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NGP Shoulder - Coggle Diagram
NGP Shoulder
Physical Ax
Observation - surface anatomy, scap position, 4 point palpation, clavicle angle
Shoulder AROM +/- scapula assist, HoH assist, Thx assist, neurodynamics bias
Thx AROM - sitting, upper vs lower Thx ROM
Cx screen - AROM +/- Spurlings test or Quadrant
Instability - sulcus sign, apprehension/relocation test (most sens/spec for ant), posterior apprehension test, ?? jerk test (otherwise leave for advanced)
GHJ PROM esp ER - rule out/in frozen shoulder
Hegedus cluster - RC tear - over 60 + painful arc, drop arm sign, pain resisted ER
ACJ testing - palpation, horizontal abduction resisted
Palpation - mm, cervical spine, Thx, GHJ, scap
Strength/endurance/control Ax - standing (upper traps in diff positions of abd'n, ER/IR, serratus - wall, row), 4 pt kneel (scap & neck control, serratus), prone (traps/scap in by side, 45, 90, 120 abd'n)
Impingement Cluster - Hawkins Kennedy & arc of pain & resisted ER weak/pain
Subjective:
Body Chart - location of pain, type, vague/pinpoint, clicking, burning/P&N/neuro signs, weakness/loss of power, dead arm, unstable/fear, ?? neck pain
Aggs & Eases - try be specific e.g. throwing at end-range wind-up P4/10, then nil pain on release
MOI - traumatic or gradual onset, related factors (e.g workload, training load)
Past Hx on this or opposite shld (frozen shoulder, instability, disloc etc)...family Hx (esp instab & frozen)
Previous Treatment - what worked, what didn't, use that to help your treatment, don't repeat what didn't work, use what did help
24 hour - night pain ++ (frozen vs inflam vs positional), AM pain (inflam ?), during day (time based/fatigue related vs aggs throughout day)
Anatomy
Review - GHJ, scapula, surface anatomy, muscles
Scapulohumeral Rhythm - combo of scap & humerus, scapula upwardly rotates
Red Flags - Shoulder esp L shoulder - cardiac, metastases, trauma, abdominal referral
Age - younger vs middle aged vs older...common presentations based on age
Case Studies
Frozen Shoulder
MDI
Rotator Cuff Tear/Tendon
Videos
Observation
Shld AROM +/- scap/HoH/Thx/Cx assist/modification
Shld PROM
Hegedus cluster
Impingement cluster – Hawk-Kennedy
Instability cluster – sulcus, apprehension ant + post + relocation
Thx AROM
Cx Quadrant & Spurlings as clearing (if not done by someone else?)
ACJ
Muscle Testing
GHJ mobilisations - AP, caudad in 0 abd & 90 abd Muscle techniques – massage/trigger point etc – ER’s, subscap, LScap, rhomb Ex’s – instability ex’s – scap first then HoH control then endurance into range
Ex’s – RC tendon – unload, isometrics, ROM ex’s, progress into provocative positions
Older Shoulder
Tendon/Rotator Cuff Related Shld Pain
OA
Fracture - trauma, HoH, Osteoporosis related
Younger Shoulder
Instability/MDI
Rotator Cuff Related/previously called impingement/subacromial impingement etc
Traumatic - ACJ, dislocation, fracture
Treatment Strategies
Frozen Shoulder
Intra-artic injection before 4-6 months, GP referral/involvement, make sure intra-artic +/- subacromial, not SA alone, may inhibit myofibroblast proliferation
Where does pain come from? Need to reduce pain to reduce inflam process - gentle AROM, pain-free, reduce load
Stretching - depends on phase, nil in inflam phase - can increase myofibroblasts, can "stretch" once pain-free but much better to prevent it getting to that stage
Joint mobes over 6 weeks - improved pain & function maintained at 1 yr, ?? pain modulation
Instability/Dislocation
MRI - traumatic dislocation with ?? bony changes, fracture, may alter management, may need referral for surgery
Scap vs HoH control - what helps that person?? Retrain vs give strength for each (are you teaching postural change or trying to strengthen?) e.g. Lyn Watson Theraband ex's vs gym based
Start in lower range (e.g. by side), progress into provoc range once can achieve lower level adequately
Rotator Cuff Tendon/Tear
Pain Modulation - isometrics or through-range ex in pain-free position, often IR/add/ext, progress into provocative range,
Unload compressive forces
Scapula modification - often overusing scap shrug to gain GHJ mvt, usually facil upward rotation makes worse, often retraction is better
Manual therapy - scap mm, Cx/Thx, ER's, careful of prone too long with arm under face - often leads to more pain on getting up (?? hanging arm in 90deg abd'n for 10 mins)
Dry needling - depending on patient preference, good for pain modulation, esp ER's muscle belly avoiding tendon insertion
Middle Aged
Frozen Shoulder
ACJ
Spine - cervical/thoracic referral? Rib?