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Tóm tắt nội dung (trích từ tài liệu gốc): Physical Therapy of the Shoulder FIFTH EDITION � Image Collection � Reference lists linked to Medline � Video clips Physical Therapy of the Shoulder FIFTH EDITION Edited by Robert A. Donatelli, PhD, PT, OCS National Director of Sports Rehabilitation Physiotherapy Associates Las Vegas, Nevada 3251 Riverport Lane St. Louis, Missouri 63043 PHYSICAL THERAPY OF THE SHOULDER, FIFTH EDITION ISBN: 978-1-4377-0740-3 Copyright # 2012, 2004, 1997, 1991, 1987 by Churchill Livingstone, an imprint of Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form
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Physical Therapy of the Shoulder
FIFTH EDITION
� Image Collection
� Reference lists linked to Medline
� Video clips
Physical Therapy of the Shoulder
FIFTH EDITION
Edited by
Robert A. Donatelli, PhD, PT, OCS
National Director of Sports Rehabilitation
Physiotherapy Associates
Las Vegas, Nevada
3251 Riverport Lane
St. Louis, Missouri 63043
PHYSICAL THERAPY OF THE SHOULDER, FIFTH EDITION ISBN: 978-1-4377-0740-3
Copyright # 2012, 2004, 1997, 1991, 1987 by Churchill Livingstone, an imprint of Elsevier Inc.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without
permission in writing from the publisher.
Details on how to seek permission, further information about the Publisher's permissions policies and our
arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be
found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using
any information, methods, compounds, or experiments described herein. In using such information or methods
they should be mindful of their own safety and the safety of others, including parties for whom they have a
professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current
information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered,
to verify the recommended dose or formula, the method and duration of administration, and contraindications.
It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate
safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability
for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or
from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Physical therapy of the shoulder / edited by Robert A. Donatelli. � 5th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4377-0740-3 (hard copy)
1. Shoulder�Wounds and injuries. 2. Shoulder�Wounds and injuries�Treatment. 3. Shoulder�Wounds
and injuries�Physical therapy. I. Donatelli, Robert. II. Title.
[DNLM: 1. Shoulder�injuries. 2. Shoulder Joint�injuries. 3. Physical Therapy Modalities. WE 810]
RD557.5.P48 2011
617.5'72044�dc22
2011001297
Executive Editor: Kathy Falk
Developmental Editor: Megan Fennell
US/Chennai Publishing Services Managers: Julie Eddy and Rajendrababu Hemamalini
US/Chennai Project Managers: Celeste Clingan and Srikumar Narayanan
Designer: Jessica Williams
Printed in United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Dedication
I would like to dedicate this book to my family--my wife Georgi Donatelli, my son,
Robby, and my daughters, Briana and Rachel. They have added a new meaning of love,
joy and happiness to my life.
This page left intentionally blank
Contributors
RANDA A. BASCHARON, DO, AT XAVIER A. DURALDE, MD
Owner, President, Orthopedic and Sports Medicine Peachtree Orthopedics Clinic, Assistant Clinical Professor
Institute Of Las Vegas, Sports Performance Institute of of Orthopedic Surgery, Clinical Instructor, Emory University
Las Vegas, Las Vegas, Nevada School of Medicine, Atlanta, Georgia
MOLLIE BEYERS, DPT RICHARD A. EKSTROM, PT, DSC, MS
Physical Therapist, Biomax Rehabilitation, Effingham, Professor, Department of Physical Therapy, University of
Illinois South Dakota, Vermillion, South Dakota
PETER BONUTTI, MD, FACS, FAAOS, FAANA TODD S. ELLENBECKER, DPT, MS, SCS, OCS, CSCS
Founder and Director, Bonutti Clinic, Founder and Clinic Director, Physiotherapy Associates Scottsdale Sports
Director, Bonutti Technology, Effingham, Illinois, Assistant Clinic, National Director of Clinical Research, Physiotherapy
Clinical Professor, Department of Orthopedic Surgery, Associates, Director of Sports Medicine, ATP World Tour,
University of Arkansas, Fayetteville, Arkansas Scottsdale, Arizona
KENJI C. CARP, MPT, OCS, ATC ROBERT L. ELVEY, BAPPSC, GRAD. DIP. MANIP. THER.
Certified Vestibular Therapist, Director, Owner, Senior Lecturer, Curkin University, Physiotherapy
Cooperative Performance and Rehabilitation, Eugene, Consultant, Southcare Physiotherapy, Perth, Australia
Oregon
KATHLEEN GEIST, PT, DPT, OCS, COMT
JEFF COOPER, MS, ATC Assistant Professor, Division of Physical Therapy,
Athletic Training Solutions, Wilmington, Delaware,
Department of Rehabilitation Medicine, Emory University
Consultant, Player Development, Philadelphia Phillies, School of Medicine, Atlanta, Georgia
Philadelphia, Pennsylvania
JOHN C. GRAY, DPT, OCS, FAAOMPT
DONN DIMOND, PT, OCS Lead Clinical Specialist, Department of Physical
Director of Clinical Operations, Owner, The KOR Physical
Therapy, Sharp Rees-Stealy, Clinical Instructor, Ola
Therapy, Portland, Oregon Grimsby Institute, Credentialed Clinical Instructor,
American Physical Therapy Association, Associate Editor,
JAN DOMMERHOLT Journal of Manual and Manipulative Therapy, San Diego,
President and Physical Therapist, Bethesda Physiocare, California
Inc/Myopain Seminars, LLC, Bethesda, Maryland BRUCE H. GREENFIELD, PT, PHD, OCS
Assistant Professor, Department of Rehabilitation, Center
PHILLIP B. DONLEY, PT ATC MS
Optimum Physical Therapy, West Chester, Pennsylvania for Ethics, Emory University, Atlanta, Georgia
viii Contributors
OLA GRIMSBY, PT DOUGLAS M. MURRAY, MD
Chairman of the Board, Ola Grimsby Institute, San Diego, Surgeon, Peachtree Orthopedic Clinic, Consulting
California Physician, Shepherd Center, Atlanta, Georgia
TOBY M. HALL, PHD, MSC, POST GRAD DIP MANIP THER, ROY W. OSBORN, PT, MS, OCS
ASSOC IN PHYSIOTHERAPY Associate Professor, Physical Therapist, Physical Therapy
Director Manual Concepts, Perth, Australia, Adjunct Department, Avera McKennan Hospital and University
Senior Teaching Fellow, School of Physiotherapy, Curtin Health System, Sioux Falls, South Dakota
Innovation Health Research Institute, Curtin University of
Technology, Bentley, Australia, Senior Teaching Fellow, The JAIME C. PAZ, PT, DPT, MS
University of Western Australia, Perth, Australia, Director Clinical Associate Professor, Division of Physical Therapy,
Manual Concepts, Perth, Australia
Walsh University, North Canton, Ohio
SCOT IRWIN, DPT, CCS{
Formerly, Associate Professor, Department of Physical SCOTT D. PENNINGTON, MD
Surgeon, Peachtree Orthopedic Clinic, Atlanta, Georgia
Therapy, North Georgia College and State University,
Dahlonega, Georgia VIJAY B. VAD, MD
Assistant Professor of Rehabilitation Medicine, Hospital
ROBERT C. MANSKE, PT, DPT, SCS, MED, ATC, CSCSC
Associate Professor, Department of Physical Therapy, for Special Surgery, New York, New York
Wichita State University, Wichita, Kansas JOSEPH S. WILKES, MD
Clinical Associate Professor, Orthopedics, Emory
JOHNSON MCEVOY, PT, BSC, MSC, DPT, MISCP, MCSP
Chartered Physiotherapist in Private Practice, United University, Active Staff Member, Piedmont Hospital,
Specialty Consulting, Crawford Long Hospital, Atlanta,
Physiotherapy Clinic, Limerick, Ireland, Head Georgia, Active Staff Member, Fayette Community Hospital,
Physiotherapist, Irish Boxing High Performance Team, Fayetteville, Georgia
Dublin, Ireland, External Lecturer, Sports Science, University
of Limerick, Limerick, Ireland MICHAEL S. ZAZZALI, DSC, PT, OCS
Co-Director and Partner, Physical Therapy Associates of
CRAIG D. MORGAN, MD
Clinical Professor, University of Pennsylvania, Department New York, New York, New York
of Orthopaedics, Philadelphia, Pennsylvania, Morgan Kalman
Clinic, Wilmington, Delaware
{Deceased.
Preface
The first edition of Physical Therapy of the Shoulder was pub- Part 2, Neurologic Considerations, has been updated with
lished in 1987, and now we are publishing the fifth edition new information and references. John C. Gray and Ola Grimsby's
nearly 25 years later. I would like to thank my readers for chapter, Interrelationship of the Spine, Rib Cage, and Shoulder,
their support throughout the years that has made this book along with Neural Tension Testing by Tobby Hall and Bob
successful. The fifth edition has kept up with the tradition Elvy have been revised, and Bruce H. Greenfield and Kathleen
of Physical Therapy evidence-based practice. It is amazing Geist did a great job updating the chapter on Evaluation and
how the literature now has developed our profession from Treatment of Brachial Plexus Lesions. A new chapter, Sensory
and art to a science. Each chapter is a excellent example of Integration and Neuromuscular Control of the Shoulder by
how the science of Physical Therapy continues to grow. Kenji Carp has been added to the neurological section. I think
you will find that Kenji did an excellent job on defining
The shoulder joint is a complicated structure consisting of neuromuscular control in the upper limb. The chapter is an
three synovial joints, the scapula thoracic articulation, and 17 excellent representation of state of the art information that is
muscles. The shoulder complex hangs off the rib cage and is critical to the rehabilitation of shoulder patients.
connected to the cervical and thoracic spine. The complexity of
the shoulder makes many rehabilitation students and clinicians Part 3, Special Considerations, was highlighted by the
uncertain in assessing shoulder pathomechanics and in establish- separation of Chapter 10 into two chapters, Impingement
ing treatment approaches for different shoulder pathologies. Syndrome and Shoulder Instabilities. Bruce Greenfield did
an excellent job on describing the mechanisms of impinge-
In keeping up to date with new and innovative treatment ment and the new chapter, on shoulder instabilities, by
techniques, surgical procedures, and evaluation methods for Michael Zazzali, focused on the conservative approach to the
the shoulder, this fifth edition of Physical Therapy of the Shoulder evaluation and treatment of shoulder instabilities. The Frozen
has been updated appropriately. There are 7 new chapters and Shoulder chapter was update by Mollie Beyers and Peter
8 new authors. The fifth edition is once again divided into five Bonutti. This chapter provides an excellent summary of the
parts; Mechanics of Movement and Evaluation, Neurologic evidence-based research on treatment of frozen shoulder
Considerations, Special Considerations, Treatment Approaches, pathology. John C. Gray's chapter on Visceral Referred Pain
and Surgical Considerations. to the Shoulder, was rewritten, along with important updates
from Todd S. Ellenbecker on rotator cuff pathology.
In honor of the memory of the late Scot Irwin, Jaime Paz
helped to revise the Guide to Physical Therapist Practice. In the Treatment Approaches Section, Richard A. Ekstrom
The chapter is an overview of the Guide. Chapter 2 was and Roy W. Osborn did an excellent job on adding addition
updated with new anatomic and biomechanical information research on Muscle Length Testing and Electromyographic
on how the shoulder moves. Chapter 3 was rewritten by Jeff Evidence for Manual Strength Testing and Exercises for the
Cooper with all the new information on the throwing injuries Shoulder. The Manual Therapy Techniques was updated with
to the shoulder. Jeff has included new research data that he additional illustrations of new manual procedures for the
has collected over the past several years on professional baseball shoulder, with a section on evidence-based manual therapy
pitchers. His approach to evaluation and treatment is state treatment approaches. The treatment section was highlighted
of the art. Chapter 4 is a new chapter by Donn Dimond by one of two new chapters by Donn Dimond on strength
that finishes the first section with updates on all the new- training in the shoulder. As previously noted the shoulder
evidenced-based special tests for the shoulder. The special tests has 17 muscle that allow it to move in multiple planes.
on the shoulder greatly assist the clinician in the development Therefore this chapter is long awaited as the strength of
of a differential soft tissue diagnosis. In addition, manual the shoulder muscles is critical to the overall function. Finally,
muscle testing to isolate the shoulder muscles is illustrated.
x Preface
I am honored to have Johnson McEvoy and Jan Dommerholt I am pleased to include a companion Evolve site with the
in the fifth edition with a new chapter on Myofascial Trigger fifth edition of Physical Therapy of the Shoulder. The Evolve site
Points of the Shoulder. The chapter is very comprehensive compliments the text and enhances the clinical application with
covering evaluation and treatment of trigger points. The excerpts of an evaluation of a patient using manual therapy
treatment approaches described include, Myofascial release treatment techniques of the shoulder. A link to an electronic
techniques using manual therapy, massage techniques, dry image collection that features most of the illustrations contained
needling, spray and stretch, and the use of modalities. in the book are included on Evolve.
The Surgical Considerations Section includes the addition Any rehabilitation professional entrusted with the care and
of a chapter by Dr. Ronda Bascharon and Robert Manske on treatment of mechanical and pathologic shoulder dysfunction
the Surgical Approach to Shoulder Instabilities. The chapter will benefit from this book. I trust that the fifth edition will
includes state-of-the-art concepts in evaluation and treatment meet the reader's expectation of comprehensive, clinically
of the Bankart lesion, S.L.A.P lesions, and rotator cuff interval relevant presentations and case studies that are well documen-
concepts. Dr. Joseph Wilkes and Dr. Xavier Duralde made ted, contemporary, and personally challenging to the student
important updates in their chapters on Rotator Cuff Repairs and the experienced specialist alike.
and Total Shoulder Replacements, respectively.
Robert A. Donatelli, PhD, PT, OCS
CHAPTER Scot Irwin and Jaime C. Paz
1
The Guide to Practice
In this fifth edition of Donatelli's Physical Therapy of the none alone. For most of the decade of the 1980s and early
Shoulder, the clinical cases continue to be written in the 1990s, the APTA debated the merits and even the existence
format of Guide to Physical Therapist Practice1 (the Guide) of of physical therapy diagnoses. The term diagnosis is so fraught
the American Physical Therapy Association (APTA). This with interpretations that, within the APTA, confusion and
format was developed and has been promoted by the APTA, debate have consumed an inordinate amount of the associa-
which is the largest professional representative for physical tion's governance time. Finally, the APTA House of Delegates
therapists, physical therapy assistants, and physical therapy came to an agreement that physical therapists did diagnose
students in the United States. and that those diagnoses were directed at movement and
movement dysfunction.
This chapter is designed to orient the reader to the origins,
purposes, content, and nature of the Guide. In this way, the The basic premise here is that human movement, like
intent of this chapter is to encourage clinicians and students digestion, is a system. The movement system has normal
who use this current book to incorporate the Guide's language behaviors that can become dysfunctional, and a physical ther-
and philosophy into the examination, evaluation, diagnosis, apist can provide remedies for those dysfunctions. Eventually,
prognosis, intervention, and outcome provided for their because of a need to describe the scope of a physical therapist's
patients with shoulder dysfunction. practice more clearly for many health care agencies and for the
physical therapy profession, the APTA undertook the develop-
ORIGINS ment of the Guide. From 1992 through the completion of the
current edition, a handful of physical therapists and staff
To speak at any length about the origins of this document members of the APTA constructed this document. Those
would take most of this text. For the abbreviated yet complete who have tried to produce anything by committee can imag-
review, the reader is encouraged to read the Guide.1 Since ine the amount of time and effort required to write the Guide.
Mary McMillan first constructed and presided over the The authors of the Guide are too numerous to list, but they are
Women's Physiotherapy Association in the early 1920s--and acknowledged within the Guide itself, and they deserve the
until the first edition of the Guide in 1997--the reconstruc- respect and thanks of every physical therapist. All the authors
tion aides, general practitioners, and certified clinical specia- were chosen for their expertise and knowledge in a particular
lists all intuitively have known the value and importance of practice pattern arena (musculoskeletal, neuromuscular, car-
rehabilitation services. Throughout that short but illustrious diovascular/pulmonary, and integumentary). Each of those
history, the association members have professed the unique- authors is quick to point out that this document is not writ-
ness and talent within the physical therapy profession to any ten on a stone tablet. Its origins derive from the cataclysmic
who cared to listen. The scientific evidence of this effective- changes that have occurred in health care delivery and reim-
ness, in contrast, remains to be presented. No defined body bursement in the United States. Those driving forces, along
of knowledge for physical therapists exists. The Guide pro- with the dynamic growth and development of the profession
vides a foundation for developing the evidence for the effec- of physical therapy, created an environment that required this
tiveness of physical therapist interventions. The body of document's publication and demanded that the Guide be in
knowledge will be defined from the evidence that proves the constant evolution. Evidence of this evolution is electronic
value of these interventions. access to the revised second edition of the Guide in compact
disk format, which includes a catalog of tests and measures
Physical therapy originated from many facets of health care employed by physical therapists. Furthermore, the APTA
and health sciences, nursing, physical education, medicine, has provided Internet access to the latest edition of the
pathology, and rehabilitation--yet physical therapists claim Guide.2
2 Physical Therapy of the Shoulder
The challenge for future physical therapists is to continue research. The current edition of the Guide was not written
to amend and edit the Guide by documenting errors and omis- to provide that level of information.
sions and by providing new practice patterns for impairments
and functional limitations yet to be identified or discovered. In this book, the case examples have been "Guideized,"
A future edition of the Guide is likely to include the Interna- including formatting and terminology. It is the intention that
tional Classification of Functioning, Disability, and Health the reader should become familiar with this system of patient
(ICF) developed by the World Health Organization (WHO) evaluation and treatment and incorporate it into his or her
to promote human functioning with a standardized frame- daily practice. It is also hoped that academic and clinical fac-
work and language. The APTA House of Delegates endorsed ulty will use the Guide approach when instructing future gen-
this model in 2008.3 erations of physical therapists and will thus fulfill the purpose
of the Guide.
PURPOSES CONTENT
The list of purposes for the Guide can be found in the first The Guide was developed with three key concepts in mind:
section, "About the Guide," of the revised second edition.1 (1) the Nagi model of disablement4 (Table 1-1); (2) the variety
Throughout the document, these purposes are reiterated. of work settings for physical therapists; and (3) the provision
Each of the diagnostic patterns described in the Guide uses of services by physical therapists through the continuum of
terminology found in the list of purposes. Although many health care.
readers find this constant redundancy a distracting feature
of the Guide, it is used to demonstrate the basic constructs To understand the Guide, a good understanding of the dis-
of a physical therapist's approach to patient management. ablement model is required. Articles by Guccione5 and Jette6
The authors of the Guide also used the combined term have provided the background for understanding disablement.
patient/client throughout the Guide. For this chapter, the The reader can find these articles in the journal Physical Therapy
term client is used. from 1991 and 1994, respectively. The Nagi model4 was
selected by the authors of the Guide because it provides the best
A summary of the purposes is as follows: The Guide was fit for the development of physical therapy practice patterns
developed to assist internal (physical therapists) and external and diagnoses. As Guccione's diagram (Fig. 1-1) so aptly
(all others involved in health care delivery and reimburse- demonstrates, the Nagi model encompasses the entire spec-
ment) individuals in understanding the scope of a physical trum of health care. Pathology and pathophysiology lead to
therapist's practice. As stated in the Guide, this list impairment, which can either cause more pathology or lead
includes--but is not limited to--practice settings, roles, ter- to functional limitations. These functional limitations may
minology, tests and measures, and interventions used by phys- revert back to impairments or progress to disability. The
ical therapists in the delivery of physical therapy. Perhaps domain of a physical therapist's practice is outlined by the dot-
most important, the Guide establishes preferred practice pat- ted lines in Figure 1-1. The Guide was developed to address the
terns based on the Nagi model of disablement.4 Common delivery of health care services by physical therapists from
themes within the purposes listed in the Guide are the promo- pathology to impairment to functional limitation and to dis-
tion of health, wellness, and fitness along with prevention of ability with the greatest emphasis on identification and rectifi-
movement dysfunction and the appropriate use of physical cation of impairments and functional limitations. In effect, the
therapy services as provided by physical therapists. Guide is saying that physical therapists are the diagnosticians of
movement impairments and provide interventions to prevent,
The authors of the Guide clearly describe what the Guide is improve, or eliminate functional limitations and disability.
not. To quote the authors: "The Guide does not provide spe-
cific protocols for treatments, nor are the practice patterns The Guide goes on to enhance and adapt the Nagi model
contained in the Guide intended to serve as clinical guide- by expanding it to include the larger arena of quality of life
lines."1 The authors go on to state that the Guide is only an (Fig. 1-2). This enhancement requires that the Guide include
initial step in the development of clinical guidelines. Clinical psychological and social functions, as well as the constructs
guideline development requires evidence from peer-reviewed of the promotion of wellness, prevention, and fitness.
Table 1-1 Nagi Model of Disablement
Active Pathology Impairment Functional Limitation Disability
Interruption or interference with Anatomic, physiologic, Limitation in performance Limitation in performance of socially
normal processes, and efforts of the mental, or emotional at the level of the whole defined roles and tasks within a
organism to regain normal state abnormalities or loss organism or person sociocultural and physical environment
Chapter 1 The Guide to Practice 3
Medical aspects Health care Social aspects
Domain of physical therapist practice
Pathology/ Impairment Functional Disability
pathophysiology limitation
Figure 1-1 Scope of physical therapist practice within the continuum of health care services and the context of the disablement model. (Modified from
the American Therapist Association from Guccione AA: Physical therapy diagnosis and the relationship between impairments and function, Phys Ther
71:499�504, 1991.)
Pathology/ Impairment Functional Disability
pathophysiology limitations
Physical function Physiologic function Social function
Non-health factors Health-related
quality of life
� Economic status
Quality of life
� Individual
expectations
and achievements
� Personal
satisfaction with
choices and life
� Sense of
personal safety
Figure 1-2 Relationship of the disablement model, health-related quality of life, and quality of life.
The actual content of the Guide currently includes five become a physical therapist; the types of settings in which
major parts. The first part is a description of the Guide itself physical therapists practice; the roles of physical therapists
that provides insight into its development, purpose, scope, in primary, secondary, tertiary, and preventive care; the
and content overview. The second part of the Guide defines components of a physical therapist's episode of care; and
who physical therapists are and describes their approaches to the criteria for termination of physical therapy services. In
the management of clients. The second part of the Guide also addition, this section describes in greater detail the six ele-
provides a description of the tests and measures used by phys- ments of patient management: (1) examination, (2) evalua-
ical therapists as a part of their examination process. In addi- tion, (3) diagnosis, (4) prognosis, (5) intervention, and
tion, the second part provides definitions and lists of physical (6) outcomes (Fig. 1-3). Finally, this section gives a broader
therapists' interventions. The third and by far the longest por- description of the roles of physical therapists in manage-
tion of the Guide is made up of preferred practice patterns. ment, administration, communication, critical inquiry, and
The fourth part provides expanded access to the catalog of education.
tests and measures. The fifth part provides a document tem-
plate to facilitate the use of Guide terminology and the patient The second part of the Guide provides the list of the tests
management system in clinical practice. A glossary is and measures used by physical therapists in their examination
included at the end of the Guide. of clients. If a test or measure is not listed in the Guide, this
does not preclude physical therapists from using that test or
The section that describes physical therapists provides measure. It is the intent of the Guide, however, that any test
information on the following: the prerequisites required to or measure used is valid and reliable and that each follows
4 Physical Therapy of the Shoulder
DIAGNOSIS
Both the process and the end
result of evaluating examination
data, which the physical therapist
organizes into defined clusters,
syndromes or categories to help
determine the prognosis (including
the plan of care), and the most
appropriate intervention strategies.
EVALUATION PROGNOSIS
A dynamic process in which the (Including plan of care)
physical therapist makes clinical Determination of the level of
judgments based on data gathered optimal improvement that may be
attained through intervention and
during the examination. This the amount of time required to
process may also identify possible reach that level. The plan of care
problems that require consultation specifies the interventions to be
with or referral to another provider. used and their timing and
EXAMINATION frequency.
The process of obtaining a history,
performing a systems review, and INTERVENTION
selecting and administering tests Purposeful and skilled interaction
and measures to gather data about of the physical therapist with the
patient/client and, if appropriate,
the patient/client. The initial with other individuals involved in
examination is a comprehensive
care of the patient/client, using
screening and specific testing various physical therapy methods
process that leads to a diagnostic
and techniques to produce
classification. The examination changes in the condition that are
process also may identify possible consistent with the diagnosis and
problems that require consultation prognosis. The physical therapist
with or referral to another provider.
conducts a re-examination to
determine changes in patient/client
status and to modify or redirect
intervention. The decision to
re-examine may be based on new
clinical findings or on lack of
patient/client progress. The
process of re-examination also
may identify the need for
consultation with or referral to
another provider.
OUTCOMES
Results of patient/client
management, which include the
impact of physical therapy
interventions in the following
domains: pathology/
pathophysiology (disease,
disorder, or condition);
impairments, functional limitations,
and disabilities; risk reduction/
prevention; health, wellness, and
fitness; societal resources; and
patient/client satisfaction.
Figure 1-3 The elements of patient management leading to optimal outcomes. (From American Physical Therapy Association: Guide to Physical
Therapist Practice, ed 2. Baltimore, APTA, 2003.)
the Standards for Tests and Measurements in Physical Therapy required to perform when intervening on behalf of a client.
Practice as presented in the journal Physical Therapy in 1991.7 This list includes coordination, communication, administra-
tion, client education, and the entire spectrum of the physical
The interventions section is provided primarily for external therapists' interventions from therapeutic exercise to physical
groups. This section contains definitions and descriptions of agents and modalities.
all the activities in which physical therapists are trained and
Chapter 1 The Guide to Practice 5
The bulk of the Guide is dedicated to the practice patterns. projection of the frequency and duration of treatment required
The patterns are broken up into four broad classifications: and plans for discharge from therapy.
(1) musculoskeletal, (2) neuromuscular, (3) cardiovascular/
pulmonary, and (4) integumentary. All the client cases Perhaps the most important contribution of the Guide to
described in this edition of Physical Therapy of the Shoulder the clinician is in the intervention segments of each practice
can be found in the musculoskeletal and neuromuscular prac- pattern. These suggested interventions are not cookbooks for
tice patterns. Although the physical therapists' evaluations care, but rather are listed specifically as possible physical thera-
direct them initially to a specific pattern, this does not pist approaches to achievement of the desired outcomes for
preclude therapists from changing to an alternative pattern the client. In all cases, education of the client or of supportive
if the examination information leads them to another conclu- personnel is included as part of the interventions listed
sion. It is also possible for a client to fit into more than one regardless of the selected practice pattern. Alternative inter-
pattern. In this case, the professional opinion of the therapist ventions listed under a particular pattern should not be inter-
directs the allocation of resources and time to the pattern of preted by the therapist as an indication to try one or two
highest priority. interventions and then move on to the next practice pattern
if the interventions do not work. Each intervention should
The practice patterns were developed using the Nagi be applied as appropriate to the client's responses, goals,
model4 and the patient management system previously needs, and projected outcomes. Nowhere in the Guide is it
described.1 This system includes six components. Each com- suggested that the interventions listed are the only ones
ponent in the patient management system is found in every appropriate to a particular practice pattern. As the reader will
practice pattern. The purpose of this format is to create a con- learn later in this book, however, application of the correct
sistent, uniform methodology for patient examination and intervention to the client with shoulder dysfunction has been
treatment. As depicted in Figure 1-3, each component of this found to improve the client's functional level and to reduce
system has specific supportive parts. Examination includes his or her overall impairment.
obtaining a history, review of systems (cardiopulmonary, mus-
culoskeletal, neuromuscular, and integumentary), choice and In few, if any, cases are the interventions of the physical
administration of tests, measurements of appropriate values, therapist directed solely toward the pathologic or pathophysi-
and identification of any need for referral to another ologic features of the client's medical condition. The Guide is
practitioner. a textbook for providing direction for physical therapists to
intervene at the level of impairment and functional limitation
Figure 1-4 provides an in-depth summary of the data that without the use of medication for the most part or surgical
can be gathered during client history taking. The evaluation interventions. Intervention also includes the need for the ther-
is the process of using the information obtained during the apist to interact with the rest of the medical community
examination to determine a diagnosis or need for referral. This involved in the client's care. This interaction requires coordi-
process continues throughout the client's contact with the nation and communication with, and documentation of, all
therapist and requires clinical judgment on a regular and rou- the physical therapist's clients.
tine basis. The diagnosis is a determination of which practice
pattern is a "best fit" for the previously gathered examination Inherent in the system of patient management is that at
and evaluation information. This physical therapist diagnosis any point during the client's treatment, the therapist is man-
relates directly to an impairment classification in the Nagi dated to provide re-examination. The re-examination should
model4 and should lead the therapist to determine the relative be performed periodically during an episode of care, to ensure
level of functional loss the client is experiencing. This infor- that the client is progressing according to his or her prognosis
mation, in turn, directs the therapist to the appropriate inter- and that short- and long-term goals are being achieved. Dur-
vention to obtain the optimal outcome for the client. ing re-examination, the patient management system steps are
repeated as in the original examination process.
The next component is the prognosis. This component also
includes the plan of care. The prognosis is a natural extension SUMMARY
of the diagnosis. Once the diagnosis has been made, the ther-
apist should begin to formulate a realistic prognosis and esti- Why is the Guide entitled Guide to Physical Therapist Practice
mate how much improvement in function can be achieved and not Guide to Physical Therapy Practice? That is the nature
given the amount of impairment suffered as a result of the of the document. It is intended to describe the scope, role,
disease. The logical progression of these interwoven formula- and spectrum of the physical therapist's activity. Why not
tions between the Nagi model and the patient management physical therapy? Because many other practitioners who are
system has been included in the Guide to create a continuum not physical therapists are legally allowed to provide and be
of care that leads to improved function or appropriate referral. reimbursed for physical therapy. The APTA believes that
physical therapy per se is well described within the Guide,
The plan of care is the culmination of all the steps previ- but physical therapy is really performed only by physical
ously listed and includes the client's goals, the short- and therapists. Therefore, the Guide correctly describes the physi-
long-term goals of the therapist, specific interventions, and cal therapists' diagnoses (practice patterns), tests and mea-
the projected outcomes of those interventions. Included sures, interventions, and responsibilities within the context
within the interventions and outcomes should be some of the Nagi model.4
6 Physical Therapy of the Shoulder
General Demographics Medical/Surgical History Current Condition(s)/
� Age � Cardiovascular Chief Complaint(s)
� Gender � Endocrine/metabolic � Concerns that led the
� Race/ethnicity � Gastrointestinal
� Primary language � Genitourinary patient/client to seek the services
� Education � Gynecological of a physical therapist
� Integumentary � Concerns or needs of
Social History � Musculoskeletal patient/client who requires the
� Cultural beliefs and behaviors � Neuromuscular services of a physical therapist
� Family and caregiver resources � Obstetrical � Current therapeutic
� Social interactions, social � Prior hospitalizations, surgeries, interventions
� Mechanisms of injury or disease,
activities, and support systems and preexisting medical and including date of onset and
other health-related conditions course of events
Employment/Work � Psychological � Onset and pattern of symptoms
(Job/School/Play) � Pulmonary � Patient/client, family, significant
� Current and prior work other, and caregiver expecta-
tions and goals for the therapeu-
(job/school/play), community, tic intervention
and leisure actions, tasks, or � Patient/client, family, significant
activities other, and caregiver perceptions
of patient's/client's emotional
Growth and Development response to the current clinical
� Developmental history situation
� Hand dominance � Previous occurrence of chief
complaint(s)
Living Environment � Prior therapeutic interventions
� Devices and equipment (eg,
Functional Status and
assistive, adaptive, orthotic, pro- Activity Level
tective, supportive, prosthetic) � Current and prior functional
� Living environment and
community characteristics status in self-care and home
� Projected discharge destinations management, including activities
of daily living (ADL) and instru-
General Health Status mental activities of daily living
(Self-Report, Family Report, (IADL)
Caregiver Report) � Current and prior functional
� General health perception status in work (job/school/play),
� Physical function (eg, mobility, community, and leisure actions,
tasks, or activities
sleep patterns, restricted bed
days) Medications
� Psychological function � Medications for current
(eg, memory, reasoning ability,
depression, anxiety) condition
� Role function (eg, community, � Medications previously taken for
leisure, social, work)
� Social function (eg, social current condition
activity, social interaction, � Medications for other conditions
social support)
Other Clinical Tests
Social/Health Habits � Laboratory and diagnostic tests
(Past and Current) � Review of available records (eg,
� Behavioral health risks
medical, education, surgical)
(eg, smoking, drug abuse) � Review of other clinical findings
� Level of physical fitness
(eg, nutrition and hydration)
Family History
� Familial health risks
Figure 1-4 Types of data that may be generated from a client history. (From American Physical Therapy Association: Guide to Physical Therapist
Practice, ed 2. Baltimore, 2003, APTA.)
The template for defining the body of knowledge of phys- REFERENCES
ical therapy has been produced in the Guide. The physical
therapist community has been challenged to provide the evi- 1. American Physical Therapy Association: Guide to physical thera-
dence to prove or disprove the usefulness of the interventions pist practice, ed 2 rev, Alexandria, Va, 2003, American Physical
provided within each practice pattern. The Guide has provided Therapy Association.
all physical therapists with a common language, a patient
management system, and an opportunity to develop definitive 2. American Physical Therapy Association: Guide to physical thera-
and reproducible methods of optimally improving impair- pist practice (website). http://guidetoptpractice.apta.org/. Accessed
ments and functional limitations of a physical therapist's cli- May 17, 2010.
ents. The Guide to Physical Therapist Practice is indeed a truly
epic document. 3. American Physical Therapy Association: House of Delegates Policies
2009, Page 32, line 8. http://www.apta.org/AM/Template.cfm?
Section�Policies_and_Bylaws1&TEMPLATE�/CM/Content
Display.cfm&CONTENTID�67833. Accessed October 28, 2010.
Chapter 1 The Guide to Practice 7
4. Nagi S: Disability and rehabilitation, Columbus, Ohio, 1969, 6. Jette AM: Physical disablement concepts for physical therapy
Ohio State University Press. research and practice, Phys Ther 74:381, 1994.
5. Guccione AA: Physical therapy diagnosis and the relationship 7. American Physical Therapy Association: Standards for tests
between impairments and function, Phys Ther 71:499�504, and measurements in physical therapy practice, Phys Ther
1991. 71:589�622, 1991.
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[Cuối tài liệu]
Index 471
etiology of, 245�248, 246b Rotator interval
glenohumeral joint ROM measurement for, 252�254, anatomy of, 219�222, 219f
shoulder instability and, 219�222
252f case study on, 220b
impingement tests for, 254 test for, 220, 220f
instability tests for, 254
Lachman test of the shoulder for, 255 Rowing exercise, 344�345, 344f
muscular strength testing for, 254, 254f RVM. See Rostral ventromedial medulla
rehabilitation of, 256�264
S
biomechanical concepts for, 255�256, 255f Saccades
promotion of muscular strength balance/local muscular
gap effect and, 152
endurance, 257�260, 258f, 259f, 260f vision and, 150
reduction of overload and total arm rehabilitation, Same side pull, 54f, 57t
Sarcomeres, 383
256�257, 256f SAT. See Scapular assistance test
restoration of normal joint arthrokinematics SC. See Sternoclavicular joint
Scalenus medius muscle, 98
for, 257 Scaption: external rotation (core 1), 48t, 50f
scapular examination for, 249�252 Scapula. See also Plane of the scapula
shoulder evaluation for, 249�255 antetilting of, 250
supraspinatus and, 248 closed chain exercises (ball on wall) for, 257�258,
Rotator cuff interval, 13
Rotator cuff muscles, 15 259f
degeneration of, 189 flip sign for, 251, 252, 252f
exercise patterns for, 257, 258f force couple of, 187
force couple of deltoid muscle and, 255�256, 255f
forces produced by, 15�16 muscles acting at, 17, 18f
friction massage therapy for MTrPs at, 363�364, 363f rotators of, 17, 18f
glenohumeral joint stabilization with, 245 glenohumeral joint instability of and abnormalities of,
impingement and, 188, 188f
shoulder arthroplasty rehabilitation and 226�227
ICR of, 18�19
good, 451�453 impingement and, 187�188
poor/repaired, 454 inferior angle scapular dysfunction, 250, 250f
SWT for MTrPs at, 370, 371f injury patterns of, 35�36
tearing of, classification based on diameter for, 192t medial border scapular dysfunction, 250, 250f
weakness in, 84 medial tilting angle of, 9
Rotator cuff repair, 400�403 movements of, 17, 19f
arthroscopy assisting, 400�401, 400f, 401f posterior, massage therapy for MTrPs at, 362�363,
case studies for, 404b, 405b
results of, 403�407 362f
superior-lateral incision in, 401, 402f posture impacting, 94
V-Y repair, 402, 402f rhomboid muscles length impacting, 330, 330f, 331f
Rotator cuff tears. See also Rotator cuff injury rib cage's relationship to, 91f, 92
anatomic description of, 248�249 roles of, 31
case studies on, 404b, 405b rotator cuff disease in athletes and role of, 198
causes of, 397 rotator cuff injury and examination of, 249�252
calcific tendinitis, 397, 399f SAT for, 251�252, 251f
fraying, 397�398, 399f scoliosis affecting spine and, 94
inferior spurs, 397, 399f serratus anterior muscle and, 198
diagnosis of, 398�400 SICK, 32, 32f, 187
arthrography for, 398�399, 399f
arthroscopy for, 400, 400f pain from, 32
MRI for, 399, 399f symptoms of, 32
etiology of, 397�398, 398f, 399f SRT for, 251, 252, 252f
full-thickness, 248�249 strength exercises for, 339�347
impingement syndrome and, 397�398, 398f strength training for, 389�392
interstitial/intratendinous, 249 superior scapular dysfunction, 250, 250f
partial-thickness, 249 throwing injuries and
rehabilitation of asymmetric malposition of, 31�32
factors influencing results of nonoperative, 261 mobilization of, 38�40
surgical approach to, 260�261 Scapula circles, 48t, 49f
surgical procedure for, 261 Scapular assistance test (SAT), 251�252, 251f
treatment of, 400�403 Scapular depression
nonoperative, 400 bilateral, 48t, 53f
operative, 400�403 seated exercises, 43t, 44f
unilateral, 48t, 52f
472 Index
Scapular distraction, 324�325, 325f Shock wave therapy (SWT), for MTrPs, 370
posterior approach to, 325, 325f rotator cuff, 370, 371f
prone, 326, 326f
Short head of biceps (SHB), 14, 15
Scapular dyskinesis, 187 Shortness of breath (SOB), 277
Scapular elevation Shoulder. See also Abduction of shoulder; Frozen shoulder;
internal rotation: prone, 40t, 42f Interrelationship of spine, rib cage, shoulder; Visceral
seated exercises, 43t, 44f disease, referred pain to shoulder
unilateral, 48t, 52f anatomy of, 411�414
Scapular external rotation, 325, 325f biomechanics of, 413�414
Scapular plane. See Plane of the scapula girdle region, 88f
Scapular protraction exercises, 340 strength exercises for, 339�347
Scapular protraction/retraction, 43f, 43t latissimus dorsi muscle causing dysfunction of, 113
side lying manual, 256�257, 256f lumbar spine causing dysfunction of, 113�126
Scapular retraction test (SRT), 251, 252, 252f mobility of, 9
Scapular stabilizing exercises, 452f negative tests with, 118
Scapular taping, 159 nonprotective injuries of, case study of, 314b, 315t, 317t
Scapular winging, 226, 249�250 pelvic tissues causing dysfunction of, 113�126
Scapular-cervical mobilization, 365�366, 366f positive tests with, 118
Scapular-thoracic soft tissue manipulation, 365, posterior dominant, 259
protective injuries of, case study of, 311b, 311t, 314t
365f rib cage interrelationship with
Scapulohumeral muscles, 15, 329. See also Infraspinatus; biomechanical, 92
bones and, 91�92
Subscapularis muscle; Teres major muscle; Teres fascia and, 91
minor muscle musculoskeletal, 87�92, 90f
muscle length assessment of, 333f ribs/rib cage injuries referring pain/dysfunction to,
Scapulohumeral rhythm ratio, 226 112�113
Scapulothoracic joint, 9, 92 rotator cuff injury and evaluation of, 249�255
AC joint and, 17 sensory integration and NMC of, 148�154
Schwannomas, 171 somatosensory sensation and, 148�149
Scientific therapeutic exercise progressions (STEP), 124 vestibular sensation and, 153�154
SCM. See Sternocleidomastoid muscle vision and, 149�152
Scoliosis, scapula/spine affected by, 94 vision and reaching with, 151�152
SDN. See Superficial dry needling visual impairment's relevance to, 150�151
Seated dips (core 5), 48t, 52f spine interrelationship with
Seated exercises biomechanical, 92
scapular depression/elevation, 43t, 44f musculoskeletal, 87�92, 88f, 90f
scapular protraction/retraction, 43f, 43t musculoskeletal syndromes involving, 101�102
Secondary compressive disease, 246 neurologic, 96�98
Secondary frozen shoulder, 232 occupational, 95
Secondary impingement. See Rotator cuff disease postural, 92�94
Secondary tensile overload, 195�196 stabilizers of, 411�413
Semicircular canals, 152�153, 153f active (dynamic), 413
Sensory integration static (passive), 411�413
definition of, 147 synchronous mobility for, 413
NMC of shoulder and, 148�154 strength exercises for
somatosensory sensation and, 148�149 external rotation, 341, 342f
vestibular sensation and, 153�154 internal rotation, 341�343, 343f
vision and, 149�152 thoracic disk referring pain to, 109�110
vision and reaching with, 151�152 thoracic facet joints referring pain to, 110�112, 111f
visual impairment's relevance to, 150�151 thoracic nerves referring pain to, 110, 111f
Serratus anterior muscle thoracic spine referring pain to, 109�112
anatomy/origin of, 88f, 91 Shoulder arthroplasty
lift exercise for, 389t, 391f acute fractures and, 445
medial, TrP-DN for MTrPs at, 369, 369f arthritis of dislocation and, 443
muscle length assessment of, 330f, 331 avascular necrosis and, 443, 444f
push-up plus for, 340, 340f clinical considerations for, 439�446
scapula and, 198 examination for, 440
STM and history, 439�440
lower portion, 324, 324f ROM as, 440
upper portion, 324, 324f cuff tear arthropathy and, 444�445
strength tests for, 73t, 75f, 337, 338f history of, 439
SHB. See Short head of biceps
Shingles, 136
Index 473
osteoarthritis and, 441�442, 441f SLAP lesions and, 214�219, 416�417, 418f
post-traumatic arthritis and, 445�446 case study on, 216b
rehabilitation after, 446�449, 451 compressive force causing, 215
nonoperative management of, 216
categories of, 446 postoperative treatment for, 216�219
critical points and technique of, 446�449, 446f, 447f,
surgical intervention for, 424�425, 426t
448f, 449f terminology of, 207
good rotator cuff and deltoid, 451�453 treatment for
limited goals program, 455
poor/repaired rotator cuff and deltoid, 454 course of, 420�421
reverse prosthesis, 455 decision-making process for, 419�421
reverse, 444�445 decision-making process for conservative, 421�424
rheumatoid arthritis and, 442�443, 442f diagnosis defined in, 419�420
Shoulder dystocia, 170 Shoulder joint complex, components of, 9, 10f
Shoulder elevation Shoulder Pain and Disability Index (SPADI), 69�70,
definition of, 17
final phase, 140-180, 20�21 175�176
initial phase, 0-60, 17�19 Shoulder shrugs, 48t, 49f
middle (critical) phase, 60-100, 19�20, 19f, 20f
PTs examining, 70, 70f muscle test, 336�337, 338f
rotation of humerus for, 12 strength exercises using, 345, 345f
summary of, 21 SICK scapula, 32, 32f, 187
Shoulder external rotation on bent knee, 389t, 390f pain from, 32
Shoulder impingement. See Impingement symptoms of, 32
Shoulder instability Side lying external rotation, 48t, 52f
Bankart surgical stabilization for, 209 Side lying manual scapular protraction, 256�257, 256f
Bankart's lesion and, 208, 209f, 416, 417f Simons, David, 351�352
Bankart's repair for, case study of, 210b Simple Shoulder Test (SST), 175�176, 234
causes of, 207 Sitting posture, 93, 94f
classification of, 414�418, 414t SLAP lesions. See Superior labrum anterior to posterior
CT for, 419, 421t Sleeper stretch, 260, 260f
examination for, 418�419, 419t, 420t Sliding filament theory, 354�355
Hill-Sachs lesion and, 208, 209f, 417 Smooth pursuits, 150
history for diagnosis of, 418�419 Snapping scapula syndrome, 102
MDI, 418 SNS. See Sympathetic nervous system
MRI for, 419, 421t SOB. See Shortness of breath
muscle mechanics and, 213�214 Soft tissue mobilization (STM), 120�121, 121f, 306.
NMC in rehabilitation of, 424, 424f
open Bankart's repair for, 209�213 See also Mobilization
open inferior capsular shift for, 223�226 definition of, 322
case study on, 224b inferior clavicle and, 324, 324f
operative technique in, 223�226, 224f pectoralis minor muscle and, 323, 323f
pathophysiology of, 415t serratus anterior muscle and
posterior, 222�223
examinations/symptoms of, 223 lower portion, 324, 324f
rehabilitation of, 223 upper portion, 324, 324f
reverse Hill-Sachs lesion from, 222�223 subscapularis and, 322�323, 322f
radiography for, 419, 421t arc stretch, 323, 323f
recurrent, 415�418 side-lying, 323, 323f
rehabilitation of, 425�436 techniques for, 322b
anterior capsulolabral reconstruction, 428t teres major and, tilt stretch, 323, 323f
anterior stabilization, 425�434 Somatic pain, 267�268
Bankart's repair, 425�426, 429t Somatosensory sensation
errors in, 436 Golgi tendon organs and, 148�149, 149f
general principles of, 427�434 sensory integration, NMC of shoulder and, 148�149
multidirectional instability: capsular shift procedures, muscle spindles and, 148, 148f
SPADI. See Shoulder Pain and Disability Index
431t, 435�436 Speed's test, 77t, 78f
posterior stabilization, 435, 435t dynamic, 77t, 78f
thermal-assisted capsulorrhaphy for patients with Spine. See also Interrelationship of spine, rib cage, shoulder
in ADL, 92
acquired laxity, 433t anatomy of, 96, 96f
rotator interval and, 219�222 cancer of, 274
scoliosis affecting scapula and, 94
case study on, 220b shoulder interrelationship with
test for, 220, 220f biomechanical, 92
musculoskeletal, 87�92, 88f, 90f
474 Index
Spine (Continued) latissimus dorsi muscle, 73t, 74f, 336, 337f
musculoskeletal syndromes involving, 101�102 lower trapezius muscle, 73f, 73t, 337, 338f
neurologic, 96�98 middle trapezius muscle, 73f, 73t, 337, 338f
occupational, 95 pectoralis major, 336, 337f
postural, 92�94 rhomboid muscles, 73t, 74f, 337, 338f
rotator cuff injury, 254, 254f
Splinting, brachial plexus injury examinations for, 176, 176f serratus anterior muscle, 73t, 75f, 337, 338f
Spray and Stretch (S&S), 366�367 shoulder girdle, 339�347
SRT. See Scapular retraction test subscapularis, 335�336, 335f, 336f
S&S. See Spray and Stretch suprascapularis, 73t, 75f
SST. See Simple Shoulder Test supraspinatus, 334�335, 335f
Stability ball teres major muscle, 73f, 73t, 336, 337f
teres minor muscle, 73t, 74f, 335, 335f
dynamic hug, 57f, 57t upper trapezius muscle, 336�337, 338f
horizontal abduction with 90/90, 56f, 57t Strength training, 381
Standards for Tests and Measurements in Physical Therapy aging/muscle changes and, 384�385
cellular adaptations to, 382�383
Practice, 3�4 clinical application of, 386�387
Standing posture, 92, 93f concentric strengthening, 386
Static progressive stretching, 242, 242f eccentric strengthening, 385�386
STEP. See Scientific therapeutic exercise progressions explosive, 388
Sternoclavicular joint (SC), 9, 16�17, 16f gender differences in, 385
glenohumeral joint and, 389�392
manual therapy techniques for, 321�322 hormonal responses during, 384
inferior-posterior glide of, 321, 321f hypertrophy v. hyperplasia, 383
superior glide of, 321, 321f isometric strengthening, 386
mechanical changes in passive/dynamic muscle stiffness
Sternocleidomastoid muscle (SCM), 88, 90f
anatomy/origin of, 88�89, 90f during, 383�384
muscle actions for, 381�382
Stiff painful shoulder syndrome, 136
Stiffness, muscle, 383�384 adaptations of, 385�386
STM. See Soft tissue mobilization concentric, 382
Stomach eccentric, 381�382
isometric, 382
cancer of, 279 neural adaptations to, 382
visceral disease referred pain to shoulder from, 279 scapula and, 389�392
Strabismus (crosseye), 150�151 tendon/connection tissue changes during, 384
Strength, 381 variables of, 387�388
Strength exercises Stress relaxation stretching, 242, 242f
abduction of shoulder Stretch reflex, monosynaptic, 147�148
Stretch-shorten cycle, 381�382
horizontal, 343�344, 344f Stroke, 151
in POS, 340�341, 340f, 341f Subacromial space, 245
decline bench press, 339 Subclavius muscle, 88f, 91
diagonal shoulder exercise Subluxation, 414�415
with extension-adduction-medial rotation, 346, 346f Subscapular lift exercise, 389t, 391f
with flexion-adduction-lateral rotation, 346�347, Subscapular nerve, 98
Subscapularis muscle, 15
346f anatomy of, 83�84
dumbbell fly, 344 lateral, TrP-DN for MTrPs at, 368�369, 368f
glenohumeral joint, 339�347 medial, TrP-DN for MTrPs at, 369, 369f
horizontal bench press, 339 muscle length assessment of, 333, 333f
incline bench press, 339, 339f stabilization from, 214
for MTrPs, 370�372 STM for, 322�323, 322f
press ups, 345, 345f arc stretch, 323, 323f
pull-downs, 346, 346f side-lying, 323, 323f
push-ups, 345 strength tests for, 335�336, 335f, 336f
rowing, 344�345, 344f TPCR for MTrPs at, 360, 360f
scapula, 339�347 trigger points within, 84
scapular protraction, 340 Subscapularis syndrome, 83
shoulder girdle, 339�347 Sulcus sign test, 76f, 76t
shoulder rotation Superficial dry needling (SDN), 367
Superior glenohumeral ligament, 13�14
external, 341, 342f
internal, 341�343, 343f
shoulder shrugs, 345, 345f
upper extremity weight-bearing exercises, 347
Strength tests, 73�76
deltoid muscle, 336
posterior, 336, 337f
infraspinatus, 73t, 74f, 335, 335f
Index 475
Superior labrum anterior to posterior lesions (SLAP lesions) Thoracic kyphosis, 93, 94
arthroscopic repair for, 65 Thoracic motion, 71
week 1: acute stage, 65�66 Thoracic nerves, shoulder pain referred from, 110, 111f
weeks 2-3: stitches removed, 66 Thoracic outlet, 32
weeks 4-6: subacute phase: discontinue sling, 66
weeks 6-12: intermediate program, 66�67 effort thrombosis in abnormal, 277
weeks 13-18: strengthening phase, 67 tumors of, 136
weeks 18-24, 67 Thoracic outlet syndrome
weeks 24 plus, 67 arterial occlusion and, 276
classification of, 215�216, 215f axillary arch and, 165
Morgan-Burkhart peel-back model for, 215 tests on, 293
shoulder instability and, 214�219, 416�417, 418f Thoracic spine
case study on, 216b CT of, 109�110
compressive force causing, 215 negative tests for, 119
nonoperative management of, 216 positive tests for, 118�119
postoperative treatment for, 216�219 shoulder and pain from, 109�112
throwing injuries and, 29�31 Thrombophlebitis, 277, 277f
signs of, 277
Superior scapular dysfunction, 250, 250f symptoms of, 277
Supraclavicular lesion, 167�168 Throwing athletes
Suprahumeral space, impingement syndrome and, 185, 186f arthroscopic repair for SLAP lesion, 65
Suprahyoid muscles, 89, 90f hyperangulation and, 247�248, 248f
Suprascapularis, strength tests for, 73t, 75f Throwing injuries, 25�68. See also Overhand throwing
Supraspinatus
injuries
glenohumeral joint compression and, 213�214 asymmetrical scapular malposition, 31�32
rotator cuff injuries and, 248 from baseball, 25
strength tests for, 73t, 75f, 334�335, 335f
TPCR for MTrPs at, 359�360, 359f in youth leagues, 25�26
Supraspinatus test, 192f essential-essential lesion, 35
SWT. See Shock wave therapy glenohumeral capsule and, 28�29
Sympathetic nervous system (SNS), 98�99 measurements for, 36�38
role of, 101 nine-level rehabilitation program for, 65
posterior shoulder tightness, 32�35
T preventive protocol for, 35�36
Table top exercises, 43�44 scapula mobilization and, 38�40
Tape technique, 159 SLAP lesions, 29�31
TBI. See Traumatic brain injury Tinel's sign, 175
Temporomandibular joint (TMJ), 102 TMJ. See Temporomandibular joint
Tendinitis Total rotation range-of-motion concept, 253�254
Total shoulder replacement. See Shoulder arthroplasty
calcific, 397, 399f TPCR. See Trigger point compression release
primary compressive disease stage with, 246 Traditional anterior approach to surgery, 246
Tendinosis, 246�247 Transcutaneous electrical nerve stimulation (TENS), 370
Tendon failure, macrotraumatic, 247 Transversus abdominis, 113�126
Tendon rupture, primary compressive disease stage with, 246 Trapezius muscle
TENS. See Transcutaneous electrical nerve stimulation anatomy/origin of, 87, 88f
Tensile overload lower, strength tests for, 73f, 73t
primary, 195 middle, strength tests for, 73f, 73t
rotator cuff injury and, 246�247 muscle length assessment of, 330, 330f
secondary, 195�196 upper
Teres major muscle
muscle length assessment of, 332f, 333 strength tests for, 336�337, 338f
STM, tilt stretch, 323, 323f TPCR for MTrPs at, 360, 360f
strength tests for, 73f, 73t, 336, 337f Traumatic, Unidirectional Bankart Surgery (TUBS), 419
Teres minor muscle Traumatic brain injury (TBI)
muscle length assessment of, 333, 333f mild, 151
strength tests for, 73t, 74f, 335, 335f vision and, 151
TPCR for MTrPs at, 359, 359f Travell, J. G., 351�352
Thera-Band resistance exercises, 449f Triceps extension, 389t, 392f
Thermal-assisted capsulorrhaphy for patients with acquired Trigger point compression release (TPCR), for MTrPs, 357,
laxity, 433t 358�361
Thoracic disk, referring pain to shoulder, 109�110 infraspinatus and teres minor, 359, 359f
Thoracic facet joints, referring pain to shoulder, 110�112, levator scapulae, 361, 361f
locating muscles in, 358�359
111f pectoralis minor muscle, 361, 361f
476 Index
Trigger point compression release (TPCR), for MTrPs function of, 152�154
(Continued) NMC tests with, 156�157
subscapularis, 360, 360f HTT for, 156�157, 157f
supraspinatus, 359�360, 359f sensory integration, shoulder NMC and, 153�154
upper trapezius muscle, 360, 360f Video games, 159�160, 160f
Trigger point dry needling (TrP-DN) Virtual reality, 159�160, 160f
for MTrPs, 367�369 Visceral disease
orthopedic dysfunction from, 267�268
infraspinatus, 368, 368f orthopedic evaluation for, 268, 268b
lateral subscapularis, 368�369, 368f patient questionnaire for, 268�269, 269f
medial subscapularis/lateral aspect of rhomboids/medial referred pain to shoulder, 267�304
serratus anterior, 369, 369f case studies of, 280b, 285b, 289b, 294b, 298b, 314b
superficial, 367 elderly and, 271
Trigger point intramuscular manual therapy. See Trigger point theories on, 271
screening for, 267
dry needling sites of referred pain to shoulder, 271�280
Trigger points. See Myofascial trigger points colon, 280
Tropomyosin, 382 diaphragm, 271�272, 272f
Troponin, 382 esophagus, 274�275
Trunk lesions, 168 gallbladder, 278
TUBS. See Traumatic, Unidirectional Bankart Surgery heart, 275�276, 275f
Tumors kidney, 279
large intestine, 280
of brachial plexus, 171 liver, 277�278
MPNSTs, 171 lung, 273�274
Pancoast's tumor, 110 pancreas, 278
pneumoperitoneum, 272�273, 273f
signs of, 274 stomach, 279
symptoms of, 274 vascular system, 276�277
of thoracic outlet, 136 Vision
foveal, 150
U MTBI and, 151
Ulcerative colitis, 280 NMC of shoulder, sensory integration and, 149�152
Ulnar nerve, 136 reaching and, 151�152
Ultrasound visual impairment's relevance to, 150�151
NMC tests with, 156�157
low-intensity pulsed, 369�370 Brock string test, 156, 157f
for MTrPs, 369�370 orthopedists demands of, 149�150
Undersurface impingement. See Posterior impingement process of, 149
Unilateral rowing exercise, 344�345, 344f saccades and, 150
Upper extremity conditioning protocol, off-season, 61 smooth pursuits and, 150
weeks 1-5 (block one), 61, 62t TBI and, 151
weeks 6-10 (block two), 61, 62t Visual Analog Scales (VAS), 234
week 11 (recovery week), 61, 63t Volumetrics, 175
weeks 12-16 (block three), 61, 64t VOR. See Vestibular ocular reflex
week 17, 61, 65t
week 18, 61�64, 65t W
Upper extremity weight-bearing exercises, 347 Wall exercises, 44�46, 44f, 45f, 46f
Upper quarter pain, 132�135 Wall push, 44t, 46f
PTs treating, 135 Wall slide, 44t, 341, 341f
Upper trapezius muscle
strength tests for, 336�337, 338f with arms overhead, 333, 345f
TPCR for MTrPs at, 360, 360f with terminal elevation, 453f
Upper trunk lesion, 168 Weight shift with scapular movement, 43f, 43t
Upward/downward rotation stretch: side lying, 38t, 39f "Wiihab," 159�160, 160f
Windup, overhand throwing injuries and, 26
V Within normal limits (WNL), 102
VAS. See Visual Analog Scales WNL. See Within normal limits
Vascular system, visceral disease referred pain to shoulder Women's Physiotherapy Association, 1
from, 276�277 Y
Ventral rami, 96 Yocum's test for impingement, 79f, 79t
Ventral root, 96, 96f
Vergence, 150
Vestibular ocular reflex (VOR), 150
HTT for, 156�157, 157f
Vestibular sensation
apparatus of, 153f