Review. Stroke Rehabil, tion. Painful HemipJegrc Shoulder' Robert leasell MD Sanjit Bhogal MSc Norine Foley BASc Mark Speechley PhD

Size: px
Start display at page:

Download "Review. Stroke Rehabil, tion. Painful HemipJegrc Shoulder' Robert leasell MD Sanjit Bhogal MSc Norine Foley BASc Mark Speechley PhD"

Transcription

1 Review of Stroke Rehabil, tion,-.. '. i7~:7 -;; -, -" ;,.,,,/;; :.. -".".: -'",'.,--., ", - ';-- ','. ". Painful HemipJegrc Shoulder' Robert leasell MD Sanjit Bhogal MSc Norine Foley BASc Mark Speechley PhD From the Departments of Physical Medicine and Rehabilitation, S1. Joseph Health Care, London, Parkwood Hospital, London and Epidemiology and Biostatistics, University of Westem Ontario, London, Ontario. Canada Ontario Canadian Stroke Network

2 Painful Hemiplegic Shoulder Robert Teasell MD, Sanjit K. Bhogal MSc, Norine Foley BASe, Mark Speeehley PhD Last Updated May 9,

3 Table of Contents 11.1 Causes of Hemiplegic Shoulder Pain Shoulder Subluxation PATHOPHySiOLOGy SCAPULAR ROTATION PAIN IN SHOULDER SUBLUXATION Spasticity, Contractures and Hemiplegic Shoulder Pain (HSP) SPASTIC MUSCLE IMBALANCE FROZEN OR CONTRACTED SHOULDER Rotator Cuff Disorders Functional Impact of Painful Hemiplegic Shoulder Management of the Painful Hemiplegic Shoulder POSITIONING OF THE HEMIPLEGIC SHOULDER SLINGS AND OTHER AIDS STRAPPING THE HEMIPLEGIC SHOULDER ACTIVE THERAPIES IN THE HEMIPLEGIC SHOULDER INJECTIONS IN THE HEMIPLEGIC SHOULDER FUNCTIONAL ELECTRICAL STIMULATION (FES) IN THE HEMIPLEGIC SHOULDER SURGERY AS TREATMENT FOR MUSCLE IMBALANCE MOTOR BLOCKS AS TREATMENT FOR MUSCLE IMBALANCE SUMMARY OF THE MANAGEMENT OF HEMIPLEGIC SHOULDER Shoulder Hand Syndrome PATHOPHySiOLOGy CLINICAL PICTURE DIAGNOSTIC TESTS TREATMENT OF SHOULDER-HAND SYNDROME CORTICOSTEROID TREATMENT OF SHOULDER-HAND SYNDROME Summary...a 37 3

4 Key Points Spasticity and hemiplegic shoulder pain are related. Further research is needed before conclusions regarding positioning of the hemiplegic shoulder can be made. There is limited evidence that shoulder slings influence clinical outcomes. Strapping the hemiplegic shoulder does not appear to influence clinical outcomes, including pain. Aggressive range of motion exercises (i.e. pullies) results in a markedly increased incidence of painful shoulder; a gentler range of motion program is preferred. Adding ultrasound treatments is not helpful while NSAIDs may be helpful. Corticosteroid injections do not improve hemiplegic shoulder pain or range of motion. A potentially new treatment of the painful hemiplegic shoulder that requires further research involves deinnervation of the subscapularis and pectoralis major ~ muscles. Oral corticosteroids appear to improve shoulder-hand syndrome for at least the first 4 weeks. 4

5 11. Painful Hemiplegic Shoulder Hemiplegia is a common clinical consequence of a focal cerebral insult resulting from a vascular lesion (ie. hemorrhagic or ischemic stroke). Good shoulder function is a prerequisite for successful transfers, maintaining balance, performing activities of daily living and for effective hand function (Risk et al. 1984). The incidence of shoulder pain varies between studies, with estimates which range from 48% to 84% (Najenson et al. 1971, Poulin de Courval et al. 1990). Shoulder pain can result in significant disability in and of itself (Najenson et al. 1971, Poduri 1993) and can occur as early as 2 weeks post stroke, but usually occurs 2-3 months post stroke onset (Poduri 1993). Although many etiologies have been proposed for hemiplegic shoulder pain, increasingly it appears to be a consequence ofspasticity and the sustained hemiplegic posture. Shoulder pain may be more common among patients with neglect following stroke (Kaplan 1995) Causes of Hemiplegic Shoulder Pain Possible sources of hemiplegic shoulder pain are listed in Table Factors most frequently associated with shoulder pain are shoulder (glenohumeral) SUbluxation (Crossens-Sills and Schenkman 1985, Moskowitz et al. 1969b, Savage and Robertson 1982, Shai et al. 1984), shoulder contractures or restricted shoulder range of motion (Bloch and Bayer 1978, Braun et at 1981, Fugl-Meyer et al. 1975, Crossens-Sills and Schenkman 1985, Hakuno et al. 1984, Risk et al. 1984) and spasticity, particularly of the subscapularis and pectoralis muscles (Braun et al. 1981, Caldwell et al. 1969, Moskowitz 1969a, 1969b).. Other suggested causes of shoulder pain include reflex sympathetic dystrophy (Chu et al. 1981, Davis et at. 1977, Perr;got et al. 1975), or injury to the rotator cuff musculotendinous unit Table 11.1 Potential Causes of Hemiplegic shoulder Pain Anatomical Site Mechanism Muscle Rotator Cuff Muscle Imbalance Subscapularis Spasticity Pectoralis Spasticity Bone Joint Bursa Tendon Joint Capsule Other (Najenson et al. 1971, Nepomuceno et al. 1974). Humeral Fracture Glenohumeral Subluxation Bursitis Tendonitis Frozen or Contracted Shoulder (Adhensive Capsulitis) Shoulder-hand Syndrome (Reflex Sympathetic Dystrophy) 5

6 11.2 Shoulder Subluxation Pathophysiology Shoulder subluxation is best defined as changes in the mechanical integrity of the glenohumeral joint causing a palpable gap between the acromion and humeral head. The most reliable clinical measurement of the subacromial space used in clinical research is calipers (Boyd 1992). The glenohumeral joint is multiaxial and has a range of motion, which exceeds that of other joints in the body. To achieve this mobility the glenohumeral joint must sacrifice stability. Stability is achieved through the rotator cuff, a musculotendinous sleeve which maintains the humeral head in the glenoid fossa, while at the same time allowing shoulder mobility. During the initial period following a stroke the hemiplegic arm is flaccid or hypotonic. 1herefore the shoulder musculature, in particular the rotator cuff musculotendinous sleeve, cannot perform its function of maintaining the humeral head in the glenoid fossa ~nd there is a high risk of shoulder subluxation. Shoulder subluxation is a very common problem inlhemiplegic patients. During the initial flaccid stage of hemiplegia the involved extremity must be adequately supported or the weight of the arm will result in shoulder subljxation. Improper positioning in bed, lack of support while the patient is in the upright po$ition or pulling on the hemiplegic arm when transferring the patient all contribute to gllenohumeral subluxation. Down and lateral subluxation commonly occur secondary to prolonged downward pull on the arm against which hypotonic muscles offer little resistance (Chaco and Wolf 1971). The resulting mechanical effect is overstretching of the glenohumeral capsule (especially its superior aspect) and flaccid supraspinatus and del~oid muscles (Basmajian and Bazant 1959, Shahani et al. 1981) (Figure 11.1). i Figure 11.1 A. Normal Shoulder. The humeral head is ma~ntained in the glenoid fossa by the supraspinatus muscle. I I I I! HUMERAL HEAD --I-~~ 6

7 Figure 11.1 B. Shoulder Subluxation. During the initial phase ofhemiplegia, the supraspinatus muscle is flaccid. The weight ofthe unsupported arm can cause the humeral head to sublux downward out ofthe glenoid fossa. SUPRASPfNATUS MUSCLE SHOtlLOER SUBLUXATION HUMfRALHE Scapular Rotation There appear to be other factors playing a role in subluxation of the glenohumeral joint. Basmajian and Bazant (1959) proposed that in the normal state, subluxation of the humeral head was prevented by upward angulation of the glenoid fossa and the upper part of the shoulder capsule, the coracohumeral ligament and supraspinatus muscle. After a hemiplegic stroke they hypothesized that the upward angulation of the scapula would be lost. Calliet (1980) added that in the flaccid stage, the scapula assumed a {jepr-essedanddownward rotated -position, as the paretic serratus anteriofand the upper part of the trapezius muscles no longer support the scapula. The combination of flaccid supportive musculature (in particular, the supraspinatus muscle) and a downward rotated scapula was presumed to predispose the head of the humerus to undergo inferior subluxation relative to the glenoid fossa. Table 11.2 Scapular Rotation In the Hemiplegic Shoulder Author, Year Prevost et al Canada Method 50 patients who had experienced a cerebrovascular accident, presenting with right hemiplegia. Inferior subluxation of the shoulder in hemiplegia was measured using a tridimensional (3-D) x-ray technique, giving true vertical distance Outcome The angle of abduction of the arm of the affected side was significantly greater than on the non-affected side, p<0.05, but the relative abduction of the arm was on the same order of magnitude for both sides. There was no significant 7

8 Author, Year Method separating the apex of the humeral head and the inferior margin of the glenoid cavity. Both shoulders were evaluated and the difference used as a measure of subluxation. The measure was then compared to the orientation of the scapula relative to the vertical and the abduction of the arm. Outcome relationship between the orientation of the scapula and the severity of the subluxation. The abduction of the humerus was weakly (r=.24) related to the subluxation, which partly explained the weak association found between the relative abduction of the arm and the SUbluxation. Cuiham et al. 34 hemiplegic patients were divided into Scapula was significantly further from the 1995 high-tone and low-tone groups according midline and lower on the thorax on the Canada to Ashworth scoring of muscle tone. affected side in the low-tone group. Glenohumeral subluxation was Significantly greater in the low-tone group. Scapular abduction angle was significantly greater on the non-affected side in the low-tone group. In the high-tone group, no differences were found between the affected and the non-affected side in either the angular or linear measures. Prevost et al. (1987), using a 3-D x-ray technique, studied the movement of the scapllla and humerus in stroke patients. They studied 50 stroke patients comparing the affected to the non-affected shoulder. They were able to demonstrate that there was a difference between the affected and non-affected shoulders in terms of the vertical position of the humerus (ie. degree of subluxation) in relation to the scapula. The orientation of the glenoid fossa was also different; however, they found that with the subluxed shoulder it was actually facing less downward. There was no Significant relationship noted between the orientation of the scapula and the severity of subluxation. They concluded that the scapular position was not an important factor in the occurrence of inferior subluxation in hemiplegia (Prevost et al. 1987). This finding was confirmed by Culham et al. (1995) Pain in Shoulder Subluxation Shoulder subluxation may be associated with several conditions including: shoulder pain (Crossens-Sills and Schenkman 1985, Mos.kowitz et a!. 1969b, Savage and Robertson 1982, Shai et al. 1984, Roy et al. 1994) and frozen shoulder or brachial plexus traction injury (Kingery et a/. 1993), although evidence for the latter is lacking (Kingery et al. 1993). It has long been assumed that if not corrected; a pattern of traction on the flaccid shoulder will result in pain, decreased range of motion and contracture. However, not ai/ patients with a subluxed hemiplegic shoulder experience shoulder pain and it remains controversial as to whether it causes hemiplegic shoulder pain (Fitzgerald-Finch and Gibson 1975, Moskowitz et al. 1969b, Shahani et al. 1981, Bender and McKenna 2001). The failure to consistently report an association may be due, in part to a failure to examine the contribution of other probable etiological factors concurrently. Although several studies have reported an association, others have not 8

9 confirmed this finding. The reader is also reminded that statistical associations are also not evidence of causality. (see Table 11.3) Table 11.3 Studies which Support or Fail to Report an Association between Shoulder Subluxation and Pain Studies Supporting the Role of Shoulder Subluxation in Pain Shai et al Van Ouwenaller et al Poulin de Courval et al Roy et al Chantraine et at 1999 Aras et al Studies Which Fall to Support the Role of Shoulder Subluxation in Pain Peszczynski & Rardin 1965 Bohannon 1988 Vangenberge & Hogan 1988 Bohannon & Andrews 1990 Kumar et al Arsenault et al Joynt 1992 Zorowitz et at 1996 Ikai et al Individual Studies A selection of studies examining the relationship between shoulder subluxation and pain are presented in Table Table 11.4 Pain and Subluxation in the Hemiplegic Shoulder Author, Year Main Outcome Bohannon & 28 consecutively admitted patients undergoing 70.8% of patients demonstrated Andrews rehabilitation for their first stroke who could follow enough shoulder pain to at least 1990 instructions, and were aware of the position of cause them to wince when their USA their paretic limb in space were included. Paretic shoulder SUbluxation and paretic shoulder pain were measured. Shoulder SUbluxation was measured while the patients sat on the edge of a mat table with their paretic upper extremity dependent and the examiner used his thumb to palpate the separation between the acromion and the head of the humerus. He then graded subluxation as none (0), minimal (1) or substantial (2). Shoulder pain was measured during slow lateral rotation of the joint while the patients were supine. All patients' shoulders were abducted about 45 and their elbows were held at 90 0 with their forearms pronated with measurements beginning from neutral shoulder rotation. Patients' responses were graded on a 3-point scale (Ritchie Index) of: no pain, complaint of pain and wince, complaintof pain, wince and withdrawal. SROMP measurements taken with patients' shoulders laterally rotated until they first expressed pain in the shoulder, at shoulders were rotated laterally 90. The SROMP of the paretic side was measured as :!;.28.8 and 64.6 :!; A significant Pearson correlation (-77s, p<0.001) was observed between the Ritchie Index and SROMP indicating that patients with higher scores on the Ritchie Index had fewer degrees. of lateral rotation of the shoulder before pain was experienced. 9

10 Author, Year Main Outcome which point a fluid-filled gravity goniometer. was applied and read. Joynt 1992 A convenience sample of 97 patients suffering 49 patients with specific shoulder USA from pain in the upper extremity was examined. The interval from stroke onset to examination ranged from several days to a few years. 49 patients had specific complaints of shoulder pain. pain were compared to 18 patients with pain, not localized to the shoulder. Patients complaining of shoulder pain did not exhibit subluxation more frequently than patients with general pain in the affected extremity. Zorowitz et 20 stroke patients with shoulder pain, admitted to Shoulder pain after stroke was not al a rehabilitation hospital within 6 weeks of their correlated with age, vertical, USA first stroke were studied. horizontal, or total asymmetry, shoulder f1exion or abduction. or Fugl-Meyer scores. However, shoulder pain was strongly correlated with degree of shoulder extemal rotation Aras etal. 85 consecutive stroke patients admitted to one of 27 patients had glenohumeral joint 2004 the largest rehab facilities in Turkey were studied subluxation and reported shoulder Turkey to identify the incidence of shoulder pain and the factors associated with it. pain. compared to 5 patients with the same finding, but without pain. Conclusions Regarding Shoulder Subluxation Post-Stroke Shoulder subluxation occurs early on in the hemiplegic arm due to flaccid supporting shoulder musculature and is not a result of downward scapular rotation. Shoulder subluxation may be a cause ofshoulder pain; however, patients with shoulder subluxation do not necessarily experience pain and not all cases of hemiplegic shoulder pain suffer from subluxation. Although it has not been established that shoulder subluxation is the primary cause of hemiplegic shoulder pain it would still seem prudent to take care early on with the hemiplegic upper extremity to avoid subluxation Spasticity, Contractures and Hemiplegic Shoulder Pain (HSP) Abnormal muscle tone, including spasticity may be directly related to HSP. Spasticity is defined as a disorder of motor function characterized by a velocity-dependent increase in resistance to passive stretch of muscles accompanied by hyperactive muscle stretch reflexes and often associated with a clasp-knife phenomena. Spasticity is one component of the upper motor neuron (UMN) syndrome and is the inevitable accompaniment of hemiplegia and an incomplete motor recovery. Under normal 10

11 circumstances a delicate balance exists between facilitating and inhibiting influences upon both alpha and gamma motor neurons, which together maintain appropriate control of skeletal muscle length and strength of contraction at the spinal cord level. After a stroke, input from one or more of the supraspinal suppressor areas will decrease or stop entirely. The balance of control over the muscle tips in favour of facilitation and spasticity results. Spasticity develops only if there is loss of input from both pyramidal and extrapyramidal motor systems. Spasticity presents as increased tone and reflexes on the involved side of the body. Individual Studies Table 11.5 Spasticity and Hemiplegic Shoulder Pain Author, Year Outcome Bohannon et 50 patients with hemiplegia was Of the 50 patients reviewed. 72% had al secondary to cerebrovascular accident, shoulder pain. 20 had some pain while 16 had USA whose unaffected shoulders severe pain. Three zero-order correlations No score demonstrated normal and pain-free range of hemiplegia shoulder external rotation (ROSER. 90 ); able to adequately follow instructions to allow testing of all variables pertinent to the study. Information was retrieved from patients' records concerning their initial physical therapy evaluation. Relationships between pain and other variables were determined. were significant: ROSER and shoulder pain (r=-0.061, p<0.001), time since onset of hemiplegia and shoulder pain (r=0.45, p<0.01). and time since onset of hemiplegia and ROSER (r=0.37, p<0.01). One-way ANOVA demonstrated that time since onset of hemiplegia (F=8.28, p<0.001) and the ROSER (F=18.44, p<0.001) were significantly different in patients with no pain, some pain, and pronounced/severe pain. Van Ouwenaller et al Switzerland No score 219 hemiplegia patients were followed for 1 year after their stroke. Radiographic examinations were done for each patient. 72% of patients had shoulder pain at least once during their recovery occurring most often in patients having spasticity (85%) than in patients which flaccidity (18%). Appearance of spasticity was evident in 80% of patients while 20% remained hypotonic. Van Ouwenaller et al. (1986) looked at various factors in 219 patients followed for one year after a stroke and identified a much higher incidence of shoulder pain in spastic (85%) than in flaccid (18%) hemiplegics. They identified spasticity as "the prime factor and the one most frequently encountered in the genesis ofshoulder pain in the hemiplegic patient." They were unsure of the etiology of the subsequent shoulder pain. Poulin de Courval et al. (1990) examined 94 hemiplegic subjects involved in a rehabilitation program after stroke and reported that subjects with shoulder pain had significantly more spasticity of the affected limb than those without pain. In contrast, Bohannon et al. (1986) conducted a statistical analysis of 50 consecutive hemiplegic patients (36 with shoulder pain) and asserted that "spasticity... was unrelated to shoulder pain." Joynt (1992) also supported this finding after examining 67 patients with shoulder problems following stroke. Nevertheless, evidence for spasticity in particular hypertonic muscle imbalance, as a cause of hemiplegic shoulder pain is growing. 11

12 Spastic Muscle Imbalance Hemiplegia following stroke is characterized by typical posturing reflecting hypertonic muscle patterns. Flexor tone predominates in the hemiplegic upper extremity and results in scapular retraction and depression as well as internal rotation and adduction of the shoulder. This posture is the consequence of ablation of higher centers and subsequent release of motor groups from pyramidal and extrapyramidal control. In stroke recovery, this "synergy pattern" of muscles is 'inevitable where recovery is incomplete. One consequence of this is the development of spastic muscle imbalance about the shoulder joint. Clinically the internal rotators of the shoulder predominate after a stroke involving that arm and external rotation is one of the last areas of shoulder function to recover. Hence, during recovery motor units are not appropriately recruited or turned off; the result is simultaneous co-contraction of agonist and antagonist muscles. A shortened agonist in the synergy pattern becomes stronger and the constant tension of the agonist can become painful. Stretching of these tightened spastic muscles causes more pain. Shortened muscles inhibit movement, reduce range of motion, and prevent other movements especially at the shoulder where external rotation of the humerus is necessary for arm abduction greater than 90 degrees. Muscles that contribute to spastic internal rotation/adduction of the shoulder include the subscapularis, pectoralis major, teres major and latissimus dorsi muscles. However, two muscles in particular have been implicated as most often being spastic leading to muscle imbalance. These are the subscapularis and pectoralis major muscles. Subscapularis Spasticity Disorder The subscapularis muscle originates on the undersurface of the scapula and inserts on the lesser tuberosity of the humerus as well as the capsule of the shoulder joint (Figure 11.2). It is a major internal rotator of the shoulder (Hollinshead and Jenkins 1981). The subscapularis muscle also participates in arm abduction and extension from a flexed position (Cole and Tobis 1990). In normal individua.ls, nerve impulses to the subscapularis are inhibited during arm abduction; the muscle then relaxes and allows the humerus to externally rotate, thus preventing impingement of the greater tuberosity on the acromion (Codman 1934). As part of the typical flexor synergy pattern in spastic hemiplegics, internal rotators, including the subscapularis muscle, are tonically active. This limits shoulder abduction, flexion and external rotation. Bohannon et al. (1986) found limitation of external rotation of the hemiplegic shoulder was the factor which most correlated with hemiplegic shoulder pain. Zorowitz et al. (1996) also found that limitation in shoulder external rotation correlated strongly with pain. Hecht (1995) specifically linked this problem to the subscapularis muscle when he noted, "The subscapularis muscle is the primary cause ofshoulder pain in spastic hemiplegia where external rotation is most limited. Although other muscles may contribute to spasticity, pain and functional contracture, the subscapularis is the keystone ofthe abnormal synergy pattern." 12

13 Figure 11.2 The Subscapularis Muscle. The subscapularis muscle is a major internal rotator ofthe shoulder. As part ofthe typical flexor synergy pattern in spastic hemiplegics, the subscapularis is tonically active limiting not only external rotation but also shoulder abduction and flexion. Subscapularis The subscapularis spasticity disorder is characterized by motion being most limited and pain being reproduced on extemal rotation. A tight band of spastic muscle is palpated in the posterior axillary fold. In support of this, Inaba and Piorkowski (1972) reported external rotation was the most painful and limited movement of the hemiplegic shoulder. Pectoralis Spasticity Disorder The pectoralis major muscle serves to forward 'Hex, adduct and internally rotate the arm. Hecht (1995) has reported on a subset of hemiplegic patients with greater limitations in abduction (and flexion) than on external rotation. In these patients a spastic pectoralis major muscle appears to be problematic. This disorder is characterized by motion being most limited and pain produced on abduction. A tight band of spastic muscle can be palpated in the anterior axillary fold (Hecht 1995). It is also noteworthy that the pectoralis major muscle is a synergist of the subscapularis muscle. 13

14 Figure 11.3 The Pectoralis Major Muscle. The pectoralis major muscle serves to adduct, internally rotate and forward flex the arm at the shoulder Pecto#alis Majof (c:javictjiar division) Pec1ora1is MajOr (slerna' di'llision) Frozen or Contracted Shoulder A frozen or contracted shoulder is a frequently identified source of pain in the spastic hemiplegic shoulder (Bohannon et al. 1986, Eto et al. 1980, Fugl-Meyer et al. 1975, Grossens-Sills and Schenkman 1985, Hakuno et al. 1984, Risk et al. 1984). Individual Studies Table 11.6 Evidence of Frozen Shoulder Post Stroke Author, Year Outcome Hakuno et al. 77 patients with hemiplegia caused by Contractures/adhesions were found in 1984 cerebrovascular accidents were randomly paralyzed shoulders at a statistically Japan selected from all hemiplegic patients treated at rehab centre. Cases with dementia and verbal dysfunction were eliminated. Paralysis affected the right side in 35 patients and the left side in 42 patients. In 35 cases the affected arm was dominant whereas 42 cases had paralysis in nondominant arm. Positive contrast arthography was preformed on both shoulders of all patients. An anterior approach for injection of the joint with contrast material was employed. The needle was inserted directly into the glenohumeral joint space under fluoroscopic control. Anteroposterior significant higher rate (54.6%) than in the non-paralysed side (32.5%). The occurrence rate of contrast leakage from a capsule tear on the subscapular bursa and the bicipital tendon sleeve was higher on the non-paralysed side than on the paralysed side. It was suggested that capsular contracture due to hemiplegia reduces capsular tearing during arthrographic maneuvers. 14

15 i Author, Year radiographs were made in internal and external rotation. 21 male patients all received standard physical therapy treatment. Shoulder pain, range of motion and subluxation were assessed on admission, three weeks post admission and at discharge. Outcome Crossen-Sills & Schenkman 1985 USA 67% of the patients entered the rehab centre with Signs of shoulder pain. An additional 10% developed initial signs of shoulder pain by 3 weeks post admission and another 5% developed signs of pain at time of discharge. Positive correlation noted between loss shoulder range and increase in pain and between subluxation and pain. There was no correlation between subluxation and range of motion. Suggestion that pain began in the acute cares facility and worsened while in rehab. Rizketal. Study of 30 spastic hemiplegic (18 with left 23 patients had capsular constriction 1984 hemiplegia and 12 with right hemiplegia) typical of frozen shoulder (adhesive USA patients with painful ipsilateral shoulders meeting the following criteria: maximum passive range of motion (ROM) of 60 0 abduction, 90 forward flexion, 15 0 external rotation, 45 extension; any stress at the limit of motion produced severe shoulder, with no improvement during the previous 2 weeks, no history of recent trauma to the affected shoulder during the previous 2 weeks, no history of seizures or anticonvuslant medications; no clinical signs suggesting shoulder-hand syndrome, no bone disease or polyarthritis or previous shoulder pain before stroke onset. All patients had shoulder arthrograms performed. Electromyographic studies were done on the deltoid, triceps, and biceps brachii muscles on the muscles on the involved side. capsulitis). 7 patients had normal arthrograms. None showed rotator cuff of capsular tears. Electromyography revealed electrical silence in the shoulder musculature at rest. Bohannon et 50 patients whose hemiplegia was Of the 50 patients reviewed, 72% had at 1986 secondary to a stroke, whose unaffected shoulder pain. 20 had some pain while USA shoulders demonstrated normal and pain 16 had severe pain. Three zero-order No Score free range of hemipl~ia shoulder external rotation (ROSER, 900); able to adequately follow instructions to allow testing of all variables pertinent to the study. Information was retrieved from patients' records concerning their initial physical therapy evaluation. Relationships between pain and other variables were determined. correlations were Significant: ROSER and shoulder pain (r=-0.061, p<0.001); time since onset of hemiplegia and shoulder pain (r=0.45, p<0.01); and time since onset of hemiplegia and ROSER (r=0.37, p<o.01). One-way ANOVA demonstrated that time since onset of hemiplegia (F=8.28. p<0.001) and the ROSER (F=18.44, p<0.001) were significantly different in patients with no pain, some pain, and pronounced/severe pain. 15

16 In summary, while shoulder subluxation is not always associated with shoulder pain, spasticity generally is. The problem of hemiplegic shoulder pain appears to be due to a combination of spastic muscle imbalance and a frozen contracted shoulder. However, overaggressive stretching of the shoulder through an aggressive stretching program may simply aggravate pain (see Treatment), as it does not address the issue of spastic muscle imbalance. Conclusions Regarding Spastic Hemiplegic Shoulder There is an association between spasticity and the development ofhemiplegic shoulder pain. Spasticity and subsequent frozen shoulder are the most likely causes of hemiplegic shoulderpain. Spasticity and hemiplegic shoulder pain are related Rotator Cuff Disorders Because shoulder pain is so often associated with rotator cuff disorder in a non-stroke population it should not be surprising that it would be seen as a potentially common cause of hemiplegic shoulder pain. However, Risk et al. (1984) failed to demonstrate any evidence of rotator cuff tears on arthrography in 30 patients with hemiplegic shoulder pain (Risk et al. 1984). A similar study (Nepomuceno and Miller 1974) reported a 33% incidence of rotator cuff tears in painful shoulders after strokes. Partial tears of the rotator cuff musculature are common and it is always difficult determining whether they were present premorbidly even in previously asymptomatic patients. Joynt (1992) diagnosed 67 stroke patients as having hemiplegic shoulder pain. 28 patients received a subacromial injection of 1 % lidocaine; approximately half obtained moderate or marked relief of pain and improved range of motion. However, this provides only indirect evidence of rotator cuff disorders as a possible cause of hemiplegic shoulder pain. Generally, hemiplegic shoulder pain is not commonly associated with rotator cuff disorders Functional Impact of Painful Hemiplegic Shoulder A painful hemiplegic shoulder can be very limiting. It has the potential to further add to the disability seen with hemiplegia. 16

17 , Table 11.7 Impact of Painful Hemiplegic Shoulder on Function Author, Year Outcomes Wankyln et 108 post stroke patients were studied. 63.8% of all patients developed hemiplegic at 1996 Patients were over the age of 60, shoulder pain (HSP). HSP was associated with UK about to be discharged home and had reduced shoulder shrug and reduced pinch grip. No Score suffered stroke with persisting disability defined as a Barthellndex score less than 20. Patients who required assistance with transfer were more likely to suffer with HSP. Significantly more patients with Barthellndex scores less than 15 reported HSP compared to those with a score between 15~20 at both discharge (59% vs. 25%) and at 8 weeks (77% vs. 51O/~: Aras et al. 85 consecutive stroke patients 54 patients (63.5%) had shoulder pain. Shoulder 2004 admitted to one of the largest rehab pain was reported more frequently among patients Turkey facilities in Turkey were studied to with reflex sympathetic dystrophy, lower motor No Score identify the incidence of shoulder pain. functional level of shoulder and hand, subluxation, and limitation of external rotation and flexion of shoulder. Age was also associated with.the development of shoulder pain. No relationships were found between shoulder pain and sex, time since onset of disease, hemiplegic side, pathogenesis, spasticity, neglect, and thalamic pain, or extension of hospital stay. Wanklyn et al. (1996) and Roy et al. (1996) both demonstrated an association between hemiplegic shoulder pain and poor functional outcomes. However, a cause and effect relationship has not yet been established. Conclusions Regarding Functional Impact ofhemiplegic Shoulder Pain The development ofpainful hemiplegic shoulder is associated with severe strokes and poorer functional outcome Management of the Painful Hemiplegic Shoulder Management of the painful hemiplegic shoulder is difficult and response to treatment is frequently unsatisfactory (Risk et al. 1984). Early passive shoulder range of motion is an important prophylactic treatment. Supporting and protecting the involved shoulder in the initial flaccid stage is also regarded as important. Treatment involves analgesics, nonsteroidal anti-inflammatory medications, physical modalities (local heat and cold), transcutaneous electrical nerve stimulation, and local steroid injections. Surgical procedures are rarely utilized Positioning of the Hemiplegic Shoulder The muscles around the hemiplegic shoulder are often paralyzed, initially with flaccid tone and later with associated spasticity. Careful positioning of the shoulder serves to 17

18 minimize subluxation and later contractures as well as possibly promote recovery. Bender and Mckenna (2001) have noted that a primary goal of early stroke management is to prevent the development of hypertonicitiy (Johnstone 1992) and to discourage inefficient patterns (Bobath 1990). Bender and McKenna (2001) noted that the "recommended position for the upper limb is towards abduction, external rotation and flexion ofthe shoulder," however, from Carr and Kenny (1992) review, Bender and McKenna cite that "most popular theories failed to yield consensus for exact degrees of the positioning." Individual Studies Table 11.8 Positioning ofthe Shoulder in Stroke Patients Author, Year Outcomes PEDro Score Carr and Review of the literature. General agreement about postures with the Kenney 1992 No Score shoulder protracted. the arm brought forward, the spine straight and fingers extended. Still controversy regarding height of the arm in the forward position. Dean et al. 23 patients were randomized to receive Changes in active and passive range of motion 2000 an experimental therapy or to a control were not Significant between the groups with Australia group. Subjects in both groups the level of pain remaining unchanged. 5 (RCT) participated in a multidisciplinary rehabilitation program and participated in active training of reaching and manipulation tasks. The experimental group received prolonged positioning to the affected shoulder each day, five days a week for six days (positionina). Ada et al. 36 stroke patients were randomized to Positioning the shoulder in maximal extemal 2005 an intervention or a control condition. rotation (position 1) significantly reduced the Australia Patients in the experimental group development of contractures, compared to the 6 (RCT) received two, 30-minute sessions of sustained shoulder positioning. Patients in both groups received 10 minutes of shoulder exercises and routine upper limb care. The treatment was provided for 4 weeks. Assessments of contracture were taken at weeks 2 and 6 after stroke. control group. In position 2 (where patients sat with the affected arm resting on a table with the shoulder at 90, for 30 minutes daily), did not prevent the development of contractures. Conclusions Regarding Positioning ofthe Hemiplegic Shoulder There is consensus (Level 3) opinion that proper positioning of the hemiplegic shoulder helps to avoid subluxation. However, there is conflicting (Level 4) evidence that prolonged positioning does not influence active and passive range of motion or level ofpain. Given the small numbers ofstudies and the "fair" quality rating of the only RCT, further research is warranted..~. 18

19 Further research is needed before conclusions regarding positioning of the hemiplegic shoulder can be made Slings and Other Aids Arm slings are often used in the initial stages following a stroke to support the affected arm. However, their use is controversial and they can have disadvantages in that they encourage flexor synergies, inhibit arm swing, contribute to contracture formation and decrease body image causing the patient to further avoid using that arm. However, a Sling remains the best method of supporting the tlaccid hemiplegic arm while the patient is standing or transferring. Ada et al (2005) conducted a systematic Cochrane review evaluating the benefit of shoulder slings and supports, and concluded that there is insufficient evidence that thj3se devices reduce or prevent shoulder subluxation following a stroke. The review included only four RCTs (Ancliffe et al. 1992, Griffin et al [unpublished data]. Hanger et al and Hurd et al. 1974). The results are presented in Table Table 11.9 Results from Systematic Review (Ada et al. 2005) Outcome Studies Included & Intervention Peto Odds ratio (95% Cl) or Weighted Mean Difference (WMD) (95% Cl) Proportion of patients with pain at follow up Hurd et a! hemisling ORS.7(1.1,67.1) (Favours no slinqs) Number of days pain was delaved with treatment Ancliffe et al. -strapping Griffin et a!. WMD 14 days (9.7, 17.8) (Favours slings) Pain scores on VAS (10 cm scale) Hanger et al strapping WMD 0.83 (-1.46,3.12) (No difference) Motor Assessment sub scores! (0-18) Hanger et al. -strapping WMD 0.8 (-1.5,3.1) (No difference)., Proportion of patients with Hurd et al sling OR 1.00 (0.1, 9.3) contractures (No difference) Range of shoulder external rotation at end of follow up Hanger et al strapping WMD -1.4 degrees (-10.9,8.10) (No difference) I As tone returns to the shoulder muscles, the risk of shoulder subluxation decreases and slings can then be withdrawn. Slings tend to accentl!ate the adduction and internal rotation posture and may contribute to shortening of tonically active muscles. The best method to support the shoulder has yet to be determined. In the absence of empirical evidence of their efficacy, many devices are available and in common use, including a variety of slings and lapboards.. 19

20 Individual Studies Table Slings and Other Aids in Hemiplegic Shoulders Author, Year Outcomes PEDro Score Hurd et al. 14 patients were alternately Of the 7 patients without slings, 5 had no pain, while assigned to be treated with a had little pain. Of the 7 patients treated with slings, 6 USA sling or without a sling, assessed had little pain, while 1 had no pain. No Score 2 to 3 weeks and 3 to 7 months post stroke. Moodie et al. Series of radiographs Shoulder roll and Hook-Hemi Harness did not reduce 1986 (anterior/posterior view) of 10 SUbluxation to the same extent as the other 3 devices. Canada patients' affected and unaffected Subluxation was reduced within 20% of the correct No Score limbs in order to permit comparisons for degree of subluxation and the 5 aids to be evaluated were then applied to the patients' affected arm and an AlP view was taken of each: conventional sling; shoulder roll; Hook-Hemi Harness; arm trough; and plexiglass lap tray. alignment in Bout of 10 patients when treated with the sling; 6 of the 10 treated with the arm trough, and 7 of the 10 patients treated lap tray. Suggested that the sling, trough, and lap tray reduced the mean SUbluxation to within.56 cm of normal control while the roll and hook tended to under-correct the subluxation. Williams et al. Radiographs were taken of 26 There was no significant difference in the reduction of 1988 hemiplegic patients with inferior subluxation between the two types of shoulder Canada subluxated shoulders with two supports. However, there were significant differences in No Score different supports-the Bobath shoulder roll and the Henderson shoulder sling. Radiographs of the unsupported affected shoulder were compared with radiographs of the same shoulder with each support applied. Radiographs of the unaffected shoulder were used as a comparison in determining the amount of subluxation. subluxation between measurements of the unsupported affected shoulder and the unaffected shoulder and between measurements of the unsupported affected shoulder and the supported affected shoulder using both supportive devices. BrooKe et al. Three different shoulder supports Harris hem i-sling improved correction of the 1991 were applied to 10 patients by subluxation with mean vertical distance of 37.Bmm vs USA their occupational and physical 3B.5mm compared to the uninvolved shoulder while the No Score therapists: Hams hemi-sling, the Bobath sling and the arm trough or lapboard. mean difference between Harris and Bobath sling was 5.5(2.9) mm, in favour of the Harris sling. For horizontal measurement, mean difference between Harris and Bobath slings was 8.3(6.3) mm, in favour of the Hams sling. Zorowitz et An occupational therapist applied The single-strap hemisling corrected vertical al each shoulder support to each of displacement, while the Roylan and Bobath roll USA 20 patients in the following order: significantly reduced vertical displacement. The No Score (1) single-strap hemisling; (2) Rolyan humeral cuff sling; (3) Bobath roll; and (4) Cavalier support. Bobath roll and the Cavalier support produced a significant lateral displacement of the humeral head of the affected shoulder compared with the unaffected shoulder. The Roylan humeral cuff sling significantly decreased the total SUbluxation a~mme!!y. 20

Rotator Cuff Pathophysiology. treatment program that will effectively treat it. The tricky part about the shoulder is that it is a ball and

Rotator Cuff Pathophysiology. treatment program that will effectively treat it. The tricky part about the shoulder is that it is a ball and Rotator Cuff Pathophysiology Shoulder injuries occur to most people at least once in their life. This highly mobile and versatile joint is one of the most common reasons people visit their health care

More information

Occupational Therapy Toolkit Stroke

Occupational Therapy Toolkit Stroke Impairments and Functional Limitations: ADL, IADL, work and leisure impairment Impaired sit-to-stand, transfers, bed mobility and gait Hemiparesis, hemiplegia Impaired postural control Impaired coordination

More information

Shoulder Instability. Fig 1: Intact labrum and biceps tendon

Shoulder Instability. Fig 1: Intact labrum and biceps tendon Shoulder Instability What is it? The shoulder joint is a ball and socket joint, with the humeral head (upper arm bone) as the ball and the glenoid as the socket. The glenoid (socket) is a shallow bone

More information

Post-stroke pain. Defining pain 4.1. Duration of pain. Sources of pain. Section overview. Your role as health care provider. This section looks at:

Post-stroke pain. Defining pain 4.1. Duration of pain. Sources of pain. Section overview. Your role as health care provider. This section looks at: SECTION 4 Post-stroke pain Section overview This section looks at: Defining pain Facts about post-stroke pain Types of pain in stroke survivors Identifying pain in stroke survivors Pain assessment and

More information

Chapter 5. The Shoulder Joint. The Shoulder Joint. Bones. Bones. Bones

Chapter 5. The Shoulder Joint. The Shoulder Joint. Bones. Bones. Bones Copyright The McGraw-Hill Companies, Inc. Reprinted by permission. Chapter 5 The Shoulder Joint Structural Kinesiology R.T. Floyd, Ed.D, ATC, CSCS Structural Kinesiology The Shoulder Joint 5-1 The Shoulder

More information

Shoulder Orthopedic Tests

Shoulder Orthopedic Tests Shoulder Orthopedic Tests Tendinitis (Supraspinatus) Supraspinatus tendinitis is a common inflammatory condition of the shoulder that causes anterior shoulder pain. Pain is present especially in abduction.

More information

Open Rotator Cuff Repair Rehabilitation Program Methodist Sports Medicine Center, Indianapolis, IN Department of Physical Therapy

Open Rotator Cuff Repair Rehabilitation Program Methodist Sports Medicine Center, Indianapolis, IN Department of Physical Therapy Open Rotator Cuff Repair Rehabilitation Program Methodist Sports Medicine Center, Indianapolis, IN Department of Physical Therapy Rotator Cuff Repair is a surgical procedure utilized for a tear in the

More information

Biomechanics of the Shoulder and Throwing

Biomechanics of the Shoulder and Throwing Biomechanics of the Shoulder and Throwing Shoulder Anatomy Most mobile joint in the body Ball-and-socket joint 3 bones connected by muscles, ligaments & tendons Clavicle Humerus Scapula Range of Motion

More information

William J. Robertson, MD UT Southwestern Orthopedics 1801 Inwood Rd. Dallas, TX 75390-8882 Office: (214) 645-3300 Fax: (214) 3301 billrobertsonmd.

William J. Robertson, MD UT Southwestern Orthopedics 1801 Inwood Rd. Dallas, TX 75390-8882 Office: (214) 645-3300 Fax: (214) 3301 billrobertsonmd. Arthroscopic Rotator Cuff Repair Postoperative Rehab Protocol Starting the first day after surgery you should remove the sling 3-4 times per day to perform pendulum exercises and elbow/wrist range of motion

More information

SCAPULAR FRACTURES. Jai Relwani, Shoulder Fellow, Reading Shoulder Unit, Reading.

SCAPULAR FRACTURES. Jai Relwani, Shoulder Fellow, Reading Shoulder Unit, Reading. SCAPULAR FRACTURES Jai Relwani, Shoulder Fellow, Reading Shoulder Unit, Reading. Aims Anatomy Incidence/Importance Mechanism Classification Principles of treatment Specific variations Conclusion Anatomy

More information

A Patient s Guide to Shoulder Pain

A Patient s Guide to Shoulder Pain A Patient s Guide to Shoulder Pain Part 2 Evaluating the Patient James T. Mazzara, M.D. Shoulder and Elbow Surgery Sports Medicine Occupational Orthopedics Patient Education Disclaimer This presentation

More information

THE SHOULDER JOINT T H E G L E N O H U M E R A L ( G H ) J O I N T

THE SHOULDER JOINT T H E G L E N O H U M E R A L ( G H ) J O I N T THE SHOULDER JOINT T H E G L E N O H U M E R A L ( G H ) J O I N T CLARIFICATION OF TERMS Shoulder girdle = scapula and clavicle Shoulder joint (glenohumeral joint) = scapula and humerus Lippert, p115

More information

Biceps Tenodesis Protocol

Biceps Tenodesis Protocol Department of Rehabilitation Services Physical Therapy The intent of this protocol is to provide the clinician with a guideline of the postoperative rehabilitation course of a patient that has undergone

More information

2. Repair of the deltoid - the amount deltoid was released and security of repair

2. Repair of the deltoid - the amount deltoid was released and security of repair Johns Hopkins Shoulder Surgery Rotator Cuff Rehabilitation Program Johns Hopkins Shoulder Surgeons INTRODUCTION: This program is designed for rotator cuff repairs involving fixation of the tendon to bone,

More information

Dr. Enas Elsayed. Brunnstrom Approach

Dr. Enas Elsayed. Brunnstrom Approach Brunnstrom Approach Learning Objectives: By the end of this lab, the student will be able to: 1. Demonstrate different reflexes including stimulus and muscle tone response. 2. Demonstrate how to evoke

More information

Rehabilitation after shoulder dislocation

Rehabilitation after shoulder dislocation Physiotherapy Department Rehabilitation after shoulder dislocation Information for patients This information leaflet gives you advice on rehabilitation after your shoulder dislocation. It is not a substitute

More information

ANATOMY: ACROMIAL SHAPE AND SLOPE:

ANATOMY: ACROMIAL SHAPE AND SLOPE: ROTATOR CUFF DISEASE AND IMPINGEMENT Irritation and injury of the rotator cuff are the most common shoulder problems encountered the sports medicine community. While these problems can occur after a specific

More information

Rotator Cuff and Shoulder Conditioning Program. Purpose of Program

Rotator Cuff and Shoulder Conditioning Program. Purpose of Program Prepared for: Prepared by: OrthoInfo Purpose of Program After an injury or surgery, an exercise conditioning program will help you return to daily activities and enjoy a more active, healthy lifestyle.

More information

Rotator Cuff Tears in Football

Rotator Cuff Tears in Football Disclosures Rotator Cuff Tears in Football Roger Ostrander, MD Consultant: Mitek Consultant: On-Q Research Support: Arthrex Research Support: Breg Research Support: Arthrosurface 2 Anatomy 4 major muscles:

More information

Hand and Upper Extremity Injuries in Outdoor Activities. John A. Schneider, M.D.

Hand and Upper Extremity Injuries in Outdoor Activities. John A. Schneider, M.D. Hand and Upper Extremity Injuries in Outdoor Activities John A. Schneider, M.D. Biographical Sketch Dr. Schneider is an orthopedic surgeon that specializes in the treatment of hand and upper extremity

More information

Orthopaedic and Spine Institute 21 Spurs Lane, Suite 245, San Antonio, TX 78240 www.saspine.com Tel# 210-487-7463

Orthopaedic and Spine Institute 21 Spurs Lane, Suite 245, San Antonio, TX 78240 www.saspine.com Tel# 210-487-7463 Phase I Passive Range of Motion Phase (postop week 1-2) Minimize shoulder pain and inflammatory response Achieve gradual restoration of gentle active range of motion Enhance/ensure adequate scapular function

More information

UPPER EXTREMITY INJURIES. Recognizing common injuries to the upper extremity

UPPER EXTREMITY INJURIES. Recognizing common injuries to the upper extremity UPPER EXTREMITY INJURIES Recognizing common injuries to the upper extremity ANATOMY BONES Clavicle Scapula Spine of the scapula Acromion process Glenoid fossa/cavity Humerus Epicondyles ANATOMY BONES Ulna

More information

Muscular Force and Biomechanical Implications

Muscular Force and Biomechanical Implications Page 1 of 6 Biomechanics Muscular Force and Biomechanical Implications William L. Cornelius, Ph.D. Associate Professor of Education University of North Texas Understanding basic concepts of biomechanics

More information

SHOULDER PAIN. Procedures: Subacromial, Glenohumeral and Acromioclavicular Injections Nonprocedural Treatments

SHOULDER PAIN. Procedures: Subacromial, Glenohumeral and Acromioclavicular Injections Nonprocedural Treatments SHOULDER PAIN Anatomy Conditions: Muscular Spasm Pinched Nerve Rotator Cuff Tendonitis Procedures: Subacromial, Glenohumeral and Acromioclavicular Injections Nonprocedural Treatments Surgery: Rotator Cuff

More information

Gregory N. Lervick, MD Jason Ash, ATC, PA-C POSTSURGICAL CORACOACROMIAL DECOMPRESSION REHABILITATION PROTOCOL

Gregory N. Lervick, MD Jason Ash, ATC, PA-C POSTSURGICAL CORACOACROMIAL DECOMPRESSION REHABILITATION PROTOCOL Phase 1: Weeks 0-4 Gregory N. Lervick, MD Jason Ash, ATC, PA-C POSTSURGICAL CORACOACROMIAL DECOMPRESSION REHABILITATION PROTOCOL Acromioplasty Coracoplasty Distal clavicle resection Biceps tenodesis Rotator

More information

Rotator Cuff Injury and Pathology

Rotator Cuff Injury and Pathology Rotator Cuff Injury and Pathology The rotator cuff is made up of four muscles - supraspinatus, infraspinatus, subscapularis and teres minor. The tendons of these muscles blend together to form a cuff around

More information

Impingement series what and why?

Impingement series what and why? SHOULDER Impingement series what and why? ANATOMY Bony elements of the shoulder include Humerus Scapula Clavicle http://www.frozenshoulder.ca/anatomyimages/bones3.jpg ROTATOR CUFF Supraspinatus Infraspinatus

More information

UHealth Sports Medicine

UHealth Sports Medicine UHealth Sports Medicine Rehabilitation Guidelines for Arthroscopic Rotator Cuff Repair Type 2 Repairs with Bicep Tenodesis (+/- subacromial decompression) The rehabilitation guidelines are presented in

More information

Notice of Independent Review Decision DESCRIPTION OF THE SERVICE OR SERVICES IN DISPUTE:

Notice of Independent Review Decision DESCRIPTION OF THE SERVICE OR SERVICES IN DISPUTE: Notice of Independent Review Decision DATE OF REVIEW: 12/10/10 IRO CASE #: NAME: DESCRIPTION OF THE SERVICE OR SERVICES IN DISPUTE: Determine the appropriateness of the previously denied request for right

More information

A Simplified Approach to Common Shoulder Problems

A Simplified Approach to Common Shoulder Problems A Simplified Approach to Common Shoulder Problems Objectives: Understand the basic categories of common shoulder problems. Understand the common patient symptoms. Understand the basic exam findings. Understand

More information

Anterior Capsular Repair Rehabilitation Program Methodist Sports Medicine Center, Indianapolis, IN Department of Physical Therapy

Anterior Capsular Repair Rehabilitation Program Methodist Sports Medicine Center, Indianapolis, IN Department of Physical Therapy Anterior Capsular Repair Rehabilitation Program Methodist Sports Medicine Center, Indianapolis, IN Department of Physical Therapy Anterior Capsule reconstruction is a surgical procedure utilized for anterior

More information

Biceps Tenotomy Protocol

Biceps Tenotomy Protocol Department of Rehabilitation Services Physical Therapy The intent of this protocol is to provide the clinician with a guideline of the postoperative rehabilitation course of a patient that has undergone

More information

Shoulder Biomechanics. Lecture originally developed by Bryan Morrison, Ph.D. candidate Arizona State University Fall 2000

Shoulder Biomechanics. Lecture originally developed by Bryan Morrison, Ph.D. candidate Arizona State University Fall 2000 Shoulder Biomechanics Lecture originally developed by Bryan Morrison, Ph.D. candidate Arizona State University Fall 2000 1 Outline Anatomy Biomechanics Problems 2 Shoulder Complex Greatest Greatest Predisposition

More information

POST OPERATIVE ROTATOR CUFF REPAIR PROTOCOL. Therapist Instructions

POST OPERATIVE ROTATOR CUFF REPAIR PROTOCOL. Therapist Instructions MOON SHOULDER GROUP For information regarding the MOON Shoulder Group, speak to surgeon or contact: Rosemary Sanders 4200 Medical Center East 1215 21st Avenue South Vanderbilt University Medical Center

More information

The Role of Acupuncture with Electrostimulation in the Prozen Shoulder

The Role of Acupuncture with Electrostimulation in the Prozen Shoulder The Role of Acupuncture with Electrostimulation in the Prozen Shoulder Yu-Te Lee A. Aim To evaluate the efficacy of acupuncture with electrostimulation in conjunction with physical therapy in improving

More information

Latissimus Dorsi Tendon Transfer

Latissimus Dorsi Tendon Transfer Rehabilitation Protocol Latissimus Dorsi Tendon Transfer Department of Orthopaedic Surgery Lahey Hospital & Medical Center, Burlington 781-744-8650 Lahey Outpatient Center, Lexington 781-372-7020 Lahey

More information

Injuries to Upper Limb

Injuries to Upper Limb Injuries to Upper Limb 1 The following is a list of common sporting conditions and injuries. The severity of each condition may lead to different treatment protocols and certainly varying levels of intervention.

More information

Ms. Ruth Delaney ROTATOR CUFF DISEASE Orthopaedic Surgeon, Shoulder Specialist

Ms. Ruth Delaney ROTATOR CUFF DISEASE Orthopaedic Surgeon, Shoulder Specialist WHAT DOES THE ROTATOR CUFF DO? WHAT DOES THE ROTATOR CUFF DO? WHO GETS ROTATOR CUFF TEARS? HOW DO I CLINICALLY DIAGNOSE A CUFF TEAR? WHO NEEDS AN MRI? DOES EVERY CUFF TEAR NEED TO BE FIXED? WHAT DOES ROTATOR

More information

Rehabilitation Guidelines for Post-Operative Stiff Shoulder

Rehabilitation Guidelines for Post-Operative Stiff Shoulder Rehabilitation Guidelines for Post-Operative Stiff Shoulder Please note that this is advisory information only. Your experiences may differ from those described. A fully qualified Physiotherapist must

More information

Musculoskeletal System

Musculoskeletal System CHAPTER 3 Impact of SCI on the Musculoskeletal System Voluntary movement of the body is dependent on a number of systems. These include: The brain initiates the movement and receives feedback to assess

More information

SHOULDER INJURIES Overuse Injuries

SHOULDER INJURIES Overuse Injuries SHOULDER INJURIES Overuse Injuries Michael Petrizzi, MD, CAQ 12 Shoulder : Overuse Injuries Michael J. Petrizzi, MD Clinical Professor of Family Medicine Virginia Commonwealth University Richmond, Virginia

More information

Rehabilitation Guidelines for Shoulder Arthroscopy

Rehabilitation Guidelines for Shoulder Arthroscopy Rehabilitation Guidelines for Shoulder Arthroscopy Front View Long head of bicep Acromion Figure 1 Shoulder anatomy Supraspinatus Image Copyright 2010 UW Health Sports Medicine Center. Short head of bicep

More information

The Rotator Cuff Explained

The Rotator Cuff Explained The Rotator Cuff Explained Live Teleseminar with Brian Schiff, PT, CSCS January 24, 2008 Objectives Review pertinent shoulder anatomy Discuss tendonitis, bursitis & tears Highlight common injury causes

More information

Lateral Epicondylitis. Extensor carpi radialis longus Humerus. Extensor carpi radialis brevis Ulna

Lateral Epicondylitis. Extensor carpi radialis longus Humerus. Extensor carpi radialis brevis Ulna UNC SPORTS MEDICINE FAMILY MEDICINE Lateral Epicondylitis What is lateral epicondylitis? Lateral epicondylitis, or tennis elbow, affects 1-3% of Americans each year. The epicondyles are the two bumps on

More information

The Sw S immers immer Shoulder Katie Foster BSc. Sport, BSc. Phy Ph s y iother s apy iother, apy MMT. MMT

The Sw S immers immer Shoulder Katie Foster BSc. Sport, BSc. Phy Ph s y iother s apy iother, apy MMT. MMT The Swimmers Shoulder Katie Foster BSc. Sport, BSc. Physiotherapy, MMT. Overview Anatomy Swimming and the shoulder Posture Impingement Causes and progressions Treatment Prevention The shoulder The shoulder

More information

Upper limb injuries. Traumatology RHS 231 Dr. Einas Al-Eisa

Upper limb injuries. Traumatology RHS 231 Dr. Einas Al-Eisa Upper limb injuries Traumatology RHS 231 Dr. Einas Al-Eisa Pain in the limbs: May be classified under 4 headings: 1. Joint pain 2. Soft tissue pain 3. Neurogenic pain 4. Orthopaedic causes (fractures,

More information

SHOULDER INJURIES Orthopaedic Perspective of Injuries: When Do you Need to Refer Your Patients to Me

SHOULDER INJURIES Orthopaedic Perspective of Injuries: When Do you Need to Refer Your Patients to Me SHOULDER INJURIES Orthopaedic Perspective of Injuries: When Do you Need to Refer Your Patients to Me Thomas Loughran, MD 26 SHOULDER INJURIES An Orthopaedic Perspective When to Refer Thomas Loughran, MD

More information

Biceps Brachii Tendon Proximal Rupture

Biceps Brachii Tendon Proximal Rupture 1 Biceps Brachii Tendon Proximal Rupture Surgical Indications and Considerations Anatomical Considerations: Biceps brachii, one of the dominant muscles of the arm, is involved in functional activities

More information

North Shore Shoulder Dr.Robert E. McLaughlin II 1-855-SHOULDER 978-969-3624 Fax: 978-921-7597 www.northshoreshoulder.com

North Shore Shoulder Dr.Robert E. McLaughlin II 1-855-SHOULDER 978-969-3624 Fax: 978-921-7597 www.northshoreshoulder.com North Shore Shoulder Dr.Robert E. McLaughlin II 1-855-SHOULDER 978-969-3624 Fax: 978-921-7597 www.northshoreshoulder.com Physical Therapy Protocol for Patients Following Shoulder Surgery -Rotator Cuff

More information

J F de Beer, K van Rooyen, D Bhatia. Rotator Cuff Tears

J F de Beer, K van Rooyen, D Bhatia. Rotator Cuff Tears 1 J F de Beer, K van Rooyen, D Bhatia Rotator Cuff Tears Anatomy The shoulder consists of a ball (humeral head) and a socket (glenoid). The muscles around the shoulder act to elevate the arm. The large

More information

CAPPAGH NATIONAL ORTHOPAEDIC HOSPITAL, FINGLAS, DUBLIN 11. The Sisters of Mercy. Rotator Cuff Repair

CAPPAGH NATIONAL ORTHOPAEDIC HOSPITAL, FINGLAS, DUBLIN 11. The Sisters of Mercy. Rotator Cuff Repair 1.0 Policy Statement... 2 2.0 Purpose... 2 3.0 Scope... 2 4.0 Health & Safety... 2 5.0 Responsibilities... 2 6.0 Definitions and Abbreviations... 3 7.0 Guideline... 3 7.1 Pre-Operative... 3 7.2 Post-Operative...

More information

LOURDES MEDICAL ASSOCIATES PROFESSIONAL ORTHOPAEDICS SPORTS MEDICINE & ARTHROSCOPY

LOURDES MEDICAL ASSOCIATES PROFESSIONAL ORTHOPAEDICS SPORTS MEDICINE & ARTHROSCOPY LOURDES MEDICAL ASSOCIATES PROFESSIONAL ORTHOPAEDICS SPORTS MEDICINE & ARTHROSCOPY Sean Mc Millan, DO Director of Orthopaedic Sports Medicine & Arthroscopy 2103 Burlington-Mount Holly Rd Burlington, NJ

More information

Hemiplegic shoulder pain/shoulder subluxation

Hemiplegic shoulder pain/shoulder subluxation UPPER LIMB NEUROMUSCULAR ELECTRICAL STIMULATION: Electrode positions Please note that the polarity (red and black leads) can be altered according to your clinical reasoning. The area in which you want

More information

Impingement Syndrome of the Shoulder & Rotator Cuff Problems

Impingement Syndrome of the Shoulder & Rotator Cuff Problems H U N T E R D O N ORTHOPEDIC P.A. INSTITUTE L IVE L IFE B ETTER www.hunterdonortho.com Impingement Syndrome of the Shoulder & Rotator Cuff Problems Types of Injuries Treatment Options Rehabilitation Robert

More information

Shouldering the Burden

Shouldering the Burden Shouldering the Burden Wheelchair Athletes and Shoulder Injuries Dr. Julia Alleyne BHSc(PT) MD MScCH Dip Sport Med CMO, 2015 Parapan Games, Toronto Faculty/Presenter Disclosure Faculty: Dr. Julia Alleyne

More information

X-ray shows no bony abnormally except disuse osteoporosis.

X-ray shows no bony abnormally except disuse osteoporosis. ADHESIVE CAPSULITIS DR. P. P. MOHANTY, ASSOCIATE PROFESSOR, DEPT. OF PHYSIOTHERAPY Adhesive capsulitis is a condition of glenohumeral joint, in which there is restriction of active and passive ROM in capsular

More information

FUNCTIONAL HUMAN ANATOMY LAB #7 UPPER EXTREMITY MUSCULATURE

FUNCTIONAL HUMAN ANATOMY LAB #7 UPPER EXTREMITY MUSCULATURE FUNCTIONAL HUMAN ANATOMY LAB #7 UPPER EXTREMITY MUSCULATURE The following tips will help you in naming the muscles of the forearm and hand: The Ulna is located on the pinky side of the wrist, the Radius

More information

THE THERAPIST S MANAGEMENT OF THE STIFF ELBOW MARK PISCHKE, OTR/L, CHT NOV, 17, 2014

THE THERAPIST S MANAGEMENT OF THE STIFF ELBOW MARK PISCHKE, OTR/L, CHT NOV, 17, 2014 THE THERAPIST S MANAGEMENT OF THE STIFF ELBOW MARK PISCHKE, OTR/L, CHT NOV, 17, 2014 ELBOW FUNCTION 1. Required to provide stability for power and precision tasks for both open and closed kinetic chain

More information

Muscle Energy Technique. Applied to the Shoulder

Muscle Energy Technique. Applied to the Shoulder Muscle Energy Technique Applied to the Shoulder MUSCLE ENERGY Theory Muscle energy technique is a manual therapy procedure which involves the voluntary contraction of a muscle in a precisely controlled

More information

Frozen Shoulder Adhesive Capsulitis

Frozen Shoulder Adhesive Capsulitis Frozen Shoulder Adhesive Capsulitis Brett Sanders, MD Center For Sports Medicine and Orthopaedic 2415 McCallie Ave. Chattanooga, TN (423) 624-2696 If you're having trouble lifting your arm above your head,

More information

Musculoskeletal: Acute Lower Back Pain

Musculoskeletal: Acute Lower Back Pain Musculoskeletal: Acute Lower Back Pain Acute Lower Back Pain Back Pain only Sciatica / Radiculopathy Possible Cord or Cauda Equina Compression Possible Spinal Canal Stenosis Red Flags Initial conservative

More information

Shoulder Injuries. Why Bother? QAS Injury Prevalence. Screening Injury 29.2% 12 month cumulative injury prevalence. Dr Simon Locke

Shoulder Injuries. Why Bother? QAS Injury Prevalence. Screening Injury 29.2% 12 month cumulative injury prevalence. Dr Simon Locke Shoulder Injuries Dr Simon Locke Why Bother? Are shoulder and upper limb injuries common? Some anatomy What, where, what sports? How do they happen? Treatment, advances? QAS Injury Prevalence Screening

More information

28% have partial tear of the rotator cuff.

28% have partial tear of the rotator cuff. ROTATOR CUFF TENDON RUPTURE Anatomy: 1. Rotator cuff consists of: Subscapularis anteriorly, Supraspinatus superiorly and Infraspinatus and Teres minor posteriorly. 2 Biceps tendon is present in the rotator

More information

The Shoulder Complex & Shoulder Girdle

The Shoulder Complex & Shoulder Girdle The Shoulder Complex & Shoulder Girdle The shoulder complex 4 articulations involving The sternum The clavicle The ribs The scapula and The humerus Bony Landmarks provide attachment points for muscles

More information

The Rotator cuff. Dr Tom Lieng June 2011

The Rotator cuff. Dr Tom Lieng June 2011 The Rotator cuff Dr Tom Lieng June 2011 Content 1. Anatomy 2. Rotator cuff pathology 3. Treatment of rotator cuff injury 4. Prognosis 5. Other common shoulder conditions:adhesive capsulitis 6. Acromio-clavicular

More information

Shoulder Examination

Shoulder Examination Shoulder Examination Summary Inspection Palpation Movement Special Tests Neurological examination Introduction Shoulder disorders are can be broadly classified into the following types: Pain Stiffness

More information

SHOULDER ACROMIOPLASTY/ SHOULDER DECOMPRESSION

SHOULDER ACROMIOPLASTY/ SHOULDER DECOMPRESSION ORTHOPAEDIC WARD: 01-293 8687 /01-293 6602 BEACON CENTRE FOR ORTHOPAEDICS: 01-2937575 PHYSIOTHERAPY DEPARTMENT: 01-2936692 GUIDELINES FOR PATIENTS HAVING A SHOULDER ACROMIOPLASTY/ SHOULDER DECOMPRESSION

More information

Refer to Specialist. The Diagnosis and Management of Shoulder Pain 1. SLAP lesions, types 1 through 4

Refer to Specialist. The Diagnosis and Management of Shoulder Pain 1. SLAP lesions, types 1 through 4 The Diagnosis Management of Shoulder Pain 1 Significant Hisry -Age -Extremity Dominance -Hisry of trauma, dislocation, subluxation -Weakness, numbness, paresthesias -Sports participation -Past medical

More information

Body Mechanics. Rotator Cuff Injury. by Joseph E. Muscolino Artwork Giovanni Rimasti Photography Yanik Chauvin

Body Mechanics. Rotator Cuff Injury. by Joseph E. Muscolino Artwork Giovanni Rimasti Photography Yanik Chauvin Expert Content Body Mechanics by Joseph E. Muscolino Artwork Giovanni Rimasti Photography Yanik Chauvin Rotator Cuff Injury working with clients affected by this common condition Rotator Cuff Group The

More information

Diagnosis of Acromioclavicular Joint Injuries

Diagnosis of Acromioclavicular Joint Injuries PO Box 15 Rocky Hill, CT 06067 (860) 463-9003 Chiroeducation@aol.com www.chirocredit.com ChiroCredit.com is proud to present a section from one of our continuing education programs: Physical Diagnosis

More information

Biomechanics of Overarm Throwing. Deborah L. King, PhD

Biomechanics of Overarm Throwing. Deborah L. King, PhD Biomechanics of Overarm Throwing Deborah L. King, PhD Ithaca College, Department of Exercise and Sport Science Outline Review Fundamental Concepts Breakdown Throwing Motion o Identify Key Movements o Examine

More information

Frozen Shoulder. Let s take a moment to take a look at the shoulder structure and its mechanics.

Frozen Shoulder. Let s take a moment to take a look at the shoulder structure and its mechanics. March 2011 Frozen Shoulder Writing about frozen shoulder seemed so apropos considering the deep frozen state we have reached here in the great state of NH this year. Just like the three stages of frozen

More information

SLAP Repair Protocol

SLAP Repair Protocol SLAP Repair Protocol Anatomy and Biomechanics The shoulder is a wonderfully complex joint that is made up of the ball and socket connection between the humerus (ball) and the glenoid portion of the scapula

More information

Bankart Repair using the Smith & Nephew BIORAPTOR 2.9 Suture Anchor

Bankart Repair using the Smith & Nephew BIORAPTOR 2.9 Suture Anchor Shoulder Series Technique Guide *smith&nephew BIORAPTOR 2.9 Suture Anchor Bankart Repair using the Smith & Nephew BIORAPTOR 2.9 Suture Anchor Gary M. Gartsman, M.D. Introduction Arthroscopic studies of

More information

Reverse Total Shoulder Replacement

Reverse Total Shoulder Replacement SPORTS & ORTHOPAEDIC SPECIALISTS Reverse Total Shoulder Replacement 6-10 Visits over 4 months Reverse Total Shoulder Replacements are especially susceptible to dislocation during internal rotation, glenohumeral

More information

Rehabilitation Protocol: SLAP Superior Labral Lesion Anterior to Posterior

Rehabilitation Protocol: SLAP Superior Labral Lesion Anterior to Posterior Rehabilitation Protocol: SLAP Superior Labral Lesion Anterior to Posterior Department of Orthopaedic Surgery Lahey Hospital & Medical Center, Burlington 781-744-8650 Lahey Outpatient Center, Lexington

More information

Rehabilitation Program for Children With Brachial Plexus and Peripheral Nerve Injury

Rehabilitation Program for Children With Brachial Plexus and Peripheral Nerve Injury Rehabilitation Program for Children With Brachial Plexus and Peripheral Nerve Injury Lorna E. Ramos and Joan P. Zell An aggressive and integrated physical and occupational therapy program is essential

More information

Temple Physical Therapy

Temple Physical Therapy Temple Physical Therapy A General Overview of Common Neck Injuries For current information on Temple Physical Therapy related news and for a healthy and safe return to work, sport and recreation Like Us

More information

Post-operative rehabilitation guidelines Latissimus Dorsi Transfer to Posterosuperior Cuff

Post-operative rehabilitation guidelines Latissimus Dorsi Transfer to Posterosuperior Cuff Post-operative rehabilitation guidelines Latissimus Dorsi Transfer to Posterosuperior Cuff Please note that this is advisory information only. Your experiences may differ from those described. A fully

More information

CERVICAL DISC HERNIATION

CERVICAL DISC HERNIATION CERVICAL DISC HERNIATION Most frequent at C 5/6 level but also occur at C 6 7 & to a lesser extent at C4 5 & other levels In relatively younger persons soft disk protrusion is more common than hard disk

More information

Shoulder Exam: Rapid Exam

Shoulder Exam: Rapid Exam Shoulder Exam: Rapid Exam and Diagnosis Levi Miller, D.O. University of Washington University of Washington Departments of Physical Medicine & Rehabilitation Objectives Be able to perform three minute

More information

:{ic0fp'16. Evaluation and Management of Knee and Shoulder Pain. Andrew Ferris, DO. ACOFP 53 rd Annual Convention & Scientific Seminars

:{ic0fp'16. Evaluation and Management of Knee and Shoulder Pain. Andrew Ferris, DO. ACOFP 53 rd Annual Convention & Scientific Seminars :{ic0fp'16 ACOFP 53 rd Annual Convention & Scientific Seminars Evaluation and Management of Knee and Shoulder Pain Andrew Ferris, DO Evaluation and management of Knee and Shoulder pain Andrew Ferris DO

More information

Rehabilitation Guidelines for Post-Operative Shoulder Instability Repair

Rehabilitation Guidelines for Post-Operative Shoulder Instability Repair Rehabilitation Guidelines for Post-Operative Shoulder Instability Repair Please note that this is advisory information only. Your experiences may differ from those described. A fully qualified Physiotherapist

More information

Muscle Terminology. Intrinsic - pertaining usually to muscles within or belonging solely to body part upon which they act

Muscle Terminology. Intrinsic - pertaining usually to muscles within or belonging solely to body part upon which they act Muscle Terminology Intrinsic - pertaining usually to muscles within or belonging solely to body part upon which they act Ex. small intrinsic muscles found entirely within the hand or feet Muscle Terminology

More information

IMPINGEMENT REVISITED. W. Ben Kibler, MD. From what angle are you looking at impingement -WHAT IS IT - EVALUATION - TREATMENT GUIDES

IMPINGEMENT REVISITED. W. Ben Kibler, MD. From what angle are you looking at impingement -WHAT IS IT - EVALUATION - TREATMENT GUIDES IMPINGEMENT REVISITED -WHAT IS IT - EVALUATION - TREATMENT GUIDES W. Ben Kibler, MD Medical director From what angle are you looking at impingement Bone spur- Acromion type 1, 2, 3 Rotator cuff injury

More information

Rehabilitation Protocol: Biceps Tenodesis

Rehabilitation Protocol: Biceps Tenodesis Rehabilitation Protocol: Biceps Tenodesis Department of Orthopaedic Surgery Lahey Hospital & Medical Center, Burlington 781-744-8650 Lahey Outpatient Center, Lexington 781-372-7020 Lahey Medical Center,

More information

BODY BODY PEDICLE PEDICLE TRANSVERSE TRANSVERSE PROCESS PROCESS

BODY BODY PEDICLE PEDICLE TRANSVERSE TRANSVERSE PROCESS PROCESS Learning Objective Radiology Anatomy of the Spine and Upper Extremity Identify anatomic structures of the spine and upper extremities on standard radiographic and cross-sectional images Timothy J. Mosher,

More information

Overhead Strength Training for the Shoulder: Guidelines for Injury Prevention and Performance Training Success

Overhead Strength Training for the Shoulder: Guidelines for Injury Prevention and Performance Training Success Overhead Strength Training for the Shoulder: Guidelines for Injury Prevention and Performance Training Success Robert Panariello MS, PT, ATC, CSCS Strength training is an important component in the overall

More information

Shoulder Injury Prevention and Rehabilitation for Health & Fitness Professionals

Shoulder Injury Prevention and Rehabilitation for Health & Fitness Professionals s EDUCATION WORKSHOPS Shoulder Injury Prevention and Rehabilitation for Health & Fitness Professionals with B.App.Sc (Physio), Dip.Ed (P.E.) CONTENTS Topic Page 1. Functional Anatomy 3 2. Scapulohumeral

More information

MOON SHOULDER GROUP POST OPERATIVE ROTATOR CUFF REPAIR PROTOCOL. For information regarding the MOON Shoulder Group, speak to your surgeon or contact:

MOON SHOULDER GROUP POST OPERATIVE ROTATOR CUFF REPAIR PROTOCOL. For information regarding the MOON Shoulder Group, speak to your surgeon or contact: MOON SHOULDER GROUP For information regarding the MOON Shoulder Group, speak to your surgeon or contact: Rosemary Sanders 6000 Medical Center East 1215 21 st Avenue South Vanderbilt University Medical

More information

.org. Shoulder Pain and Common Shoulder Problems. Anatomy. Cause

.org. Shoulder Pain and Common Shoulder Problems. Anatomy. Cause Shoulder Pain and Common Shoulder Problems Page ( 1 ) What most people call the shoulder is really several joints that combine with tendons and muscles to allow a wide range of motion in the arm from scratching

More information

Surgery of the Upper Extremity in Children with Hemiplegic Cerebral Palsy

Surgery of the Upper Extremity in Children with Hemiplegic Cerebral Palsy Article submitted, at the request of CHASA, by Robert Bunata, M.D., Board Certified Orthopedic Surgeon. Dr. Bunata has a special interest in upper extremity surgery in children who have hemiplegia. He

More information

Postoperative Protocol For Posterior Labral Repair/ Capsular Plication-- Dr. Trueblood

Postoperative Protocol For Posterior Labral Repair/ Capsular Plication-- Dr. Trueblood Postoperative Protocol For Posterior Labral Repair/ Capsular Plication-- Dr. Trueblood Indications: Posterior shoulder instability is a relatively uncommon finding in normal adult shoulders. The most common

More information

ALL ABOUT SPASTICITY. www.almirall.com. Solutions with you in mind

ALL ABOUT SPASTICITY. www.almirall.com. Solutions with you in mind ALL ABOUT SPASTICITY www.almirall.com Solutions with you in mind WHAT IS SPASTICITY? The muscles of the body maintain what is called normal muscle tone, a level of muscle tension that allows us to hold

More information

CEDAC FINAL RECOMMENDATION

CEDAC FINAL RECOMMENDATION CEDAC FINAL RECOMMENDATION CLOSTRIDIUM BOTULINUM NEUROTOXIN TYPE A, FREE FROM COMPLEXING PROTEINS (Xeomin Merz Pharma Canada Ltd.) Indication: Post-stroke Spasticity Recommendation: The Canadian Expert

More information

Medical Treatment Guidelines Washington State Department of Labor and Industries

Medical Treatment Guidelines Washington State Department of Labor and Industries Complex regional pain syndrome (CRPS) Formerly known as reflex sympathetic dystrophy 1. Introduction This bulletin outlines the Department of Labor and Industries guidelines for diagnosing and treating

More information

Tension Type Headaches

Tension Type Headaches Tension Type Headaches Research Review by : Dr. Ian MacIntyre Physiotherapy for tension-type Headache: A Controlled Study P. Torelli, R. Jenson, J. Olsen: Cephalalgia, 2004, 24, 29-36 Tension-type headache

More information

SLAP repair. An information guide for patients. Delivering the best in care. UHB is a no smoking Trust

SLAP repair. An information guide for patients. Delivering the best in care. UHB is a no smoking Trust SLAP repair An information guide for patients Delivering the best in care UHB is a no smoking Trust To see all of our current patient information leaflets please visit www.uhb.nhs.uk/patient-information-leaflets.htm

More information

Workers who do overhead activities such as painting, stocking shelves or construction Athletes such as swimmers, pitchers and tennis players

Workers who do overhead activities such as painting, stocking shelves or construction Athletes such as swimmers, pitchers and tennis players Rotator Cuff Tears Description Rotator cuff tears are a common cause of pain and disability in the adult population. The rotator cuff is made up of four muscles and their tendons. These combine to form

More information

Rehabilitation Guidelines for Arthroscopic Capsular Shift

Rehabilitation Guidelines for Arthroscopic Capsular Shift Rehabilitation Guidelines for Arthroscopic Capsular Shift The anatomic configuration of the shoulder joint (glenohumeral joint) is often compared to a golf ball on a tee. This is because the articular

More information