Kulsum International Hospital

Introduction:

Shoulder is one of the largest and most complex joints in the body. The shoulder joint is formed where the Humerus (upper arm bone) fits into the scapula (shoulder blade), like a ball and socket. Other important bones in the shoulder include:

The acromion, a bony projection off the scapula.
The clavicle (collarbone), meets the acromion in the acromioclavicular joint.
The coracoid process, a hook-like bony projection from the scapula.

The shoulder has several other important structures:

The rotator cuff is a collection of muscles and tendons that surround the shoulder, giving it support and allowing a wide range of motion.
The bursa is a small sac of fluid that cushions and protects the tendons of the rotator cuff.
A cuff of cartilage called the labrum forms a cup for the ball-like head of the humerus to fit into.
The humerus fits relatively loosely into the shoulder joint. This gives the shoulder a wide range of motion, but also makes it vulnerable to injury.

Shoulder Conditions:

Frozen shoulder: Inflammation develops in the shoulder that causes pain and stiffness. As a frozen shoulder progresses, movement in the shoulder can be severely limited.
Osteoarthritis: The common “wear-and-tear” arthritis that occurs with aging. The shoulder is less often affected by osteoarthritis than the knee.
Rheumatoid Arthritis: A form of arthritis in which the immune system attacks the joints, causing inflammation and pain. Rheumatoid Arthritis can affect any joint, including the shoulder.
Gout: A form of Arthritis in which crystals form in the joints, causing inflammation and pain. The shoulder is, however, an uncommon location for gout.
Rotator cuff tear: A tear in one of the muscles or tendons surrounding the top of the Humerus. A rotator cuff tear may be a sudden injury, or result from steady overuse.
Shoulder impingement: The acromion (edge of the scapula) presses on the rotator cuff as the arm is lifted. If inflammation or an injury in the rotator cuff is present, this impingement causes pain.
Shoulder dislocation: The Humerus or one of the other bones in the shoulder slips out of position. Raising the arm causes pain and a “popping” sensation if the shoulder is dislocated.
Shoulder tendonitis: Inflammation of one of the tendons in the shoulder’s rotator cuff.
Shoulder bursitis: Inflammation of the bursa; the small sac of fluid that rests over the rotator cuff tendons. Symptoms include pain with overhead activities or pressure on the upper, outer arm.
Labral tear: An accident or overuse can cause a tear in the labrum, the cuff of cartilage that overlies the head of the Humerus. Most labral tears heal without requiring surgery.

Shoulder Tests:

(MRI Scan): This scanner uses a high-powered magnet and a computer to create high-resolution images of the shoulder and surrounding structures.
(CT Scan): A CT scanner takes multiple X-rays, and a computer creates detailed images of the shoulder.
Shoulder X-ray: A plain X-ray film of the shoulder may show dislocation, Osteoarthritis or a fracture of the Humerus. X-ray films cannot diagnose muscle or tendon injuries.

Shoulder Treatments:

Shoulder surgery: Surgery is generally performed to help make the shoulder joint more stable. Shoulder surgery may be Arthroscopic (several small incisions) or open (large incision). In an Arthroscopic surgery, the surgeon makes small incisions in the shoulder and performs surgery through an endoscope (a flexible tube with a camera and tools on its end). Arthroscopic surgery requires less recovery time than open surgery.
Physical therapy: An exercise program can strengthen shoulder muscles and improve flexibility in the shoulder. Physical therapy is an effective, nonsurgical treatment for many shoulder conditions.

Strength:

Strengthening the muscles that support your shoulder will help keep your shoulder joint stable. Keeping these muscles strong can relieve shoulder pain and prevent further injury.

Flexibility:

Stretching the muscles that you strengthen is important for restoring range of motion and preventing injury. Gently stretching after strengthening exercises can help reduce muscle soreness and keep your muscles long and flexible.

Target Muscles:

The muscle groups targeted in this conditioning program include:

Deltoids (front, back and over the shoulder)
Trapezius muscles (upper back)
Rhomboid muscles (upper back)
Teres muscles (supporting the shoulder joint)
Supraspinatus (supporting the shoulder joint)
Infraspinatus (supporting the shoulder
Subscapular (front of shoulder)
Biceps (front of upper arm)
Triceps (back of upper arm)

Pain relievers:

RICE Therapy: RICE stands for Rest, Ice, Compression (not usually necessary), and Elevation. RICE can improve pain and swelling of many shoulder injuries.
Corticosteroid (cortisone) injection: A doctor injects cortisone into the shoulder, reducing the inflammation and pain caused by Bursitis or Arthritis. The effects of a cortisone injection can last several weeks.

Shoulder Replacement Indications: Severe Osteo or Rheumatoid Arthritis where the predominant feature is pain.

Post-Shoulder Replacement Treatment Protocol

In Patient
Day 0	Master sling with body belt or Cold Compression sling fitted in theatre Finger, wrist and elbow movements Occupational Therapy
Day 1Level 1 Exercises	Body belt removed Axillary hygiene taught Pendular exercises Scapular setting Passive flexion in the scapula plane as comfortable External rotation to neutral Discharge usually at day 1
Out Patient
Day 5 – 3 weeksLevel 2 exercises	No resisted internal rotation or forced passive external rotation (reattached subscapular is muscle is vulnerable) Begin passive abduction (maintain shoulder in IR) Passive external rotation to neutral only Active assisted flexion in supine and progress to sitting position as soon as the patient is able. Progress to active when possible Begin isometric strengthening of all muscle groups (except IR) Remove sling as able Functional reaching activities below 90 degrees
3 weeks +Level 2 exercises	Encourage active movement into all ranges with some gentle self-stretching at the end of range. Add isometric IR Progress functional activities
6 Weeks +Progress to level 3 exercises	Progress strengthening through range Regularly stretch the joint to the end of its available range Soft tissue manipulation if required

Improvement continues for 18 months to 2 years and the patients should continue exercising until their maximum potential has been reached.

Return to functional activities

Driving After 4 weeks
Swimming

Breaststroke: 6 weeks

Freestyle: 12 weeks

Golf 3 Months
Lifting Light lifting can begin at 3 weeks.
Avoid lifting heavy items for 6 months.
Return Sedentary job: 6 weeks
to work Manual job: Guided by Surgeon

References

O’Sullivan. S. and Schmitz. T.,2011. Physical Rehabilitation. 5^th Edition. F.A. Davis Company.
ShoulderDoc, 2015, Shoulder Replacement. [Online] Available at < https://www.shoulderdoc.co.uk/article/16> [Accessed Dec 21, 2015]
Healthwise, 2014, Shoulder Replacement Surgery. [Online] Available < http://www.webmd.com/arthritis/shoulder-replacement-surgery> [Accessed Dec 21, 2015]
Porter. S., .2008, Tidy’s Physiotherapy. 14^th Edition. Elsevier Health Sciences.