Periarthritis Shoulder
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Transcript of Periarthritis Shoulder
PERIARTHRITIS SHOULDER 2012
PERIARTHRITIS SHOULDER
Periarthritis is a term used to indicate a clinical syndrome where glenohumeral
motion has a restricted range of active & passive motion for which no other cause can be
identified.
All patients with idiopathic loss of shoulder range of motion complain of decreased
motion.
Additional complaints include disturbed sleep and difficulty accomplishing personal
hygiene, donning and doffing clothing and overhead movement, reaching or rotation
activities.
Codman initially coined the term “Frozen Shoulder” in 1934
Terminology has been based on assumed etiology. Terms based on
Inflammation include – “adhesive capsulitis”, “Adhesive subacramial bursitis”
“Biceps Tenosynovitis” Scapulo humeral periarthritis subdeltoid bursitis
“Obliterative bursitis and tendinitis of the short rotators.
Non inflammation based terms include stiff and painful shoulder calcification of Supraspinatus tendon particular adhesions Duply Disease” “An Alogodys Trophic process and checkrein shoulder
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Gleno humeral motion was chosen for this investigation as a more accurate
representation of the actual joint where the idiopathic motion loss is believed to
orginate, rather than humerus to trunk motion, which is a function of multiple joints.
In this various etiological factors are described, different pathological changes are
explained numerous tests and investigation are put in regarding periathritis
shoulder.
Physiotherapy plays a vital role in maintaining the patients shoulder mobility and
with the effective use of various modalities that presents the progression of the
degenerative changes of the shoulder.
Early diagnosis is very important in periarthritis shoulder patients otherwise it may
leads to adverse effects. For the creating awareness in the patients about this
condition is very necessary.
The main aim in treating the periarthritis patients is to improve the range of motion
and to make the person functionally independent and lost but not the least to
minimize the discomfort to the patient.
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Incidence
Usually it effects unilaterally but on occasion becomes bilateral Incidence of
periarthritis is not precisely known however if estimated that 3% of people develop
the disease over their life time.
The incidence of shoulder complaints in general practice is 15-25 per 1000 patients
per year.
A higher incidence of periarthritis shoulder exists among patients with diabetics
(10-20%) compare to the general population (2-5%).
Incidence among patients with insulin dependent diabetes is even higher (36%) with
an increased frequency of bilateral shoulder involvement.
Bridgman reported that up to 7% of outpatients seen at a community hospital had
symptoms of periarthritis and Bunder and Anthony reported that more than 5% of
all patients in their study who were seen at shoulder clinics were diagnosed with
frozen shoulder.
Age and sex distributions reported in the literature have been widely variable with
ages ranging from 22 yrs to 85 yrs and with percentage of female subjects ranging
from 48% to 84%.
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Codman concluded that symptoms resolved and full movement returned in 21 of 22
patients within 2 years.
This tends to effect women than men. Menopause often is cited as a cause of
periarthritis shoulder in female.
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ANATOMY
The shoulder girdle
The shoulder girdle connects the upper limb to the axial Skelton.
The shoulder complex is composed of the scapula, clavicle, humerus and the joints
that links these bones into a functional entity.
The 3 segments (scapula, clavicle and humerus) are controlled by 4 inter dependent
linkages.
They are :
1. Scapulothoracic Joint (ST) Functional Articulation
2. Sternoclavicular (SC) Joint
3. Acromio Clavicular (AC) Joint
4. Gleno Humeral (GH) Joint
A 5th functional articulation is commonly described as part of the complex and is
formed by the Coraco Acromial arch and the head of the humerus
1. Scapulo Thoracic Joint:
ST joint is formed by the articulation of the scapula with the thorax on which it sits.
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Joint union is by fibrous, cartilaginous, or synovial tisues
The SC and AC joints are inter dependent with the ST joint because scapula is
attached by its acromion process to the lateral end of the clavicle via the AC joint.
The clavicle, inturn is attached to the axial skelton at the manubrium sterni via SC
joint.
The functional ST joint is part of a true closed chain with the AC and sc joint.
The Motions of the Scapula are:
i) Elevation
ii) Depression
iii) Protraction (Abduction)
iv) Retraction (Adduction)
v) Upward rotation (Lateral rotation)
vi) Downward rotation (Medial rotation)
Elevation and Depression of the scapula are trnslatory motions in which the
scapula moves upwards (Cephalad) or downwards (Caudally) along the rib cage from its
resting position.
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Protraction and retration of the scapula retranslatory motions of the scapula away
from or towards the vertebral column respectively. Upward rotation is the movement of
inferior angle of scapula away from the vertebral column and downward rotation is
movement of inferior angle forwards the vertebral column other movements of scapula:
Anterior Tipping
Posteriror Tipping
2. Sterno Clavicular (SC) Joint:
Type:
i) It is a plane synovial joint.
ii) It is a compound joint as there as 3 elements taking part in it, namely
iii) Medial end of the clavicle
iv) Clavicular notch of the Manubrium Sterni
v) Upper surface of the first costal cartilage
It is a complex joint as its cavity is sub divided into two parts by an intra articular
disc.
Articular surfaces:
Clavicular :
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Articular surface of the clavicle is covered with fibro cartilage. The surface is
convex from above downwards and slightly concave from front to back. Sternal :
Sternal articular surface is smaller than the clavicular surface. It has a reciprocal
convexity and concavity.
Because of the concavo – convex shape of the articular surfaces. The joint can be
classified as a “Saddle Joint”.
SC joint has :
i) A Joint Capsule
ii) Articular disc or joint disc
iii) Three major ligaments
1. Capsular ligament
It is attached
Laterally
To the margins of the Clavicular Articular surface
Medially :
To the margins of the articular areas on the sternum and on the first costal
cortilage.
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2. Articular Disc:
It is attached
Laterally:
To the clavicle on a rough area above and posterior to the articular area for the
sternum.
Inferiorly:
To the sternum and to the first costal cartilage at their junction.
Anteriorly and posteriorly the disc fuses with the capsule.
Ligaments:
a) Steno Clavicular Ligament
b) Costo Clavicular Ligament
Attached above to the rough area on the inferior aspect of the medial end of the
Clavical.
Inferiorly, it is attached to the first costal cartilage and to the first rib.
c) Interclavicular ligament
Passes between the sternal ends of the right and left clavicles.
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Some of its fibres being attached to the upper border of the manubrium stern
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Blood supply
1. Internal thoracic artery
2. Supra scapular artery.
Nerve supply
Medial supraclavicular nerve
Movements:
1. Elevation and depression of the clavicle.
2. Protraction and retration of the clavicle.
3. Anterior and posterior rotations of the clavicle.
3. Acromioclavicular (AC) joint:
Type:
AC joint is a plane synovial joint.
Articular surfaces:
‘AC’ joint is formed by articulation of small facets present.
i) At the lateral end of the clavicle and
ii) On the medial margin of the acromion process of the scapula.It has a Joint Capsule, two major ligaments and a joint disc may or may not be
present.
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Capsular ligament:
Completely surrounds the articular margins.
It is weak and can not maintain integrity of the joint without reinforcement
of the superior and inferior AC and the Coraco Clavicular ligaments.
Acromioclavicular joint disc:
Disc of the ac joint is variable in size and differs individuals, at various times in the
life of same individual and between sides of the same individual.
Ligaments:
i) Superior acromioclavicular ligament.
Extends between upper part of the acromial end of the clavicle and adjoining part
of the upper surface of the acromian.
ii) Inferior Acromioclavicular Ligament:
Attached to adjoining surface of the two bones.
iii) Coracoclavicular Ligament:
This ligament is divided into a lateral portion, the trapezoid ligament and a medial portion, the conoid ligament.
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Trapezoid ligament:
Attached below to the upper surface of the coracoid process and above to the
trapezoid line on the inferior surface of the lateral part of the clavicle.
Conoid Ligament:
Attached below to the root of the coracoid process just lateral to the scapular notch
and above to the inferior surface of the clavicle on the conoid tubercle.
Blood Supply :
i) Suprascapular Artery
ii) Thoraco Acromial Artery
Nerve Supply:
Lateral Supraclavicular Nerve
Movements:
i) Medial and lateral rotation of the scapula
ii) Anterior and posterior tipping of the scapula
4. Glenohumeral (GH) joint (or) Shoulder Joint:
Type:
The shoulder joint is a synovial joint of the ball and socket variety.
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Articular Surfaces:
Small glenoid fossa of the scapula articulates with the large head of the humerus.
It is a weak joint because the glenoid cavity is too small and shallow to hold the
head of the humerus in place. However this arrangement permits great mobility.
Stability of the joint is maintained by the following factors:
i) The coracoacromial arch
ii) The musculotendinous cuff of the shoulder
iii) The glenoid labrum which helps in deepening the glenoidfossa
iv) And also by the muscles attaching the humerus to the pectoral girdle, the long
head of the biceps, the long head of the triceps and atmospheric pressure. Ligaments of
the Joint:
i) Capsular Ligament
ii) Coracohumeral Ligament
iii) Transverse Humeral Ligament
iv) Glenoid Labrum
i. Capsular Ligament:
F It is very loose and permits free movements.
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It is least supported inferiorly where dislocations are common
Medially the capsule is attached to the scapula beyond the supraglenoid tubercle and
the margins of the labrum
Laterally it is attached to the anatomical neck of the humerus with the following
exception.
Interiorly the attachment extends down to the surgical neck.
Superiorly it is deficient for passage of the tendon of the long head of the biceps
brachii.
The joint cavity communicates with the subscapular bursa, with the synovial sheath
for the tendon of the long head of the biceps brachii and often with the infraspinatus
bursa. Anteriorly the capsule is reinforced by superior, middle and inferior “GH”
ligaments.
ii. Coracohumeral ligament
F Extends from the root of the coracoid process to the neck of the humerus opposite
the greater tubercle.
F It gives strength to the capsule.
iii. Transverse Humeral Ligament:
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It bridges the upper part of the bicipital groove of the humerus between greater and
lesser tubercles.
Tendon of the long head of the biceps passes deep to the ligament.
iv. Glenoid labrum:
It is firbocartilaginous rim which covers the margins of the glenoid cavity, thus
increasing the depth of the cavity.
Bursae related to the shoulder joint:
1. The Subacromial (subdeltoid) bursae
2. Sub Scapularis bursa, communicates with joint cavity
3. Infraspinatus bursae, may communicates with joint cavity
4. Several other bursae related to the coraco brachialis, teres major, long head of the
triceps, latismus dorsi and the coracoid process are present. Relations:
Superiorly
Coracoacromial Arch
Subacromial Bursa
Supraspinatus and Deltoid
Inferiorly:
Long head of the triceps Brachii
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PERIARTHRITIS SHOULDER 2012
Anteriorly:
Subscapularis
Coraco Brachialis
Short head of biceps and Deltoid
Posteriorly:
Infraspinatus
Teres minor and deltoid
Within the joint:
Tendon of the long head of the biceps brachii
Blood supply
i) Anterior circumflex humeral vessels
ii) Pasterior circumflex humeral vessels
iii) Suprascapular vessels and
iv) Subscapular vessels
Nerve Supply
i) Axiallary Nerve
ii) Musculo Cutaneous nerve and
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iii) Supra Scapular Nerve.
Movements:S.No. Movement Main Muscles Accessory Muscles
1 Flesion (1800) Clavicular head of coraco brachialis
the pectoralis major short head of biceps
anterior fibers of deltoid
2. Extension (0-450) Posterior fibers of deltoid Teres major
Latissimus Dorsi Long head of triceps
Sternocostal head
of the pectoralis
major.
3. Adduction (0-450) Pectoralis major Teres major
Latissimus dorsi Coraco brachialis
Short head of biceps
Long head of triceps
4. Abduction (0-1800) Deltoid
Supraspinatus
Serratus anterior
Upper and lower
fibers of traperzius
5. Medial Roation Pectoralis major Subscapularis
(0-550) Anteriof fibers of deltoid
Latissimus clorsi
Teres major
6. Lateral rotation Posterior fibres of deltoid
(0-450) Infraspinatus ,Teres Minor.
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BIOMECHANICS
GLENOHUMERAL MOTIONS
OSTEOKINEMATICS
The GH joint is having 30 of the freedom.
a. Flexion / Extension
b. Abduction / Adduction
c. Medial / Lateral Rotation
The joint have 1200of flexion and about 500 of extension.
The range of medial / lateral rotation of the humerus varies with position.
With the arm at the side, medial and lateral rotation may be limited to as little as 50 0
of combined motion.
Abducting the humerus to 900 frees the arc of rotation to 1200.
The restricted arc of medical / lateral rotation when the arm is at the side is due to
the impact of the lesser tubercle on the anterior glenoid fossa with medial rotation
and the impact of the greater tubercle on the acromion with lateral rotation.
When the arm is abducted, these bony restrictions play little role, so the checks of
motion become capsular and muscular.
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The range of abduction of the humerus in the frontal plane will be diminished if
the humerus is maintained in neutral or medial rotation.
When the humerus is medially rotated, the humerus will not abduct on the glenoid fossa
beyond 600, at neutral rotation 900 of GH abduction can be obtained.
The restriction to abduction is caused by the impingement of the greater tubercle on
the coracoacromial arch.
When the humerus is laterally rotated 350 to 400, the greater tubercle will pass under
or behind the arch so, that abduction can continue unimpeded.
The forward movement of the humerus in flexion, the greater tubercle slides behind
or under the acromion process regardless of rotation. So to achieve full range
flexion, not the same need for rotation of the humerus.
The range of motions for abduction of the GH joint are reported to be anywhere
from 900 to 1200 with varying citations in between.
In man and coworkers found active abduction to be limited to 900 when the scapula
did not participate in the motion, but claimed 1200 of motion was available
passively.
The plane of the scapula 300 to 400 anterior to the frontal plane.
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PERIARTHRITIS SHOULDER 2012
When the humerus elevates in the plane of the scapula (scaption). There is
presumably less restriction to motion because the capsule is less twisted than when
the humerus is brought further back into the frontal plane.
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ARTHROKINEMATICS:
The convex humeral head is a substantially larger surface and may have a different
radius of curvature than the shallow Concave Fossa.
Given this incongruence, rotations of the joint around its three axes do not occur as
pure spins, but have changing centers of rotation and shifting contact patterns within
the joint.
There is somewhat surprising lack of consensus on the extent and direction of
movement of the humeral head on the fossa.
There is agreement that elevation of the humerus requires that the humeral head
glide inferiorly in a direction opposite to movement of the shaft of the humerus.
For example:
Abduction of the humerus as a pure superior rolling of the large humeral head on
the small glenoid fossa would cause impaction of the head into the acromion.
Abduction of the humerus occuring as a combination of rolling and sliding prevents
impaction and allows a full range of motion.
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PERIARTHRITIS SHOULDER 2012
Although inferior glide of the humeral head is necessary to minimize upward roll of the
humeral head, it would appear that the center of rotation of the head still moves
superiorly on the glenoid even though the magnitude of reported shift differs.
Additionally, the humeral head may glide anteriorly or pasteriorly and medially or
laterally on the fossa.
Static stabilization of the dependent arm
When the arm is relaxed at the side, the dislocation, effect of gravity is
counteracted by the passive tension in the superior capsule, superior glenohumeral
ligament and coracohumeral ligament.
Dynamic stabilization of the Gleno humeral joint:
The Infraspinatus, Subscapularis and teres minor muscles together have a negative
translatory component that nearly offsets the positive translatory component of the
deltoid force.
Gravity acts as a stabilizing synergist to the supraspinatus muscle. Activity of the
supraspinatus and gravity produce a resultant force that abducts the humerus and
causes the downwards sliding of articular surfaces necessary for a full range of
motion.
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PERIARTHRITIS SHOULDER 2012
The long head of biceps appears to contribute to GH stabilization by centering the head
in the fossa, and by reducing vertical and anterior translations.
Long head may produce its effect by tightening the relatively loose superior labrum
and translating increased tension to the superior and middle GH ligaments.
Scapulo Humeral Rhythm: (SHR)
The combination of concomitant GH and ST motion is most commonly referred to
as “Scapulohumeral Rhythm”
Importance of SHR is :
i) Distributing movement between 2 joints will enhance the range of motion with out
compromising the stability.
ii) Maintaining an optional position between glenoid fossa and humeral head to
increase the joint congruency.
iii) To maintain the optional length of the muscles and to prevent length tension
insufficiency.
20 movement of humerus have 10 rotation of scapula.
Setting Phase :
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During the initial 600 of flexion or the initial 300 of abduction of humerus, scapular
motion takes place relative to GH motion.
During this period, the scapula seeks a position of stability in relation to the
humerus.
SHR involves the concerned action of SC and ac joints, as well as the ST and GH
joints.
Phase One :
The upper and lower fibres of trapezius combine with the upper and lower fibers
of serratus anterior to produce upward rotation of scapula.
This motion at the ac joint is prevented by the conoid and trapezoid part of
coracoclavicular ligament.
Upward rotation would result in movement of coracoid process of scapula
inferiorly.
This is prevented by coracoclavicular ligament.
The upward rotatory force continues to produce no movement at sc joint i.e.,
elevation of clavicle to produce 300 of upward rotation of scapula and 600 of GH
motion.
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Phase Two :
As the lower trapezius and serratus anterior continue to generate an upward
rotatory force on the scapula, upward rotation at the ac joint is still restrained by
the coracoclavicular ligament while the sc joint is now constrained by tension in
the costoclavicular ligament.
This causes coracoid process of scapula to pull downwards with the
coracoclavicular ligament and carrying to posteriorly located conoid tubercle of
clavicle downwards. The resulting motion is rotation of clavicle around its
longitudinal axis to produce 300 of upward rotation of scapula and 600 of GH
motion to produce a combined 1800 motion.
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PERIARTHRITIS SHOULDER 2012
ETIOLOGY
Etiology for the periarthritis shoulder is:
1. IDIOPATHIC:
Idiopathic adhesive capsulitis results from capsular fibrosis. The pathologic
mechanism for this fibrosis is not well understood.
2. SHOULDER CAUSES:
Problems directly related to shoulder joint, which can give rise to periarthritis
shoulder they are:
1) Trauma:
It occurs due to suddenly in road traffic accidents; any direct or indirect violence
over the shoulder joint.
2) Immobilisation:
The shoulder is immobilized due to any avulsion fracture of the greater tubercle of
the humerus, dislocations, and subluxation. It is also immobilized due to any referred
pain. It is intriguing possible etiology factor for Peri – arthritis, in patients with stroke or
post myocardial infarction. 3) Bursitis:
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Bursitis involves deposition of a calcium salt into the substance of the rotator cuff
tendon. This paste like material may escape into the subacromial bursa, causing an acute
inflammatory bursitis, which leads to periarthritis shoulder.
4) Tendinitis:
In a passive stage with the arm totally dependent, the effect of gravity imposes its
stress upon the supraspinatus tendon.
Sustained isometric contraction of the supraspinatus muscle has been implicated as
on cause of muscular degeneration.
When muscles loses its integrity it leads to pathological changes shoulder
tendonitis is frequent.
The pre – disposing factor leading to tendonitis is nutritional deprivation and
mechanical stress cause degeneration.
5) Rotator cuff injuries:
A rotator cuff rupture can be desired as degenerative thinning and fissuring of the
cuff in the Hypo Vascular zone exposed to impingement or direct trauma and
consequently leading to tearing of rotator cuff.
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6) Calcification
Calcium crystals are often deposited within the models of the collagen hyaline
debris.
The hydrated calcium may also initiate pain and further impairment.
Calcium deposit presents a mechanical obstacle to abduction and over head
elevation.
Repeated abduction and over head elevation increases inflammation and increase
the dissolved calcium.
7) Bicipital Tendonitis:
Injuries of the long head of the biceps tendon may occur with forceful elbow
flexion or hand supination. 80% cases are associated with on going rotator cuff problems
and shoulder impingement syndrome.
8. Degenerative Changes:
Any changes in the articulation may lead to degeneration.
9. Over Stretching and exercises :
Repeated elevation movements also cause repeated tension with in the tendon.
Due to repeated contractions the tendons gets inflammation.
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III. NON – SHOULDER CAUSES :
Problem no related to shoulder joint and causes shoulder pain due to prolonged
immobilization. They are
i) Diabetes Millitus:
Diabetic patients who are insulin dependent have a high incidence of periathritis
shoulder with a marked frequency of bilateral involvement.
ii) Cardiovascular Diseases:
Cardiovascular diseases with referred pain to the shoulder, which keeps the joint
immobile, and causes periarthritis of shoulder joint.
iii) Thyroid disorders:
The disorder o the thyroid of the both hypo & hyper type are commonly associated
with periarthritis shoulder.
iv) Cervical disc diseases:
Patients with the degeneration of the intervertebral discs of the cervical spine also
leads to periarthritis shoulder.
v) Neoplastic disorders of thorax:
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Any tumours in thorax cause pain in the shoulder.
Other Causes:
Reflex sympathetic dystrophy
Frozen hand shoulder syndrome
Complication of colle’s fracture can lead to frozen shoulder.
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PATHOLOGY
Pathological events in periarthritis shoulder are
1) During abduction and repeated overhead activities of the shoulder, long head of
biceps, & rotator cuff undergo repeated strain. This results in inflammation,
fibrosis and consequent thickening of the shoulder capsule, which results in loss of
movements.
If the movements are continued, then the fibrosis gradually breaks, movements
return but never come back to normal.
2) Prolonged activity causes small capsular and biceps muscles to waste faster, load
on joint increases and degenerative changes sets in. capsule is fibrosed and
shoulder movements are decreased.
Macroscopic:
Thick and contracted glenohumeral capsule
Contracted glenohumeral ligaments and rotatory interval.
Microscopic:
Chronic inflammation and fibrotic inflammation.
Dense capsular matrix.Type I & III collagen
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PERIARTHRITIS SHOULDER 2012
Fibro blasts & Myofibroblasts
Subsynovial Angiogenesis
Synovial Layer no involved.
Pathological events in degenerative arthritis pathology of shoulder
There is a cascade of cellular and bio mechanical events that occurs leading to the
breakdown of articular cartilage, which is followed by insufficient cartilage repaid.
The biochemical events associated with O.A. include
Loss of collagen matrix
Increased water content
Alterations in proteoglycon composition and increased proteolytic
enzymes and cytokines
The increase in cartilage degeneration and repaid processes results in an increase
in cartilage breakdown products as well as increase in the synthesis of cartilage
proteoglycons pathological events in.
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Inflammatory arthritis pathology of shoulder :
Joint changes progress though the following three stages.
Stage – I
Inflammation of the synovial membrane spread to articular cartilage and other soft
tissues. There occurs limitation of joint movements with pain and muscle spasm.
Stage – II
Granulation tissue formation occurs within the synovial membrane & spread to the
periarticular tissues.
The cartilage starts disintegrating and the joint is filled with granulation tissue.
There occurs thickening of the joint capsule tendons and their sheaths impairing
the joint movement permanently.
Stage – III
The granulation tissue gets organized into fibrous tissue with adhesion formation
between the tendon, joint capsule and the articular surfaces.
The articular surfaces get partly covered by cartilage and partly by fibrous tissue.They may give rise to contractures.
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PERIARTHRITIS SHOULDER 2012
CLINICAL FEATURES
There are three classical stages in frozen shoulder, according to REEVES.
Stage – I (or) Stage of pain:
Patient complains of acute pain, decreased movements, external rotation greatest
followed by loss of abduction and then forward flexion. Internal rotation is least affected.
This is lasts for 10 to 36 weeks.
Stage – II (or) Stage of Stiffness:
In this stage pain gradually decrease and the patient complains of stiff shoulder.
Slight movements are present this lasts for 4 to 12 months.
Stage III (or) Stage of Recovery :
Patient will have no pain and movements will have recovered but will never be
regained to normal. It lasts for 6 months to two years.
1. Pain :
A dull ache comes on which become more intense and constant over a few weeks
or months. Pain located at acromioclavicular joint and deltoid first then gradually spread
drawn to elbow and up to neck.
Pain also located at antero – lateral aspect of joint and radiate to the anterior aspect
of arm and occasionally flexor aspect of forearm. Pain is worse at night. Especially if the
patient lies flat.Pain is noted at the end stage of stretch.
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PERIARTHRITIS SHOULDER 2012
2. Decreased range of motion:
Both active and passive range of motions of shoulder are decreased in periarthritis
shoulder.
3. Restriction of Movements:
The patient demonstrates a capsular pattern of movement restriction i.e., external
rotation, abduction, international rotation.
4. Accessory joint play is reduced.
5. Tenderness:
Tenderness is present above the humeral head and over the bicipital groove.
6. Patient is unable to do routine daily activities like combing the hair, in case of
women wearing the buttons of their blouse, doing overhead activities etc.,
7. Mild to moderate wasting of supraspinatus, infraspinatus and deltoid.
8. May be history of insignificant injury following which the symptoms develop.
9. In late cases, rarefaction in surrounding bones, more of tuberosities.
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PERIARTHRITIS SHOULDER 2012
DIAGNOSTIC TESTS
1. Active test of range of motion with slight over pressure at the terminal point of
each movement.
This test will reveal definite capsular restriction of the gleno – humeral joint. The
movements principally involved will be abduction and external rotation; the movements
of flexion and internal rotation are involved to a lesser extent. No apparent muscular
weakness will be present in the available range of motion, but over pressure at the end of
the range will elicit pain.
2. Active resisted test of range of motion:
At the initial range usually there is no pain, however considerable resistance may
be painful.
3. Passive test of range of motion :
With the patient in supine position it is important of confirm the capsular pattern
of restriction of the joint and the diagnosis of adhesive capsulitis.
Physical Tests:
1. Rotation screening Test - I
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PERIARTHRITIS SHOULDER 2012
With slight restriction, the patient is unable to get the hand for up the back, and
with severe restriction, he will not be able to get it behind the back at all.
2. Rotation screening Test – II
Ask the patient to place both hands behind the head to screen external rotation at
900 abduction compare the 2 sides lack of success or restriction is common in frozen
shoulder.
Differential Diagnosis:
Frozen Shoulder
Atraumatic Instability
Cervical Spondylosis
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PERIARTHRITIS SHOULDER 2012
INVESTIGATIONS
The laboratory studies are rarely required for evaluation of severe cases of pa
shoulder.
Whether lab investigation should be considered mandatory in a patient presenting
with the classic syndromes of idiopathic cases of shoulder in the absence of symptoms of
concomitant system rheumatoid, inflammatory or metastapic disorders remains unclear.
The following lab tests are ordered
1. Thyroid stimulating hormone level test
2. The serum triglyceride level test
3. The fasting blood sugar levels in most patients particularly. Those
presenting with bilaleral disease.
4. ESR level
5. Free Thyroxine Hormone.
I. Arthrographic Findings:
l Arthrographic findings appears to be one of the most prevalent characteristics of
long cases of PA shoulder. The shoulder joint can accept 28-35 ml of solution with 16 ml
of contrast fluid allowing the best viewing of normal joint.
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PERIARTHRITIS SHOULDER 2012
The contrast dye is injected posteriorly since the capsule is usually contracted
superiorly, inferiorly and anteriorly.
Abnormal findings include retraction of the capsule away from the greater
tuberosity ragged and irregular outline of the capsule and absence of the dependent
axillary fold and poor filling of the biceps.
The joint volume is markedly decreased to less than 10 ml, and pain is usually
experienced as the capacity is reached.
2. X-Ray :
Usually normal but in a few cases “sclerosis” may be seen on the outer edge of
greater tuberosity (Golding’s sign)
3. Magnetic Resonance Imaging :
MRI is an expensive and non specific test, however if the patient does not improve
after a period of time (6 weeks to 3 months) then MRI is approximately to rule out.
It is a special radiological test where magnetic waves are used to create pictures
that 100K like slices of shoulder. It can also show the tendon of shoulder and rule out
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PERIARTHRITIS SHOULDER 2012
whether there has been tear in those tendons that is rotator cuff fear infra articular
pathology.
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PERIARTHRITIS SHOULDER 2012
PREVENTION
The primary consideration in the treatment should be prevention.
The golden rule for all painful shoulder syndromes is avoiding prolonged
immobilization.
Prevention is better than cure don’t let the shoulder stiff in the first place.
Preventive programme:
a. Prevention of primary capsulitis
b. Prevention of secondary capsulitis and
c. Prevention of further damage
a. Prevention of primary capsulitis
It is very difficult to know the on set of the disease in its early phase as the
symptoms of pain and stiffness are not acute.
From observations noticed that the initial pain and stiffness were elevated when
the shoulder was passively taken to its terminal range of overhead abduction in elevation.Secondly, the early symptom is pain in lying on the side of the affected shoulder.
Therefore, the regular practice of this particular movement could be instrumental in
prevention, early defection and lessening the impact of this condition.
b. Prevention of secondary capsulitis :
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PERIARTHRITIS SHOULDER 2012
l Careful early mobilization to the extreme range of motion needs to be emphasized
for the other benefits of exercise in addition to the prevention of secondary adhesive
capsulitis in the following situations.
i. All the procedures around the chest and shoulder requiring prolonged
immbilisation.
ii. All situations requiring prolonged bed rest
Ex: coronary artery disease, fractures in the upper limb
iii. Paralysed arm following stroke.
iv. Unconscious patient following stroke.
v. Mastectomy
c. Prevention of further damage
i. Suddenly applied jerky stretching and
ii. Crude – self styled manipulations by a quack, result in high tensile resistance
and give rise to further constriction of the already constricted capsule. Thus
there is an increase in pain due to muscle spasm leading to further stiffness.
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PERIARTHRITIS SHOULDER 2012
Adhesive capsulitis can be avoided through proper measures by education t the
masses to seek proper advice on simple terminal stretching of the shoulder.
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PERIARTHRITIS SHOULDER 2012
MEDICAL TREATMENT
Analgesics to reduce pain
Non steroidal anti inflammatory drugs (NSID’S) to reduce inflammation.
The oral corticosteroids provides an even stronger anti inflammatory effect than
the non – steroidal medication.
Either medication may be used in conjunction with a subacromial corticosteroid
injection.
Depending upon the severity of symptoms prescribed a weak tapered course of oral
corticosteroid.
Corticosteroid dosage in patients with pa shoulder
1. Day 1 to 7 predniselone 40 mg / day
2. Day 8 to 14 predniselone 30 mg / day
3. Day 15 to 18 predniselone 20 mg / day
4. Day 19 to 21 predniselone 10 mg / day
5. Day 22+ predniselone
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PERIARTHRITIS SHOULDER 2012
SURGICAL TREATMENT
It is indicated when pain is severe and persistant. When recovery of motion must
be hastend and when a lesion is suspected.
Technique :
Transacromial approach is used and the acromion is discarded. Subacromial bursa
are resected.
Splitting the ligaments longitudinally enters the joint.
The intra articular biceps tendon is freed when where it is adherent to the capsule
and the head of humerus.
Its origin at the glenoid rim is cut and the tendon is removed to the point where it
enters the bicipital groove.
Transverse humeral ligament is cut, the facial roof is split, and the extra articular
tendon is elevated.
If the tendon is to be fixed to the groove, all soft tissue is curative from the groove
and the tendon is replaced and held by sutures run through adjacent drill holes.
Otherwise tendon may be attached to the coracoid process.
Another alternative is to elevate the lateral wall of the groove with an osteotomy.Post operatively, the arm is immobilized at the side for several weeks
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PERIARTHRITIS SHOULDER 2012
PHYSIOTHERAPY TREATMENT
IN ACUTE STAGE
Aims:
1. To reduce inflammation
2. To reduce pain
3. To maintain muscle strength
P.T. Management :
To Decrease pain:
1. Cryotherapy
Cryotherapy is helpful in decreasing pain and discomfort especially during the
acute phase of disease.
Cryotherapy is a treatment of a pathological lesion by use of low temperature to
relieve pain and muscle spasm.
Cooling by ice cubes will act in a counter irritant, which causes a reduction in
acetyl choline and produce an asynchrony of impulse, which can break the pain
pattern.
It is useful in removing swelling and in the repair.
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PERIARTHRITIS SHOULDER 2012
Ice applied in with a towel is stroked over the effected part.
2. TENS:
(Transcutaneous electrical nerve stimulation)
Works on the principle of pain gate mechanism and achieves pain relief by
stimulating large afferent fibers preferentially and thus inhibiting transmission of
the pain impulse.
It is significantly most effective in reducing acute pain.
Therefore, tens is an excellent treatment choice when the patient is in discomfort.
3. ULTRASOUND :
Ultrasound waves are the sound waves with a frequency of more than 20,000 Hz.
Therapeutically 1-3 M.Hz.
Useful in reducing the pain
Micro massage effect in pulse mode will block the pain pathway by lowering the
nerve conducting velocity.
It is useful in prior to the stretching capsule.
Patient will be in position with arm should be abducted and externally rotated.
Treatment duration in 5-6 min.
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PERIARTHRITIS SHOULDER 2012
2. To decrease inflammation:
Iontophorosis:
It is a process by which electrically charged molecules and ions are driven into the
tissues with the help of an electric field. It may also be called as ion exchange.
During Iontophorosis the tissue is an electrolyte form with electrode pads
containing drugs are attached to one sides.
When electric charge is applied, the movement of charged ions occurs from the
positive to the negative pole through the skin and vice versa.
Usually the active electrode placed on the treatment area liberates more ions in the
tissues. It is extremely effective in hyper hydrosis and soft tissue inflammation
conditions.
Salicylate and copper diclophenyle, sodium are used to decrease the inflammation
in periarthritis of shoulder.
To maintain muscle strength :
Strengthening exercises:
Aim of strengthening is to restore normal equal function of the shoulder.
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PERIARTHRITIS SHOULDER 2012
In addition to full range of motion, strength and endurance of the rotator cuff
muscles and other shoulder girdle muscles must be regained.
Isometric and isokinetic strengthening exercises enhance further healing by
increasing blood flow.
Strengthening of the rotator cuff muscles are exhibited by the arm at the side and
elbow flexed to 900, the hand goes from internal rotation to full external rotation
without abduction at the shoulder.
If the arm can be abducted to 900 without pain, external rotation can be performed
in this position.
With the arm in abduction the flexed arm can be rotated extremely against
resistance.
IN CHRONIC STAGE:
Aims :
1. To reduce pain
2. To increase joint range of motion.
3. To decrease spasm
4. To restore joint movement.
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PERIARTHRITIS SHOULDER 2012
5. To improve functional ability.
6. To gain confidence.
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P.T. MANAGEMENT :
1. Short ware diathermy : (SWD)
It is a high frequency current commonly used at a frequency of 27.12 MHZ. with a
wavelength of 11 metres.
In PA shoulder the method of application is contra planar where use electrodes are
place over the opposite aspect of the limb so the effect is deeper in the treatment
part.
Electrode type may be pad or disc electrodes.
Patient position for pad electrode is supine lying and for disc electrode in sitting
position.
Duration of treatment is 20-30 min.
Effects & Uses:
Relieves pain
Increases metabolism
Increases blood supply
Reduces muscle spasm.
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PERIARTHRITIS SHOULDER 2012
2. Paraffin wax:
Paraffin wax is superficial heating agent that uses conductivity as the primary form
of heat transfer.
The boiling point is 52% to 54% but during application it is reduced to 400 to 450C
Method of application is by dipping a towel in the melted wax and keeping on the
shoulder for 3 to 5 minutes and the patient is used to move the limb actively up to
pain free region and then therapist increases the range of motion passively.
Effects & Uses:
Decreases the pain and spasm.
Increases the local temperature superficially.
Increased blood flow washout the metabolic waste products and decreases the pain.
3. Hydro collator Packs:
Application of hydro collator packs causes moist heat.
Effects & Uses :
Reduce pain and spasm
4. Massage :
It is to relieve pain and spasm.
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The manipulation that are used as follows.
a. Kneading :
It is a type of pressure manipulation, which is performed all over the 3 types of
deltoid muscles and reduces the muscles spasm and relaxes the muscle.
b. Friction :
It is given around the shoulder joint so that the synovial fluid around the joint by
loosing the adhesions and tightness of the shoulder structures.
c. Picking up:
Performed over deltoid, biceps muscles. It gives a squeezing effect, which
increases the elasticity of muscles fibers and maintain muscles properties.
5. Inter Ferential Therapy : (IFT)
It is a form of electrical treatment in which two medium frequency currents are
used to produce a low frequency effect.
The principle on which it is based is it produces the LF effect where two medium
frequency currents cross in the patient tissue. Beat frequency is the difference
between the two medium frequency currents.
Methods of Application :
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PERIARTHRITIS SHOULDER 2012
The patient is in sitting position.
One channel of electrodes placed anteriorly and posteriorly to the shoulder.
Other channel electrodes placed one on above the shoulder and other at deltoid
insertion.
Duration of treatment is 15-20 minutes.
Effects & Uses:
Relieves pain
Produces placebo effect and relieves pain.
Reduces muscles spasm.
Improves blood supply.
6. Pulsed Ultra Sound :
Duration of treatment is 10-20 minutes.
Effect :
To break down the adhesions and to reduce pain.
7. Moist Heat :
Applied in the form of hydro collator packs.
Effects :
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PERIARTHRITIS SHOULDER 2012
Reduces pain
Decreases muscle spasm
To improve shoulder joint movements :
1. Free Exercises :
a. Stoop stride sitting : arm swinging forward and backward.
b. Half reach fallout standing : One arm swinging backward, forward
and circling.
c. Arms crossed sitting : One arm lateral rotation with
swinging obliquely forwards and upwards.
d. Stride standing : arm swinging across, sideways and sideways
upwards and circling.
e. Walk standing : overhead throw
f. Walk standing : throw and catch quoits.
2. Codman’s Pendular Exercises :
These are techniques use the effects of gravity to distract the humerus from the
glenoid fossa.
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PERIARTHRITIS SHOULDER 2012
They help to relieve pain through gentle traction and oscillating movements and
provide early motion of joint structures and synovial fluid.
Patient Position & Procedure :
Standing with the trunk flexed at the hips about 900 the arm hangs loosely
downward in a position between 600 & 900 flexion.
A pendulum of swinging motion of the arm is initiated by having the patient move
the trunk slightly back & forth. Motion of flexion, extension, abduction, abduction
and circumduction can be done. Increase the arc of motion as tolerated. This
technique should not cause pain.
If patient cannot balance themselves leaning over, have them hold on to a solid
object or lie prone on a table. If the patient experiences back pain from bending over, use the prone position.
3. Assisted Exercise:
Towel Stretch :
Drop a towel arm the opposite shoulder, grasp with the hand behind patient back.
Gently pull the towel upward with other hand so that he should felt the stretch in
shoulder and upper arm.
Self assisted:
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PERIARTHRITIS SHOULDER 2012
Overhead stretch :
Lie on back with the arms at sides. Left one arm straight up and over the patients
head.
Grasp the elbow with other arm exert gentle pressure to stretch the arm as far as
you can.
Cross body reach :
Stand and lift one arm at the same height brings its to the front and across the
body. As it passes the front of the body grab the elbow with the other arm extent
gentle pressure to stretch the shoulder.
Self Stretching Techniques:
Here the patient should be taught to allow intensity prolonged stretching
To increase the flexion & elevation, the patient sits with the side next to the table
in front arm resting along with the elbow slightly flexed.
The patient is asked to slide the forearm along with the table while bending from
the wrist.
To increase the abduction the patient is seated as above & asked to slide sideways.
The patient is asked to stand 2-3 feet away from the wall without bending the
elbow with a full stretched hand against the wall.
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Then the patient is asked to climb the wall with the fingers.
This exercise is performed both for flexion and abduction.
Pulley Exercises :
These are the type of overhead exercises performed by using a pulley placed above
the head.
The normal arm passively elevates the involved arm by baring the pulley slightly
behind the head.
The arm gets a further range of motion to over come the stable signs of limitation.
Wand exercises:
The patient lies in supine position by holding a wand on both sides with an over
headed grip and the arm above the chest. Move the elbows fully extended until the
arm is over headed.
The affected shoulder is fully relaxed while the other arm guides the affected arm
and the discomfort areas held in the over headed position for 2-3 seconds.
Standing wand Abduction :
Patient grips on both sides of the wand & the wand is moved straight away from the
body.
With the affected arm above & unaffected arm below the wand abduct in sideways.
Five repetitions are given.
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Mariner’s Wheel :
The patient is made to stand by the side of the wheel & asked to rotate without
bending the elbow.
Bracing exercises :
The patient is asked to clasp his hand at the back of the head and asked to stretch the
hand outwards so the overall range of motion of shoulder is increased.
In this the normal arm pulls the limited arm over and behind the hand.
Strengthening exercises :
a. Isometrics for External Rotators :
Position the humerus at the patient side, in slight flexion, slight abduction, and
with the elbow flexed 900, apply resistance against the external rotation motion.
Isometrics for Abductore :
Maintain the humerus neutral to rotation and resist abduction at 00, 300, 450, 600,. If
there are no contra indication to motion above 900, preposition the humerus in
external rotation before elevating the humerus and resting above 900 abduction.
b) Dynamic strengthening for external rotators : (Infraspinatus & Teresminor) :
Sitting and standing, using elastic resistance or wall pulley in front of the body at
elbow level. Instruct the patient to grasps the elastic material (or) the pulley handle
and rotate his / her arm outward.
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PERIARTHRITIS SHOULDER 2012
Side lying on normal side with involved shoulder upright and arm resulting on the
side of thorax with a rolled towel under the axialla. Have the patient use a hand held
weight, weight cuff, or elastic resistance and rotate the arm through the desired
range of motion. Prone on a treatment table upper arm resting on the table with
shoulder at 900 if possible, elbow flexed with forearm over the edge of the table.
Lift the weight as far as possible by rotating the shoulder, not extending the elbow.
Activation, of the infraspinatus and teresminor is maximized with this exercise.
Sitting with elbow flexed 900 & supported on a table so that the shoulder is in the
resting position. The patient lifts the weight from the table by rotating the shoulder.
Dynamic Strengthening for Abductors (Deltoid & Supraspinatus)
1. “Military Press:
Sitting, arm at the side in external rotation with elbow flexed & forearm supinated.
Have the patient lift the weight straight up overhead.
2. Abduction against gravity :
Sitting or standing with a weight in hand. Have the patient abduct the arm to 900,
then laterally rotate & elevate the arm through the rest of range.
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PERIARTHRITIS SHOULDER 2012
Side lying with involved arm upper most. Have the patient lift a weight upto 900.
Prone on a treatment table upper arm resting on the table with shoulder at 900 if
possible, elbow flexed with forearm over the edge of the table. Lift the weight as far
as possible by rotating the shoulder, not extending the elbow. Activation, of the
infraspinatus and teresminor is maximized with this exercise.
Sitting with elbow flexed 900 & supported on a table so that the shoulder is in the
resting position. The patient lifts the weight from the table by rotating the shoulder.
Dynamic Strengthening for Abductors (Deltoid & Supraspinatus)
1. “Military Press:
Sitting, arm at the side in external rotation with elbow flexed & forearm supinated.
Have the patient lift the weight straight up overhead.
2. Abduction against gravity :
Sitting or standing with a weight in hand. Have the patient abduct the arm to 900,
then laterally rotate & elevate the arm through the rest of range. Side lying with involved arm upper most. Have the patient lift a weight upto 900.
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PERIARTHRITIS SHOULDER 2012
PHYSIOTHERAPY ASSESSMENT
1. SUBJECTIVE ASSESSMENT :
2. OBJECTIVE ASSESSMENT
1. Subjective Assessment :
Patient Profile :
Name :
Age :
Sex :
Occupation :
Address :
Date of
Admission :
Chief Complaints :
Pain and unable to do routine daily activities live combing the hair, in case of
women wearing the buttons of their blouse, during over head activities etc.,
History :
Present Medical History : Includes about the present condition and what is the medication now he has using.
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PERIARTHRITIS SHOULDER 2012
Also includes whether he was suffering with other conditions now like hypertension,
diabetes mellitus, ischimic heart disease and what are the medications he using for that.
Past medical history :
It includes any illness in the past like trauma, stroke and medication he had taken
for that.
Family history :
Includes about general family health, familial (or) hereditary disease like diabetes.
Personal history :
It includes the life style of the patient
Smoking
Alcohol consumption
Drug abuse etc.
Socio economic history :
Poor
Middle classRich
Pain assessment :
J Site of pain – localized or diffused
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PERIARTHRITIS SHOULDER 2012
J Side of pain – right or left
J On set – sudden, gradual or incidious
J Type of pain – aching / stabbing / throbbing burning
J Duration of pain
J Character of pain – intermittent / continuous
J Severity of pain
J Measured by numerical visual analogue scale (VAS)
0 10
0 no pain 10 = untolerable pain
J Irritability – mild / moderate / severe
Aggrevating factors:
Relieving factors :
Objective assessment :
1. On observation :
Swelling
Redness
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PERIARTHRITIS SHOULDER 2012
Skin changes
Any abnormal contour in bone / muscle / soft tissue
Limb alignment.
2. On palpation :
Tenderness :
Examination of the bone and their structural alignment to defect
tenderness.
Warmth
Swelling
3. On Examination :
a. Vital signs :
- Temperature
- Respiratory rate
- Pulse rate
- Heart rate b) Motor Examination :
1. Active Range of Motion :
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PERIARTHRITIS SHOULDER 2012
Present of pain or any other symptoms to be noted. Degree of pain to be evaluated
active movement is tested to evaluate strength, endurance and flexibility.
2. Passive Range of Motion Test :
It could be normal, is excess or restricted. At the end of passive range of motion
gentle over pressure is given to assess the end feel.
The restriction may be :
Capsular type : restriction of overhead abduction and external rotation.
Non capsular type : all movements are restricted due to intra
articular mechanical blocking or extra articular lesion.
Soft end feel : Muscular restriction.
Hard end feel : Capsular restriction.
Firm End feel : Bony restriction.
c. Muscle Power :
Assessed by manual muscles testing (MMT) method.
0 - No contraction
1 - Flicker of contraction
2 - Movement in gravity eliminated position
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PERIARTHRITIS SHOULDER 2012
3 - Movement against gravity
4 - Movement against gravity with minimal resistance
5 - Normal
d. Muscle girth measurement :
- By using inch type
e) Functional activity examination or assessment :
The influence of the disease on the functional performance of the patient are
examined and recorded on a functional evaluation chart.
Activities effected by pa shoulder are :
Wearing dress
Combing hair
Over head activities etc.
4. Investigation :
By X-Ray
CT Scan
MRI etc.,
5. Provisional diagnosis :6. Treatment
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PERIARTHRITIS SHOULDER 2012
CASE-I
1. Subjective Assessment :Name : P.D.L.AnnapurnaAge : 45 YearsSex : FemaleOccupation : HousewifeAddress : Sivajicafe Centre, Vijayawada.
Chief Complaints :
Pain in the left shoulder from six weeksDifficult to move the left shoulderDifficulty in wearing clothes.
Present Medical History :
History of diabetic & B.P.Using medication for diabetics.
Past Medical History :
At earlier, she taken analgesics for shoulder pain.
Family History :
Patients mother was diabetic.
Socio - Economic History :
Middle Class.
Pain Assessment:Slow onsetAching typeConstantAggravating factor : Lifting or taking any object from sideways.Relieving Factor : Rest
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PERIARTHRITIS SHOULDER 2012
- VAS
2. Objective Assessment :
On Observation :
No swellingNo muscle wasting
On Palpation :
Tenderness in front of shoulderWarmth is present
On Examination :
Vital signs are normalTemperature 370CRespiratory rate 15 per minutePulse rate 70 / minute
Range of Motion :
Presence of pain on doing active movements.
Active ROM :
Flexion 850 Extension 200
Abduction 750 Adduction 300
External Rotation 150 Internal Rotation 250
Passive ROM:
Flexion 900 Extension 200
Abduction 750 Adduction 300
External Rotation 150 Internal Rotation 300
Muscle Power :Deltoid : Grade 3Rotator Cuff Muscles : Grade 3
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PERIARTHRITIS SHOULDER 2012
End Feel : Bonny end feel
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PERIARTHRITIS SHOULDER 2012
Functional Assessment :
Unable to do overhead activities
Feeling difficulty in clothing.
Physiotherapy Management :Aims:
To relieve painTo improve Joint ROMTo increase mobility of teh shoulderTo strengthen the shoulder girdle muscles.
Means & Methods:
Ice therapyUltra SoundIFTMariner’s wheel exercisesOverhead pulley exercisesCodman’s pendular ExercisesStrengthening exercises for deltoid and rotator cuff musclesMobilization exercises
Home Programme :Do’s:
Codman’s Pendular exercisesSelf assisted and self resisted exercisesWall ladder exercisesIce application or hot water fermentation to reduce pain
Dont’s:
Advice not to lift heavy weights with affective shoulder.Advice not to sleep on affected shoulder side.
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CASE-II
1. Subjective Assessment :Name : K.S.SaraswathiAge : 60 YearsSex : FemaleOccupation : HousewifeAddress : Maruthinagar, Vijayawada.
Chief Complaints :Pain in the right shoulder from five weeksRestricted over head activitiesUnable to comb the hairFeeling difficulty in dressing.
Present Medical History :Patient was diabeticsSuffering from Asthma.
Past Medical History :Taken insulin therapy for diabetic10 years back opposite side fore arm both bone fracture.Medications using from 10 years for diabetics.
Family History :Patients father was diabetic.
Socio - Economic History :Middle Class.
Pain Assessment:Pain in right shoulder from 5-6 monthsDiffused painSudden onsetContinuous painVAS
Aggravating factor : Sleeping on affected shoulder Movement of the left shoulder
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PERIARTHRITIS SHOULDER 2012
Relieving Factor : Rest
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PERIARTHRITIS SHOULDER 2012
2. Objective Assessment :
On Observation :
No swellingNo muscle wasting
On Palpation :
Tenderness on above and back of the shoulder
On Examination :
Vital signs are normalTemperature 370CRespiratory rate 15 per minutePulse rate 70 / minute
Range of Motion :
Active ROM :
Flexion 1000 Extension 350
Abduction 800 Adduction 350
External Rotation 200 Internal Rotation 400
Passive ROM:
Flexion 1100 Extension 350
Abduction 900 Adduction 350
External Rotation 250 Internal Rotation 400
Muscle Power :
Deltoid : Grade 4Rotator Cuff Muscles : Grade 3End Feel : Bonny end feel
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PERIARTHRITIS SHOULDER 2012
Functional Assessment :
Patient is unable to reach the hand behind his back.
Unable to comb hair.
Investigations :
X-ray shows decreased to joint space.
Physiotherapy Management :Aims:
To relieve painTo reduce Joint stiffnessTo increase joint range of motionTo increase mobility of shoulder.
Means & Methods:
Ice therapySWDUltra SoundIFTTENS
Exercise Therapy :
Active Pendular ExerciseHydro therapyWall ladder exercisesMariner’s wheel exercises
Home Programme :
Regular follow up of pendular exercises.Wall climbing exercises.
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