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Adhesive Capsulitis

Adhesive Capsulitis, also known as Frozen Shoulder, is a condition where the capsule of the shoulder joint becomes inflamed and results in scarring down and tightening of the capsule. The capsule of the shoulder joint is the soft tissue surrounding the joint that holds the joint together at its deepest layer. The true cause of frozen shoulder is still unknown, but risk factors include: minor traumas, hyperthyroidism, diabetes, post-surgical states and prolonged immobilization; with prevalence in diagnosis seen in females ages 40-65.

Frozen shoulder is classified in three stages: the freezing stage, frozen stage and thawing stage; where the shoulder will grow stiffer, then there is loss of motion, followed by regain in motion over time. Frozen shoulder is a self-limiting disease where it can resolve itself over time, typically over a 1 to 3 year time span. While frozen shoulder can resolve on its own, physical therapy can assist with progressing through the stages quicker to regain function and return to normal activities of failing living sooner.

Physical therapy treatments for Frozen Shoulder consist of:
- Patient education of the disease process, progression and activity modification
- Passive range of motion; both to prevent further loss and to improve available range
- Mobilizations of joint; for pain reduction and improvement in motion
- Active motion/strengthening to improve activity tolerance
- Corticosteroids may be used by Physicians for short-term relief to help reduce inflammation to improve range and tolerance to physical therapy treatments.

Shoulder Instability

The shoulder joint (glenohurmeral joint) is a ball and socket joint which is very mobile, and therefore, susceptible to having too much motion. Static and dynamic structures normally work to stabilize the ball of the joint (humeral head) within the socket (glenoid fossa). Multidirectional instability of the shoulder refers to a general laxity (looseness) of the shoulder, allowing the humeral head to be able to more excessively forward, backward and/or downwards within the socket. This may cause the humeral head to come out partially of the socket (subluxation) or all the way out of the socket (dislocation). This may occur due to damage or weakness to static structures including the lining of the socket (labrum), ligaments (structures that connect the bones), or joint capsule (tissue that surrounds the joint), or dynamic structures, specifically the muscles and tendons around the shoulder called the rotator cuff muscles. Certain individuals may also have a genetic condition or previous diagnosis that causes hyper laxity (looseness of the joints), which can predispose them to multidirectional instability. Multidirectional instability is often seen in individuals who perform repetitive overhead movements, including overhead athletes.

Individuals with this condition may experience symptoms including pain, weakness, and clunking or clicking. A medical professional will perform a battery of tests to assess for excessive movement of the shoulder joint in order to help diagnosis multidirectional instability. Treatment most often involves long term conservative, non surgical treatment via physical therapy and/or sports specific rehabilitation. Physical therapy includes exercises to help strengthen the rotator cuff muscles, as well as the shoulder blade (scapular) muscles, to improve stability of the shoulder joint. Treatment will also focus on improving specific movement techniques that may have contributed to injury. The majority of people will respond well to a conservative program and will not require surgery. However, certain surgical procedures that help further stabilize the shoulder joint may be indicated if an individual continues with pain symptoms following rehabilitation.

Reoccurring Dislocations

After an initial dislocation of a shoulder, the shoulder is more vulnerable to repeat injuries and dislocations. This initial dislocation and continued dislocation can cause injuries to the muscles, tendons, ligaments and joint itself. Reoccurring dislocations are sometimes caused by repetitive overhead motions in sports like baseball/softball, swimming, tennis or volleyball Conservative treatment is the first course of action when patients begin to have shoulder dislocations. Activity modification and physical therapy can help strengthen and stabilize the shoulder to prevent further dislocations.

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Posterior Dislocation

Posterior dislocations account for only 3% of shoulder dislocations. They occur when there is a force from the front of the shoulder, pushing the humerus backwards. This is most often caused by falling on an outstretched hand (FOOSH injury). Posterior dislocations often have concurrent labral or RTC pathology.

A recurrent dislocation in young individuals is extremely high and may require surgery for those that are highly active. If surgery is required, patients typically require a period of immobilization followed by physical therapy to restore normal shoulder function. The risk of redislocation is much lower in middle-aged and older adults and conservative treatment with physical therapy is often indicated initially.

Multidirectional Instability Signs and Symptoms

Signs of ligamentous laxity are present. Pain and weakness are present in the shoulder that subluxes (partially moves out of joint) forward, backward, or downward. A positive “sulcus sign” is present on examination by a medical professional.

Most patients respond well with physical therapy. Rarely surgery is indicated because it is hard to stabilize the shoulder in all directions.

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Shoulder Tendonitis and Impingement

Shoulder impingement occurs when one of the structures of the shoulder (most often the supraspinatus muscle or subacrominal bursa) become compressed between the bones that make up the shoulder joint typically when reaching over head or behind your back. This compression causes damage to these structures resulting in shoulder tendonitis. Common symptoms include localized shoulder pain, tenderness to the touch, shoulder weakness, and stiffness. Treatment typically consists of ice, pain medications and exercise. In physical therapy patients’ strength, range of motion, pain severity and posture all are addressed through the use of specific exercises as well as modalities such as ice, heat etc. Surgery is not typically indicated.

Rotator Cuff Tears

Rotator cuff tears are a common cause of pain and disability in the adult population. A torn rotator cuff is usually the result of trauma to the shoulder, such as a fall, or overuse. Overhead athletes, people over the age of 40, and people who perform overhead work are at a greater risk. These are four rotator cuff muscles that help to stabilize the shoulder joint: the supraspinatus, ingfraspinatus, teres minor and subscapularis. The supraspinatus is the most commonly torn of the four muscles.

Rotator cuffs can be partial or full tears, full tears defined by the tendon fully removed from the bone. Rotator cuffs can be diagnosed by a physical therapist using special tests, but are often diagnosed with MRI or ultrasound.

Rotator cuff tears are often treated non-surgically with physical therapy to reduce pain and improve shoulder function. Physical therapy involves education, activity modification, rest, and therapeutic exercises to strengthen shoulder musculature. Rotator cuff tears may also be treated with pain medication or injections to reduce pain and inflammation.

If surgery is indicated, physical therapy will begin soon after the surgical date and begin with gentle range of motion exercises and progress slowly toward shoulder strengthening and functional activities.

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Acromioclavicular Separation (Separated Shoulder)

An acromioclavicular (AC) separation is when there is an injury to the junction between the acromion (bone on the shoulder blade) and the clavicle (collar bone). This is typically the result of trauma such as falling onto your shoulder or a motor vehicle accident. If severe enough this could cause a “step down” deformity where the clavicle protrudes upwards. Common symptoms of a separated shoulder include shoulder pain, swelling, reduced shoulder strength as well as reduced shoulder range of motion. Treatment typically consists of ice, pain medication, rest initially and physical therapy. In physical therapy patient’s strength, range of motion, pain severity and posture are all addressed through the use of specific exercises as well as modalities such as ice/heat/etc. Surgery is not typically included unless the ligaments holding the joint together are compromised.

Shoulder Labral Tears

The labrum is a piece of fibrocartilarge (rubbery tissue) which attaches to the rim of the shoulder socket. This helps keep the ball of the shoulder joint (head of humerus) in place. Traumatic injury and wear and tear from repetitive motion of the upper arm can both cause labral tears. This can include a fall on an outstretch arm, a direct hit to the shoulder, a violent blow while reaching overhead or a sudden tug on the arm. Symptoms can include painful clicking, locking, popping and instability. Diagnosis may include a medical exam and a CT scan or MRI. Labral tears are often treated with rest, over the counter medication and physical therapy. Physical therapy can help strengthen the muscles of the shoulder, especially the rotator cuff muscles. In addition, your PT will show you what activities to avoid as well as gentle stretching exercises to do at home. Physical therapy can last 4-8 weeks depending on the severity of the injury.

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