Swati

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- [email protected] 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.

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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.

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It affects approximately 10% to 20% of diabetics.

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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.

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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.

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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.

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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.

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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:

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Rest—Reduce activity or stop using the injured area for 48 hours.

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Ice—Put an ice pack on the injured area for 20 minutes, four to eight times/day.

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Compression—Compress the area with an elastic wrap or other bandage to stabilize the shoulder and help reduce swelling.

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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.

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Physical Therapy is also about helping people help themselves!

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

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Physical Therapy is the evaluation and treatment of numerous physical conditions of all age groups.

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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.

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Physical Therapy is provided in the hospital, for outpatients, in schools, in the home, and in nursing homes.

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

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Physical Therapy helps people lead more active and independent lives. Return To Top Of Page

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.

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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.

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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.

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Physical Therapy provides "hands on techniques" like massage or joint mobilization skills to restore joint motion or increase soft tissue flexibility.

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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.

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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.

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

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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.

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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.

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

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A Physical Therapist will consult with other health professionals to facilitate your recovery. Return To Top Of Page

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.

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Ask your Doctor for a referral to physical therapy.

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

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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. Return To Top Of Page

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 . Return To Top Of Page

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. Return To Top Of Page

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. Return To Top Of Page

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. Return To Top Of Page

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. Return To Top Of Page

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. Return To Top Of Page

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. Return To Top Of Page

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. Return To Top Of Page

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. Return To Top Of Page

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. Return To Top Of Page

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. Return To Top Of Page

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. Return To Top Of Page

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. Return To Top Of Page

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. Return To Top Of Page

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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), nonacute 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 balland-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 DEFICITS

SENSORY DEFICIT

NERVES

Loss of Posterior and abduction, lateral aspect of flexion and arm - axillary n. rotation at shoulder ; Weak shoulder extension deltoid, rotator cuff

Axillary, Suprascapular, Upper and Lower subscapular

Very weak elbow flexion and supination of radioulnar

Musculocutaneo us ; Radial N. brs. to supinator & brachioradialis muscles

Radial side of Forearmmusculocutaneo us n. Thumb and 1st finger superficial br. of

jointbiceps brachii & brachialis

radial; digital brs. - Median n.

Susceptible to shoulder dislocation - loss of rotator cuff muscles

Suprascapular, Upper and Lower subscapular

"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 Occipital Protuberanc e

2. Lig . nuchae

Levator Scapulae

Rhomboid Major &

1. Lat. 1/3 Spinal Retracts of clavicle portion of XI and (upper) upwardly rotates 2. scapula Acromion

(middle)

3. Lower cervical & thoracic spines

3. Spine of scapula (lower)

Transverse processes of C 1 to or 4

Upper medial border of the scapula

Cervical Plexus

C3&C4

Elevation and downward rotation of the scapula

1. Ligamentu

Medial border of

Dorsal Scapular

1. Retraction,

Minor

m nuchae,

the (Nerve to scapula; Rhomboids) from the C 4; (C5) root of the spine to the inferior angle

downward rotation, some elevation of the scapula,

Anterior Long surface of Thoracic the medial ( C 5,6,7) border of the scapula

1.Protractio n and upward rotation of scapula

Ribs 3, 4, & Coracoid Medial 5 process of Pectoral scapula Nerve (C8,T1)

Protract, downward rotation o f scapula

2. spinous processes of C7 to T 5

Serratus Anterior

Outer surface of ribs

1-8

Pectoralis Minor

2. Fixes the scapula against the trunk

2. Fixes scapula against the thoracic wall

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 border of scapula,

Inferior Axillary (C fact of the 5,6) greater

Lateral shoulder rotation

superior to tubercle of Teres Major the humerus MUSCLE

PROXIMAL DISTAL

Subscapula Subscapular Lesser ris fossa of the tubercle of scapula humerus

NERVE

FUNCTIO NS

Subscapula 1. Medial r Nerves (C shoulder 5,6) rotation

Intrinsic: Attach humerus to scapula Deltoid

1. Lateral Deltoid one third of tuberosity clavicle on the

2. Acromion

humeral shaft

3. Spine of the scapula

Axillary (C 5,6)

Anterior portion flexes, medially rotates shoulder

Middle portion abducts the shoulder Posterior Portion extends, laterally rotates the shoulder

Teres major

Dorsal Crest of the scapula near lesser inferior tubercle of angle humerus

Lower 1. Subscapula Adduction r and 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, intertubercul rotate the iliac crest ar sulcus) shoulder

3. Spinous processes of T 6 to L5

Pectoralis Major

2. Depress and downward rotation of scapula

1. Medial 1/2 Lateral lip of of the the bicipital clavicle groove (also called the 2. Sternum, intertubercul costal cartilages of ar sulcus)

Lateral and Medial Pectoral nerves (C6T1)

ribs 2 6

1. Adduction , Flexion, Medial Rotation of the shoulder

2. Horizontal Adduction 3. Protraction of scapula

Chart 2 - MOVEMENTS OF THE SCAPULA Motion

Prime Movers

Nerve

Elevation

Trapezius- upper

Accessory

Levator scapulae

N. to L. scapulae

Critical Segment

C 3,4

Depression

Upward Rotation

Downward Rotation

Protraction

Retraction

Rhomboideus major*

Dorsal scapular

C (4),5

Rhomboideus minor*

Dorsal scapular

C (4),5

Latissimus dorsi1

Thoracodors C 7 al

Pectoralis major sternal head1

Pectoral Nerves

C 6, 7,8

Pectoralis minor

Medial pectoral

C 8, T1

Serratus anterior

Long thoracic

C 5, 6, 7

Trapezius-Upper & Lower

Accessory

Latissimus dorsi1

Thoracodors C 7 al

Pectoralis major sternal head1

Pectoral Nerves

C 6, 7,8, 1

Pectoralis minor

Medial pectoral

C 8, T1

Levator scapulae

N. to L. scapulae

C 3,4

Serratus anterior

Long thoracic

C 5, 6, 7

Pectoralis minor

Medial pectoral

C 8, T 1

Pectoralis major 1

Pectoral Nerves

C 6, 7,8, 1

Trapezius

Accessory

Rhomboideus major

Dorsal scapular

C (4),5

Rhomboideus minor

Dorsal scapular

C (4),5

* 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 clavicular head

Lateral Pectoral C 5, 6

Coracobrachialis*

Musculocutane C 5, 6, 7 ous

Deltoid - posterior

Axillary

C5

Latissimus dorsi

Thoracodorsal

C7

Teres major

Lower subscapular

C 5, 6

Supraspinatus1

Suprascapular

C 5, 6

Deltoid - anterior

Axillary

C5

Latissimus dorsi

Thoracodorsal

C7

Pectoralis major sternal head

Pectoral nerves C 6, 7, 8, 1

Subscapularis

Upper subscapular

C 5, 6

Deltoid - anterior

Axillary

C5

Infraspinatus

Suprascapular

C 5, 6

Teres minor

Axillary

C5

Extension

Abduction

Adduction

Inward Rotation

Outward Rotation

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-today 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 1MHz 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.

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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 from your shoulder?

7.Could you brush/comb your hair with the affected 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 because of your shoulder?

8) How would you describe the pain you usually had from your shoulder?

No trouble at all

None

Little trouble

Very mild

Moderate trouble

Mild

Extreme difficulty

Moderate

Impossible to do

3) Have you had any trouble getting in and out of a car or using public transport because of your shoulder?

Severe

9) Could you hang your clothes up in a wardrobe, using the affected arm? (whichever you tend to use)

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 same time?

10) Have you been able to wash and dry yourself 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 across a room?

12) Have you been troubled by pain from your 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

Nb: This page cannot be saved due to patient data protection so please print the filled in form before closing the window.

The Oxford Shoulder Score is: 0

Interpreting the Oxford Shoulder Score Score 12 to 20

May indicate satisfactory joint function. May not require any formal treatment.

Score 21 to 30

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

Score 31 to 40

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

Score 41 to 60

May indicate severe shoulder arthritis. It is highly likely that you may well require some form of surgical intervention, contact your family physician for 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: [email protected]

Background and Purpose: For many years, ultrasound (US) has been a widely used and wellaccepted 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 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. 1

Correspondence to: R. Ainsworth, Consultant Physiotherapist, Physiotherapy Department, Torbay Hospital, Lawes Bridge, Torquay TQ2 7AA, UK.E-mail: [email protected]

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 Form36 (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. Page 8

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) Page 9

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 Page 10

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? Page 12

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. Page 13

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