In most adults who present with atraumatic shoulder pain, symptoms arise from impingement syndromes (previously called rotator cuff tendonitis). These symptoms become more common as patients age.
The rotator cuff is made up of four muscle-tendon structures (supraspinatus, infraspinatus, teres minor, subscapularis) (Figure 7-1). Their combined activity is to move the shoulder through space and maintain the joint’s integrity. The symptoms of impingement can be managed initially by manual techniques. When followed by an aggressive physical therapy program, impingment syndrome can often be cured without surgery. Trauma-related shoulder pain is also often effectively treated without surgery, but an accurate diagnosis is needed as well as the recognition that failure to resolve may result in operative correction.
Impingement (rotator cuff tendonitis)
Angina (left shoulder)
History Consistent With Impingement Syndrome (Rotator Cuff Tendonitis)
Onset without history of trauma.
Pain initially bothersome with abduction movements; progresses to painful with reaching over head and may cause awakening while sleeping.
Testing for Impingement Syndrome (Rotator Cuff Tendonitis)
Range of Motion: Active and Passive
Ask the patient to keep elbows straight and abduct the arms to horizontal and ultimately over their heads, looking for asymmetry of muscle use.
If there is a significant asymmetry have the patient relax and move that extremity through passive range of motion through abduction.
Pronate the patient’s arms, moving the arms off center to 45 degrees with the thumbs down.
Place your hands on the patient’s wrists and resist the patient’s attempt to raise their arms, comparing sides for weakness of involved side and/or if the maneuver causes pain.
Move the arm in forward flexion, first through active and then passive flexion, noting if and when the patient has pain.
If pain occurs with active range on motion (ROM) only, consider impingement. If pain occurs with both active and passive ROM, consider adhesive capsulitis.
Forward flex the patient’s shoulder and bend the elbow to 90 degrees. Support the patient’s elbow and wrist with your hands.
Rotate the patient’s forearm to 90 degrees, then beyond the horizontal, looking to determine if moving past horizontal induces pain or discomfort. If pain or discomfort occur, impingement is likely the cause.
Testing for Joint Laxity/Subluxation/Dislocation
With the patient sitting or supine, abduct the patient’s arm to 90 degrees and bend the elbow.
GENTLY move the patient’s hand posteriorly, then ask the patient to press forward against resistance.
Then, have them press posteriorly against resistance.
If either movement makes the patient feel uncomfortable or agitated, consider a lax joint.
Remember the Rules
1. Move to a position of less pain and apply trigger point care
2. Stretch the SHORTENED muscle
3. Treat the region (above and below pain)
4. Tape to support neutral position
5. Support definitive treatment (physical therapy, orthopedics, neurosurgery)
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Pain/Restriction with Abduction: Supraspinatus Treatment
While supine, have the patient forward flex the affected arm to their limit. The patient’s thumb should be pointing behind the patient’s head.
Hold resistance against the patient’s wrist and shoulder.
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