orthopedic manual - prohealthsys

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Vizniak www.prohealthsys.com Shoulder & Arm | 121

Shoulder & Arm Contents

BicipitalTendinopathy

Anterior

AC osteoarthitis

Lateral Posterior

AC osteoarthitis

Subacromial bursitis

Posterior shoulder

muscle strain

Adhesive capsulitis

Supraspinatus tendinopathy

Selected Shoulder Pain Referral Patterns

Shoulder Exam Flow ............ 122Shoulder Exam Form ........... 123

Kinematics ........................ 124Anatomy Review ............... 125

Scapulocostal Syndrome ..... 128Upper & Lower Cross ........ 128

Rotator Cuff Strain .............. 130Subscapularis Tendinopathy 132Impingement Syndrome ....... 134Bicipital Tendinopathy ......... 136Calcific Tendinopathy .......... 138AC Sprain ............................. 140Frozen Shoulder ................... 142GH Instability ....................... 144Glenoid Labral Tear ............. 146Glenohumeral Arthritis ........ 148References ........................... 150

• Remember: shoulder pain can be referred from either the chest or the abdomen (coronary artery disease, pulmonary tumors, & gallbladder disease may be associated with pain referred to shoulder)

4-shoulder NMS.indd 121 2014-01-14 11:05:12 AM

Shoulder &

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www.prohealthsys.com Vizniak122 | Orthopedic Conditions

Shoulder Exam FlowSpecial history questions• Specific mechanism of injury & forces involved? -

Did you fall on outstretched hand? • Any numbness, tingling or weakness?• Type of work, typical posture, sleeping posture? -

Overuse/overhead work? (Impingement)• Prior injuries?

Inspection/Observation (standing or seated)• Asymmetry, bruising, color, swelling, height, head

tilt, winging of scapula, shoulder hiking• Posture of head, neck & thoracic spine, shoulder• Step defect, sulcus sign, antalgia

Palpation (may be done after ROM assessment)Middle trapezius Rotator cuff superiorLower trapezius Rotator cuff anteriorRhomboids Teres majorThoracic spine Latissimus dorsiRibs 1-9 posterior SubscapularisLevator scapulae Serratus anteriorUpper trapezius Triceps brachiiScalenes DeltoidThoracic outlet Deltoid tuberosityCervical spine Pectoralis minorSupraspinatus Coracoid processAC joint CoracobrachialisInfraspinatus Biceps brachiiTeres minor Bicipital grooveAC step defect Pectoralis majorRotator cuff posterior SC joint

Functional assessment (ADLs)• Apley’s superior & inferior

AROM Flexion ............................ 180°Extension ....................... 50°Int./ext. rotation ............. 90°/80°Abduction ...................... 180°Adduction ...................... 35°Horizontal Add./Abd. ..... 130°/30°Scapulocostal rhythm

PROM & Joint Play (if lacking AROM in any motion)

Myotomes (resisted isometric movements)• Shoulder elevation (C4, XI)• Deltoid (C5, C6 - axillary)• Brachioradialis (C5, C6 - radial)• Biceps (C5, C6 - musculocutaneous)• Triceps (C6, C7, C8, T1 - radial, axillary)• Wrist extensors (C6, C7, C8 - radial) • Wrist flexors (C6, C7 - median/ulnar)• Finger flexors (C7, C8, T1 - ulnar/median)• Interossei (C7, C8, T1 - ulnar)

Neurovascular screen• Sensory: light touch, two point discrimination,

Vibration (3rd digit), Tinel’s, sharp/dull• DTR’s: Biceps (C5), Brachioradialis (C6),

Triceps (C7)• Grip strength (Dynamometer)• Radial & brachial pulse, blanching, temperature

Orthopedic tests (as indicated)Screening

• Apley’s superior & inferior scratch• Codman’s arm drop• Dugas, AROM (Empty can)

Impingement• Hawkins-Kennedy• Impingement sign• Painful arc, Passive Neer’s test

Biceps tendinopathy• Hyperextension• Speed’s, Yergason’s (modified Yergason’s)

Rotator cuff• Empty can, Arm drop test (Codman’s)• Lift-off test, Bear-hug test, Internal rotation lag

Labral tear (SLAP lesion)• Hyperabduction, Passive compression• Clunk, Crank, O’brien’s test• Biceps Load Test, Anterior shift test

Glenohumeral joint instability• Ant/post drawer, Ant/post apprehension• Load & shift

AC joint• Passive horizontal adduction, Resisted

horizontal abduction, AC shear

Elbow & Spinal Screen - Imaging (if indicated)

Free for personal use download of full size exam form available athttp://www.prohealthsys.com



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Shoulder Exam Form

Free for personal use download of full size exam form available athttp://www.prohealthsys.com



Shoulder &

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Shoulder KinematicsJoint type: synovial

Ball & socket (glenohumeral)Gliding (scapulothoracic - not a true joint)

Articular surfacesGlenohumeral: convex (head of humerus) on

concave (glenoid fossa)Scapulothoracic: concave (subscapular fossa)

on convex (posterior ribs)

Active range of motion (shoulder)Flexion .........................180°Extension ....................60°Int./ext. rotation ...........90°/80°Abduction ....................180°Adduction ....................35°Horizontal Add./Abd. ..130°/45°Scapulohumeral (humerus: scapula) 120°:60° (2:1)

Main muscle actionsFlexion: anterior deltoid, biceps brachii,

coracobrachialis, pectoralis majorExtension: posterior deltoid, latissimus dorsi,

triceps brachii, teres majorAbduction: middle deltoid, supraspinatusAdduction: latissimus dorsi, teres major,

pectoralis majorHorizontal adduction: pectoralis major,

coracobrachialis, anterior deltoidHorizontal abduction: posterior deltoid, teres

majorInternal rotation: subscapularis, pectoralis

major, latissimus dorsiExternal rotation: infraspinatus, teres minor

Resting positionGH: 55°-70° abduction, 30° horizontal abductionAcromioclavicular: arm at sideSternoclavicular: arm at side

Close packed positionGlenohumeral: maximal abduction & lateral rot.Acromioclavicular: 90° abductionSternoclavicular: full elevation

Normal end feelFlexion: elastic, firm capsularAbduction: elasticExtension: firmInternal/External : elastic / firmHorizontal adduction: soft tissueHorizontal abduction: firm/elastic

Abnormal end feelEmpty → severe instabilityHard capsular → frozen shoulderLate myospasm → instability

Capsular pattern of restrictionGlenohumeral: external rotation > abduction > internal rotation

Capsular pattern restrictions (detailed)Posterior capsule: ↓ horizontal adduction,

internal rotation & end range flexion, ↓ posterior glide

Posterior inferior capsule: ↓ elevation, internal rotation & horizontal adduction

Posterior superior capsule: ↓ internal rotationAnterior superior capsule: ↓ end range flexion

& extension, ↓ external rotation & horizontal abduction

Anterior capsule: ↓ abduction, extension, external rotation & horizontal adduction

Anterior view of right shoulder

Subscapular bursa

Transverse humeral ligament

Articular capsule

Glenoid labrum

Biceps long head tendon

Scapula


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anterior view

lateral view

Scapulothoracic jointNot considered a true joint, it is the space between the scapula & thoracic cage & consists of muscle, connective tissue & bursa that allow for gliding type motions

1. Acromioclavicular (AC) joint2. Trapezoid ligament

3. Conoid ligament Sternoclavicular (SC) joint

4. Anterior SC ligament

5. Interclavicular ligament

6. Costoclavicular ligament Glenohumeral (GH) joint

7. Coracoacromial ligament

8. Joint capsule

9. Biceps brachii long head tendon

10. Triceps brachii long head tendon

11. Glenoid labrum

Shoulder Anatomy Review

Glenoid labrum

Subacromial bursa

Subdeltoid bursa

GH Joint Capsule


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Shoulder Anatomy Review

1. Trapezius

2. Deltoid

3. Supraspinatus

4. Infraspinatus

5. Teres minor

6. Teres major

7. Subscapularis

8. Serratus anterior

9. Pectoralis major

10. Latissimus dorsi

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Shoulder Anatomy ReviewLateral view of right shoulder

1. Acromion

2. Subacromial bursa

3. Supraspinatus

4. Articular capsule

5. Biceps brachii (long head)

6. Subscapularis

7. Glenoid fossa

8. Glenoid labrum

9. Deltoid

10. Biceps brachii (short head)

11. Latissimus dorsi

12. Pectoralis major

13. Teres major

14. Triceps (long head)

15. Teres minor

16. Infraspinatus

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Anterior view of right shoulder

Subscapular bursa

Transverse humeral ligament

Articular capsule

Glenoid labrum

Biceps long head tendon

Scapula

Humerus


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Scapulocostal Syndrome

BasicsDefinition: common musculoskeletal, pain-producing

syndrome that affects the posterior shoulder area & may be associated with altered scapulothoracic motion, ‘snapping shoulder’ & bursitis

Pathophysiology: multiple potential pain generators due to abnormal relationship between scapula & ribs resulting in pain referral over region of posterior scapula, back & shoulder

Possible causes:• Poor posture (rounded shoulder, forward head

tilt, suboccipital extension & slouching)• MFTP in serratus anterior or subscapularis• Adhesions or scar tissue formation• Exostosis of ribs under scapula• Traumatic injury (whiplash, direct blow)

Demographics Incidence: very common (no specific data) Age: 25-50 Gender: female > male Risk factors: poor posture (desk jobs/students or

activities with arms extended in front of body for long periods of time)

Overuse during sports/work (swimming, gymnastics, laborers)

Diagnosis

History• Pain in scapular region, possible crepitus with

movement or dyskinesis• Possible history of prior injury: whiplash, repetitive

activity (swimming, throwing), poor ergonomic set-up of desk work station, hyperkyphosis

• Pain with shoulder activities or prolonged sitting

PhysicalInspection: possible hyperkyphosis of thoracic spine,

head forward position, rounded shoulders, upper cross syndrome

Upper & Lower Cross Syndromes

TightUpper trap.

Levator scap.

WeakRhomboids

Serratus ant.

WeakDeep neck

flexors

WeakAbdominal

muscles

WeakGlut. maximus

TightPectoralis major

TightIliopsoas

TightErector spinae

Palpation: tenderness over medial border of scapula (possible MFTP in levator scapulae, trapezius & rhomboids)

• Myospasm of scapular stabilization muscles

Motion: • AROM - usually full or slightly decreased motion

due to pain; may have altered scapulohumeral rhythm & audible/visible crepitus with motion

• PROM - possible myospasm end-feel with palpable crepitus during motion (possible contracture if adhesions have formed)

• RROM: WNL or mild weakness due to pain (pay particular attention to lower trapezius & rhomboids with muscle testing

Neurovascular: usually WNL (watch for long thoracic nerve damage & winging of scapula)

Differential Diagnosis • Cervical radicular pain, Thoracic outlet syndrome• Rotator cuff or labral tear, GH instability• Long thoracic nerve damage, Rib subluxation• Myofascial pain syndrome or Fibromyalgia• Visceral pain referral (lung, heart, gall bladder)

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Scapulocostal musculature

Common Scapulocostal Pain Referral


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Scapulocostal SyndromeSpecial Test• Orthopedic tests are mainly used to rule out other

pathologies• Impingement - Hawkins-Kennedy, Impingement

sign, Painful arc, Passive Neer’s test• Rotator cuff - Empty can, Arm drop test, Lift-off

test, Bear-hug test, Trumpeter’s test• Glenohumeral joint stability - Ant/Post drawer, Ant/

Post apprehension, Load & shift, Fagean’s• C-cpine tests - Cervical compression/distraction

Diagnostic Imaging• Usually not indicated but may be used to rule out

other pathologies• Ultrasonography may show fluid collection in

scapulothoracic bursa indicating bursitis

Treatment

General Measures• Initial reduction of pain & discomfort (PRICE)• Correct postural faults, get patient up and moving!• Restore altered muscle activation or coordination

during shoulder motion (scapulohumeral rhythm)

Massage Therapy• Address tissue contracture, MFTP & myospasm• Myofascial release, MFTP therapy, Swedish• Heat & hydrotherapy

Osseous Mobes/Manipulation• Extremely effective in treating condition• Assess & treat costal dysfunctions• Also focus on extension restrictions/flexion

malpositions of thoracic sine• Address compensations in C-spine, shoulders &

lumbar spine (mobilize scapula)

Electrotherapy• Consider IFC & TENS for pain reduction• Ultrasound to improve healing (iontophoresis)• Diathermy to increase deep heat & blood flow

Acupuncture• Local shoulder points• LI15, 16, SJ5, 14, SI3, 10, 15, LI4,

Diet & Botanicals• Anti-inflammatory diet, ↑ Vit A,C, Zn, Mg, fish oils• Salix alba (analgesic, anti-inflammatory),

Boswellia serrata, Curcumine longa

Medications• NSAIDs, muscle relaxants• Some evidence to support scapulothoracic bursal

injections of Hyaluronic Acid & corticosteroids

• Hyaluronic Acid is thought to act as a lubricant & offer protective effects (maintain tissue structure & inhibit neovascularization)

Surgery (rarely required)• Arthroscopic or open methods are only indicated

in patients with a clearly identifiable osseous or soft tissue mass

Follow-up

Rehabilitation Program• Realize that scapula stabilization requires

coordinated muscle control of upper & lower trapezius & rhomboid muscles coupled with serratus anterior during activities - shoulder actions are further coupled to the scapula via the rotator cuff muscles & deltoid

• During acute stage focus on restore basic muscle control & balanced as well as basic stretches within the patients tolerance

• In recovery phase progress to more advanced activities (PNF, increased weight & endurance) paying particular attention to try & activate middle/lower trapezius & serratus anterior• Prone horizontal abduction with the shoulder at

90º & 120º abduction

Prevention/Education• Ergonomic evaluation

of work station & daily sitting habits are a must

• Educate patient on importance of proper posture

• Brügger’s exercises are highly recommended• Sit at the edge of their chair, tuck chin in

slightly, breathe through the abdomen, rotate arms laterally, & spread fingers, lift sternum slightly & pull shoulders back

• Some clinicians describe it as if there are strings pulling the patient’s neck up, shoulders back & sternum forward

Prognosis• Excellent with multidiciplinary conservative

care (study showed combined active & passive physical medicine offered complete relief in 57% of cases, moderate relief in 33% & no relief 10%)

• Another study of showed 96% (187/195) relief with combination of physical medicine & corticosteroid injection

Brügger’s Exercise


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Rotator Cuff StrainBasics

Definition: stretch or tear of the rotator cuff tendon or muscle belly. Grade of strain depends on amount of fibers damaged, degree of pain & strength of muscle contraction

Give an exact diagnosis of tendons involved as it will change treatment - do NOT call an isolated subscapularis tear a rotator cuff strain!!!

Pathophysiology• Degenerative strain - associated with minimal

trauma, often prior to chronic tendonitis or chronic impingement syndrome

• Acute traumatic strain – can present following a specific trauma (FOOSH, or a single violent blow or force to shoulder)• Prolonged or repetitive overuse of muscle/

tendon over a short period of time• Lifting or pulling• Pre-existing impingement syndrome

Demographics Incidence: ~30% of population Age: degenerative type is common in elderly Gender: male > female Risk factors: motions that require repeated overhead motions or forceful pulling motions

• Sports injuries or trauma• Athletes (esp those making repetitive motions):

• Baseball pitchers, swimmers• Quarterbacks, volleyball, boxers• Kayaking, tennis

• Poor nutrition, obesity & reduced strength or flexibility & previous injury

History• Pain over superior lateral shoulder• Pain aggravated by leaning on elbow & pushing

upwards on shoulder• Popping or tearing sensation at moment of injury,

followed by pain & weakness• Edema, erythema and/or hematoma of shoulder,

axilla, and/or upper arm (severe case)• Intolerance to overhead activity• Pain at night, especially when lying directly on

affected shoulder• Weakness may be reported, but is often masked

by pain and is usually found only through examination. With longer standing pain, the opposite shoulder is favored and gradually loss of motion and weakness may develop

• Loss of strength, possible crepitus with motion

DiagnosisPhysical• Inspection: normal bone and soft tissue outlines

• Protective shoulder hike may be seen• Possible wasting in the supraspinatus and

infraspinatus fossae (chronic cases)• Palpation: tenderness over rotator cuff muscles

• Myospasm & myofascial trigger points• Motion:

• AROM: weakness or pain during abduction, external rotation, internal rotation, or any combination of these actions - depends on which muscle(s) is specifically damaged

• PROM: pain if impingement occurs or pain at end-range if muscle is stretches

• RROM: pain and weakness during abduction, lateral &/or medial rotation

Differential Diagnosis • Supraspinatus rupture, Impingement syndrome• GH ligament laxity or Instability• Labral tear• Biceps strain/ tendinopathy• Remember: shoulder pain can be referred from

either the chest or abdomen (coronary artery disease, pulmonary tumors, & gallbladder disease)

Special Test• (+) ↓ ROM with

Apley’s tests• (+) Codman’s

Arm Drop; if not severe, apply slight downward pressure at elbow

• (+) Empty Can test• (+) Lift off test combined w/ weakness during

internal rotation• (+) Weakness during Bear-hug test, Belly press• (+) Internal Rotation lag sign

Diagnostic Imaging• Ultrasound: provides a dynamic assessment of

cuff integrity (best initial imaging modality)• X-rays: evaluate bony injury, including a rotator

cuff avulsion fracture, subluxation or dislocation• MRI: evaluates co-existing shoulder injuries such

as Labral tear & other soft tissue pathologies

Other• Arthroscopy - gold standard investigation, allowing

a direct inspection and repair of torn structures in the shoulder joint

Empty Can


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Rotator Cuff StrainTreatment

General Measures• PRICE - avoid prolong immobilization (increases

risk of Frozen shoulder)• Avoid actions that cause aggravation• Consider cold application if acute, switch to heat

in chronic cases• Avoid premature return to activity - can result in

chronic tendinopathy or impingement

Massage Therapy• Can be started 2 days to 2 weeks after the injury

depending on severity & patient tolerance• Myofascial trigger point therapy, myofascial

release & cross fiber, pin & stretch

Osseous Mobes/Manipulation• Do not perform on shoulder during acute phase• Initially focus on thoracic & cervical spine then

move to shoulder mobes & manip. as tolerated

Electrotherapy• Ultrasound - set at a level that produces a mild

feeling of warmth (increase local blood flow, help activate cells involved in healing process & speed repair of tissue)

• Interferential or microcurrent may offer benefit

Acupuncture• LI4, SI3, SJ4, 5 & 6; UB 17, 18, & 19• LV3, GB34, SP10, UB17

Diet & Botanicals• ↑ protein intake to help muscle/tendon heal• Vitamin C, E, selenium, fish oils, Ca, Mg• Anti-inflammatory: Curcuma longa, Boswellia• Analgesic: Salix alba, Filipendula ulmaris• Vulnerary: Arnica montana, Symphytum officinale

Medications• NSAIDs (Aspirin, Ibuprofen, Celebrex)• Injection of steroid medication directly into

injury site to help reduce any inflammation may be needed in chronic rotator cuff tear to allow rehabilitation to proceed

Surgery (last resort)• Arthroscpic, open or or mini-open repair• After surgical repair ~80% of patients achieve

a satisfactory result (adequate pain relief, restoration or improvement of function, improvement in range of motion)

Follow-upRehabilitation Program• Goals: elimination of pain & restoration of motion,

flexibility, strength & endurance• Initial period of rest (allows adequate healing)• Consider short-term use of a sling• Pain free PROM exercises & stretching• Progress to pain free AROM• Consider aquatherapy to add resistance to AROM• Progress to resisted weight exercises & stretching• Then functional activities & ADLs

Patient Monitoring• Begin rehab. as an outpatient therapy, followed

by an at-home routine - be sure to have patient demonstrate exercise routines to ensure proper technique

Prevention/Patient Education• Adequate warm-up prior to sports activity • Wear properly fitted & appropriate protective

equipment during contact sports (pads & tape)• Complete rehabilitation of previous injuries• Improve technique, avoid aggravating activities &

avoid overuse

Prognosis• Early, active intervention is essential for a rapid

return to activity or sport• The severity of the strain will determine how fast

the patient heals • Grade 1 (mild): 2-4 weeks• Grade 2 (moderate): 4-12 weeks• Grade 3 (severe): 6-16 weeks• Grade 4 (full tear): 3 months-1 year

• Complications: Shoulder instability, which can lead to Impingement or Adhesive capsulitis

Medical Legal• Workers’ compensation claims seemed to play a

role in the satisfaction of surgical results (‘green back’ syndrome)

Lateral Rotation

Medial Rotation


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Subscapularis Tendinopathy

BasicsDefinition: overuse or traumatic injury to the

subscapularis tendon resulting in pain, swelling & functional limitation

Pathophysiology: overuse or traumatic damage to the subscapularis tendon or muscle; actions or activities that may cause injury include:• Overuse with repeated

active internal rotation especially when combined with over head activities (throwing, swimming)

• Single traumatic event (rapid excessive stretch into external rotation, ballistic throw without warm-up)

Demographics Incidence: common (esp. athletic populations) Age: 20-40 (can happen at any age >20) Gender: male > female (usually sport/work related) Risk factors: may be predisposed to compensation

& improper biomechanics of shoulder action if there is co-existing Anterior instability, Hypermobility or Impingement

• Increased age & obesity Diagnosis

History• Usually gradual onset of shoulder pain felt in

anterior or posterior axillary fold• Pain is worse with internal rotation (esp. over

head) activities - giving a high five ☺• Pain may be “sharp” with activity but decreases

with warm-up, worse with excessive activity• Possible prior history of trauma or instability

PhysicalInspection: usually WNLPalpation: tenderness over subscapularis tendon or

lesser tubercle of humerus Motion:• AROM - external rotation may be painful at end-

range if subscapularis tendon is stretched• PROM painful or myospasm end-feel with ext. rot.• RROM - weakness on resisted internal rotationNeurovascular: usually WNL

Differential Diagnosis • Other Rotator cuff tear, Adhesive capsulitis• Labral tear, Impingement, Instability

Special Test• (+) Internal rotation lag sign

• Patient seated, affected arm behind back; examiner stabilizes patients elbow & wrist and lifts arm away from back, examiner instructs patient to hold position then releases wrist stabilization. (+) patient unable to maintain position → Subscapularis tear (sn: 97 sp: 96 lr+: 24 lr-: 0.03)

• (+) Lift off test (ask patient to lift hand away from back. (+) inability to lift hand away

s

Diagnostic Imaging (usually not necessary)• MRI or Ultrasonography can detect subscapularis

tear or tendinopathy

Treatment

General Measures• PRICE - avoid prolong immobilization• Avoid aggravating activities• Consider cold application if acute, switch to heat

in chronic casesMassage therapy: myofascial release, trigger point

therapy, friction massageOsseous Mobes/Manipulation: address GH,

cervical, thoracic & costal subluxationsElectrotherapy: low intensity ultrasoundAcupuncture: local shoulder points - LI15, LI16,

SJ14, SI10, LI4, SJ5, SI3Diet & Botanicals: see appendixMedications: NSAIDs, corticosteriods (controversial)Surgery: last resort for cases that do not respond to

conservative careRehabilitation Program: proper warm-up, see

rotator cuff strain sectionPrevention: avoid repeated internal rotation activitiesPrognosis: most subscapularis injuries respond

extremely well to conservative care with resolution usually taking 2-6 weeks depending on the severity of the injury

Internal Rotation Lag Sign

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Supraspinatus TendinopathyBasics

Definition: overuse or traumatic injury to the supraspinatis tendon &/or continuous soft tissues resulting in pain, swelling & functional limitation

Pathophysiology: overuse or traumatic damage to the supraspinatus tendon or muscle; actions or activities that may cause injury include:• Overuse with repeated

active internal rotation especially when combined with over head activities (throwing, swimming)

Demographics Incidence: ~50% of shoulder pain cases (common) Age: 20-40 (can happen at any age >20) Gender: male > female (usually sport/work related) Risk factors: direct trauma (shoulder tackle)

• Overhead activities (laborers, sports, swimming, basket ball, tennis)

Diagnosis

History• Usually gradual onset of dull, achy shoulder pain

directly below acromion that is worse following activity

• May affect ADLs (getting dressed or sleeping)• Pain is better with rest or ice• Possible prior history of trauma or instability

PhysicalInspection: usually WNL, rarely visible swellingPalpation: tenderness over supraspinatus tendon Motion:• AROM - may show a painful arc of motion

between 50º-130º of shoulder abduction• PROM - painful myospasm end-feel with ext. rot.• RROM - weakness on resisted shoulder abductionNeurovascular: usually WNL

Differential Diagnosis • Other Rotator cuff tear, Adhesive capsulitis• Glenoid labral tear, Impingement, Instability• Calcific tendinopathy

Special Test• (+) Empty can test• (+) Full can test• (+) Codman’s arm drop test

Diagnostic Imaging (usually not necessary)• X-ray may be useful to show Calcific tendinopathy

or Osteoarthritis changes• MRI or Ultrasonography can detect Supraspinatus

tear or tendinopathy

Treatment

General Measures• PRICE - avoid prolonged immobilization• Avoid actions that aggravate symptoms• Consider cold application if acute, switch to heat

in chronic casesMassage therapy: myofascial release, trigger point

therapy, friction massage (mobilizes scar tissue tissue & increases local blood flow to promote healing)

Osseous Mobes/Manipulation: address GH, cervical, thoracic & costal subluxations

Electrotherapy: low intensity ultrasound may increase local blood flow & promote healing

Acupuncture: local shoulder points - LI15, LI16, SJ14, SI10, LI4, SJ5, SI3

Diet & Botanicals: see appendixMedications: NSAIDs, corticosteriods (controversial)Surgery: last resort for cases that do not respond to

conservative careRehabilitation Program: proper warm-up, see

rotator cuff strain sectionPrevention: avoid repeated overhead activities or

change technique; consider work place ergonomic evaluation & assessment

Prognosis: most supraspinatus injuries respond extremely well to conservative care with resolution usually taking 2-6 weeks depending on the severity of the injury

• In chronic cases, there may be an increased risk of degeneration for geriatric population that could lead to full rupture


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Impingement SyndromeBasics

Definition: narrowing of space between acromion & humeral that results in ‘pinching’ of the rotator cuff tendons (esp. supraspinatus) &/or biceps brachii long head

Pathophysiology: (stages after Neer)• Stage 1: usually < 25 yrs old - edema &

hemorrhage resulting from excessive overhead activities; reversible with conservative treatment

• Stage 2: usually 25-40 yrs - tendinopathy resulting from repeated episodes of mechanically induced inflammation; shoulder functions satisfactorily during light activity but becomes symptomatic after vigorous overhead use, excessive repetitive use or heavy lifting; conservative treatment may offer benefit

• Stage 3: > 40 yrs - trophic changes in rotator cuff, biceps, & adjacent bone (osteophytes) leading to tendon ruptures & alterations of acromion & greater tuberosity; progressive disability often leads to surgical intervention

Demographics Incidence: higher in athletes & laborers Age: 25-40 yrsGender: male > female (2:1) Risk factors: prior injury or repeated overhead

activities (swimmers, baseball, volleyball, painters, racket sports), GH instability, enlarged acromion or coracoid process

Diagnosis

History• Dull achy shoulder pain that is worse with

shoulder abduction above 80º, overhead activity or excessive use

• Sudden onset of sharp pain in shoulder with tearing sensation suggests rotator cuff tear

• Gradual increase in shoulder pain with overhead activities suggests impingement

• Pain may be worse after sleep if arm was abducted over head or sleeping on a firm mattress (ask about sleeping position - very important)

PhysicalInspection: check muscle atrophy, asymmetry &

swelling, warmth, rednessPalpation: • Pain on top of shoulder → AC joint arthritis• Pain over bicipital groove → Bicipital tendonitis• Lateral shoulder → Supraspinatus tendinopathyMotion: • AROM: painful arc - pain with shoulder

abduction or flexion from 80-120º & shoulder hiking on affected side• Other AROM may be limited above 80º

• PROM: usually WNL unless tendon is com-pressed with passive action (see special tests)

• RROM: possible muscle weakness due to pain with muscle tests if there co-existing tears or inflammation

Neurovascular: usually WNL, but need to rule out cervical raduculopathy or other neurologic issues

Differential Diagnosis • Difficult to diagnosis - similar to other shoulder

pathologies that may co-exist • Biceps tendonitis, rotator cuff injuries• Adhesive capsulitis, AC joint pathology• Glenoid labral tear, subacromial bursitis

Special Test (see yellow Physical Assessment text)• (+) Impingement sign (AROM in flexion with palm

up then repeated with palm down)• (+) Neer’s test (PROM in flexion with palm up then

repeated with palm down)• (+) Hawkins-Kennedy test causes supraspinatus

tendon to impinge against coracoacromial ligamentous arch

• (+) Pain with rotator cuff tests - Drop arm test, Empty can test

Painful arc on left shoulder(note shoulder hike & slower motion)


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Impingement Syndrome

Diagnostic Imaging: (usually not indicated)• X-rays: may be indicated to rule out arthritis or

other pathologies• MRI: best imaging to evaluate soft tissue changes

& rule in or out other shoulder pathologies

Other• Impingement test: injection 10 mL of 1% lidocaine

solution into subacromial space & repeat special impingement test - (+) = elimination or significant reduction of pain

Treatment

General Measures• Pain reduction & avoidance of aggravating activity• PRICE, NSAIDs• Ensure proper warm-up prior to activity

Massage Therapy• Myofascial release & trigger point therapy for

surrounding shoulder muscles• Cross fiber massage if not in acute stage• In subacute phase consider PNF stretching in

office (internal & external rotation; extension/flexion; add/abduction)

Osseous Mobes/Manipulation• Address subluxations of AC & SC joints & cervical

& thoracic spine

• Direct GH mobes & manip are indicated in cases that are not acute or hypermobile/unstable

Electrotherapy• TENS for pain reduction• Ultrasound therapy • Some studies show short term benefit with high-

intensity laser therapy (HILT)

Acupuncture• Local shoulder point & LI4, 15, 16, SI3, 10, SJ5, 14

Diet & Botanicals: see appendix

Medications• NSAIDs, Corticosteroid injection (controversial)• Glyceryl trinitrate/nitroglycerin

Surgery (last resort)• Depends on cause (open or arthroscopic)

resection of distal clavicle, excision of osteophytes, repair rotator cuff tear, acromioplasty, subacromial decompression

Follow-up

Rehabilitation Program• Ensure proper warm-up before activity• Acute goals - relieve pain & inflammation

• Ice & rest shoulder, avoid aggravation• PFROM, pendulum arm swings, AROM• Stretching as tolerated (esp. posterior capsule)

• Subacute goals - normalize ROM, perform symptom free ADLs, ↑ strength & flexibility• Progress to PFAROM then mild resistance

exercises (weights, tubing, aqua aerobics)• Eventually progress to more advanced

activities (increased resistance, activities that mimic sport or work activity, PNF)

Prevention/Patient Education• Evaluation of sport or work technique may be

needed to observe ergonimics• Avoid sleeping on a hard mattress with shoulder

abducted over head

Prognosis• Depends on coexisting factors (instability, arthritis,

labral or cuff tears, longer standing condition in older patient)

• 60-90% of simple case will usually resolve quick to pre-injury status (2-6 wks)

• Complicated cases can take much longer & should involve secondary consultation

Impingement Sign (palm up then palm down)

Neer’s Test

Hawkins Kennedy


Shoulder &

Arm


Bicipital TendinopathyBasics

Definition: inflammation of biceps brachii long head tendon & surrounding sheath, biceps musculotendinous junction is particularly susceptible to overuse injuries; usually co-exists with other pathologies of the shoulder including rotator cuff tendinopathy & tears, GH instability & other muscle imbalances

Pathophysology (4 main theories): • Mechanical theory: repetitive loading of tendon

results in microscopic degeneration → fibroplasia within tendon → scar tissue

• Vascular theory: tendon degeneration occurs as a result of focal areas of vascular compromise

• Neural modulation: tendinopathy results from neurally mediated mast cell degranulation & release of substance P

• Subluxating tendon: tendon is held in place by transverse humeral ligament, rupture of ligament or shallow bicipital groove allows tendon to repeatedly shift out of place in bicipital groove

Demographics Incidence: very common Age: 20-30s most commonGender: male > female (2:1) Risk factors:

• Repetitive overhead activities• Prior injuries to shoulder• Sport specific - pitchers, swimmers, gymnasts,

racquet sports, rowing

History• History usually suggests diagnosis, but clinical

tests are needed to confirm• Pain over the anterior shoulder & bicipital groove• Pain is worst with activity especially with repeated

shoulder & elbow flexion &/or supination & overhead activities

• ↓ pain with rest, massage, heat• Possible repeatable ‘snapping’ or ‘clicking’ with

subluxation of tendon

PhysicalInspection: possible mild swelling & redness (rare)• Patient may have a tendency to want to hold or

rub shoulder to relieve painPalpation: hallmark sign is local tenderness to

palpation over the bicipital grooveMotion: possible repeated snapping if tendon is

subluxating out of bicipital groove

• PROM: usually WNL until end-play stretches bicipital tendon → pain

• AROM: possible aggravation of symptoms with shoulder & elbow flexion &/or supination

• RROM: pain with resisted shoulder & elbow flexion

Neurovascular screen: WNL

Diagnosis

Differential Diagnosis • Glenoid labral tear (often co-exist)• Impingement syndrome• Rotator cuff tear• GH instability• Inflam. arthropathy

Special Test• (+) Speed test• (+) Hyper-extension test• (+) Yergason

Diagnostic Imaging• Ultrasound: provides a dynamic assessment of

tendon (best initial imaging modality) • X-ray: usually not necessary but may be useful to

rule in/out other co-existing pathologies • MRI: can show entire pathway of tendon but is

usually not cost effective - may be indicated if there is a suspected labral lesion

Speed’s Test

Hyperextension Test

Yergason Test


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Bicipital TendinopathyTreatment

General Measures• PRICE to reduce pain & inflammation

• Ice area 10-15 min 2-3 x/day for first 48 hrs• Short term avoidance of aggravating motions

(above head activities)

Massage Therapy• During acute phase - Swedish, myofascial trigger

point therapy & myofascial release of musculature around shoulder girdle & back

• During recovery phase consider switching to cross friction massage over bicipital groove

Osseous Mobes/Manipulation• During acute phase focus on cervical &

thoracic spine compensation issues; as patient improves move to shoulder therapies to improve biomechanical function

Electrotherapy• TENS for pain reduction, consider ultrasound• Consider phonophoresis (ultrasound) or

iontophoresis (electric current) to deliver medication without injection

Acupuncture• Local shoulder points & GB34, LI4

Diet & Botanicals• Vitamin C (1-3g/day), Calcium (400mg tid),

Bioflavinoids (900-1800 mg/day-only useful before peak inflammation)

• Kava (100mg tid), Valerian (350 mg bid), Bromelain (1200 mg/day for 5-10 days)

Medications• Consider NSAIDs for 2-3 weeks to reduce pain &

inflammation• Consider capsaicin creams, Tiger balm• Injection of steroids into biceps sheath can be

effective

Surgery• Rarely indicated, except if patient fails to respond

to conservative care after 6 month - may involve musculotendinous decompression or tendon relocation (tenodesis)

Follow-up

Rehabilitation Program• If shoulder is stable consider ROM exercises;

• Gradual stretching of the biceps tendon• Circumduction, pendulum - 5-10 lb weight held

lightly in the hand - arm swings ~1-3 inches in any direction

• Lateral/front finger wall walking• Isometrics progress to concentric exercises, then

to eccentric exercises, and finally to sport-specific exercises to potentially reverse degenerative changes

• Perform proprioceptive shoulder exercises with a Swiss ball

Prevention/Patient Education• Work or sport activity ergonomic evaluation

should be performed to ensure proper techniques are being used

• Modify risk factors where possible• Strengthen muscles concentrically & eccentrically

prior to a return to full activity• Perform sport-specific or work-specific training

prior to returning to work or sports activity• Educate the patient about using proper body

mechanics to prevent recurrent injury • Advocate regular warm-up before & stretching

after exercise

Prognosis• Dependant on severity of injury, usually pain is

gone in 2-4 weeks with full recovery in 6-8 weeks• In more severe cases healing takes longer (8+

weeks) & spontaneous rupture of biceps tendon may occur in ~5-10% of patients

Medical Legal• In patients that do not respond to conservative

care consider a secondary referral or diagnostic imaging (look for other co-existing pathologies)

• Injection of corticosteriods directly into tendon itself can result in biceps tendon degeneration & rupture

Deltoid insertion myofascial release


Shoulder &

Arm


Demographics Incidence: 7% of painful shoulders (3-20% general population) Age: peak incidence 30-50 years Gender: female > male (2:1)Risk factors: exact cause is not known

• Chronic impingement, trauma• Wear & tear (repeated microtrauma)• Aging, genetic/metabolic factors

Diagnosis

History• Chronic, mild pain with occasional flare-up• Pain may be aggravated by overhead activity or

sleeping on the affected shoulder• Possible stiffness or weakness

PhysicalInspection: possible swelling or rednessPalpation: possible tenderness or warmth over

affected tendonMotion: possible intense pain with motion• Possible decreased ROM into shoulder abduction• Painful arc of motion from 70-120 º of flexion or

abduction

Differential Diagnosis • Frozen shoulder• Impingement syndrome• Rotator cuff tear (elderly)• Biceps tendinopathy

Special Tests• (+) Neer’s test• (+) Push button sign

Calcific Tendinopathy

Push Button Sign

BasicsDefinition: condition characterized by calcium

deposits occurring in the rotator cuff tendons (usually supraspinatus) causing pain & inflammation (may occur in any tendon in the body - biceps brachii, infraspinatus)

Synonyms: calcifying/calcified/calcareous tendonitis

Pathophysiology: calcifying tendinopathy proposed pathologic & clinical phases (Uhthoff & Loehr)

• Formative phase: consequence of an unknown trigger, portion of the tendon undergoes fibrocartilaginous transformation; calcification occurs in this transformed tissue; the deposit enlarges (calcific deposit resembles chalk)

• Resting phase: calcific deposit enters a resting period which may or may not be painful (if large enough, it may cause mechanical symptoms)

• Resorptive phase: after a variable period, an inflammatory reaction may cause vascular tissue to develop at the periphery of the deposit; macrophages absorb the deposit; this stage may be very painful (at this stage, the calcific deposit resembles toothpaste)

• Postcalcific phase: once calcific deposit has been resorbed, fibroblasts reconstitute collagen pattern of tendon and symptoms subside

Neer’s Test

Shoulder & Rotator Cuff Muscles

Supraspinatus


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Calcific TendinopathyDiagnostic Imaging• Ultrasonography: with experienced operators,

ultrasound is more sensitive than plain x-rays & does not expose patient to radiation

• X-ray: common way to confirm diagnosis• Deposits range from a toothpaste to a chalky

consistency• Usually 1-2 cm in length• Sensitivity of x-rays for detecting calcific

deposits is 0.90 (compared to ultrasonography as standard)

• MRI (not indicated unless other co-existing pathology is suspected) may show • T1 - decreased signal intensity• T2 - increased signal intensity if edema is

present

Arrow denotes calcific density in supraspinatus tendon(Calcific Tendinopathy)

Treatment

General Measures• Treatment varies with phase of calcification• PRICE for acute or painful flare-ups• Start Codman pendulum exercises ASAP to

maintain basic ROM

Massage Therapy• Trigger point & myofascial release for surrounding

muscles• Consider cross-friction massage to dissolve

deposit (contraindicated during acute inflammation - resorptive phase)

Osseous Mobes/Manipulation• Initially focus on lower cervical & thoracic spine• Mobes/manip of acute shoulder is contraindicated,

but after may be beneficial if there is hypomobility

Electrotherapy• Ultrasound (good supporting research)

• Iontophoresis with acetic acid to break down calcium deposits

• Consider TENS for pain control• Extracorporeal shock wave therapy (ECSW) uses

sound waves to mechanical disintegrate calcific deposits which are then reabsorbed by body

Acupuncture• Local shoulder points, consider moxibustion

Diet & Botanicals• Bromelain, turmeric (curcumins), Salix alba

(salicin), licorice, glycyrrhiza glabra• Consider decreasing calcium intake, vitamin A, C

& E, fish oils

Medications• NSAIDs• Corticosteroid injections are NOT indicated

Surgery• Needling - needle inserted into calcium deposits

to break up and/or aspirate as much as possible• Lavage - needle placed into shoulder, saline

injected, deposits are broken up for removal & flushed out

• Open or arthroscopic removal ~90% success rate

Follow-up

Rehabilitation Program• ROM exercises ASAP, gradual stretching of

affected tendon & roator cuff• Circumduction, pendulum - 5-10 lb weight held

lightly in the hand - arm swings ~1-3 inches in any direction

• Isometrics progress to concentric exercises, then to eccentric exercises

Patient Monitoring• Follow-up visit 2-3 days then 1/week for 3 weeks• Consider referral if conservative care fails to

improve condition

Prevention/Patient Education• Avoid aggravating activities

Prognosis• Usually responds well to conservative care, acute

symptoms usually resolve in ~2-3 weeks• Rarely may develop into frozen shoulder


Shoulder &

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AC SprainBasics

Definition: damage or tearing of the ligaments or joint capsule of the AC joint; AC separation is the displacement of the AC joint from its normal position

Cause of injury• Mechanism 1: direct force to the superior aspect

of the acromion, usually from a fall with arm in an adducted position → drives acromion inferiorly, spraining the intra-articular acromioclavicular ligaments

• Mechanism 2: FOOSH (fall on an outstretched hand) that can occur during collision sports → indirect force transmitted up arm, through humeral head to acromion, displacing it superiorly and stressing the AC ligaments

Demographics Age: 15-25 most commonGender: male > female (5:1) Risk factors: contact or extreme sports

Grade of InjuryType 1• Local to AC capsule• Mild trapezius & levator

myospasm• No visible

displacement, X-ray (-)

Type 2• AC capsule & coraco-

clavicular ligaments• AC & coracoid

tenderness• Marked trapezius &

levator myospasm• Visible clavicle elevation (less than grade 3)• X-ray (+) clavicle elevation• < ½ thickness of distal clavicle (4-5 mm joint

space)

Type 3• Major AC &

coracoclavicular ligament involvement

• Severe AC & coracoid tenderness• Possible swelling & visible displacement• X-ray (+) displacement

• > ½ thickness of clavicle, > 5 mm joint space• > 25% increase in coracoclavicular space• > 1.3 cm coracoclavicular space

DiagnosisHistory• History of trauma (impact, FOOSH or heavy

lifting)• Possible antalgic posture (support arm to protect)

PhysicalInspection: • Step defect - prominent lateral clavicle with loss of

normal shoulder contour is highly suggestive of a ligamentous disruption - consider asking patient to hold a 10-15 pound weight in hand of affected arm to make more visible

Palpation:• Pain & tenderness over AC joint (pain = pathology

SN: 96, SP: 10, LR+: 1.1, LR-: 0.40)• Reactive myospasm of trapezius, subclavius,

deltoid & pectoralis minorMotion:• AROM & PROM cause increased pain at > 90º of

abduction (AC closed packed position)• Possible empty end-feel with superior glide• RROM may be normal or decreased due to pain

Differential Diagnosis • Usually very obvious diagnosis• Rule out Adhesive capsulitis, Dislocation, Rotator

cuff tear & pain referral from cardiac, pulmonary & GI system

Special Test• (+) AC shear test• (+) Piano key sign• (+) Horizontal Adduction test• (+) AC resisted extension test• (+) O’Brien’s test

AC Shear test


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AC Sprain

TreatmentGeneral Measures• PRICE• Consider short-term use of arm sling• Sleep with injured side up

Massage Therapy• Initially focus on myofascial trigger point therapy,

myofascial release of shoulder muscles• After acute stage consider friction massage

Osseous Mobes/Manipulation• Do NOT work on AC joint directly (unstable)• Focus on T-spine, ribs & neck initially• Later consider mobes & manip in direction

opposite to force of injury

Electrotherapy• Consider pulsed ultrasound over shoulder• Microcurrent or IFC may offer benefit

Acupuncture• Local shoulder points LI4, SI3, SJ4 UB17 18 & 19

Follow-upRehabilitation Program• Depends on grade & stage of injury - go slow &

stay pain free - don’t re-injure• Type 1: activity modification may include the use

of a sling until symptoms subside and range of motion is reasonably comfortable• Cross arm in front of body to touch opposite

shoulder• Reach arm behind back• Slowly incorporate weights

• Type 2: sling for 2-4 weeks with PROM & AROM exercises - heavy lifting and contact sports should be avoided for 6-12 weeks to allow healing and prevent progression to a type 3 injury

• Type 3: consider surgical evaluation

Prevention/Patient Education• Avoid aggravating factors & causative activities

Prognosis• Type 1: conservative treatment result in resolution

in ~2 weeks• Type 2 & 3: usually responds well to conservative

care over 5-8 weeks • Increased risk of impingement symptoms, muscle-

fatigue discomfort & osteoarthrosis

Grade 3 AC separation

Diagnostic Imaging• X-ray: usually confirm diagnosis - consider

bilateral comparison with patient holding 10-15 lbs weight during x-ray

Diet & Botanicals• Connective tissue healing: vitamin C, omega-3,

protein, collagen, glucosamine• Anti-inflammatory: Curcuma longa• Analgesic: Salix alba• Vulnerary: Calendula off

Medications• Prolotherapy (Proliferative Injection Therapy)

- injection of irritant solution into ligament attachment sites to cause tissue regrowth

• NSAIDs, lidocaine injection into joint

Surgery (last resort)• Only indicated in severe cases or failure of

conservative care• Threaded wire or suture to hold joint together

s

Horizontal adduction test


Shoulder &

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Frozen ShoulderBasics

Definition: frozen shoulder, or adhesive capsulitis, is an idiopathic condition of the shoulder associated with marked pain & contracture of the joint capsule

Contracture & adhesions Contracture & adhesions of inferior axillary foldof inferior axillary fold

Pathophysiology: etiology is not fully understood• Process involves hyperplastic fibroplasia &

excessive type III collagen secretion that lead to soft-tissue contractures of GH joint capsule

• Frozen shoulder typically develops in three stages (each stage can last for months to years): • Painful stage: shoulder pain occurs with

movement & ROM starts to become limited• Frozen stage: shoulder pain may begin to

decrease, ROM substantially reduced (frozen)• Thawing stage: shoulder range of motion

begins to improve & return to normal

Demographics Incidence: 2% of general pop. (11% in diabetics) Age: usually 40-60 yrs of age Gender: female > male (2:1) Genetics: possible trisomy 7 & trisomy 8 in GH

capsular fibroblasts may be notedRisk factors:

• Age (over the age of 40)• Prolonged immobility of the shoulder increases

risk of developing frozen shoulder• Systemic diseases (diabetes, hyperthyroidism)• Prior trauma

History• Pain & loss of ROM are hallmark symptoms• May be idiopathic - no prior injury or visible cause• Gradual increase in shoulder pain & loss of range

of motion (patient may be unable to brush hair or raise arm on affected side)

• Prior history of shoulder immobilization (sling or surgery recovery)

• Possible systemic disease (diabetes)

PhysicalInspection: usually WNL, possible GH muscle

atrophy in more advanced casesPalpation: direct pressure of the joint capsule is

painfulMotion: decreased external rotation & abduction• AROM: decrease in ROM & inability to perform

Apley’s scratch (reach over head to shoulder)• PROM: painful capsular end-feel especially with

external rotation & abduction• Motion most severely is external rotation, then

abduction, internal rotation & flexion• RROM: may also cause pain as the rotator cuff

muscle become continuous with the GH joint capsule

Neurovascular: usually WNL

Diagnosis

Differential Diagnosis • Rotator cuff or Labral tear, GH osteoarthritis• Brachial neuritis, Cervical radiculopathy• Complex regional pain syndrome (RSD)• Thoracic outlet syndrome• Calcific tendonitis, Impingement syndrome

Special Test• (+) Apley’s superior scratch• (+) Arm drop test indicates supraspinatus tear• (+) Speeds test indicates biceps long head issue

Diagnostic Imaging• Usually not required - may be used to rule out

other pathologies• MRI or ultrasonography may show thickening of

GH joint capsule

Laboratory• CBC & blood glucose may be indicated -

Lequesne & colleagues found that 28% of 60 new patients who presented with idiopathic frozen shoulder had undiagnosed diabetes


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Frozen ShoulderTreatment

General Measures• Early ROM exercises & stretching are

fundamental to treatment • Consider NSAIDs & ice or heat to reduce pain• Continue with ADLs as much as pain will allow

Massage Therapy• Indicated during the “thawing” or recovery stage • Myofascial release (avoid during acute pain)• Myofascial trigger point therapy & Swedish • Heat therapy immediately before or after massage

Osseous Mobes/Manipulation• Shoulder mobilization as tolerated by patient

• Emphasis on anteroinferior capsular stretch• Inferior glide, anterior glide & axial distraction

• Also address thoracic & C-spine subluxations• Manipulation under anesthetic

• If conservative treatment fails, patient is given local anesthesia & shoulder is literally ‘ripped’ through normal ROM - the procedure is painless & ruptures chronic adhesions

Electrotherapy• Consider TENS to help modulate pain perception• Ultrasound to increase local blood flow

Acupuncture• Local points & GB34, LI15, 16, 11, SI9-10• Often used in conjunction with local massage

Diet & Botanicals• Anti-inflammatory diet (bromelain, valerian)• Consider vitamin B6, D supplementation

Medications• NSAIDs, Celebrex• Corticosteroid injection - “researchers at the

Manchester Rheumatology Service studied the accuracy of a variety of joint injections that were administered by using anatomic landmarks to the upper and lower extremities; their study demonstrated inaccurate placement of the drug in 65% of 108 joints injected!!!”

Surgery (not usually required)• Arthroscopic release• Suprascapular nerve block

Follow-up

Rehabilitation Program• Should be used in conjunction with other

modalities (manip., ultrasound, acupuncture)• Follow rehab program with massage & ice• Start with basic PFROM exercises, then pin &

stretch, then progress to PNF patterns & contract relax methods

Patient Monitoring• Give home care program & have patient

demonstrate exercises with each office visit• Warm-up with pendulum arm swings• Stretch with towel pulls & finger wall walking &

door stretches• Progress to aquatic therapy (pool/hot tub)• Then elastic tubing exercises that focus on

shoulder external rotation & abduction• Add resistance weight training as tolerated• Always stretch after activity

Prognosis• With good patient compliance, recovery with

conservative care is usually excellent• Inform the patient that the healing process for

frozen shoulder will be slow (6 -24 months), but they will get better!

• Realize frozen shoulder spontaneously resolves ~2 years after initial onset in ~60% of cases

External rotation mobilization

Anterior mobilization at 90º

Door stretch Towel stretch


Shoulder &

Arm


GH InstabilityBasics

Definition: inability to maintain the humeral head centered in the glenoid fossa due to laxity of the shoulder capsule, ligaments &/or rotator cuff muscle imbalances or congenital joint anomalies

Degrees of instability• Apprehension - fear that shoulder will subluxate

or dislocate• Subluxation - transient partial separation of

articular surfaces - humeral head usually spontaneously returns to normal position

• Dislocation - complete separation of articular surfaces

Types of glenohumeral instability• Anterior inferior (80% of cases) - humeral head

slides anterior & inferior• Posterior (~10%) - humeral head slides posteriorly• Multidirectional (~10%) - usually congenital

Grades of instability

Grade DescriptionWNL 0-25% translation

1 25-50% translation, humeral head riding up on glenoid labrum

2 50-75% translation, humeral head rides up & over glenoid labrum, immediately reduces

3 > 75% translation & humeral head remains dislocated

WNL = within normal limits

Pathophysiology: • Traumatic: instability secondary to damage of the

rotator cuff, glenoid labrum &/or GH ligaments• Can be single events or recurrent injury• Direct trauma - tackle

from behind with shoulder in abduction & external rotation or long axis traction force applied to arm

• Overuse trauma - repeated overhead activities (boxers, swimmers, racket sports, throwers)

• Intentional subluxation or dislocation - patient can voluntarily demonstrate instability

• Atraumatic: congenital local anomalies may have familial tendencies & are more likely bilateral• Generalized joint laxity - these patients have

less cross-linked collagen fibers in their capsule = increase flexibility

• Glenoind dysplasia - shallow glenoid fossa, anterior of posterior tilt of glenoid

Demographics Incidence: ~2-3% of population Age: 15-30 (young athletes) Gender: female > male (2:1)Genetics: specifics unknown but does tend to run

in families Risk factors: prior injury, rotator cuff damage,

repeated overhead activities, nerve damage

History• General shoulder pain, worse with activity or

certain arm positions (overhead activity, carrying objects at side, overuse, prior injury)

• Pain is better with rest or heat• Patient may note a history of catching or locking

with motion or prior athletic injury (dislocation)• Often associated with impingement symptoms

(painful arc of motion)

PhysicalInspection: possible sulcus sign or rednessPalpation: possible tenderness over joint if it is

inflamed or there are damaged fibers present• Trigger points & myospasm of rotator cuff

Motion: AROM & PROM may show repeatable clunk or apprehension with abduction & external rotation• Pain/impingement with 80-120º shoulder

abduction & altered scapulohumeral rhythm • RROM - usually WNL (may be weak due to

pain or coexisting damage)Neurovascular screen: WNL - be sure to check

axillary & suprascapular nerve function as well as radial pulse

Diagnosis

Differential Diagnosis • Glenoid labral tear or GH osteoarthritis • Biceps tendinopathy• Rotator cuff tendinopathy or strain• Shoulder impingement • Subacromial bursitis• Any of above may co-

exist with GH instability

Special Test (see yellow physical assessment text)• (+) Load & shift (anterior

& posterior instability)

©VIZNIAK

Load & Shift


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GH InstabilityInferior instability tests• (+) Sulcus test (arm dependant & pull down)• (+) Faegin’s test (arm abducted 90°)

Anterior instability (best done supine)• (+) Anterior apprehension test• (+) Relocation test• (+) Release maneuver

Posterior instability tests• (+) Sitting & supine posterior apprehension test• (+) Norwoods posterior drawer test

Posterior Apprehension

Diagnostic Imaging• Ultrasonography: useful first imaging modality

may detect full thickness tears• X-ray: may show increased joint space, shallow

glenoid & is useful to rule out other pathologies• MRI: excellent for visualization of shoulder soft

tissues & general bone detail; visualize rotator cuff tears & ligament damage - better seen with injection of contrast dye into joint before MRI eval.

• Arthroscopic: excellent for GH visualization

Treatment

General Measures• Pain & inflammation control (PRICE)• If dislocated, refer for reduction ASAP• Consider short-term use of an arm sling

Massage Therapy• Focus on shoulder & cervcal-thoracic regions• Swedish, MFTP therapy, myofascial release

Osseous Mobes/Manipulation• Shoulder manip./mobilization is contraindicated• Focus on area of compensation (scapulocostal,

thoracic & cervical spine subluxations)

Acupuncture• Local shoulder points, LI4, SI3, SJ4, UB17, UB18

Diet & Botanicals• Bromelain, turmeric (curcumins), white willow

(salicin), licorice• Consider increase vitamin A, C & E, fish oils

Medications• Prolotherapy - tighten ligaments (capsular growth)• NSAIDs, hydrocodone

Surgery• Indicated if failure of conservative care• Open or arthroscopic surgery to reattach torn

labrum or arthroscopic thermal denaturation of GH capsule (tightens up ligaments)

Follow-up

Rehabilitation Program• Start with basic PFROM as tolerated by patient• Ensure a good warm-up prior to activity• Progress to mild resistive exercises (gentle PNF,

tubing exercises, water exercises, mild weight resistance)

• Rotator cuff muscles provide a full 50% of the GH stability - strengthening & proprioceptive retraining of these muscles are fundamental!!!

Lateral Rotation

Medial Rotation

Patient Monitoring• When determining a patient’s return to competitive

sports or physically demanding job• Normal scapulohumeral rhythm• Full AROM & PROM• Rotator cuff strength at 90% of opposite side• Pain-free activities of daily living (ADLs)

Prevention/Patient Education• Educated patient on activities to avoid or how to

modify ADLs to prevent injury

Prognosis• Most respond extremely well to conservative care

without dislocation or the need for surgery• In severe cases instability may lead to GH

degeneration or progress to a full dislocation• The younger a patient the more likely a dislocation

will re-occur (recurrence rate is ~90% if initial dislocation occurs in teen years, but only 15% after the age of 40)

Medical Legal - in acute trauma rule out fractures, neurologic, vascular damage & rotator cuff tears


Shoulder &

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Glenoid Labral TearBasics

Definition: often overlooked cause of chronic shoulder pain due to tearing or detachment of the fibrocartilagenous glenoid labrum & insertion point of the biceps brachii long head

Labral lesions can occur in isolation or in combination with rotator cuff tears, GH instability, impingement, dislocation & other shoulder injuries

Pathophysiology: types of glenoid labrum lesions:• SLAP lesion (more common) - tearing superior

labrum anterior posterior - see classification below

Type SLAP clinical description

1 Fraying of the labrum, but the biceps anchor is intact

2 Tear of superior labrum that results in instability of biceps anchor (most common)

3 Bucket-handle tear of the superior labrum

4 Bucket-handle tear that expands into biceps tendon

• Bankhart lesion (less common) - tear of lower half of labrum & inferior glenohumeral ligament - seen with shoulder dislocations

• Bennett lesion (least common) - posterior labral tear associated with posterior rotator cuff damage

Demographics Incidence: ~10-20% of patients with shoulder pain,

higher in athletes & on dominant armAge: usually 20-40, but can occur at any age Gender: male > female (5:1) Risk factors: trauma & instability

• Repetitive stress (throwing, swimming)• Direct trauma (dislocation, subluxation, direct

blow to shoulder, FOOSH, overhead activity)• Instability can result in labral tear

Diagnosis

History• Pain with overhead or cross body activities• Snapping, popping, catching with motion• Occasional night pain or pain with ADLs • A sense of instability in the shoulder • ↓ range of motion & strength • Prior history of overuse or direct trauma

(dislocation, subluxation or instability)• Patient may have seen a number of other

healthcare providers with a history of failed conservative care treatments

PhysicalInspection: patient maybe protective & have

shoulder/arm in a sling positionPalpation: tenderness around bicipital tendon,

anterior deltoid & supraspinatus insertion• Possibly slight edema & warmthMotion: • AROM: pain, crepitus, ↓ ROM above head• PROM: crepitus (rule out AC crepitus - very

common), ↓ ROM with myospasm end-feel & muscle guarding or apprehension

• RROM: weakness due to pain of bicepsNeurovascular: usually WNL (check pulse & DTRs)

Differential Diagnosis • Similar to other shoulder pathologies that may

co-exist - difficult to diagnosis • Biceps tendonitis• Rotator cuff injuries (occur in 40% of labral tears)• Adhesive capsulitis• Shoulder impingement or sprain• AC joint pathology• Subacromial bursitis

Special Test (see yellow Physical Assessment text)• (+) O’Brien’s test (active compression)• (+) Clunk test & Crank test• (+) Hawkins-Kennedy test

Crank Test O’Brien’s Test

Glenoid Labrum

Biceps attachment


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Glenoid Labral Tear(+) Biceps Load Test IIProcedure: patient supine, shoulder abducted ~120°

& elbow flexed ~90°; examiner fully externally rotates shoulder then asks patient to flex elbow while resisting action

Interpretation: ant. shoulder pain → SLAP lesionClinical notes: This test is very reliable (valid) for

the diagnosis SLAP lesions (R: 0.82 SN: 90 SP: 97 LR+: 26.4 LR-: 0.11)

Diagnostic Imaging• X-ray: may be useful to rule out other pathologies• MRI: standard for initial diagnosis, use of

gadolinium-enhanced MR arthrography increase the sensitivity (82-96%) & specificity (91-98%)

• On MRI look for:• High signal intensity at labrum/anchor interface• Increased signal at superior glenoid fossa• Displacement of the superior labrum away

from the glenoid surface• Presence of a glenoid-labral cyst

Treatment

General Measures• Avoid positions & actions that exacerbate pain• Primary goals should focus on pain &

inflammation reduction during acute phase (NSAIDs & PRICE); then ↑ ROM, & strengthening scapulothoracic & glenohumeral musculature to improve static & active joint stability

• Special attention must be given to the biceps

tendon as it may help lift away the labrum & is a key player in GH stability

Massage Therapy• Focus on shoulder & cervical-thoracic regions• Swedish, MFTP therapy, myofascial release

Osseous Mobes/Manipulation• Focus on areas of compensation (scapulocostal,

thoracic & cervical spine subluxations)

Electrotherapy• Consider TENS &/or pulsed ultrasound

Acupuncture• Local shoulder points for pain reduction

Diet & Botanicals• Standard musculoskeletal protocol (see appendix)

Medications: NSAIDs

Surgery• Conservative management of more severe labral

tears is usually unsuccessful• Open or arthroscopic debridment & labral

reattachment ~60-90% success rate to return to preinjury level (repair with suture anchors)

Follow-up

Rehabilitation Program (after surgery or injury)• Consider sling for 1-2 weeks & gripping exercises

or wrist AROM may begin immediately • After 3-6 weeks progress to pain free PROM

that may apply gentle stress to biceps long head tendon; begin basic scapular strengthening

• 6-8 weeks progress to active assisted ROM (AAROM) in flexion (less than 90º); progress to more advanced scapular training (elastic tubing exercises); consider ergonomic evaluation at this time to begin shoulder proprioceptive retraining

• 8-10 weeks: full ROM should be possible switch to basic shoulder strengthening exercises - carefully monitor activities that challenge biceps

• 10-14 weeks: eccentric training can begin & endurance activity can be started (plyometrics)

• 14+ weeks: time to consider return to play/work at near normal level (but start slowly)

Prognosis• Minor tears may respond well to conservative

care, however with repeated injury may progress to more severe tears ultimately requiring surgery

• With concomitant injuries (instability, rotator cuff tears, etc.) prognosis is reduced

Biceps Load Test II

MRI: inferior prolapse of superior labrum (see arrow)


Shoulder &

Arm


Glenohumeral Arthritis

BasicsDefinition: progressive degradation & damage to the

glenohumeral joint articular surfaces that can lead to inflammation and painArthrosis = degeneration in jointArthritis = inflammation of joint

Pathophysiology:• Progressive wear & tear damage to the GH

joint articular surfaces result in asymmetric narrowing of the joint space which progresses to subchondral sclerosis & osteophyte formation; later with complete loss of articular cartilage & finally bone destruction

Demographics Incidence: ~20% of elderly population (common) Age: usually > 65 yrs (possible 40+ yrs) Gender: male > female (2:1)Genetics: unclear but there is familial predisposition Risk factors:

• Prior injury or repetitive stress use of shoulder• Joint infection, Rheumatoid arthritis• Ligament or Rotator cuff tear (GH instability)• Paget’s disease, Lyme disease• Osteonecrosis (stages by Ficat System below)

Stage Clinical description

1 X-ray shows mottling of trabeculae with resorption & normal shape of the head

2 X-ray shows a crescent sign (ie, meniscus-shaped area of sclerosis)

3 Collapse of the articular surface (loss of joint space)

4 Arthritic changes in the GH joint occur secondary to collapse of articular surface

Diagnosis

History• Insidious onset of shoulder pain & discomfort -

often ‘stiff’ in the morning, better with mild activity then worse with excessive activity

• Pain is better with rest or heat, pain may change with variation in barometric pressure

• Crepitus with motion (snapping & popping)• Possible loss of ROM & affected ADLs

PhysicalInspection: look for signs of wasting & asymmetry

over shoulder & upper back/neck

Palpation: possible tenderness over GH capsule• MFTP & myospasm of upper back neck &

shoulder musculatureMotion: general ↓ in AROM with possible pain• PROM - may reveal clicking or popping (crepitus)

with limited or firm abnormal end-feels• RROM - muscle weakness due to painNeurovascular: usually WNL

Differential Diagnosis • Frozen shoulder (Adhesive capsulitis)• GH instability, Supraspinatus tear• Labral tear or Rotator cuff tendinopathy• Cervical radiculopathy

Special Test• (+) Apley’s scratch tests• (+) Ellman’s compression rotation test - humeral

head is compressed into the glenoid fossa and the shoulder is internally and externally rotated

Ellman’s Compression Rotation Test(look for pain or crepitus with movement)

Apley Inferior

Apley Superior


Sho

ulde

r &

Arm


Glenohumeral ArthritisDiagnostic Imaging• X-ray: definitive diagnosis - joint space loss

possible osteophyte formation (see arrows below) • Superior humeral displacement indicates co-

existing supraspinatus tear• MRI: useful to assess soft tissue involvement

(labral or rotator cuff tear)

Laboratory• Consider CBC with differential, chem screen or

arthritis panel to rule-in/out other causes

Treatment

General Measures• Conservative care is good to relieve symptoms &

slow degeneration, but often has minimal effect on reversal of degenerative changes

• General pain control, NSAIDs, hot packs• Stretching to maintain normal ROM

Massage Therapy• Focus on shoulder & cervical-thoracic regions• Swedish, MFTP therapy, myofascial release

Osseous Mobes/Manipulation• Shoulder manip/mobes are indicated if there is

decreased ROM (contraindicated in hypermobility)• Also address cervical & thoracic subluxations

Electrotherapy• Consider ultrasound to increase local blood flow• TENS for pain management

Acupuncture - local shoulder points• BL11, LI4, 14 & 15, SI 3, 10 & 12, SJ5 & SJ14

Diet & Botanicals• MSM & glucosamine supplementation• Hypoallergenic diet (reduce night shades)• Emphasize good fats: olive oil, fish & flax, limit

trans and long chain saturated fatty acids• Increase fruit & vegetable intake for antioxidant

benefits• Limit sugar & maintain healthy body weight

(adipose tissue can release pro-inflammatory cytokines)

Medications• Acetaminophen, ibuprofen, celebrex• Topical NSAIDs, capsaicin cream• Corticosteroid injection (controversial) - may lead

to further cartilage, bone & tendon damage for only short term pain reduction

Surgery• If conservative treatment fails to offer relief,

consider surgical referral for arthroplasty (joint replacement)

Follow-up

Rehabilitation Program• Maintain as many ADLs as possible, avoid

activities that aggravate symptoms• Use good warm-up techniques - pendulum arm

swings• Consider water aerobics followed by hot-tub• Occupational therapy

Prevention/Patient Education• Avoid aggravating position/activities both at work

& sleeping (consider a new mattress)• Do not perform heavy lifting or ballistic actions

with shoulder• Stretch & rest during acute flare-ups

Prognosis• Fair to good prognosis for symptomatic relief,

however there is no conservative cure given the progressive nature of this condition

• Failure of conservative care warrants a surgical consultation

Glenohumeral degeneration (arrows denote osteophyte formation)


Shoulder &

Arm


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