Clavicle Fracture (Broken Collarbone)

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A broken collarbone is also known as a clavicle fracture. This is a very common fracture that occurs in people of all ages.

The clavicle is a long bone and most breaks occur in the middle of it. Occasionally, the bone will break where it attaches at the ribcage or shoulder blade.




Anatomy:
The collarbone (clavicle) is located between the ribcage (sternum) and the shoulder blade (scapula), and it connects the arm to the body.

The clavicle lies above several important nerves and blood vessels. However, these vital structures are rarely injured when the clavicle breaks, even though the bone ends can shift when they are fractured.


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The clavicle is part of your shoulder and connects your ribcage to your arm.
Causes:
Clavicle fractures are often caused by a direct blow to the shoulder. This can happen during a fall onto the shoulder or a car collision. A fall onto an outstretched arm can also cause a clavicle fracture. In babies, these fractures can occur during the passage through the birth canal.

Symptoms:
Clavicle fractures can be very painful and may make it hard to move your arm. Additional symptoms include:
  • Sagging shoulder (down and forward)
  • Inability to lift the arm because of pain
  • A grinding sensation if an attempt is made to raise the arm
  • A deformity or "bump" over the break
  • Bruising, swelling, and/or tenderness over the collarbone.
Doctor Examination:
During the evaluation, your doctor will ask questions about the injury and how it occurred. After discussing the injury and your symptoms, your doctor will examine your shoulder.

There is usually an obvious deformity, or "bump," at the fracture site. Gentle pressure over the break will bring about pain. Although a fragment of bone rarely breaks through the skin, it may push the skin into a "tent" formation.

Your doctor will carefully examine your shoulder to make sure that no nerves or blood vessels were damaged.

In order to pinpoint the location and severity of the break, your doctor will order an x-ray. X-rays of the entire shoulder will often be done to check for additional injuries. If other bones are broken, your doctor may order a computed tomography (CT or CAT) scan to see the fractures in better detail.

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This x-ray shows a fracture in the middle of the clavicle. Note how far out of place the broken ends are.
Treatment:

Nonsurgical Treatment
If the broken ends of the bones have not shifted out of place and line up correctly, you may not need surgery. Broken collarbones can heal without surgery.

Arm Support A simple arm sling or figure-of-eight wrap is usually used for comfort immediately after the break. These are worn to support your arm and help keep it in position while it heals.

Medication Pain medication, including acetaminophen, can help relieve pain as the fracture heals.

Physical Therapy While you are wearing the sling, you will likely lose muscle strength in your shoulder. Once your bone begins to heal, the pain will decrease and your doctor may start gentle shoulder and elbow exercises. These exercises will help prevent stiffness and weakness. More strenuous exercises can gradually be started once the fracture is completely healed.

Complications The fracture can move out of place before it heals. It is important to follow up with your doctor as scheduled to make sure the bone stays in position.

If the fracture fragments do move out of place and the bones heal in that position, it is called a "malunion." Treatment for this is determined by how far out of place the bones are and how much this affects your arm movement.

A large bump over the fracture site may develop as the fracture heals. This usually gets smaller over time, but a small bump may remain permanently.

Surgical Treatment:
If your bones are out of place (displaced), your doctor may recommend surgery. Surgery can align the bones exactly and hold them in good position while they heal. This can improve shoulder strength when you have recovered.

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Impingement Syndrome (Swimmer's Shoulder)

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Impingement Syndrome, which is sometimes called Swimmer’s shoulder or Thrower’s shoulder, is caused by the tendons of the rotator cuff (supraspinatus, infraspinatus, teres minor and subscapularis muscles) becoming 'impinged' as they pass through a narrow bony space called the Subacromial space – so called because it is under the arch of the acromion. With repetitive pinching, the tendon(s) become irritated and inflamed.


This can lead to thickening of the tendon which may cause further problems because there is very little free space, so as the tendons become larger, they are impinged further by the structures of the shoulder joint and the muscles themselves.


Impingement Syndrome in itself is not a diagnosis, it is a clinical sign.  There are at least NINE different diagnoses which can cause impingement syndrome. These include:
  • Bone spurs
  • Rotator cuff disease/injury
  • Labral injury
  • Shoulder instability
  • Biceps tendinopathy
  • Scapula (shoulder blade) movement dysfunctions
If left untreated, shoulder impingements can result in a rotator cuff tear.

Impingement Syndrome can be classified as:
1. External Impingement
2. Internal Impingement


External Impingement:
Which can be either primary or secondary:

Primary
  • Is usually due to bony abnormalities in the shape of the acromial arch.
  • Can sometimes be due to congenital abnormalities (known as os acromial), or due to degenerative changes, where small spurs of bone grow out from the arch with age, and impinge on the tendons.
Secondary
  • Usually due to poor scapular (shoulder blade) stabilisation which alters the physical position of the acromion, hence causing impingement on the tendons.
  • Is often due to weak serratus anterior and tight pectoralis minor muscles
  • Other causes can include weakening of the rotator cuff tendons due to overuse (e.g. throwing and swimming) or muscular imbalance with the deltoid muscle and rotator cuff muscles.  
Internal Impingement:
  • Occurs predominantly in athletes where throwing is the main part of the sport (e.g. pitches in baseball)
  • The under side of the rotator cuff tendons are impinged against the glenoid labrum – this tends to cause pain at the back of the shoulder joint as well as sometimes at the front.
Symptoms Of Impingement Syndrome:
  • Shoulder pain comes on gradually over a long period.
  • Pain at the front and/or side of the shoulder joint with overhead activity such as throwing, front crawl swimming - most common in external impingements.
  • Pain at the back and/or front of the shoulder when the arm is held out to the side (abducted) and turned outwards (external rotation) - most common in internal impingements.
  • Pain when lifting the arm above 90 degrees.
  • Pain on internal (medial rotation) movements - for example reaching up behind your back.
  • Positive shoulder impingement tests.
Investigation:
The following examples are for information purposes only. We highly recommend seeing a sports injury professional or Doctor to receive a full assessment of your injury

Special Tests:
There are a range of tests which can be performed which are used to indicate certain injuries:
  • Empty Can Test
    You will be asked to put your arm out in front of you at a 45 degree angle to your body, with the thumb pointing to the floor (as if holding an empty can). The therapist will ask you to raise your arm whilst they resist your movement. This tests the supraspinatus tendon.

  • Neer’s Sign
    The therapist will position your arm with the thumb facing down and at a 45 degree angle to your body. They will then lift your arm up, above your head. If you experience pain or discomfort, you may have an impingement of supraspinatus.

  • Hawkins-Kennedy Test
    Your arm will be raised in front of you to 90° and the elbow bent. The therapist will then medially rotate (turn the wrist down and elbow up) the arm. If this causes pain you probably have an impingement of Supraspinatus.
            Impingement Syndrome Treatment
  • Rest
  • Apply ice or cold therapy to the painful area for 10-15 minutes per 2 hour period.  Remember to use an ice bag or a towel wrapped around the ice to protect against ice burn. 
  • Prescribe anti-inflammatory medication such as Ibuprofen or other NSAID's (non steroidal anti inflammatory drugs).
  • Advise on rehabilitation programme's to improve function and decrease pain.
  • Discuss the option of directly injected steroids into the subacromial space to reduce inflammation and reduce inflammation in the local area (this is not usually an early option).
  • Discuss the option of surgery in cases which have failed conservative rehabilitation efforts – this is usually after a period of at least 6-12 months.

       Impingement Syndrome Rehabilitation


Aims of rehabilitation
  • Reduce pain and inflammation.
  • Improve or maintain mobility of the shoulder joint.
  • Strengthen the shoulder.
  • Work on correcting any postural problems.
  • Get a coach or trainer to correct your technique.
  • Gradual return to full fitness.
Reducing pain and inflammation
  • Rest from all aggravating activities, especially those involving overhead movements. Every time you catch the tendons in the joint causing pain you may be making the condition worse. Maintain aerobic fitness on a stationary cycle.
  • NSAID's (Non Steroidal Anti-Inflammatory Drugs) e.g. Ibuprofen may be prescribed by a doctor. Athletes with asthma should not take Ibuprofen. The drugs may help in the early stages of rehabilitation (first few days) but longer term are unlikely to help as much.
  • Apply ice to the painful area for the first few days. 15 minutes at a time, every 2-3 hours.
  • This period of rest, icing and anti-inflammatory medication should last up to a week.
Mobility & Stretching Exercises:
  • Full mobility of the shoulder joint is key in rehabilitation of this injury. If there is insufficient mobility in the joint then the condition is likely to reoccur as the shoulder will not function correctly and allow enough space for the tendons to exist.
  • Mobility exercises should begin as soon as pain will allow and should avoid any areas of movement that do cause pain.
  • Generally any movements that involve lifting the arm out to the side (abduction) above horizontal should be done with the arm rotated outwards. The same applies to movements lifting the arm up forwards (flexion).
  • Stretching is also very important. Stretches should be held for 30 seconds at a time.
  • Massage can be used to help relax any tight muscles, such as the rotator cuff and upper back muscles.
  • These exercises can begin after 2-3 days, provided they are pain-free.
  • They should continue throughout the rehabilitation programme and beyond.
Simple Stretching Exercises Pictures ( Click on the picture to read description)

Strengthening Exercises
  • Strengthening the rotator cuff muscles is the key to strengthening the shoulder.
  • It is important to get an equal balance of strength between the external and internal rotators at the shoulder. It is thought that an imbalance of strength here will contribute to the likelihood of impingement.
  • Strengthening exercises can begin after a week or so's rest and mobility exercises, provided they are pain-free.
  • You should start with gentle rotator cuff strengthening exercises, with the arm by your side.
  • Strengthening should be progressed gradually throughout the programme as pain allows.
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Muscle Energy Technique

The therapist rotates the arm in the direction of the white arrow as far as it will comfortably go.

The athlete then does a static contraction aiming to rotate the arm against the resistance of the therapist in the direction of the black arrow. Resistance should be enough so that the arm does not move.

Hold the contraction for only a couple of seconds at 50% of maximum effort. The therapist is then able to rotate the arm further in the direction of the white arrow again. This cycle is continued until no further improvement is made - usually 3 to 6 contractions.


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Shoulder Dislocation

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The shoulder joint is the body's most mobile joint. It can turn in many directions. But, this advantage also makes the shoulder an easy joint to dislocate.

A partial dislocation (subluxation) means the head of the upper arm bone (humerus) is partially out of the socket (glenoid). A complete dislocation means it is all the way out of the socket. Both partial and complete dislocation cause pain and unsteadiness in the shoulder.



Symptoms:
Symptoms to look for include:
  • Swelling
  • Numbness
  • Weakness
  • Bruising
Sometimes dislocation may tear ligaments or tendons in the shoulder or damage nerves.

The shoulder joint can dislocate forward, backward, or downward. A common type of shoulder dislocation is when the shoulder slips forward (anterior instability). This means the upper arm bone moved forward and down out of its joint. It may happen when the arm is put in a throwing position.

Diagnosis:
The muscles may have spasms from the disruption, and this can make it hurt more. When the shoulder dislocates time and again, there is shoulder instability.

The doctor will examine the shoulder and may order an X-ray. It is important that the doctor know how the dislocation happened and whether the shoulder had ever been dislocated before.


        Treatment For Shoulder Dislocation

Following a reduction you will usually be advised to:
  • Rest and immobilise the shoulder in a sling for 5-7 days.
  • If there are complications such as fractures or soft tissue damage, immobilisation may be over a longer period.
  • You may be prescribed NSAIDS such as ibuprofen to ease pain and inflammation.
  • After the period of initial immobilisation you should be directed to gradually increase your range of pain free movement.
  • You will also need to strengthen the rotator cuff muscles which support the shoulder joint to prevent reoccurrences.
  • Exercises using resistance band are excellent for this in the early stages.
Rehabilitation Program

Stage 1: Following Reduction
  • Aim: Immobilise to prevent further damage and support joint, reduce pain and inflammation
  • Duration: Day 0-7
  • The shoulder should be immobilised in a sling for at least a week depending on the severity of any associated damage
  • Perform wrist and hand exercises such as moving each finger through its range of motion and clenching the fist to prevent stiffness and keep the blood flowing to the area
  • Continue icing the injury regularly to reduce pain and swelling.
  • If prescribed, take anti-infammatories
  • You can try taping the shoulder for extra support
Stage 2:
  • Aim: Start to mobilise the shoulder
  • Duration:Week 2-4
  • When pain allows start mobility exercises for the shoulder
  • Avoid the combined movements of abduction (taking the arm out to the side) and external rotation (turning the shoulder outwards) as this is often the position the injury occurred - see image above.
  • Only exercise if pain free
  • Continue to wear a sling when not performing exercises if you feel it necessary
  • Ice after exercise if swelling occurs
Stage 3:
  • Aim:Achieve full range of motion and begin strengthening
  • Duration: Weeks 4-6
  • Begin isometric (without movement) strengthening exercises providing there is no pain
  • Begin to move the shoulder into abduction and external rotation if comfortable to do so, but do not perform strengthening exercises in this position.
  • Continue with mobility exercises
  • Try to achieve a full pain free range of movement
  • Try to avoid wearing a sling
Stage 4:
  • Aim: Achieve strength equal to uninjured side and maintain mobility.
  • Duration:Weeks 6-10
  • Progress strengthening to resisted exercises if pain free
  • Progress to perform external rotation strengthening in the abducted position if comfortable.
  • Continue with mobility exercises to maintain full range of motion
  • Introduce proprioception exercises
Stage 5:
  • Aim: Return to sport
  • Duration: Weeks 10-16
  • Increase resistance used for strengthening, progress to dumbells and body weight exercises
  • Start functional activities such as throwing (start underarm and progress) and catching
  • Begin a gradual return to sport, starting with training drills, non-contact and slowly increase the demand on the shoulder

Mobility (Dislocated Shoulder)



Active Unassisted Exercises
These involve you using your muscles against gravity, and are working towards you gaining full use of the shoulder again.  These involve you practicing all the movements you would expect from the shoulder
  • Flexion - Lift the arm in front of you & above the head
  • Extension - Move the arm out behind out
  • Abduction- Take the arm away from the body to the side and up above the head
  • Adduction - Move the arm across the body
  • Internal Rotation - Keep the elbow bent by your side, turn the forearm in so that your wrist touches your stomach
  • External Rotation - Keep the elbow bent by your side, turn the forearm outwards so that your hand points away from you.
Strengthening Exercises:

Isometric Exercises
Isometric means 'without movement, also known as static contractions – these are exercises where the muscles are being worked without moving the joint, and are often quite useful if the joint itself is still healing.

Isometric Extension
Standing with your back against a wall, with your arms by your side.  While keeping your elbows and wrists straight, push back into the wall and hold for 5 seconds (work to increase to 10). Repeat this 5 times (work to increase to 10)

Isometric Adduction
With a small pillow or a rolled up newspaper between your injured arm and your torso, squeeze inwards and try to hold it in position.  Start with a small item and gradually move to larger sizes to work through a larger range of movement.  Hold for 5 seconds (work to increase to 10). Repeat this 5 times (work to increase to 10)

Isometric Abduction
Stand side-on to a wall, with the arm to be worked next to it. Place the back of the wrist against the wall and push outwards as if trying to raise the arm to the side (see picture). Hold for 5 seconds (work to increase to 10).  Repeat this 5 times (work to increase to 10)

External Rotation
Stand facing a door frame. Keep the elbow bent to 90 degrees and place the back of the hand against the frame (see picture). Push against the it. Hold for 5 seconds (work to increase to 10) and repeat 5 times (work to increase to 10)

Internal Rotation
Stand facing a door frame. Bend the elbow to 90 degrees, and place the palm of the hand on the side of the door frame and push against it (see picture). Hold for 5 seconds (work to increase to 10) and repeat 5 times (work to increase to 10).


Resisted Exercises
These work on your strength, and involve using different resistances to help you train the muscles gradually. The ideal method of doing this involves using a resistance band which is basically like a large elastic band. It comes in different 'strengths' according to the colour.

External Rotation
Wrap the resistance band around something stable and hold the other end standing so that the band crosses the body. Keeping the elbow bent to 90 degrees and the upper arm by the side, rotate the shoulder to pull the band away from the body.

Internal Rotation
Turn yourself around, so that the injured arm is closest to the attachment of the band. Again, keeping the elbow bent and the upper arm by your side, pull your hand in towards your stomach.

Abduction
Stand on one end of the band and hold the other end. Keeping the elbow straight, pull your arm out to the side so that the hand ends up level with your shoulder

Adduction
Wrap the band around something secure, hold the other end and stand with your injured side closest to the attachment. Keeping the elbow straight, pull your hand accross your body as far as is comfortable.

Flexion
Stand on the band holding the other end in the hand of your injured arm. Keeping the elbow straight, pull your hand straight up in front of you to about shoulder height.

Once the athlete is comfortable with the exercises above, the resistance band can be replaced with weights to progress the strengthening exercises described above. An external rotation exercise with a dumbbell is shown opposite.

Shoulder Press
Stand on the centre of the band and hold the ends in either hand. Start with the elbows bent and hands at shoulder height. From there, strighten your arms and push up above your head. Slowly return to the starting position and repeat.


When is Surgery An Option?
Surgery is sometimes necessary following a shoulder dislocation if there has been extensive damage to muscles, tendons, nerves, blood vessels or the labrum. Surgery is then usually performed as soon as possible after the injury.

In cases of recurrent shoulder dislocations, surgery may be offered in an attempt to stabilise the joint. There are a number of procedures which can be performed. The decision over which procedure to use depends largely on the patients lifestyle and activity. Some procedures result in reduced shoulder external rotation and so are not suitable for athletes involved in throwing or racket sports as this would affect performance.
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Rotator Cuff Injury

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The rotator cuff is a group of muscles which work together to provide the Glenohumeral (shoulder) joint with dynamic stability, helping to control the joint during rotation (hence the name).

The rotator cuff muscles include:
  • Supraspinatus
  • Infraspinatus
  • Teres Minor
  • Subscapularis

Supraspinatus and Infraspinatus are the most commonly injured rotator cuff muscles. Due to the function of these muscles, sports which involve a lot of shoulder rotation – for example, bowling in cricket, pitching in baseball, swimming, kayaking – often put the rotator cuff muscles under a lot of stress.
Problems with the rotator cuff muscles can be classed into two categories – Tears of the tendons/muscles, and inflammation of the tendons (often called tendinopathy or tendonitis).

Acute Tear:
This tends to happen as a result of a sudden, powerful movement. This might include falling over onto an outstretched hand at speed, making a sudden thrust with the paddle in kayaking, or following a powerful pitch/throw.

The symptoms will usually include:
  • Sudden, tearing feeling in the shoulder, followed by severe pain through the arm
  • Limited movement of the shoulder due to pain or muscle spasm
  • Severe pain for a few days (due to bleeding and muscle spasm) which usually resolves quickly
  • Specific tenderness (“x marks the spot”) over the point of rupture/tear
  • If there is a severe tear, you will not be able to abduct your arm (raise it out to the side) without assistance
Chronic Tear:
A chronic tear develops over a period of time. They usually occur at or near the tendon, as a result of the tendon rubbing against the overlying bone. This is usually associated with an impingement syndrome.
  • Usually found on the dominant side
  • More often an affliction of the 40+ age group
  • Pain is worse at night, and can affect sleeping
  • Gradual worsening of pain, eventually some weakness
  • Eventually unable to abduct arm (lift out to the side) without assistance or do any activities with the arm above the head
  • Some limitations of other movements depending on the tendon affected
Investigation:
The following examples are for information purposes only. We highly recommend seeing a sports injury professional or Doctor to receive a full assessment of your injury.

Special Tests:
There are a range of tests which can be performed which are used to indicate certain injuries:
  • Empty Can Test
    You will be asked to put your arm out in front of you at a 45 degree angle to your body, with the thumb pointing to the floor (as if holding an empty can). The therapist will ask you to raise your arm whilst they resist your movement. This tests the supraspinatus tendon.

  • Drop Arm Test (Codman’s Test)
    Your arm will be moved above your head, and you’re asked to gently lower your arm to your side. If you can’t do this slowly and under control, or have severe pain in doing so, it suggests a tear in the rotator cuff

  • Abrasion Sign
    You will be asked to sit and raise your arm to your side with the elbow bent. You will be asked to rotate your arm forwards and backwards. If there is any crunching noise (crepitus) there may be some inflammation or degenerative changes.

  • Neer’s Sign
    The therapist will position your arm with the thumb facing down and at a 45 degree angle to your body. They will then lift your arm up, above your head. If you experience pain or discomfort, you may have an impingement of supraspinatus.

  • Hawkins-Kennedy Test
    Your arm will be raised in front of you to 90° and the elbow bent. The therapist will then medially rotate (turn the wrist down and elbow up) the arm. If this causes pain you probably have an impingement of Supraspinatus.



Rotator Cuff Injury Rehabilitation
The following guidelines are for information purposes only. We recommend seeking professional advice before beginning rehabilitation.

Rehabilitation of rotator cuff injuries should consist of:
  • Reducing initial pain and inflammation
  • Identifying and correcting any shoulder abnormalities that might increase the chance of rotator cuff injury
  • Regaining full shoulder mobility
  • Strengthening the rotator cuff muscles and others surrounding the joint.
Stage 1: To reduce the pain and inflammation.
  • Apply cold therapy or ice to the shoulder. This will help reduce pain and inflammation. Apply ice for up to 15 minutes every 2 hours, gradually reducing the frequency of applications as the shoulder improves.
  • Rest the shoulder. Do not do anything that causes pain. Every time you cause pain, you are making the injury worse. If you need to use a sling to restrict movement then do so but only for a few days.
  • NSAID's or anti-inflammatory medication (e.g. ibuprofen) may help in the early stages. Always check with your Doctor before taking medication if you are not sure.
  • Apply massage therapy. Simply applying pressure to the tendon initially may be all that is needed. As pain reduces, cross friction techniques may be applied.
Stage 2: To re-establish range of motion and strength (usually 5 to 7 days after injury).
  • Improving range of motion is achieved through mobility exercises. These involves gradually increasing the range of motion the joint will go through without pain and specific stretching exercises to stretch all muscles around the shoulder joint.
  • Massage techniques can help to improve greatly the condition of the rotator cuff muscles, therefore allowing more joint flexibility and better response to strengthening exercises.
  • Strengthening exercises concentrate more specifically on the external rotator muscles (the ones that rotate the arm out) and the scapular stabilisers (muscles that support the shoulder blade). It is also important to strengthen the whole joint.
  • Strengthening exercises should only be done if they are pain free and in conjunction with stretching exercises.
Stage 3: To return the athlete to competition or specific training.
  • These exercises need to be specifically tailored to the athletes sport. For example throwers would start throwing a tennis ball against a wall. Five sets of 20 throws gradually increasing the number of sets and number of repetitions assuming no pain during, after or the next day.
Mobility Exercises:
Stretching should be done as soon as pain will allow and maintained throughout the rehabilitation process and beyond. Little and often is generally better than a big effort for a few days and then forget it as soon as the injury has settled down.

Strengthening Exercises:

Static (or isometric) exercises do not involve any movement. The patient pushes against a stationary object such as a wall, doorframe, or resistance provided by another person.

Because there is no movement, static exercises can be performed soon after injury, usually within 3-7 days, provided they are pain-free. If any exercises are painful, then do not continue with them. Rest for a longer period until they are comfortable.

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Lateral Rotation
  • The photograph opposite shows static lateral rotation performed against a wall.
  • Push against the wall, start off gently, (e.g. about 50% max) and gradually increase the intensity.
  • Keep the shoulder and upper arm still.
  • Aim to hold the position for 10 seconds, relax for three seconds and contract again for 10 seconds.

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Medial Rotation
  • Stand facing the corner of the wall, with the palm and lower forearm against the wall (the other side from the photo opposite).
  • Push against the wall, as if trying to rotate the forearm towards the body, keep the shoulder and upper arm still.
  • Again, start off at 50% for 10 seconds, repeated twice. Gradually increase the intensity, duration and repetitions.

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Abduction
  • Stand side-on to a wall, with the elbow bent and side of the forearm against the wall.
  • Push outwards, against the wall, as it trying to lift the arm above the head.
  • Start at 50%, hold for 10 seconds and repeat twice. Gradually increase as above.

Resistance Band Exercises
Resistance bands are great for strengthening the shoulder muscles. They can be used in many different positions and can easily be progressed as your strength improves. Tie one end of the band to something sturdy at waist height, such as a door handle (make sure the door is closed!). Always start with the band just taught to make sure you are working the muscles through the whole range. These exercises can replace the static exercises (above) as soon as pain allows (usually 7 days plus)

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Lateral Rotation
  • Hold the untied end of the band in the injured hand
  • Keep the elbow bent by your side and start with the forearm/hand close to your stomach
  • Make sure you keep the elbow in as you rotate the shoulder so that the arm moves away from the stomach as far as you can.
  • Slowly return to the start position
  • Repeat this 10 times initially (provided it is pain free).

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Medial Rotation
  • Turn around so that the attachment point of the band is on the same side as your injured shoulder
  • Make sure the elbow is bent and by your side
  • Start with the arm laterally rotated, with the forearm away from the body (the end position of the above exercise)
  • Rotate the shoulder so that the forearm moves in towards your stomach as far as you can.
  • Keep your elbow still and by your side throughout.

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Frozen Shoulder

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Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. Over time, the shoulder becomes very hard to move.

Frozen shoulder occurs in about 2% of the general population. It most commonly affects people between the ages of 40 and 60, and occurs in women more often than men.

Anatomy:
Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

The head of the upper arm bone fits into a shallow socket in your shoulder blade. Strong connective tissue, called the shoulder capsule, surrounds the joint.

To help your shoulder move more easily, synovial fluid lubricates the shoulder capsule and the joint.

Description:
In frozen shoulder, the shoulder capsule thickens and becomes tight. Stiff bands of tissue — called adhesions — develop. In many cases, there is less synovial fluid in the joint.

The hallmark sign of this condition is being unable to move your shoulder - either on your own or with the help of someone else. It develops in three stages:

1 . Freezing Phase
In the"freezing" stage, you slowly have more and more pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months.

2. Frozen Phase
Painful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the "frozen" stage, daily activities may be very difficult.

3. Thawing Phase
Shoulder motion slowly improves during the "thawing" stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.

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In frozen shoulder, the smooth tissues of the shoulder capsule become thick, stiff, and inflamed.
Causes Of Frozen Shoulder:
The causes of frozen shoulder are not fully understood. There is no clear connection to arm dominance or occupation. A few factors may put you more at risk for developing frozen shoulder.

Diabetes: Frozen shoulder occurs much more often in people with diabetes, affecting 10% to 20% of these individuals. The reason for this is not known.

Other diseases: Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease.

Immobilization: Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, a fracture, or other injury. Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder.

Symptoms
Of Frozen Shoulder:
Pain from frozen shoulder is usually dull or aching. It is typically worse early in the course of the disease and when you move your arm. The pain is usually located over the outer shoulder area and sometimes the upper arm.

Inverstigation:
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Doctor Examnination: After discussing your symptoms and medical history, your doctor will examine your shoulder. Your doctor will move your shoulder carefully in all directions to see if movement is limited and if pain occurs with the motion. The range of motion when someone else moves your shoulder is called "passive range of motion."  Your doctor will compare this to the range of motion you display when you move your shoulder on your own ("active range of motion"). People with frozen shoulder have limited range of motion both actively and passively.



Imaging Tests
Other tests that may help your doctor rule out other causes of stiffness and pain include:
X-rays;Dense structures, such as bone, show up clearly on x-rays. X-rays may show other problems in your shoulder, such as arthritis.
Magnetic resonance imaging (MRI) and ultrasound; These studies can create better images of problems with soft tissues, such as a torn rotator cuff.


                 Frozen Shoulder Treatment


Even though adhesive capsulitis is believed to be a "self limiting" process, it can be severely disabling for months to years and, as a result, requires aggressive treatment once the diagnosis is made. Initial treatment should include an aggressive frozen shoulder exercises to help regain shoulder motion. For patients in the initial painful or freezing phase, pain relief may be obtained with a course of anti-inflammatory medications, the judicious use of GH joint corticosteroid injections, or therapeutic modality treatments. Intra-articular corticosteroid injections help to abort the abnormal inflammatory process often associated with this condition.

Operative intervention is indicated in patients who show no improvement after a three month course of aggressive management that includes medications, corticosteroid injection and physical therapy.


Frozen Shoulder Exercises (Rehabilitation Protocol):

Phase 1: Weeks 0-8

Goals
  • Relieve pain
  • Restore Motion
No restriction or immobilization.


Pain Control
  • Medications
  • NSAIDS- first line medication for pain control
  • GH joint injection: corticosteroid/local anesthetic combination
  • Oral steroid taper- for patients with refractive or symptomatic frozen shoulder.
  • Therapeutic modalities
  • Ice, ultrasound, HVGS
  • Apply moist heat before therapy and ice pack at the end of session.
Motion: Frozen Shoulder Exercises
  • Initially focus on forward flexion and internal and external rotation with the arm at the side, and the elbow at 90 degrees.
  • Active ROM exercises.
  • Active assisted ROM exercises.
  • Passive ROM exercises.
  • In home these Frozen Shoulder Exercises should be performed 3-5 times per day.
  • A sustained stretch, of 15-30 seconds, at the end ROMs should be part of all ROM routines.
Phase 1: Weeks 8-16

Criteria for progression to Phase 2
  • Improvement in shoulder discomfort.
  • Improvement in shoulder motion.
  • Satisfactory physical examination.
Goals
  • Improve shoulder motion in all plane
  • Improve strength and endurance of rotator cuff and scapular stabilizers
Pain Control: By same means as used in 1st 8 weeks.

Motion: Frozen Shoulder Exercises
  • Perform active, active assisted and passive range of motion exercises to obtain around 140 degree of forward flexion, 45 degree of external rotation and internal rotation to twelfth thoracic spinous process.
Muscle Strengthening

Start with rotator cuff strengthening exercises 3 times per week, 8-12 repetitions for three sets.
  • Closed chain isometric strengthening with the elbow flexed to 90 degrees and the arm at the side. Perform internal rotation, external rotation, abduction and forward flexion.
  • Progress to open chain strengthening exercises with theraband for same greoup of muscles.
  • Progress to light weight dumbbell exercises for internal rotators, external rotators, abductors and forward flexors.
  • Perform strengthening of scapular stabilizers.
  • Deltoid strengthening.
Phase 3: 4 months and beyond

Criteria for progression to Phase 3
  • Significant functional recovery of shoulder motion.
  • Successful participation in activities of daily living.
  • Resolution of painful shoulder.
  • Satisfactory physical examination.
Goals
  • Home maintenance frozen shoulder exercises.
  • ROM exercises 2 times a day.
  • Rotator cuff strengthening 3 times a week.
  • Scapular stabilizer strengthening 3 times a week.
Please check with your Physical Therapist before starting with this frozen shoulder exercises.

Warning Signs:
  • Loss of motion
  • Continued Pain
Treatment of Complications:
  • These patients may need to move back to earlier routines
  • May require increased utilization of pain control modalities as outlined above
  • If loss of motion is persistent and pain continues, patients may require surgical intervention
  • Manipulation under anesthesia
  • Arthroscopic release