Shoulder Region Examination and Intervention

what is the purpose of manual muscle testing

to provide resistance throughout active range of motion in order to obtain a relative picture of a patient's strength within a particular muscle

what are the three examination principles

- a thorough history is imperative

- obtain baseline measures and retest throughout examination and treatment

- the concordant sign or reproducible sign is the pain or symptom that is familiar with the patient

what is a concordant sign

pain or symptom that is familiar to the patient

what are the shoulder MMTs we should be familiar with

- flexion

- extension

- abduction

- horizontal abduction

- horizontal adduction

- internal rotation

- external rotation

what are the scapular MMTs we should be familiar with

- elevation

- adduction

- adduction/depression

- adduction/downward rotation

- abduction/upward rotation

if pain is reproduced during MMTs, what might this indicate

muscle or contractile lesion

- not always but possible

what are the examination and correction principles for shoulder flexibility

- movement faults result from a failure to move around the path of the axis of rotation of a joint

- muscles which are lengthened (overstretched) will test weak

- a short and tight muscle is not necessarily a strong muscle

- muscle balance may be restored via contraction of lengthened (weakened) muscle, and stretching the short and tight muscle

how may someone compensate when testing shoulder external rotator flexibility

bring shoulder up off table

how might someone compensate when testing shoulder internal rotator flexibility

arch their back / lengthen core

when do we perform shoulder special tests during our examination

Last!!!

- we want to rule in or out more common pathologies earlier in the examination

- special tests often take up time, and we want to have a good idea of what we are testing before throwing a dart blindly

what are the two special tests used for biceps tendinopathy

- Speed's

- Yergason's

what is Speed's test

test for biceps tendinopathy

- patient standing and flex shoulder to 90 degrees

- supinate forearm

- add resistance to distal forearm while palpating biceps tendon

- reproduction of symptoms is positive test

what is Yergason's test

test for biceps tendinopathy

- patient seated or standing, flex elbow to 90 degrees

- passively pronate forearm

- patient turns palm towards ceiling against resistance, while PT palpates biceps tendon

- positive test is reproduction of symptoms

what are the tests used for subacromial pain (impingement) syndrome

- painful arc

- Neer

- Hawkins-Kennedy

- empty can

- rotator cuff manual resistive tests

what is the test cluster for shoulder impingement syndrome (SIS)

- Hawkins-Kennedy: shoulder 90-90 (positive test with passive IR)

- painful arc catching at 60-120

- infraspinatis muscle test (resisted ER)

what is the painful arc test

test for subacromial pain syndrome

- pain occurs midway through AROM may indicate subacromial pain syndrome

what is the Neer test

test for subacromial pain syndrome

- take patient shoulder into full flexion while maintaining IR while looking for pain

- apply overpressure into flexion and adduction on scapula and GH if no pain is felt

what is the Hawkins-Kennedy test

test for subacromial pain syndrome

- passively take patients arm into flexion and horizontal adduction, and stabilize the top of the shoulder

- IR humerus looking for ROM and reproduction of symptoms

what are some tests we can use for a rotator cuff tear

- atrophy of rotator cuff muscles (complete tear)

- positive drop arm test (complete tear)

- painful arc

- resisted movement of shoulder

what is the test cluster for a rotator cuff tear

Drop Arm Sign

- full active scaption with pain or a sudden drop

Painful arc

- painful catching at 60-120 degrees

infraspinatus MMT (resisted ER in neutral shoulder position)

- Rotator cuff MMTs

what is the drop arm test

assess for supraspinatus muscle tear

- passively abduct patient arm to 90 degrees while maintaining neutral rotation

- ask patient to hold position

- if patient can hold arm, ask patient to lower arm slowly

- if patient cannot hold arm, or slowly lower arm, test is indicative of supraspinatus tear

what are the special tests used for AC joint instability

- AC shear

- Sulcus sign

- AC observation and palpation

what are the special tests for shoulder instability

- Sulcus sign

- jerk test

- anterior apprehension with relocation test

what is the Sulcus sign

test for laxity or labral tear

- provide distal glide to humerus

- see if a depression is found inferior to the acromion

what is the jerk test

test for posterioinferior labral lesion

- bring shoulder out to 90 degrees, internally rotate, and horizontally adduct arm to see if a click/clunk is found in the shoulder

what is the anterior apprehension with relocation test

test for anterior dislocation

- externally rotate humerus

- if apprehension or fear is seen, positive test

- provide a posterior translation of the humerus to see if it relocates

what are the special tests for a shoulder labral tear

- biceps load II

- anterior slide test

- crank test

- RSERT

what is a biceps load II test

test for SLAP lesion

- bring humerus into abduction (120) and flex elbow (90)

- resist elbow flexion to see if pain is reproduced

what is an anterior slide test

- patient places elbow in hip

- bring elbow toward PT behind patient

- PT provides force against patient force to see if there is an anterior labral tear

- see if there is anterior translation of humerus

what is a crank test

rule in or out labral pathology

- abduct shoulder to 160 in supine

- humerus is internally and externally rotated with elbow flexed to 90

- clunk or click may indicate labral tear

what is a RSERT test

- patient externally rotates

- PT resists motion

- pain, click, or clunk may be indicative of SLAP lesion

what are the special tests used for thoracic outlet syndrome

Grade C (weak) evidence

- Adson's test

- costoclavicular

- hyperabduction (Allen maneuver)

- Roo's

- lateral flexion rotation

what is Adson's test

- test for thoracic outlet syndrome

- patient rotates neck toward examiner

- PT abducts and externally rotates humerus (stretches pec minor)

- this motion would reproduce pain or symptoms related to thoracic outlet syndrome

what is the costolclavicular test

- test for thoracic outlet syndrome

- PT abducts and externally rotates humerus (stretches pec minor)

- patient inhales and narrows outlet between ribs and clavicle

- reproduction of symptoms, loss of pules in distal extremity is a positive test

what is hyperabduction (Allen maneuver)

- test for thoracic outlet syndrome

- PT raises arm overhead and checks for pulse in distal extremity

- may not be reliable due to position of artery relative to heart

what is Roo's test

test for thoracic outlet syndrome

- place arms in 90-90 and open close hand for 1 minute

- reproduction of symptoms is positive

what are the three neural tension tests

- median

- radial

- ulnar

true or false: shoulder instability and labral tears can be linked to one another

True!

- special tests for these two classifications may overlap

true or false: special tests for subacromial impingement and rotator cuff tears may be linked to one another

True!

what are some questions you can ask to help narrow down your classification

- can you tell me where your pain is located (does the pain change locations; radicular or referred)

- how would you rate this pain on a scale from 0-10

- what brought on your pain (mechanism of injury)

- is the pain constant or intermittent (disease/neuromusculoskeletal/prognosis)

- how long has this pain been a problem

- is the pain getting any better or worse

- how would you describe the pain

- what makes your pain better or worse

- have you had any imaging

- what is your past medical or surgical history (potential red flags)

when do we see contractile tissue causing pain at rest

during the acute phase

what are red flags related to the upper quarter

- cervical central cord lesion

- cervical spine fracture or ligamentous instability

- pancoast tumor

- septic arthritis

how can we classify cervical radiculopathy

Neck pain with radiating pain

- entrapment of cervical nerve roots in the neuroforamina, resulting in neck and arm pain or parasthesia

how can we classify AC joint sprain

Shoulder pain with movement coordination impairments

- AC joint separation resulting from a FOOSH or landing directly on the tip of the shoulder

how can we classify adhesive capsulitis or frozen shoulder

Shoulder pain with mobility deficits

- contracture of the GH joint capsule and surrounding soft tissues

how can we classify labral tears, SLAP lesions, Bankhart lesions, anterior or multidirectional instability

Shoulder pain with movement coordination impairments

- disruption of the labrum and or capsuloligamentous structures of the GH joint (dislocation)

how can we classify sub-acromial pain syndrome (impingement syndrome)

Shoulder pain with mobility deficits

- subacromial pain resulting in irritation or tears of the bursa or rotator cuff or biceps

how can we classify thoracic outlet syndrome

Shoulder pain with referred pain

- a combination of neck and arm complaints often related to compression of the neuro and/or vascular elements at soft tissue or bony entrapment sites

what are some outcome measures we may use for shoulder region classification

- ASES

- DASH

- Neck Disability Index

- Shoulder Score

- SPADI

what are the typical activity limitations we see for people with shoulder conditions

- carrying objects in arms

- desk work

- lifting objects

- monitor viewing

- pushing objects

- putting down objects

- reaching overhead

- reaching behind back

- sleeping

- sports

- throwing

what are some things we want to consider when prescribing interventions for shoulder conditions

- Biomechanical (AROM, length tension relationships, starting position)

- Neuromuscular (sensory input, sensory facilitation or inhibition)

- Cognitive/effective

- Physiologic (frequency, duration, speed, etc.)

what are some other things we want to consider when prescribing therapeutic exercise

- tissue repair

- training principles

- load management

- recovery

- motor learning

how can we monitor patient response to guide intervention

- clinical practice guidelines

- patient response systems (concordant/reproducible sign)

- "test become treatment"

what are four things that are appropriate to consider when assigning shoulder interventions

- patient education (Grade B: moderate evidence)

- manual therapy

- therapeutic exercise

- modalities

what are some questions we want to answer during patient education

- What's going on

- How long will it take

- What are we going to do during your care

- What can you do to help yourself

what are some things we can do to promote patient education

We want to utilize patient education that

- describes the natural course of the disease or impairment

- promotes activity modification to encourage functional, pain free ROM

- match the intensity of stretching to patient's current level of irritability

True or false: thoracic manual therapy should not be used in shoulder intervention

False!

- thoracic MT may provide neurophysiologic relief to the patient, and is proven to help patient's in recovery

what are the parameters for therapeutic exercise

- directional preference

- flexibility

- mobility

- stability

- strengthening

what are some interventions we would want to use for AC joint sprain

- Patient education

- Manual therapy

- Therapeutic exercise

- Physical agents

- AC joint AP and SI mobilizations

- GH oscillations grades I-II

- GH inferior glide

- Scapulothoracic mobilization

- Motor control

- Strengthening

what is necessary for the treatment of adhesive capsulitis

prolonged static stretching to improve extensibility of joint capsule

true or false: adhesive capsulitis presents pain without motion

False!

according to the CPG, what are the grades of evidence linked with adhesive capsulitis treatment

Patient education

- grade B

Manual therapy

- mobilizations and manipulations: (grade C)

Therapeutic exercise

- stretching (grade B)

- corticosteroid injection (grade A)

Physical agents

- Heat, US, E-stim (grade C)

what might we use for patients with high irritability adhesive capsulitis

- heat (ultrasound) and E-Stim

- home management training

- grade 1-2 joint mobilization

- pain free PROM and AROM

what might we use for patients with moderate irritability adhesive capsulitis

- heat and E-Stim

- home management training

- moderate joint mobilizations (grades 2-3)

- gentle to moderate stretching exercise

- neuromuscular reeducation to reinforce normal scapulothoracic movement

what might we use for patients with low irritability adhesive capsulitis

- home management training

- end range joint mobilizations (grades 3-4)

- stretching exercises into tissue resistance

- neuromuscular reeducation

what are some MT and mobilization techniques for adhesive capsulitis

- grades 1-2 GH oscillations

- GH inferior glide assessment and mobilization

- GH anterior glide assessment and mobilization

- GH posterior glide assessment and mobilization

- scapulothoracic assessment and mobilization

- AC joint mobilization

what are some exercises we can perform for patients with adhesive capsulitis

- pendulums (high irritability)

- low to high repetition PROM with end range stretch (high to moderate irritability)

- cane active assisted ER (high to moderate irritability)

- cane active assisted elevation (high to moderate irritability)

- low to high repetition AROM with end range stretch (moderate irritability)

- side lying sleeper stretch, inferior capsule stretch (moderate irritability)

- hand behind back towel stretching, pulleys (moderate irritability)

true or false: corticosteroid injection combined with shoulder mobility and stretching exercise was beneficial to patients with adhesive capsulitis for short term relief

True!

- one or the other is often not as beneficial

when correcting shoulder mobility and stability deficits, what should we try to restore

path of instantaneous axis of rotation of the joint

- activation of core muscles may assist in this

what are some exercises we can perform for patients with labral tears, SLAP lesions, Bankart lesions, and anterior or multidirectional instability (High Irritability)

- external oblique contraction

- excessive humeral anterior glide postural assessment and correction

- wall slides

what are some exercises we can perform for patients with labral tears, SLAP lesions, Bankart lesions, and anterior or multidirectional instability (Moderate Irritability)

- supine IR, ER AROM precision training

- prone IR, ER AROM with lack of scapular control and correction

what are some exercises we can perform for patients with labral tears, SLAP lesions, Bankart lesions, and anterior or multidirectional instability (Low Irritability)

- protraction plank

- quadraped rolling on ball for instability

- posterior shoulder endurance training

what are some interventions we can use for subacromial pain syndrome (High Irritability)

- GH inferior glide assessment and mobilization

what are some interventions we can use for subacromial pain syndrome (Moderate Irritability)

- side lying sleeper stretch, posterior/inferior capsule stretch

- scapular stabilization

- active elevation to 90 with optimal scapular alignment

- resisted shoulder abduction in the scapular plane

- resisted shoulder ER at 90 degrees abduction

- quadruped push up plus camel

what are some interventions we can use for subacromial pain syndrome (Low Irritability)

- body blade below 60 degrees abduction

- lawn mower pull

- protraction plank

- quadruped rolling on ball

- prone scapular retraction Y and T

what are some interventions we can use for thoracic outlet syndrome

- first rib mobilization

- scalene self stretch

- pec minor stretch

- neurodynamics

what are some interventions we can use for adverse neural tension

- median, radial, ulnar nerve tensioner (low irritability)

- median, radial, ulnar nerve slider (moderate to high irritability)

true or false: patients who have thoracic outlet syndrome may benefit from centralization exercises

True!

- in some cases

what should guide shoulder post op rehab

patient response and stage of tissue healing

what may need to occur due to subacromial pain syndrome

subacromial decompression / acromioplasty

what may need to occur due to a rotator cuff tear

rotator cuff repair due to poor self healing

what may need to occur due to a bankhart lesion

bankhart repair

what may need to occur due to a SLAP lesion

SLAP lesion repair

what are the modalities we can use for patients with adhesive capsulitis

shortwave US, or E-Stim combined with mobility and strengthening exercise to reduce pain and improve shoulder ROM