supinatoro Superficial radial caused by direct trauma to lateral radius

Referred to: dorsum of the radial palm to PIP of 1st thru 4th phalanx- Medial Nerve

o Pronator syndrome- compressed at the pronator teres Referred to: radial palm and 1st thru 4th phalanx

Joint hypomobility (non-op)ACUTE PROTECTION SUBACUTE/CHRONIC CONTROLLED

MOTIONCommon impairments

Jt. effusion Mm guarding Pain (@ rest)

Educate pt.Decrease inflammGr I/II distractionMaintain ROMMaintain function

Common impairments

Cap. Pattern Firm end-feel Decreased

joint play Pro/sup

restricted(OA)

Increase soft tissue & joint mob

HEP Gd III/IV mob Manual & self

stretchingIncrease strength & function

Myositis ossificansExam step Finding/impairmentPalpate for Cond. Increased warmth/firmness of brachialis regionAROM/PROM Elbow ext > flex (and painful)

End range elbow flex is painful due to muscle being compressedMSTT/MMT Resisted elbow flexion causes increased painPalpate for Tender. Palpation of the brachialis mm is painful

Tendonitis of the elbow- TreatmentACUTE SUBACUTE CHRONIC/SETTLEDIce/splintNo AROMPROM in pain free rangeGrade I mobsStop the aggravating activityOnly non-stressful activities

Keep icingAAROM – AROM in pain free rangeGently stretch 1 joint at a timeTFM as toleratedLight MRE****find the cause****

Ice pre/post exerciseAdd resistance to AROMIncrease intensity of passive stretching, inhibition tech, be specific to the mmGrade III/IV mobsDeeper TFMProgress weights/T-bandsWork on endurance!

Cubital tunnel syndrome(Ulnar Nerve Compression)-TreatmentACUTE SUBACUTE CHRONIC/SETTLEDTreat any swelling/warmth w/modalitiesNo AROM @ elbowAROM of neighboring jointsPROM in pain free rangeGrade I mobsStretch to prevent contract.Defer strengthening

AAROM AROM to elbowGentle PROM mild discomfortGrade II/III joint mobsContinue w/modalities + massage to FCULight manual/mechanical RE to bis/tris & ulnar n. mm

AROM active RE to UEPROM, passive stretching to elbow & wrist, especially intrinsicsGrade III/IV joint mobsStrengthen wrist flexors & intinsics (ulnar n.)Gripping/fine motor therapy

Treat the cause of compress.Consider bracing at night

Continue treating the causeNeuromobilizations

Increase intensity of neuromobilizations

Overuse syndromes- Lateral Epicondylitis (Tennis Elbow)

o Tendonitis of the wrist extensorso Common Extensor Tendon- ECRB most common

- Medial Epicondylitis (Golfers Elbow)o Tendonitis of the wrist flexorso Common Flexor Tendon- FCR and pronator teres most common

- Triceps tendonitis: Distal triceps- Antecubital tendonitis: Distal biceps

WRIST AND HANDCapsular patternsWrist Flexion = ExtensionIP of digits 2-5 flexion(more limited)> extensionMCP digits 2-5

Open packo Slight flexion

Closed packo Full flexion

Length-tension relationship Wrist position controls length of extrinsic muscles

o Wrist extension for gripo Wrist flexion stability for finger extension

Hand function Extensor hood

o Made up of: Extensor digitorum Dorsal and palmar interossei Lumbricals

o Reciprocal motion of MCP flexion and IP extension interosseio Lumbricals remove tension from FDP and assists IP extensiono Isolated contraction of Extensor Digitorum causes clawing motion

Hand Grips Power grip(Primarily isometric function)

o Cylindrical gripo Spherical gripo Hook gripo Lateral prehensiono Major gripping force extrinsic finger flexorso Compressive force ED which also increase stability

Precision patterns(Object does not come in contact with palm)o Between thumb and fingerso Compressive force extrinsic muscleso Object manipulation

Interossei abduct and adduct Thenar muscles control thumb Lumbricals help move object away from palm

o Tip to tipo Pad to pado Pad to side prehension

Combined gripso Digits 1 & 2 precision o Digits 3-5 powero Pinch

Nerve disorders Median nerve

o Carpal tunnel most common Ulnar nerve

o Guyon’s canal most common

Rheumetoid Arthritis- RAStage Acute RemissionPFC Massage/Modalities Massage/ModalitiesAROM Painfree AROM/PROM AAROM w/progression to active exercise

PROM Classical Painfree AROM/PROM- DON’T STRETCH! Gentle stretching

PROM Accessory Grade I & II manips Grade I & II manipsPossibly Grade III

MLT Painfree AROM/PROM Gentle stretching (intrinsics)MMT Gentle muscle setting Light-moderate resistance exercise

o Active Pt. education Joint protection- NO STRETCHING Active exercise if possible

o Remission Improve function

Flexibility Muscle performance CV endurance

Nonimpact or low impact conditioning Swimming Bike Water aerobics

o RA and other Hand Deformities Swan neck Boutonniere deformity Ulnar drift Volar sublux of triquetrium Ulnar sublux or carpals Z deformity of thumb

Osteoarthritis- OAo Acute stage

Achiness and stiffness lessen w/movement Inflammation

Affects prehension and ADLso Advanced stages

Capsular laxity hypermobility/instability Contractures develop as it progresses

Limits in flexion and extension firm capsular end feel Muscle weakness

o Weak grip strengtho Poor muscle endurance

o Protection phase Control pain

Grade I & II manips Splinting Modify activities

Educate pt. Maintain joint & tendon mobility

PROM/AAROM/AROM Heat Aquatics Muscle setting (multiple angle)

o Controlled motion and Return to function phase Increase joint play and accessory motion

Grade III and IV manips Improve joint tracking Mulligan

Mobility w/movement Lateral glide of wrist while pt. actively moves Other hand passively stretches at end range

Improve mobility, strength & function

Tenosynovitis/Tendonitiso Protection phase

Splint Cross fiber friction in elongated position Tendon gliding exercises to prevent adhesions Multiangle muscle setting Painfree ROM

o Controlled motion and return to function phase Progress intensity of massage, exercise, and stretching

Dynamic exercises Be careful of eccentric exercises- May provoke symptoms

Traumatic Lesions Sprain

o Possible impairments Hypermobility

Torn ligaments Pain

o Management Maintain mobility Minimize stress to healing tissue

Laceration of tendons

o Flexor tendon zones Zone 1

FDP insert insert of FDS

FDP, A4 & A5 pulleys Unable to fully make fist

Zone 2 FDS insert palmar

crease (prox to neck of MCP)

FDS, FDP tendons, annular pulleys

Unable to flex PIP & DIP if both severed

No mans land Zone 3

Neck of MCP distal carpal tunnel FDP, FDS, lumbricals MCP flexion affected

Zone 4 Carpal tunnel FDP, FDS, FPL Nerve injury

Zone 5 Proximal to wrist Flexor tendons of digits and wrist

o Loss of finger & wrist flexiono Damage to median & ulnar nerves possible

o Extensor Tendon Zones Zone 1

DIP region No active DIP extension Flexion contracture Swan neck deformity

Zone 2 Middle phalanx Same as Zone 1

Zone 3 PIP region Central slip damaged Possibly lateral bands Cannot extend PIP from 90° Boutonniere deformity Prone to adhesion forming

o Multiple soft tissue attachmentso Broad bone-tendon interface

Volar splintso Wrist in 30° active flexion

o MCP in neutralo Splint limits PIP flexion (30°) and DIP flexion (20-25°)

Zone 4 Proximal phalanx Same as Zone 3

Zone 5 Apex MCP joint EDC, EIP, EDM damaged Unable to extend MCP

Zone 6 Dorsum of hand Retinaculum and multiple tendons damaged Bowstring effect of tendons Loss of wrist and digit extension

Zone 7 Wrist Same as Zone 6

o Repairs Balance between protection & movement

Excess movement tendon rupture Early ROM important to prevent contractures1. Immediate primary repair: Done within 24 hours of injury2. Delayed primary repair: Done within 10 days3. Secondary repair: Done 10 days to 3 weeks post injury4. Late reconstruction: Done well beyond 3-4 weeks post injury

o Direct repair no longer possible, Tendon graft necessaryo Treatment

Immobilization PIP extensor joint: 4-6 weeks DIP extensor joint: 6-8 weeks Flexor tendons

o Early movement important Decreases edema Maintains tendon gliding Decreases adhesion forming Increases synovial fluid production Increases tensile strength of tendon

o Position of immobilization Zones 1-3

Wrist & MCP flexion, PIP & DIP extension Zone 4

MCP flexion 70°, neutral wrist

Management for flexor tendon laceration

Max Protection PhaseModerate

Protection phaseMinimum Protection

Phase/return to functionTiming 1-3 days postop to 5 weeks 4-8 weeks 8 weeks postopSplintin

gSplint (dorsal blocking splint

w/dynamic traction)-Static blocking

splint (day)-Night splint for

Splinting discontinued

protection

Exercise-Very low controlled stresses

-Passive & active exercises-Place & hold

Tendon gliding & blocking

-Place & hold-AROM

Gradual progressive resistance exercises

Goals-Control pain & edema-Wound management

-Prevent adhesions

-Safely increase stresses

-Full AROMFull activity by 12 weeks

Colles Fractureo FOOSHo Distal radiuso Complications

Capsule tightness UCL sprain Avulsion fx CRPS complications Malalignment Carpal tunnel syndrome

Volar sublux of lunate Rupture of EPL

Malalignment of Lister’s tubercle

Colle’s FractureAcute Sub-acute Chronic

Posture

Not likely to see in acute phase.-Avoid exercise

-Educate pt. about posture

- Holds arm to side Educate pt. to use normal swing motion

-Codmans

Palpation for Condition

Swelling RICE

AROMLimited in all directions AAROM & AROM as

tolerated. Maintain ROM of Shoulder/elbow/fingersProgress to full

end range

PROM Classical

Capsular pattern progress to endrange stretches

Progress as tolerated-passive

stretching in HEP

PROM Accessory

Hypomobile Grade II & III manips, soft tissue work

Grade III & IV manips

MMTGenerally weak UE light MRE progressing to

weights, t-band

Progress MRE & isotonics

-use functional activities

Skier’s thumbo Sprain of UCL of 1st MCP jointo Hyperabduction force to thumbo Signs & symptoms

Tender to palpation and swelling over UCL Pain w/pinching + adduction stress testing

Scaphoid fractureo FOOSHo Signs & symptoms

Tender over snuffbox Especially palmar side

Possible swelling Decreased ROM X-rays 4 views

If negative, treat as fx and reorder films in 2 weeksTFCC Tear- Triangular Fibrocartilage Complex

Loading wrist in pronation Usually 2° to ulnar impaction Signs & symptoms

Pain on ulnar side or wrist Swelling Decrease grip strength Tender distal to ulnar Styloid process Click w/ulnar deviation

CRPS(RSD)- Complex Regional Pain Sydrome (Reflex Sympathetic Dystrophy)o Type I

Triad of symptoms Sensory Autonomic Motor

Stages Stage 1

o Acuteo Persistent paino Edemao Warm skin

Stage 2o Dystrophico Same as Stage 1 o Deteriorating changes to tissues & nailso Hair losso 3 weeks – 3 months post

Stage 3o Atrophico Same as Stage 2o Add cold skino Atrophy of skin, soft tissue, muscle & boneo 6-9 months post

o Type II(Causalgia)- Specific Nerve Associated with CRPS Precedes w/partial injury of peripheral nerve or major branches Symptoms same as Type I

Only in region of specific nerve Symptoms unique to Type II

Electrical shooting sensation of pain Hyperalgesia in nerve distribution Swelling & trophic changes very discrete Usually NO CHANGE in bone metabolism

Treatment Decrease pain

o Gradual desensitization TENS Fluidotherapy Contrast baths

o Elevated massage Maintain or increase ROM

o Small, gentle active and passive therapieso Dynamic & static splinting

Increase strengtho Posture correction

Reduce edemao Elevation & compressiono Massage distal proximal

Carpal Tunnel Syndromeo Signs & symptoms

Night pain Tingling, numbness, pain Usually insidious unless following trauma Decreased strength/sensation in median nerve distribution Pain referred proximally + Tinels, Phalens, Reverse Phalens

Carpal Tunnel SyndromeAcute Subacute Settled

InspectionAtrophy of thenar muscles Reduce

inflammation, night splint

Wean from splint-Continue to

decrease inflammation

AROM/PROM Classical

Decreased w/pain in carpal tunnel decrease inflammation

AAROM/AROM to UE

-Begin light passive stretching

Increase vigorousness of passive stretch-Progress AROM

w/hand weights as tolerated

PROM AccessoryPossible limited pisiform and/or lunate

Grade I manipGrade II & III manips Grades III & IV manips

MMTdecreased strength in median nerve

distribution defer

Isometrics to elbow & wrist

-Light MRE to thumb & intrinsics

-Pinching activities-Open/close fingers

Grip strengthening-HEP rubberbands

-Fingertip pushups-Functional tasks

Special TestsDecreased grip strength rest, decrease

inflammationMovement Clumsiness avoid extreme wrist Look at ergonomics

Analysis flex/ext

NeurovascularDecreased strength/sensation in median nerve distribution rest, splint, remove

causative factors

Neural mobs as indicated

Modes of exerciseMuscle setting MRE

Isometrics Isotonics

Isokinetics

Eccentrics

Plyometric

Test grades Exercises0 PROM1 (Trace) AAROM2-/2 (Poor) AAROM/AROM in GL

AAROM against gravity2+/3 (P+/ Fair)

AAROM/AROM against gravityResistive in GL

3+/5 (Fair) Resistive against gravity

Intervention progression

Injury pain management flexibility strength proprioception endurance power skilled activity full activity

Include tissue healing, pain free functional activity & pt. education