SECTION D: SHOULDER DISORDERS

CONDITION/DISORDER SYNONYMS

• Separated Shoulder

• AC separation

• AC dislocation

• Shoulder Separation

ICD-9-CM CODES

• 840.0 Acromioclavicular (joint or ligament) sprain

• 831.04 Closed dislocation of acromioclavicular (joint)

• 831.14 Open dislocation of acromioclavicular (joint)

ICD-10-CM CODES

• S43.109A Unspecified dislocation of unspecified acromioclavicular joint, initial encounter

• S43.50XA Sprain of unspecified acromioclavicular joint, initial encounter

PREFERRED PRACTICE PATTERN

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation¹

KEY FEATURES

Description

• Inflammation, irritation, or separation of the joint between the clavicle and acromion (AC joint)²

• Three ligaments of stability:

  • Acromioclavicular ligament²

  • Coracoacromial ligament

  • Coracoclavicular ligament: Made up of the conoid ligament and trapezoid ligament²

Essentials of Diagnosis

• Patient history and clinical examination

• X-ray

• Occurs most often from falling on an outstretched arm or hand

• AC separation occurs when the ligaments are completely torn and there is a dislocation of the joint

• Look for separation of the clavicle and acromion

• Step deformity often noticed when the clavicle is raised due to ligament tearing

• Six grades of sprain to separation: Rockwood Scale

  • Grade I

    • Slight displacement of the joint

    • Partially torn AC ligament

    • Separation <4 mm

  • Grade II

    • Partial dislocation of the joint

    • Complete disruption tear of the AC ligament

    • Partial disruption of the coracoclavicular ligament

    • Separation >5 mm

  • Grade III

    • Partial dislocation of the joint

    • Complete disruption tear of the AC ligament

    • Complete disruption/rupture of the coracoclavicular ligament

  • Grade IV

    • Dislocation of the joint

    • Posterior displacement

    • Requires surgery

  • Grade V

    • Dislocation of the joint

    • Superior displacement

    • Requires surgery

  • Grade VI

    • Dislocation of the joint

    • Inferior displacement

    • Requires surgery

General Considerations

• Not a synovial joint.

• Osteoarthritis is common without treatment or with prolonged instability.

Demographics

• Predominately in individuals with a history of activities involving overhead reach: Swimming, tennis, and baseball as well as with occupational activities involving repetitive overhead activity

CLINICAL FINDINGS

Functional Implications

• May limit overhead activities, especially lifting

• May limit throwing and other rapid arm movements

Possible Contributing Causes

• Trauma

• Direct blow on the lateral tip of the acromion

• Rotator cuff weakness

• Shoulder instability

• Fall on outstretched hand

Differential Diagnosis

• AC joint arthritis

• Bicep tear

• Clavicle fracture

• Labral tear³

• Rotator cuff impingement

• Rotator cuff tear

• Shoulder instability

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• Radiographs while a patient holds a weight at his or her side

• MRI

Findings and Interpretation

• Radiographs will show a gap/step deformity between the clavicle and acromion.

• MRI will help evaluate ligament for structural changes or rupture.⁴

• Swelling may be minimal with Grade I separation.

TREATMENT

Medication

• Nonsteroidal anti-inflammatory drugs (NSAIDs)³

• Steroid injection

MEDICAL PROCEDURES

• Surgical repair of Grades IV through VI

• Mumford procedure

• Weaver–Dunn procedure

IMPAIRMENTS

• Inability to carry a briefcase due to the traction on the arm

• Inability to perform overhead activities such as swimming, baseball, or tennis

• Inability to perform jobs involving repetitive overhead reaching, lifting, or carrying

TESTS AND MEASURES

• Acromioclavicular shear test³

• O’Brien test³

• Acromioclavicular resisted extension test³

• Crossover impingement/horizontal adduction test³

• Pain provocation test³

• Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function

• Shoulder Pain and Disability Index³

INTERVENTION

• Acute

  • Rest

  • Electrotherapeutic modalities

  • Ice⁵

  • Transverse friction massage

  • Gentle stretching and AROM

  • Hemiplegic sling that draws the humeral head upward without keeping the shoulder internally rotated

  • Taping of the AC joint to unload weight of the arm⁶

• Post-acute

  • Once pain and inflammation are controlled, progress through further active exercises in pain-free ranges

  • Posterior glenohumeral glides

  • Progressive closed-chain strengthening once pain-free

• Injury prevention

  • Avoid activities that involve repetitive or excessive overhead movement

FUNCTIONAL GOALS

• Patient will be able to

  • Carry a brief case pain-free.

  • Resume all overhead activities and ADLs without exacerbating inflammation.

  • Resume all sports activities as prior to onset.

  • Resume all reach activities without symptoms or limitation.

  • Resume all lifting activities without limitations due to pain or weakness of the upper extremities.

  • Drive without return of anterior shoulder pain.

PROGNOSIS

• Patients with Grade III separation require 4 to 5 months of rehabilitation, but do not always need surgery.

• Symptoms improve and resolve with treatment, rest, and unloading of weight on the arm.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Separated shoulder

• AC separation

• AC dislocation

• Shoulder separation

ICD-9-CM CODE

• 840.0 Acromioclavicular (joint, ligament) sprain

ICD-10-CM CODE

• S43.50XA Sprain of unspecified acromioclavicular joint, initial encounter

PREFERRED PRACTICE PATTERN

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation¹

KEY FEATURES

Description

• Inflammation, irritation, or separation of the joint between the clavicle and acromion (AC joint)²

• Three ligaments of stability:

  • Acromioclavicular ligament²

  • Coracoacromial ligament

  • Coracoclavicular ligament: Made up of the Conoid ligament and trapezoid ligament²

Essentials of Diagnosis

• Patient history and clinical examination

• X-ray

• Occurs most often from falling on an outstretched arm or hand

• Occurs when the ligaments are completely torn and there is a dislocation of the joint

• Look for separation of the clavicle and acromion

• Step deformity often noticed when the clavicle is raised due to ligament tearing

• Six grades of sprain to separation: Rockwood Scale

  • Grade I

    • Slight displacement of the joint

    • Partially torn AC ligament

    • Separation <4 mm

  • Grade II

    • Partial dislocation of the joint

    • Complete disruption tear of the AC ligament

    • Partial disruption of the coracoclavicular ligament

    • Separation >5 mm

  • Grade III

    • Partial dislocation of the joint

    • Complete disruption tear of the AC ligament

    • Complete disruption/rupture of the coracoclavicular ligament

  • Grade IV

    • Dislocation of the joint

    • Posterior displacement

    • Requires surgery

  • Grade V

    • Dislocation of the joint

    • Superior displacement

    • Requires surgery

  • Grade VI

    • Dislocation of the joint

    • Inferior displacement

    • Requires surgery

General Considerations

• No synovial joint

• Osteoarthritis is common without treatment or with prolonged instability

Demographics

• Predominately in individuals with a history of activities involving overhead reach: Swimming, tennis, and baseball as well as with occupational activities involving repetitive overhead activity

CLINICAL FINDINGS

Functional Implications

• May limit overhead activities, especially lifting

• May limit throwing and other rapid arm movements

Possible Contributing Causes

• Frequent and prolonged overhead activity

• Prolonged repetitive use of the involved arm

• Poor posture (i.e., rounded shoulders)

• Anterior displacement of the humeral head

• Rotator cuff weakness

• Fall on outstretched hand

• Landing on lateral tip of the acromion

Differential Diagnosis

• Bicep tear

• Bicep tendinopathy

• Labral tear³

• Rotator cuff impingement

• Rotator cuff tear

• Rotator cuff tendinitis

• Subacromial bursitis

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• Radiographs while patient holds a weight at his or her side

• MRI

FINDINGS AND INTERPRETATION

• Radiographs will show a gap between the clavicle and acromion

• MRI images to evaluate ligament for structural changes or rupture⁴

• Swelling may be minimal with Grade I separation

TREATMENT

Medication

• Nonsteroidal anti-inflammatory drugs (NSAIDs)³

• Steroid injection

MEDICAL PROCEDURES

• Surgical repair of Grades IV through VI

• Mumford procedure

• Weaver–Dunn procedure

IMPAIRMENTS

• Inability to carry a briefcase due to traction on the arm

• Inability to perform overhead activities such as swimming, baseball, or tennis

• Inability to perform jobs involving repetitive overhead reaching or lifting

TESTS AND MEASURES

• Acromioclavicular shear test³

• O’Brien test³

• Acromioclavicular resisted extension test³

• Crossover impingement/horizontal adduction test³

• Pain provocation test³

• Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function

• Shoulder Pain and Disability Index³

INTERVENTION

• Acute

  • Rest

  • Reduce inflammation with NSAIDs and electrotherapeutic modalities

  • Ice/heat⁵

  • Transverse friction massage

  • Gentle stretching and AROM

  • Hemiplegic sling that draws the humeral head upward without keeping the shoulder in internally rotated

  • Taping of the AC joint to unload weight of the arm⁶

• Post-acute

  • Once pain and inflammation are controlled, progress through further active exercises in pain-free ranges

  • Posterior glenohumeral glides

  • Progressive closed-chain strengthening once pain-free

• Injury prevention

  • Avoid activities that involve repetitive or excessive overhead movement

FUNCTIONAL GOALS

• Patient will be able to

  • Carry a brief case pain-free.

  • Resume all overhead activities and ADLs without exacerbating inflammation.

  • Resume all sports activities as prior to onset.

  • Resume all reach activities without symptoms or limitation.

  • Resume all lifting activities without limitations due to pain or weakness of the upper extremities.

  • Drive without return of anterior shoulder pain.

PROGNOSIS

• Patients with Grade III separation require 4 to 5 months of rehabilitation, but do not always need surgery.

• Symptoms improve and resolve with treatment, rest, and unloading of weight on the arm.

• If the injury is the result of overuse, a change in activity and work habits may be needed.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYM

• Frozen shoulder syndrome

ICD-9-CM CODE¹

• 726.0 Adhesive capsulitis of shoulder

ICD-10-CM CODE²

• M75.00 Adhesive capsulitis of unspecified shoulder

PREFERRED PRACTICE PATTERN³

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation

KEY FEATURES

Description

• Self-limiting shoulder pain and dysfunction due to:

  • Localized inflammation of the glenohumeral joint capsule

  • Paucity of synovial fluid

  • Fibrosis of the capsule causing adherence to the humeral head

• Three pathologic pathways

  • Primary (idiopathic)

  • Secondary: Can be attributed to a known intrinsic, extrinsic, or systemic cause

  • Tertiary: Postoperative or post-fracture

• Adhesive capsulitis can be divided into four stages

  • Stage 1: “Preadhesive”

    • Near normal range of motion (ROM), pain at end points of motion and mild synovitis

  • Stage 2: “Freezing”

    • Marked loss of motion, pain at end points with thickened read synovitis

  • Stage 3: “Frozen”

    • Marked loss of motion, painless ROM with capsule fibrosis and adhesions

  • Stage 4: “Thawing”

    • Improved glenohumeral motion, painless ROM; no synovitis present

Essentials of Diagnosis

• Extrinsic factors

  • Cardiopulmonary disease

  • Cervical disc

  • CVA

  • Humerus fractures

  • Parkinson disease

• Intrinsic factors

  • Dupuytren disease

  • Rotator cuff tendinitis

  • Rotator cuff tears

  • Biceps tendinitis

  • Calcific tendinitis

• Systemic factors

  • Diabetes mellitus

  • Hypothyroidism

  • Hyperthyroidism

  • Hypoadrenalism

  • Dupuytren disease

Demographics

• Affects 2% to 5% of the general population

• Affects 10% to 38% of patients with thyroid disease or diabetes mellitus

• Primary AC generally affects individuals aged 40 to 65 years

• Greater incidence in females than in males

• Occurrence in one shoulder increases the risk of contralateral shoulder involvement from 5% to 34%

CLINICAL FINDINGS

Functional Implications

• Pain/Limitation with overhead activities

• Pain/Limitation with reaching

• Pain/Limitation with lifting

• Pain/Limitation while dressing

• Pain/Limitation with sustained or repetitive shoulder activities

• Pain at night disrupting sleep

Possible Contributing Causes

• Degenerative changes at the acromioclavicular (AC) joint

• Rotator cuff tendinopathy

• Bicipital tendinopathy

• Humeral fracture

• Capsular tightness

• Increased thoracic kyphosis and suboptimal posture

• History of trauma

• Diabetes mellitus

• Treatment with antiretroviral therapy

Differential Diagnosis

• Cervical radiculopathy

• Full-thickness rotator cuff tear

• Glenohumeral arthritis

• Glenohumeral contracture

• Internal impingement

• Labral tear

• Neuropathy (suprascapular nerve)

• Referred pain from the lungs or diaphragm

• Subacromial impingement

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• Radiograph

  • Glenohumeral joint space

  • OA

  • Allows for secondary causes to be viewed

  • Views: AP, axillary lateral, scapular Y-view

• MRI

  • Not required to make the diagnosis of adhesive capsulitis

  • Usually will demonstrate decreased hydration

  • Tissue quality

  • Capsulolabral and biceps labral pathology

Diagnostic Procedure

• Subacromial injection with lidocaine

Findings and Interpretations

• Subacromial injection with lidocaine: If pain decreases and motion improves, cuff pathology is present

TREATMENT

Medication

• Anti-inflammatory

• Corticosteroid injection

  • Short-term symptom improvement only

MEDICAL PROCEDURE

• Surgery warranted if conservative management ≥6 months yields no change in symptoms

• Arthroscopic surgical release of the capsule

• Manipulation under anesthesia

• Capsular distention

IMPAIRMENTS

• Limited AROM/PROM

• Capsular pattern of accessory hypomobility

• Impaired or suboptimal posture

• Muscle imbalances

  • Rotator cuff weakness

  • Periscapular muscle weakness (particularly upward rotators and depressors/retractors)

  • Pectoralis minor/major, tightness in latissimus

• Decreased thoracic ROM

• Pain with active movements away from the body and reaching hand behind back

TESTS AND MEASURES

• Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function

• Inferior glenohumeral glide

INTERVENTION

• Acute stage

  • Rest, ice/cryotherapy, and activity modification (avoid aggravating positions)

  • Specific home exercise plan with short stretches (1–5 seconds)

  • Low-grade (I and II) mobilizations

  • Intra-articular steroid injections by physician if highly irritable and severe functional limitations

• Sub-acute and chronic stages

  • Address joint impairments

    • GH hypomobility (mobilization grades I–IV)

    • Thoracic spine hypomobility (mobilization/manipulation)

  • Address muscle imbalances

    • Rotator cuff strength and endurance exercises

    • Muscle length of pectoralis major, minor, latissimus, and other muscles with decreased length

  • Strengthening of scapular musculature

    • Lower trapezius

    • Serratus anterior

    • Other scapular stabilizers

  • Functional activities such as dressing (depending on work or recreational desires)

  • Address pain and inflammation

    • Ice/Cryotherapy

    • Rest

    • Activity modification (avoiding impingement positions)

    • Ultrasound, phonophoresis, iontophoresis

    • Electrical stimulation

  • Address lack of flexibility through stretching

    • Posterior capsule/posterior cuff

    • Pectoralis minor

    • Pectoralis major

    • Latissimus dorsi

  • Address joint mobility

    • Posterior humeral glides

    • Inferior humeral glides

    • Anterior humeral glides

    • Thoracic mobilization/manipulation

    • Scapulothoracic mobility

      • Distraction

      • Retraction

      • Upward rotation

      • Posterior tip

FUNCTIONAL GOALS

• Patient will be able to

  • Move upper extremity through full range of elevation without pain while reaching in the cabinet for a cup.

  • Reach back pocket (or fasten brassier, if female) without pain

  • Reach for a gallon of milk without pain.

PROGNOSIS

• Dependent on current stage of condition.

• Patient’s ability to control exacerbating activities and perform the optimal dosage of therapeutic exercise.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Biceps distal tear

• Biceps proximal tear

ICD-9-CM CODES

• 727.62 Nontraumatic rupture of the tendons of biceps (long head)

• 840.8 Sprains and strains of other specified sites of shoulder and upper arm

ICD-10-CM CODES

• M66.829 Spontaneous rupture of other tendons, unspecified upper arm

• S46.119A Strain of muscle, fascia and tendon of long head of biceps, unspecified arm, initial encounter

PREFERRED PRACTICE PATTERNS

• 4D: Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation¹

KEY FEATURES

Description

• Rupture of the biceps brachii tendon either complete or partial

• Distal rupture will cause swelling, bruising, and a gap in front of elbow created by absence of tendon

  • Avulsion of the tendon from the radial tuberosity

• Proximal rupture will cause bulging, bruising, and gathering of the muscle (“Popeye” sign may indicate rupture)

  • Avulsion of the long head of the biceps brachii from the superior rim of the anterior glenoid labrum

Essentials of Diagnosis

• History and clinical examination

• Diagnosis of proximal tear often easily visible with observation due to bulge left by deformed muscle (“Popeye sign”)

• Diagnosis of distal tear

  • Palpation of gap at the elbow

  • Manually testing supination strength compared with uninvolved side

  • Sudden event trauma

• Partial tears harder to diagnose and may require manually testing bicep muscle for signs of pain with activation of muscle

• Occurs from a sudden high force, typically with weightlifting (i.e., biceps curls or activities with elbow flexion), eccentric force

• May arise from a repetitive type activity that leads to a gradual degeneration

• MRI to show both partial and complete tendon tears

General Considerations

• History of repetitive motion, especially activities overhead

• Common in swimming, tennis, baseball, and with occupational activities involving repetitive or overhead activity due to microtrauma

• Smoking affects overall nutrition of tendon due to nicotine side effects

• Corticosteroid medications has been linked to decreased muscle and tendon strength

Demographics

• Predominately individuals involved in repetitive activities in sports or work

• Long head tears are seen in the fourth decade of life

CLINICAL FINDINGS

Functional Implications

• For proximal long head tear mild weakness can persist in elbow flexion

• For distal tears significant loss of supination will limit patient from performing activities that include motions involving rotating forearm from palm down to palm up

• Overhead activities may be limited

• Inability to lift heavy objects

Possible Contributing Causes

• Frequent and prolonged overhead activity

• Prolonged repetitive use of the involved arm

• Poor posture (rounded shoulders)

• Anteriorly displaced humeral head

• Rotator cuff weakness

• Steroid use

• Aging

• Systemic diseases, such a rheumatoid arthritis or diabetes

• Previous bicipital injury

Differential Diagnosis

• Bicep tendinopathy

• Labral tear²

• Pectoralis muscle tear

• Rotator cuff impingement

• Rotator cuff tear

• Rotator cuff tendonitis

• Subacromial bursitis

• Upper anterior arm compartment syndrome

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• Diagnostic ultrasound

• Radiographs

• MRI³

FINDINGS AND INTERPRETATION

• Radiographs may show calcification or other bony abnormalities of the shoulder

• MRI to evaluate soft tissue for structural changes or rupture³

• Acute tears will demonstrate hemorrhage and edema and chronic tears will demonstrate fibrosis and scarring

TREATMENT

Medication

• NSAIDs²

• Steroid injection

MEDICAL PROCEDURE

• Surgery to repair tendon

IMPAIRMENTS

• Debilitating pain, limiting movement and exertion

• Decreased torque and work/repetition, especially with shoulder adduction

• Inability to perform overhead activities, such as swimming, baseball, or tennis

• Inability to perform jobs involving repetitive overhead reaching or lifting

TESTS AND MEASURES

• Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function

• Functional reach test

• Yergason test²

• Speed test²

• Clunk test²

• O’Brien test²

• Anterior slide test²

• Biceps load test²

• Compression–rotation test²

• Pronated load test²

• Pain provocation test²

• Resisted supination external rotation test²

• Shoulder pain and disability index²

INTERVENTION

• Acute

  • Rest

  • Reduce inflammation with NSAIDs

  • Pulsed ultrasound

  • Soft-tissue massage

  • Electrotherapy

  • Ice/Heat⁴

  • Gentle AROM

  • Posture correction

• Post-acute

  • Once pain and inflammation are controlled, progress through further active exercises in pain-free ranges

  • Progress stretching

  • Posterior glenohumeral glides

  • Progressive strengthening once pain-free

• Injury prevention

  • Avoid activities that place repetitive, excessive stress on the tendon

  • Cross-training

  • Warm-up and stretching prior to activity

  • Use proper ergonomics

  • Keep muscles strong and flexible

FUNCTIONAL GOALS

• Patient will be able to resume

  • All overhead activities and ADLs without exacerbating inflammation.

  • All sport activities as prior to onset.

  • All reach activities without symptoms or limitation.

  • All lifting activities without limitation from pain or weakness in upper extremities.

  • Driving without return of anterior shoulder pain.

PROGNOSIS

• For proximal long head bicep tears surgery is rarely performed.

  • Older, less active patient will resume prior activities with only slight decrease in overall strength.

  • For athletes and younger patients, surgery may be to attempt restoring full return to activity and prior strength levels.

• Distal tendon tears are generally more uncommon; however, surgery is required to prevent severe loss of prior strength, especially supination.

• Symptoms should improve and resolve with treatment and rest.

• If injury is the result of overuse, changes in activity and work habits may be needed.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Biceps tendinitis

• Biceps tendonitis

• Bicep tenosynovitis

• Bicipital tenosynovitis

ICD-9-CM CODE

• 726.12 Bicipital tenosynovitis

ICD-10-CM CODE

• M75.20 Bicipital tendinitis, unspecified shoulder

PREFERRED PRACTICE PATTERN

• 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation¹

KEY FEATURES

Description

• Irritation of the long head of biceps tendon

• Occurs most often from repetitive motion injuries or impingement syndrome, but can occur with sudden strain/stress to the tendon, or with rotator cuff tendonitis or pathology

• Early stages

  • Tendon becomes swollen and red

  • As tendinosis develops, the tendon sheath may thicken

• Late stages

  • Chronic irritation may result in fraying of the tendon or necrosis

  • May progress to rupture

• Rupture will cause bulging, bruising, and gathering of the muscle (“Popeye” sign may indicate rupture)

Essentials of Diagnosis

• History and clinical examination

• Look for signs of pain with A/PROM, resistance, palpation, and specific tests for the bicep tendon

• Pain with palpation of the bicipital groove with arm at 10 degrees of internal rotation

• Pain with passive stretch of the bicep

General Considerations

• History of repetitive motion, especially activities overhead

• Common in swimming, tennis, baseball, and with occupational activities involving repetitive or overhead activity due to micro trauma

• Can be seen in individuals with other system-wide diseases such as rheumatoid arthritis or diabetes

• Often occurs secondary to impingement syndrome or rotator cuff injury

Demographics

• Predominately individuals involved in repetitive activities in sports or work

CLINICAL FINDINGS

Functional Implications

• Limited overhead activities, especially lifting

• Limited throwing and other rapid arm movements

Possible Contributing Causes

• Frequent and prolonged overhead activity

• Prolonged repetitive use of the involved arm

• Poor posture (rounded shoulders)

• Anteriorly displaced humeral head

• Rotator cuff weakness

• Aging

• Systemic diseases, such as rheumatoid arthritis or diabetes

• Previous bicipital or FOOSH injury

• Labral tears

Differential Diagnosis

• Biceps calcific tendinitis

• Bicep tear

• Labral tear²

• Pectoralis tendonitis

• Rotator cuff impingement

• Rotator cuff tear

• Rotator cuff tendonitis

• Sub-acromial bursitis

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• Radiographs looking for calcification or boney abnormalities

• Ultrasound

• MRI³

FINDINGS AND INTERPRETATION

• Radiographs may show calcification or other boney abnormalities of the shoulder

• MRI to evaluate soft tissue for structural changes or rupture³

• Swelling may be apparent

TREATMENT

Medication

• NSAIDs²

• Steroid injection

MEDICAL PROCEDURES

• Arthroscopic debridement of chronic fraying

• Biceps tenodesis in severe chronic cases

• Tenotomy

IMPAIRMENTS

• Inability to perform overhead activities, such as in swimming, baseball, or tennis

• Inability to perform jobs involving repetitive overhead reaching or lifting

TESTS AND MEASURES

• Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function

• Functional reach test

• Yergason’s test²

• Speed’s test²

• Clunk test²

• O’Brien’s test²

• Anterior slide test²

• Biceps load test²

• Compression–rotation test²

• Pronated load test²

• Pain provocation test²

• Resisted supination external rotation test²

• Shoulder pain and disability index²

INTERVENTION

• Acute

  • Rest

  • Reduce inflammation with NSAIDs and electrotherapeutic modalities

  • Ice/Heat⁴

  • Transverse friction massage

  • Gentle stretching and AROM

• Post-acute

  • Once pain and inflammation are controlled, progress through further active exercises in pain-free ranges

  • Progress stretching

  • Posterior glenohumeral glides

  • Progressive strengthening once pain-free

  • Painful eccentric training for 12 weeks

• Injury prevention

  • Avoid activities that place repetitive, excessive stress on the tendon

  • Cross-training

  • Improve technique

  • Warm-up and stretching prior to activity

  • Use proper ergonomics

  • Keep muscles strong and flexible

FUNCTIONAL GOALS

• Patient will be able to resume

  • All overhead activities and ADLs without exacerbating inflammation.

  • All sport activities as prior to onset.

  • All reach activities without symptoms or limitation.

  • All lifting activities without limitation from pain or weakness in upper extremities.

  • Driving without return of anterior shoulder pain.

PROGNOSIS

• Symptoms should improve and resolve with treatment and rest.

• If injury is the result of overuse, changes in activity and work habits may be needed.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYM

• Shoulder bursitis

ICD-9-CM CODE¹

• 726.19 Other specified disorders of bursae and tendons in shoulder region

ICD-10-CM CODE²

• M75.80 Other shoulder lesions, unspecified shoulder

PREFERRED PRACTICE PATTERN³

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation

KEY FEATURES

Description

• Shoulder pain and dysfunction due to compression and abrasion of the subacromial bursa beneath the coracoacromial arch.

• The coracoacromial arch consists of the undersurface of the acromion, coracoacromial ligament as well as the undersurface of the acromioclavicular (AC) joint.

• Subacromial bursa lies beneath the acromion and serves to cushion the rotator cuff tendons from the osseous undersurface of the acromion.

• Subacromial bursitis results when the subacromial bursa fills with blood and serous fluid as response to either acute or repeated micro-trauma (compression and/or abrasion).

  • Fibrotic changes in the bursa can result from chronic impingement or stress.

  • Increase in bursa size decreases volume of subacromial space and can lead to subacromial impingement syndrome.

• Subacromial bursitis leads to subacromial impingement syndrome, which is the most commonly diagnosed shoulder problem and likely has numerous potential mechanisms that can impact both treatment and prognosis.

Essentials of Diagnosis

• Compression or abrasion of the subacromial bursa can be either acute, involving a fall, usually on a flexed elbow, or chronic, which can be more multifactorial in nature

• Chronic (repeated micro-trauma) mechanism thought to be related to intrinsic and/or extrinsic mechanisms

  • Extrinsic mechanisms (extratendinous, cause decreased subacromial space and subsequent micro-trauma with repetitive movements)

    • Mechanical wear under the coracoacromial arch

    • Aberrant movement patterns due to rotator cuff and or periscapular muscular dysfunction

    • Capsular abnormalities

    • Capsular tightness (particularly posterior capsule)

    • Capsular laxity (poor humeral head dynamic control)

    • Suboptimal posture

    • Muscle imbalances

    • Overuse/repetitive motions occurring at more than 90 degrees of elevation

  • Intrinsic factors (directly associated with the narrowing of the subacromial space)

    • Vascular supply/changes to the cuff tendons

    • Acromial morphology (structural variations)

      • Type I (flat)

      • Type II (curved)

      • Type III hooked)

    • Degenerative and/or structural changes to the AC joint

• Other trophic changes in the coracoacromial arch or humeral head

• Differential diagnosis from other shoulder pathologies that may warrant surgical intervention is essential (rotator cuff tear, superior labral tear)

General Considerations

• Commonly diagnosed and associated with presence of other orthopedic pathologies: subacromial impingement syndrome, rotator cuff pathology, labral pathology

• Commonly associated with repeated overhead or overuse activities.

• Full history of symptoms, medical history screening, and differential shoulder orthopedic examination will ensure appropriate diagnosis

Demographics

• Occurs primarily in adults but can occur in teenagers participating in overhead athletics or with trauma

• Similar demographics as subacromial impingement syndrome

  • Primary impingement (generally occurs in patients ages 40 and older)

  • Secondary impingement (generally occurs in younger patients ages 15 to 35)

CLINICAL FINDINGS

Functional limitations

• Pain/Limitation with overhead activities

• Pain/Limitation with reaching

• Pain/Limitation with lifting

• Pain/Limitation dressing and grooming

• Pain/Limitation with sustained or repetitive shoulder activities

• Pain at night (sleep disruption)

Possible Contributing Causes

• Acromion morphology

  • Type I

  • Type II

  • Type III

• Degenerative changes at the AC joint

• Rotator cuff pathology

• Bicipital pathology

• Capsular laxity, glenohumeral (GH) hypermobility

• Capsular tightness

• Increased thoracic kyphosis and suboptimal posture

• Repetitive overhead activities

• Poor neuromuscular control

Differential Diagnosis

• AC separation

• Adhesive capsulitis

• Cervical radiculopathy

• Fluid can be aspirated to rule out septic bursitis

• GH arthritis

• GH instability

• Internal impingement

• Labral tear

• Neuropathy (suprascapular nerve)

• Referred pain from lungs or diaphragm

• Rotator cuff pathology (tendonitis, full- or partial-thickness tear)

• Subacromial impingement syndrome (per another origin)

MEANS OF CONFIRMATION OR DIAGNOSIS

• Diagnosis made based on orthopedic special tests, signs and symptoms, imaging studies, and exclusion of differential diagnosis.

• Special tests

  • Neer test

  • Horizontal adduction test

  • Painful arc test

  • Hawkins–Kennedy test

  • Yocum test

• Tests can be repeated post-injection of analgesic into bursa to confirm diagnosis.

• Imaging

  • Radiographs are usually normal.

    • May show osseous abnormalities of acromion, clavicle, or subacromial space, and may lead to suspicion of diagnosis.

  • MRI will show increased fluid/edema isolated within the subacromial bursa.

    • T2-weighted MRI would best visualize and result in increased signal intensity within subacromial bursa.

    • MRI will help visualize other potential soft tissue sources of patient symptoms.

• Laboratory studies for suspected rheumatoid disorders

  • Aspirated fluid can be cultured and evaluated for crystals to rule out gout.

TREATMENT

Medication

• NSAIDs

• Corticosteroid injection

• Antibiotics if infection confirmed

MEDICAL PROCEDURES

• Surgical intervention

  • Surgical intervention via arthroscopy to restore subacromial space and address other concomitant pathologies.

  • Could potentially involve:

    • Subacromial decompression: debridement of subacromial bursa, resection of the coracoacromial ligament

    • Acromioplasty

    • Distal clavicle excision

IMPAIRMENTS

• Weakness and pain limiting overhead activities or activities involving arm out to side or across body including dressing or grooming daily activities

• Impaired (suboptimal) posture

• Muscle imbalances

  • Rotator cuff weakness

  • Periscapular muscle weakness (particularly upward rotators and depressors/retractors)

  • Pectoralis minor tightness

• Decreased thoracic ROM (particularly extension)

• Rotator cuff overuse/fatigue

• Neuropathy and subsequent muscle weakness

• Hypermobility at the GH joint and or scapulothoracic articulations

• Pain with active elevation

• Hypo- or hypermobility at the GH, scapulothoracic, AC, or sternoclavicular (SC) joints

TEST AND MEASURES

• Selective tissue tension tests

• Neer impingement test

• Drop arm (Codman) test

• External rotation lag sign (ERLS)/dropping arm sign

• Empty can test

• Hawkins–Kennedy impingement sign/test

• Passive horizontal adduction test

• Pain with resisted abduction

• Painful arc sign/test

• C5–6 dermatome/myotome testing

• Infraspinatus muscle test¹

• Diagnostic test properties for subacromial impingement

• Yergason test

• Speed test

• Clunk test

• O’Brien test

• Anterior slide test

• Biceps load test

• Compression–rotation test

• Pronated load test

• Pain provocation test

• Resisted supination external rotation test

• Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function

• Shoulder pain and disability index

INTERVENTION

• Intervention will vary depending upon the severity of impingement and presence of concomitant pathologies such as rotator cuff or labral pathology.

• Acute Phase

  • PRICE: Protection, rest, ice compression, elevation

  • Activity modification: To avoid positions that elicit pain.

  • Low-level cold laser

  • Ice massage

  • Ultrasound

• Subacute to chronic stages (addressing specific impairments associated with the impingement)

  • Address joint impairments

    • GH hypomobility (mobilization)

    • GH hypermobility (stabilization)

    • Thoracic spine hypomobility (mobilization/manipulation)

  • Address muscle imbalances

    • Rotator cuff strength and endurance exercises

    • Muscle length of pectoralis (pec) major and minor, latissimus dorsi (lats) and other muscles with decreased length

  • Strengthening of scapular musculature

    • Lower trap

    • Serratus anterior

    • Other scapular stabilizers

  • Functional activities (depending on work/recreational desires)

  • Addressing pain and inflammation

    • Ice

    • Rest

    • Activity modification (avoiding impingement positions)

    • Ultrasound, phonophoresis, iontophoresis

    • Electronic stimulation

  • Addressing weakness, joint hypermobility

    • Shoulder lateral and medial rotation

      • Isometric

      • Thera-Band resisted

      • Handheld-weight resisted

      • Progression through higher ranges of elevation

    • Scapular strength/stabilization

      • Retraction

      • Prone shoulder extension, abduction, scapular plane elevation

  • Addressing lack of flexibility

    • Stretching

      • Posterior capsule/posterior cuff

      • Pectoralis minor

      • Pectoralis major

      • Lats

  • Addressing joint mobility

    • Posterior humeral glides

    • Inferior humeral glides

    • Thoracic mobilization/manipulation

    • Scapulothoracic mobility

      • Distraction

      • Retraction

      • Upward rotation

      • Posterior tip

FUNCTIONAL GOALS

• Patient will be able to:

  • Reach into overhead cabinets in kitchen without pain or restriction.

  • Lift a gallon milk carton from refrigerator at shoulder level, pain free.

  • Turn steering wheel, pain free.

  • Perform all dressing and grooming activities (tuck in shirt behind back, wash hair, etc.) without pain or compensation.

PROGNOSIS

• Good. A prolonged period of healing can last several months.

• Prognosis is dependent on the underlying cause of the bursitis.

  • Presence of concomitant shoulder pathology.

  • Quality of the tissues involved.

  • Ability of the patient to control exacerbating activities and perform the optimal dosage of therapeutic exercise.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Torn pectoral

• Pectoral rupture

ICD-9-CM CODE

• 840.8 Sprains and strains of other specified sites of shoulder and upper arm

ICD-10-CM CODES

• S43.499A Other sprain of unspecified shoulder joint, initial encounter

• S46.819A Strain of other muscles, fascia and tendons at shoulder and upper arm level, unspecified arm, initial encounter

PREFERRED PRACTICE PATTERNS

• 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Connective Tissue Dysfunction

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation

KEY FEATURES

Description

• Partial or complete rupture of the pectoral muscles

• Grades of tear^1,2

  • Grade 1: Contusion or strain

  • Grade 2: Partial tear

  • Grade 3: Complete rupture

  • Grade 3A: Tear muscle origin

  • Grade 3B: Tear muscle belly

  • Grade 3C: Musculotendinous junction

  • Grade 3D: Muscle tendon itself

• Four common locations

  • Rupture at the humeral insertion

  • Rupture at the musculotendinous junction

  • Rupture at the muscle belly

  • Muscle torn off the sternum

• Commonly affects the pectoralis major muscle

Essentials of Diagnosis

• Rare condition

• Diagnosis is made by history and clinical examination with MRI for confirmation of location

• Occurs from a sudden high force, typically with weightlifting (i.e., bench or chest press)

• May arise from a repetitive type activity that leads to a gradual degeneration

• Sudden pain or tearing sensation in the chest may be experienced

General Considerations

• Swelling, ecchymosis, and functional pain

• Treatment may depend on location of rupture with tendon avulsion from the humerus treated with prompt surgical repair

Demographics

• More common in men between the ages of 20 and 50 that participate in contact sports and weight lifting

CLINICAL FINDINGS

Functional Implications

• Pushing activities

• Weight training with overload eccentric contractions: Such as bench press, push ups, chin ups, dips, and chest flys can cause a rupture

• Overhead activities may be limited

• Inability to lift heavy objects

Possible Contributing Causes

• Abnormal biomechanics

• Muscle weakness or imbalance

• Muscle tightness

• Poor posture with change in humeral head position

• Excessive or inappropriate activity

• Inadequate warm up

• Steroid use

• Forceful eccentric activity (i.e., bench pressing)

• Often seen in football and rugby injuries

Differential Diagnosis

• Long head of biceps tendon rupture

• Shoulder dislocation

• Proximal humerus fracture

• Rotator cuff tendon tear

• Medial Pectoral nerve entrapment

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• Radiographs

• MRI

• Diagnostic ultrasound

Findings and Interpretation

• Radiographs may show avulsion from humerus

• MRI can be useful in assessing location and severity of tear

• Acute tears will demonstrate hemorrhage and edema and chronic tears will demonstrate fibrosis and scarring

TREATMENT

Medication

• NSAIDs

• Steroid injection

MEDICAL PROCEDURES

• Surgical repair of tendon rupture for site 1 and type 2 ruptures

• Ruptures at site 3 and 4 are not surgically repaired

IMPAIRMENTS

• Debilitating pain, limiting movement and exertion

• Inability to perform overhead activities, such as in swimming, baseball, or tennis

• Inability to perform jobs involving repetitive overhead reaching or lifting

• Decreased torque and work/repetition, especially with shoulder adduction

TESTS AND MEASURES

• Anterior slide test

• Biceps load test

• Clunk test

• Compression–rotation test

• Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function

• Functional reach test

• O’Brien test

• Pain provocation test

• Pronated load test

• Resisted supination external rotation test

• Shoulder pain and disability index²

• Speed test

• Yergason test

INTERVENTION

• Acute

  • Rest

  • Reduce inflammation with NSAIDs

  • Ultrasound

  • Soft tissue massage

  • Electrotherapy

  • Ice/Heat

  • Gentle AROM

  • Posture correction

• Post-acute

  • Once pain and inflammation are controlled, progress through further active exercises in pain-free ranges

  • Progress stretching

  • Posterior glenohumeral glides

  • Progressive strengthening once pain-free

• Injury prevention

  • Avoid activities that place repetitive, excessive stress on the tendon

  • Cross-training

  • Improve technique

  • Warm-up and stretching prior to activity

  • Use proper ergonomics

  • Keep muscles strong and flexible

FUNCTIONAL GOALS

• Patient will be able to resume

  • All overhead activities and ADLs without exacerbating inflammation.

  • All sports activities as prior to onset.

  • All push activities without symptoms or limitation.

  • All lifting activities without limitations due to pain or weakness of the upper extremities.

PROGNOSIS

• Grade 1 and 2 tears: Rest, immobilization and therapy.

• Grade 3 tear: Depends on the location.

• Grade 3A, 3B, and 3C tears: Immobilization and rehabilitation.

• Conservative treatment: Several weeks to months but may not regain normal strength.

• Grade 3D¹ is a good surgical candidate depending on location.

• Type 1 has a good success rate with surgery, to return to prior level of function.

• Post surgery: 12 to 16 weeks for treatment; weightlifters may be limited with some activities for 6 months following surgery.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Supraspinatus tendonitis

• Infraspinatus tendonitis

ICD-9-CM CODES

• 726.10 Disorders of bursae and tendons in shoulder region, unspecified

• 840.3 Infraspinatus (muscle) (tendon) sprain

• 840.4 Rotator cuff (capsule) sprain

• 840.5 Subscapularis (muscle) sprain

• 840.6 Supraspinatus (muscle) (tendon) sprain

ICD-10-CM CODES

• S43.429A Sprain of unspecified rotator cuff capsule, initial encounter

• S43.80XA Sprain of other specified parts of unspecified shoulder girdle, initial encounter

PREFERRED PRACTICE PATTERN

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation

KEY FEATURES

Description

• Inflammation, irritation, swelling of one or more of the rotator cuff tendons.

  • Supraspinatus muscle

  • Infraspinatus muscle

  • Teres minor muscle

  • Subscapularis muscle

• Occurs most often from repetitive motion injuries or impingement syndrome but can occur with a sudden strain/stress to the tendon.

• Early stages: The tendon becomes swollen and red, and as the tendonitis develops, the tendon sheath may thicken.

• Late stages: Chronic inflammation may result in fraying of the tendon (tendinosis) and could progress to rupture with long-term inflammation.

• Shoulder pain and dysfunction due to compression and abrasion of one or more of the rotator cuff tendons.

• Impingement is the most commonly diagnosed shoulder problem and likely has numerous potential mechanisms, which can impact both treatment and prognosis.

Essentials of Diagnosis

• Multifactorial and thought to be related to intrinsic and/or extrinsic mechanisms.

  • Extrinsic mechanisms (extratendinous, caused by decreased sub-acromial space and subsequent micro-trauma with repetitive movements)

    • Mechanical wear under the coracoacromial arch

    • Aberrant movement patterns due to rotator cuff and/or periscapular muscular dysfunction

    • Capsular abnormalities

      • Capsular tightness (particularly posterior capsule)

      • Capsular laxity (poor humeral head dynamic control)

    • Sub-optimal posture

      • Muscle imbalances

    • Overuse/repetitive motions occurring at more than 90 degrees of elevation

  • Intrinsic factors (directly associated with the narrowing of the sub-acromial space)

    • Vascular supply/changes to the cuff tendons

    • Acromial morphology (structural variations)

      • Type I (flat)

      • Type II (curved)

      • Type III hooked)

    • Degenerative and/or structural changes to the AC joint

    • Other trophic changes in the coracoacromial arch or humeral head

• Classification

  • Primary impingement is usually associated with degenerative changes to any of the following tissues:

    • Rotator cuff tendons

    • Acromioclavicular (AC) joint

    • Coracoacromial arch

  • Secondary impingement is the result of muscle imbalances and/or joint instability, which can result in altered dynamics and subsequent secondary impingement.

  • A third class of impingement, not sub-acromial in nature, is referred to as internal impingement and occurs between the undersurface (articular side) of the rotator cuff tendons and the posterior/superior surface of the labrum in the position of abduction and external rotation that occurs with throwing.

  • Regardless of the specific classification, all types of impingement are proposed to be mechanisms of rotator cuff and biceps tendinopathy.

General Considerations

• The rotator cuff stabilizes and steers the head of the humerus in the glenoid of the scapular at the glenohumeral (GH) joint.

• Rotator cuff and possibly the biceps are thought to compresses the head of the humerus into the glenoid to allow for the deltoid muscle to elevate the humerus in synchronicity with the scapula known as scapulohumeral rhythm.

Demographics

• History of repetitive motion and activities, especially overhead

• Common in swimming, tennis, and baseball as well as with occupational activities involving repetitive or overhead activity due to micro-trauma.

• Predominately in individuals involved in repetitive activities in sports or work.

• Can be seen in individuals with other system-wide diseases such as rheumatoid arthritis and diabetes.

• Primary impingement (generally occurs in patients ages 40 and older).

• Secondary impingement (generally occurs in younger patients ages 15 to 35).

CLINICAL FINDINGS

Functional Implications

• Pain/Limitation with overhead activities

• Pain/Limitation with reaching

• Pain/Limitation with lifting

• Pain/Limitation dressing

• Pain/Limitation with sustained or repetitive shoulder activities

• Pain at night (sleep disruption)

• May limit throwing and other rapid arm movements

Possible Contributing Causes

• Acromion morphology

  • Type I

  • Type II

  • Type III

• Degenerative changes at the AC joint

• Instability of the GH capsule

• Frequent and prolonged overhead activity

• Prolonged repetitive use of the involved arm

• Poor posture, rounded shoulders

• Anteriorly displaced humeral head

• Rotator cuff weakness

• Aging

• Systemic diseases such as rheumatoid arthritis or diabetes

• Bicipital tendinopathy or previous biceps injury

• Capsular laxity

• Capsular tightness

• Increased thoracic kyphosis and sub-optimal posture

• Repetitive overhead activities

• Poor neuromuscular control

Differential Diagnosis¹

• AC separation

• Adhesive capsulitis

• Cervical radiculopathy

• Full-thickness rotator cuff tear

• GH arthritis

• GH instability

• Internal impingement

• Labral tear

• Neuropathy (suprascapular nerve)

• Referred pain from lungs or diaphragm

• Sub-acromial bursitis

• Tendonitis of the long head of the bicep tendon

Means of Confirmation or Diagnosis

• Sub-acromial injection (lidocaine) to see if impingement signs reduce

Imaging

• Radiograph

  • Acromion type

  • Spurs

  • Humeral head position

  • Osteoarthritis

  • Sclerotic changes

  • Views

  • Anteroposterior

  • Lateral

  • Supraspinatus outlet view

• Diagnostic Ultrasound

• MRI

  • Rotator cuff tear

  • Tissue quality

  • Capsulolabral and biceps labral pathology

  • Acromion

  • AC joint

  • Labrum

Findings and Interpretation

• Imaging to diagnose additional pathology

• Diagnostic ultrasound

  • Maybe helpful in diagnosing moderate to large cuff tear

  • Less effective in diagnosing small tears or tendonitis

TREATMENT

Medication

• Anti-inflammatory

• Corticosteroid injection

MEDICAL PROCEDURE

• Surgery

  • Acromioplasty is commonly performed on patients who have not responded to conservative care including activity modification, PT, NSAIDs, and injections and have imaging evidence of intrinsic changes to the acromion, rotator cuff, or AC joint (minimum 6 months).

  • If the condition has progressed to a full-thickness rotator cuff tear, acromioplasty is often performed concomitantly with a cuff repair.

  • If the biceps tendon has changes associated with wear, then a tenotomy or tenodesis are often performed.

IMPAIRMENTS

• Impaired (sub-optimal) posture

• Muscle imbalances

  • Rotator cuff weakness

  • Periscapular muscle weakness (particularly upward rotators and depressors/retractors)

  • Pectoralis minor tightness

• Decreased thoracic ROM (particularly extension)

• Rotator cuff overuse/fatigue

• Neuropathy and subsequent muscle weakness

• Hypomobile posterior GH capsule

• Hypermobility at the GH and or scapulothoracic articulations

• Pain with active elevation

• Hypo- or hypermobility at the GH, scapulothoracic, AC, or sternoclavicular (SC) joints

TESTS AND MEASURES

• Diagnosis is usually made by clinical examination and often accompanies three or more special tests¹

  • Anterior slide test

  • Biceps load test

  • C5–6 dermatome/myotome testing

  • Clunk test

  • Compression–rotation test

  • Diagnostic test properties for sub-acromial impingement

  • Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function

  • Drop arm (Codman’s) test

  • Empty can test

  • External rotation lag sign (ERLS)/dropping arm sign

  • Hawkins–Kennedy impingement sign/test

  • Infraspinatus muscle test¹

  • Neer impingement test

  • O’Brien test

  • Pain provocation test

  • Pain with resisted abduction

  • Painful arc sign/test

  • Passive horizontal adduction test

  • Pronated load test

  • Resisted supination external rotation test

  • Shoulder pain and disability index

  • Speed test

  • Yergason test

INTERVENTION

• This will vary depending on the type of impingement, causes, stage of healing, and tissue quality but generally involve portions of the following.

  • Acute stage

    • Rest, ice, and activity modification (avoiding impinging positions)

  • Sub-acute–chronic stages (addressing specific impairments associated with the impingement)

    • Address joint impairments

      • GH hypomobility (mobilization)

      • GH hypermobility (stabilization)

      • Thoracic spine hypomobility (mobilization/manipulation)

    • Address muscle imbalances

      • Rotator cuff strength and endurance exercises

      • Muscle length of pectoralis major, minor, latissimus, and other muscles with decreased length

    • Strengthening of scapular musculature

      • Lower trapezius

      • Serratus anterior

      • Other scapular stabilizers

    • Functional activities (depending on work/recreational desires)

  • Addressing pain and inflammation

    • Ice

    • Rest

    • Activity modification (avoiding impingement positions)

    • Ultrasound, phonophoresis, ionophoresis

    • Electric stimulation

  • Addressing weakness, joint hypermobility

    • Shoulder lateral and medial rotation

      • Isometric

      • Painful eccentric exercises

      • Thera-Band resisted

      • Handheld weight resisted

      • Progression through higher ranges of elevation

    • Scapular strength/stabilization

    • Retraction

    • Prone shoulder extension, abduction, scapular plane elevation

    • Front and side plank exercises

    • Closed chain stability exercises

  • Addressing lack of flexibility

    • Stretching

      • Posterior capsule/posterior cuff

      • Pectoralis minor

      • Pectoralis major

      • Latissimus dorsi

  • Addressing joint mobility

    • Posterior humeral glides

    • Inferior humeral glides

    • Thoracic mobilization/manipulation

    • Scapulothoracic mobility

      • Distraction

      • Retraction

      • Upward rotation

      • Posterior tip

  • Addressing tendinopathy

    • Eccentric cuff exercises

FUNCTIONAL GOALS

• Patient will be able to:

  • Move upper extremity through full range of elevation without pain to reach in the cabinet.

  • Reach back pocket (or fasten brassiere for female) without pain

  • Reach for a gallon of milk without pain.

PROGNOSIS

• Prognosis is dependent on the underlying cause, the quality of the tissues involved as well as the patient’s ability to control exacerbating activities and perform the optimal dosage of therapeutic exercise.

• Some tendonitis can progress to a tear/rupture if untreated.

REFERENCE

ADDITIONAL REFERENCES