The human sensory system is designed to give us the information we need to manage the challenges of the world. We take in vast amounts of information every minute of the day, much of it not relevant, the brain deciding what is important and what is not. We are familiar with vision, hearing and touch and consciously and unconsciously use the incoming information to guide our actions and responses in daily life. However, there are two more sensory input systems, related to the others, which are vital to normal functioning. These are the sensory feedback we get from our bodies and the joint position sense.

Profound loss of sensory input is more common than we think as it happens every time we get a numb, dead feeling arm when we wake up. When I woke up with my arm completely numb I moved if off my chest grumpily twice until I began to understand, by feeling the arm gradually from the elbow up, that it was my own arm I was trying to get rid of. The loss of sensibility was so great that as far as I was concerned the arm did not exist and therefore must have belonged to someone else. Without our sensory input we are limited in our abilities.

In my work as a physiotherapist I have treated all kinds of conditions and some of these interactions were very instructive. A patient who had had a stroke got hold of my hand and moved it back and forth, bending and straightening the fingers and stretching the wrist. Suddenly I realised that he thought it was his arm! He could feel nothing from his own arm when he did the same movements to it, so moving my arm seemed entirely natural until he looked more closely at it and realised it wasn’t his. The next time you get a dead arm in bed, try and move it. Apart from feeling unpleasant, the limb is extraordinarily difficult to move, it feels right out of control and just lies there despite you willing it to move.

Sensory input, the constant incoming signals to the brain from the various parts of the body, informs us what is going on and where we are in space. This is much more important than we realise. Losing muscle power is difficult but people adapt and manage well but losing sensory information from a body part makes it extremely difficult or impossible to use the part. Losing sensibility is more troublesome than losing muscle power, although both are important.

In stroke we see the lack of movement easily, what we don’t see is the underlying sensory abnormality which may be partly or wholly responsible for the disability. Joint position sense (JPS), also called proprioception, is the body sense which indicates to our brain where our joints are at all times. The sense also tells us what state our joints are in such as what angle they are at, what muscular effort is being exerted and in which direction the effort is being expended.

The positions of our joints are constantly being monitored by the integrative centre of our brain, fed by the sensory input of our JPS. Without this stream of input we can’t understand the position of our joints and limbs and so are unable to plan what action to take next. Planning the next movement we want to depend on the ability to have accurate information coming in from the JPS.

Losing the sense of feeling our body parts accurately is fundamentally important to our ability to manage independent movement in our daily lives. Paraplegia, stroke and direct nerve trauma can cause loss of proprioception but lesser injuries can reduce this sense also. Anterior cruciate ligament rupture or even an ankle sprain can reduce the precision of the JPS and make treatment advisable. Physiotherapy rehabilitation skills are used to develop increased proprioception in many conditions and both stroke and sports therapists must be equally aware of its importance.



By: Jonathan Blood-smyth

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The function of the human arm is to allow placement of the hand in useful positions so the hands can perform activities where the eyes can see them. Because of the huge range of positions required the shoulder is very flexible with a large motion range, but this is at the expense of some reduced strength and greatly reduced stability. A “soft tissue joint” is often a description of the shoulder, indicating it is the tendons, muscles and ligaments which are important to the joint’s function. Shoulder treatment and rehabilitation is a core physiotherapy skill.

The shoulder joint is constructed from the socket of the scapula and the humeral head, the ball at the top of the upper arm bone. The head of the upper arm is a large ball and important tendons insert onto it to move and stabilise the shoulder, but the shoulder socket, the glenoid, is small in comparison and very shallow. A cartilage rim, the labrum of the glenoid, deepens the socket and adds to stability. The acromio-clavicular joint lies above the shoulder joint proper and provides dynamic stability during arm movements, being made up from part of the scapula and the outer end of the clavicle.

The major stability and flexibility joints of the upper limb shoulder girdle are the scapulothoracic and glenohumeral joints and these joints are held steady and moved by large and powerful muscles. The pectoralis major and latissimus dorsi muscles stabilise and perform strong movements, the serratus anterior stabilises the scapula on the thorax, the rotator cuff stabilises the humeral head on the socket and the deltoid and other muscles perform movements. The shoulder blade and thorax need to be kept in a stable relationship for the glenohumeral joint to perform precise and controlled movements.

Around the shoulder all the muscles narrow down into flat, fibrous tendons, some larger and stronger, some thinner and weaker. All these tendons are anchoring themselves to the humeral head, allowing their muscles to act on the shoulder. The rotator cuff includes a group of relatively small shoulder muscles, the subscapularis, the supraspinatus, the infraspinatus and the teres minor. The tendons form a wide sheet over the ball, allowing muscle forces to act on it. The rotator cuff, despite its name, acts to hold the humeral head down on the socket and allow the more powerful muscles to perform shoulder movements.

With age, small degenerative tears occur in the tendons of the cuff, in some cases painful and in others not, causing loss of movement and strength. As tears progress they can become massive, cutting off the cuff muscle power from the humeral head and severely reducing function. Rotator cuff strengthening work is performed by physiotherapists and if the tears are severe they concentrate on anterior deltoid strength to improve functional ability in the absence of cuff power. Shoulder surgeons can repair many rotator cuff tears and physiotherapists rehabilitate patients following the shoulder protocols.

Osteoarthritis (OA) more commonly affects the hips and the knees, however the shoulder can be severely affected in which cases physiotherapy can help with advice, mobilisation of the joints and work on strength and joint motion. Once physiotherapy treatment has been tried then total shoulder replacement is the only remaining treatment option, surgical replacement occurring of the head of the arm bone and the socket of the shoulder blade. As the shoulder is referred to as a “soft-tissue joint” it is the balance and strength of the tendons, muscles and ligaments that determines a good outcome for the replacement. Physiotherapists closely follow the surgical protocols to get the optimal results.

Physiotherapists treat many other types of shoulder problems such as impingement, tendinitis, hypermobility, abnormal muscle patterning, fractures and dislocations. Impingement is treated by strengthening the rotator cuff or by subacromial injection or acromioplasty operation, where the end of the acromion can be excised. Tendinitis is treated by direct treatment of the tendon and graded strengthening and hypermobility by stability work and accepting the limitations dictated by the condition. Abnormal muscle patterning is managed by teaching normal patterns functionally and fractures and dislocations by the protocols laid down by the surgeons and trauma physiotherapists.



By: Jonathan Blood-smyth

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The human sensory system is designed to give us the information we need to manage the challenges of the world. We take in vast amounts of information every minute of the day, much of it not relevant, the brain deciding what is important and what is not. We are familiar with vision, hearing and touch and consciously and unconsciously use the incoming information to guide our actions and responses in daily life. However, there are two more sensory input systems, related to the others, which are vital to normal functioning. These are the sensory feedback we get from our bodies and the joint position sense.

Profound loss of sensory input is more common than we think as it happens every time we get a numb, dead feeling arm when we wake up. When I woke up with my arm completely numb I moved if off my chest grumpily twice until I began to understand, by feeling the arm gradually from the elbow up, that it was my own arm I was trying to get rid of. The loss of sensibility was so great that as far as I was concerned the arm did not exist and therefore must have belonged to someone else. Without our sensory input we are limited in our abilities.

In my work as a physiotherapist I have treated all kinds of conditions and some of these interactions were very instructive. A patient who had had a stroke got hold of my hand and moved it back and forth, bending and straightening the fingers and stretching the wrist. Suddenly I realised that he thought it was his arm! He could feel nothing from his own arm when he did the same movements to it, so moving my arm seemed entirely natural until he looked more closely at it and realised it wasn’t his. The next time you get a dead arm in bed, try and move it. Apart from feeling unpleasant, the limb is extraordinarily difficult to move, it feels right out of control and just lies there despite you willing it to move.

Sensory input, the constant incoming signals to the brain from the various parts of the body, informs us what is going on and where we are in space. This is much more important than we realise. Losing muscle power is difficult but people adapt and manage well but losing sensory information from a body part makes it extremely difficult or impossible to use the part. Losing sensibility is more troublesome than losing muscle power, although both are important.

In stroke we see the lack of movement easily, what we don’t see is the underlying sensory abnormality which may be partly or wholly responsible for the disability. Joint position sense (JPS), also called proprioception, is the body sense which indicates to our brain where our joints are at all times. The sense also tells us what state our joints are in such as what angle they are at, what muscular effort is being exerted and in which direction the effort is being expended.

The positions of our joints are constantly being monitored by the integrative centre of our brain, fed by the sensory input of our JPS. Without this stream of input we can’t understand the position of our joints and limbs and so are unable to plan what action to take next. Planning the next movement we want to depend on the ability to have accurate information coming in from the JPS.

Losing the sense of feeling our body parts accurately is fundamentally important to our ability to manage independent movement in our daily lives. Paraplegia, stroke and direct nerve trauma can cause loss of proprioception but lesser injuries can reduce this sense also. Anterior cruciate ligament rupture or even an ankle sprain can reduce the precision of the JPS and make treatment advisable. Physiotherapy rehabilitation skills are used to develop increased proprioception in many conditions and both stroke and sports therapists must be equally aware of its importance.



By: Jonathan Blood-smyth

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The rotator cuff is a musculotendinous cuff which surrounds the humeral head and through which the shoulder stabilising and movement muscles exert their forces onto the shoulder. The cuff enables us to put our shoulder through a very large range of motion, the greatest range of any joint in the body, for the purpose of putting our hands in functional positions. The shoulder’s function is to allow our hands to be put in useful positions within our visual field so we can perform the intricate activities that define being human to a degree.

As the muscles approach their insertions on the humeral head they become more and more fibrous until they become wholly tendinous. Many bodily tendons are cylindrical and long but the shoulder tendons are flatter structures which coalesce over the top of the humeral head. The rotator cuff has a relatively poor blood supply and little or no ability to heal and with time and physical stresses tears appear which are often painful but not always so. Rotator cuff tears are a major part of a shoulder surgeon’s work and rotator cuff surgery is common, complex and demands detailed physiotherapy follow up for successful outcomes.

Many causes of rotator cuff tears have been postulated by there is no agreed single cause, with competing ideas which favour external factors to the tendon and its rival which favours internal degeneration of the tendon itself. The leading shoulder surgeon Neer named impingement syndrome as a condition where the shoulder tendons are repeatedly stressed against the anatomical structures which overlie them. These structures include the acromio-clavicular joint and the front of the acromion, the outside end of the shoulder blade. The supraspinatus tendon can be compressed regularly as the shoulder goes into repetitive flexion and medial rotation,

The natural anatomical shape of our acromion plays a role in the likelihood of us having impingement type problems and therefore the tendency to get cuff tears. X-ray studies have shown that a hooked acromion is strongly related to the development of cuff tears although a proven causal link is not yet clear. The acromioclavicular joint develops degenerative outgrowths on its underside and the underlying cuff tendons are pressed against this area on repetitive movement. Repeated overhead work in younger people can cause bleeding and oedema in the tendon, with inflammation and scarring of the tendon after many such small injuries. With time in patients older than forty years complete or partial tears and bony spurs can develop.

A third impingement type can occur in throwing as the arm is cocked back for the throw and the edge of the glenoid socket can be forced repeatedly against the lower surface of the supraspinatus tendon. Minor trauma is produced each time this occurs, gradually developing into small tears particularly in athletes who throw a lot. The biceps and supraspinatus tendons and the lesser tuberosity impinge against the coracoid process. Most rotator cuff tears are probably contributed to by these three impingement process.

The intrinsic view holds that the external factors may be contributory but that the fundamental underlying process is age-related degeneration inside the tendons themselves. This helps explain why young people rarely suffer cuff tears and that tears increase strongly with age, for example after fifty years old. Under the supraspinatus tendon near to its insertion onto the greater tuberosity is an area which has been called the critical zone and postulated to have a poor vascular supply. This could increase the risk of injury and poor healing in this area but further studies have not confirmed this idea so degenerative changes in the tendons may still be important.

It is likely that the cause of rotator cuff degeneration is a combination of both extrinsic and intrinsic causes, with the tendon tending to fail first in the areas of greatest load, leading to rupture of small tendon fibres. This causes increased forces being loaded onto close fibres, detachment of some fibres from bone, reduction in cuff power and compromised blood supply due to kinked fibres. Wound healing could be reduced and this would impair the possibility of repair.



By: Jonathan Blood-smyth

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If you are a family member who deals with another’s mental illness, chances are your life can get very full and often confusing. I hope this article about healthy boundaries helps.

OK, so your life has changed. Things are a bit different after the diagnosis of a family member’s illness. It could be a daughter with bi-polar, a husband with clinical depression or your own sudden experiences with panic disorder. These circumstances happen every year to millions of Americans and family members — the “affected others” — need to adjust and compensate for this new situation.

Presumably, if you are an affected other, you have the professional medical support you need to help your loved one. But you’re realizing that still things do not work as smoothly as they did before. This is hard! Learning how to implement boundaries and raising your personal standards are good ways of “surviving” another’s mental illness. Some things that used to be OK in your life suddenly are just too much. This is to be expected — but not tolerated. Let’s consider a typical problem that most people face at some time in their life: people who drop by your home without notice.

Some people don’t mind drop-in traffic. However, at some point you may feel overwhelmed by this prospect since you are now dealing with the new challenges of a family member’s mental illness. If you used to be fine with drop-in guests but now find them overwhelming, you may want to implement a new “boundary” to improve your life and reduce your stress.

Without boundaries, you’re constantly tiptoeing around hoping your friend Suzy doesn’t suddenly pop in to “dump” all her woes on you. Caring for and worrying about your own family member can be a 24/7 preoccupation

By: Mary Logan

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Colles’ fractures, named after Abraham Colles who first described in 1814 the common fracture of the last inch of the radius and ulna near the wrist, is a very common consequence of a fall on the outstretched hand (FOOSH). Typical treatment is immobilisation in a plaster of Paris or similar material for five to six weeks to allow bony union, followed by a rehabilitation period of a month or more, a short period of which might involve a wrist brace for comfort during activity. Due to the functional importance of the hand, the period of immobilisation is kept to a minimum to prevent dysfunction of the hand and wrist.

Physiotherapy examination starts once the hand has been released from the Plaster of Paris, manually feeling the fracture site which should not be more than minimally uncomfortable, signifying the fracture is well on the way to healing. Hand colour should be normal, the hand should not be swollen much nor have severe muscle wasting. Wrist movements are often restricted in one or two planes but all the movements should not normally be reduced or not significantly. Pain may be present but again should not be severe or occur on all hand movements.

Two hourly range of motion exercises are the first treatment taught to the patient by the physiotherapist and in many cases the wrist movements improve sufficiently for this alone to be required. Elbow and shoulder movement should be reviewed to rule out restrictions before moving on to the rotatory forearm movements of pronation and supination which are important for normal hand use. Further movements assessed are flexion and extension of the wrist, fingers and thumb, along with thumb adduction and abduction. Wrist extension and forearm supination are the most commonly affected movements.

After the plaster comes off the wrist often feels vulnerable, partly because the plaster is seldom left on until the bone is entirely healed to prevent the onset of complications due to immobilisation. Physiotherapists may give the patient a futura type brace, a fabric brace with Velcro straps and a metal piece for the underside of the wrist to stiffen it. This is not meant to keep the wrist immobilised further but to support the wrist while the patient is performing functional activities and then to be removed for light activities and regular exercise performance.

If the ranges of motion do not improve as they should then the physiotherapist will consider using joint mobilisations to ease the movements. Accessory movements can be performed to the inferior radio-ulnar joint to help pronation and supination, and to the radiocarpal (wrist) and midcarpal joints, with the physiotherapist fixing one side of the joint as he or she moves the other side of the joint passively. This can be done gently or more vigorously at the end of range to push against the restrictions within the joint. Mobilisations can also be performed with the joint at the end of its available movement to give it the sliding and gliding movements it requires.

Strengthening the wrist occurs with a gradual increase in functional activities but joining a hand class can instruct the patient in practicing the large variety of small movements that the hand can perform and needs to strengthen for optimum hand function. Repetitive work at pieces of apparatus can strengthen and harden the hand to turning, twisting, pulling, grasping and fine work with the thumb and index finger. This can move on to work with weights or functional activities if the person needs to return to manual labour or another job requiring upper limb strength.

Urgent treatment is indicated if the hand is extremely painful, tightly swollen and has poor movements, before a pain syndrome develops. At this stage medical review is important to make sure there are no complications with the fracture such as poor healing or lack of healing. Analgesia and contrast baths can help with the pain, desensitisation with the hypersensitive areas which can develop and massage and exercise with the swelling. Patient education is vital so they know they have to work hard and through the pain to rehabilitate their hand.



By: Jonathan Blood-smyth

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Mental illnesses are biological brain disorders that many people suffer from, through no fault of their own. They cannot be wished away or combated through will power. While there are very real stigmas associated with these illnesses, the best way to get by is to diagnose the problem, study mental health treatment options and seek social support.

One group of mental illnesses is centered on serious depression. The World Health Organization reported that Major Depressive Disorder or Bipolar is the leading cause of disability in the United States and Canada.

Many people wonder how to tell the difference between serious mental illness and just having “the blues.” The American Psychiatric Association characterizes clinical depression by time endured. If “the blues” don’t go away within two weeks, then there may be a more serious underlying problem.

Other symptoms prey upon the body and make the simplest of day-to-day tasks almost impossible. These include decreased energy and motivation, loss of pleasure in hobbies, social withdrawal, thoughts of death or suicide, feelings of helplessness, guilt and worthlessness, irritability, insomnia, loss of appetite and persistent emptiness.

It is believed that most depression is caused by the lack of naturally-occurring monoamines like serotonin, norephinephrine and dopamine. Antidepressants can help stimulate production of monoamines and psychotherapy can further prevent relapses.

Another group of mental illnesses are the personality disorders. These involve ongoing patterns of thoughts and actions and create social impairment for the sufferer. For example, the person with Avoidant Personality Disorder (APD) withdraws from social contact and has an intense fear of inadequacy and being disliked.

There are extreme fears of being rejected or of being in social situations, making it much like a chronic phobia or panic disorder at times. In fact, research suggests that approximately 50% of the people who have agoraphobia (fear of open spaces, public settings) also suffer from APD.

Borderline Personality Disorder (BPD) is one of those mental illnesses that leads to a pervasive pattern of instability and failed interpersonal relationships. People with mental illness like BPD may exhibit a wide array of strange behaviors, from self-mutilation, to preoccupation with sex, binge eating, drinking, substance abuse, reckless driving, inappropriate explosive anger, an unstable self image and patterns of anxiety or moodiness that last a few hours at a time.

BPD sufferers are thought to be on the borderline between psychosis and neurosis, and behavior therapy is traditionally used, with other cases requiring medical intervention. Recent research suggests that 56% of the people diagnosed with BPD can show big improvement within one year of mental health treatment.

Schizoid Personality Disorder is fairly rare and occurs in 1% of the population, but results in coldness towards others, lack of emotion, indifference to social norms, odd behavior, indifference to praise or criticism and preoccupation with fantasy. The Schizoid has no sexual drive; few close relationships and may feel superior to others or extremely independent.

Some schizoids may give an outward appearance of giving and receiving, but may in fact give or receive very little because they are merely “playing a part.” Schizoids are an interesting breed of people with mental illness because they seldom care to resolve it and feel quite comfortable in their own dueling loneliness and superiority. However, long term mental health treatment can be done through therapy, which involves adopting a whole new way of thinking.

The road to recovery starts with admitting that you may have a problem. Once diagnosed, there are a variety of books you can read, medications you can take or mental health association professionals with whom you can discuss your illness. You may not be able to “wish away” mental illnesses, but you can certainly understand more about them, treat the symptoms and work through your innermost fears and unhappiness.



By: MIKE SELVON

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The rotator cuff is a musculotendinous cuff which surrounds the humeral head and through which the shoulder stabilising and movement muscles exert their forces onto the shoulder. The cuff enables us to put our shoulder through a very large range of motion, the greatest range of any joint in the body, for the purpose of putting our hands in functional positions. The shoulder’s function is to allow our hands to be put in useful positions within our visual field so we can perform the intricate activities that define being human to a degree.

As the muscles approach their insertions on the humeral head they become more and more fibrous until they become wholly tendinous. Many bodily tendons are cylindrical and long but the shoulder tendons are flatter structures which coalesce over the top of the humeral head. The rotator cuff has a relatively poor blood supply and little or no ability to heal and with time and physical stresses tears appear which are often painful but not always so. Rotator cuff tears are a major part of a shoulder surgeon’s work and rotator cuff surgery is common, complex and demands detailed physiotherapy follow up for successful outcomes.

Many causes of rotator cuff tears have been postulated by there is no agreed single cause, with competing ideas which favour external factors to the tendon and its rival which favours internal degeneration of the tendon itself. The leading shoulder surgeon Neer named impingement syndrome as a condition where the shoulder tendons are repeatedly stressed against the anatomical structures which overlie them. These structures include the acromio-clavicular joint and the front of the acromion, the outside end of the shoulder blade. The supraspinatus tendon can be compressed regularly as the shoulder goes into repetitive flexion and medial rotation,

The natural anatomical shape of our acromion plays a role in the likelihood of us having impingement type problems and therefore the tendency to get cuff tears. X-ray studies have shown that a hooked acromion is strongly related to the development of cuff tears although a proven causal link is not yet clear. The acromioclavicular joint develops degenerative outgrowths on its underside and the underlying cuff tendons are pressed against this area on repetitive movement. Repeated overhead work in younger people can cause bleeding and oedema in the tendon, with inflammation and scarring of the tendon after many such small injuries. With time in patients older than forty years complete or partial tears and bony spurs can develop.

A third impingement type can occur in throwing as the arm is cocked back for the throw and the edge of the glenoid socket can be forced repeatedly against the lower surface of the supraspinatus tendon. Minor trauma is produced each time this occurs, gradually developing into small tears particularly in athletes who throw a lot. The biceps and supraspinatus tendons and the lesser tuberosity impinge against the coracoid process. Most rotator cuff tears are probably contributed to by these three impingement process.

The intrinsic view holds that the external factors may be contributory but that the fundamental underlying process is age-related degeneration inside the tendons themselves. This helps explain why young people rarely suffer cuff tears and that tears increase strongly with age, for example after fifty years old. Under the supraspinatus tendon near to its insertion onto the greater tuberosity is an area which has been called the critical zone and postulated to have a poor vascular supply. This could increase the risk of injury and poor healing in this area but further studies have not confirmed this idea so degenerative changes in the tendons may still be important.

It is likely that the cause of rotator cuff degeneration is a combination of both extrinsic and intrinsic causes, with the tendon tending to fail first in the areas of greatest load, leading to rupture of small tendon fibres. This causes increased forces being loaded onto close fibres, detachment of some fibres from bone, reduction in cuff power and compromised blood supply due to kinked fibres. Wound healing could be reduced and this would impair the possibility of repair.



By: Jonathan Blood-smyth

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Our ability to participate in functional activities is greatly dependent on the state of our body joints, from the knees and hips which bear weight and allow walking to the jaw joints which aid speaking and eating. Our joints are exceptionally well designed to allow us to move about and accomplish tasks and mostly they do their jobs quietly and very well. Illness, injury or disease can damage the joints, causing pain and stiffness and limiting functional activity. Physiotherapy examination of the joints is a core skill, demanding a logical approach, the finding of pathological signs and the formation of a treatment plan.

Joints, the junctions between two bones, can have weight carrying, force transmission or movement properties depending on their design and position in the body. An example of a movement joint is the shoulder with its great range, the acromio-clavicular joint is a force transmission joint allowing arm function and the back and hips are weight bearing joints with some movement function. The most obvious of our joints are all synovial joints, a particular and very important joint type. The bone ends are coated with articular cartilage which reduces friction, the joint fluid is secreted by the synovial joint lining membrane and the joint capsule, formed by the ligaments, holds the joint protected against mechanical forces.

Physiotherapy examination of a joint starts with observating how the person uses the joint as they move into the consultation room and sit down. They may hold the joint protectively in a low-risk position, move carefully and guardedly to avoid stressing the joint or splint the joint in some way. The physio takes a history then looks at the joint, noting any deformity, warmth, swelling or effusion, all signs of inflammation. A cool, non-swollen joint in a good position may still have a problem but it is not acute and will need to be searched for. A hot joint with tight swelling will need immediate treatment with the acute injury protocols.

After the visual examination the physiotherapist will palpate the joint and surrounding structures, which means exploring or stressing an area logically with the fingers or hand, an important physio skill to clarify the diagnosis. The physio will palpate around the joint margins, the joint line itself, the tendon insertions and the ligaments surrounding the joint. Effusion, which means the presence of synovial fluid in a joint, can be felt by the resistance it gives if it is tight, by its thickness and plasticity if it is sticky and by the way it can be moved around the joint if it watery.

Once the joint has been assessed visually, which takes a very short time, the physiotherapist will move on to palpation of the joint structures which will help identify which parts of the joint are affected. Palpation involves systematically feeling and stressing structures in an anatomical area to pin down faulty structures more closely. Palpation of the joint involves testing the joint line, the insertions of the tendons and ligaments, along the ligaments themselves and around the joint margins. Fluid in the joint is called an effusion and can be thick and sticky, very tight and firm if there is a lot, or movable if the fluid is thin

The physiotherapist will assess the active range of the joint movement which is what the patient can manage independently, noting the ranges as a proportion of normal and why the joint could not achieve full range, e.g. pain or muscle weakness. The physio will then move the patients joint passively without the patients effort to see if the joint ranges are different. If the physio can move the joint through its full normal range but the patient cannot do this, then either pain or muscle weakness is the likely cause. If neither the physio nor the patient can get the joint to full range, pain or joint stiffness may be the problem.

Ligaments are very important for normal function of a joint and the physiotherapist will routinely test their integrity, stressing them strongly by manual testing. The ligaments of major joints are very strong and testing a normal ligament should show no effect but it can uncover an absent, painful or stretched ligament by its effect on joint stability. Physios use the Oxford 0-5 scale to grade muscle strength, allowing for anxiety or pain which might interfere with a patients effort. Proprioception and joint sensibility may also be tested to ascertain if good feedback from the joint to the brain is present, this being important in normal movement planning.



By: Jonathan Blood-smyth

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The gleno-humeral joint, known in lay terms as the shoulder, is a vital part of the links in the upper limb and responsible for our ability to place our hands where we can see them to perform activities. Because flexibility is a prime requirement the shoulder is a less stable joint with moderate muscle power and a large range of motion. It is described as a “soft tissue joint”, implying that the joint’s functional ability is dependent on its soft and not its hard components. Physiotherapists are closely involved in treating and rehabilitating the shoulder, dealing with the muscles, ligaments and tendons.

The shoulder joint is constructed from the socket of the scapula and the humeral head, the ball at the top of the upper arm bone. The head of the upper arm is a large ball and important tendons insert onto it to move and stabilise the shoulder, but the shoulder socket, the glenoid, is small in comparison and very shallow. A cartilage rim, the labrum of the glenoid, deepens the socket and adds to stability. The acromio-clavicular joint lies above the shoulder joint proper and provides dynamic stability during arm movements, being made up from part of the scapula and the outer end of the clavicle.

The glenohumeral and scapulothoracic joints of the upper limb are acted on by large, strong, prime mover muscles as well as smaller stabilisers. The major back and hip muscles keep the shoulder stable to allow strong movements, the thoracic stabilisers keep the scapula stable so that the rotator cuff can act on a stable humeral head. The deltoid can then perform shoulder movements on the background of a solid base and allow precise placement and control of the arm for hand function to be optimal.

Around the shoulder all the muscles narrow down into flat, fibrous tendons, some larger and stronger, some thinner and weaker. All these tendons are anchoring themselves to the humeral head, allowing their muscles to act on the shoulder. The rotator cuff includes a group of relatively small shoulder muscles, the subscapularis, the supraspinatus, the infraspinatus and the teres minor. The tendons form a wide sheet over the ball, allowing muscle forces to act on it. The rotator cuff, despite its name, acts to hold the humeral head down on the socket and allow the more powerful muscles to perform shoulder movements.

With age, small degenerative tears occur in the tendons of the cuff, in some cases painful and in others not, causing loss of movement and strength. As tears progress they can become massive, cutting off the cuff muscle power from the humeral head and severely reducing function. Rotator cuff strengthening work is performed by physiotherapists and if the tears are severe they concentrate on anterior deltoid strength to improve functional ability in the absence of cuff power. Shoulder surgeons can repair many rotator cuff tears and physiotherapists rehabilitate patients following the shoulder protocols.

Osteoarthritis (OA) more commonly affects the hips and the knees, however the shoulder can be severely affected in which cases physiotherapy can help with advice, mobilisation of the joints and work on strength and joint motion. Once physiotherapy treatment has been tried then total shoulder replacement is the only remaining treatment option, surgical replacement occurring of the head of the arm bone and the socket of the shoulder blade. As the shoulder is referred to as a “soft-tissue joint” it is the balance and strength of the tendons, muscles and ligaments that determines a good outcome for the replacement. Physiotherapists closely follow the surgical protocols to get the optimal results.

Physiotherapists treat many other types of shoulder problems such as impingement, tendinitis, hypermobility, abnormal muscle patterning, fractures and dislocations. Impingement is treated by strengthening the rotator cuff or by subacromial injection or acromioplasty operation, where the end of the acromion can be excised. Tendinitis is treated by direct treatment of the tendon and graded strengthening and hypermobility by stability work and accepting the limitations dictated by the condition. Abnormal muscle patterning is managed by teaching normal patterns functionally and fractures and dislocations by the protocols laid down by the surgeons and trauma physiotherapists.



By: Andrew Mitchell

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