Eric Shamus, PhD, DPT, PT, CSCS, Jennifer Shamus, PhD, DPT, COMT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
Separated Shoulder
AC separation
AC dislocation
Shoulder Separation
++
840.0 Acromioclavicular (joint or ligament) sprain
831.04 Closed dislocation of acromioclavicular (joint)
831.14 Open dislocation of acromioclavicular (joint)
++
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
++
PATIENT PRESENTATION
A 53-year-old woman presents with 8/10 pain in the left shoulder after a bicycle accident 2 days ago. The patient states she fell off of her bike onto her outstretched arm during the “sprint” phase of interval training on the road. The patient complains of pain in the top aspect of her left shoulder and is unable to lift her left arm. The patient also states she hears a snapping sound if attempting to move her shoulder. Upon palpation, the patient reports severe pain in the acromioclavicular joint and a significant step deformity is present. Inflammation is present throughout the entire acromioclavicular joint. The Full Can/Empty Can, Neer, and Yergason tests are negative. The Acromioclavicular Resisted Extension Test is positive.
++
Inflammation, irritation, or separation of the joint between the clavicle and acromion (AC joint)2
Three ligaments of stability:
+++
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
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
++
++
++
SIGNS AND SYMPTOMS
Ache in the anterior top aspect of the shoulder
Frequently worsens with overhead lifting or activity
Pain with palpation at the AC joint
Step deformity of the clavicle and acromion
Occasional sound or sensation of snapping
Pain with traction on the arm
+++
Functional Implications
++
+++
Possible Contributing Causes
++
+++
Differential Diagnosis
++
AC joint arthritis
Bicep tear
Clavicle fracture
Labral tear3
Rotator cuff impingement
Rotator cuff tear
Shoulder instability
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
+++
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.
++
++
++
++
++
++
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
++
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
++
++
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
++
++
++
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.
++
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.
++
1. +
The American Physical Therapy Association. Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.1_5. Accessed January 25, 2013.
6. +
Shamus
J, Shamus
E. A taping technique for the treatment of acromioclavicular joint sprains: A case study. J Orthop Sports Phys Ther. 1997;25(6):390-–394.
[PubMed: 9168346]
CrossRef
+++
ADDITIONAL REFERENCES
Eric Shamus, PhD, DPT, PT, CSCS, Jennifer Shamus, PhD, DPT, COMT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
Separated shoulder
AC separation
AC dislocation
Shoulder separation
++
++
+++
PREFERRED PRACTICE PATTERN
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation1
++
PATIENT PRESENTATION
A 42-year-old man presents with right shoulder pain due to a fall he sustained on his outstretched arm while walking his dog one week ago. The patient complains of an ache in the top, anterior aspect of the right shoulder and reports that he cannot lift his arm to wash his hair or complete other overhead activities without a significant increase in pain. Upon palpation, the patient reports pain and tenderness in the acromioclavicular joint, most notably along the acromioclavicular ligament. A step deformity of 5 mm is present with elevation of the clavicle. The Full Can/Empty Can, Neer, and Yergason tests are negative. The Acromioclavicular Resisted Extension Test is positive.
++
Inflammation, irritation, or separation of the joint between the clavicle and acromion (AC joint)2
Three ligaments of stability:
+++
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
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
++
++
++
SIGNS AND SYMPTOMS
Ache in the anterior top aspect of the shoulder
Frequently worsens with overhead lifting or activity
Pain with palpation at the AC joint
Step deformity of the clavicle and acromion
Occasional sound or sensation of snapping
Pain with traction on the arm
+++
Functional Implications
++
+++
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
++
+++
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
++
++
++
++
++
++
++
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
++
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
++
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
++
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.
++
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.
++
1. +
The American Physical Therapy Association. Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.1_5. Accessed March 1, 2013.
6. +
Shamus
JL, Shamus
EC. A Taping Technique for the Treatment of Acromioclavicular Joint Sprains: A Case Study. J Orthop Sports Phys Ther. 1997;25(6):390–394.
[PubMed: 9168346]
CrossRef
+++
ADDITIONAL REFERENCES
Matthew Daugherty, DPT, MOT, OCS, FAAOMPT
++
+++
CONDITION/DISORDER SYNONYM
++
++
++
+++
PREFERRED PRACTICE PATTERN3
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation
++
PATIENT PRESENTATION
A 48-year-old woman, whom is employed as an insurance agent, comes to your outpatient physical therapy clinic self-referred with a 3-month history of right shoulder pain. She first noticed general pain around her glenohumeral joint when putting on her seat belt and fastening her bra. She denies any mechanism of injury and feels that the symptoms are gradually worsening. In addition to the pain, she reports an inability to reach overhead or behind her back and is unable to sleep on her right side.
Her right shoulder passive range of motion (PROM) is limited to 115 degrees of flexion, 100 degrees of abduction, 35 degrees of extension, 30 degrees of external rotation, and 50 degrees of internal rotation. Her left shoulder PROM is 175 degrees of flexion, 175 degrees of abduction, 40 degrees of extension, 90 degrees of external rotation, and 70 degrees of internal rotation. When testing her right glenohumeral joint mobility you determine global hypomobility with a very firm end feel and local discomfort reported during motion testing. She has palpable tenderness at the coracoid process, intertubercular groove, and the greater tuberosity of the humerus. Functionally she has difficulty finding a position of comfort.
++
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”
Stage 2: “Freezing”
Stage 3: “Frozen”
Stage 4: “Thawing”
++
++
+++
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
++
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%
++
SIGNS AND SYMPTOMS
Pain in the anterior lateral shoulder described as achy at rest and sharp with end-range motion
Symptoms typically present for <3 months if stage 1
Nighttime pain and pain when reaching behind the back are common
Active and passive ROM are equally limited
+++
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
++
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
++
+++
Findings and Interpretations
++
++
Anti-inflammatory
Corticosteroid injection
++
Surgery warranted if conservative management ≥6 months yields no change in symptoms
Arthroscopic surgical release of the capsule
Manipulation under anesthesia
Capsular distention
++
REFERRALS/ADMITTANCE
To physician or radiologist for imaging
To physician or pharmacist for medication
To orthopedic surgeon for surgical consult if conservative treatment unsuccessful, possible manipulation under anesthesia
++
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
++
Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function
Inferior glenohumeral glide
++
++
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.
++
++
+++
ADDITIONAL REFERENCES
+
Dutton
M. Orthopedic Examination, Evaluation, and Intervention. 3rd ed. New York, NY: McGraw-Hill; 2004:420–519.
+
Griesser
MJ, Harris
J, Campbell
J, Jones
G. Adhesive capsulitis of the shoulder: a systematic review of the effectiveness of intra-articular corticosteroid injections. J Bone Joint Surg Am. 2011;93:1727–1733.
[PubMed: 21938377]
CrossRef +
Kisner
C, Colby
LA. Therapeutic Exercise. 5th ed. Philadelphia, PA: FA Davis; 2007:502–511.
+
Krabak
BJ, Banks
NL. Adhesive capsulitis. In:Frontera
WR,
Silver
JK Essentials of Physical Medicine and Rehabilitation. 2nd ed. Philadelphia, PA: Saunders Elsevier; 2008:chap 10.
+
Miller
RH, Dlabach
JA. Shoulder and elbow injuries. In:Canale
ST, Beatty
JH Campbell’s Operative Orthopaedics. 11th ed. Philadelphia, PA: Mosby Elsevier; 2007:chap 44.
+
Neviaser
A, Neviaser
R. Adhesive capsulitis of the shoulder. J Am Acad Orthop Surg. 2011;19:536–542.
[PubMed: 21885699]
+
Skirven
T, Osterman
A, Fedorczyk
J, Amadio
P. Rehabilitation of the Hand and Upper Extremity. 6th ed. Philadelphia, PA: Elsevier Mosby; 2011:1174–1188.
Jesse Solotoff, DPT, Tiffany M. Barber, DPT, Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
Biceps distal tear
Biceps proximal tear
++
++
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
++
PATIENT PRESENTATION
A 42-year-old man presents with upper arm pain and decreased ability to flex or extend the arm. The patient is a construction worker and tried to catch a falling piece of heavy metal. The patient states he heard a loud pop in the upper arm. Upon observation he has an abnormal biceps appearance with limited strength in elbow flexion. The patient smokes two packs of cigarettes a day.
++
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
Proximal rupture will cause bulging, bruising, and gathering of the muscle (“Popeye” sign may indicate rupture)
++
+++
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
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
++
++
SIGNS AND SYMPTOMS
Patient will describe an audible pop or snap associated with injury
Sharp pain occurring suddenly in the upper arm
Ecchymosis, swelling, bulging of the upper arm
Pain and tenderness with palpation of the shoulder and elbow
Diminished strength of elbow flexion and supination
Appearance of bulge (“Popeye muscle”) with indentation closer to shoulder for proximal tear
Distal tear will result in bulge in upper part of arm due to recoiled, shortened tendon
Distal tear will result in gap at elbow due to severed tendon
+++
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
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
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
++
NSAIDs2
Steroid injection
++
++
REFERRALS/ADMITTANCE
For imaging: Orthopedist, family physician, radiologist
For surgery: Orthopedic surgeon
For injection: Orthopedist, family physician
++
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
++
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
++
++
Acute
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
++
++
++
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.
++
1. +
The American Physical Therapy Association. Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.1_5. Accessed March 1, 2012.
+++
ADDITIONAL REFERENCES
+
Cope
MR, Ali
A, Bayliss
NC. Biceps rupture in body builders: Three case reports of rupture of the long head of the biceps at the tendon-labrum junction. J Shoulder Elbow Surg. 2004;13(5):580-–582.
[PubMed: 15383821]
CrossRef +
Vidal
AF, Drakos
MC, Allen
AA. Biceps tendon and triceps tendon injuries. Clin Sports Med. 2004;23(4):707–722.
[PubMed: 15474231]
CrossRef
E. Thomas Pitney, DPT, PT, SCS, ATC, Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
Biceps tendinitis
Biceps tendonitis
Bicep tenosynovitis
Bicipital tenosynovitis
++
++
+++
PREFERRED PRACTICE PATTERN
++
4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation1
++
PATIENT PRESENTATION
This patient is a 45-year-old male who recently returned to a fitness center exercise program. He began to experience pain in the anterior shoulder and upper one-third of the arm after significantly increasing resistance with his upper body program, especially taking preacher curls to fatigue failure and doubling his weight over a 2-week period. The patient has specific tenderness over the bicipital groove and the long head of the bicep tendon to the musculotendinous junction. Resistive elbow flexion is painful in the same region and is 4-/5 compared to 5/5 through the remainder of the shoulder girdle. A/PROM is full and symmetrical with the uninvolved side. Speed’s test is positive and Neer and Hawkins-Kennedy tests are negative. There is no visible deformity, swelling, or asymmetry of appearance.
++
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
Late stages
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
++
++
SIGNS AND SYMPTOMS
Ache in the anterior medial or anterior lateral aspect of the shoulder
Frequently worsens with overhead lifting or activity
Pain or ache with palpation at the bicipital groove that may travel down the anterior upper arm
Occasional snapping sound or sensation often alleviated with active scapular retraction
Full A/PROM, though pain may occur at the end ROM
Pain with resisted elbow-flexion or resisted forward-flexion of the shoulder
Pain with passive stretch of the bicep
Positive special tests for the biceps
+++
Functional Implications
++
+++
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
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
+++
FINDINGS AND INTERPRETATION
++
++
NSAIDs2
Steroid injection
++
++
REFERRALS/ADMITTANCE
For MRI3
For surgery
For injection
++
++
Inability to perform overhead activities, such as in swimming, baseball, or tennis
Inability to perform jobs involving repetitive overhead reaching or lifting
++
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
++
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
++
++
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.
++
1. +
The American Physical Therapy Association. Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. Interactive Guide to Physical Therapist Practice. 2003. doi: 10.2522/ptguide.3.1_5. Accessed June 17, 2013.
+++
ADDITIONAL REFERENCES
Patrick S. Pabian, DPT, PT, SCS, OCS, CSCS
++
+++
CONDITION/DISORDER SYNONYM
++
++
++
+++
PREFERRED PRACTICE PATTERN3
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation
++
PATIENT PRESENTATION
A 40-year-old male carpenter presents with right shoulder pain that has been present for the past 2 months. The patient complains of a dull ache at the anterolateral shoulder that is worsened after working. He reports pain is increasing and he now has difficulty with washing his hair or reaching up into overhead cabinets. He also notes weakness with holding objects out away from his body and lifting a gallon of milk out of refrigerator. He has protracted scapular posture. Posterior capsular tightness is evident. The patient has positive Hawkins Kennedy, Neer, and Painful Arc tests, and negative Drop Arm and ER Lag tests.
++
++
++
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).
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
++
++
SIGNS AND SYMPTOMS
Pain in anterior lateral shoulder with active movement involving primarily overhead activities and motions across the body (horizontal abduction)
Painful arc commonly present in the mid-range of shoulder elevation
Pain to palpation of the subacromial bursa
Weakness is commonly noted with functional reaching tasks
Weakness primarily in shoulder abduction and external rotation
+++
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
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
Tests can be repeated post-injection of analgesic into bursa to confirm diagnosis.
Imaging
Laboratory studies for suspected rheumatoid disorders
++
++
++
REFERRALS/ADMITTANCE
Radiologist for imaging: X-ray, MRI
Primary care for aspiration and laboratory studies
Orthopedist for surgical consult for injection or subacromial decompression, acromioplasty
++
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
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
++
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 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
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
Addressing lack of flexibility
Addressing joint mobility
++
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.
++
++
3. +
Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. In: Guide to Physical Therapist Practice. 2nd ed. Alexandria,
VA: American Physical Therapy Association; 2001. Revised 2003.
+++
ADDITIONAL REFERENCES
+
Cleland
JA, Koppenhaver
SK. Shoulder. In:Cleland
JA, Koppenhaver
SK Netter’s Orthopaedic Clinical Examination: An Evidence-Based Approach. Philadelphia, PA: Saunders Elsevier; 2011: 377–438.
+
Dutton
M. The Shoulder Complex. In:Dutton
M Dutton’s Orthopaedic Examination, Evaluation, and Intervention. 3rd ed. New York, NY: McGraw-Hill; 2012. New York, NY: McGraw-Hill; 2008: 489–653.
+
Hamilton
N, Weimar
W, Luttgens
K. The upper extremity: The shoulder region, Chapter 5. In:Hamilton
N, Weimar
W, Luttgens
K Kinesiology: Scientific Basis of Human Motion. New York, NY: McGraw-Hill; 2008.
http://www.accessphysiotherapy.com/content/6150569. Accessed March 11, 2013.
+
Prentice
WE. The shoulder complex. In:Prentice
WE Principles of Athletic Training: A Competency-Based Approach. New York, NY: McGraw-Hill; 2011: 639–680.
Kelley Henderson, MEd, ATC, Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
Torn pectoral
Pectoral rupture
++
++
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
++
PATIENT PRESENTATION
A 23-year-old male college gymnast presents with right shoulder pain and significant ecchymosis that spreads down to the elbow. He reports that he over-rotated during a flip on the parallel bars and he caught himself with his right arm. He felt a sudden sharp pain in his right shoulder and then a cramp-like contraction in his right arm and chest. He later noticed discoloration in his chest and right arm and a depression in the right anterior portion of his chest. He states that he feels a constant pain in his right shoulder along with noticeable weakness.
++
++
++
++
+++
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
++
++
++
SIGNS AND SYMPTOMS
Audible snap or pop at the time of injury
Sudden pain or tearing sensation in chest
Mild swelling and ecchymosis over anterior lateral chest wall or in proximal arm
Loss of normal pectoralis contour
Weakness with horizontal shoulder adduction
+++
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
++
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
++
++
++
++
REFERRALS/ADMITTANCE
For imaging: Orthopedist, family physician, radiologist
For surgery: Orthopedic surgeon
For injection: Orthopedist, family physician
++
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
++
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
++
Acute
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
++
++
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.
++
2. +
Bak
K, Cameron
EA, Henderson
IJ. Rupture of the Pectoralis major: a meta-analysis of 112 cases. Knee Surg Sports Traumatol Athrosc. 2000;8(2):113–119.
CrossRef
+++
ADDITIONAL REFERENCES
+
Aarimaa
V, Rantanen
J, Heikkila
J, Helttula
L, Orava
S. Rupture of the pectoralis major muscle. Am J Sports Med. 2004;32(5):1256–1262.
[PubMed: 15262651]
CrossRef +
Connell
DA, Potter
HG, Sherman
MF, Wickiewicz
TL. Injuries of the pectoralis major muscle: evaluation with MR imaging. Radiology. 1999;210(3):785–791.
[PubMed: 10207482]
CrossRef +
Park
JY, Espiniella
JL. Rupture of pectoralis major muscle: A case report and review of literature. J Bone Joint Surg Am. 1970;52(3):577–581.
[PubMed: 5425653]
+
Petilon
J, Carr
DR, Sekiya
JK, Unger
DV. Pectoralis muscle injuries: evaluation and management. J Am Acad Orthop Surg. 2005;13(1):59–68.
[PubMed: 15712983]
Eric Shamus, PhD, DPT, PT, CSCS, W. Justin Jones, DPT, PT, OCS
++
+++
CONDITION/DISORDER SYNONYMS
++
Supraspinatus tendonitis
Infraspinatus tendonitis
++
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
++
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
++
PATIENT PRESENTATION
A 20-year-old right hand dominant male college student who recently started painting houses for his summer employment. He reports working 5 consecutive days painting primarily with his right arm for 10+ hours each day. He subsequently developed progressive pain in the anterior/lateral aspect of his shoulder and had difficulty using his right arm for work activities. In addition, he reports currently experiencing pain reaching behind his back to tuck in his shirt, and with any reaching out to the side which is impacting his ability to perform his normal ADLs. He consulted with his PCP who started him on an oral NSAID and referred him to PT. Some of his examination findings include pain provocation with resisted isometric lateral rotation, and abduction, positive Neer and Hawkins Kennedy Impingement signs, and tenderness to palpation over the greater tuberosity. His cervical range of motion is WNL and Spurlings test is negative. In addition, his drop arm and external rotation lag signs were negative.
++
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
++
++
+++
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.
++
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).
++
++
SIGNS AND SYMPTOMS
Pain anterior lateral shoulder with active movement and overhead activities
Deep ache in the shoulder
Painful arc commonly present in the mid-range of shoulder elevation
Weakness is commonly noted with functional reaching tasks
Scapular dyskinesis may be present
Acute pain with the inability to elevate the arm
+++
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
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
++
++
Radiograph
Diagnostic Ultrasound
MRI
++
+++
Findings and Interpretation
++
++
Anti-inflammatory
Corticosteroid injection
++
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.
++
REFERRALS/ADMITTANCE
Orthopedic surgeon or radiologist for imaging
Physician or pharmacist for medication
Orthopedic surgeon for surgical consult if failed conservative treatment
When to refer to a specialist
++
Impaired (sub-optimal) posture
Muscle imbalances
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
++
++
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
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
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
Scapular strength/stabilization
Retraction
Prone shoulder extension, abduction, scapular plane elevation
Front and side plank exercises
Closed chain stability exercises
Addressing lack of flexibility
Addressing joint mobility
Addressing tendinopathy
++
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 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.
++
1. +
Park
HB, Yokota
A, Gill
HS
et al.. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg Am. 2005;87:1446–1455.
[PubMed: 15995110]
CrossRef
+++
ADDITIONAL REFERENCES
+
Bang
MD, Deyle
GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;30(3):26–137.
CrossRef +
Bigliani
LU, Levine
WN. Current Concepts Review: Sub-acromial Impingement Syndrome. J Bone Joint Surg Am. 1997;79(12):1854–1868.
[PubMed: 9409800]
+
Hamilton
N, Weimar
W, Luttgens
K. The upper extremity: The shoulder region, Chapter 5. In:Hamilton
N, Weimar
W, Luttgens
K Kinesiology: Scientific Basis of Human Motion. New York, NY: McGraw-Hill; 2008.
http://www.accessphysiotherapy.com/content/6150569. Accessed July 8, 2013.
+
Kisner
C, Colby
LA. Therapeutic Exercise. 5th ed. Philadelphia, PA: F.A. Davis Company; 2007:502–511.
+
Ludewig
PM, Braman
JP. Shoulder impingement: biomechanical considerations in rehabilitation. Man Ther. 2011;16(1):33–39. doi:10.1016/j.math.2010.08.004. [PMID: 20888284]
[PubMed: 20888284]
CrossRef +
Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. In: Guide to Physical Therapist Practice. 2nd ed. Alexandria,
VA: American Physical Therapy Association; 2001. Revised 2003.
+
Theisen
C, van Wagensveld
A, Timmesfeld
N
et al. Co-occurrence of outlet impingement syndrome of the shoulder and restricted range of motion in the thoracic spine–a prospective study with ultrasound-based motion analysis. BMC Musculoskelet Disord. 2010;11:135. doi:10.1186/1471-2474-11-135.
[PubMed: 20587014]
CrossRef +
Wilk
KE, Reinold
MM, Andrews
JR The Athlete’s Shoulder. 2nd ed. New York, NY: Churchill Livingstone; 2009:115–140.
Eric Shamus, PhD, DPT, PT, CSCS, Mae L. Yahara, MS, PT, ATC
++
+++
CONDITION/DISORDER SYNONYMS
++
++
++
+++
PREFERRED PRACTICE PATTERN3
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation
++
PATIENT PRESENTATION
Patient is a 35-year-old male immigrant farm worker who does not speak English. He had an accident at work in which he sustained fractures to the left tibia and fibula which required ORIF. Postoperatively he used a walker with a non-weight bearing gait pattern. As his weight bearing was progressed, he began to utilize one axillary crutch on the right side. He did not receive any instruction with the crutch. He began to notice symptoms in his right shoulder approximately one month later. He states that his girlfriend noticed his shoulder blade “sticking out” and he reported it to the doctor. He is complaining of weakness in the right upper extremity with overhead activities and pain in the right peri-scapular region.
++
Inferior angle tilting of the scapula
Instability of the scapula to the thoracic wall
Scapula has the greatest number of muscles attached to it than any other bone
Scapula dysrhythmia
Result of serratus anterior muscle dysfunction
Injury to long thoracic nerve
+++
Essentials of Diagnosis
++
Often asymptomatic
Winging can help identify a dysfunction possibly occurring in the shoulder
Symptoms of pain and weakness
Can be a result of a brachial plexus injury
Parsonage–Turner syndrome (brachial neuritis) underlying
++
+++
General Considerations
++
Loss of serratus anterior muscle
Weakness of trapezius strength
Weakness of scapular stabilizers
Commonly associated with presence of other orthopedic pathologies: subacromial impingement syndrome, rotator cuff pathology, labral pathology
Creates an abnormal scapulothoracic rhythm
Commonly associated with repeated overhead or overuse activities
Full history of symptoms, medical history screening, and differential shoulder orthopedic examination will ensure appropriate diagnosis
++
++
SIGNS AND SYMPTOMS
Pain
Weakness is commonly noted with functional reaching tasks
Scapula instability, moving away from rib cage
++
+++
Functional Limitations
++
Inability to raise or lower the arms without the scapula’s inferior angle tilting away from the rib cage
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
+++
Possible Contributing Causes
++
Serratus anterior palsy
Trapezius palsy
Increased thoracic kyphosis and sub-optimal posture
Repetitive overhead activities
Posterior shoulder capsule tightness
Pectoralis minor tightness
Poor neuromuscular control
Non-traumatic injury to the long thoracic nerve
Traumatic injury to the long thoracic nerve
Clavicle fracture
Rupture of the lower trapezius and Rhomboid major4
Brachial neuritis (Parsonage–Turner syndrome)
+++
Differential Diagnosis
++
Cervical radiculopathy, C7
Referred pain from lungs or diaphragm
Rotator cuff pathology (tendonitis, full- or partial-thickness tear)
Glenohumeral (GH) instability
Labral tear
Neuropathy
Internal impingement
++
+++
Means of Confirmation or Diagnosis
++
Diagnosis based on orthopedic special tests, signs and symptoms, imaging studies, and exclusion of differential diagnosis
Special tests
Push-ups test
Serratus wall test
++
++
++
++
++
Weakness and pain limiting overhead activities or activities involving arm out to side or across body including, dressing or grooming daily activities
Impaired (sub-optimal) posture
Muscle imbalances
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
++
Diagnosis made based on orthopedic special tests, signs and symptoms, imaging studies, and exclusion of differential diagnosis.
Disabilities of the Arm, Shoulder and Hand (DASH) score to assess physical function
Special tests
Push-ups
Serratus wall test
++
Address muscle imbalances
Strengthening of scapular musculature
Lower trap
Serratus anterior
Other scapular stabilizers
Shoulder lateral and medial rotation
Isometric
Thera-Band resisted
Handheld weight resisted
Progression through higher ranges of elevation
Scapular strength/stabilization
Functional activities (depending on work/recreational desires)
Addressing pain and inflammation
++
Patient will be able to:
Reach into overhead cabinets in kitchen without pain or restriction while maintaining scapular control.
Lift a gallon milk carton from refrigerator at shoulder–level, pain free, while maintaining scapular control.
Turn steering wheel, pain free, while maintaining scapular control
Perform all dressing and grooming activities (tuck in shirt behind back, wash hair, etc.) without pain or compensation while maintaining scapular control.
++
++
++
If neurologic based, control may not be regained.
Good to control symptoms.
Prognosis is dependent on the underlying cause, the presence of concomitant shoulder pathology, the quality of the tissues involved, and the ability of the patient to control exacerbating activities and perform the optimal dosage of therapeutic exercise.
++
3. +
Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. In: Guide to Physical Therapist Practice. 2nd ed. Alexandria,
VA: American Physical Therapy Association; 2001. Revised 2003.
4. +
Lee
SG, Kim
JH, Lee
SY, Choi
IS, Moon
ES. Winged scapula caused by rhomboideus and trapezius muscles rupture associated with repetitive minor trauma: A case report. J Korean Med Sci. 2006;21(3):581–584. doi: 10.3346/jkms.2006.21.3.581. [PMID 16778411]
[PubMed: 16778411]
CrossRef
+++
ADDITIONAL REFERENCES
+
Atasoy
E, Majd
M. Scapulothoracic stabilization for wining of the scapula using strips of autogenous fascia lata. J Bone Joint Surg Br. 2000;82(6):813–817. [PMID 10990302]
[PubMed: 10990302]
CrossRef +
Dutton
M. Chapter 8. Musculoskeletal physical therapy. In:Dutton
M McGraw-Hill’s NPTE (National Physical Therapy Examination)2e. New York, NY: McGraw-Hill; 2012.
+
Hamilton
N, Weimar
W, Luttgens
K. The Shoulder Girdle (Acromioclavicular and Sternoclavicular Articulations). In:Hamilton
N, Weimar
W, Luttgens
K Kinesiology: Scientific Basis of Human Motion. New York, NY: McGraw-Hill; 2008.
http://www.accessphysiotherapy.com/content/6150577. Accessed July 1, 2013.
+
Marin
R. Scapula winger’s brace: a case series of the management of long thoracic nerve palsy. Arch Phys Med Rehabil. 1998;79(10):226–1230. doi: 10.1016/S0003-9993(98)90266-0. [PMID 9779675]
[PubMed: 9474009]
CrossRef +
Martin
RM, Fish
DE. Scapular winging: anatomical review, diagnosis, and treatments. Curr Rev Musculoskelet Med. 2008;1(1):1–11. doi: 10.1007/s12178-007-9000-5. [PMID 19468892]
[PubMed: 19468892]
CrossRef +
Novak
CB, Mackinnon
SE. Surgical treatment of a long thoracic nerve palsy. Ann Thorac Surg. 2002;73(5):1643–1645. doi: 10.1016/S0003-4975(01)03372-0. [PMID 12022573]
[PubMed: 12022573]
CrossRef +
Prentice
WE. The shoulder complex. In:Prentice
WE Principles of Athletic Training: A Competency-Based Approach. New York, NY: McGraw-Hill; 2011:639–680.
+
Vinson
EN. Clinical images: Scapular winging. Arthritis Rheum. 2006;54(12):4027. doi: 10.1002/art.22274. [PMID 17133539]
[PubMed: 17133539]
CrossRef
Eric Shamus, PhD, DPT, PT, CSCS, Marangela Obispo, MSPT, GCS
++
+++
CONDITION/DISORDER SYNONYMS
++
Shoulder dislocation
Humerus dislocation
++
831 Dislocation of shoulder
831.0 Closed dislocation of shoulder
831.00 Closed dislocation of shoulder, unspecified
831.01 Closed anterior dislocation of humerus
831.02 Closed posterior dislocation of humerus
831.03 Closed inferior dislocation of humerus
831.09 Closed dislocation of shoulder, other
831.1 Open dislocation of shoulder
831.10 Open dislocation of shoulder, unspecified
831.11 Open anterior dislocation of humerus
831.12 Open posterior dislocation of humerus
831.13 Open inferior dislocation of humerus
831.19 Open dislocation of shoulder, other
++
S43.006A Unspecified dislocation of unspecified shoulder joint, initial encounter
S43.016A Anterior dislocation of unspecified humerus, initial encounter
S43.026A Posterior dislocation of unspecified humerus, initial encounter
S43.036A Inferior dislocation of unspecified humerus, initial encounter
S43.086A Other dislocation of unspecified shoulder joint, initial encounter
S43.109A Unspecified dislocation of unspecified acromioclavicular joint, initial encounter
+++
PREFERRED PRACTICE PATTERN
++
4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Connective Tissue Dysfunction
++
PATIENT PRESENTATION
A 57-year-old male arrived with a complaint of right shoulder pain. Patient reports sudden onset of pain 2 days ago after falling on his outstretched right arm while playing soccer. He reports has been in “extreme” pain since then for which has been taking ibuprofen. He reports enjoys playing soccer at least once a week. Patient’s PMH includes HTN, appendectomy, tonsillectomy, and right humeral fracture as a child due to a fall. He reports feeling concerned due to his current inability to work as a plumber as well as his inability to perform some ADLs. Patient lives with his wife, who has been helping him mainly to get dressed and shower. He was unable to sleep on his right side (as usual) due to increased pain. Upon examination, patient appears in pain with a guarded posture to his right arm which is in mild abduction and external rotation. ROM and strength of the right shoulder were unable to assess due to pain. MMT of the right hand and elbow were decreased. Sensation on the right anterior shoulder area was diminished to light touch. Special tests were positive for the Sulcus sign on the right shoulder. Right shoulder Anterior Drawer, Load and Shift, and Apprehension tests were unable to assess due to pain (which were expected to be positive). Right shoulder x-rays showed anterior dislocation of the humeral head. Right shoulder MRI showed tear of the anterior inferior labrum.
++
++
Humerus can dislocate anteriorly, posteriorly or inferiorly out of the socket.
Excessive translation of the humeral head in one or more directions.
The instability may be associated with dislocation or subluxation associated with a trauma event.
GH instability may also be secondary to atraumatic factors associated with structural, postural, or movement dysfunction and possibly from recurrent minor injury to the structures of the glenohumeral joint.1–3
Symptomatology and management is different depending on the onset, degree, frequency, direction, associated pathology, neuromuscular control, and premorbid activity level.3
+++
Essentials of Diagnosis
++
Diagnosis is made primarily by clinical examination; however, imaging is often necessary to rule in or out associated pathology.
Anterior instability is the most common followed by multidirectional and then posterior instability.
+++
General Considerations
++
Dislocation can tear ligaments, cartilage, and cause vascular or nerve (brachial plexus) injuries.
Onset, degree, frequency, direction, associated pathology, neuromuscular control, and premorbid activity level dictate the diagnosis and management.3
The GH, scapulothoracic, acromioclavicular, and sternoclavicular joint interaction must be examined to determine the optimal treatment plan.7,8
++
Young athletes are most commonly affected.6
Males are more affected than females by traumatic instability; inconclusive evidence for atraumatic or multidirectional.
Multidirectional instability may be associated with gymnastics, swimming, and weightlifting, and the individual may have increased joint laxity throughout the body.6
++
++
SIGNS AND SYMPTOMS
Specific signs and symptoms depend on the onset, degree, frequency, direction, and associated pathology of the injury
Pain in the shoulder, location is often dependent on the primary direction of instability
Feelings of instability and apprehension that are direction dependent to the primary direction of instability
Hypermobility of the GH joint that is direction specific to the primary direction of instability1
Clicking and popping may be present in the shoulder with movement
Decreased upward rotation and increased internal rotation and protraction of the scapula
Special tests for instability specific to the primary direction of instability
In multidirectional instability, the patient may have higher scores on the Beighton scale for assessing generalized joint hypermobility
Numbness for brachial plexus injury
Vascular tearing or impingement
+++
Functional Implications
++
Difficulty with overhead activities
Pain with end range motions of the shoulder
Pain and difficulty with pushing and pulling activities
Pain and difficulty with weight-bearing activities on the arm
Pain with sleeping on the affected side
+++
Possible Contributing Causes
++
Poor posture: Specifically forward-shoulder posture and downwardly rotated, internally rotated, and/or protracted scapula
Athletes, specifically swimmers, gymnasts, and overhead athletes3,6
Increased joint laxity elsewhere in the body (high Beighton scale scores)
Atraumatic instability may be increased by prior traumatic instability injury or a history of other shoulder injury9
Genetic laxity
Trauma
+++
Differential Diagnosis
++
Bankart lesion (anterior)
Differential diagnosis may be direction specific
Ehlers–Danlos
Hill–Sachs lesion (anterior)
Humeral avulsion of glenohumeral ligaments (HAGL) (anterior)
Marfan syndrome
Osteogenesis imperfect
Reverse Hill–Sachs lesion (posterior)
Tearing of the posterior capsule (posterior)
Tearing of the Teres minor (posterior)
+++
Means of Confirmation or Diagnosis
++
++
+++
FINDINGS AND INTERPRETATION
++
Physical examination is the current accepted means of diagnosis.
Imaging to diagnose additional pathology.
Hypermobility of the GH joint that may be direction specific.1
Decreased upward rotation of the scapula and/or increased medial winging (internal rotation) of the scapula with humeral elevation.
Increased scapulohumeral rhythm.
Direction-specific positive special tests.
Increased joint laxity throughout the body may be present.
See Case Study: Neck Pain and Arm Paresthesia on AccessPhysiotherapy.com for more information
++
++
++
REFERRALS/ADMITTANCE
For diagnostic imaging, MRI, CT, or radiograph as indicated
Surgical consult with orthopedic surgeon if conservative treatment fails or if associated pathology is suspected
++
Hypermobility of the GH joint that may be direction specific;1
Excessive, direction-specific accessory motions of the humeral head with physiologic shoulder movements;
Decreased upward rotation of the scapula and/or increased medial winging (internal rotation) of the scapula with humeral elevation;
Muscle performance impairment of stiffness, shortness, or dominance of the pectoralis minor, levator scapulae, or rhomboid major and minor;
Muscle performance impairment of weakness, excessive length, or decreased neuromuscular control of the supraspinatus, infraspinatus, teres minor, subscapularis, upper trapezius, middle trapezius, lower trapezius, and serratus anterior;
Structural impairments of the humerus or glenoid, such as flattening of the glenoid may be present;
Pain with direction-specific shoulder motions. Range of motion may initially be excessive; however, the shoulder ROM may be limited by pain once symptomatic.
++
++
Intervention based on the type (traumatic or atraumatic), onset, degree, frequency, direction, and potential associated pathology.3
Traumatic
Acute
Immobilization may be used with the arm in 30 degrees of abduction and 30 degrees of external rotation.13
Passive ROM (PROM) and active ROM (AROM) within pain-free ranges.
External rotation may be limited to 65 to 70 degrees to prevent overstressing the anterior structures for anterior instability.
Internal rotation may be limited to prevent overstressing the anterior structures for posterior instability.
Isometric, pain-free strengthening.
Gentle, pain-free weight bearing on the arm.
Pain-free dynamic stabilization with the arm in 30 degrees of abduction, neutral rotation and 30 degrees into the scapular plane.
Modalities as needed to control pain, inflammation, and muscle guarding.
Intermediate
Progression of items from the acute stage.
Isotonic strengthening may be initiated with emphasis on rotator cuff musculature to promote stability.
Progression of weight-bearing exercise such as modified push-ups with an emphasis on maintaining correct scapular alignment may be initiated to promote stability.
Trunk stabilization exercise may be initiated to enhance correct movement patterns and reduce abnormal stress to the GH joint.
Neuromuscular electrical stimulation (NMES) to the muscles of the rotator cuff during exercise to improve muscle fiber recruitment.
Advanced
Progression of all items from intermediate stage.
Unilateral weight-bearing stability exercise, such as wall stabilization drills with medicine or stability balls.
Proper alignment of the scapula should be maintained during all stabilization exercise.
Plyometric exercise progressing to overhead and then unilateral may be indicated if the patient is returning to sport.
Atraumatic
Intervention is very similar to that used following traumatic instability.
Progression may be slower than with traumatic.
Care should be taken to prevent stretching of capsular tissues.
Exercise that emphasizes co-contraction and proprioception is indicated.
Exercise with an emphasis on muscle balance about the shoulder girdle with correct positioning and movement of the scapula should be performed.
Trunk-stability exercise to improve stability during functional tasks should be initiated once patient is able to stabilize the GH joint.
++
++
++
Note: The duration portion of the goals will be dependent on the onset, degree, frequency, direction, associated pathology, neuromuscular control, and premorbid activity level.3
++
Patient will be able to
Dress without pain or instability 95% of the time.
Perform all self-care activities without pain or instability 95% of the time.
Sleep through the night without being woken by pain 95% of the time.
Bear full weight through the arms without pain or instability 95% of the time.
Lift 10 pounds overhead without pain or instability 95% of the time.
Perform all daily activities without pain or instability 95% of the time.
Return to recreational tasks without pain or instability 95% of the time.
++
Return to function may be anywhere from 2 weeks to 6 months and rehabilitation visits may range from 3 to 36 visits, dependent on the onset, degree, frequency, direction, associated pathology, neuromuscular control, and premorbid activity level.3,14
Recurrence is common in the younger population, while additional pathology is often seen in individuals more than 40 years of age.15
++
1. +
Cameron
KL, Duffey
ML, DeBerardino
TM, Stoneman
PD, Jones
CJ, Owens
BD. Association of generalized joint hypermobility with a history of glenohumeral joint instability. J Athl Train. 2010;45(3):253–258. [PMID: 20446838]
[PubMed: 20446838]
CrossRef 2. +
Owens
BD, Duffey
ML, Nelson
BJ, DeBerardino
TM, Taylor
DC, Mountcastle
SB. The incidence and characteristics of shoulder instability at the United States Military Academy. Am J Sports Med. 2007;35(7):1168–1173. doi: 10.1177/0363546506295179. [PMID: 17581976]
[PubMed: 17581976]
CrossRef 3. +
Wilk
KE, Macrina
LC, Reinold
MM. Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability. N Am J Sports Phys Ther. 2006;1(1):16–31. [PMID: 21522197]
[PubMed: 21522197]
4. +
Pope
EJ, Ward
JP, Rokito
AS. Anterior shoulder instability - a history of arthroscopic treatment. Bull NYU Hosp Jt Dis. 2011;69(1):44–49. [PMID: 21332438]
[PubMed: 21332438]
5. +
Hottya
GA, Tirman
PF, Bost
FW, Montgomery
WH, Wolf
EM, Genant
HK. Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthrographic findings with arthroscopic correlation. AJR Am J Roentgenol. 1998;171(3):763–768. [PMID: 9725313]
[PubMed: 9725313]
CrossRef 6. +
Cordasco
FA. Understanding multidirectional instability of the shoulder. J Athl Train. 2000;35(3):278–285. [PMID: 16558641]
[PubMed: 16558641]
7. +
Kikuchi
K, Itoi
E, Yamamoto
N
et al.. Scapular inclination and glenohumeral joint stability: a cadaveric study. J Orthop Sci. 2008;13(1):72–77. doi: 10.1007/s00776-007-1186-2. [PMID: 18274859]
[PubMed: 18274859]
CrossRef 8. +
Ludewig
PM, Reynolds
JF. The association of scapular kinematics and glenohumeral joint pathologies. J Orthop Sports Phys Ther. 2009;39(2):90–104. doi: 10.2519/jospt.2009.2808. [PMID: 19194022]
[PubMed: 19194022]
CrossRef 9. +
Jana
M, Gamanagatti
S. Magnetic resonance imaging in glenohumeral instability. World J Radiol. 2011;3(9):224–232. doi: 10.4329/wjr.v3.i9.224. [PMID: 22007285]
[PubMed: 22007285]
CrossRef 10. +
Cook
CE, Hegedus
EJ. Orthopedic Physical Examination Tests: An Evidence-Based Approach. Upper Saddle River, NJ: Prentice Hall; 2008.
11. +
Magee
DJ. Orthopedic physical assessment. 5th ed. St. Louis, MO: Saunders Elsevier; 2008.
12. +
Waldt
S, Rummeny
EJ. [Magnetic resonance imaging of glenohumeral instability]. Rofo. 2006;178(6):590–599. doi: 10.1055/006-926745. [PMID: 16703494]
[PubMed: 16703494]
CrossRef 13. +
Itoi
E, Hatakeyama
Y, Kido
T
et al.. A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study. J Shoulder Elbow Surg. 2003;12(5):413–415. doi:10.1016/S1058-2746(03)00171-X. [PMID: 14564258]
[PubMed: 14564258]
CrossRef 14. +
American Physical Therapy Association. Guide to Physical Therapists Practice 2nd Ed. Phys Ther. 2002;81:9–744. [PMID: 11175682]
15. +
Sonnabend
DH. Treatment of primary anterior shoulder dislocation in patients older than 40 years of age. Conservative versus operative. Clin Orthop Relat Res. 1994;(304):74–77. [PMID: 8020237]
+++
ADDITIONAL REFERENCES
+
Pattern 4D: Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction. In: Guide to Physical Therapist Practice. 2nd ed. Alexandria,
VA: American Physical Therapy Association; 2001. Revised 2003.
Jennifer Cabrera, DPT, GCS, Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
++
812.00 Fracture of unspecified part of upper end of humerus closed
812.01 Fracture of surgical neck of humerus closed
812.02 Fracture of anatomical neck of humerus closed
812.03 Fracture of greater tuberosity of humerus closed
812.09 Other closed fractures of upper end of humerus
812.10 Fracture of unspecified part of upper end of humerus open
812.11 Fracture of surgical neck of humerus open
812.12 Fracture of anatomical neck of humerus open
812.13 Fracture of greater tuberosity of humerus open
812.19 Other open fractures of upper end of humerus
++
S42.209A Unspecified fracture of upper end of unspecified humerus, initial encounter for closed fracture
S42.209B Unspecified fracture of upper end of unspecified humerus, initial encounter
S42.213A Unspecified displaced fracture of surgical neck of unspecified humerus, initial encounter for closed fracture
S42.213B Unspecified displaced fracture of surgical neck of unspecified humerus, initial encounter for open fracture
S42.216A Unspecified nondisplaced fracture of surgical neck of unspecified humerus, initial encounter for closed fracture
S42.216B Unspecified nondisplaced fracture of surgical neck of unspecified humerus, initial encounter for open fracture
S42.253A Displaced fracture of greater tuberosity of unspecified humerus, initial encounter for closed fracture
S42.253B Displaced fracture of greater tuberosity of unspecified humerus, initial encounter for open fracture
S42.256A Nondisplaced fracture of greater tuberosity of unspecified humerus, initial encounter for closed fracture
S42.256B Nondisplaced fracture of greater tuberosity of unspecified humerus, initial encounter for open fracture
S42.293A Other displaced fracture of upper end of unspecified humerus, initial encounter for closed fracture
S42.293B Other displaced fracture of upper end of unspecified humerus, initial encounter for open fracture
S42.295A Other nondisplaced fracture of upper end of left humerus, initial encounter for closed fracture
S42.296A Other nondisplaced fracture of upper end of unspecified humerus, initial encounter for closed fracture or open fracture
S42.296B Other nondisplaced fracture of upper end of unspecified humerus, initial encounter for open fracture
++
+++
PREFERRED PRACTICE PATTERN
++
++
PATIENT PRESENTATION
An 83-year-old woman went to use the restroom, slipped and hit her right arm against the sink. She felt immediate pain in her arm and was unable to move her shoulder. Patient has diagnosed osteoporosis × 10 years for which she does not take bisphosphonates. She presented with pain and swelling throughout the upper extremity (UE) with visible deformity. She demonstrated increased tenderness upon palpation of humerus and shoulder. Radiograph showed a displaced transverse fracture of the proximal humerus.
++
Fracture
Any defect in continuity of the proximal humerus
Displaced (proximal humerus is moved on either side of the fracture) or nondisplaced (proximal humerus has not moved)
Closed (skin is intact) or open (skin is breached)
++
+++
Essentials of Diagnosis
++
Diagnosis is usually made by clinical examination
May not be a fracture, but a dislocation, an acromioclavicular (AC) sprain, or a rotator cuff strain
+++
General Considerations
++
++
++
+++
Functional Implications
++
Patient will present with involved UE in position of protection: Shoulder adduction, internal rotation, and elbow flexion.
Patient will be unable to tolerate any functional use of involved UE secondary to pain.
++
+++
Possible Contributing Causes
++
+++
Differential Diagnosis
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
+++
FINDINGS AND INTERPRETATION
++
Involved UE in position of protection: Shoulder adduction and internal rotation and elbow flexion secondary to glenohumeral (GH) capsular pattern (external rotation, abduction, internal rotation).
Unable to tolerate active ROM (AROM)/passive ROM (PROM) of involved UE secondary to pain.
If vascular structures are involved, the UE will appear cool and pale, with diminished palpable pulses.
If neurologic structures are involved, the individual will report numbness and decreased ability to move the involved UE (e.g., axillary nerve).
++
++
++
Inability to
Perform self-care needs secondary to pain and impaired ROM
Reach overhead secondary to pain
Bear weight on involved UE secondary to pain
Carry groceries secondary to pain and muscle weakness
++
++
Aerobic endurance
Functional strength, manual muscle testing (MMT)
Upper-extremity ROM
Posture
Structural (shoulder complex, cervical, thoracic)
Disabilities of the Arm, Shoulder and Hand (DASH) score to assess physical function
Sensory integrity
++
Address swelling
Ice/cryotherapy
Compression
Elevation
Electrical stimulation
Address pain
Ice/cryotherapy
Massage
Electrical stimulation
Address lack of flexibility via stretching
Address mobilization upon healing of fracture site (after 6 weeks postoperative)
GH distraction
GH caudal glide for abduction
GH posterior glide for flexion and internal rotation
GH anterior glide for extension and external rotation
Address weakness via strengthening activities
Closed-chain weight-bearing activities
Isometric exercises (initially submaximal)
Open chain via use of free weights and resistance bands
Address functional mobility if applicable
Address scar mobility
++
Patient will
Demonstrate decreased QuickDASH (disability of the arm, shoulder, and hand) score to 18 in order to exhibit diminishing disability.
Increase shoulder internal rotation to 70 degrees in order to don/doff brassiere.
Increase shoulder abduction to 112 degrees in order to comb hair.
Increase arm curl test repetitions to 24 in order to increase UE strength for household chores.
++
Shoulder fracture as a whole requires 1 year of recovery.
Major cause of morbidity in the elderly population.
Individuals who undergo an open reduction internal fixation.
++
3. +
Pattern 4G: impaired joint mobility, muscle performance, and range of motion associated with fracture. In: Guide to Physical Therapist Practice. 2nd ed. Alexandria,
VA: American Physical Therapy Association; 2001. Revised 2003.
+++
ADDITIONAL REFERENCES
+
Goodman
CC, Boissonnault
WG, Fuller
KS. Pathology: Implications for the Physical Therapist. 2nd ed. Philadelphia, PA: Saunders; 2003.
+
Kisner
C, Colby
LA. Therapeutic Exercise: Foundations and Techniques. 5th ed. Philadelphia, PA: F.A. Davis Company; 2007.
+
Magee
DJ. Orthopedic Physical Assessment. 5th ed. St. Louis, MO: Saunders Elsevier; 2008.
+
Maxey
L, Magnusson
J. Rehabilitation for the Postsurgical Orthopedic Patient. 2nd ed. St. Louis, MO: Mosby Elsevier; 2007.
W. Justin Jones, DPT, PT, OCS, Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
++
++
+++
PREFERRED PRACTICE PATTERN3
++
Pattern 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation
++
PATIENT PRESENTATION
A 43-year-old male presents to the OP PT clinic with complaints of right shoulder pain. The patient states it has been bothering him for about 4 weeks. He describes the pain as more of a discomfort. He denies any cervical pain and any radicular symptoms in the arms. He thinks it began when he was throwing a Nerf football with his 10-year-old son. The football does not weigh very much and he says he has to throw the ball hard when passing. If he does not use the arm overhead the shoulder does not bother him much. The patient has good strength throughout the shoulder and is negative for an empty can test and acromioclavicular (AC) compression test.
++
Shoulder pain and dysfunction due to compression and abrasion of one or more of the rotator cuff tendons, the long head of the bicep tendon, and/or the subacromial bursa beneath the coracoacromial arch due to an abnormal mechanical relationship.
The coracoacromial arch consists of the undersurface of the acromion, coracoacromial ligament as well as the undersurface of the AC joint.
Impingement is the most commonly diagnosed shoulder problem and likely has numerous potential mechanisms, which can impact both treatment and prognosis.
++
++
+++
Essentials of Diagnosis
++
++
+++
General Considerations
++
++
++
++
SIGNS AND SYMPTOMS
Pain in anterior lateral shoulder with active movement and overhead activities
Painful arc commonly present in the midrange of shoulder elevation
Weakness is commonly noted with functional reaching tasks
+++
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)
+++
Possible Contributing Causes
++
Acromion morphology
Degenerative changes at the AC joint
Rotator cuff tendinopathy
Bicipital tendinopathy
Capsular laxity
Capsular tightness
Increased thoracic kyphosis and suboptimal posture
Repetitive overhead activities
Poor neuromuscular control
+++
Differential Diagnosis1
++
AC separation
Cervical radiculopathy
Referred pain from lungs or diaphragm
Full-thickness rotator cuff tear
Glenohumeral (GH) arthritis
GH instability
Labral tear
Adhesive capsulitis
Neuropathy (suprascapular nerve)
Internal impingement
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
Diagnostic ultrasound
Radiograph
MRI
++
Anti-inflammatory
Corticosteroid injection
++
++
++
Impaired (suboptimal) posture
Muscle imbalances
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
++
AC compression test
Anterior slide test
Biceps load test
C5–C6 dermatome/myotome testing
Clunk test
Compression–rotation test
Diagnostic test properties for subacromial impingement
Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function
Drop arm (Codman) 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
++
Note:Varies depending on the type of impingement, causes, stage of healing, and tissue quality but generally involves portions of the following:
++
Acute stage
Subacute/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 pec major/minor, latissimus dorsi (lats), and other muscles with decreased length
Strengthening of scapular musculature
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
Scapular strength/stabilization
Retraction
Prone shoulder extension, abduction, scapular plane elevation
Addressing lack of flexibility
Addressing joint mobility
Addressing tendinopathy
++
Patient will be able to:
Move upper extremity (UE) through full range of elevation without pain to reach in the cabinet.
Reach back pocket (or fasten bra for female) without pain.
Reach for a gallon of milk without pain.
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Prognosis depends on the underlying cause of the impingement, 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.
The stage of the impingement according to Neer can be prognostic with Stage I generally having a better prognosis than Stage III.
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3. +
Pattern 4E: impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. In: Guide to Physical Therapist Practice. 2nd ed. Alexandria,
VA: American Physical Therapy Association; 2001. Revised 2003.
4. +
Park
HB, Yokota
A, Gill
HS
et al.. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg Am. 2005;87:1446–1455. doi:10.2106/JBJS.D.02335.
[PubMed: 15995110]
CrossRef
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ADDITIONAL REFERENCES
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Bang
MD, Deyle
GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;30(3):26–137.
CrossRef +
Bigliani
LU, Levine
WN. Current Concepts Review: Sub-acromial Impingement Syndrome. J Bone Joint Surg Am. 1997;79:1854–1868.
[PubMed: 9409800]
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Bigliani
LU, Levine
WN. Current Concepts Review: Sub-acromial Impingement Syndrome. J Bone Joint Surg Am. 1997;79:1854–1868.
[PubMed: 9409800]
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Hamilton
N, Weimar
W, Luttgens
K. The upper extremity: the shoulder region. In:Hamilton
N, Weimar
W, Luttgens
K Kinesiology: Scientific Basis of Human Motion. New York, NY: McGraw-Hill; 2008:Chapter 5.
http://www.accessphysiotherapy.com/content/6150569. Accessed August 9, 2014.
+
Kisner
C, Colby
LA. Therapeutic Exercise: Foundations and Techniques. 5th ed. Philadelphia, PA: FA Davis; 2007:502–511.
+
Ludewig
PM, Braman
JP. Shoulder impingement: Biomechanical considerations in rehabilitation. Man Ther. 2011;16(1):33–39. doi:10.1016/j.math.2010.08.004.
[PubMed: 20888284]
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Theisen
C, van Wagensveld
A, Timmesfeld
N
et al.. Co-occurrence of outlet impingement syndrome of the shoulder and restricted range of motion in the thoracic spine–a prospective study with ultrasound-based motion analysis. BMC Musculoskelet Disord. 2010;11:135. doi:10.1186/1471-2474-11-135.
[PubMed: 20587014]
CrossRef +
Wilk
KE, Reinold
MM, Andrews
JR. The Athletes Shoulder. 2nd ed. Philadelphia, PA: Churchill Livingstone Elsevier; 2009;115–140.