Painful Shoulder Treatment

Management: Painful Shoulder Syndromes (Without Dislocation)

Management: Protection Phase Control Inflammation and Promote Healing

Modalities and low-intensity cross-fiber massage are applied to the site of the lesion. While applying the modalities, position the extremity to maximally expose the involved region. Support the arm in a sling for rest.

Painful shoulder treatment

Patient Education

The environment and habits that provoke the symptoms must be modified or avoided completely during this stage. The patient should be informed about the mechanics of the irritation and given guidelines for anticipated recovery with compliance.

Maintain Integrity and Mobility of the Soft Tissues

Passive, active-assistive, or self-assisted ROM is initiated in pain-free ranges. Multiple-angle muscle setting and protected stabilization exercises are initiated. Of particular importance in the shoulder is to stimulate the stabilizing function of the rotator cuff, biceps brachii, and scapular muscles at an intensity tolerated by the patient

Control Pain and Maintain Joint Integrity

Pendulum exercises without weights can be used to cause pain-inhibiting grade II joint distraction and oscillation motions

 Develop Support in Related Regions

Postural awareness and correction techniques are used. Supportive techniques such as shoulder strapping or scapular taping, tactile cues, and mirrors can be used for reinforcement. Repetitive reminders and practice of correct posture is necessary throughout the day.

Management: Controlled Motion Phase

Once the acute symptoms are under control, the main emphasis becomes use of the involved region with progressive, nondestructive movement and proper mechanics while the tissues heal. The components of the desired functions are analyzed and initiated in a controlled exercise program.  If there is a functional laxity in the joint, the intervention is directed toward learning neuromuscular control of and developing strength in the stabilizing muscles of both the scapula and glenohumeral joint.  If there is restricted mobility that prevents normal mechanics or interferes with function, mobilization of the restricted tissue is performed.

 

Patient Education

Patient adherence with the program and avoidance of irritating the healing tissues are necessary. The home exercise program is progressed as the patient learns safe and effective execution of each exercise.

Develop a Strong, Mobile Scar

Manual therapy techniques such as cross-fiber or friction massage are used. The extremity is positioned so the tissue is on a stretch if it is a tendon or in the shortened position if it is in the muscle belly. The technique is applied to the tolerance of the patient. Following massage, the patient is instructed to perform an isometric contraction of the muscle in several positions of the range. The intensity of contraction should not cause pain. The patient should be taught how to self-administer the massage and isometric techniques.

Improve Postural Awareness

It is important to continue to reinforce proper postural habits. Tactile and verbal cues are used to increase patient awareness of scapular and cervical posture every time an exercise is performed, such as touching the scapular adductors and chin and reminding the patient to “pull the shoulders back” and “lift the head” while doing the shoulder exercises Thoracic and scapular taping had a positive influence in modifying posture; there was less forward head posture, smaller kyphosis, less lateral scapular displacement, less elevated and forward scapula position, and increased painfree range of scaption compared with the measurements taken after placebo taping in both the symptomatic and asymptomatic groups.

Modify Joint Tracking and Mobility

Mobilization with movement (MWM) may be useful for modifying joint tracking and reinforcing full movement when there is painful restriction of shoulder elevation because of a painful arc or impingement. Posterolateral glide with active elevation .

Patient position: Sitting with the arm by the side and head in neutral retraction.

Therapist position and procedure: Stand on the side opposite the affected arm and reach across the patient’s torso to stabilize the scapula with the palm of one hand. The other hand is placed over the anteromedial aspect of the head of the humerus. Apply a graded posterolateral glide of the humeral head on the glenoid. Request that the patient perform the previously painful elevation. Maintain the posterolateral glide mobilization throughout both elevation and return to neutral. Ensure that no pain is experienced during the procedure. Adjust the grade and direction of the glide as needed to achieve pain-free function. Add resistance in the form of elastic resistance or a cuff weight to load the muscle.

Self-Treatment

 A mobilization belt provides the posterolateral glide while the patient actively elevates the affected limb against progressive resistance to end range

 

Develop Balance in Length and Strength of Shoulder Girdle Muscles

It is important to design a program that specifically addresses the patient’s impairments. Typical interventions in the shoulder girdle include but are not limited to:

Stretch shortened muscles

 Shortened muscles typically include the pectoralis major, pectoralis minor, latissimus dorsi and teres major, subscapularis, and levator scapulae. Strengthen and train the scapular stabilizers. Scapular stabilizers typically include the serratus anterior and lower trapezius for posterior tipping and upward rotation and the middle trapezius and rhomboids for scapular retraction. It is important that the patient learns to avoid scapular elevation when raising the arm. Therefore, practice scapular depression when abducting and flexing the humerus. Strengthen and train the rotator cuff muscles, especially the shoulder lateral rotators.

Develop Muscular Stabilization and Endurance

Alternating isometric resistance is applied to the scapular muscles in open-chain positions (side-lying, sitting, supine), including protraction/retraction, elevation/ depression, and upward/downward rotation so the patient learns to stabilize the scapula against the outside forces. Scapular and glenohumeral patterns are combined using flexion, abduction, and rotation. Alternating isometric resistance is applied to the humerus while the patient holds against the changing directions of the resistance force.

Closed-chain stabilization is performed with the patient’s hands fixated against a wall, a table, or the floor (quadruped position) while the therapist provides a graded, alternating isometric resistance or rhythmic stabilization. Observe for abnormal scapular winging. If it occurs, the scapular stabilizers are not strong enough for the demand; so the position should be changed to reduce the amount of body weight .

Muscular endurance is progressed by increasing the amount of time the individual holds the pattern against the alternating resistance. The limit is reached when any one of the muscles in the pattern can no longer maintain the desired hold. The goal at this phase should be stabilization for approximately 3 minutes.

Progress Shoulder Function

As the patient develops strength in the weakened muscles, it becomes important to develop a balance in strength of all shoulder and scapular muscles within the range and tolerance of each muscle. To increase coordination between scapular and arm motions, dynamically load the upper extremity within tolerance of the synergy with submaximal resistance. To improve muscular endurance, have the patient increase control from 1 minute to 3 minutes.

 

Management: Return to Function Phase

Specificity of training toward the desired functional outcome begins as soon as the patient has developed control of posture and the basic components of the desired activities without exacerbating the symptoms. While working with the patient, continue to instruct him or her on how to progress the program when discharged as well as how to prevent recurrences.

Increase Muscular Endurance

To increase muscular endurance, repetitive loading of the defined patterns is increased from 3 minutes to 5 minutes.

Develop Quick Motor Responses to Imposed Stresses

The stabilization exercises are applied with increased speed. Plyometric training in both open-chain and closed-chain patterns is initiated if power is a desired outcome.

Progress Functional Training

Specificity of training progresses to an emphasis on timing and sequencing of events. Eccentric training is progressed to maximum load. Desired functional activities are simulated—first under controlled conditions, then under progressively challenged situations using acceleration/deceleration drills. The patient is involved in assessing performance in  terms of safety, symptom provocation, postural control, and ease of execution and then practices adaptations to correct any problems.

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