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NAME- Swati Chokra.

DATE OF BIRTH- 24th December 1985.


NATIONALITY- Indian.
ADDRESS- Rly Qr, RB/3/424, Block ‘E’, Ajni, Nagpur.
CONTACT NUMBER- 9960619515.
E-mail- capricron24@yahoo.com
LANGUAGE KNOWN- English, Hindi, Marathi.
EDUCATION QULIFICATION
COURSE PERCENTAGE BOARD/
UNIVERSITY
SSC 60.66% Maharashtra State
Board
HSSC 56.67% Maharashtra State
Board
BPTH 1st Year 65.78% PT. Ravishankar
Shukla University
BPTH 2nd Year 63% PT. Ravishankar
Shukla University
BPTH 3rd Year 70% PT. Ravishankar
Shukla University
BPTH 4th Year 59.56% PT. Ravishankar
Shukla University
AGGREGATE 64.1% PT. Ravishankar
Shukla University

PROJECT TOPIC OF 4thYEAR- “Prevalence of Cervical and


Lumbar Spine Discomfort in Bank Officials.”

Joints
People who are immobile have a higher tendency to suffer from muscular-skeletal
problems such as malformed, inflamed or frozen joints (particularly if accompanied by
Cerebral Palsy).
Common muscular-skeletal problems include instability of the spine or cervical area,
often due to kyphosis or scoliosis (curvature of the spine) from osteoporosis, or from
having to stoop to use a walking frame; there may also be foot, ankle. knee, hip and
shoulder problems due to arthritis, a recent fall or injury due to osteoporosis; Contracted
tendons and ligaments are very common and can be damaged if handled incorrectly.
Avoid the specific joints and areas of undiagnosed pain, but massage on the
areas above and below can help to improve circulation and distract from any pain
and aching.
A knowledge of remedial massage may be required as well as seeking advice from
the Physiotherapist.
Make sure you have access to a manual-handling plan for your own safety and that
of the client.
Eucalyptus and peppermint are useful for passive muscle warming (Hong, et al.
1997).

OBJECTIVE To assess the efficacy of bipolar interferential electrotherapy (ET) and pulsed ultrasound (US) as
adjuvants to exercise therapy for soft tissue shoulder disorders (SD).
METHODS Randomised placebo controlled trial with a two by two factorial design plus an additional control group
in 17 primary care physiotherapy practices in the south of the Netherlands. Patients with shoulder pain and/or
restricted shoulder mobility, because of a soft tissue impairment without underlying specific or generalised condition,
were enrolled if they had not recovered after six sessions of exercise therapy in two weeks. They were randomised to
receive (1) active ET plus active US; (2) active ET plus dummy US; (3) dummy ET plus active US; (4) dummy ET plus
dummy US; or (5) no adjuvants. Additionally, they received a maximum of 12 sessions of exercise therapy in six
weeks. Measurements at baseline, 6 weeks and 3, 6, 9, and 12 months later were blinded for treatment. Outcome
measures: recovery, functional status, chief complaint, pain, clinical status, and range of motion.
RESULTS After written informed consent 180 patients were randomised: both the active treatments were given to
73 patients, both the dummy treatments to 72 patients, and 35 patients received no adjuvants. Prognosis of groups
appeared similar at baseline. Blinding was successfully maintained. At six weeks seven patients (20%) without
adjuvants reported very large improvement (including complete recovery), 17 (23%) and 16 (22%) with active and
dummy ET, and 19 (26%) and 14 (19%) with active and dummy US. These proportions increased to about 40% at
three months, but remained virtually stable thereafter. Up to 12 months follow up the 95% CI for differences between
groups for all outcomes include zero.
CONCLUSION Neither ET nor US prove to be effective as adjuvants to exercise therapy for soft tissue SD.
No effect of bipolar interferential electrotherapy and
pulsed ultrasound for soft tissue shoulder disorders: a
randomised controlled trial
G. J M G van der Heijden, P. Leffers, P. Wolters, J. Verheijden, H. van
Mameren, J. Houben, L. Bouter, and P. Knipschild
Institute for Rehabilitation Research, Hoensbroek, The Netherlands.
This article has been cited by other articles in PMC.
Abstract
OBJECTIVE—To assess the efficacy of bipolar interferential electrotherapy (ET) and
pulsed ultrasound (US) as adjuvants to exercise therapy for soft tissue shoulder
disorders (SD).
METHODS—Randomised placebo controlled trial with a two by two factorial design
plus an additional control group in 17 primary care physiotherapy practices in the
south of the Netherlands. Patients with shoulder pain and/or restricted shoulder
mobility, because of a soft tissue impairment without underlying specific or
generalised condition, were enrolled if they had not recovered after six sessions of
exercise therapy in two weeks. They were randomised to receive (1) active ET plus
active US; (2) active ET plus dummy US; (3) dummy ET plus active US; (4) dummy
ET plus dummy US; or (5) no adjuvants. Additionally, they received a maximum of
12 sessions of exercise therapy in six weeks. Measurements at baseline, 6 weeks
and 3, 6, 9, and 12 months later were blinded for treatment. Outcome measures:
recovery, functional status, chief complaint, pain, clinical status, and range of
motion.
RESULTS—After written informed consent 180 patients were randomised: both the
active treatments were given to 73 patients, both the dummy treatments to
72 patients, and 35 patients received no adjuvants. Prognosis of groups appeared
similar at baseline. Blinding was successfully maintained. At six weeks seven
patients (20%) without adjuvants reported very large improvement (including
complete recovery), 17 (23%) and 16 (22%) with active and dummy ET, and
19 (26%) and 14 (19%) with active and dummy US. These proportions increased to
about 40% at three months, but remained virtually stable thereafter. Up to
12 months follow up the 95% CI for differences between groups for all outcomes
include zero.
CONCLUSION—Neither ET nor US prove to be effective as adjuvants to exercise
therapy for soft tissue SD.

Full Text
The Full Text of this article is available as a PDF (115K).
Selected References
These references are in PubMed. This may not be the complete list of references from this article.

• Jayson MI. Frozen shoulder: adhesive capsulitis. Br Med J (Clin Res Ed). 1981 Oct
17;283(6298):1005–1006. [PubMed]

• Bland JH, Merrit JA, Boushey DR. The painful shoulder. Semin Arthritis Rheum. 1977
Aug;7(1):21–47. [PubMed]

• Uhthoff HK, Sarkar K. An algorithm for shoulder pain caused by soft-tissue disorders. Clin
Orthop Relat Res. 1990 May;(254):121–127. [PubMed]

• Roberts WJ. A hypothesis on the physiological basis for causalgia and related pains. Pain.
1986 Mar;24(3):297–311. [PubMed]

• van der Windt DA, Koes BW, Boeke AJ, Devillé W, De Jong BA, Bouter LM. Shoulder
disorders in general practice: prognostic indicators of outcome. Br J Gen Pract. 1996
Sep;46(410):519–523. [PubMed]

• van der Windt DA, Koes BW, de Jong BA, Bouter LM. Shoulder disorders in general
practice: incidence, patient characteristics, and management. Ann Rheum Dis. 1995
Dec;54(12):959–964. [PubMed]

• Yamanaka K, Matsumoto T. The joint side tear of the rotator cuff. A followup study by
arthrography. Clin Orthop Relat Res. 1994 Jul;(304):68–73. [PubMed]

• Chard MD, Sattelle LM, Hazleman BL. The long-term outcome of rotator cuff tendinitis--a
review study. Br J Rheumatol. 1988 Oct;27(5):385–389. [PubMed]

• Bulgen DY, Binder AI, Hazleman BL, Dutton J, Roberts S. Frozen shoulder: prospective
clinical study with an evaluation of three treatment regimens. Ann Rheum Dis. 1984
Jun;43(3):353–360. [PubMed]

• Hazleman BL. The painful stiff shoulder. Rheumatol Phys Med. 1972 Nov;11(8):413–421.
[PubMed]
• Croft P, Pope D, Silman A. The clinical course of shoulder pain: prospective cohort study in
primary care. Primary Care Rheumatology Society Shoulder Study Group. BMJ. 1996 Sep
7;313(7057):601–602. [PubMed]

• Mulcahy KA, Baxter AD, Oni OO, Finlay D. The value of shoulder distension arthrography
with intraarticular injection of steroid and local anaesthetic: a follow-up study. Br J Radiol.
1994 Mar;67(795):263–266. [PubMed]

• Pollock RG, Duralde XA, Flatow EL, Bigliani LU. The use of arthroscopy in the treatment of
resistant frozen shoulder. Clin Orthop Relat Res. 1994 Jul;(304):30–36. [PubMed]

• Binder AI, Bulgen DY, Hazleman BL, Roberts S. Frozen shoulder: a long-term prospective
study. Ann Rheum Dis. 1984 Jun;43(3):361–364. [PubMed]

• Peters D, Davies P, Pietroni P. Musculoskeletal clinic in general practice: study of one


year's referrals. Br J Gen Pract. 1994 Jan;44(378):25–29. [PubMed]

• Hackett GI, Bundred P, Hutton JL, O'Brien J, Stanley IM. Management of joint and soft
tissue injuries in three general practices: value of on-site physiotherapy. Br J Gen Pract.
1993 Feb;43(367):61–64. [PubMed]

• Gentle PH, Herlihy PJ, Roxburgh IO. Controlled trial of an open-access physiotherapy
service. J R Coll Gen Pract. 1984 Jul;34(264):371–376. [PubMed]

• Rush PJ, Shore A. Physician perceptions of the value of physical modalities in the
treatment of musculoskeletal disease. Br J Rheumatol. 1994 Jun;33(6):566–568. [PubMed]

• Lindsay DM, Dearness J, McGinley CC. Electrotherapy usage trends in private


physiotherapy practice in Alberta. Physiother Can. 1995 47(1):30–34.Winter; [PubMed]

• Robinson AJ, Snyder-Mackler L. Clinical application of electrotherapeutic modalities. Phys


Ther. 1988 Aug;68(8):1235–1238. [PubMed]

• ter Haar G, Dyson M, Oakley EM. The use of ultrasound by physiotherapists in Britain,
1985. Ultrasound Med Biol. 1987 Oct;13(10):659–663. [PubMed]
• van der Heijden GJ, van der Windt DA, de Winter AF. Physiotherapy for patients with soft
tissue shoulder disorders: a systematic review of randomised clinical trials. BMJ. 1997 Jul
5;315(7099):25–30. [PubMed]

• Green S, Buchbinder R, Glazier R, Forbes A. Systematic review of randomised controlled


trials of interventions for painful shoulder: selection criteria, outcome assessment, and
efficacy. BMJ. 1998 Jan 31;316(7128):354–360. [PubMed]

• Gam AN, Johannsen F. Ultrasound therapy in musculoskeletal disorders: a meta-analysis.


Pain. 1995 Oct;63(1):85–91. [PubMed]

• Falconer J, Hayes KW, Chang RW. Therapeutic ultrasound in the treatment of


musculoskeletal conditions. Arthritis Care Res. 1990 Jun;3(2):85–91. [PubMed]

• Robinson AJ. Transcutaneous electrical nerve stimulation for the control of pain in
musculoskeletal disorders. J Orthop Sports Phys Ther. 1996 Oct;24(4):208–226. [PubMed]

• Knipschild P, Leffers P, Feinstein AR. The qualification period. J Clin Epidemiol.


1991;44(6):461–464. [PubMed]

• Sato A, Schmidt RF. Somatosympathetic reflexes: afferent fibers, central pathways,


discharge characteristics. Physiol Rev. 1973 Oct;53(4):916–947. [PubMed]

• Guyatt G, Walter S, Norman G. Measuring change over time: assessing the usefulness of
evaluative instruments. J Chronic Dis. 1987;40(2):171–178. [PubMed]

• van der Windt DAWM, van der Heijden GJMG, de Winter AF, Koes B, Deville W, Bouter L.
The responsiveness of the Shoulder Disability Questionnaire. Ann Rheum Dis. 1998
Feb;57(2):82–87. [PubMed]

• Jaeschke R, Singer J, Guyatt GH. A comparison of seven-point and visual analogue scales.
Data from a randomized trial. Control Clin Trials. 1990 Feb;11(1):43–51. [PubMed]

• Carlsson AM. Assessment of chronic pain. I. Aspects of the reliability and validity of the
visual analogue scale. Pain. 1983 May;16(1):87–101. [PubMed]

• Revill SI, Robinson JO, Rosen M, Hogg MI. The reliability of a linear analogue for evaluating
pain. Anaesthesia. 1976 Nov;31(9):1191–1198. [PubMed]
• Guyatt GH, Berman LB, Townsend M, Taylor DW. Should study subjects see their previous
responses? J Chronic Dis. 1985;38(12):1003–1007. [PubMed]

• Westerberg CE, Solem-Bertoft E, Lundh I. The reliability of three active motor tests used in
painful shoulder disorders. Presentation of a method of general applicability for the
analysis of reliability in the presence of pain. Scand J Rehabil Med. 1996 May;28(2):63–70.
[PubMed]

• Solem-Bertoft E, Lundh I, Westerberg CE. Pain is a major determinant of impaired


performance in standardized active motor tests. A study in patients with fracture of the
proximal humerus. Scand J Rehabil Med. 1996 May;28(2):71–78. [PubMed]

• Ure BM, Tiling T, Kirchner R, Rixen D. Zuverlässigkeit der klinischen Untersuchung der
Schulter im Vergleich zur Arthroskopie. Eine prospektive Studie. Unfallchirurg. 1993
Jul;96(7):382–386. [PubMed]

• Bamji AN, Erhardt CC, Price TR, Williams PL. The painful shoulder: can consultants agree?
Br J Rheumatol. 1996 Nov;35(11):1172–1174. [PubMed]

• Pellecchia GL, Paolino J, Connell J. Intertester reliability of the cyriax evaluation in


assessing patients with shoulder pain. J Orthop Sports Phys Ther. 1996 Jan;23(1):34–38.
[PubMed]

• Buchbinder R, Goel V, Bombardier C, Hogg-Johnson S. Classification systems of soft tissue


disorders of the neck and upper limb: do they satisfy methodological guidelines? J Clin
Epidemiol. 1996 Feb;49(2):141–149. [PubMed]

• Brox JI, Staff PH, Ljunggren AE, Brevik JI. Arthroscopic surgery compared with supervised
exercises in patients with rotator cuff disease (stage II impingement syndrome). BMJ.
1993 Oct 9;307(6909):899–903. [PubMed]

• Ginn KA, Herbert RD, Khouw W, Lee R. A randomized, controlled clinical trial of a
treatment for shoulder pain. Phys Ther. 1997 Aug;77(8):802–811. [PubMed]

• van der Heijden GJ, van der Windt DA, Kleijnen J, Koes BW, Bouter LM. Steroid injections
for shoulder disorders: a systematic review of randomized clinical trials. Br J Gen Pract.
1996 May;46(406):309–316. [PubMed]
• Goupille P, Sibilia J. Local corticosteroid injections in the treatment of rotator cuff
tendinitis (except for frozen shoulder and calcific tendinitis). Groupe Rhumatologique
Français de l'Epaule (G.R.E.P.). Clin Exp Rheumatol. 1996 14(5):561–566.Sep–Oct;
[PubMed]

• van der Windt DAWM, Koes BW, Devillé W, Boeke AJP, de Jong BA, Bouter LM.
Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful
stiff shoulder in primary care: randomised trial. BMJ. 1998 Nov 7;317(7168):1292–1296.
[PubMed]

• Winters JC, Sobel JS, Groenier KH, Arendzen HJ, Meyboom-de Jong B. Comparison of
physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints
in general practice: randomised, single blind study. BMJ. 1997 May 3;314(7090):1320–
1325. [PubMed]

• van der Windt DA, van der Heijden GJ, Scholten RJ, Koes BW, Bouter LM. The efficacy of
non-steroidal anti-inflammatory drugs (NSAIDS) for shoulder complaints. A systematic
review. J Clin Epidemiol. 1995 May;48(5):691–704. [PubMed]
Written by: DoctorNDTV team

What is frozen shoulder?


What are the causes?
Who is at risk?
What are the symptoms?
How is the diagnosis made?
What is the treatment?

What is frozen shoulder?

Frozen shoulder or adhesive capsulitis is a painful condition in which the shoulder loses its range of
movements. This condition is referred to as "frozen shoulder" because it becomes very difficult for a
person to move his shoulder. The shoulder is not actually frozen, it is just stiff. It may follow an injury
to the shoulder, but may also arise gradually without warning or injury.

What are the causes?

Adhesive capsulitis causes scar tissue to form in the shoulder region. This may occur as a result of
injury. Other conditions like tendonitis (inflammation or irritation of a tendon) and bursitis
(inflammation or irritation of a bursa). If the shoulder has been immobilized for a long period of time,
adhesive capsulitis could develop as a result. The condition could also develop as a result of an
autoimmune reaction. The body thinks it is under attack during an autoimmune reaction and will start
to attack parts of itself causing an inflammatory reaction in the tissues. However, in most cases, the
cause is unknown.

Who is at risk?

• The usual age of onset begins between ages 40 and 65.

• It affects approximately 10% to 20% of diabetics.

• Other factors include: - a period of immobility, resulting from trauma, overuse injuries or
surgery, hyperthyroidism, cardiovascular disease, clinical depression and Parkinson’s
disease.

What are the symptoms?

Initially, the shoulder may feel stiff and ache and gradually becomes very painful. This stage can last
up to eight months. The second stage is referred to as the adhesive stage and this is when the
shoulder becomes stiffer. This stage usually lasts 4 to 6 months and is generally less painful than
the first stage. The final stage lasts about one to three months. At this time, it usually becomes
easier to move the shoulder. Pain may still persist and the full range of motion may still not be got
with treatment.

It hurts the patient regardless of whether he moves the shoulder or someone else is moving it for
him. The movement will simply stop if there was something preventing the shoulder from moving any
further. The pain may increase at night.

How is the diagnosis made?

A doctor will examine the patient and ask for his medical history to be able to accurately diagnosis
his condition. Other conditions have similar symptoms to adhesive capsulitis so the doctor may need
to take an X-ray.

The most common test used is the MRI scan. An MRI scan is used to create pictures that look like
slices of the shoulder. This scan is used to create pictures that look like slices of the shoulder. It can
show the tendons as well as the bones, and whether there has been a tear in those tendons.

What is the treatment?

Successful treatment of adhesive capsulitis include:


• Anti-inflammatory drugs
• Cortisone injections to the shoulder
• Physical therapy

Anti-inflammatory drugs and cortisone injections reduce the inflammation of the shoulder allowing
the shoulder to be more easily stretched. Physical therapy is essential because it helps regain the
range of motion in the shoulder.

Treatment can be a long process. Initial treatment is aimed at reducing inflammation and pain and
increasing the range of motion of the shoulder. Exercise is a very important part of the treatment.
Exercises will help break up the scar tissue in the shoulder and should be done twice a day. The
doctor or physical therapist will show the patient what kind of exercises should be performed. Since
the exercises may be painful, using ice packs afterwards may help. With all exercises, the patient
should warm up before attempting to do them.

If progress is slow, the doctor may recommend a manipulation of the shoulder while the patient is
under anaesthesia. This procedure allows the doctor to stretch the shoulder joint capsule, and break
up the scar tissue. In most cases, a manipulation of the shoulder will increase the motion in the
shoulder joint faster than allowing nature to take its course. It may be necessary to repeat this
procedure several times.

Arthroscopic surgery may also help break up the scar tissue.


A camera is inserted through a small incision allowing the doctor to access the damage to the joint
and at the same time, aid in the healing process.

Last updated: 29 January 2006This


disease goes through three distinct phases: Adhesive Capulitis
is a condition that affects the lining of the shoulder joint, mostly affecting middle-aged Top
people. The cause of this condition is unknown, though there is a fairly common theory that
this is triggered from a viral infection. People with diabetes are more prone to this infection,
and recovery time is longer in such cases.

• The inflammatory phase - wherein the lining of the shoulder becomes heavily
inflamed, typically becoming very painful especially during the nighttime. Ultrasound
application in this stage is extremely helpful for reducing the inflammaton levels and
alleviating pain.

• After approximately six months, the inflammation reduces moving the patient into
the scarring phase. The lining becomes scarred and when arm movement is
attempted, sharp pains are experienced as the newly formed scar tissue is
stretched. Ultrasound application in this stage will soften the scar tissue, helping
minimize the sharp pains occuring during movement, and speeding the recovery
process. This will last about six months as well.
• The recovery phase. In this phase, scarring is eventually broken down and
movement slowly returns, usually taking about 12 months to complete.
Generally, the condition is considered to last over a 2 year span though there are times
when recovery lasts much longer.

The level of pain a person will experience in the inflammatory stage varies widely. Some
people experience only small amounts of discomfort, while others experience a debilitating
level of pain that alters their daily activities. If ultrasound application is begun quickly, the
symptoms of the condition can be reduced, and recovery time shortened. Treatment will
vary depending on the stage in which a suffer of adhesive capulitis will see a specialist,
though physical therapy and steroid injections are common. As a last resort, surgery is also
a good treatment.

Ultrasound therapy is also a helpful tool for recovery of adhesive capulitis, and
having a portable ultrasound device at home can be a powerful and convenient
treatment tool. If you have symptoms or are recovering from adhesive capulitis,
using ultrasound on a regular basis before your activity or throughout the day will
help relax your muscles, tendons and tissues, diminish pain and inflammation,
soften scar tissue and contribute greatly to the healing of your condition.

If you suffer from mild inflammation or pain after certain activities or movements
use ultrasound therapy when you complete the activity and then rest. Limit the
application of ultrasound to a couple of treatments per day (the manual will
recommend treatment frequency depending upon the injury or condition). In
between ultrasound treatments, maximize your pain relief and injury recovery by
using the Thermotex Personal Therapy System. When you're on the go, and not
near an electrical outlet, take advantage of the "wear anywhere" concept of our
hot/cold wraps - the highest rated wraps in the industry. Proven Performance,
Proven Relief - only found at MendMeShop.com. If you have been given a
treatment plan by your health professional, make sure you adhere to it to ensure
pain free living. In general, people who are committed to their therapies and
exercises will have the best medical outcomes.
. Frozen Shoulder (Adhesive Capsulitis)
As the name implies, movement of the shoulder is severely restricted in people with a "frozen shoulder." This
condition, which doctors call adhesive capsulitis, is frequently caused by injury that leads to lack of use due to pain.
Rheumatic disease progression and recent shoulder surgery can also cause frozen shoulder. Intermittent periods of
use may cause inflammation. Adhesions (abnormal bands of tissue) grow between the joint surfaces, restricting
motion. There is also a lack of synovial fluid, which normally lubricates the gap between the arm bone and socket to
help the shoulder joint move. It is this restricted space between the capsule and ball of the humerus that distinguishes
adhesive capsulitis from a less complicated painful, stiff shoulder. People with diabetes, stroke, lung disease,
rheumatoid arthritis, and heart disease, or those who have been in an accident, are at a higher risk for frozen
shoulder. Frozen shoulder is more common among women than men. People between the ages of 40 and 70 are
most likely to experience it.
Signs and symptoms: With a frozen shoulder, the joint becomes so tight and stiff that it is nearly
impossible to carry out simple movements, such as raising the arm. Stiffness and discomfort may worsen at
night.
Diagnosis: A doctor may suspect a frozen shoulder if a physical examination reveals limited shoulder
movement. X rays usually appear normal.
Treatment: Treatment of this disorder focuses on restoring joint movement and reducing shoulder pain.
Usually, treatment begins with nonsteroidal anti-inflammatory drugs and the application of heat, followed by
gentle stretching exercises. These stretching exercises, which may be performed in the home with the help
of a therapist, are the treatment of choice. In some cases, transcutaneous electrical nerve stimulation
(TENS) with a small battery-operated unit may be used to reduce pain by blocking nerve impulses. If these
measures are unsuccessful, an intra-articular injection of steroids into the glenoid humeral joint can result in
marked improvement of the frozen shoulder in a large percentage of cases. In those rare people who do not
improve from nonoperative measures, manipulation of the shoulder under general anesthesia and an
arthroscopic procedure to cut the remaining adhesions can be highly effective in most cases.
History of Presenting Complaint:
As elsewhere accurate diagnosis depends on careful history, physical examination and
appropriate investigations.
Prior to assessment, it is necessary to obtain a detailed history of the onset(Acute or
traumatic versus slow and insidious) and duration of the current, and any previous
symptoms. Relating the stage of the pathology then gives an insight to the total
management which is required. Information about the patient occupation, leisure
interests and hand dominance is also obtained to form an accurate prognosis of the
effect of treatment on lifestyle.
The patient chosen for this study was a 52 year old lady with a history of left shoulder
pain following a fall onto her left shoulder 1 month previously. The patient is a hair
dresser by profession. Following the fall the patient was referred by her General
Practitioner for radiological inverstigations. Nothing abnormal was seen on the
radiograph. Non Steroidal medication was prescribed over a course of three weeks.
Initially these reduced the pain. Approximatley 2 months later the patient reported
increasing levels of pain and difficulty sleeping at night due to pain levels.
At this point the patient was referred by the general Practitioner to attend for
physiotherapy.
Overall the patient was quite depressed about her shoulder pain, as it was interfering
quite badly with her sleep. She works as a hairdresser and was fearful that she may be
unable to continue working. Her hobbies included walking and golf.
Subjective Examination:
On attending the physiotherapy department a subjective examination was carried out to
determine the site and nature of the symptoms, the level of pain experienced, the
behaviour of pain over a 24 hour period and irritability of the condition. Information was
obtained and recorded on the appropriate assessment form with the inclusion of the
body chart,(Fig 1).
The patient complained of pain:
1. Difficult to pinpoint, and felt deep in the shoulder and over the deltoid area.(P1)
2. Occasional pain along the posterior aspect of the arm to the elbow.
P1 was described as an intermittent nagging pain and was made worse by shoulder
flexion and abduction and relieved by rest. She reported experiencing increasing levels
of pain while at work by day, which wakes her at night especially if she moves onto her
left side. She complains that she can no longer tie her brassiere from behind, though
she can perform most functional activities with her right dominant upper extremity.
It was established that there were no other relevant symptoms to be considered.
No vertebrobasilar symptoms
No spinal cord symptoms
No abnormal sympathetic symptoms
No parasthesia
No diminished or loss of sensation
Finally it was established that there were no other relevant current or past medical
history that may affect treatment choice. The patient’s drug history consisted of
distalgesic for pain relief.
Objective Examination:
The objective examination began with the patient standing undressed to the waist in a
cubicle with a good light. The method for diagnosis of shoulder lesions as described by
Cyriax was used during assessment.
On examination of posture it was noted that the patient had a slightly forward head
posture. Slight wasting of the bellies of the musculocutaneous cuff musculature was
observed.
Prior to examining the shoulder joint the Cervical Spine was assessed, as pathology of
the cervical spine can have a major influence on shoulder pain. Assessment was
carried out using six active movements as recommended by Cyriax. During these
movements full range of motion in all directions at the cervical spine, without pain was
noted. There was no provocation of the left shoulder pain during any of the cervical
spine tests.
The affected limb was then taken through a group of ten active, passive and resisted
movements to determine which structure was at fault. During the active elevation tests
pain, range and willingness to move were being observed.
Active elevation was to 90 degrees and caused P1 at the end of range.
Passive elevation was limited to 90 degrees with P1 and had a hard end feel.
Active elevation through abduction was 80 degrees and caused P1 with a
compensatory shoulder girdle elevation.
Passive tests were then applied to the joint during which pain, range and end feel was
observed.
Passive lateral rotation was 45 degrees and caused P1 with a hard end feel.
Passive abduction was limited to 80 degrees and caused P1
Passive medial rotation was 70 degrees and did not cause pain.
Resisted tests were applied to examine the response in terms of pain and power to:the
rotator cuff muscles, the adductors, and the biceps and triceps.
The patient exhibited left shoulder weakness, with strength grades of 4/5 for the motions
of abduction, external and internal rotation.
A negative scarf test cleared involvement of the acromioclavicular joint and the lower
fibres of subscapularis.
Palpation revealed no focal point of tenderness.
Clinical Diagnosis:
From the assessment it was evident there was a capsular involvement (most limitation
of lateral rotation, followed by abduction, followed by medial rotation).The presentation
correlated with the clinical signs and symptoms of adhesive capsulitis as reported by
Cyriax:
Pain sometime after initial minor trauma.
Initial pain worsening and spreads further down the arm.
Generally reduced ROM at the shoulder joint. Capsular Pattern at the shoulder: most
limitation of lateral rotation, followed by abduction and medial rotation.

What causes a frozen shoulder?


There are several different causes of a frozen shoulder. Some are obvious, whereas the
others are difficult to find. A history of a fracture, a previous dislocated shoulder, or
other trauma to the shoulder, can often aggravate the process of scar tissue formation.
This is often made much worse by a period of prolonged immobilization in which the
arm is held in a sling -- a measure that is often necessary as a fracture heals or
because pain from the original trauma limits motion. Loss of motion can also commonly
occur as the result of a prior shoulder surgery for the treatment of other conditions --
such as fractures or a torn rotator cuff.
Causes

CLICK TO ENLARGE
Frozen shoulder

Doctors don't know the precise cause of frozen shoulder. It can occur after an injury to your shoulder or prolonged
immobilization of your shoulder, such as after surgery or an arm fracture. People who have diabetes have a greater
risk of frozen shoulder. For this reason, frozen shoulder may have an autoimmune component, meaning your immune
system may begin to attack the healthy parts of your body — in this case, the capsule and connective tissue of your
shoulder. People with other health conditions, including heart disease, lung disease and hyperthyroidism, also may
have an increased risk of developing frozen shoulder.
Your shoulder is a ball-and-socket joint. The round end of your upper arm bone (humerus) fits into a shallow groove
on your shoulder blade (scapula), much like a golf ball rests on a tee. Tough connective tissue, called the shoulder
capsule, surrounds the joint.
When frozen shoulder occurs, the shoulder capsule becomes inflamed and stiff. The inflammation may cause bands
of tissue (adhesions) to develop between your joint's surfaces. Synovial fluid, which helps to keep your joint
lubricated and moving smoothly, may decrease. As a result, pain and subsequent loss of movement may occur. In
some cases, mobility may decrease so much that performing everyday activities — such as combing your hair,
brushing your teeth or reaching for your wallet in your back pocket — is difficult or even impossible

Frozen shoulder, also known as Adhesive Capsulitis, is a condition that affects the shoulder joint
capsule and results in stiffness and loss of movement in the shoulder joint. It is different to
rotator cuff injury or shoulder tendonitis in that frozen shoulder affects the joint capsule, where
as the other two conditions affect the muscles and tendons of the shoulder joint.
Anatomy of the Shoulder Joint
The shoulder joint is a truly remarkable creation. It's quite
a complex formation of bones, muscles and tendons and
provides a great range of motion for your arm. The only
downside to this extensive range of motion is a lack of
stability, which can make the shoulder joint vulnerable to
injury.
The shoulder is made up of three bones, and the tendons of
four muscles. (Remember, tendons attach muscle to bone.)
The bones are called the "Scapula," the "Humerus" and the
"Clavicle." Or, in layman's terms, the shoulder blade, the
upper arm bone and the collarbone, respectively.
The four muscles which make up the shoulder joint are
called, "Supraspinatus," "Infraspinatus," "Teres Minor" and
"Subscapularis." It is the tendons of these muscles, which
connect to the bones that help to move your arm.
Frozen shoulder occurs in the shoulder joint at the point where the humerus bone fits into the
socket of the shoulder, (the glenohumeral joint). The supporting ligaments and surrounding
capsule become inflamed causing stiffness and limited motion.
Causes
The exact cause of frozen shoulder is unknown, however in a number of cases, frozen shoulder
occurs after another shoulder injury like rotator cuff tear, arthritis or shoulder surgery.
Also, poor posture can cause a shortening of the ligaments around the shoulder joint, which can
lead to frozen shoulder. Other theories have suggested that hormonal and genetic conditions like
diabetes and hyperthyroidism can also contribute to frozen shoulder.
Symptoms
The most common symptoms of frozen shoulder are pain and stiffness. Pain usually takes the
form of a persistent dull ache and stiffness prevents the full range of motion of the shoulder and
upper arm. Patients are often unable to lift the arm above their head or rotate their arm inward.
The normal progression of frozen shoulder has been described as having three stages.
 In stage one, (the freezing phase) the patient begins to develop mild pain and stiffness in the
shoulder joint. This stage can last from a few weeks to a few months.
 In stage two, (the frozen phase) the stiffness remains but the pain begins to decline. This stage
can last from a few months to nearly a year.
 In stage three, (the thawing phase) the full range of movement begins to return to the shoulder
joint. This stage can also last a few months.
Most sufferers of frozen shoulder will be fully recovered within 4 to 6 months but some cases
have lasted for up to three year, although these are extremely rare.
Treatment
Frozen shoulder treatment primarily consists of pain relief and physical therapy techniques. Pain
relief usually takes the form of anti-inflammatory medication and the aim here is to reduce the
pain enough so that physical therapy can be initiated.
Two other forms of therapy should also be considered; heat and massage.
 Heat is extremely good for increasing blood flow to a particular area. Heat lamps and hot water
bottles are the most effective way to increase blood flow; while heat based creams are distant
second choices.
 Massage is one of the best ways to increase blood flow to an injured area, and of course the
oxygen and nutrients that go with it. The other benefit of massage is that it helps to reduce the
amount of scar tissue which is associated with all muscle, tendon and joint injuries.
During this period of pain relief treatments physical therapy should also be initiated. This is an
extremely important part of the treatment process and full recovery will not occur without a
dedicated approach to physical therapy treatments.
Firstly, don't stop moving. Some doctors will often tell patients to keep the injured area still, and
this is not always the best advice. Gentle movement will help to keep the blood flowing to the
injured area. Of course, if pain is present, limit the amount of moving you do, but don't stop
moving all together.
Next, specific stretching and strengthening exercises should be started to help loosen up the
shoulder joint and speed up the recovery process. A full description of appropriate stretching and
strengthening exercises are included in the next section.
Prevention
Mark my words, "Prevention is much better than Cure." Anything you can do to prevent an
injury from occurring is worth it. The prevention of frozen shoulder and other shoulder injuries
comes down the conditioning of the shoulder muscles, tendons and ligaments, which ultimately
involves both stretching and strengthening of the shoulder joint.
Also, don't forget the common injury prevention techniques like, warming up properly and using
a bit of old-fashioned common-sense. However, for the most part, stretching and strengthening
are going to be your best defense against frozen shoulder. Even if you don't have a shoulder
problem now, the following stretching and strengthening exercises could save you from a major
headache in the future.
Firstly, below you'll find two good stretches for the shoulder area. Although both are quite basic
stretches, please be careful. If you haven't been stretching your shoulder joint, or your shoulders
are normally very stiff, these stretches will put quite a lot of stress on the muscles and tendons.
Be sure to warm-up first, then gently and slowly is the best way to proceed.

In the stretch to the left, simply stand


upright and clasp you hands behind
your back. Keep your arms straight
and slowly lift your hands upwards.
Hold this stretch for about 15 to 20
seconds and then repeat it 3 to 4 times.

In the stretch to the right, place one


arm across your body, keeping it
parallel to the ground. Then slowly
pull your elbow towards your body.
As above hold this stretch for about
15 to 20 seconds and then repeat it 3
to 4 times.
Stretching is one of the most under-utilized techniques for improving athletic performance,
preventing sports injury and properly rehabilitating sprain and strain injury. Don't make the
mistake of thinking that something as simple as stretching won't be effective.

Teach Patients to Treat With RICE


If a patient discloses a shoulder injury, offer the following advice:
• Rest—Reduce activity or stop using the injured area for 48 hours.
• Ice—Put an ice pack on the injured area for 20 minutes, four to eight times/day.
• Compression—Compress the area with an elastic wrap or other bandage to stabilize the
shoulder and help reduce swelling.
• Elevation—Keep the injured area elevated above heart level.
HOW TO TREAT ADHESIVE CAPSULITIS
Treatment focuses on restoring joint movement and reducing shoulder pain. Usually, treatment
begins with nonsteroidal anti-inflammatory drugs and the application of heat, followed by gentle
stretching exercises. Stretching exercises can be performed in the home with the help of a
physical therapist and are the treatment of choice.
In some cases, transcutaneous electrical nerve stimulation (TENS) with a small battery-operated
unit may be used to reduce pain by blocking nerve impulses. If these measures are unsuccessful,
an intra-articular steroid injection into the glenoid humeral joint can result in marked
improvement of adhesive capsulitis in a large percentage of cases. In rare cases where patients do
not improve from nonoperative measures, manipulation of the shoulder under general anesthesia
and arthroscopic procedure to cut remaining adhesions is usually highly effective.
WHAT IS PHYSICAL THERAPY?
• Physical Therapy is about helping people.

• Physical Therapy is also about helping people help themselves!

• Physical Therapy aims to restore movement and function, relieve pain, and
prevent further injury.

• Physical Therapy is the evaluation and treatment of numerous physical


conditions of all age groups.

• Physical Therapy treats people with musculoskeletal disorders such as back and
neck strains or knee injuries; neurological deficits such as stroke patients or
cerebral palsy children, and skin disorders such as wounds, burns or diabetic
foot ulcers.

• Physical Therapy is provided in the hospital, for outpatients, in schools, in the


home, and in nursing homes.

• Physical Therapy is about teaching people about their body, their disorder, and
their health.

• Physical Therapy helps people lead more active and independent lives.
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WHAT DOES A PHYSICAL THERAPIST DO?
• A Physical Therapist will perform an evaluation of your problem or difficulty. This
includes taking a history of a problem and then evaluating your problem by
performing tests and measures to assess the problem. These tests include
muscle strength tests, joint motion tests, sensory and neurological tests,
coordination tests, balance tests, observation, palpation, flexibility tests, postural
screening, movement analysis, and special tests designed for a particular
problem. Also includes past medical history.

• A Physical Therapist will then develop a treatment plan and goals and then
administer the appropriate treatment to aid in recovery of a problem or
dysfunction.

• Physical Therapy treatments include patient education to teach you how deal
with a current problem and how to prevent this problem from recurring in the
future.

• Physical Therapy provides "hands on techniques" like massage or joint


mobilization skills to restore joint motion or increase soft tissue flexibility.

• Physical Therapy aids in postural reeducation and movement awareness.


Therapeutic exercise instructions will help restore strength, movement, balance,
or coordination as a guide towards full functional recovery.

• Physical Therapy participates in functional training for work-related issues, and


home activities, and recreational or sports interests.

• Physical Therapy teaches basic mobility skills such as learning to move and get
out of bed, transferring to a chair, walking with crutches or special devices on
stairs or varied terrain.

• Physical Therapy can assist one in meeting special equipment needs such as
wheelchairs or other adaptive equipment to improve function and independence.

• Physical Therapy often involves the use of modalities which include properties of
heat, cold, air, light, water, electricity, ultrasound, and traction. These modalities
are used to help decrease pain and increase movement and function.

• Examples of Physical Therapy modalities are: Hotpacks, Coldpacks, Whirlpools,


TENS (Transcutaneous Electrical Nerve Stimulation), Ultrasound, Traction,
Electrical Stimulation, Intermittent Compression Pumps, and Myofascial
Release. This list is not all inclusive but should give you an idea of some of the
modalities that are available.

• A Physical Therapist will monitor your progress and adjust treatments and
treatment goals as appropriate.

• A Physical Therapist will consult with other health professionals to facilitate your
recovery.
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WHEN SHOULD YOU SEE A PHYSICAL THERAPIST?
• You should see a physical therapist when: you have suffered an injury--to
decrease pain and restore movement and function.

• Ask your Doctor for a referral to physical therapy.

• After surgery--to restore strength, range of motion, balance and function.

• If your illness or injury interferes with your daily normal tasks and your ability to
function or if your child has had birth defects before accidents or injuries occur to
prevent difficulties in the future.
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PHYSICAL THERAPY ASSISTIVE DEVICES
A variety of implements or equipment used to aid patients in performing tasks or
movements. Assistive devices include crutches, canes, walkers, wheelchairs,
power devices, long-handled reachers, and static and dynamic splints.
Therapists will fit and instruct the patient in the use and care of the assistive
device with the goal being optimal independence and safety .
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HOME EXERCISE PROGRAMS (HEP)
Positive physical therapy results are largely dependent on a person's adherence
to a specific exercise regime that is established by a Physical Therapist.
Individual home programs are written, taught, and monitored closely by the
therapist through the duration of one's therapy with progressive modifications
that are based on the individual's needs, progress and established goals.
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BALANCE / COORDINATION TRAINING
Balance is the ability to maintain the body in equilibrium with gravity both
statically (e.g. while stationary) and dynamically (e.g. while walking). Persons
with balance / coordination deficits due to trauma, disease, stroke or other
impairment are assisted through physical therapy in improving their balance by
following individual treatment plans established by a physical therapist after a
thorough evaluation. Treatment plans may include balance activities, sensory
training, ambulation training possibly with an assistive device, therapeutic
exercise and modalities as appropriate.
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SPINE CLINIC
You don't have to live with the pain! Providing specialized treatment to control
back and neck pain related to acute and chronic spine conditions. Involves
intensive rehabilitation of the spine in order to return the patient to a maximum
level of function. Rehabilitation will consist of individualized exercises, training in
proper posture, body mechanics, lifting techniques, and pain management.
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PROSTHETIC AND ORTHOTIC TRAINING
A prosthesis is an artificial device, often mechanical used to replace a missing
part of the body. Prosthetic training involves working with an amputee on overall
conditioning as well as specific stretching and strengthening of the involved limb
and training in the use and wearing of the prosthesis. Therapy also emphasizes
care of the amputation site, and performance of tasks of daily living with the
prosthesis. An orthosis is a device that supports weak or ineffective joints or
muscles, such as a splint, brace, shoe insert, or cast. Orthotic training
concentrates on the increase of motion, function, and use of a limb that requires
an orthosis for support. Therapy also emphasizes balance and coordination of
activities.
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WHIRLPOOL
Whirlpool is a water bath in which water is agitated by an electric turbine.
Whirlpools come in various shapes and sizes, but all work on the same
principles. Warm whirlpools are a source of moist heat and are used to increase
local metabolism, promote muscle relaxation, sedate sensory nerve endings,
and to increase cell permeability to aid with healing. The agitation in a whirlpool
can increase lymphatic circulation, assist in the removal of debris and keeps the
water at a constant temperature throughout the tank. Whirlpools are used to
treat open wounds, burns, subacute and chronic traumatic or inflammatory
conditions, and peripheral vascular disease or peripheral nerve injuries.
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THERAPEUTIC EXERCISE
A broad range of activities intended to improve strength, range of motion
(including muscle length), cardiovascular fitness, flexibility, or to otherwise
increase a person's functional capacity. An individualized program is
established, taught and monitored by a physical therapist/assistant that is based
on an initial evaluation and aimed at achieving specific goals.
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REHABILITATION THERAPY PROGRAMS FOR POST SURGICAL /
ACCIDENT / FRACTURE PATIENTS
Therapy programs may follow specific protocols or individualized treatment
plans with the aim of therapy being the return of strength, function and mobility.
The programs may involve a variety of treatment options with goals set for the
patient to resume normal activities of living as much as possible are established
by a physical therapist after a thorough evaluation. In-hospital and skilled units
may involve the inclusion of other therapeutic disciplines (i.e. speech therapy,
occupational therapy, art therapy, etc.), depending on the patient's needs.
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TRACTION
The therapeutic use of manual or mechanical tension created by a pulling force
to produce a combination of distraction and gliding to relieve pain and increase
tissue flexibility. Indications for traction therapy include, but are not limited to,
decreased sensation that temporarily improves with manual traction, increased
muscle tone that is reduced with manual traction, extremity pain or tingling that
is temporarily relieved with manual traction, spinal nerve root impediment due to
bulging, herniated or protruding disc, and muscle spasms that are causing nerve
root impingement and general hypomobility of lumbar or cervical spine regions.
Electric traction units exert a pulling force through a rope with various halters
and straps.
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PARAFFIN BATH
A superficial thermal modality using paraffin wax and mineral oil. Paraffin is a
means of delivering heat, especially to areas that are difficult to heat with
anything but a liquid medium, i.e. hands and feet. The effects of paraffin are:
increase of local metabolism, increased local perspiration, promotion of muscle
relaxation, sedation of sensory nerve endings reducing pain and softening of the
skin. Paraffin bath can be used for subacute, chronic traumatic, and
inflammatory conditions. All jewelry is removed prior to treatment. The area to be
treated is washed and examined for temperature sensation and skin integrity
then the patient dips the extremity into the paraffin. During the treatment, layers
of paraffin build up on the area being treated and the paraffin is allowed to
harden. At the conclusion of the treatment, the paraffin is pealed off and the
therapist may do massage or have the patient do stretching exercises to the
area that was treated.
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MODALITIES
Modality is a term used to identify a broad group of agents that may include
thermal acoustic, radiant, mechanical, or electric energy to produce
physiological changes in tissues for therapeutic purposes.
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ULTRASOUND
Ultrasound is a name given to sound waves that are of such high frequency that
they are not detectable by the human ear. The sound waves when applied to
human tissue are absorbed by the various tissues with the production of heat.
Ultrasound does penetrate heat into human tissues deeper that any other heat
modality, 4-6 cm. The benefits of heat from ultrasound include promotion of
muscle relaxation, increased local metabolism, and reduction of pain by sedating
nerve endings. Ultrasound waves also have non-thermal benefits resulting from
vibration of molecules. These effects include increases in the flexibility of
connective tissues such as joint capsules, ligaments, tendons, adhesions, scars
and cellular membrane permeability that accelerates healing. Therapeutic
ultrasound is a safe and effective tool for treating a variety of conditions that a
physical therapist commonly encounters. Pulsed and continuous modes allow
for ultrasound to be used for both acute and chronic cases, and ultrasound is
most effective as part of an overall treatment plan, including stretching,
therapeutic exercise, and mobilization.
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INTERMITTENT COMPRESSION PUMPS
Intermittent compression pumps are pneumatic pumps designed to apply
external pressure to a swollen body part. The amount of pressure and the time
for which it is applied are adjustable according to condition and persons blood
pressure. Some appliances have multiple compartments with separate tubes
and controls. These chambers can be filled sequentially and in some cases to
different pressures. External pressure, when applied to a swollen extremity, will
help to reduce edema by moving the fluid in the extremity to sites of normal
lymphatic or venous drainage. Intermittent compression pumps are used to treat
post-mastectomy lymphedema, venous insufficiency, amputations and traumatic
edema.
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ELECTRICAL STIMULATION
Intervention through the application of electricity. Electrical stimulation of
individual muscles is a means of providing exercise to muscles that the patient is
unable to contract voluntarily. If the muscle has lost its physical connection with
its nerve supply (is denervated), electrical stimulation can maintain nutrition of
the muscle through promoting blood flow, decrease fibrotic changes and retard
denervation atrophy. Electric stimulation used on muscles that have a nerve
supply (are innervated) can strengthen healthy muscle, prevent or reverse
disuse atrophy, maintain or improve mobility, promote peripheral circulation and
prevent fibrotic changes. There are various types of electrical stimulation in use
today and the type used and its specific application depends on the goals of
treatment.
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TENS UNITS
Transcutaneous Electrical Nerve Stimulation is a generic name for a method of
nerve stimulation designed to control pain. There are now a variety of TENS
units designed for specific modes of application. The different modes are
identified by their parameter ranges of amplitude, frequency and pulse width.
The units are small, battery powered, and light weight weighing only a few
ounces. Electrodes are placed on the skin near the area of pain and are
attached to the TENS unit. A physical therapist/assistant instructs the patient on
the positioning of the electrodes and the duration and frequency of the treatment
and also sets the parameters for the amplitude, frequency and pulse width
based on the patient's individual needs. The TENS unit is used at home by the
patient for use as instructed as part of a comprehensive treatment program
designed for the appropriate management of pain.
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MYOFASCIAL RELEASE
Fascia is the interwoven connective tissue that surrounds our muscles and
internal organs. Fascia shrinks when it is inflamed, is slow to heal because of
poor blood supply, and painful when inflamed because of its rich nerve supply.
Myofascial restrictions occur when the fascia is disrupted or stretched by any
injury, no matter how minor. Myofascial release is a therapeutic stretching
technique that relies entirely upon the feedback received by the therapist from
the patient nonverbally through the patient's tissues. Myofascial release removes
restrictions that impede efficient movement and use of energy for daily tasks.
Myofascial release is often incorporated in a patient's therapeutic treatment plan
along with other exercises and/or modalities.
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REFERENCES

1. Anderson, BC. Office Orthopedics for Primary Care: Diagnosis, 3rd ed, WB Saunders,
Philadelphia 2005.
2. Clark, JM, Harryman DT, 2nd. Tendons, ligaments, and capsule of the rotator cuff. Gross
and microscopic anatomy. J Bone Joint Surg Am 1992; 74:713.
3. Harryman DT, 2nd, Sidles, JA, Clark, JM, et al. Translation of the humeral head on the
glenoid with passive glenohumeral motion. J Bone Joint Surg Am 1990; 72:1334.
4. Vanderhooft, JE, Lippitt, SB, Harris, SL, et al. Glenohumeral stability from concavity-
compression: a quantitative analysis. Orthop Trans 1992; 16:774.
5. Gosk, J, Urban, M, Rutowski, R. Entrapment of the suprascapular nerve: anatomy, etiology,
diagnosis, treatment. Ortop Traumatol Rehabil 2007; 9:68.
6. Martin, SD, Warren, RF, Martin, TL, et al. Suprascapular neuropathy. Results of non-
operative treatment. J Bone Joint Surg Am 1997; 79:1159.
7. Gleason, PD, Beall, DP, Sanders, TG, et al. The transverse humeral ligament: a separate
anatomical structure or a continuation of the osseous attachment of the rotator cuff?. Am J
Sports Med 2006; 34:72.
8. Miranda, H, Viikari-Juntura, E, Heistaro, S, et al. A population study on differences in the
determinants of a specific shoulder disorder versus nonspecific shoulder pain without clinical
findings. Am J Epidemiol 2005; 161:847.
9. Johnson, TR. The shoulder. In: Essentials of Musculoskeletal Care, Snider, RK (Ed),
American Academy of Orthopaedic Surgeons, Rosemont, IL, 1997.
10. Worland, RL, Lee, D, Orozco, CG, et al. Correlation of age, acromial morphology, and
rotator cuff tear pathology diagnosed by ultrasound in asymptomatic patients. J South
Orthop Assoc 2003; 12:23.
11. Tempelhof, S, Rupp, S, Seil, R. Age-related prevalence of rotator cuff tears in asymptomatic
shoulders. J Shoulder Elbow Surg 1999; 8:296.
12. Chakravarty, K, Webley, M. Shoulder movement and its relationship to disability in the
elderly. J Rheumatol 1993; 20:1359.
13. Neer CS, 2nd. Impingement lesions. Clin Orthop Relat Res 1983; :70.
14. Lequesne, M, Dang, N, Bensasson, M, Mery, C. Increased association of diabetes mellitus
with capsulitis of the shoulder and shoulder-hand syndrome. Scand J Rheumatol 1977;
6:53.
15. Moren-Hybbinette, I, Moritz, U, Schersten, B. The clinical picture of the painful diabetic
shoulder — natural history, social consequences and analysis of concomitant hand
syndrome. Acta Med Scand 1987; 221:73.
16. Arkkila, PE, Kantola, IM, Viikari, JS, Ronnemaa, T. Shoulder capsulitis in type I and II
diabetic patients: association with diabetic complications and related diseases. Ann Rheum
Dis 1996; 55:907.
17. de Winter, AF, Jans, MP, Scholten, RJ, et al. Diagnostic classification of shoulder disorders:
interobserver agreement and determinants of disagreement. Ann Rheum Dis 1999; 58:272.
18. Norregaard, J, Krogsgaard, MR, Lorenzen, T, Jensen, EM. Diagnosing patients with
longstanding shoulder joint pain. Ann Rheum Dis 2002; 61:646.
19. Hoppenfeld, S. Physical examination of the shoulder. In: Physical Examination of the Spine
and Extremities, Prentice Hall, Upper Saddle River, New Jersey 1976.
20. Warner, JJ, Navarro, RA. Serratus anterior dysfunction. Recognition and treatment. Clin
Orthop Relat Res 1998; :139.
21. Kibler, WB, Sciascia, A, Dome, D. Evaluation of apparent and absolute supraspinatus
strength in patients with shoulder injury using the scapular retraction test. Am J Sports Med
2006; 34:1643.
22. Tennent, TD, Beach, WR, Meyers, JF. A review of the special tests associated with shoulder
examination. Part I: the rotator cuff tests. Am J Sports Med 2003; 31:154.
23. Leroux, JL, Thomas, E, Bonnel, F, Blotman, F. Diagnostic value of clinical tests for shoulder
impingement syndrome. Rev Rhum Engl Ed 1995; 62:423.
24. Hertel, R, Ballmer, FT, Lombert, SM, Gerber, C. Lag signs in the diagnosis of rotator cuff
rupture. J Shoulder Elbow Surg 1996; 5:307.
25. Garrick, JF, Webb, DR. Shoulder girdle injuries. In: Sports Injuries: Diagnosis and
Management, 2nd ed, W B Saunders, Philadelphia, 1999.
26. Calis, M, Akgun, K, Birtane, M, et al. Diagnostic values of clinical diagnostic tests in
subacromial impingement syndrome. Ann Rheum Dis 2000; 59:44.
27. Luime, JJ, et al. Does this patient have an instability of the shoulder or a labrum lesion?
JAMA 2004; 292:1989.
28. Fraenkel, L, Lavalley, M, Felson, D. The use of radiographs to evaluate shoulder pain in the
ED. Am J Emerg Med 1998; 16:560.
29. Fraenkel, L, Shearer, P, Mitchell, P, et al. Improving the selective use of plain radiographs in
the initial evaluation of shoulder pain. J Rheumatol 2000; 27:200.
30. Torstensen, ET, Hollinshead, RM. Comparison of magnetic resonance imaging and
arthroscopy in the evaluation of shoulder pathology. J Shoulder Elbow Surg 1999; 8:42.
31. Burk, DL Jr, Karasick, D, Kurtz, AB, et al. Rotator cuff tears: prospective comparison of MR
imaging with arthrography, sonography, and surgery. AJR Am J Roentgenol 1989; 153:87.
32. Yeu, K, Jiang, CC, Shih, TT. Correlation between MRI and operative findings of the rotator
cuff tear. J Formos Med Assoc 1994; 93:134.
33. Sher, JS, Uribe, JW, Posada, A, et al. Abnormal findings on magnetic resonance images of
asymptomatic shoulders. J Bone Joint Surg Am 1995; 77:10.
34. Iannotti, JP, Zlatkin, MB, Esterhai, JL, et al. Magnetic resonance imaging of the shoulder.
Sensitivity, specificity, and predictive value. J Bone Joint Surg Am 1991; 73:17.
35. Stevenson, JH, Trojian, T. Evaluation of shoulder pain. J Fam Pract 2002; 51:605.
36. Teefey, SA, Rubin, DA, Middleton, WD, et al. Detection and quantification of rotator cuff
tears. Comparison of ultrasonographic, magnetic resonance imaging, and arthroscopic
findings in seventy-one consecutive cases. J Bone Joint Surg Am 2004; 86-A:708.
37. Iannotti, JP, Ciccone, J, Buss, DD, et al. Accuracy of office-based ultrasonography of the
shoulder for the diagnosis of rotator cuff tears. J Bone Joint Surg Am 2005; 87:1305.
38. Moosmayer, S, Smith, HJ. Diagnostic ultrasound of the shoulder--a method for experts
only? Results from an orthopedic surgeon with relative inexpensive compared to operative
findings. Acta Orthop 2005; 76:503.
39. Teefey, SA, Middleton, WD, Payne, WT, Yamaguchi, K. Detection and measurement of
rotator cuff tears with sonography: analysis of diagnostic errors. AJR Am J Roentgenol
2005; 184:1768.
40. Schibany, N, Zehetgruber, H, Kainberger, F, et al. Rotator cuff tears in asymptomatic
individuals: a clinical and ultrasonographic screening study. Eur J Radiol 2004; 51:263.
41. Sugimoto, K. Ultrasonographic evaluation of the Bankart lesion. J Shoulder Elbow Surg
2004; 13:286.
42. Martinoli, C, Bianchi, S, Prato, N, et al. US of the shoulder: non-rotator cuff disorders.
Radiographics 2003; 23:381.
43. Middleton, WD,Payne, WT, Teefey, SA, et al. Sonography and MRI of the shoulder:
comparison of patient satisfaction. AJR Am J Roentgenol 2004; 183:1449.
44. Blanchard, TK, Bearcroft, PW, Constant, CR, et al. Diagnostic and therapeutic impact of MRI
and arthrography in the investigation of full-thickness rotator cuff tears. Eur Radiol 1999;
9:638.

Anatomy
The shoulder is a highly mobile joint, consisting of 3 bones, surrounded by ligaments, tendons, capsule
and muscle. These soft tissues give the shoulder joint its stability, along with its mobility. The various
muscles attach to the humerus or ‘arm bone’. (See diagram)

In close proximity to the shoulder joint is the acromioclavicular joint, or ‘A/C’ joint by which it is
commonly known.

This AC joint works in close relationship with the shoulder joint in order for the shoulder joint to do all
of its actions.
Frozen Shoulder (Adhesive Capsulitis)
What Is a Frozen Shoulder?
As the name implies, movement of the shoulder is severely restricted in people with a "frozen
shoulder." This condition, which doctors call adhesive capsulitis, is frequently caused by injury
that leads to lack of use due to pain. Rheumatic disease progression and recent shoulder surgery
can also cause frozen shoulder. Intermittent periods of use may cause inflammation. Adhesions
(abnormal bands of tissue) grow between the joint surfaces, restricting motion. There is also a
lack of synovial fluid, which normally lubricates the gap between the arm bone and socket to
help the shoulder joint move. It is this restricted space between the capsule and ball of the
humerus that distinguishes adhesive capsulitis from a less complicated painful, stiff shoulder.
People with diabetes, stroke, lung disease, rheumatoid arthritis, and heart disease, or who have
been in an accident, are at a higher risk for frozen shoulder. The condition rarely appears in
people under 40 years old.
What Are the Signs of a Frozen Shoulder and How Is It Diagnosed?
With a frozen shoulder, the joint becomes so tight and stiff that it is nearly impossible to carry
out simple movements, such as raising the arm. People complain that the stiffness and discomfort
worsen at night. A doctor may suspect the patient has a frozen shoulder if a physical examination
reveals limited shoulder movement. An arthrogram may confirm the diagnosis.
How Is a Frozen Shoulder Treated?
Treatment of this disorder focuses on restoring joint movement and reducing shoulder pain.
Usually, treatment begins with nonsteroidal anti-inflammatory drugs and the application of heat,
followed by gentle stretching exercises. These stretching exercises, which may be performed in
the home with the help of a therapist, are the treatment of choice. In some cases, transcutaneous
electrical nerve stimulation (TENS) with a small battery-operated unit may be used to reduce
pain by blocking nerve impulses. If these measures are unsuccessful, the doctor may recommend
manipulation of the shoulder under general anaesthesia. Surgery to cut the adhesions is only
necessary in some cases.
Ultrasound is a therapeutic modality that has been used by physical therapists since the
1940s. Ultrasound is applied using a round-headed wand or probe that is put in direct
contact with the patient's skin. Ultrasound gel is used on all surfaces of the head in order to
reduce friction and assist in the transmission of the ultrasonic waves. Therapeutic
ultrasound is in the frequency range of about 0.8-1.0 MHz.
The waves are generated by a piezoelectric effect caused by the vibration of crystals within
the head of the wand/probe. The sound waves that pass through the skin cause a vibration
of the local tissues. This vibration or cavitation can cause a deep heating locally though
usually no sensation of heat will be felt by the patient. In situations where a heating effect
is not desirable, such as a fresh injury with acute inflammation, the ultrasound can be
pulsed rather than continuously transmitted.
Ultrasound can produce many effects other than just the potential heating effect. It has
been shown to cause increases in tissue relaxation, local blood flow, and scar tissue
breakdown. The effect of the increase in local blood flow can be used to help reduce local
swelling and chronic inflammation, and, according to some studies, promote bone fracture
healing. The intensity or power density of the ultrasound can be adjusted depending on the
desired effect. A greater power density (measured in watt/cm2 is often used in cases where
scar tissue breakdown is the goal.
Ultrasound can also be used to achieve phonophoresis. This is a non-invasive way of
administering medications to tissues below the skin; perfect for patients who are
uncomfortable with injections. With this technique, the ultrasonic energy forces the
medication through the skin. Cortisone, used to reduce inflammation, is one of the more
commonly used substances delivered in this way.
A typical ultrasound treatment will take from 3-5 minutes. In cases where scar tissue
breakdown is the goal, this treatment time can be much longer. During the treatment the
head of the ultrasound probe is kept in constant motion. If kept in constant motion, the
patient should feel no discomfort at all. If the probe is held in one place for more than just a
few seconds, a build up of the sound energy can result which can become uncomfortable.
Interestingly, if there is even a very minor break in a bone in the area that is close to the
surface, a sharp pain may be felt. This occurs as the sound waves get trapped between the
two parts of the break and build up until becoming painful. In this way ultrasound can often
be used as a fairly accurate tool for diagnosing minor fractures that may not be obvious on
x-ray.
Some conditions treated with ultrasound include tendonitis (or tendinitis if you prefer), non-
acute joint swelling, muscle spasm, and even Peyronie's Disease (to break down the scar
tissue). Contraindications of ultrasound include local malignancy, metal implants below the
area being treated, local acute infection, vascular abnormalities, and directly on the
abdomen of pregnant women. It is also contraindicated to apply ultrasound directly over
active epiphyseal regions (growth plates) in children, over the spinal cord in the area of a
laminectomy, or over the eyes, skull, or testes.
What Are the Structures of the Shoulder and How Does the Shoulder
Function

The shoulder joint is composed of three bones: the clavicle (collarbone), the scapula
(shoulder blade), and the humerus (upper arm bone) (see diagram). Two joints
facilitate shoulder movement. The acromioclavicular (AC) joint is located between
the acromion (part of the scapula that forms the highest point of the shoulder) and
the clavicle. The glenohumeral joint, commonly called the shoulder joint, is a ball-
and-socket type joint that helps move the shoulder forward and backward and
allows the arm to rotate in a circular fashion or hinge out and up away from the
body. (The "ball" is the top, rounded portion of the upper arm bone or humerus; the
"socket," or glenoid, is a dish-shaped part of the outer edge of the scapula into
which the ball fits.) The capsule is a soft tissue envelope that encircles the
glenohumeral joint. It is lined by a thin, smooth synovial membrane.

The bones of the shoulder are held in place by muscles, tendons, and ligaments.
Tendons are tough cords of tissue that attach the shoulder muscles to bone and
assist the muscles in moving the shoulder. Ligaments attach shoulder bones to each
other, providing stability. For example, the front of the joint capsule is anchored by
three glenohumeral ligaments.

The rotator cuff is a structure composed of tendons that, with associated muscles,
holds the ball at the top of the humerus in the glenoid socket and provides mobility
and strength to the shoulder joint.

Two filmy sac-like structures called bursae permit


smooth gliding between bone, muscle, and tendon.
They cushion and protect the rotator cuff from the bony
arch of the acromion.

Causes

The shoulder is the most movable joint in the body.


However, it is an unstable joint because of the range of
motion allowed. It is easily subject to injury because the ball of the upper arm is
larger than the shoulder socket that holds it. To remain stable, the shoulder must be
anchored by its muscles, tendons, and ligaments. Some shoulder problems arise
from the disruption of these soft tissues as a result of injury or from overuse or
underuse of the shoulder. Other problems arise from a degenerative process in
which tissues break down and no longer function well.

Shoulder pain may be localized or may be referred to areas around the shoulder or
down the arm. Disease within the body (such as gallbladder, liver, or heart disease,
or disease of the cervical spine of the neck) also may generate pain that travels
along nerves to the shoulder.

Diagnosis

Following are some of the ways doctors diagnose shoulder problems:

? Medical history (the patient tells the doctor about an injury or other condition that
might be causing the pain).

? Physical examination to feel for injury and discover the limits of movement,
location of pain, and extent of joint instability.

? Tests to confirm the diagnosis of certain conditions. Some of these tests include:

? x ray

? arthrogram--Diagnostic record that can be seen on an x ray after injection of a


contrast fluid into the shoulder joint to outline structures such as the rotator cuff. In
disease or injury, this contrast fluid may either leak into an area where it does not
belong, indicating a tear or opening, or be blocked from entering an area where
there normally is an opening.

? MRI (magnetic resonance imaging)--A non-invasive procedure in which a machine


produces a series of cross-sectional images of the shoulder.

? Other diagnostic tests, such as injection of an anesthetic into and around the
shoulder joint, are discussed in specific sections of this booklet.

THE SHOULDER GIRDLE


Required Reading : pages 310 -329
I. INTRODUCTION
A. The shoulder or pectoral girdle consists of articulations between the clavicle,
scapula and the proximal end of the humerus. The sternoclavicular articulation is
the only bony link between the upper limb and the axial skeleton. Movements at
this joint are largely passive in that the occur as a result of active movements of the
scapula. Through the acromioclavicular articulation, the clavicle can act as a strut
maintaining the upper limb away from the thorax permitting a greater range of
upper limb motion. This joint also helps provide static stability to the upper limb
reducing the need to use muscle energy to keep the upper limb in its proper
alignment. The glenohumeral articulation (shoulder joint) has the greatest range of
motion of any joint in the body. The mobility of the shoulder joint is necessary for
placement of the hand to maximize manipulation. The scapula is suspended on the
thoracic wall by muscle forming a "functional joint" called the scapulothoracic joint.
These muscles act to stabilize and/ or to actively move the scapula. Active
movements of the scapula help increase the range of motion of the shoulder joint.
B. The student will be asked to demonstrate their understanding of shoulder girdle
anatomy by applying this information in the diagnosis of problems of these often
injured joints
II. COMPONENTS OF THE SHOULDER GIRDLE (310 -317)
A. Bones
1. Clavicle
2. Scapula
3. Proximal end of humerus
B. Articulations
1. Acromioclavicular Joint
a. Planar type joint between lateral portion of the clavicle and the
acromion of the scapula.
Sternoclavicular Joint
a. Sellar joint between the medial end of the clavicle and the manubrium
of the sternum.
3. Glenohumeral ( Shoulder ) Joint
a. Ball and socket articulation between head of humerus and glenoid
cavity.
b. Favors mobility over stability
Scapulothoracic "Joint"
a. Scapula suspended on rib cage by muscles
i. highly mobile
b. capula movements increases range of motion at the
shoulder joint
III. MUSCLES ACTING ON THE SHOULDER GIRDLE (pgs. 322-326)
A. Extrinsic - Suspend scapula from the trunk .Stabilize and/or actively moves scapula
1. Trapezius
2. Levator Scapulae
3. Rhomboid Major and Minor
4. Serratus Anterior
5. Pectoralis minor
B. Intrinsic - Attach scapula to humerus
1. Deltoid
2. Teres Major
3. Rotator Cuff (active stabilization of shoulder joint)
a. Supraspinatus
b. Infraspinatus
c. Teres Minor
d. Subscapularis
B. Attach trunk to humerus
Latissimus dorsi
Pectoralis Major
C. Attachments and Functions (See Chart 1)
IV. STABILITY OF THE SHOULDER GIRDLE (pgs 318 -321)
A. Acromioclavicular Joint
1. Ligaments
a. Acromioclavicular
b. Coracoclavicular
c. Conoid
d. Trapezoid
2. Functions
a. Bind clavicle to scapula supporting weight of upper limb minimizing
use of muscle energy
3. Shoulder Separation
a. Tearing of acromioclavicular and /or coracoclavicular ligaments
b. Clavicle overrides acromion
c. Weight of upper limb pulls scapula and acromion inferiorly below
clavicle
B. Sternoclavicular Joint
Ligaments
a. Sternoclavicular
b. ianterior and posterior
c. Interclavicular
d. Costoclavicular
Fibrocartilage Disc
a. Strengthens articulation
B. Glenohumeral Joint
Capsule
a. Attaches from glenoid cavity to anatomical neck of humerus
b. Least amount of support inferiorly
Ligaments
a. Coracoacromial
i. Helps resist upward displacement of the head of the
humerus
b. Coracohumeral
i. Strengthens superior portion of capsule
ii. Some support during shoulder abduction
b. Transverse Humeral Ligament
i. holds long head of biceps in the groove
b. Glenohumeral Ligaments - 3 parts all attach from upper
margin of glenoid cavity and strengthen anterior portion
of capsule
i. Superior - over the humeral head to a depression above the
lesser tuberosity
ii. Middle - in front of humerus to lower lesser tuberosity
iii. Inferior - to lower part of the anatomical neck
Rotator Cuff Muscles
a. Active stabilizers of shoulder joint
i. act throughout entire range of motion at shoulder
b. Depress head of humerus in glenoid cavity when humerus
moves
i. Prevents compression of structures between humeral head and
acromion
b. Muscles also help rotate shoulder (See Chart: "Movements
of Glenohumeral Joint" )
B. D.Scapulothoracic Articulation
1. Stability
a. Dependent upon activity of extrinsic muscles
b. Winged scapula
2. Alignment
a. Upwardly rotated and elevated position of scapula at rest
i. action of trapezius muscle
V. MOVEMENTS OF THE STERNOCLAVICULAR JOINT
A. Passive movements.
1. Acromial end moves as consequence of movements of the scapula
2. Sternal end of clavicle moves in a direction opposite from that of the
scapula.
B. Types of Movements
1. Protraction - scapula is retracted causing the sternal end to move
forward
2. Retraction - scapula is protracted causing the sternal end to move
backward
3. Elevation - scapula is depressed causing the sternal end to move
upward
4. Depression - scapula is elevated causing the sternal end to move
downward
C. Muscles Acting on Sternoclavicular Joint
1. The muscles acting on the Sternoclavicular joint are outlined in Chart
1. These are the same muscles that act on the scapula.
2. Movements of the Sternoclavicular joint and the muscles producing
these movements are outlined in Chart 2. Remember the SC joint
moves in a direction opposite from the way in which the scapula
moves.
VI. MOVEMENTS OF THE SCAPULA ( pg 316)
A. Types
1. Elevation - moving the superior border of the scapula and the acromion
in an upward direction.
2. Depression - moving the superior border of the scapula and the
acromion in an downward direction.
3. Upward Rotation - Moving the scapula so that the glenoid cavity faces
upward.
a. Increased the ranges of motion during abduction and/or flexion
of the shoulder.
Downward Rotation - moving the scapula so that the glenoid cavity faces inferiorly.
a. Increases range of motion during extension and / or adduction of the
shoulder.
Protraction ( Abduction) - moving the scapula away from the midline
Retraction (Adduction) - moving the scapula toward the midline
B. Muscles Acting to Move Scapula
Very mobile
a. Muscles suspend scapula from vertebral column and chest wall
b. Axis around which scapulae move changes
c. Muscles attach to scapula obliquely
i. Produce many motions
Movements
a. See chart Movements of the Scapula
Muscle Synergy at the Shoulder Joint
a. Retraction of the Scapula
i. Trapezius -- retract and rotates upward
ii. Rhomboids -- retract and rotate downward
b. Upward rotation of the Scapula
i. Serratus anterior -- protracts and rotates upward
ii. Trapezius -- Retract and rotates upward
VII. MOVEMENTS OF THE GLENOHUMERAL JOINT ( pgs 322-323)
A. Properties
1. Movements of the shoulder joint (glenohumeral joint) usually involve
moving the humerus on the scapula.
2. All movements are to be studied starting from the ANATOMICAL
POSITION
3. Axis of motion
a. Flexion - Extension
i. Coronal axis through head of humerus
b. Abduction /Adduction
i. Sagittal axis through humeral head
b. Rotation
i. Longitudinal axis through shaft of humerus
B. Types of Movements
Flexion moving the humerus forward and upward in the sagittal plane.
Extension - bringing the arm down to the side in the sagittal plane.
a. Hyperextension - moving the arm in the sagittal plane behind the body.
Abduction - moving the arm in the coronal plane away from the midline
a. Stages
i. initiate -supraspinatus
ii. 900 - deltoid
iii. 1800 - deltoid with upward rotation of scapula
Adduction - moving the arm in the coronal plane towards the midline.
Inward Rotation - rotating the arm in a transverse plane so that the anterior surface of the
bone turns inward.
Outward Rotation - rotating the arm in a transverse plane so that the anterior surface of
the bone turns outward.
B. Scapulohumeral Rhythm
Coordinated movements of the scapula and the humerus increasing the range of motion at
the glenohumeral joint
a. Most noticeable during complete flexion and abduction of the shoulder
b. 2 - 30 of humeral abduction is associated with 1 - 20 of scapula rotation
B. Movements of the Shoulder Joint
Chart 3 - MOVEMENTS of the SHOULDER JOINT indicates which muscles interact to produce
a given movements of the shoulder
VIII. CLINICAL ANATOMY OF THE SHOULDER JOINT ( pgs. 317,319,321)
A. Dislocation
1. Weakness of rotator cuff tendons and / or trauma
2. Head of humerus subluxes (separated ) from glenoid cavity of humerus
3. Usually occurs when humerus is in position of abduction or flexion
a. Least amount of contact between apposing bony surfaces
Occurs in an inferior direction
a. Weakest region of capsule
b. Humerus pulled either anterior to or posterior to shoulder joint depending upon
which rotator cuff muscles are injured.
Arm hangs limp at side with a prominent "step deformity" (space) between acromion and
humeral head
B. Impingement Syndrome
Weakness or fatigue of rotator cuff muscles
Activity of shoulder joint accompanied by intense pain
a. Movements of abduction and flexion usually more painful
b. Painful arc
i. Very painful abducting from neutral position to horizontal. Then
pain subsides
Compression of supraspinatus tendon between head of humerus and acromion.
B. Nerve Lesions (pg 329)
Lesions to components of the brachial plexus, especially those components
associated with the C 5 and/or C 6 nerve roots, will have and major effect on the
ability of the shoulder girdle to carry out normal functions. Often, the signs and
symptoms concerning loss or reduction in function can be used to localize the site
of the nerve lesion. The effects of various types of nerve lesions can have on the
shoulder girdle is summarized below:
Accessory nerve - innervates the trapezius muscle. Paralysis of this muscle will result in a
marked drooping and down turning of the affected shoulder at rest because of the
loss of the ability of the trapezius to elevate and upwardly rotate the scapula. The
latter loss will also prevent the patient from abducting their arm above the
horizontal ( shoulder level).
Dorsal Scapular nerve - innervates the rhomboideus muscles. Any attempt to retract the
scapula will be accompanied by a marked upward rotation of the shoulder because
the rhomboideus can no oppose the upward rotation on the scapula exerted by the
trapezius. The patient will have difficulty retracting the scapula against resistance
on the affected side.
Long thoracic nerve - Innervates the serratus anterior muscle. Active contraction of this
muscle results in scapula protraction and upward rotation. When the scapula is
passively protracted by action of the pectoralis major muscle on the humerus , the
serratus anterior acts to stabilize the scapula and keep it applied to the thoracic
wall. Such action occur when a boxer throws a jab or a cross. Paralysis of the
serratus anterior prevents the scapula from moving smoothly across the thoracic
wall resulting in a bowing out of the medial border of the scapula. This condition is
called "winged" scapula. In addition, the ability to actively upwardly rotate the
shoulder is diminished and the patient can not abduct the humerus above the
horizontal.
Suprascapular nerve - innervates the supraspinatus and infraspinatus muscles. Paralysis of
this nerve will result is weakness of the rotator cuff muscles resulting in pain form
impingement and an inability of the patient to begin shoulder abduction. Such
patients tend to swing the affected limb away from their side in order to provide
momentum to start abduction.
Axillary nerve - innervates the deltoid and teres minor muscles. Since the deltoid plays a
major role in movement of the glenohumeral joint, paralysis will cause a loss &/or
weakness of most shoulder functions. Symptoms of deltoid paralysis include:
a. loss or roundness to the shoulder and a very visible acromion process
b. inability to abduct the glenohumeral joint more than a few degrees away from the
side.
c. inability to laterally rotate the humerus
d. weakened movements of glenohumeral flexion and extension
e. loss of sensation just below the point of the shoulder
C5, C6 root damage ( Erb's palsy) - axons from the C5 and C6 ventral rami innervate the
following muscles acting on the shoulder girdle:
deltoid, supraspinatus, infraspinatus , teres minor, subscapularis. Lesion to these
roots will result in paralysis of these muscles. The symptoms of such a lesion are
outlines in the chart below.

C5, C6 Nerve Root Lesion (Erb's Palsy)


MOTOR SENSORY NERVES
DEFICITS DEFICIT

Loss of Posterior and Axillary,


abduction, lateral aspect of Suprascapular,
flexion and arm - axillary n. Upper and
rotation at Lower
shoulder ; subscapular
Weak
shoulder
extension -
deltoid,
rotator cuff

Very weak Radial side of Musculocutaneo


elbow Forearm- us ; Radial N.
flexion and musculocutaneo brs. to supinator
supination us n. Thumb and & brachioradialis
of 1st finger - muscles
radioulnar superficial br. of
joint- radial; digital
biceps brs. - Median n.
brachii &
brachialis

Susceptible Suprascapular,
to shoulder Upper and
dislocation Lower
- loss of subscapular
rotator cuff
muscles

"Waiters
Tip"position

Chart 1 - Muscles Acting On The Shoulder Girdle

MUSCLE PROXIMAL DISTAL NERVE FUNCTION


S

Extrinsic: Attach scapula to neck and trunk

Trapezius 1. Ext 1. Lat. 1/3 Spinal Retracts


Occipital of clavicle portion of XI and
Protuberanc (upper) upwardly
e rotates
2.
Acromion scapula
2. Lig .
nuchae (middle)
3. Lower 3. Spine of
cervical & scapula
thoracic (lower)
spines
Levator Transverse Upper Cervical Elevation
Scapulae processes medial Plexus and
of C 1 to or border of downward
C3&C4
4 the rotation of
scapula the scapula

Rhomboid 1. Medial Dorsal 1.


Major & Ligamentu border of Scapular Retraction,
Minor m nuchae, the downward
(Nerve to
scapula; Rhomboids) rotation,
2. spinous
processes of from the some
C 4; (C5)
C7 to T 5 root of the elevation of
spine to the scapula,
the 2. Fixes the
inferior scapula
angle against the
trunk
Serratus Outer Anterior Long 1.Protractio
Anterior surface of surface of Thoracic n and
ribs the medial ( C 5,6,7) upward
border of rotation of
1-8
the scapula
scapula 2. Fixes
scapula
against the
thoracic wall
Pectoralis Ribs 3, 4, & Coracoid Medial Protract,
Minor 5 process of Pectoral downward
scapula Nerve rotation o f
(C8,T1) scapula

Intrinsic: Rotator Cuff ( Active stabilization of shoulder joint


by preventing downward displacement of the humerus)

Supraspinat Supraspino Superior Suprascapul Starts


us us fossa of facet of ar shoulder
scapula the abduction
(C 5,6)
greater
tubercle of
humerus

Infraspinatu Infraspinous Middle Suprascapul Lateral


s fossa of facet of ar shoulder
scapula the rotation
(C 5,6)
greater
tubercle of
humerus

Teres Minor Lateral Inferior Axillary (C Lateral


border of fact of the 5,6) shoulder
scapula, greater rotation
superior to tubercle of
Teres Major the
humerus

MUSCLE PROXIMAL DISTAL NERVE FUNCTIO


NS

Subscapula Subscapular Lesser Subscapula 1. Medial


ris fossa of the tubercle of r Nerves (C shoulder
scapula humerus 5,6) rotation

Intrinsic: Attach humerus to scapula

Deltoid 1. Lateral Deltoid Axillary (C Anterior


one third of tuberosity 5,6) portion -
clavicle flexes,
on the
humeral shaft medially
2. Acromion
rotates
3. Spine of the shoulder
scapula
Middle
portion -
abducts the
shoulder
Posterior
Portion -
extends,
laterally
rotates the
shoulder
Teres Dorsal Crest of the Lower 1.
major scapula near lesser Subscapula Adduction
inferior tubercle of r and
angle humerus medial
(C 5,6)
rotation of
the
shoulder
2.
Stabilizes
shoulder
during
abduction
3. Extend
shoulder
from flexed
position
Attach humerus to trunk ( Act primarily on humerus;
scapula moves passively in response to movement of
humerus)

Latissimus 1. Floor of Thoracodor 1.Extend,


Dorsi Thoracolum bicipital sal Adduct,
bar fascia groove (also (C 6,7,8) and
called Medially
2. Sacrum,
iliac crest intertubercul rotate the
ar sulcus) shoulder
3. Spinous
processes of T 2. Depress
6 to L5 and
downward
rotation of
scapula
Pectoralis 1. Medial 1/2 Lateral lip of Lateral and 1.
Major of the the bicipital Medial Adduction
clavicle groove (also Pectoral , Flexion,
called the nerves (C6- Medial
2. Sternum,
costal intertubercul T1) Rotation
cartilages of ar sulcus) of the
ribs 2 6 shoulder
2.
Horizontal
Adduction
3.
Protraction
of scapula

Chart 2 - MOVEMENTS OF THE SCAPULA

Motion Prime Movers Nerve Critical


Segment

Elevation Trapezius- upper Accessory

Levator scapulae N. to L. C 3,4


scapulae
Rhomboideus major* Dorsal C (4),5
scapular

Rhomboideus minor* Dorsal C (4),5


scapular

Depression Latissimus dorsi1 Thoracodors C 7


al

Pectoralis major - Pectoral C 6, 7,8


sternal head1 Nerves

Pectoralis minor Medial C 8, T1


pectoral

Upward Serratus anterior Long C 5, 6, 7


Rotation thoracic

Trapezius-Upper & Accessory


Lower

Downward Latissimus dorsi1 Thoracodors C 7


Rotation al

Pectoralis major - Pectoral C 6, 7,8, 1


sternal head1 Nerves

Pectoralis minor Medial C 8, T1


pectoral

Levator scapulae N. to L. C 3,4


scapulae

Protraction Serratus anterior Long C 5, 6, 7


thoracic

Pectoralis minor Medial C 8, T 1


pectoral

Pectoralis major 1 Pectoral C 6, 7,8, 1


Nerves

Retraction Trapezius Accessory

Rhomboideus major Dorsal C (4),5


scapular
Rhomboideus minor Dorsal C (4),5
scapular

* When the rhomboids assist in elevation, the resultant movement is a combination of elevation
and retraction.
1 Muscles passively move scapula through their active action on the humerus

Chart 3 -MOVEMENTS OF THE GLENOHUMERAL JOINT

Motion Prime Movers Nerve Critical


Segments

Flexion Deltoid - anterior Axillary C5

Pectoralis major - Lateral Pectoral C 5, 6


clavicular head

Coracobrachialis* Musculocutane C 5, 6, 7
ous

Extension Deltoid - posterior Axillary C5

Latissimus dorsi Thoracodorsal C7

Teres major Lower C 5, 6


subscapular

Abduction Supraspinatus1 Suprascapular C 5, 6

Deltoid - anterior Axillary C5

Adduction Latissimus dorsi Thoracodorsal C7

Pectoralis major - Pectoral nerves C 6, 7, 8, 1


sternal head

Inward Subscapularis Upper C 5, 6


Rotation subscapular

Deltoid - anterior Axillary C5

Outward Infraspinatus Suprascapular C 5, 6


Rotation
Teres minor Axillary C5
Deltoid - posterior Axillary C5

Figure 1
SCAPULA
MOVEMEN
TS

Retraction means the scapula is drawn


towards the midline; protraction is
movement away from the midline.
Elevation is raising the entire scapula
upwards as in shrugging ones shoulder;
depression is lowering the scapula.
Figure 2
SCAPULA
ROTATION

Upward Rotation of the scapula involves


rotating the glenoid cavity upward while
moving the inferior angle laterally;
downward rotation involves rotating the
glenoid cavity downward while the
inferior angle moves medially. Upward
rotation occurs during flexion and
abduction of the shoulder to increase
the range of motion when the humerus
moves on the scapula. Downward
rotation is used to increase the range of
motion of the humerus when it moves
on the scapula during shoulder
extension and adduction.
Figure 3
Shoulder
Girdle -
Anterior

1. Name the bony features of the


shoulder girdle indicated by each
number
2. Draw in the ligaments the support the joints
of the shoulder girdle

Figure 4.
Shoulder
Girdle -
Posterior

1. Name the bony components of the


shoulder girdle indicated by each
number.
2. The dashed line is the
__________________________________.
What structure attaches here?
3. What are the names and functions of the
muscles inserting at the dark rectangles?
4. What is the name and function(s) of the
muscle inserting along the bones labeled 3, 4,
5?

IX. OBJECTIVES

A. A Know the bones, supporting ligaments and function of the articulations that
comprise the shoulder girdle
1. Understand the primary factors that account for the stability of each
joint
B. B Understand the types of movements that can take place at the sternoclavicular
and glenohumeral joints.
1. Know the prime mover(s) for each type of movement
2. Be able to distinguish between active and passive movements
C. C Be familiar with the concept of the "scapulothoracic" joint
1. Know the types of movements that can take place between the
scapula and rib cage
2. Be able to figure out the prime movers for each type of movement
3. Be able to distinguish between active and passive movements of the
scapula
a. Give examples of how muscles act to "fix" or stabilize the scapula
b. Be able to give examples of muscles acting synergistically on the scapula
Define scapulohumeral rhythm
a. Understand the importance of this rhythm in shoulder abduction
B. Be able to distinguish between a shoulder separation and
shoulder dislocation.
Know what types of structures are damaged in each case
Be able to distinguish between each injury based upon the resultant position that the limb
will assume as a result of each type of injury
C. Understand the anatomical basis of Impingement Syndrome
D. Understand how nerve lesions of the following nerves will affect
movements of the scapulothoracic and glenohumeral joints .
Long thoracic nerve
Suprascapular nerve
Axillary nerve
Thoracodorsal nerve
C5 - C6 nerve roots
E. Be prepared to demonstrate by testing the action(s) of the
appropriate muscles how the above nerve lesions will affect
movement of the scapula and / or humerus

Shoulder Anatomy

Introduction
The shoulder is an elegant piece of machinery. It has the greatest range of motion of
any joint in the body. However, this large range of motion can lead to joint problems.
Understanding how the different layers of the shoulder are built and connected can
help you understand how the shoulder works, how it can be injured, and how
challenging recovery can be when the shoulder is injured. The deepest layer of the
shoulder includes the bones and the joints. The next layer is made up of the ligaments
of the joint capsule. The tendons and the muscles come next.
This guide will help you understand
• what parts make up the shoulder
• how these parts work together

Important Structures
The important structures of the shoulder can be divided into several categories. These
include
• bones and joints
• ligaments and tendons
• muscles
• nerves
• blood vessels
• bursae
Bones and Joints

The bones of the shoulder are the humerus (the upper arm bone), the scapula (the
shoulder blade), and the clavicle (the collar bone). The roof of the shoulder is formed
by a part of the scapula called the acromion.
There are actually four joints that make up the shoulder. The main shoulder joint,
called the glenohumeral joint, is formed where the ball of the humerus fits into a
shallow socket on the scapula. This shallow socket is called the glenoid.
The acromioclavicular (AC) joint is where the clavicle meets the acromion. The
sternoclavicular (SC) joint supports the connection of the arms and shoulders to the
main skeleton on the front of the chest.
A false joint is formed where the shoulder blade glides against the thorax (the rib
cage). This joint, called the scapulothoracic joint, is important because it requires that
the muscles surrounding the shoulder blade work together to keep the socket lined up
during shoulder movements.
Articular cartilage is the material that covers the ends of the bones of any joint.
Articular cartilage is about one-quarter of an inch thick in most large, weight-bearing
joints. It is a bit thinner in joints such as the shoulder, which don't normally support
weight. Articular cartilage is white and shiny and has a rubbery consistency. It is
slippery, which allows the joint surfaces to slide against one another without causing
any damage. The function of articular cartilage is to absorb shock and provide an
extremely smooth surface to make motion easier. We have articular cartilage
essentially everywhere that two bony surfaces move against one another, or
articulate. In the shoulder, articular cartilage covers the end of the humerus and
socket area of the glenoid on the scapula.
Ligaments and Tendons

There are several important ligaments in the shoulder. Ligaments are soft tissue
structures that connect bones to bones. A joint capsule is a watertight sac that
surrounds a joint. In the shoulder, the joint capsule is formed by a group of ligaments
that connect the humerus to the glenoid. These ligaments are the main source of
stability for the shoulder. They help hold the shoulder in place and keep it from
dislocating.

Ligaments attach the clavicle to the acromion in the AC joint. Two ligaments connect
the clavicle to the scapula by attaching to the coracoid process, a bony knob that
sticks out of the scapula in the front of the shoulder.
A special type of ligament forms a unique structure inside the shoulder called the
labrum. The labrum is attached almost completely around the edge of the glenoid.
When viewed in cross section, the labrum is wedge-shaped. The shape and the way
the labrum is attached create a deeper cup for the glenoid socket. This is important
because the glenoid socket is so flat and shallow that the ball of the humerus does not
fit tightly. The labrum creates a deeper cup for the ball of the humerus to fit into.
The labrum is also where the biceps tendon attaches to the glenoid. Tendons are much
like ligaments, except that tendons attach muscles to bones. Muscles move the bones
by pulling on the tendons. The biceps tendon runs from the biceps muscle, across the
front of the shoulder, to the glenoid. At the very top of the glenoid, the biceps tendon
attaches to the bone and actually becomes part of the labrum. This connection can be
a source of problems when the biceps tendon is damaged and pulls away from its
attachment to the glenoid.
The tendons of the rotator cuff are the next layer in the shoulder joint. Four rotator
cuff tendons connect the deepest layer of muscles to the humerus.
Muscles

The rotator cuff tendons attach to the deep rotator cuff muscles. This group of
muscles lies just outside the shoulder joint. These muscles help raise the arm from the
side and rotate the shoulder in the many directions. They are involved in many day-to-
day activities. The rotator cuff muscles and tendons also help keep the shoulder joint
stable by holding the humeral head in the glenoid socket.
The large deltoid muscle is the outer layer of shoulder muscle. The deltoid is the
largest, strongest muscle of the shoulder. The deltoid muscle takes over lifting the arm
once the arm is away from the side.
Nerves

All of the nerves that travel down the arm pass through the axilla (the armpit) just
under the shoulder joint. Three main nerves begin together at the shoulder: the radial
nerve, the ulnar nerve, and the median nerve. These nerves carry the signals from the
brain to the muscles that move the arm. The nerves also carry signals back to the brain
about sensations such as touch, pain, and temperature.
Blood Vessels

Traveling along with the nerves are the large vessels that supply the arm with blood.
The large axillary artery travels through the axilla. If you place your hand in your
armpit, you may be able to feel the pulsing of this large artery. The axillary artery has
many smaller branches that supply blood to different parts of the shoulder. The
shoulder has a very rich blood supply.
Bursae

Sandwiched between the rotator cuff muscles and the outer layer of large bulky
shoulder muscles are structures known as bursae. Bursae are everywhere in the body.
They are found wherever two body parts move against one another and there is no
joint to reduce the friction. A single bursa is simply a sac between two moving
surfaces that contains a small amount of lubricating fluid.
Think of a bursa like this: If you press your hands together and slide them against one
another, you produce some friction. In fact, when your hands are cold you may rub
them together briskly to create heat from the friction. Now imagine that you hold in
your hands a small plastic sack that contains a few drops of salad oil. This sack would
let your hands glide freely against each other without a lot of friction.

Summary
As you can see, the shoulder isn't working well. the shoulder is extremely complex,
with a design that provides maximum mobility and range of motion. Besides big
lifting jobs, the shoulder joint is also responsible for getting the hand in the right
position for any function. When you realize all the different ways and positions we
use our hands every day, it is easy to understand how hard daily life can be when

Cyriax, J. (1998) Orthopaedic Medicine A Practical Approach. Oxford: Butterworth


Heinemann
Roth, G. (1999) Matrix Repatterning: Wellness Systems,Tottenham,ON,1999
Watson, E and Sumaband, D.(2001) Shoulder Problems-A Guide to Common disorders,
modern Medicine of Ireland,31,2.
Van der Windt,D A W M,KOes,B W, Deville, W,Boeke,A J P,De Jong, BA and
Bouter,LM(1998).Effectiveness of corticosteroid injections versus physiotherapy for
treatment of painful stiff shoulder in primary care: Randomised trial, British Medical
Journal,317,1292-96.
Vermeulen,H M,Obermann,W M, Burger,B J, Kok, G J,Rosing, P M nad van den
Ende,H M C (2002) End range mobilisation techniques in adhesive capsulitis of the
shoulder joint: A multiple subject case report, Physical Therapy,80,1204-13
Winters,J C, Sobel,J S, Groenier, KH.Aredsen,H J and Meyboom-de
Jong,B(1997).’Comparison of physiotherapy, manipulation, and corticosteroid injection
for treating shoulder complaints in general practice: Randomised single blind study’,
British Medical Journal,314,1320-24.

ULTRASOUND
For deeper penetration and more flexible usage, the use of ultrasound as therapy for shoulder
pain management and musculoskeletal injuries is on the rise.
Therapeutic ultrasound delivers sound waves to tissue at frequencies of 0.75 MHz to 3 MHz
(both above the range of human hearing), either in thermal (continuous) or nonthermal (pulsed)
applications. The sound waves vibrate the tissue deep inside the injured area, creating heat that
draws more blood into the tissues, sparking the healing process. The specific techniques and
duration of therapy depend on equipment used and type of injury.
The benefits of therapeutic ultrasound are significant. Within tendons and joint capsules,
elasticity of collagen is increased. Motor and sensory nerve conduction increases, muscle spindle
activity decreases, and muscle contractile activity decreases. Taken together, pain is reduced,
muscle spasms are diminished, and healing is promoted.
Mettler developed a therapeutic ultrasound machine back in 1957 and has provided innovative
solutions ever since. The Sonicator® is a portable and lightweight ultrasound tool featuring
unique crystal-to-patient technology that delivers ultrasound directly to the patient without a
metal interface. The various models provide relative depth of ultrasound penetration between 1-
MHz and 3.3-MHz frequencies for the different pain locations. For deep-tissue pain, like that
with injured shoulders, a 1-MHz application is typically the best.
Specific Sonicator models include the 740, 740x, 730, and 716, all offering different applicators
that change out quickly and easily. The 716 is specifically geared toward shoulders and other
large, muscular areas. All devices come with detachable applicator cables, continuous and pulsed
modes, and watertight characteristics to enable simultaneous underwater therapy.
Amrex Electrotherapy Equipment, Carson, Calif, is another company that offers versatile
therapeutic ultrasound options. Machines come with 1-MHz and 3.3-MHz generators with
standard or small soundheads. The ultrasound beam is continuous, but also the devices offer a
unique modulated beam, where peak power is generated for only a portion of the pulse. The
momentary burst of ultrasonic energy improves penetration of the sound waves. The U/20 and
U/50 Portable Ultrasounds are Amrex's flagship therapeutic ultrasound models, and they feature
lightweight transducers sealed for underwater therapy.
Selected References
These references are in PubMed. This may not be the complete list of references from this article.

• Jayson MI. Frozen shoulder: adhesive capsulitis. Br Med J (Clin Res Ed). 1981 Oct
17;283(6298):1005–1006. [PubMed]

• Bland JH, Merrit JA, Boushey DR. The painful shoulder. Semin Arthritis Rheum. 1977
Aug;7(1):21–47. [PubMed]

• Uhthoff HK, Sarkar K. An algorithm for shoulder pain caused by soft-tissue disorders. Clin
Orthop Relat Res. 1990 May;(254):121–127. [PubMed]

• Roberts WJ. A hypothesis on the physiological basis for causalgia and related pains. Pain.
1986 Mar;24(3):297–311. [PubMed]
• van der Windt DA, Koes BW, Boeke AJ, Devillé W, De Jong BA, Bouter LM. Shoulder
disorders in general practice: prognostic indicators of outcome. Br J Gen Pract. 1996
Sep;46(410):519–523. [PubMed]

• van der Windt DA, Koes BW, de Jong BA, Bouter LM. Shoulder disorders in general
practice: incidence, patient characteristics, and management. Ann Rheum Dis. 1995
Dec;54(12):959–964. [PubMed]

• Yamanaka K, Matsumoto T. The joint side tear of the rotator cuff. A followup study by
arthrography. Clin Orthop Relat Res. 1994 Jul;(304):68–73. [PubMed]

• Chard MD, Sattelle LM, Hazleman BL. The long-term outcome of rotator cuff tendinitis--a
review study. Br J Rheumatol. 1988 Oct;27(5):385–389. [PubMed]

• Bulgen DY, Binder AI, Hazleman BL, Dutton J, Roberts S. Frozen shoulder: prospective
clinical study with an evaluation of three treatment regimens. Ann Rheum Dis. 1984
Jun;43(3):353–360. [PubMed]

• Hazleman BL. The painful stiff shoulder. Rheumatol Phys Med. 1972 Nov;11(8):413–421.
[PubMed]

• Croft P, Pope D, Silman A. The clinical course of shoulder pain: prospective cohort study in
primary care. Primary Care Rheumatology Society Shoulder Study Group. BMJ. 1996 Sep
7;313(7057):601–602. [PubMed]

• Mulcahy KA, Baxter AD, Oni OO, Finlay D. The value of shoulder distension arthrography
with intraarticular injection of steroid and local anaesthetic: a follow-up study. Br J Radiol.
1994 Mar;67(795):263–266. [PubMed]

• Pollock RG, Duralde XA, Flatow EL, Bigliani LU. The use of arthroscopy in the treatment of
resistant frozen shoulder. Clin Orthop Relat Res. 1994 Jul;(304):30–36. [PubMed]

• Binder AI, Bulgen DY, Hazleman BL, Roberts S. Frozen shoulder: a long-term prospective
study. Ann Rheum Dis. 1984 Jun;43(3):361–364. [PubMed]

• Peters D, Davies P, Pietroni P. Musculoskeletal clinic in general practice: study of one


year's referrals. Br J Gen Pract. 1994 Jan;44(378):25–29. [PubMed]
• Hackett GI, Bundred P, Hutton JL, O'Brien J, Stanley IM. Management of joint and soft
tissue injuries in three general practices: value of on-site physiotherapy. Br J Gen Pract.
1993 Feb;43(367):61–64. [PubMed]

• Gentle PH, Herlihy PJ, Roxburgh IO. Controlled trial of an open-access physiotherapy
service. J R Coll Gen Pract. 1984 Jul;34(264):371–376. [PubMed]

• Rush PJ, Shore A. Physician perceptions of the value of physical modalities in the
treatment of musculoskeletal disease. Br J Rheumatol. 1994 Jun;33(6):566–568. [PubMed]

• Lindsay DM, Dearness J, McGinley CC. Electrotherapy usage trends in private


physiotherapy practice in Alberta. Physiother Can. 1995 47(1):30–34.Winter; [PubMed]

• Robinson AJ, Snyder-Mackler L. Clinical application of electrotherapeutic modalities. Phys


Ther. 1988 Aug;68(8):1235–1238. [PubMed]

• ter Haar G, Dyson M, Oakley EM. The use of ultrasound by physiotherapists in Britain,
1985. Ultrasound Med Biol. 1987 Oct;13(10):659–663. [PubMed]

• van der Heijden GJ, van der Windt DA, de Winter AF. Physiotherapy for patients with soft
tissue shoulder disorders: a systematic review of randomised clinical trials. BMJ. 1997 Jul
5;315(7099):25–30. [PubMed]

• Green S, Buchbinder R, Glazier R, Forbes A. Systematic review of randomised controlled


trials of interventions for painful shoulder: selection criteria, outcome assessment, and
efficacy. BMJ. 1998 Jan 31;316(7128):354–360. [PubMed]

• Gam AN, Johannsen F. Ultrasound therapy in musculoskeletal disorders: a meta-analysis.


Pain. 1995 Oct;63(1):85–91. [PubMed]

• Falconer J, Hayes KW, Chang RW. Therapeutic ultrasound in the treatment of


musculoskeletal conditions. Arthritis Care Res. 1990 Jun;3(2):85–91. [PubMed]

• Robinson AJ. Transcutaneous electrical nerve stimulation for the control of pain in
musculoskeletal disorders. J Orthop Sports Phys Ther. 1996 Oct;24(4):208–226. [PubMed]

• Knipschild P, Leffers P, Feinstein AR. The qualification period. J Clin Epidemiol.


1991;44(6):461–464. [PubMed]
• Sato A, Schmidt RF. Somatosympathetic reflexes: afferent fibers, central pathways,
discharge characteristics. Physiol Rev. 1973 Oct;53(4):916–947. [PubMed]

• Guyatt G, Walter S, Norman G. Measuring change over time: assessing the usefulness of
evaluative instruments. J Chronic Dis. 1987;40(2):171–178. [PubMed]

• van der Windt DAWM, van der Heijden GJMG, de Winter AF, Koes B, Deville W, Bouter L.
The responsiveness of the Shoulder Disability Questionnaire. Ann Rheum Dis. 1998
Feb;57(2):82–87. [PubMed]

• Jaeschke R, Singer J, Guyatt GH. A comparison of seven-point and visual analogue scales.
Data from a randomized trial. Control Clin Trials. 1990 Feb;11(1):43–51. [PubMed]

• Carlsson AM. Assessment of chronic pain. I. Aspects of the reliability and validity of the
visual analogue scale. Pain. 1983 May;16(1):87–101. [PubMed]

• Revill SI, Robinson JO, Rosen M, Hogg MI. The reliability of a linear analogue for evaluating
pain. Anaesthesia. 1976 Nov;31(9):1191–1198. [PubMed]

• Guyatt GH, Berman LB, Townsend M, Taylor DW. Should study subjects see their previous
responses? J Chronic Dis. 1985;38(12):1003–1007. [PubMed]

• Westerberg CE, Solem-Bertoft E, Lundh I. The reliability of three active motor tests used in
painful shoulder disorders. Presentation of a method of general applicability for the
analysis of reliability in the presence of pain. Scand J Rehabil Med. 1996 May;28(2):63–70.
[PubMed]

• Solem-Bertoft E, Lundh I, Westerberg CE. Pain is a major determinant of impaired


performance in standardized active motor tests. A study in patients with fracture of the
proximal humerus. Scand J Rehabil Med. 1996 May;28(2):71–78. [PubMed]

• Ure BM, Tiling T, Kirchner R, Rixen D. Zuverlässigkeit der klinischen Untersuchung der
Schulter im Vergleich zur Arthroskopie. Eine prospektive Studie. Unfallchirurg. 1993
Jul;96(7):382–386. [PubMed]

• Bamji AN, Erhardt CC, Price TR, Williams PL. The painful shoulder: can consultants agree?
Br J Rheumatol. 1996 Nov;35(11):1172–1174. [PubMed]
• Pellecchia GL, Paolino J, Connell J. Intertester reliability of the cyriax evaluation in
assessing patients with shoulder pain. J Orthop Sports Phys Ther. 1996 Jan;23(1):34–38.
[PubMed]

• Buchbinder R, Goel V, Bombardier C, Hogg-Johnson S. Classification systems of soft tissue


disorders of the neck and upper limb: do they satisfy methodological guidelines? J Clin
Epidemiol. 1996 Feb;49(2):141–149. [PubMed]

• Brox JI, Staff PH, Ljunggren AE, Brevik JI. Arthroscopic surgery compared with supervised
exercises in patients with rotator cuff disease (stage II impingement syndrome). BMJ.
1993 Oct 9;307(6909):899–903. [PubMed]

• Ginn KA, Herbert RD, Khouw W, Lee R. A randomized, controlled clinical trial of a
treatment for shoulder pain. Phys Ther. 1997 Aug;77(8):802–811. [PubMed]

• van der Heijden GJ, van der Windt DA, Kleijnen J, Koes BW, Bouter LM. Steroid injections
for shoulder disorders: a systematic review of randomized clinical trials. Br J Gen Pract.
1996 May;46(406):309–316. [PubMed]

• Goupille P, Sibilia J. Local corticosteroid injections in the treatment of rotator cuff


tendinitis (except for frozen shoulder and calcific tendinitis). Groupe Rhumatologique
Français de l'Epaule (G.R.E.P.). Clin Exp Rheumatol. 1996 14(5):561–566.Sep–Oct;
[PubMed]

• van der Windt DAWM, Koes BW, Devillé W, Boeke AJP, de Jong BA, Bouter LM.
Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful
stiff shoulder in primary care: randomised trial. BMJ. 1998 Nov 7;317(7168):1292–1296.
[PubMed]

• Winters JC, Sobel JS, Groenier KH, Arendzen HJ, Meyboom-de Jong B. Comparison of
physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints
in general practice: randomised, single blind study. BMJ. 1997 May 3;314(7090):1320–
1325. [PubMed]

• van der Windt DA, van der Heijden GJ, Scholten RJ, Koes BW, Bouter LM. The efficacy of
non-steroidal anti-inflammatory drugs (NSAIDS) for shoulder
The MRI scan shows tendons and other soft tissues as well as the bones.

Colorized to illustrate soft tissues revealed in MRI

What is therapeutic ultrasound?


Therapeutic ultrasound as a treatment modality that has been used by therapists over the last 50
years to treat soft tissue injuries. Ultrasonic waves (sound waves of a high frequency) are produced
by means of mechanical vibration of the metal treatment head of the ultrasound machine. This
treatment head is then moved over the surface of the skin in the region of the injury. When sound
waves come into contact with air it causes a dissipation of the waves, and so a special ultrasound gel
is placed on the skin to ensure maximal contact between the treatment head and the surface of the
skin.

What is therapeutic ultrasound?


Therapeutic ultrasound as a treatment modality that has been used by therapists over the last 50
years to treat soft tissue injuries. Ultrasonic waves (sound waves of a high frequency) are produced
by means of mechanical vibration of the metal treatment head of the ultrasound machine. This
treatment head is then moved over the surface of the skin in the region of the injury. When sound
waves come into contact with air it causes a dissipation of the waves, and so a special ultrasound gel
is placed on the skin to ensure maximal contact between the treatment head and the surface of the
skin.
What are the effects of therapeutic ultrasound?
The effects of therapeutic ultrasound are still being disputed. To date, there is still very little evidence
to explain how ultrasound causes a therapeutic effect in injured tissue. Nevertheless practitioners
world wide continue to use this treatment modality relying on personal experience rather than
scientific evidence. Below are a number of the theories by which ultrasound is proposed to cause a
therapeutic effect.
Thermal Effect:
As the ultrasound waves pass from the treatment head into the skin they cause the vibration of the
surrounding tissues, particularly those that contain collagen. This increased vibration leads to the
production of heat within the tissue. In most cases this cannot be felt by the patient themselves. This
increase in temperature may cause an increase in the extensibility of structures such as ligaments,
tendons, scar tissue and fibrous joint capsules. In addition, heating may also help to reduce pain and
muscle spasm and promote the healing process.
Effects on the Inflammatory and Repair Processes:
One of the greatest proposed benefits of ultrasound therapy is that it is thought to reduce the healing
time of certain soft tissue injuries.
1. Ultrasound is thought to accelerate the normal resolution time of the inflammatory process by
attracting more mast cells to the site of injury. This may cause an increase in blood flow which can
be beneficial in the sub-acute phase of tissue injury. As blood flow may be increased it is not advised
to use ultrasound immediately after injury.
2. Ultrasound may also stimulate the production of more collagen- the main protein component
in soft tissue such as tendons and ligaments. Hence ultrasound may accelerate the the proliferative
phase of tissue healing.
3. Ultrasound is thought to improve the extensibility of mature collagen and so can have a
positive effect to on fibrous scar tissue which may form after an injury.
Application of Ultrasound:
1. Ultrasound is normally applied by use of a small metal treatment head which emits the
ultrasonic beam. This is moved continuously over the skin for approximately 3-5 mins. Treatments
may be repeated 1-2 times daily in more acute injuries and less frequently in chronic cases.
2. Ultrasound dosage can be varied either in intensity or frequency of the ultrasound beam.
Simply speaking lower frequency application provides a greater depth of penetration and so is used
in cases where the injured tissue is suspected to be deeply situated. Conversely, higher frequency
doses are used for structures that are closer to the surface of skin.
Contraindications For Use:
As ultrasound is thought to affect the tissue repair process and so it is also highly possible that it may
affect diseased tissue tissue in an abnormal fashion. In addition the proposed increase in blood may
also function in spreading malignancies around the body. Therefore a number of contraindications
should be followed when using therapeutic ultrasound:
Do not use if the patient suffers from:
1. Malignant or cancerous tissue
2. Acute infections
3. Risk of haemorrhage
4. Severely ischeamic tissue
5. Recent history if venous thrombosis
6. Exposed neural tissue
7. Suspicion of a bone fracture
8. If the patient is pregnant
9. Do not use in the region of the gonads (sex organs), the active bone growth plates of children,
or the eye.

www.orthopaedicscores.com Date of completion


September 11, 2008

Oxford Shoulder Score


Patient's name (or ref)

Clinician's name (or ref)

Please answer the following 12 multiple choice questions.

During the past 4 weeks......

1. How would you describe the worst pain you had 7.Could you brush/comb your hair with the affected
from your shoulder? arm?

None Yes, easily

mild With little difficulty

Moderate With moderate difficulty

Severe With extreme difficulty

Unbearable No, impossible

2. Have you had any trouble dressing yourself 8) How would you describe the pain you usually had
because of your shoulder? from your shoulder?

No trouble at all None

Little trouble Very mild

Moderate trouble Mild

Extreme difficulty Moderate


Impossible to do Severe

3) Have you had any trouble getting in and out of a


9) Could you hang your clothes up in a wardrobe,
car or using public transport because of your
using the affected arm? (whichever you tend to use)
shoulder?

No trouble at all Yes, easily

Very little trouble With little difficulty

Moderate trouble With moderate difficulty

Extreme difficulty With great difficulty

Impossible to do No, impossible

4) Have you been able to use a knife and fork – at the 10) Have you been able to wash and dry yourself
same time? under both arms?

Yes, easily Yes, easily

With little difficulty With little difficulty

With moderate difficulty With moderate difficulty

With extreme difficulty With extreme difficulty

No, impossible No, impossible

11) How much has pain from your shoulder


Yes, easily Not at all

With little difficulty A little bit

With moderate difficulty Moderately

With extreme difficulty Greatly

No, impossible Totally

6) Could you carry a tray containing a plate of food 12) Have you been troubled by pain from your
across a room? shoulder in bed at night?

Yes, easily No nights

With little difficulty Only 1 or 2 nights

With moderate difficulty Some nights

With extreme difficulty Most nights

No, impossible Every night

Reset The Oxford


Shoulder Score is:
0
Nb: This page cannot be saved due to patient data protection so please print the filled in form before
closing the window.
Interpreting the Oxford Shoulder Score

Score 12 to
May indicate satisfactory joint function. May not require any formal
20 treatment.

Score 21 to May indicate mild to moderate shoulder arthritis. Consider seeing you
family physician for an assessment and possible x-ray. You may benefit
30 from non-surgical treatment, such as exercise, weight loss, and /or anti-
inflammatory medication

Score 31 to May indicate moderate to severe shoulder arthritis. See your family
40 physician for an assessment and x-ray. Consider a consult with an
Orthopaedic Surgeon.

May indicate severe shoulder arthritis. It is highly likely that you may well
Score 41 to
require some form of surgical intervention, contact your family physician for
60
a consult with an Orthopaedic Surgeon.

Reference for Score: Dawson J, Fitzpatrick R, Carr A. Questionnaire on the perceptions of patients about shoulder
surgery. J Bone Joint Surg Br. 1996 Jul;78(4):593-600. Link
Reference for grading: Website

Clinical Symptoms of Adhesive Capsulitis


Primary capsulitis has three periods, each of them lasts about 3-4 months

Painful period
A sudden origin of the problems, with a superiority of night problems. Resting pains. A
spasm of musculature is developing, and a restriction of motility of the joint.

Adhesive period

It starts with a gradual developing of the restriction of motility and a recession of


soresness which is tolerable now in this period.
Period of resolution

In this period a depression of pains and an enlargement of motility which does not
have to be wholly altered.

Etiology of Adhesive Capsulitis


Even if the cause of this affection is not known, a consequence with some other
affections is obvious. Adhesive capsulitis more often occurs, f. e. at diabetes mellitus
(at this disease also bilateral capsulitis can occur??), pulmonary affections, illnesses of
thyroidea or renal insufficiency.
REHABILITATION PROTOCOL (Bach, Cohen, & Romeo)
PHASE 1: WEEKS 0-8
GOALS
• Relieve pain.
• Restore motion.
RESTRICTIONS
• None.
IMMOBILIZATION
• None.
PAIN CONTROL
• Reduction of pain and discomfort is essential for recovery
• Medications
• NSAIDS - first-line medications for pain control.
• GH joint injection: corticosteroid/local anesthetic combination.
• Oral steroid taper - for patients with refractive or symptomatic frozen shoulder (Pearsall and Speer, 1998)
• Because of potential side effects of oral steroids, patients must be thoroughly questioned about their past
medical history.
• Therapeutic modalities
• Ice, ultrasound, HVGS.
• Moist heat before therapy, ice at end of session.
MOTION: SHOULDER
GOALS
• Controlled, aggressive ROM exercises.
• Focus is on stretching at ROM limits.
• No restrictions on range, but therapist and patient have to communicate to avoid injuries.
EXERCISES
• Initially focus on forward flexion and external and internal rotation with the arm at the side, and the elbow at
90 degrees.
• Active ROM exercises.
• Active-assisted ROM exercises
• Passive ROM exercises
• A home exercise program should be instituted from the beginning
• Patients should perform their ROM exercises three to five times a day.
• A sustained stretch, 15-30 seconds, at the end of ROMs should be part of all ROM routines.
PHASE 2: WEEKS 8-16
CRITERIA FOR PROGRESSION TO PHASE 2
• Improvement in shoulder discomfort.
• Improvement of shoulder motion.
• Satisfactory physical examination.
GOALS
• Improve shoulder motion in all planes.
• Improve strength and endurance of rotator cuff and scapular stabilizers.
PAIN CONTROL
• Reduction of pain and discomfort is essential for recovery
• Medications
• NSAIDS - first-line medications for pain control.
• GH joint injection: corticosteroid/local anesthetic combination.
• Oral steroid taper - for patients with refractive or symptomatic frozen shoulder (Pearsall and Speer, 1998)
• Because of potential side effects of oral steroids, patients must be thoroughly questioned about their past
medical history.
• Therapeutic modalities
• Ice, ultrasound, HVGS.
• Moist heat before therapy, ice at end of session.
MOTION: SHOULDER
GOALS
• 140 degrees of forward flexion.
• 45 degrees of external rotation.
• Internal rotation to twelfth thoracic spinous process.
EXERCISES
• Active ROM exercises.
• Active-assisted ROM Exercises.
• Passive ROM Exercises.
MUSCLE STRENGTHENING
• Rotator cuff strengthening - three times per week, 8 to 12 repetitions for three sets
• Closed-chain isometric strengthening with the elbow flexed to 90 degrees and the arm at the side.
• Internal rotation.
• External rotation.
• Abduction.
• Forward flexion.
• Progress to open-chain strengthening with Therabands
• Exercises performed with the elbow flexed to 90 degrees.
• Starting position is with the shoulder in the neutral position of 0 degrees of forward flexion, abduction, and
external rotation.
• Exercises are performed through an arc of 45 degrees in each of the five planes of motion.
• Six color-coded bands are available; each provides increasing resistance from 1 to 6 pounds, at
increments of one pound.
• Progression to the next band occurs usually in 2 to 3wk. intervals. Patients are instructed not to progress
to the next band if there is any discomfort at the present level.
• Theraband exercises permit concentric and eccentric strengthening of the shoulder muscles and are a
form of isotonic exercises (characterized by variable speed and fixed resistance)
• Internal rotation
• External rotation
• Abduction
• Forward flexion
• Progress to light isotonic dumbbell exercises
• Internal rotation
• External rotation
• Abduction
• Forward flexion
• Strengthening of scapular stabilizers
• Closed-chain strengthening exercises
• Scapular retraction (rhomboideus, middle trapezius).
• Scapular protraction (serratus anterior).
• Scapular depression (latissimus dorsi, trapezius, serratus anterior).
• Shoulder shrugs (trapezius, levator scapulae).
• Progress to open-chain strengthening.
• Deltoid strengthening.
PHASE 3: MONTHS 4 AND BEYOND
CRITERIA FOR PROGRESSION TO PHASE 4
• Significant functional recovery of shoulder motion
• Successful participation in activities of daily living.
• Resolution of painful shoulder.
• Satisfactory physical examination.
GOALS
• Home maintenance exercise program
• ROM exercises two times a day.
• Rotator cuff strengthening three times a week.
• Scapular stabilizer strengthening three times a week. Maximum improvement by 6-9 mo after initiation of
treatment program.
WARNING SIGNS
• Loss of motion.
• Continued pain.
TREATMENT 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.

OBJECTIVE—To assess the efficacy of bipolar interferential electrotherapy (ET) and


pulsed ultrasound (US) as adjuvants to exercise therapy for soft tissue shoulder
disorders (SD).
METHODS—Randomised placebo controlled trial with a two by two factorial design
plus an additional control group in 17 primary care physiotherapy practices in the
south of the Netherlands. Patients with shoulder pain and/or restricted shoulder
mobility, because of a soft tissue impairment without underlying specific or
generalised condition, were enrolled if they had not recovered after six sessions of
exercise therapy in two weeks. They were randomised to receive (1) active ET plus
active US; (2) active ET plus dummy US; (3) dummy ET plus active US; (4) dummy
ET plus dummy US; or (5) no adjuvants. Additionally, they received a maximum of
12 sessions of exercise therapy in six weeks. Measurements at baseline, 6 weeks
and 3, 6, 9, and 12 months later were blinded for treatment. Outcome measures:
recovery, functional status, chief complaint, pain, clinical status, and range of
motion.
RESULTS—After written informed consent 180 patients were randomised: both the
active treatments were given to 73 patients, both the dummy treatments to
72 patients, and 35 patients received no adjuvants. Prognosis of groups appeared
similar at baseline. Blinding was successfully maintained. At six weeks seven
patients (20%) without adjuvants reported very large improvement (including
complete recovery), 17 (23%) and 16 (22%) with active and dummy ET, and
19 (26%) and 14 (19%) with active and dummy US. These proportions increased to
about 40% at three months, but remained virtually stable thereafter. Up to
12 months follow up the 95% CI for differences between groups for all outcomes
include zero.
CONCLUSION—Neither ET nor US prove to be effective as adjuvants to exercise
therapy for soft tissue SD.

What is Therapeutic Ultrasound?


Therapeutic Ultrasound is a method of stimulating tissue beneath the skin's surface
using sound waves. It is a very high frequency massage that can penetrate up to 4
inches below the surface of your skin.

The sound waves are very high frequency, typically between 800,000Hz and
2,000,000Hz. The sound can not be heard by humans or animals. Humans can only
hear sounds up to about 20,000Hz. This very high frequency sound, like medicine,
affects very small molecules and cells in the body and actually causes them to move.
How ultrasound energy is transferred into the body is a function of many factors. The
frequency of the ultrasound waves is actually opposite to how deep they will penetrate
the body. A 1MHz ultrasound will penetrate about 4" below the skin whereas a 2MHz
ultrasound unit will only penetrate about 2". While a low frequency means deeper
penetration, using a frequency too low will mean that the waves are too wide to properly
move the molecules. For therapeutic applications, 1MHz is the optimal frequency for
both effect and penetration.
Power Output
Power output is another significant factor. It is measured in watts per square centimeter.
The higher the power, the more energy is transferred into the body. If too high a power
output is used and an ultrasound unit is left sitting still on the body, it is possible to burn
the tissue beneath the skin. While several professional ultrasound machines are
capable of these high powers, your medical practitioner will typically use a low power
setting below 1 watt / centimeter squared. More power is not necessarily better.
Practitioners usually use higher power to speed up treatments. It is actually more
effective to use a lower power setting for a longer period of time.
Research indicates that ultrasound is 50 to 80% more effective
than superficial heat.
The power output rating is often broken down into two separate units, peak intensity and
average intensity. Peak intensity can be thought of as how tall the waves are that are
being sent into your body. The waves need to be large enough to affect the tissue and
provide the desired massage effect. At the same time, your body tissue needs breaks
between groups of waves to cool down. So, Ultrasound machines actually send the
waves in groups giving your body a vibrate-rest-vibrate-rest effect. The average
intensity is a measure of how much energy is transferred over a period vibrate-rest
cycles.

Ultrasound machines provide a Total Power Output rating. High power units are
typically used with large applicator heads to do larger parts of the body. The important
measurement part of ultrasound is the watts per square centimeter mentioned above,
not the total unit power. Again, it is more effective to treat the affected area more
frequently and for longer periods with lower power.
Why Ultrasound Gel?
When applied directly to the skin an ultrasound head cannot effectively transfer the
sound waves into the body. To make it work properly, a conductive medium is required -
ultrasound gel. The gel simply makes it possible for the sound waves to travel from the
unit head into your body. Ultrasound without gel is ineffective and can damage the
ultrasound machine.
What does it do?
The heating and massaging effects of Therapeutic Ultrasound have two primary
benefits. First, it increases blood flow in the treated area which speeds the healing
process. Second, it reduces swelling and edema which are the main sources of pain.
Ultrasound can also be used to administer therapeutic medicines into the body. In such
a case there are 3 benefits to a treatment, the first two from the massaging effect of
ultrasound discussed above, and the third from administering the medication. This is a
process known as phonophoresis. Ultrasound with Phonophoresis is rapidly becoming
more popular than Ultrasound Therapy alone.

For most injuries and ailments, a cycle of ultrasound therapy usually consists of 5-10
minute treatments 2-3 times per day for the duration of the healing period. This
surprises many people who have gone for single treatments in clinics only 2 or 3 times
each week. This has everything to do with the cost and convenience for the customer. A
proper course of therapeutic ultrasound treatments consists of 3 to 10 minute
treatments 2 to 4 times per day.
What can be Treated With Ultrasound?
An incredibly wide variety of ailments are treated using ultrasound. Essentially,
anywhere there is a desire to promote blood circulation and reduce swelling and edema,
ultrasound will help.
Injuries to the tendons, ligaments, muscles and cartilage are treated primarily with
ultrasound. Ultrasound helps to reduce swelling and edema which in turn greatly
reduces the pain from the injury. The stimulated tissue and increased blood flow speed
the healing process. Typically, these types of injuries are very slow to heal and because
people continue to try to use the injured body part, the injury is repeatedly stressed.
Regular applications of ultrasound over the duration of the healing period will
significantly reduce pain and the time to heal.

Most professional athletes use ultrasound as a preventative modality to protect against


injury. Using ultrasound before and after very strenuous activities aids in the warm-up
warm-down process. Athletes with chronic ailments from previous injuries will use
ultrasound to promote circulation to the injured area and to reduce swelling and pain
which may impact their performance. Because they use them daily, most professional
athletes have purchased personal ultrasound units.

Upper Trapezius Trigger Point (TP1)

People who suffer from chronic ailments associated with swelling and pain also gain
great benefit from ultrasound. Those who suffer from Arthritis, Bursitis, Carpal and
Tarsal Tunnel Syndrome, and swollen disks use ultrasound to reduce the swelling and
pain associated with their ailment. Ailments which are not chronic such as Bursitis,
Pulled muscles, muscle spasms, or tendon or ligament injury can be treated with
ultrasound and will typically speed the healing rate. For conditions such as arthritis,
ultrasound cannot cure the disease but it can reduce the pain and swelling significantly
which allows people to resume normal lives. When used for treating painful conditions
such as these, ultrasound is typically applied using a medicated gel to gain the
phonophoretic benefit as well.

Upper Trapezius Trigger Point (TP2),


Mid Trapezius Trigger Point (TP3)

As a therapeutic massage device, ultrasound is very effective at reducing muscle


tension. People who suffer muscle tension headaches and migraines use ultrasound on
the back of the neck. This is a very common procedure used by massage therapists and
chiropractors for headache sufferers. People receiving treatments often describe the
sensation as 'the machine seems to suck the tension and pain right out of my head
through my neck'. In reality what is happening is the ultrasound is releasing the trigger
points which are the source of the pain.
Massage therapists are increasingly offering ultrasound treatments in conjunction with
regular massage as a pain free method of releasing trigger points and knots in all the
muscles. Using ultrasound on the trigger points of injured muscles helps to relax the
muscle from the trauma of the injury. When relaxed the muscle can heal from its injury
much more quickly and more effectively with less scar tissue. While full body ultrasound
treatments are not practical, ultrasound treatments on localized trouble areas are very
effective.
Where can I get Therapeutic Ultrasound?

Traditional Ultrasound Therapy treatments can be obtained from most Doctors, Physio
Therapists, and Chiropractors. Some Massage Therapists also provide Ultrasound
treatments.
Phonophoretic Ultrasound Therapy is also available at many Doctor's offices,
Chiropractors, and Physical Therapy Clinics. Many of the professional therapists will
use a medicated Gel. Some clinics will rent out portable ultrasound units to patients for
use at home after an initial consultation. Typical pricing is $75 - $100 per week for take
home units. In-clinic treatment pricing may vary depending on your ailment. Call your
health-care professional and book an appointment today!
Our ultrasound devices are also available for purchase from most medical practitioners
who offer therapeutic ultrasound treatments, or you can order online from
MendMeShop.
Warnings for use:
• Never use the ultrasound unit for treatment without using ultrasound gel.
• Never clean the unit with water or submerge it under water.
• Never use the ultrasound unit on children under the age of 16 without the
recommendation/supervision of a physician or therapist.

Ultrasound Treatment

Ultrasound is the best form of heat treatment for soft tissue injuries. It is used to treat joint and muscle
sprains, bursitis, and tendonitis.
Ultrasound treatment is used to:
• relieve pain and inflammation
• speed healing
• reduce muscle spasms and
• increase range of motion
Ultrasound makes high frequency sound waves. The sound waves vibrate tissues deep inside the injured
area. This creates heat that draws more blood into the tissues. The tissues then respond to healing
nutrients brought in by the blood and the repair process begins.
Treatment is given with a soundhead that is moved gently in strokes or circles over the injured area. It
lasts just a few minutes. The procedure may be performed with the soundhead alone or combined with a
topical anti-inflammatory drug or gel.
Ultrasound treatment is often used by physical therapists, trainers, and many other healthcare providers.
It is very safe and is never used around the eyes, ears, ovaries, testicles, or spinal cord, or where there is
an active infection.

A Survey of Therapeutic Ultrasound Use by Physical Therapists


Who Are Orthopaedic Certified Specialists
Rita A Wong, Britta Schumann, Rose Townsend and Crystal A Phelps

RA Wong, PT, EdD, is Professor and Chair, Department of Physical Therapy, Marymount University, 2807 N Glebe
Rd, Arlington, VA 22207 (USA).
B Schumann, PT, DPT, is Clinic Director, Results Rehab & Fitness, Centreville, Va.
R Townsend, PT, MSPT, is Physical Therapist, National Children's Center–Northwest Campus, Washington, DC.
CA Phelps, PT, MSPT, is a physical therapist with Inova Health System, Ashburn, Va.
Address all correspondence to Dr Wong at: Rwong@marymount.edu
Background and Purpose: For many years, ultrasound (US) has been a widely used and well-
accepted physical therapy modality for the management of musculoskeletal conditions. However,
there is a lack of scientific evidence on its effectiveness. This study examined the opinions of
physical therapists with advanced competency in orthopedics about the use and perceived clinical
importance of US in managing commonly encountered orthopedic impairments.
Subjects: Four hundred fifty-seven physical therapists who were orthopaedic certified specialists
from the Northeast/Mid-Atlantic regions of the United States were invited to participate.
Methods: A 77-item survey instrument was developed. After face and content validity were
established, the survey instrument was mailed to all subjects. Two hundred seven usable survey
questionnaires were returned (response rate=45.3%).
Results: According to the surveys, the respondents indicated that they were likely to use US to
decrease soft tissue inflammation (eg, tendinitis, bursitis) (83.6% of the respondents), increase
tissue extensibility (70.9%), enhance scar tissue remodeling (68.8%), increase soft tissue healing
(52.5%), decrease pain (49.3%), and decrease soft tissue swelling (eg, edema, joint effusion)
(35.1%). The respondents used US to deliver medication (phonophoresis) for soft tissue
inflammation (54.1%), pain management (22.2%), and soft tissue swelling (19.8%). The study
provides summary data of the most frequently chosen machine parameters for duty cycle,
intensity, and frequency.
Discussion and Conclusion: Ultrasound continues to be a popular adjunctive modality in
orthopedic physical therapy. These findings may help researchers prioritize needs for future
research on the clinical effectiveness of US.

• Wong, R. A, Schumann, B., Townsend, R., Phelps, C. A (2007). A Survey of Therapeutic


Ultrasound Use by Physical Therapists Who Are Orthopaedic Certified Specialists.
ptjournal 87: 986-994 [Abstract] [Full text]

A prospective double blind placebo-controlled randomized trial


of ultrasound in the physiotherapy treatment of shoulder pain
R. Ainsworth1,2, K. Dziedzic3, L. Hiller4,5, J. Daniels6, A. Bruton1 and J.
Broadfield1
1
School of Health Sciences, University of Birmingham, B15 2TT, 2Physiotherapy Department, Torbay Hospital,
Lawes Bridge, Torquay TQ2 7AA, 3Primary Care Musculoskeletal Research Centre, Keele University, Keele ST5
5BG, 4Cancer Research UK Clinical Trials Unit, Institute for Cancer Studies, Birmingham B15 2TT, 5Warwick
Clinical Trials Unit, University of Warwick, Coventry CV4 7AL and 6Birmingham Clinical Trials Unit, University
of Birmingham B15 2RR, UK.
Correspondence to: R. Ainsworth, Consultant Physiotherapist, Physiotherapy Department, Torbay Hospital, Lawes
Bridge, Torquay TQ2 7AA, UK.E-mail: roberta.ainsworth@nhs.net

Abstract
Objective. To compare the effectiveness of manual therapy and ultrasound (US) with manual
therapy and placebo ultrasound (placebo US) in the treatment of new episodes of unilateral
shoulder pain referred for physiotherapy.
Methods. In a multicentre, double blind, placebo-controlled randomized trial, participants were
recruited with a clinical diagnosis of unilateral shoulder pain from nine primary care
physiotherapy departments in Birmingham, UK. Recruitment took place from January 1999 to
September 2001. Participants were 18 yrs old and above. Participants all received advice and
home exercises and were randomized to additionally receive manual therapy plus US or manual
therapy plus placebo US. The primary outcome measure was the Shoulder Disability
Questionnaire (SDQ-UK). Outcomes were assessed at baseline, 2 weeks, 6 weeks and 6 months.
Analysis was by intention to treat.
Results. A total of 221 participants (mean age 56 yrs) were recruited. 113 participants were
randomized to US and 108 to placebo US. There was 76% follow up at 6 weeks and 71% at 6
months. The mean (95% CI) reduction in SDQ scores at 6 weeks was 17 points (13–26) for US
and 13 points (9–17) for placebo US (P = 0.06). There were no statistically significant differences
at the 5% level in mean changes between groups at any of the time points.
Conclusions. The addition of US was not superior to placebo US when used as part of a package
of physiotherapy in the short-term management of shoulder pain. This has important implications
for physiotherapy practice.
KEY WORDS: Ultrasound, Shoulder pain, Physiotherapy, Double blind, Randomized trial
Ainsworth, R., Dziedzic, K., Hiller, L., Daniels, J., Bruton, A., Broadfield, J. (2007). A prospective
double blind placebo-controlled randomized trial of ultrasound in the physiotherapy treatment of
shoulder pain. Rheumatology (Oxford) 46: 815-820 [Abstract] [Full text

Effectiveness of therapeutic ultrasound in adhesive capsulitis.

Dogru H, Basaran S, Sarpel T.

Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Cukurova University,


01330 Adana, Turkey.

OBJECTIVE: There is a lack of evidence about the effectiveness of therapeutic


ultrasound (US) compared with placebo US in the treatment of adhesive capsulitis.
This study was performed to assess the effectiveness of therapeutic US in the
treatment of adhesive capsulitis. METHODS: Forty-nine patients with adhesive
capsulitis were randomized to US (n=25) and sham US (n=24) groups. Superficial heat
and an exercise program were given to both groups. Ultrasound was applied to US
group and imitative ultrasound was applied to sham US group for 2 weeks. Shoulder
range of motion (ROM), pain and Shoulder Pain and Disability Index (SPADI) were
assessed at the beginning, after treatment and after 3 months (control). Short Form-
36 (SF-36) was applied for assessing general health status at the beginning and after 3
months. Compliance with the home exercise program was recorded daily on a chart for
3 months. RESULTS: Shoulder ROM, pain with motion, two subscales and total score of
SPADI and physical component summary score of SF-36 were improved significantly in
both groups after the treatment and after 3 months (p<0.0001). Improvements in
flexion, inner and outer rotation values were significantly higher in the US group when
we compared the differences between post- and pre-treatment values of shoulder
ROM. The differences between control and pre-treatment values of inner and outer
rotation were also significantly higher in the US group (p=0.002 and p=0.02
respectively). No significant difference was detected in pain, SPADI and SF-36 scores
between groups. The exercise compliance was significantly higher in the sham US
group (p=0.04). CONCLUSION: Our results suggest that US compared with sham US
gives no relevant benefit in the treatment of adhesive capsulitis. Effectiveness of US
might be masked by worse pre-treatment values of the US group and higher exercise
compliance of the sham US group.

PMID: 18455944 [PubMed - in process]

Different Types of Frozen Shoulder


Let’s talk a little bit about the different types of frozen shoulder we see at Physical Therapy Specialists.
First of all, Frozen Shoulder is either Primary or Secondary.
Primary Frozen Shoulder
This is a spontaneous Frozen Shoulder and it may occur without a specific cause. The patient notices
their shoulder being a little bit “sore”, which results in decreased movement and use. As time goes on,
the pain intensifies and flexibility becomes more limited. At this point, the person normally seeks
medical attention. Jenny’s story at the beginning of this article is a great example of Primary Frozen
Shoulder.
Secondary Frozen Shoulder
This is where Frozen Shoulder is the result of surgery or a shoulder injury. This can either be a rotator
cuff injury; shoulder tendonitis, impingement syndrome or any other injury involves the shoulder. The
actual injury doesn’t directly cause the condition. What happens is that the injury creates a situation
where the patient doesn’t use his or her arm secondary to the pain they are experiencing. Lack of use,
immobilization and lack of stretching results in limited range of motion.
Who Does Frozen Shoulder Strike?
Normally frozen shoulder occurs in people between 40 and 60 years of age and it effects women much
more common than men.
What is Frozen Shoulder?
Your shoulder has an amazing range of motion which is a blessing and a curse, as it can
sometimes lack stability which makes it more prone to injury. The conditions adhesive capsulitis
and frozen shoulder are often used interchangeably; however there is a slight difference between
the two conditions.

Literally the word adhesive means "scarring", and capsulitis means "inflammation of the
capsule". Adhesive capsulitis happens when the shoulder joint capsule and soft tissues
surrounding your socket (glenoid cavity) become inflamed, swollen and contracted. This causes
bands of scar tissue (adhesions) to develop in your joint; as a result your tissues become less
flexible, stick together and restrict movement. You will experience pain, stiffness, a limited
range and gradual loss of overall motion in your shoulder joint, because of the adherence of your
shoulder capsule to the top of your humerus. Eventually your joint may become stuck to the
point where you have no movement at all.
Frozen shoulder is the generalized name for gradual loss of ability to move your shoulder in all
directions. A number of pre-existing conditions can cause and/or encourage adhesive capsulitis
to occur in your shoulder joint. This condition is influenced by injuries to your shoulder muscles,
tendons, ligaments and the associated bursa, as well as other diseases. Often before you can deal
with or determine the other conditions, you must first get rid of the adhesive capsulitis and regain
movement in your shoulder.
Frozen shoulder affects 2 - 5% of the population (about 1 in 50 adults will get this at some time
in their life). Generally you will experience frozen shoulder in either your left or right shoulder,
whichever is your non-dominant shoulder (if you are right handed it would be in your left
shoulder and vice versa). About 15% of the population (1 in 5 cases) will get it on both sides at
some time in their life, however rarely ever at the same time. It is very uncommon to suffer from
frozen shoulder in the same shoulder twice and normally it does not affect other joints in your
body. Frozen shoulder is not known to lead to major damage and/or other more serious
conditions; more so, it is generally a side effect of other conditions and/or a condition in and of
itself.

Since adhesive capsulitis and frozen shoulder are very similar and difficult to differentiate, they
are treated in the same way. For our purpose, we will look at these injuries as one condition.
Alternate names and/or related conditions:
Adhesive capsulitis, pitcher's arm, rotator cuff tears, calcific bursitis, arthritis, tendinitis,
supraspinatus tendinitis, brachial neuritis, reflex sympathetic dystrophy, pericapsulitis,
periarthritis, adherent bursitis, obliterative bursitis, dupuytren contracture.
WHAT IS ULTRASOUND?
Ultrasound is a sound wave that has a frequency greater than 20 KHz.
It is generated by applying an alternate current to a piezoelectric
crystal (found in the transducer in the sound head). This crystal
contracts and expands at the same frequency at which current changes
polarity. The sound field generated by this crystal in turn makes the
molecules in the sound field vibrate and oscillate.
The crystal commonly used in US units is synthetic plumbium
zirconium titanate (PZT).
The quality of the crystal is what makes your US expensive.
Crystal quality depends on the following:
Beam Nonuniformity ratio: ranges from 2 to 6 – the smaller the
better.
Effective Radiating Area: as close to sound head area as
possible
Therapeutic ultrasound has a frequency range of 0.7 and 5.0 MHz.
Most clinics will have 1 MHz and 3 MHz sound head.
Page 3
Sound wave physics
Solids and liquids consist of molecules held together by elastic forces
that behave like rubber bands connecting each molecule to each of its
nearest neighbors.
If one molecule is set in vibration, then it will cause its immediate
neighbors to vibrate, and in turn their neighbors, and so on until the
vibration has propagated throughout the entire material. This is a
wave.
A sound wave is sound energy that is transmitted from one molecule
to the next.
A sound wave cannot travel by itself. It needs a medium for
transmission (solid, liquid, gas).
Energy contained within a soundbeam is decreased as it travels
through tissue. Energy is lost to:
Reflection or scattering of the soundbeam when it strikes a
reflecting surface
Absorption – energy lost by the sound wave as it overcomes
internal friction that exists in tissue while traveling through it.
Higher the frequency, the more rapidly the molecules are forced to
move against this friction. The more they move, the more energy is
consumed (absorbed); the soundbeam will therefore have less sound
energy available to propagate further through the tissue.
The velocity of the wave travel depends on the closeness of the
molecules of the medium. The closer the molecules, the quicker they
collide with each other and sooner they respond to disturbance, the
faster they loose energy in a short distance.
Energy
final
= Energy
initial
– (E
reflected
+E
absorbed
)
So a 3MHz sound head will affect more superficial tissues while a
1MHz sound head will affect deeper tissues.
Page 4
Example:
Sound travels through air easily and can go far (yelling out in the back
yard). Sound can go further because there is little energy loss by
absorption. Air molecules are easily compressed.
Sound does not travel easily through a brick wall that is denser (someone
yells from the outside of the house and you can’t hear him from the
inside). Brick molecules are a lot closer together, harder to compress.
Brick therefore absorbs more of the sound energy going through it.
Page 5
SOUND ENERGY AND
EFFECT ON SOFT TISSUE
So how does sound wave behave when it travels through human
tissues?
From the air medium, it must enter the skin/fat which has a significantly
higher density. There is 100% reflection of the sound wave at the air-skin
interface. If we put a coupling medium such as gel to create a sound
head-gel-skin interface, reflection is reduced to only 0.1% ; the rest of the
sound energy will be transmitted through the skin barrier. As noted in
the absorption coefficients table, sound energy travels through much of
the soft tissue without much absorption until it reaches tissues with high
collagen content, namely bone, periosteum, ligaments, capsules, fascia,
tendons, and tissue interface (bursa).
Ultrasound energy is absorbed mostly in tissues with high collagen
content (bone, periosteum, cartilage, ligaments, capsules, tendons, fascia,
scar tissue and tissue interface i.e. bursa & synovium).
Ultrasound at high intensity near bony areas can be detrimental to the
periosteum because of high energy accumulation and heating effect on
the soft tissue as sound wave hits the bone (transverse or shear wave).
What happens to the tissues that absorb sound energy?
Sound energy is nonionizing radiation and therefore its use does not
impose the hazards, such as cancer production and chromosome
breakage, attributed to ionizing radiation.
Sound energy has two physiological effects:
1. Enhance inflammatory response and tissue repair
2. Heat soft tissue
Page 6
PULSED NON-THERMAL ULTRASOUND
ENHANCE INFLAMMATORY RESPONSE AND TISSUE
REPAIR
Ultrasound energy produces a mechanical pressure wave through soft
tissue. This pressure wave causes:
1. generation of microscopic bubbles in living tissues
2. Distortion of the cell membrane, influencing ion fluxes and
intracellular activity.
Three mechanisms of cell membrane distortion:
1. Acoustic streaming
2. Bubble formation
3. Microstreaming
Page 7
Three mechanisms of cell membrane distortion:
1. Acoustic streaming.
The compression phase of an ultrasound wave deforms tissue
molecules (cell membrane). This deformation is called radiation
force.
2. Bubble formation – cavitation.
Radiation force affects gas bubbles in the tissue fluids. Under this
pressure wave (compression and rarefaction), these bubbles expand
and contract which add further stress to cell boundaries. When
bubbles expand and contract, without growing to critical size, the
activity is called stable cavitation. Unstable cavitation does not
occur in therapeutic range (pulsed 20% @ 0.1 to 3 W/cm2) in
normal tissues except in air-filled cavities such as lungs and
intestines.
3. Microstreaming.
Cavitation sets up eddy currents in the fluid surrounding the
vibrating bubbles and the eddy currents in turn exert a twisting and
rotational motion on nearby cells. In the vicinity of vibrating gas
bubbles intracellular organelles are also subjected to rotational
forces and stresses. This microscopic fluid movement is called
microstreaming.
Bubble activity augments the mechanical effect of a pressure wave.
The scale of cavitation depends on the ultrasound characteristic;
bubble growth is limited by low-intensity, high-frequency, and
pulsed ultrasound. Higher frequency means shorter cycle duration,
so that the time for bubble growth is restricted. Pulsed ultrasound
restricts the number of successive growth (excessive energy
accumulation) and allows the bubble to regain its initial size during
the off period.
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What is the physiological effect of cell membrane destabilization?
Cell membrane destabilization results in an increase in the permeability,
therefore many molecules travel into the cell, precipitating secondary
effects:
1. Increase skin and cell membrane permeability
2. Increase intracellular calcium -- known as second messenger for cell
function including protein synthesis
3. Increase mast cell degranulation
4. Increase histamine and chemotactic factor release by granules from
mast cells and circulating platelets –influences circulation and protein
synthesis.
5. Histamine is released by the degranulation of mast cells. The rate at
which this occurs is proportional to the intensity. It is possible to
form too much histamine at a high intensity which could prolong the
inflammation instead of stimulating healing. The inflammatory
response may be prolonged with the application of any heat modality
in the inflammatory stage.
In summary cell membrane destabilization is thought to enhance the
inflammatory response from the inflammatory phase ( Days 1- 6) to the
proliferative phase (Days 3-20)
Refer to chapter 2 in your book.
Common use for pulsed non-thermal ultrasound
Facilitate healing in the inflammatory and proliferative phase
following soft tissue injury (tendonitis, bursitis, acute soft tissue
injuries)
Bone healing (1.5 MHz, pulsed 20%, 0.15w/cm2, 20 minutes,
daily)
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CONTINUOUS ULTRASOUND
THERMAL APPLICATION
Continuous, high intensity ultrasound increases the temperature of the soft
tissue by:
increasing kinetic energy of tissue molecules (ie.rubbing the hands
together fast enough will generate heat on your skin)
increasing the production of unstable cavitation
Ultrasound kinetic energy when absorbed by tissues can also be converted
into heat.
Unstable cavitation occurs when the bubbles collapse violently under the
pressure due to excessive energy accumulation, after growing to critical size.
This implosion produces large, brief, local pressure and temperature increase
and causes the release of free radicals.
Heating tissues between 40-45degrees using ultrasound has the following
physiological effects:
Increase the extensibility of soft tissue
Decrease the viscosity of fluid elements
Decrease pain perception by slowing nerve conduction velocity
Increase metabolic rate
Increase blood flow which assists in the reduction of swelling
Stimulate the immune system
Common use for continuous ultrasound:
Prior to stretching at tight structure (tendon, capsule, ligaments,
fascia, scar)
Pain control in chronic pain
Chronic inflammatory conditions
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CONTRAIDICATION
Undiagnosed pain
Cancer
Active tuberculosis
Psoriasis
Decreased circulation
Infection
Pregnancy
Central nervous system tissue
Joint cement (cannot use continuous mode, but may use pulsed
mode 50% or less)
Plastic components
Pacemakers
Thrombophlebitis
Uncontrolled bleeding or blood-thinning medication (coumadin)
Eyes
Reproductive organs
Heart
PRECAUTIONS
Acute inflammation (use non-thermal settings only)
Epiphyseal plates (use pulsed, low intensity <0.5w/cm2)
Decreased sensation (esp. with thermal US)
Over implanted materials
metal reflects 90% of incident US
plastic respond like periosteum and it absorbs a large % of US
generally safe if the sound head is kept moving
Page 11
DOSAGE PARAMETERS
Questions to ask yourself:
Is there any contraindications?
What is my injured and tissue? (muscle, tendon, ligament, bursa,
fascia, bone, periosteum, capsule, synovium, cartilage, joint, nerve)
What is the nature of the injury :
1. Traumatic (date & event of injury noted for stage of healing)
2. Cumulative Repetitive Trauma (tendonitis/bursitis/strain/sprain)
3. Degenerative (disc disease, chronic tendonitis, arthritis)
Is there any inflammation in this tissue?
1. If yes, you would want to consider ultrasound to enhance the
inflammatory response and promote healing.
2. If no, then is this injured tissue short and scarred down?
3. If tissue shortness and scarring is your problem than you can
also consider US to heat up the tissue so you can stretch it after
to improve flexibility.
4. If neither inflammation nor tissue scarring or shortening is an
issue then US is not the modality of choice.
Will ultrasound irritate the injured tissue?
US directly over nerves tend to irritate the nerve.
US over bony areas can cause periosteum over heating as most of the
sound energy is absorbed here, you may need to reduce the intensity
to 0.5 w/cm2 or less to avoid irritation.
Can you effectively deliver ultrasound energy to the target tissue or
is the structure too deep or inside a joint?
What are your treatment goals?
Thermalor non-thermal?
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If non-thermal, at what is the healing stage (inflammatory,
proliferative, maturation), acute or chronic?
Does the injured tissue have high, moderate, or low irritability (use
pain scale)?
If high irritability, you may treat is as acute (inflammatory phase day
1 to 3)
If moderate irritability, you may treat as sub-acute (proliferative
phase)
If low irritability, you may treat as sub-acute towards resolution
(proliferative to maturation)
Frequency:
1 MHz – US energy will penetrate to a depth of 2.5 to 5 cm
3 MHz – US energy will penetrate to a depth of 1.5 cm
The higher the frequency, the more likely most of the energy will be
absorbed superficially, leaving little energy to penetrate further into the
tissue (inverse relationship of attenuation/absorption and frequency).
Mode:
Continuous – to heat tissue/scar breakdown
Pulsed (50%, 20%) – to heal tissue
Duty cycle is 1:1 for 50% and 1:4 for 20%. Time is in milliseconds.
Intensity:
To heal:
0.05 – 0.2 W/cm2 (the lowest you can go on the machine)
o Goal: Debridement, increase cell membrane permeability
(electroporation), and increase cell energy level.
o Application:
o Day 1 to 7-10 - inflammatory phase following a traumatic event
o High irritability – pain 8-10/10 – little ROM with severe
impairments of function.
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0.2 to 0.5 W/cm2
o Goal: Increase cell membrane permeability (electroporation) and
increase fibroblastic activity
o Application:
o Day 7-10 - early proliferative phase after a traumatic event
o Moderate irritability – pain 6-8/10 in an acute/chronic/degenerative
non-traumatic condition
0.5 – 0.80 W/cm2
o Goal: Aid collagen deposition and tissue healing
o Application:
o Day 7-10 to 21 - Proliferative phase after a traumatic event
o Moderately low irritability- pain less than 4-6/10 (start with 0.5
and increase with subsequent treatments as healing takes place and
irritability decreases)
To heat: 0.8 w/cm2 – 1.0 w/cm2 for superficial tissues
Greater than 1.5 w/cm2 for deep tissues (hip)
Patient may report a sensation of warmth but not burning or
pain.
If pain is felt, it is a sign of excessive periosteal heating; the
intensity should be reduced immediately or the transducer head
should be moved more quickly.
It is possible to burn with ultrasound.
When using 3MHz in continuous mode near bony areas, you
may have to reduce the intensity due to periosteum overheating.
Treatment time:
1. Based on 3-5 minutes of continuous application for and area that is
twice the ERA of the sound head.
2. Treatment time depends on the duty cycle and treatment surface
area.
Page 14
To heal:
Pulsed 50% on an area that is 2 x ERA = 6 - 10 minutes
(3-5 min. X 2)
For non-thermal effect, intensity of a PUS 50% must be less than 0.5
W/cm2. Thermal effect begins at intensity greater than 0.5 W/cm2.
Pulsed 20% on an area that is 2 x ERA = 15 - 25 minutes
(3 min. X 5)
Pulsed 20% on an area equal to ERA = 7 - 13 minutes
N.B. The preferred duty cycle for clinicians is 50% as it delivers the full
dose in a shorter time period while conserving the non-thermal effect as
long as intensity is less than 0.5 w/cm2. A duty cycle of 20% may be
used if the clinician finds sound reason; delivery of the full dosage may
take more time. Controversy exists between text books as to which duty
cycle is physiologically advantageous.
To heat:
Continuous on an area that is 2 X ERA = 6-10 minutes
Continuous on an area that is equal to ERA = 3-5 minutes
Underwater application can be longer to 10-12 minutes
Sound head / transducer size (controversy):
1. Small – deeper
2. Large - superficial
It is due to beam divergence of the small sound head and that sound head
size in inversely proportional to depth of penetration.
Large 1 MHz good for shoulders (capsule) and hip
Large 3 MHz is good for shoulder (superficial structures) elbows
and wrist
Small 3 MHz is good for finger and toes
Latest news: sound head size does not affect depth penetration. Try
to use a sound head size that is appropriate for the part treated (SH with
ERA that is 50% of the part being treated).
Contact media: gel
Page 15
Sound head movement:
Never stay stationary
Keep it moving, slow and gentle with constant pressure.
This will minimize the risk of creating unstable cavitation and
standing waves that is detrimental / damaging to soft tissue.
Treatment frequency
Ultrasound has cumulative effects
Daily for 10 days – low irritability and scar
3-4 times/week – moderate irritability for 3-4 weeks
2 times /week – high irritability 4-5 weeks
If no change after 3-4 sessions, change settings or discontinue.
Stop after 10-15 treatments
Chronic inflammatory conditions
Thermal application may be indicated in initial stages (if chronic
inflammation is perpetuated by significant scarring)
Non-thermal application later stages (scarring is less of an issue and
inflammation reduction and debridement is your goal)
Progressions of parameters
Intensity can be increased over the healing time
Percentage of pulsation can be increased over healing time
Your lecturer’s notes serve as a general guideline based on research
evidence, book reviews and clinical experience. You will find many
controversies in the literature about dosage and parameters. Use the
above guideline with good judgment and adjust dosage as needed on
an individual basis, depending on your patient’s condition and
response to ultrasound.
Page 16
ULTRASOUND LABORATORY
Determine if US is appropriate for the following cases and write down the appropriate
parameters if applicable.
1. Patient sprained her thumb 3 days ago and is seeing you for treatment. O/E:
marked swelling of the thenar and moderate swelling of the hand, minor
echymosis and moderate pain.
2. Patient sprained his ankle 10 days ago.
O/E: moderate swelling of the ankle, minor tenderness to lateral malleoli. Patient
is PWB with crutches.
3. Patient reports sleeping the wrong way and woke up with pain in the R. shoulder
3 wks ago and pain persists
O/E: C-spine scan is –ve, ROM R. shoulder is limited. Marked tenderness to
palpation noted inferior to the acromion.
4. Patient had been playing golf for years and is now developing a golfer’s elbow. It
started 6 months ago for no apparent reason.
5. Patient reports sitting in a chair and got up the wrong way injuring his back 6 wks
ago. Pain continues to persist.
6. Patient reports having hip pain on/off for 6 months now but it’s gotten worse in
the past 2 wks after a trip to the country side with a lot of walking on uneven
terrain. Pain is found to posterolateral hip. Dr’s note says hip bursitis.
7. Patient had a cyst removed from his index 3 months ago and the area is still
“lumpy” and sensitive to touch.
8. Patient had a hysterectomy for benign cyst growth 1 year ago. She c/o numbness
is the area and thickened scar, making her feel uncomfortable during intercourse.
9. Patient has a THR 1 year ago and developed a hip bursitis recently. Pain began 6
wks ago.
10. Patient with diabetic neuropathies fell down the stairs 3 months ago and fractured
his distal tibia. He went to ER and had ORIF. He continues to c/o pain to the
ankle especially when he walks. Tenderness is found around the ankle joint.
11. An 8 y.o girl sprained her R. knee while playing soccer 2 wks ago. She is still
having pain when she bends her knee past 120 degrees and a bit of pain to touch
around MCL.
12. 65 y.o male with pacemaker has a shoulder tendonitis to the L. shoulder that is 3
months old.
13. 70 y.o female has frozen shoulder. It started 6 months ago and now she cannot
use her arm. She has a cardiac history and is on coumadin.
14. 40 y.o female came out of radiation for breast cancer and now developed scarring
in the breast tissue and limited ROM in the shoulder. She had been too fearful to
move her shoulder for 2 months and developed a frozen shoulder.

Page 17
Answers to the Ultrasound Lab.
1. Target tissue: ligament/capsule
Pulsed 50% , small 3MHz, 0.05 W/cm2, 5 min. Inflammatory phase, US to debride
excessive inflammatory products, and promote healing.
2. Target tissue: ligament / strained tendons surrounding the area
Pulsed 50%, large 3MHz, 0.5 W/cm2, 5 min. if no bruising and low irritability.
Pulsed 50%, large 3MHz, 0.3 W/cm2, 5 min if bruising present and a bit irritable.
3. Investigate for other causes possible, if clear then can US.
If Rotator cuff tendonitis, bursitis, then:
Pulsed 50%, large 3MHz, 0.5 -0.8 W/cm2, 5 min with shoulder in slight extension
and internal rotation to expose the tendon.
4. Medial epicondylitis don’t usually respond well to US and so is not the first
modality of choice to treat this condition.
If the pain is diffuse around the area and we choose to use US then we might
US the ulnar nerve (we might irritate it).
If the pain is truly localized well above and away from the ulnar nerve then
maybe we’ll consider US using a small sound head, pulsed 50%, 0.5 w/cm2,
5min.
5. Need to evaluate properly to determine if it’s a muscular strain, a disc problem or
a facet problem.
If it’s a true strain, then may consider US, continuous, 1MHz, 0.8 to 1.5
w/cm2 to break down scar tissue present.
If it’s a disc problem, with nerve irritation, US probably won’t do any good.
Your best bet is to use McKenzie protocol and traction to reduce nerve
irritation.
If it’s a facet problem then US won’t do any good either because sound energy
will most likely reflect off the bones and will not penetrate to the facet joint.
6. Target tissue: bursa
Pulsed 50%, large 1 MHz, 0.5 -0.8 W/cm2, 6 min
7. Target tissue: scar
Continuous, small 3MHz, 0.5 to 1.0 W/cm2, 5 min
The treated area is small and superficial so we start a bit lower than 0.8 w/cm2
to avoid overheating the first time and can increase gradually over the
treatment period. You should also massage the area to increase elasticity.
8. Continuous 3 MHz, 0.8 to 1.2 w/cm2, 5 min. to break down scar.
If you’re concerned about the benign tumour you should.
However in this case you can administer US because the uterus was removed
and your US will only penetrate to a depth of 1.5 cm which is not far enough
to affect internal organs. You should massage and stretch the scar after US
application.
9. Target tissue: bursa.
Pulsed 50%, large 1 MHz, 0.5 -0.8 W/cm2, 6 min
It’s OK to US over the implants as long as you keep the sound head moving.
10. Find out the pain location.
Page 18
If it is around the fracture site with screw and plate, NO US.; the fracture is
still fresh.
If the pain is distal to the fracture site and away from the plates and screws
then it’s ok, i.e. around the talo-fibular ligament is fine.
Use Pulsed 20%, large 3 MHz, 0.5 -0.8 W/cm2, 5 min to target irritable
inflamed tendons or synovial sheath in the tender area.
11. Target tissue: ligament
Pulsed 50%, large 3 MHz, 0.5 W/cm2, 5 min
OK on growth plate if pulsed less than 0.5 w/cm2.
12 Target tissue: tendon.
Pulsed 50%, large 3MHz, 0.5- 0.8 W/cm2, 5 min
You can use US if you are not directly over the pacemaker or it’s wires.
Wires and pacemaker are often visible under the patient’ skin.
13. US is contraindicated
14. US is contraindicated