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SHOULDER lecture



"painful arc" = part of ROM where pain is present

ADHESIVE CAPSULITIS
aka frozen shoulder
will see this, common, esp dt posture
poor posture-->eccentric contractions of overstretched postural muscles-->microtears-->adh caps
also-->supraspinatus impingement
**add a chapter on posture to my book
"there's a right and a wrong way to be in your body"
9/10 "that's there the problems lie"
esp in postmenopausal women, mbdt estriol def, sometimes give E3 and prob goes away
may occur dt trauma, or in men, but mb endocrine even then, men well over 50
most (all?) conventional physicians see it as a physical restriction only
she finds that usu laxity comes before restriction: compensatory pathology
surgeons will cut coracoclavicular and coracoacromial ligaments to treat it
usu by the time it presents they are progressed
she asks that we explore sex hormone, thyroid and insulin imbalance to tx this
hyperprog with hypoest-->ligamentous laxity (??who gets this?)
perimenopause, early postmenopause, early andropaural males
check for laxity of joint to prevent adhesion later

KINESIOTAPING
there are taping techniques to encourage proper posture and rotator cuff usage
(not in curriculum)
she uses kinesiotape for several conditions
info available @ apta.org and PT circles
optp.com = orthopedic PT products, may find manuals
at upcoming NW Naturopathic Physicians conf there is a segment on kinesiotaping (I'm going)
many PT's are looking for someone to help with lab medicine, nutrition, hormones, botanicals

INFERIOR GLIDE OF GLENOHUMERAL JOINT
if dysfx then humerus bangs acromion-->subacromial bursitis and other pathol
if limited abduction
assessment: best done supine
pts ROM determines best position
support arm same way as when taking BP (no tension or exertion by pt)
shake hands then hold with that hand under elbow-humerus, her forearm on mine
abduct only within comfortable range
feel humeral head with other hand, as proximal as possible with web between thumb and forefinger
turn my body to face pt's feet
take out shoulder slack
drive humeral hand toward feet to assess glide

TX for RSTRX: DUKE SCOOP aka DUKE DOWN
for restriction of inferior glide
requires 90 degrees flexion
flex shoulder 90, pt hand near ear
put my clavicle on her distal humerus
interlace fingers on humeral head with knife edge on head of humerus
push down with knife edge
grades 1-5

POSTERIOR GLIDE
supine
want glenohumeral joint to move, not scapula
table with cutout helps to keep scap flat and free humerus
this not in notes
arm slightly abducted (up to 90) but not flexed
support arm comfortably
hypothenar contact on humeral head (fingers in axilla) not on clavicle or acromion
alternate hand position with thenar eminence on humeral head
drive A-->P
end feel is capsular, ligamentous
same procedure to correct restrx, oscillation or thrust

SEATED POSTERIOR GLIDE
in notes
pt put hand to shouldertop
stand behind pt and reach around with opp arm, palm to elbow to be tested
this is driver
my sternum stabilize pt scapula of shoulder to be tested
posteriorly glide humerus
can adjust from here

ANTERIOR GLIDE
prone
make sure clavicle is well supported on table but humerus is off edge
make sure shoulder will clear headrest
hold arm in neutral position, slightly abducted up to 90, comfortable
my hand over top of lower humerus, their forearm hanging toward floor
locate hum head
place hypothenar on it and push P-->A
beware: avoid subluxing a hypermobile shoulder!
correction if done: flip to supine and push A-->P (I am skeptical about this)
**shoulder reduction is a special technique not covered here (but I am trained in it)

GLIDE IN ALL DIRECTIONS: MULTIDIRECTIONAL
in notes
circumduction
stabilize their distal arm between my upper arm and body, hand under humerus
arm in relative neutral position
both thumbs on anterior side of hum head, broad contact
fingers splayed underneath
be careful of tender biciptal tendon
make circles either direction "choo choo train"

SHOULDER APPREHENSION TEST
specific to anterior dislocations

SHOULDER TRACTION
to discern inferior laxity

STRAIN COUNTERSTRAIN to SHOULDER MM

SUBSCAP
internal rotator

INFRASPINATUS & TERES MINOR
external rotators
triggers radiate to anterior shoulder all the way to forearm
also to medial scap border and posteriolateral shoulder, arm and hand
teres minor refers to posterolateral shoulder
INFRASPINATUS
pt prone
locate tender pt in infraspinous fossa
common, often not recognized
external rotator
bring elbow up to my knee to be in neutral, mb slight extension
then ext rot by lifting wrist slightly



SUPRASPINATUS
triggers refer to clavicle, middle delt, and lateral arm to forearem
many potential points along supraspinous fossa, avoid upper trap
abduct to shorten muscle
also points at insertion just distal to acromion, abduct for these too
add external rotation if abduction isn't sufficient

PEC MINOR & MAJOR
major may cause breast pain, over heart
minor refers down medial arm and hand: mimics MI
trigger mb btw 4-5th ribs or @ coracoid
anxiety may cause diaphoresis, etc, tricky to discern, don't need EKG
but you better be sure
MINOR
protracts scaupla
sit or stand contralateral to point
check just below coracoid first
shorten muscle by lifting shoulder toward me, until pain rating decr
let off, wait
MAJOR
horizontal adductor
tender pts closer to humerus on ribs
bring arm across body toward me until pain is reduced
ok to relift arm to cross breast

BICEPS
triggers are distal
trigger to anterior shoulder (delt area)
a common point is distal
first flex elbow in supination (palm toward shoulder)
then flex shoulder to shorten muscle

SCALENES
can refer similarly to infraspinatus
upper chest breathers likely to have scalene issues
anxiety common in these pts
ANTERIOR SCALENES
flex and sidebend
start by elevating headrest
then increase sidebend/flexion as needed to reduce tenderness

LAT
refers to posterior shoulder and down arm to hand
also to scapular area

LEVATOR SCAP
can cause shouldertop and medial scapular pain
shrug ipsilateral side
same as with Upper Trap

LOWER TRAP AND POSTERIOR DELT
may refer to shoulder

MIDDLE DELT
points at insertion site (deltoid tuberosity) or muscle belly
abduct to shorten, may have to go a good way

ANT DELT
begin with shoulder flexion, pts palm to their shoulder
can horiz abduct

POST DELT
can do supine or prone
supine: just drop arm off table and lift elbow

TRICEPS LONG HEAD
extend from prone position
elbow must be extended

RHOMBOID OR MIDDLE TRAP
prone pt
tender pts along medial scapular border
retract scap by lifting shoulder to shorten muscle

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