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Sex
Gender distribution is bimodal, with peak incidence in men aged 20-30 years
(with a male-to-female ratio of 9:1) and in women aged 61-80 years (with a female-to-
male ratio of 3:1).
Age
Shoulder dislocation occurs more frequently in adolescents than in younger
children because the weaker epiphyseal growth plates in children tend to fracture before
dislocation.
In older adults, collagen fibers have fewer cross-links, making the joint capsule and
supporting tendons and ligaments weaker and dislocation more likely.
1
Anterior dislocation is most commonly seen in those aged 18-25 years due to
sporting injury. The second most common age group to sustain anterior dislocation
is in elderly persons due to their susceptibility to falls.
Pathological changes;
bankarts lesion ;dislocation causes stripping of the glenoidal labrum along with
the periostieum from the anterior surface of the glenoid and scapular neck.the head
thus comes to lie in front of the scapular neck ,in the pouch thereby created.
c)Roundening off of the anterior glenoid rim occurs as the head dislocate over it.
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3
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ANATOMY
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The osseous segment of the shoulder complex are the clavicle, scapula and
humerus (Figure 3). These three segments are joined by three interdependent
linkages:- The Sternoclavicular(SC) joint, Acromioclavicular(AC) joint and
the Glenohumeral(GH) joint. The articulation between the scapula and the
thorax is Scapulothoracic(ST) “joint”. It does not have characteristics of a
fibrous, cartilageous or synovial union rather it is “Functional Joint”. Instead,
the scapular motion on the thorox is directly a function of Sternoclavicular,
Acromioclavicular or combined Sternoclavicular and Acromioclavicular joint
motion.
Sternoclavicular Joint
The SC joint serves as the only structural attachment of the clavicle, scapula
and upper extremity to the axial skelton.
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Due to concave convex shape of the articular surfaces the joint can be
classified as a Plane Synovial Saddle joint. This joint has a synovial capsule,
a joint disk and three major ligaments.
Articulating structures
The SC articulation consist of two saddle – shaped surfaces, one at the sternal
or medial end of the clavicle and one at the notch formed by the manubrium
of the sternum and first costal cartilage. The sternal end of the clavicle and
the manubrium are incongruent; that is there is little contact between their
articular surfaces. The superior portion of the medial clavicle does not
contact the manubrium at all, serves as the attachment of sternoclavicular
joint disk and interclavicular ligament.
Sternoclavicular Disk
The SC joint has a fibrocartilage joint disk that increases congruence between
joint surfaces.
The upper portion of the SC disk has attachment to the postero superior
clavicle.
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The SC joint is surrounded by a fairly strong fibrous capsule and three
ligaments for the majority of its support. These ligaments are:-
Acromioclavicular Joint:-
The AC joint attaches the scapula to the clavicle. It is a plane synovial joint.
It has a joint capsule and two major ligaments, a joint disk may or may not
be present.
Articulating Surfaces:-
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The AC joint consist of the articulation between the lateral end of the
clavicle and a small facet on the acromion of the scapula. The articular facet
considered to be incongruent, vary in configuration. They may be flat,
reciprocally concave – convex or reversed. The facets are covered with
fibrocartilage.
The capsule of the joint is weak and cannot maintain integrity of the joint
without reinforcement of the ligaments. These ligaments as –
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The conoid part is attached below to the coracoid process just lateral
to the scapular notch. It is attached above to inferior surface of the
clavicle on the conoid tubercle.
Glenohumeral Joint:-
Articulation-
The articulation is formed by the –
Glenoid fossa of scapula proximally.
Head of the humerus distally.
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2. Musculotendinous cuff of shoulder joint.( Figure 4)
3. Glenoid labrum.
Glenoid Labrum
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dependent at the side). The capsular surface area is twice that of humeral
head. The relative laxity of the GH capsule is necessary for the large
excursion of joint surfaces but provides little stability without the
reinforcement of ligaments and muscles. When the humerus is abducted and
laterally rotated on the glenoid fossa, the capsule twist on itself and tightens,
making abduction and lateral rotation the close – packed position for the GH
joint. The capsule is reinforced by following ligaments:-
1. Superior GH ligaments.
2. Middle GH ligaments.
3. Inferior GH ligaments.
4. Coracohumeral ligaments.
The three GH ligaments vary considerably in size and extent and may
change with age. The superior GH ligaments passes from the superior
glenoid labrum to the upper neck of humerus deep to coracohumeral
ligament. The superior GH ligaments, the superior capsule, and the
coracohumeral ligament are interconnected structures that bridge the space
between the supraspinatus and subscapularis muscle tendon, forming
Rotator Interval Capsule.
The middle GH ligament runs obliquely from the superior anterior labrum to
the anterior aspect of proximal humerus below the superior GH ligaments
attachment.
The inferior GH having at least three portions and thus have been termed the
inferior GH ligaments complex (IGHLC). The three components of the
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complex are the anterior and posterior bands and the axillary’s pouch in
between.
Coracoacromial Arch
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Figure 5.Coracoacromial arch
Glenohumeral Bursae
There are various bursae present indicative of the potential for functional
forces between structures. They are –
2. Subdeltoid bursa
3. Subscapularis bursa
4. Infraspinatus bursa
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Figure 6. Subacromial bursa
Relations
Blood Supply
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3. Suprascapular artery.
4. Subscapular artery.
Nerve Supply
1. Axillary nerve
2. Musculocutaneous nerve
3. Suprascapular nerve
Scapulothoracic Joint
It is not a true anatomical joint because it has none of the usual joint
characterstics (union by fibrous, cartilageous, or synovial tissues).
Articulating Surfaces
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seventh ribs. The scapula is internally rotated 30o to 45o from the coronal
plane, is tipped anteriorly approximately 10o to 20o from vertical, and is
upwardly rotated 10o to 20o from vertical.
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BIOMECHANICS
BIOMECHANICS
SCAPULOTHORACIC JOINT
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The scapula also lies 30o to 40o forward of the frontal plane and in tipped
anteriorly approximately 10o to 20o from vertical with a good deal of
individual variability.
2. Elevation / depression
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- Elevation and depression are translatory motions in which the scapula
moves upward (cephalad) or downward (caudally) along the rib cage from
its resting position.
- Protraction and retraction of the scapula on the thorax are often described
as translatory motions of the scapula away from or towards the vertebral
column, respectively. The scapula follows the contour of the ribs by
rotating internally and externally at the AC joint in combination with
clavicular protraction and retraction at the SC joint.
These last two movements are not obvious movement but are unobtrusive
motion necessary to maintain the scapula relative flush with the curved rib
cage. These motions occur when the range of scapular motion is exhausted or
in certain pathological conditions.
Stability
2. Muscles that attach to both the thorax and scapula contact between
these surfaces while producing the movements of the scapula. In
20
addition, stabilization is provided through scapulothoracic
musculature by pulling or compressing the scapula to the thorax.
STERNOCLAVICULAR JOINT
Clavicular elevation-48o
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Protraction and retraction of the clavicle occur at the SC joint around
an approximately vertical (superoinferor) axis that also appears to lie
at the costoclavicular ligament.
From its fully rotated position, clavicle can rotate anteriorly again to
return to neutral.
Stability
Capsuloligamentous structure
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Sternoclavicular disk
ACROMIOCLAVICULAR JOINT
Internal and external rotation at the AC joint bring the glenoid fossa of
the scapula anteromedially and posterolaterally, respectively.
Anterior tipping will result in the acromion tipping forward and the
inferior angle tipping backward.
Posterior tipping will result in the acromion rotating backward and the
inferior angle forward.
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plane of the scapula, passing midway between the joint surfaces of the
AC joint.
Upward rotation tilts the glenoid fossa upward and downward rotation
is the opposite motion.
1. Flexion / Extension.
2. Abduction / Adduction.
Flexion – 120o
Extension – 50o
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GH abduction – 90o – 120o.
Medial and lateral rotation occur about a long axis parallel to the shaft of
the humerus and passing through the center of the humeral head.
This restriction to rotation when the arm are at sides may be related to
different alignment of the greater and lesser tubercle, which creates a
mechanical block.
Stability
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2. GH joint capsule has an airtight seal, which produces negative
intra-articular pressure. This pressure creates a relative vaccum
that resists inferior humeral translation caused by force of gravity.
- The action lines of the three segments of the deltoid acting together
coincide with the fibers of the middle deltoid(Figure 7). When the
26
muscle action line (FD) is resolved into its parallel (Fx) and
perpendicular (Fy) Components in relation to the long axis of the
humerus, the parallel component directly cephalad (superiorly) is by
far the larger of the two components.
- The force (Fx) applied parallel to the long axis of the bone creates a
shear force rather then stabilizing effect.
- The action lines of the four segments of the rotator cuff are –
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(ii) Posteriosly located infraspinatus teres minor
- If any one or all three of the vector pulls of the infraspinatus, teres minor
or subscapularis muscles is resolved into its components( Figure 8.), it can
be seen that the rotatory force component (Fy) not only tends to cause at
least some rotation of the humerus, gives its orientation to the long axis of
the bone, but Fy also compresses the head into the glenoid fossa.
- Long head of biceps brachii, because of its position at the superior capsule
and its connections to structure of rotator interval capsule reinforce cuff of
the GH joint.
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SHOULDER COMPLEX MOTION
Under normal condition each joint make its contribution not only in a fiercely
consistent manner but following a pattern of concomitant and co-ordinated
movement known as scapulohumeral rhythm.
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2. Optimal position of GH fossa to receive head of humerus increase
joint congruence and decrease shear forces.
Phase One
Upper and lower portion of trapezius muscle combine with upper and lower
portion of the serratus anterior muscle to produce an upward rotatory force on
the scapula. The middle trapezius may also contribute to upward rotation.
Although upward rotation of the scapula would appear to occur at the AC
joint, the coracoclavicular ligament prevents these AC movement because the
ligament bind the coracoid process of the scapula to the clavicle. The upward
rotatory force on the scapula from the contracting muscles, therefore must
produce movements at the next available joint, SC joint.
The pull of trapezius and serretus anterior muscles on the scapula (and the
direct pull of the upper trapezius on the lateral clavicle) force the clavicle to
elevate. Clavicular elevation carrier the scapula through 30o of upward
rotation as the scapula rides on the lateral end of the ring clavicle while
maintaining a relatively fixed Scapuloclavicular angle. Elevation of the
clavicle is checked when the costoclavicular ligament becomes taught.
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Because the ST upward rotation and clavicular elevation occur concurrently
with GH motion, the GH joint can be expected under normal condition to
simultaneously flex or abduct about 60o (wing an overall 2:1 into with the
understanding that individual differences exist). Given 30o of ST upward
rotation and 60o of GH flexion & abduction, the arm will be elevated
approximately 90o to 100o from the side of the body. During the initial 30o of
ST motion, the AC joint maintain a relatively fixed relation between the
scapula and clavicle, although 10o of medial rotation and some anterior
tipping of the scapula to maintain the scapula against the changing contour of
the rib cage.
Phase Two
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scapula its final position on the rib cage, the AC joint absorbs varying amount
of anterior / posterior and medial / lateral rotation.
Raising the aim from the horizontal to vertical position involves an additional
60o of GH movement (with lateral rotation needed for scaption and abduction)
and 30o of ST movement produced by clavicular rotation and AC motion. For
the clavicle to rotate about its longitudinal axis, it would appear to require
mobility of both the SC and AC joints. However the internal fixation of the
AC joint does not significantly impair range of elevation, whereas attempted
internal fixation of the SC joint most often result in extension of the fixating
harware. These observations would lead. one to conclude that the SC joint is
of primary importance both for the first 30o of ST upward rotation with the
AC joint playing supporting role.
The sequence of phase one and phase two scapulo – humeral motions occurs
regardless of the plane in which the arm is elevated. That is although the
range may vary somewhat the component event are similar whether the
motion is performed as flexion, abduction or scaption of the arm in the frontal
plane requires concomitant lateral rotation of the humerus to permit first GH
range. There is also another difference between performance of sagittal plane
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and frontal plane elevation. Although the scapula must upwardly rotate in
both stances flexion requires simultaneous protection keeping the fossa in line
with the shaft of the humerus. If it did not occur, the head of the humerus
would be unprotected posteriorly, posterior dilocation could occur with
relatively little force. In abduction of the arm in the frontal plane, the
scapula tends to remain in neutral protraction – retraction or is slightly
retracted.
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CLASSIFICATION
Classification;
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dislocation of the sholder may be the of the following type;-
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o Posterior shoulder is full with humeral head palpable beneath the
acromion process.
o Patient resists external rotation and abduction.
This is rare type where the head comes to lie in the subglenoid position.
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CLINICAL
FEATURES
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Clinical Features
• Pain. The pain is severe and is located in the region of the affected
shoulder following a traumatic first dislocation. This is mainly true of
anterior dislocations.
• Deformity. Anterior dislocations reveal themselves with the obvious
lengthening of the arm, and the elongated look of the shoulder. The
affected individual will support the afflicted arm.
• Posterior dislocations do not reveal themselves to well, and one can be
lead to think all is well, hence they are are most often upto 80% of
times missed until a later date.
• Bruising. There is a variable amount of bruising but a large bruising
should be suspicious of an underlying fracture as well as a dislocation
(fracture-dislocation)
• Numbness/Weakness. There may a weakness of lifting the shoulder
and a numbness over the shoulder, for as the shoulder dislocates, it
stretches the 'Axillary Nerve', and causes the nerve to disfunction.
This usually recovers over the following days to months.
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INVESTIGATION
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DIAGNOSIS
On examination: The patient keeps his arm abducted. The normal round
contour of the shoulder joint is lost, and it becomes flattened. On careful
inspection one may notice fullness below the clavicle due to displaced head,
which can be felt to rotate by rotating the arm, the following are some signs,
associated with anterior dislocation mostly of academic significance:
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41
TESTS FOR ANTERIOR SHOULDER INSTABILITY
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Rowe test for anterior instability
The patient lies supine and places the hand behind the head. The examiner
places one hand (clenched fist) against the posterior humeral head and
pushes up while extending the arm slightly. A look of apprehension or pain
is indicative of a positive test for anterior instability. If a clunk or grinding
sound is heard when doing the test, it may indicate a torn anterior labrum.
The patient lies supine. The examiner places the hand of the affected
shoulder in the examiner’s axilla, holding the patient remains relaxed. The
shoulder to be tested is abducted between 80o and 120o, forward flexed up to
20o, and laterally rotated up to 30o.
The examiner then stabilizes the patient’s scapula with the opposite hand,
pushing the spine of the scapula forward with the index and middle fingers.
The examiner’s thumb exerts counterpressure on the patient’s coracoid
process.using the arm that is holding the patients hand, the examiner places
his or her hand around the patient’s relaxed upper arm and draws the
humerus forward. The movement may be accompanied by a click or by
patient apprehension or both.
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Tests for posterior shoulder instability;-
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table partially stabilizes the scapula as well ). The examiner then
rotates the upper arm medially and forward flexes the shoulder to
between 60 degree and 80 degree while at the same time taking the
thumb of the other hand off the corcoid procees and pushing the
head of humerus posteriorly .The head of the humerus can be felt
by the index finger of the same hand. The test is usually pain free,
but the patient may exhibit apprehension. A positive test is
indicative of posterior instability and demonstrates significant
posterior translation ( >50% humeral head diameter).
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Test for inferior and multidirectional shoulder
instability :-
Feagin test.;
The feagin test is a modification of the sulcus sign test with the
arm abducted to 90 degree instead of being at the side. The patient
stands with the arm abducted to 90 degree and the elbow extended
and resting and top of the examiner shoulder the examiner hands
are clasped together over the patients humerus, between the upper
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and middle thirds. The examiner pushes the humerus down. Doing
the test this way often give the examiner greater control when
doing the test . a sulcus may also be seen above the coracoid
process. A look of apprehension on the patient face indicate a
positive test and the presence of anteroinferior instability
.
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TREATMENT
48
TREATMENT
CONSERVATIVE MANAGEMENT
(1) Traction- with elbow flexed to a right angle steady traction is applied
along the long axis of the humerus
(4) Internal Rotation- the arm is rotated internally so that the hand falls
across to the opposite shoulder
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A fracture of the greater tuberosity ,often associated with an anterior
dislocation usually comes back to its position as the head is reduced and
needs no special treatment.
SURGICAL TREATMENT-
The following operations may be considered:
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recurrently unstable shoulder arthroscopically. Cases where the
number of dislocations has been less then 5 from the ideal cases for
such a treatment. Apart from being a more cosmetic option, the
rehabilitation after arthroscopic repair is faster and better. It is a
technically demanding operation and the sutures used for repair are
expensive. This technique is available only in selected centres.
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PHYSIOTHERAPY MANAGEMENT
PHYSIOTHERAPY MANAGEMENT
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MOBILISATION ( AFTER 3 WEEKS)
After the removal of the strapping the limb is supported in a sling. Elbow
should be immobilised to the full extent by removing the sling
intermittently.
External rotation should be initiated in the same position and by the same
technique. It should be done with the arm adducted by the side of the body.
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As it is important to avoid secondary adhesive capsulitis, relaxed passive
movements to the shoulder be carried out to the full or near normal range at
the earliest. Self-assisted relaxed movements with wand in supine lying are
also helpful at this stage.
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Once a good passive range is attained, regime of strengthening is begun.
Self-resisted isometric and slow isotonic movements to be taught as a home
treatment programme. Resistive devices like dumbells could be used in the
department.
COMPLICATIONS
1. Fracture of the greater tuberosity or surgical neck of the humerus.
2. Supraspinatus tendonitis
3. Rotator cuff injury
4. Recurrent anterior dislocation of shoulder
5. Injury to the axillary nerve
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POSTERIOR DISLOCATION
This injury is caused by forceful internal rotation of the shoulder ,e.g. during
electroconvulsive therapy or epileptic attack or severe electrical shock.
TREATMENT
PHYSIOTHERAPY MANAGEMENT
The treatment objective and the treatment approach basically remain the
same as described for the anterior dislocation of the shoulder. The only
difference being the utmost care while carrying out the movement of
adduction and internal rotation.
The movement of adduction should be done with shoulder in external
rotation and the movement of internal rotation should be done with shoulder
in abduction. Patients need to be cautioned against performing these
movements either simultaneously or separately with jerk.
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57
RECURRENT ANTERIOR DISLOCATION OF THE
SHOULDER
Recurrent anterior dislocation of the shoulder occurs due to the failure of
healing of torn or avulsed capsule from its anterior glenoid attachment .
Lateral rotation is the most persistent cause of this , which allows the defect
to open and the head of humerus slips anteriorly . It is a common
phenomenon accounting for more than 80 % of dislocation of the upper
extremity.
TREATMENT
PHYSIOTHERAPY MANAGEMENT
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Preventive regime of physiotherapy
59
thermotherapy or cryotherapy adjunct before initiating these movements.
Once the near-normal or full range is achieved, the patient is taught to carry
out these movements.
Extra care should be taken during the terminal range of elevation and
external rotation. As adequate stabilization of the shoulder-girdle facilitates
relaxation or the gleno-humeral joint, the patient should be advised to get
some assistance at home while performing these movements. However ,
proper guidance to stabilize the shoulder girdle has to be learnt from the
physiotherapist before carrying it out at home.
For the success of this regime of prevention, long standing efforts(3 to6
months) and skilful education of the patient are essential.
The regime of physiotherapy for the patient treated with surgery proceeds
on the same lines as described for the “anterior dislocation”. The main
difference being the secured safety of performing the movements.The joint
is stable as the head of the humerus is enveloped firmly by overlapping of
the divided parts of subscapularis. Therefore, passive sustained stretching is
safe. But , it needs hard efforts to achieve active terminal range of elevation
and external rotation.
Usually the extreme range of external rotation remains deficient. However ,
a strong and functional shoulder can be achieved within 10=12 weeks.
On the whole the results are excellents.
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- Make a complete & accurate diagnosis
- Early pain reduction
- Scapular stabilization
- Early achievement of 90o of abduction
- Closed chain rehabilitation
- Plyometric exercise
- Rotator cuff exercise
- Integration of kinetic chain into rehabilitation
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Pain is a cause of altered shoulder function. Avoidance of painful
positions causes the athlete to assume abnormal positions of the arm. Pain
also creates a high degree of muscle inhibition which alter muscle firing
pattern.
Treatment- pain should be controlled by relative rest of the area or
decresed throwing activities.
- avoidance of painful arcs of motion.
- Cryotherapy
- Ultrasound
- Infection into the subacromial space
- NSAIDS
- Analgesics
- Exercise should be kept with in pain free range.
3) scapular stabilization
The scapula is the base upon which all shoulder activities rest.
The four main roles of scapula include
i) retraction & protraction in different phases of throwing motion.
ii) Elevation of acromion in abduction of the arm
iii) Acting as a socket for GH joint
iv) Acting as a base of origin for the muscle of rotator cuff, deltoid,
biceps & triceps.
Treatment- assess the motion & position of the scapula in various
phases of throwing motion & also assess muscular strength & scapular
stabilization.
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- most of the scapular control exercises are done through the method of
closed chain rehabilitation.
Eg- scapular retraction – push up-resistance a medial side of scapula by
physiotherapist.
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The predominal method of muscle activation around the shoulder
articulation is a closed chain activity & emphasing co-contraction at the
scapulo-thoracic & GH joint.
This result in proper scapular stability.
Open chain activities which involve agonist antagonist force couple
&generate force for the shoulder & kinetic chain are also done around the
shoulder.
Treatment-the exercise started at levels below 90o of abduction in early
phase of rehabilitation to allow for healing of tissues.
-the hand is placed against some object such as a table, a ball, or the wall.
Eg for closed chain exercise
i)scapular retraction
ii)scapular elevation
iii)wall push ups
iv)knee push ups
6)Plyometric exercise
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Eg rubber tubing exercise, balls are also excellent plyometric devices.
Rotator cuff muscles are very important in maintaing the humeral head
into the glenoid socket.
Rotator cuff muscles should be rehabilitated as an integrated unit rather
than as individual muscle. They do not work in isolation in shoulder
fuction.
Early rotator cuff exercise should be done in a closed chain fashion. This
allows rotator cuff strengthening with out including shear on the joint. If
rotator cuff deficits are still observed in later phases of rehabilitation,
isolation rotator cuff exercise can be administered.
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