Escolar Documentos
Profissional Documentos
Cultura Documentos
THIRD EDITION
Edited by
Robert A. Donatelli, Ph.D., P.T., O.CS.
I nsLruclor
Divisioll oj Physical T herapy
At/alita, Georgia
Physiotherapy Associates
Memphis, Tellllesse
The Publishers have made every eFronto trace the eopytight holders for bor
,'owed material. If they have inadvertently overlooked any, they will be
pleased to make the necessal)' 31T3ngements at the fil'St oppol1unity.
Mark S. Albert, M.Ed., P.T., A.T.C, S.e.S. Robert A. Dotlatelli, Ph.D., P.T., O.e.S.
Part-time InstmctOl; Department of Physical instructor, Division of Physical Therapy,
Therapy, College of Health Sciences, Georgia State Depal·tment of Rehabilitation Medicine, EmOlY
University; Clinical Specialist, Physiotherapy University School of Medicine, Atlanta, Geor
Associates, Atlanta, Georgia gia; National Director of Sports Rehabilitation,
Physiotherapy Associates, Memphis, Tennessee
Robert Catltll, M.M.Sc., P.T., M.S.e.
Assistant Professor, Institute of Physical Therapy, Peter 1. Edgelow, M.A., P. T.
SI. Augustine, Florida; Clinical Director, PhYSiO Senior Staff Therapist, Physiotherapy Associates;
therapy Associates, Atlanta, Georgia Graduate Residency in Orthopaedic Physical
Therapy, Kaiser Permanente, Hayward, Califoll1ia
Deborah Seidel Cobb, M.S. P.T.
Physical Therapist, Physiotherapy Associates, Todd S. Ellet!becker, M.S., P.T., S.C.S., e.S.e.S.
Atlanta, Georgia Clinic Director, PhYSiotherapy Associates·
Scottsdale Sports Clinic, Scottsdale, Alizona
vii
viii CONTRIBUTORS
N0n11al function of the shoulder is cdtical for I am honored to include Ola Gdmsby, John Gray,
recreational activities, occupational performance, Robcl� Elvey, Toby Hall, and Peler Edgelow as chapler
and activities of daily living. Given the impot1ance of authors in the third edition. Their contributions to the
normal shoulder biomechanics, it is not sUI-prising Neurologic Considerations section are excellenl. The
that changes in shoulder mechanics, altered kinemat chaplers on Inten'c1ationship of Ihe Spine and Shoul
ics, and anatomic deficits contribute to shoulder der Girdle, Neural Tissue Evaluation and Treatment,
pathomechanics. Our role as physical therapists is to and NeurovascuJal" Consequenses of Cumulative
assess the intricate shoulder mechanics to determine Trauma Disorders Affecting the Thoracic Outlet
abnormal movement pancrns before we begin our demonstrate the importance of understanding the
treatment program. intcn"elationship between the musculoskeletal and
Many rehabilitation students and clinicians are neurologic systems. Chapter 7 was completely rewl'it
uncertain in assessing shoulder pathomcchanics and ten with a more clinical approach 10 brachial plexus
in establishing treatment protocols for different lesions.
shoulder pathologies. This Shol1coming is due to the The Special Considerations section l1!views the
vadcLY of treatment appI'oachcs to the shoulder and most common pathologies and dysfunctions of the
the complexity of the shoulder and upper quarter shoulde.: In Chapter 12 John Gray demonst.-ales Ihe
inten"elationships. importance of understanding how other systems in
In keeping up to date with new and innovative the body can refer pain to the shoulder. MobiIi7..ation,
treatment techniques, surgical procedures, and evalu strengthening exercises (including isokinetics), and
ation methods for the shoulder, this third edition of myofascial techniques are discussed in the Treatment
Physical Therapy of Ihe Shoulder has become a LOtally Approaches section. All four chapters in this section
new book. We have expanded the third edition to 20 include figures accurately demonstrating treatment
chapters from 16. There are 18 new authors and 10 techniques. The Surgical Considerations section fea
new chapters. tures new infol"mation on the most common surgical
The third edition has been divided into five sec procedures for shoulder instabilities, rotator cuff
tions; Mechanics of Movement and Evaluation, Neu- repairs, and total joint replacements.
1"Oiogic Considerations, Special Considerations, Tt1!at Any rehabilitation professional entrusted with
ment Approaches, and Surgical Considerations. Case the care and treatment of mechanical and patho
studies are presented thT"OUghout the text. logic shoulder dysfunclion will benefit from this
Chapter t emphasizes the clinical mechanics of book. We trust that the third edition of Physical
shoulder movement. The mechanical components of Therapy of Ihe Shoulder will meel the reader's expec
shoulder elevation arc descdbed and divided into lation of comprehensive, clinically relevant presen
phases. Jeff Cooper, a new author for this edition who tations that are well documented, contemporar)"
is Ihe alhlelic Irainer for Ihe Philadelphia Phillies, and personally challenging to the student and clini
does an excellent job in descdbing the mechanics of cian alike.
pitching and injudes related to the sport. Chapter 3
reviews the traditional approach of Cyriax's differen
tial soft tissue evaluation of the shoulder and all the
special tests. Roberl A. DOl/alel/i, Ph.D., P.T., o.c.s.
ix
Contents
MECH A N IC S OF CHAPTER 8
CHAPTER 1
CHAPTER 2
CHAPTER 9
Throwing Injuries I t 9
Impingement Syndrome and
Jef{Cooper
Impingement-Related Instability I 229
Lori A. Theill and Bruce H. Greenfield
CHAPTER 3
NEU R OL O G IC CHAPTER 1 I
CHAPTER 6 T R E AT M E NT
Neurovascular Consequences of Cumulative A P P R O AC HE S
Trauma Disorders Affecting the Thoracic
Outlet: A Patient-Centered Treatment CHAPTER 13
CHAPTER 15
CHAPTER 19
Myofascial Treatment I 383
Shoulder Girdle Fractures I 447
Deborah Seidel Cobb and Robert Call1L1
Michael J. Wooden al1d David J. CO//aIVay
CHAPTER 16
CHAPTER 20
Isokinetic Evaluation and Treatment I 401
Total Shoulder Replacement I 459
Mark S. Albert al1d Michael 1. Wooden
George M. McClLlskey III al1d Timothy Uhl
SUR G IC AL
I NDE X 477
C O N S ID E R AT I O N S
Instabilities I 421
Al1gelo J. Mallalil10
CHAPTER 18
1
2 PHY S I CAL THERAPY OF THE SHOUL DER
3"-_----�
,.
,
,
,
,
I
I I
, ,,
I
, I
, I
, ,
, I
, ,
, ,
III
."
,,(
w
thermore, Tata et a1.'6 reported higher ratios of trauma is minimal, and the most advantageous
abduction to adduction and external to internal plane for strength trainjng programs.
torque when tested in the scapular plane at 30·
and 35· anterior to the frontal plane, respec
Flexiol1
tively. Whitcomb et al.l? found no significant dif
ference between torque produced by the shoul The movement of flexion has been less thor
der abductors in the coronal and scapular oughly investigated. Flexion is movement in the
planes, using a scaption position 35 · anterior to sagittal plane. Full nexion from 162· to 18 0· is
the frontal plane. possible only with synchronous motion in the
The studies cited indicate that the external glenohumeral, acromioclavicular, sternoclavic
rotators are the only muscle group that demon ular, and scapulothoracic joints. " The move
strated a significant increase in torque produc ment is similar to that of abduction.
tion in the scaption plane 30· anterior to the fron
tal plane. The pectoralis major and the latissimus
ARTHROKINEMATIC MOVEMENT
muscles groups are not attached to the scapula.
Therefore, it would seen reasonable that when The motion OCCUlTing at Jomt surfaces is
comparing the torque output of the internal rota arthrokinematic motion, of which there are
tors, the change in position of the scapula should three types: rolling, gliding, and rotation (Fig.
not effect the optimal length-tension relation 1.4) Rolling occurs when various points on a
ship. Thus, the internal rotators exhibit no moving surface contact various points on a sta
change in the torque output when testing in dif tionary surface. Gliding occurs when one point
ferent planes of movement. on a moving surface contacts multiple points on
In addition to optimal muscle length-tension a stationary surface. When rolling or gliding
relationship in the plane of the scapula, the cap occur, there is a Significant change in the contact
sular fibers of the glenohumeral joint are re area between the two joint surfaces. The third
laxeds Poppen and Walkeri' demonstrated that type of arthrokinematic movement, rotation, oc
in scaption there is an increase in joint congru curs when one or more points on a moving sur
ity, allowing for greater joint stability. Therefore, face contact one point on a stationary surface.
for reasons of glenohumeral stability, avoidance There is little displacement between the two joint
of impingement, and balance of muscle action, surfaces in rotation.
scaption may be the plane in which shoulder All three arthrokinematic movements can
4 PHYSICAL THERAPY OF THE SHOULDER
Gliding
FIGURE 1.4 Arthrokinematic molion occurr;'1g at the glenohumeral joint: rolling, rolation, and
gliding.
occur at the glenohumeral joint, but they do not order to reestablish harmonious movement
occur in equal proportions. These motions are within the shoulder complex the therapist must
necessary for the large humeral head to take ad rehabilitate the connective tissue by restoring its
vantage of the small glenoid articulating sur extensibility, and restore the normal balance of
face.'• Saha investigated the contact area be muscles.
tween the head of the humems and the glenoid
with abduction in the plane of the scapula 14 and
Rotations of the HumerLis
found that the contact area on the head of the
humerus shifted up and forward while the con Concomitant external rotation of the hume
tact area on the glenoid remained relatively con rus is necessary for abduction in the coronal
stant, indicating a rotation movement. Poppen plane.4.8,IO.1 4.17 Some investigators have postu
and Walker measured the instant centers of rota lated that this motion is necessary for the greater
tion for the same movement. tuberosity to clear the acromion and the cora
in the first 30°, and often between 30° and 60°, coacromial ligament.,·2.' 7 Saha reports that
the head of the humems moved superiorly in the there is sufficient room between the greater tu
glenoid by 3 mm, indicating rolling or gliding. berosity and the acromion to prevent bone im
At more than 60°, there was minimal movement pingement. External rotation also remains nec
of the humems, indicating almost pure rota essary for full coronal abduction even after the
tion. 15 acromion and the coracoacromial ligament are
Normal arthrokinematic movements occur surgically removed. Saha has reasoned that ex
only in the presence of normal periarticular con ternal rotation is necessary to prevent the hu
nective tissue, extensibility, and integrity and meral head from impinging on the glenoid rim.16
muscle function. A stiff shoulder has limited cap Rajendran,28 using cadaveric glenohumeral
sular nexibility and altered muscle function. In joints. demonstrated automatic external rotation
FUNCTIONAL ANATOMY AND MECHANICS 5
of the humerus is an essential component of ac aments, capsular ligaments, and the bony gle
tive as well as passive elevation of the arm noid.34 The glenohumeral joint contributes the
through abduction. Even in the absence of extra greatest amount of motion to the shoulder be
articular influences such as the coracoacromial cause of its ball and socket configuration. Saha35
arch and glenohumeral muscles, external rota confirmed the ball and socket joint of the gleno
tion of the humerus was spontaneous. An Kn et humeral articulation in 70 percent of his speci
al.29 used a magnetic tracking system to monitor mens. In the remaining 30 percent, the radius of
the three-dimensional orientation of the hume curvature of the humeral head was greater than
rus with respect to the scapula. Appropriate co the radius of curvature of the glenoid. Thus, the
ordinate transformations were then performed joint was not a true enarthrosis.'· Saha'· further
for the calculation of glenohumeral joint rota described the joint surfaces, especially on the
tion. Maximum elevation in all planes anterior head of the humerus, to be very i'Tegular and to
to the scapular plane required external axial ro demonstrate a great amount of individual va,-ia
tation of the humerus.
tion.
Furthermore, Oti et al. 30 demonstrated that
The head of the humerus is a hemispherical
external rotation of the humerus allows the in
convex articular surface that faces superior, me
sertion of the subscapularis tendon to move lat
dial, and posterior. This articular surface is in
erally, resulting in an increase in the distance
clined 130· to ISO· to the shaft of the humerus
from the axis of elevation in the scapula plane.
and is retroverted 20· to 30.3 The retroversion,
An increase in the moment arm enhances the
and the poste,;or tilt of the head of the humerus
ability of the superior fibers of the subscapularis
to participate in scaption. Conversely, internal and the glenoid, cultivate joint stability (Fig. 1 . 5 ) .
rotation of the humerus increases the moment This retroversion of the head of the humerus cor
a,m of the superior fibers of the infraspinatus, responds to the forward inclination of the sca
enhancing the ability of the muscle to participate pula, so that fTee pendulum movements of the
in scaption. Flatow et al.3I reported that acro arm do not occur in a straight sagittal plane but
mial undersurface and rotator cuff tendons are at an angle of 30· across the body.'· This CO'Te
in closest proximity between 60· and 120· of ele sponds to the natural arm swing evident in am
vation. Conditions limiting external rotation or bulation.
elevation may increase rotator cuff compression. The head of the humerus is large in relation
Rajendran and Kwek" described how the course to the glenoid fossa; therefore only one-third of
of the long head of the biceps will influence ex the humeral head can contact the glenoid Fossa
ternal rotation of the humen,s, which in turn at a given time.'·3. The glenoid fossa is a shallow
prevents tendon impingement between the structure deepened by the glenoid labrum. The
greater tuberosity and the glenoid labrum, and lab,um is wedgeshaped when the glenohumeral
allows glenohumeral elevation to move to com joint is in a resting position, and changes shape
pletion. Brems" repo'is that external rotation is with various movements.37 The glenoid and the
possibly the most impo'iant functional motion labrum combine to form a socket with a depth
that the shoulder complex allows. Loss of exter up to 9 mm in the superior-inferior direction
nal rotation could result in significant functional
and 5 mm in the anteroposterior direction.3• The
disability.
functional Significance of the lab,um is ques
tionable. Most authors agree that the labrum is
Static SWiJilizers of the a weak supporting structure.37 .39 The function of
the labrum has also been described as a "chock
Glerwhumeral Joint block" preventing humeral head translation.3•
The stability of the glenohumeral joint is depen Moseley and Overgaard37 considered the labrum
dent on the integrity of soft tissue and bony a redundant fold of the capsule composed of
structures such as the labrum, glenohumeral lig- dense fibrous connective tissue but generally de-
6 PHYSICAL THERAPY OF THE SHOULDER
FIGURE 1.6 Exlernal rolalion of the humerus in FIGURE 1.7 Exlernal rOlaliol1 o f Ihe humerus al
Ihe adducled posilion. The mosl stabilizing 45°abduclion. The mosl slabilizing struclLlres
structure 10 this movement is the subscapularis for Ihis movemel11 are Ihe middle alld il1(erior
muscle. Iigamel1ls and subscapularis muscle.
die glenohumeral ligament. and superior fibers meral ligament. The coracohumeral ligament
of the inferior ligament (Fig. J . 7). At 90° of ab appeared to have no significant suspensory role.
duction. external rotation was restricted by the Abduction to 45° and 90° demon trated the ante
inferior glenohumeral ligament (Fig. J .8). rior and posterior portions. respectively. of the
Hoi et al. glenohumeral ligament to be the main static sta
the biceps (LI-lB) and short head of the biceps bilizers resisting infel'ior translation.
(SH B) have similar [unctions as anterior stabiliz Guanche et al49 studied the synergistic ac
ers of the glenohumeral joint with the arm in tion of the capsule and the shoulder muscles. A
abduction and external rotation. Furthermore. renex arch from mechanoreceptol"S within the
the role of the L H B and S H B increased with glenohumeral capsule to muscles crossing the
shoulder instability. Warner et aJ48 studied the joint was identified. Stimulation of the anterior
capsuloligamentous restraints to superior and and the inferior axillary articular nerves elicited
inferior translation o[ the glenohumeral joint. electromyographic (EMG) activity in the biceps.
The primary restraint to inferior translation of subscapularis. supraspinatus. and infraspinatus
the adducted shoulder was the superior glenohu- muscles. Stimulation of the posterior axillary ar-
8 PHYSICAL THERAPY OF THE SHOULDER
fine the type of instability. Wuelker et al.54 dem long and short head of the biceps loading in all
onstrated that translation of the humeral head capsular conditions when the arm was in 60' or
during elevation of the glenohumeral joint be 90' of external rotation and abduction.
tween 20' and 90' averaged 9 mm supel;orly and
4.4 mm anteriorly. Translation of the humeral
head during active elevation may be diminished Sternoclnivicular JrJint
by the coordinated activity of the rotator cuff The sternoclavicular (SC) joint is the only articu
mu c1es. Thi active control of the translation lation that binds the shoulder girdle to the axial
forces provides dynamic stability to the glenohu skeleton (Fig. 1. 9). This is a sellar joint, with the
meral joint. Perry55 describe 17 muscle groups sternal articulating surface greater than the cla
providing a dynamic interactive stabilization of vicular surface, providing stability to the joint. 10
the composite movement of the thoraco-scapu The joint is also stabilized by its articular disc,
lar-humeral articulation. joint capsule, ligaments, and reinforcing mus
Abnormal glenohumeral translation is ob c1es.5 . SS The disc binds the joint together and di
served most often in overhead throwing athletes. vides the joint into two cavities. The capsule sur
Loss of coordinated balance between accelerat rounds the joint and is thickest on the anterior
ing, decelerating, and stabilizing muscle function and posterior aspects. The section of the capsule
may produce microtraumatic injuries and possi from the disc to the clavicle is more lax, therefore
bly instability of the glenohumeral joint. Further allowing more mobility here than between the
examination of the dynamic stabilizers in the disc, sternum, and first rib. 10 The interclavicular
throwing athlete will be discussed in Chapter 2. ligament reinforces the capsule anteriorly and
The deltoid muscle makes up 41 % of the infel;orly. The costoclavicular ligament con
scapulohumeral muscle mass.4 This muscle, in nectS the clavicle to the first rib. 10 The SC joint
addition to its proximal attachment on the acro gains increased stability fTom muscles, espe
mion process and the spine of the scapula, also cially the sternoclydomastoid, sternohyoid, and
arises from the clavicle. The distal insertion is sternothyroid.'8
on the shaft of the humenrs at the deltoid tuber
cle. The mechanical advantage of the deltoid is
enhanced by the distal insertion and the evolu
Acromioclavicular JrJint
tion of a larger acromion process.4 The deltoid At the other end of the clavicle is the acromioclav
is a multipennate and fatigue-resistant muscle. icular (AC) joint. This articulation is character
This may explain its rare involvement in shoul ized byvariability in size and shape of the c1avicu-
der pathology.56 The deltoid and the clavicular
head of the pectoralis major muscles have been
described as prime movers of the glenohumeral
joint because of their large mechanical advan
tage.4 Michiels and Bodem57 demonstrated that
deltoid muscle action is not restricted to the gen
eration of an abducting moment in the shoulder
joint. The clavicular and scapular regions of the
deltoid muscle group afford stability to the gle
nohumeral joint.
Itoi et al47 reported that the biceps muscle
group becomes more important than the rotator
cuff muscles as stability from the capsuloliga
mentous stnrcture decrease . The anterior dis FIGURE 1.9 The upper and lower allachmel1ls or
placement of the humeral head under 1.5 kg the lII.eI1iscus and upper and lower ligaments or
force was significantly decreased by both the the sternoclavicular joint.
10 PHYSICAL THERAPY OF THE SHOULDER
FIGURE 1.10 Axes o( l11otio/1 o( the clavicle. (a) Lon gitudinal axis o( rotatioYl. (h) Vertical axis
(or protraction and retraction. (c) HoriZOl1lal axis (or elevatiol1 and depression. The stemal end
o( the scapula is on the le(t. (From Schenkmal1 and Ru go de Cartaya!S with permissiol7.)
lar facets and the presence of an intra-articular or ligamentous connections to the thorax. except
meniscus.5 8 The AC joint capsule is more lax than for its attachments at the acromioclavicular joint
the sternoclavicular joint; thus a greater degree of and coracoacromial ligament. The scapula is pri
movement occun; at the AC joint. contributing to marily stabilized by muscles. The importance of
the increased incidence of dislocations.5 8 There the scapula rotators has been established as an
are three major supporting ligaments to the AC essential ingredient to glenohumeral mobility
joint. The conoid and trapezoid ligaments are col and stability (Fig. 1. 1 1). The stable base. and
lectively called the coracoclavicular ligament and therefore the mobility of the glenohumeral joint.
the acromioclavicular ligament. It is through the is largely dependent on the relationship of the
conoid and trapezoid ligaments that scapula mo scapula and the humerus. The scapula and hu
tion is translated to the clavicleS merus must accommodate the ever-changing po
Rotation of the clavicle is the major move sitions during shoulder movement in order to
ment at the AC joint. Steindlel.59 maintain stability6
joint rotation occun'ing around three axes. Lon
gitudinal axial rotation. vertical axis for protrac
tion and retraction. and horizontal axis for eleva
Punctional Bimnechanics
tion and depression (Fig. 1. 10) are all controlled
and facilitated by the conoid. trapezoid. and
As previously noted. shoulder elevation is de
acromioclavicular ligaments.
fined as the movement of the humerus away
from the side. and it can occur in an infinite
number of body planes.41
ScapukJtJwracic Jaint Shoulder elevation can be divided into three
phases. The initial phase of elevation is 0' to 60'
The scapulothoracic joint is not an anatomic degrees. The middle or "critical phase" is 60' to
joint. but it is an important physiologic joint that 140'. The final phase of elevation is 140' to 180'.
adds considerably to motion of the shoulder gir Specific to each phase of movement. precise
dle. The scapula is concave. articulating with a muscle function and joint kinematics allow nor
convex girdle.1.55 The scapula is without bony mal pain-free motion. Analysis of the precise
FUNC TIONAL ANATOMY AND MECH ANICS 11
A B
Force couple o{ /IIuscles aClillg 01 scapula (A) Axis o{ scaplliar rotalioll {rol1l 0°10
FIGURE 1. 1 1
30� (8) Axis o{ scapular rOlalion {rol1l 30°10 60° (FUT' (orce o{ upper lrapezius; FLT, force of
lower lrapezius; F SA force o{ serralus anlerior.) (Modified (rol11 Schel1kl11al1 al1d Ruga de
Cartaya,65 wilh perl11issiol1.)
components critical for each phase of shoulder praspinatus muscle indicates an early rise in ten
elevation will determine the success of clinical sion, producing a compressive force to the gleno
management of shoulder dysfunction. humeral joint surface.
The deltoid muscle also demonstrates EMG
°
INITIAL PHASE OF ELEVATION: 0 TO 60
° activity in the initial phase of elevation. The sub
scapularis, infraspinatus. and teres minor mus
All three arthrokinematic movements occur at cles are important stabilizers of the humerus in
the glenohumeral joint, but they do not occur in the initial phase of elevation.' Kadaba et al.SJ re
equal proportions. These movements-roll, port EMG activity of the upper and lower por
spin, and glide-are necessary for the large hu tions of the subscapularis muscle recorded by
meral head to take advantage of the small gle intramuscular wire electrodes. During the initial
noid articulating surface.'· Saha·o and Sharkey phase of elevation, EMG activity of the upper
and Marder·' investigated the contact area be subscapularis was greater at the beginning of the
tween the head of the humerus and the glenoid range, while that in the lower subscapularis in
with elevaLion in abduction and in scaption. The creased as the elevation reached 90·." A signifi
studies found that the contact area on the head cant amount of force is generated at the glenohu
of the humerus was centered at 30· and shifted meral joint during abduction4.15 In the early
superiorly 1.5 mm by 120°. Poppen and Walker14 stages of abduction, the loading vector is beyond
also studied the instant centers of rotation for the upper edge of the glenoid.·2
abduction. They reported that in the first 30· and During the initial stage of elevation, the pull
orten between 30· 60· of abduction, the head of of the deltoid muscle produces an upward shear
the humerus moved superiorly in the glenoid by of the humeral head.' This shearing force peaks
3 mm, indicating that rolling or gliding of the at 60· o[ abducLion and is counteracted by the
head had occUlTed. The EMG activity of the su- transverse compressive [orees of the rotator cuff
12 PHY S I CAL THERAPY OF THE SHOULDER
upward and laterally. The rotatory force arm of ing force at the glenohumeral joint. The activity
the upper trapezius muscle has reduced in of the supraspinatus, infraspinatus, teres minor,
length, and the role of this muscle is now suppor and subscapularis muscles counteract the forces
tive to the scapula64 The new location of the ICR of the deltoid muscle, creating a resultant force
of the scapula allows the middle trapezius to be that is stabilizing to the joint and necessary for
come a prime mover for downward scapular 1'0· full pain-free movement to continue. The result
tation64 The lower trapezius and the serratus an ant force in the nOlmal glenohumeral joint is
terior muscles continue to increase in activity maximum at 90° of elevation. The early phase
during the final phase of elevation, acting as an of scapula movement is described as the selling
upward rotator and opposing the forces of the phase, with the majority of movement OCCUlTing
upper and middle trapezius.63 at the glenohumeral joint.
As the humerus elevates towards the end of The middle phase of elevation is referred to
the elevation range of motion, it must disengage as the critical phase. At the beginning of the criti
itself fTom the scapula. As previously noted, the cal phase, maxjmum shearing forces of the del
ratio of glenohu meral to scapulothoracic motion toid muscle occur. The ratio of glenohumeral to
is 3.49 to I . Good extensibility of the latissimus, scapulothoracic movement shifts, emphasizing
pectoralis major, teres major, teres minor, infra the laller. The increased scapula movement is
spinatus. and subscapularis muscles is impor established by the activity of the upper and lower
tant in order to allow the humerus to disasso trapezius and lower anterior en-alus mll des.
ciate itself from the scapula. Often with passive The arthrokinematic movement of the head of
humeral elevation, a bulge of the scapula is noted the humerus on the glenoid has been observed
laterally. The bulge is usually the inferior angle, as an inferior and superior glide of 1.5 mm.
secondary to increased protraction of the sca During the final phase of elevation, the
pula. Lack of elongation of these muscles pre movement is once again dominated by the gleno
vents the normally dominant movement of the humeral joint. Good extensibility of the latissi
humerus at the end of the elevation range. l often mus, pectoralis major, teres major, teres minor,
observe tightness of the subscapularis muscle, and subscapularis muscles is necessary to allow
teres major muscle, or both. the increased and unconstrained movement of
Furthermore, observation of limited passive the humerus away fTom the scapula.
humeral elevation may exhibit elevation of the
chest cavity. If muscles connecting the humerus
and rib cage are not Ilexible enough, movement
will occur at both ends. The latissimus and pec Summary
toralis major muscles connect the humerus to
the rib cage. Lack of dissociation of the rib cage Patients with shoulder dysfunction are routinely
from the humerus will result in excessive rib cage treated in the physical therapy clinic. An under
mobility in passive terminal elevation. standing of the anatomy and biomechanics of
this joint can help provide the physical therapist
with a rationale for evaluation and treatment.
Most studies involving shoulder anatomy and bi
Summary oj SIuruJJJ.er Phases oj omechanics reveal a common pallem along with
Mavenumt a wide variation among subjects. The physical
therapist should keep this variation in mind
The initial phase of elevation occurs predomi when treating an individual patient.
nantly at the glenohumeral joint. A 3-mm supe Treatment may be directed toward restoring
rior glide of the humeral head has been observed mobility, providing stability, or a combination
in the initial phase of elevation. The activity of of the two. The shoulder is an inherently mobile
the deltoid muscle produces this superior shear- complex, with various joint surfaces adding to
FUNCTION A L ANA TOMY AND M E C H A N I CS 15
the freedom of movement. The shallow glenoid I I . Calliet R: Shoulder Pain. FA Davis, Philadelphia,
with its flexible labrum and large humeral head 1 966
provides mobility. At times, this vast mobility oc 1 2 . Doody SG, Freedman L, Waterland JC: Shoulder
movements during abduction in the scapular
curs at the expense of stability. The shoulder re
plane. Arch Phys Med Rehabil 5 1 d : 595, 1 970
lies on various stabilizing mechanisms, includ
1 3 . Saha AK: Mechanics of elevation or glenohumeral
ing shapes of joint surfaces, ligaments, and
joint. Acta Orthop Scand 44: 6688, 1 973
muscles to prevent excessive motion. Nearly 20 1 4. Poppen NK, Walker PS: Forces at the glenohu
muscles act on this joint complex in some man meral joint in abduction. Clin Ol1hop 1 35: 1 65 ,
ner, and at variolls limes can be both prime mov 1 978
ers and stabilizers. Harmonious actions of these 1 5 . Poppen NK, Walker PS: Normal and abnormal
muscles are necessary for the full function of this motion or the shoulder. J Bone Joint Surg 58A:
joint. 1 95 , 1 976
1 6 . Saha AK: TheOl)' of Shoulder Mechanism: De
scriptive and Applied. Charles C Thomas, Spring
field, I L , 1 96 1
1 7. Codman EA: The Shoulder. Thomas Dodd, Bos
'on. 1 934
1 8. Kondo M, Tazoe S, Yamada M: Changes of the
We give special thanks to Martha Kaput Frame tilting angle of the scapula rollowing elevation of
for her contributions to this chapter. the arm. In Ga.eman JE, Welsh RP (eds): Surgery
of the Shoulder. Philadelphia. CV Mosby. 1 984
1 9. Williams PE, Goldspink G: Changes in sarcomere
Icngth and physiological propcl-tics in immobi
References lized muscle. J Ana. 1 27 : 459, 1 978
20. Tabu.), JC, Taba.), C. Tardieu C et al: Physiologi
I . Kent BE: Functional anatomy of the shoulder cal and structural changes in the cat's soleus mus
complex. A review. Phys Ther 5 I :867. 1 97 1 cle due (0 immobilization at di fferent lengths by
2 . Lucas 0: Biomechanics orthe shoulder joint. Arch plaste.· casts. J Physiol 224:23 1 , 1 972
o f torque production during dynamic strength 42. Fl'eedman L, Munro Rl-I: Abduction of the arm
testing of shoulder abduction in the coronal plane in the scapular plane: scapular and glenohumeral
and the plane or the scapula. I Ol1hop SpOl<S Phys movements, A roentgenographic study. J Bone
Ther 2 1 :227, 1 995 Joint Surg 48A: 1 503, 1 966
28. Rajendran K: The rotary innucnce of articular 43. Kapanji [A: The Physiology or the Joints- Upper
contours during passive glenohumeral abduction. Limb, Vol 1 . Churchill Livingstone, New York,
Singapore Med J 33:493, 1 992 1 970
29. An KN, Browne AO, Korinek S et al: Three-dimen 44. Basmajian J : The surgical anatomy and function
sional kinematics of glenohumeral elevation. J Or of the aml-tnmk mechanism. Surg Clin North Am
3 0 . Oti 45. Turkel SI, Panio MW, Marshall JL, Girgis FG: Sta
J C , liang CC, Wickiewicz TL e l a l : Changes
bilizing mechanisms preventing anledor disloca
in the momcnt arms of the l"otatorcufr and deltoid
tion of the glenohumeral jOint. J Bone Joint Surg
muscles with abduction and rotation. J Boneloint
63A: 1 208, 1 98 1
Surg 76-A:667, 1 994
46. MacDonald PS, Hawkins RJ, Fowler PJ, Miniaci
3 1 . Flatow EL, Soslowsky U, Ticker J8: Excursion or
A: Release of the subscapularis for intemal rota
the rotator cuff under the acromion: patterns of
tion contracture and pain after antel-ior repair for
subacromial contact. Am J Spons Med 22:779,
,'ccun'cm antedor dislocation of the shoulder. J
1 994
Bone Ioint Surg 74A:734, 1 992
32. Rajendran K, Kwek BH: glenohumeral abduction
47. Itoi E, Kuechle DK, Newman SR, MUlTey BF, Am
and the long head or the biceps. Singapore Med
Koy et al: Stabilizing function of the biceps in sta
1 32:242, 1 99 1
ble and unstable shoulders. J Bone Joint SlIrg Br
33. Brems JJ: Rehabilitation following lOlal shoulder 75:546, 1 993
arthroplasty. Clin Ol1hop 307:70, 1 994 48. Warner JJ, Deng XH, WalTen RF, Torzilli PA:
34. TefT), GC, Hammon D, France P et al. The stabiliz Static capsuloligamentolls rcstraints to supc
ing function of passive shoulder restraints. Am J dor-infel-ior translation of the glenohu meral
Sports Med 1 99 1 ; 1 9:26-34 joint. Am J SpOJ<S Med 20:675, 1 992
35. Saha AK: Dynamic stability of the glenohumeral 49. Guanche C, Knatt T, Solomonow M et al: The syn
joint. Acta 011hop Scand 42:49 1 , 1 97 1 ergistic action of the capsule and the shoulder
36. Kessell L: Clinical Disocders or t h e Shoulder. 2nd muscles. Am J Sports Med 23: 1 995
Ed. Churchill Livingstone, Edinburgh, 1 986 SO. Hanyman DT, Sidles JA, Han-is SL, Matsen FA:
37. Moseley I-IP. Overgaard B: The anterior capsular The role of rotator interval capsule in passivc mo�
mechanism in reCUITent anterior dislocations of tion and stability of the shoulder. J Bone Joint
the shouJder: mm'phological and clinical studies Surg 74A:53, 1 992
with special reference to the glenoid labrum and 5 1 . KlImmeil BM: Spectrum of lesions of the anterior
glenohumeral ligaments. J Bone Joint Surg 448: capsular mechanism of the shoulder. Am J Sports
57. Michiels I , Bodem F: The deltoid muscle: an elec 62. Himeno S, Tsumura H: The role of the rOlatal'
lromyographical analysis of its activity in arm ab cuff as a stabilizing mechanism or the shoulder.
duction in val"ious body POStUI-eS. lnt Orthop 1 6: In Bateman S, Welch P (cds): Surgery of the
268, 1 992 Shoulder. CV Mosby, St. Louis, 1 984
58. Moseley HF: The clavicle: its anatomy and func 63. Bagg DS, FOITest WJ: A biomechanica1 analysis
tion. Clin Orthop Res 58: 1 7 , 1 968 or scapular rotation during arm abduction in the
59. Steindler A: Kinesiology of the Human Body scapular plane. Am J Phys Med Rehabil 67:238,
Under NOlmal and Pathological Conditions. 1 988
Charles C Thomas, Springfield, IL, 1 95 5 64. Bagg DS, FOITest WJ: Electromyographicstudyof
6 0 . Saha AK: Mechanism o f shoulder movements and the scapular rotators during arm abduction in the
a plea ror the recognition of "zero position" or gle scapular plane. Am J Phys Med 65: I I I , 1 986
nohumeral joint. Clin Ol1hop 1 73:3, 1 983 65. Schcnkman M, Rugo de Cartaya V: Kinesiology
6 1 . Sharkey NA, Marder RA: The rotaLOr cuff opposes of the shoulder complex. J Orthop Sports Phys
superior translation of the humeral head. Am J Ther 8:438, 1 987
SP0l1S Med 23:270, 1 995
Throwing Injuries
J EF F COO PER
To throw a baseball with high velocity and with in a controlled environment. It is assumed that
great accuracy is a skill that escapes the majority the forces recorded during these data collections
of the population. Those who have accomplished are less than those produced in a competitive
this skill often demonstrate a heightened neuro arena. Electromyographic sequence activity ap
muscular system and have invested many hours pears fairly consistent regardless of generated
of sport-specific training. This unique athletic velocities. The overhand throw as it relates to
act has produced a wide array of disabilities that pitching has been divided into the following
have been reported in the literature. These disa phases: ( I ) windup, (2) early cock.ing, (3) late
bilities include neurologic entrapments and cocking, (4) acceleration, and (5) follow
compression syndromes, acromioclavicular through.
joint degeneration, p.-imary impingement , sec
ondary impingement due to instabilities, insta WINDUP
bilities due to derangement of the glenoid, SLAP
(superior labrum anterior to posterior) lesions, The windup is an activity that is highly individu
subdeltoid bursitis, biceps tendinitis, subluxing alized. Its purpose is to organize the body be
bicipital tendon, undersurface tears of the rota neath the arm to form a stable platform. As with
tor cuff, full-thickness tears of the rotator cuff, all overarm activities, it is vital that the body per
lesions of the humeral head, fracture of the hu form in sequential links to enable the hand to be
merus, fTacture of the coricoid, posterior capsu in the correct position in space to complete the
lar syndrome, and muscle imbalances. '-'o aSSigned task. The hand can be placed in an infi
Injury to the glenohumeral complex as a re nite number of localities, and it is essential that
sult of the overhand throw is most often the re the scapulahumeral rhythm places it in an opti
sult of repetitive microlrauma. Chronic overuse mum setting for the task of propulsion. The
causes the healing process to fall behind that of drawing of the humerus into the moment center
the rate of stress. Macrotrauma injuries such as of the glenoid fossa is accomplished during the
fractures of the humerus have been reported; first 3D· of elevation as the arm is brought up
however, they represent a very small percentage ward by the deltoid and supraspinatus. Through
of the disabilities associated with the overhand out the windup phase there is no consistent pat
throw. tern of muscle activity due to these many
individual styles.
The biomechanical and electromyographic ac Early cocking is the period of time when the
tivity of the overhand throw has been investi dominant hand is separated from the gloved
gated 11-17 to give us a relative model of f'unction hand, and ends when the forward foot makes
19
20 PHYSI CAL THE R A P Y OF T H E SHOULDER
contact with the mound. The scapula is retracted the biceps. The capsule becomes wound tight in
and maintained against the chest wall by the ser preparation of acceleration.
ratus anterior. The humerus is brought into posi
tion of 90° of abduction and horizontal exten
ACCELERATION
sion, with a minimal external rotation of
approximately 50°. This is accomplished with the Acceleration is a ballistic action lasting less than
activation of the anterior, middle, and posterior one-tenth of a second. The ball is accelerated
deltoid. The external rotators of the cuff are acti from 4 miles per hour to a speed of 85 plus miles
vated toward the end of early cocking, with the per hour. " This rapid acceleration produces an
supraspinatus being more active than the infra gular velocities that have been reported as high
spinatus and the teres minor as it steers the hu as 9, 1 98°/s. '6 The scapula is protracted and ro
meral head in the glenoid. The biceps brachii and tated downward and held to the chest wall by
brachialis act on the forearm to develop the nec the serratus anterior. The arm continues into for
essary angle of the elbow. ward flexion and is marked by a maximum inter
As the body moves fOr\vard, the humerus is nal rotation of the humerus. The humerus travels
supported by the anterior and middle deltoid as fonvard in 100° of abduction but adducts about
the postel-ior deltoid puJls the arm into approxi 5° just prior to release. The lattismus dorsi and
mately 30° of horizontal extension. At this time pectoralis major develop the power to the for
the static stability of the humeral head becomes ward-moving shoulder. The subscapularis activ
dependent upon the ante!ior margin of the gle ity is at maximum levels as the humerus travels
noid, notably the inferior glenohumeral liga into medial rotation. The triceps develops strong
ment and the inferior portion of the glenoid la action in accelerating the extension of the elbow.
brum. The forces developed in this instant reflect
the body's amazing ability to develop power and
encase itself in a protective mechanism. Pappas
LATE COCKtNG
et al.'6 reported peak accelerations approaching
Late cocking is the interval in the throwing mo 600,0000/s. Gainor et al. 5 reported 1 4,000 inch
tion when the foot makes contact with the pounds of rotatory torque produced at the shoul
mound, and ends when the humerus begins in der. This torque develops 27 ,000 inch pounds of
ternal rotation. During this time the humerus is kinetic energy in the humerus.
moved into a position more forward in relation Control of the ball is lost approximately mid
to the trunk and begins to come into alignment way through the acceleration phase, when the
with the upper body. The extreme of external ro humerus is positioned slightly behind the for
tation, an additional 1 25° is achieved to provide ward-flexing trunk and at a angle of about 1 1 0°
positioning for the power phase or acceleration. of external rotation. The hand follows the ball
Supraspinatus, i nfraspinatus, and teres after release and is unable to apply further force.
minor are active in this phase but become quiet
once external rotation is achieved. Deceleration
FOLLOW-THROUGH
of the externally rotating humerus is accom
pl ished by the contraction of the subscapularis. Follow-through is the time beginning with the
It remains active until the completion of late release of the ball. Within the first tenth of a sec
cocking. The selTatus anterior and the clavicular ond the humerus travels across the midline of
head of the pectoralis major have their greatest the body and develops a slight external rotation
activity during deceleration. The biceps brachii before finishing in internal rotation. This is a
aids in maintaining the humerus in the glenoid very active phase for all glenohumeral muscles
by producing compressive axial load. At the end as the arm is decelerated. The deltoid and upper
of this phase the triceps begins activity providing trapezius have strong activity as does the lallisi
compressive axial loading to replace the force of mus dorsi. The infraspinatus, teres minor, supra-
T H R O WI N G INJU R I E S 21
spinatus, and subscapularis are all active as ec during acceleration and internal rOlation. Activ
centric loads are produced. The biceps develops ity in the biceps brachii was also lower in the
peak activity in decelerating the forearm and im professionals that in the amateurs.
poses a traction force within the glenohumeral
jOint.
The task of documenting the sequence of
muscle activity during the act of pitching has al
E!£ctromyographic Activil:y in tire
lowed the musculature acting upon the glenohu Injured Thrower
meral joint during this act to be divided into two
groups. " The first group of muscles are those Those athletes who were diagnosed as subacro
that are most active during the second and third mial impingers demonstrated differences in
phases of throwing, early and late cocking. They their electromyographic studies compared with
are least active during the acceleration phase. uninjured throwers. 's During the second phase
The deltoid, trapezius, external rotators, supra of throwing, early cocking, the injured athletes
spinatus, infraspinatus, teres minor, and biceps continued deltoid activity while the healthy ath
brachii comprise this first group. letes had deceased deltoid activity. A lower level
The second group of muscles are those used of supraspinatus activity was also noted during
primarily for the fourth phase of throwing, accel this time period. During early cocking and late
eration. These muscles are necessary to protract cocking, the internal rotators, subscapularis,
the scapula, horizontal forward flex and inter petoralis major, and latissimus dorsi had de
nally rotate the humerus, and extend the elbow. creased activity. The serratus anterior followed
This group consists of the subscapularis, sen'a t1,is pattern and was less effective. It was theo
llis anterior, pectoralis major, )atlismus dorsi, rized that the combination of these differences
and triceps brachii. The first phase of throwing may lead to increased external rotation, superior
is not included in either group due to its nonspe humeral migration, and impaired scapular rota
cific generalized activity. tion. All or some of these factors may be an un
derlying cause for the initial problem or a factor
in the continuum of the syndrome.
Throwing athletes who have been hampered
ProfessimwJ. Versus Amateur by glenohumeral instabilities were compared to
Pitchers normal athletes in a similar fashion. This series '9
tested the activity of the biceps, middle deltoid,
Gowan et al. '2 conducted a study to determine supraspinatus, infraspinatus, pectoralis major,
if the muscle-fjring sequence of professional subscapularis, latissimus dorsi, and serratus an
pitchers was S ignificantly different from that of terior. Noted were differences in every muscle
amateur pitchers. No significant differences except the middle deltoid. The authors suggest
were noted in the first three phase of the pitch, that the mildly increased activity of the biceps
the windup, early and late cocking. There were and supraspinatus may be compensatory for the
no significant differences in the follow-through, laxity present in the anterior capsule. The infra
where muscle activity was described as general. spinatus developed a pattern of activity during
During the acceleration phase, professional early cocking, reduced activity during late cock
pitchers recorded increased activity of the pec ing, and again increasing in the follow-through.
toralis major and lattisimus dorsi. There was As noted with the impingement group, the inter
also increased activity in the serratus anterior nal rotators, consisting of the subscapularis, pec
muscle. The professional pitchers had decreased toralis major, and lattisimus dorsi, had de
activity in the supraspinatus, infraspinatus, and creased activity, which was marked in the early
teres minor during the acceleration. Professional cocking phase. The serratus anterior showed de
pitchers used the subscapularis predominately creased activity as well.
22 P H Y S I C AL T H E RA P Y OF T H E S H O U LD E R
The authors concluded that these changes i n those athletes who demonstrate instability due
muscle activity allowed decreased internal rota to chronic labral microtrauma with secondary
tion force needed in both late cocking and accel impingement. This group presents signs of pos
eration. Reduced activity demonstrated in con terior labrum defects with anterior capsule and
trolling the scapula by the sen'atus anterior ligamentous involvement. There may be tears in
allowed the glenoid to be placed in a compromis the undersurface of the supraspinatus andior in
ing position during late cocking, increasing the fraspinatus muscles. These athletes will present
stress upon the labrum and capsule. a positive impingement sign and have pain but
Microtraumas can be associated with defi not apprehension when subjected to the appre
ciencies in a muscle or muscle group failing to hension test. Their pain will be relieved with the
aid in the stabilizing of the glenohumeral joint or relocation test.
failing to become active in the proper sequence Group 3 athletes present instability due to
during the distinct phases of throwing. Lack of hyperelasticity with impingement. Hyperelastic
flexibility can be a factor leading to disability, ity is defined as the ability to passively touch the
pa.1.icularly in the deceleration phase, when tre thumb to the forearm andior the ability to hyper
mendous eccentric forces are developed. extend the elbow more than 1 0°. The metacaro
pophalangeal joint can hyperextend more than
90° and the interphalangeal joint can hyperex
tended in excess of 60°." .23 A positive impinge
The /nstaiJility Continuum ment sign will be presented but the athletes will
not be apprehensive when tested. Their pain is
Repetitive stretching of the anterior static stabi relieved with the relocation test.
lizers may be the most damaging pathology to Group 4 present instability without impinge
the throwing athlete. The development of small ment. They have acquired their instability from
occult anterior translations of the humerus upon a traumatic event-a dislocation. These athletes
the glenoid during late cocking and early acceler have a negative impingement test, positive ap
ation has a cumulative effect most often mani prehension test, and pain relief with relocation.
fested as anterior shoulder pain. As the anterior Groups 2 and 3 comprise the majority of
stabilizers of the glenohumeral joint are progres throwing athletes with anterior shoulder pain.
sively overwhelmed, the rotator cuff attempts to These athletes are often unaware of the subtle
compensate for the loss of stability. They are antel;or translations occuring within their gle
eventually overcome. The scapular rotators react nohumeral joint. Their complaint is usually that
to provide a stable base for the glenohumeral of pain upon the transition fTom late cocking to
joint, become i nnervated out of sequence, and acceleration or a loss of velocity with a feeling
begin to fail.'o This pattern of disability is de of general shoulder weakness.
scribed by lobe and Pink as one of instability
permitting subluxation, and subluxation permit
ting impingement of the rotator cuff against the The Biceps Labral Complex
acromion and coracrom ial ligament and the
eventual disruption of the muscle. This sequence The role of the long head of the biceps tendon
of events has been termed the instability con has long been the stepchild of glenohumeral
linuum. 2 1 mechanism. Often dismissed as only a minor
Athletes with anterior shoulder pain are clas player at the shoulder as a humeral head depres
sified into four groups. Group I presents pure sor, it was recognized for its role as an elbow
impingement without a detectable instability. stabilizer and decelerator. [n the last decade,
They will test positive for a Neer or Hawkins since the shoulder has been thoroughly investi
sign, or for both. They prove negative to an ap gated via the athroscope. we have gained a new
prehension test for instability. Group 2 includes appreciation for' this structure.
T H R OW I N G I N JUR I E S 23
Andrews et al. 2 examined a population of 73 Rodosky et al. 22 investigated the role of the
throwing athletes and observed that 60 percent long head of the biceps and its allachment to
of this group had tears in the anterosuperior la the superior labrum in a laboratory model of the
brum and another 23 percent had tears in both glenohumeral joint positioned in abduction and
the anterosuperior and posterosuperior portion. external rotation as experienced by the overhand
In a subgroup of baseball pitchers, this lesion thrower. They hypothesized that the presence of
was associated with a partial tear of the supraspi the long head of the biceps acted to help limit
natus in 73 percent of the athletes. A smaller the external rotating shoulder. The biceps com
group of 7 percent demonstrated a partial tear pressed the humeral head against the glenOid re
of the long head of the biceps. Andrews et al. sisting the rotation. The long head of the biceps
hypothesized that the incident of injury to this withstood higher external rotational forces with
region of the glenoid labrum was due to the tre out the inferior glenohumeral ligament experi
mendous eccenll-ic stresses placed on the biceps encing a greater strain. This suggested that the
in an attempt to decelerate the arm dUting the biceps has a role in the provision of anterior sta
follow-through phase of the overhand throw. bility. The glenohumeral joint demonstrated a
A con·elation of patient history revealed 95 heightened torsional stiffness as force was in
percent of the patients reported pain during the creased through the long head.
overhand throw and 45 percent of the population When a surgical SLAP lesion was created,
reported a popping or catching sensation. On the strain produced upon the inferior glenohu
physical exam, the popping was evident in the meral ligament was significantly increased. This
position of f,ill abduction and full flexion as the model suggests that the shoulder is thus depen
upper arm was aligned with the ear in 79 percent dent upon the long head of the biceps to provide
of the athletes. None of the population demon dynamic stability to the glenohumeral joint in
strated a significant weakness of either the rota the cocking, acceleration, and follow-through
tor cuff or biceps tendon. This lesion gives the phases. This dynamic stability ensures a consis
athlete a sensation of instability; however, this tent stress upon the inferior glenohumeral liga
instability does not exist anatomically. ment. The long head acts as a continuum pro
In a retrospective totaling 2,375 arthoscopic vider of axial tension as a protective mechanism
evaluated shoulders, Snyder et al. 24 reported 1 40 for the humerus and the inferior glenohumeral
cases with superior glenoid labrum injuries. ligament. Once the integrity of the glenohumeral
These represented only 6 percent of the sample joint is reduced due to occulant subluxations, the
population. Ninety-one percent of this group was long head of the biceps becomes a larger player
male. The involvement of the dominant shoulder in the attempt to achieve stabilization to the gle
versus the nondominant shoulder was greater nohumeral joint.
than two to one. The data of Snyder et al. 24 suggest that the
No radiographic findings could be correlated SLAP lesion occurs in a very limited number of
to the pathology. No clinical exam was consid cases among the general population. However,
ered to be specific for the superior labrum. About this trauma must be among the suspected diag
half of the patients described a painful catching noses of the overhand throwing athlete with
or popping, which was consistent with Andrews shoulder problems due to the theoretical injury
et al. Only about one-third demonstrated a posi mechanism. Because there is no clear imaging
tive biceps tension test. or clinical test for this lesion, it is presently diag
Fifty-five percent of these shoulders were nosed via the arthoscope. Pathology of the biceps
categorized as having a type II SLAP lesion con labral complex should be considered in throwing
sisting of detachment of the superior labrum and athletes who report popping or clicking of the
biceps tendon fTom the glenoid rim. Of these glenohumeral joint and can reproduce these
shoulders, only 28 percent were isolated fTom a symptoms in the forward-flexed and extreme ab
rotator cuff injury or other labral problems. duction position.
24 P H VS I C A L THERAPY OF THE SHOULDER
phase. Particular attention is paid to stretching at the extremes of the available range of motion.
the posterior capsule to regain the adaptive Second, a less than adequate resistance is em
shortening associated with the overhand ployed to elicit the desired muscular response.
thrower.27 A home range-of-motion (ROM) pro Third, the use of a high repetition program has
gram is instituted via an over-the-door pulley not been explored using these exercises. Fourth,
system, and the athlete is encouraged to use this the exercises lend themselves easily to an eccen
and a posterior capsule stretch six periods dur tric, or deceleration program. When the athletic
ing the day. trainer/therapist provides the concentric compo
lobe and Pink" have suggested that the se nent of the exercise, the resistance of the eccen
quence of muscle strengthening begin with the u;c component can be significantly increased. It
scapular pivoters and glenohumeral protectors. is paramount that this negative base be estab
Once a solid foundation has been established in l ished prior to the introduction of stretch-short
these areas, the strengthening should progress ening exercises. Fifth, a goal of any rehabilita
to the humeral positioners, and then to the pro tion program is to make the patient or athlete
peller muscles or accelerators. The scapular independent. Isotonic dumbbell exercises, resis
g1ides2• taught passively in the ROM phase now tive cords, and to some extent stretch-shOltening
become active. As noted in the EMG data, the exercises can be placed in an independent arena.
sen-atus anterior is active throughout most of the Isotonic exercises are easily monitored and lend
overhand throw, and therefore it is important to themselves to be measured outside of the clinic.
include this component of the rehabilitation pro As shoulder rehabilitation builds upon PNF,
cess at the beginning of each treatment. The ser isotonic dumbbells, and resistive cords into ec
ratus is not often trained in an endurance mode, centric loading, it is important to gain knowl
but this should be a priority in establishing de edge of eccentric exercises as a means of muscle
sired scapular control. The glenohumeral protec training (Appendix 2.2). Progression into the
tors or the muscles of the rotator cuff are stretch-shortening exercises is preceded by PNF,
strengthened in association with the scapular pi isotonics, and eccentric exercises. The use of the
voters. The sequence of muscle strengthening Body Blade ( Hymanson, Playa Del Rey, CAl in
and endurance usually progresses through PNF, conditioning the upper extremity i s an excellent
isotonics, concentrideccentric resistive cords, tool to aid in the transition to the more dynamic
concentric isokinetics, and eccentric isokinelics, exercises. Stretch-shortening exercises are usu
to stretch-shortening exercises. Often an allempt ally instituted in the same general time frame as
to apply the accelerated lessons leamed from the an early throwing program. The progression of
lower kinetic chain to that of the upper extremity these exercises always begins with bilateral rou
cheat a solid, methodical isotonic strength base. tines before allempting single-extremity exer
The isotonic program in Appendix 2. 1 is in cises. Extreme care must be take to protect the
cluded for a reference. Townsend,17 Moseley, 2. stability of the glenohumeral with adequate mus
and their associates explored the commonly cle strength before stretch-shortening exercises
used exercises used by many throwing athletes are performed in the vulnerable abducted, hori
and allempted to establish specific muscle func zontally extended, and externally rotated posi
tion and the peak activity arc for each. Because tion.
the experimental model used light weights at low The reestablishment of synchrony of motion
intensity and low speed, the full benefit of this is developed through a throwing program that
element of the rehabilitation program may not emphases long throwing (Appendix 2.3). The act
be apparent. of long throwing builds arm strength by over
First, these exercises are not performed into loading the specific demands necessary for a
the arc of greatest benefit if one limits the exer pitcher who is required to compete at a range of
cise to what is commonly refelTed to as below 60 feet and 6 inches. Long throwing provides an
the plane. The majority of the exercises qualify element of deceleration in a slightly longer form
26 P H Y S I C AL T H E RA P Y OF T H E S H O U LD E R
(time), which is necessary to develop the re tion, EMS, and ice. His prophylaLic conditioning
quired eccentrics applied upon the glenohu program was adjusted to below-plane exercises
meral joint. By progressively increasing the dis and supplemented with a PNF series with parLic
tances of throwing, the additional stress is ular allention paid Lo the scapular glides and di
applied at a consistent rate. agonal pallerns with a shortened lever. His pos
Cardiovascular conditioning should be an terior capsule stretching was accelerated.
aspect of the rehabilitation process continued Five days postinjury the pitcher allempted to
and buill upon from the preinjury protocol. Be throw on the side to determine his roster status.
cause 46.7 percent of the velocity developed by After completing 42 throws with discomfort, it
the throwing arm is developed by the lower body was necessary LO place him on a disabled list.
and trunk,3o it is important to focus upon the which removed him from the active rOSLer.
conditioning of these segments as part of the en Eleven days postinjury the player again at
lire rehabilitation process. The lower extremities tempted to throw from the mound and was suc
are the larger consumers of oxygen within the cessful in completing 72 pitches without discom
muscloskeletal system. If the lower extremities forI. Fourteen days postinjury the player pitched
fail in their conversion of oxygen, the entire sys five innings totaling 5 5 pitches in a minor league
tem becomes less efficient. This failure LO per game without difficulty and reported no difficul
fo.-m compounds the sLresses in the recovery ties the following day.
cycle. N i neteen days from the original complaint,
Two programs are provided (Appendices 2.4 the player st3l1ed a major league game, com
and 2 . 5 D and E) [or the progression of the over pleted five innings, and continued in the five
hand-throwing athlete to a level o[ competition. man rotation until again complaining or similar
Appendix 2.5 represents a more aggressive proto anterior shoulder pain after six starting assign
col and can be used in rehabilitations that have ments. At this time his forward flexion was re
a shorter focus in relation to return to play. Ap duced by 1 0" in his dominant arm. His external
pendix 2.4 is suitable for the extended rehabilita rotation was reduced by IS" and his internal ro
tion periods and often used for a preseason con tation showed a marked reduction, presenting
ditioning program. only a L2 dominant compared to T4 nondomi
nant. His posterior capsule remained restricted
in spite of the active stretching. There was no
joint laxity, a negative apprehension sign, and a
CASE STUDY 1 negative relocation sign.
After an uneventful 5-week spring training con The pitcher made one more start, in which
ditioning period, the pitcher removed himself he pitched into the sixth inning, but he left the
from his first game after five completed innings. game due to a lack of velocity. Two days later
He complained of nonspecific anterior shoulder he was unable to throw. Upon examination he
pain. Upon examination, his range of motion demonstrated a subtle anterior subluxation for
was within normal limits, with the exception of the first time. There was a popping sensation
reduced internal rotation that was accompanied with pain when he was abducted with external
with pain. He presented a positive Hawkins sign. rotation and forced into extension. A radiograph
MRJ was performed, and abnormalities of and bone scan were conducted and they were
the infe.-ior aspect of the anterior glenoid were intcllJreted as normal. An arthroscopic examina
noted; however, this was consistent with an MRJ tion was performed, and the following were
of 1 3 months earlier. There were also small de nOLed. An undersurface cuff tear was seen in the
generative cysts present in the humeral head, supraspinatus, which was small, linear, and de
and Lhere was evidence of posLerior capsular lax brided. The anterior labrum was frayed and also
iLY. The player's inflammaLion was controlled debrided. The posterior labrum was frayed and
with nonsteroidal anLi-inflammatory medica- also debrided. There was a trough defect on the
T H R OW I N G I NJ U R I E S 27
posterior humeral head, indicating anterior sub covery of an avulsion fracture of the coracoid
luxation. There was innammation about the bi process.
ceps tendon but no evidence of a SLAP lesion. After a 6-week period of relative inactivity
There was an absence of a middle glenohumeral the athlete began a rehabilitation process of ac
ligament. The subacromional space was normal. tive range of motion, scapular glides, and iso
Ten days post injury his range of motion was tonic exercises. Bone scans were repealed al 2,
within normal limits and his internal range of 5, and 7 months. The following season the athlete
motion had increased by four vertebrae. At one participated in every scheduled start, compiling
month postinjury the player began a two days a total of 230 innings.
on, one day off throwing program in an aILempt
to return to the mound. Ten days later he threw
40 pitches fl'om the mound. His throwing activi
ties increased, which included throwing baILing
practice at 7 weeks and pitching in a minor
league contest in the ninth week. He continued J would like to thank Jim Richards, PhD, and
to pitch in the minor leagues on a 5-day rotation, Dan Elkins, ATe, for their assistance with the
building arm strength and velocity. At 1 2 weeks photography.
he was ready to retum to the major league roster.
The following season the athlete repeated the
cycle of early season difficulties and lack of ve
locity associated with an anteriorly unstable
References
shoulder. After another extended period of reha 1. Ahchek OW. Wan'en RF, WickiewiczTLet a1: Arh
bilitation, he was again able to return to a major roscopic labral debridement: a three-year follow
league mound, but was unable to develop the up study. Am J SpOl�S Med 20:702, 1992
necessary velocity to be competitive. He had pro 2. Andrews JR, Carson WG Cl al: Glenoid labnlO1
gressed into the instability continuum and will lean; related to the long head of the biceps. Am J
be forced to decide if he will undergo an anterior Sports Med 13:337, 1985
capsular labrum reconstruction or retire. 3. Black KP, Lombanlo JA: Suprascapular nerve in
juries with isolated paralysis of the infraspinatus.
Am J Spot1S Med 18:225, 1990
4. Branch T, Pal1in C el a1: Spontaneous fractures
CASE STUDY 2 of the humcnls during pitching: a ser-ics of 12
cases. Am J Spo.1S Med 20:468, 1992
During the fourth month of the championship S. Gainor 8J, Piotrowski G et al: The throw: bio
season a starting pitcher complained of discom mechanics and acute injury. AJSM 8:114,1980
fort in his throwing shoulder medial to the joint 6. Ga.1h WP, Allman Fl, At-mslrong WS: Occult an
line. He was examined by the aILending or tedor subluxations of the shoulder in noncontact
thopedist, which yielded no concise diagnosis, sports. Am J Spot1S Med 15:579, 1987
but was prescribed a course of general therapy. 7, lobe FW, Kvitne RS: Shoulder pain in the over
Due to scheduling, the pitcher did not have to hand or throwing athlete. Othopaed Rev 18:963,
nics of pitching with emphasis upon shoulder kin shoulder dysfunction in the overhead athlete. J
emalics. JOBST 18:402, 1993 Onhop Sports Phys Ther 18:427, 1993
12. Gowan !D, Jobe FW Tibone J E el al: A compara
,
22. Rodosky MW, Harner CD, Fu FH: The role of Ihe
tive eleclromyographic analysis of the shoulder long head of the biceps muscle and superior gle
during pilching. Am J SPOt1S Med 15:586, 1987 noid labrum in anterior stability of the shoulder.
13. lobe FW Tibone l E , PelTY l, Moynes D: An EMG
,
Am J Sports Med 22: I 2 I , 1994
23. Rubenstein DL, Jobe FW, Glousman RE et al: An
analysis of the shoulder in throwing and pitching:
terior capsulolabral reconstnlction of the shoul
a preliminary reporl . Am J SPOl-IS Med I I :3, 1983
de,- in athleles, JSES I :229,1992
14. Jobe FW, Moynes DR, Tibone lE, Pen"), J: An EMG
24. Snyder Sl, Banas MP, Karzcl RP: An analysis of
analysis of the shoulder i n pitching: a second re
140 injudes to the superior labrum. JSES 4:243,
po" . Am J SPO'1S Med 12:2 I 8, 1984
1995
15. Moynes DR, Pen"), 1, Anlonelli Dl, lobe FW: Elec
25. Montgomery WM, Jobe FW: Functional outcomes
tromyographic and motion of the upperextremity in athletes after modified anterior capsulolabral
in sporls. Phys Ther 66: I 90S, 1986 reconslruclion. Am J Spons Med 22:352, 1994
16. Pappas AM, Zawacki RM, Sullivan, TJ: Biomecha 26. Blackburn TA, McLeod WD, While B el al: EMG
nics of baseball pitching: a prel iminary report. Am analysis of posterior rotator cuff exercises. Athl
J Spons Med 14:216, 1985 Training 25:40, 1990
17, Townsend H, lobe F, Pink M el al: Eleclromyo 27. Pappas AM, Zawacki RM, McMal1hy CF: Rehabil
graphic analysis of the glenohumeral muscles itation of the pitching shoulder. Am J SPOl1S Med
during a baseball rehabi litation program. Am J 14:223, 1985
Spons Med 19:264, 1991 28. Engle RP, CannerGC: Posle"ior shoulder inslabil
18. Miller L eI al: p. 741. In Nicholas 1, Hershman E ily: ApP"oach to rehabililalion. J Ol1hop SPOI1S
Phys Ther lune 1989:488
(eds): The Upper Extremity in SPOt1S Medicine,
29. Moseley J, Jobe F, Pink M cI al: EMG analysis of
Mosby, SI. Louis, 1990
t he scapular muscles during a shoulder rehabilita
19. Glousman R, Jobe F, Tibone 1 et al: Dynamic Elec
tion prog,.. m. Am 1 SPO'1S Med 20: I 28, 1992
tromyographic analysis of the throwing shoulder
30. Toyoshima S, Hoshi kawa T, Miyashila M et al:
with glenohumeral instability. J Bone Joint Surg
Conllibution of the body pans to throwing perfor
70A:220, 1988
mance, p. 169. I n Nelson RC, MorehouseCA (cds):
20. Jobe FW Giangana CE, Kvitne RS Cl al: Anterior
,
Biomechanics. Vol. 4. Balitimore, Un iversity Park
capsulolabral reconstruction of the shoulder i n Press, 1974
athletes i n overhand spor1s. Am J SP0l1S Mcd 19: 3 I , Cain PR, Mutschler TA el al: Ante,;or slabililY of
428, 1991 the glenohumeral joint: a dynamic model. Am J
21. Jobe FW, Pink M: Classification and treatment of SPO'1S Med 15:144, 1987
ApPEN D I X 2. 1
The anterior stability of the glenohumeral joint Prone Extension 'vv;rh Exlenlai
is enhanced by the dynamics of the rotator ROll/tiol1 (Fig. 2.3)
cufL 3 1 Blackburn et al.26 examined the supraspi
natus, infraspinatus, and teres minor via electro
myographic analyses to determine which of 23 Prol1e Horizontal Abductiol1 at 90·Glld
shoulder exercises elicited the greatest muscle 90·of Elbow Flexiol1 with External
activity. They demonstrated that externally ro Rotatiol1 (Fig. 2.4)
tating the humelUs during prone exercise in
creased EMG activity to the highest levels. Spe Independently, Townsend, '7 Moseley, 2 . and
cific to the teres minor, ann extension with their associates examined the dynamic exercise
external rotation produced the best isolation. routines most commonly instituted for condi
tioning of the shoulder in the throwing athlete.
Prol1e Horizol1tal Abductiol1 at lOa· By coupling electromyography and ci nematog
with Extenlal Rotatiol1 (Fig. 2. 1 ) raphy they developed a baseline for individual
muscle activity in relation to specific patterned
Prol1e Horizontal Abductiol1 a t 90· movements. They compared the active signal to
with Extenlal Rotatiol1 (Fig. 2.2) that of a manual muscle test. Each movement
FIGURE 2 . 1
29
30 P H Y S I CA L THERAPY OF THE SHOULDER
FIGURE 2.2
F I G U R E 2.3
FIGURE 2.4
M USCLE ACTIVITY ELICITED B Y COMMON SHOULDER CONDITION I N G EXERCISES 31
A B
A B
Scaption: Intemal Rotation (Fig. 2.8) serratus ante,-ior 1 (PM 1 2 0°_ 1 50°), rhomboids
2 (PM 1 20°_ 1 50°), anterior deltoid 2 (PM
Starting position: A standing posture with
90°_ 1 20°), middle serratus anterior 3 (PM
weights in hand with the thumbs turned in to
1 2 0°_ 1 50°), supraspinatus 4 (PM 90°_ 1 20°),
ward thighs. Movement: With elbows straight,
middle deltoid 5 (PM 90°_ 1 20°), upper trapezius
lift the weights in a manner to maintain a plane
5 (PM 1 2 0°- 1 50°), infraspinatus 6 (PM
of 30° forward of vertical. Lift to the height above
90°_ 1 20°), lower trapezius 6 (PM 1 20°- 1 50
the shoulders. Qualified l1Iuscles: Anterior del
deg.), levator scapulae 6 (PM 1 20°_1 50°).
toid 1 (PM 90°_ 1 50°), middle deltoid 1 (PM
90°_ 1 20°), subscapularis 1 (PM 1 20°_ 1 50°), su
praspinatus 2 (PM 90°_ 1 20°). Military Press (Fig. 2. 1 0)
A B
A B
A B
c FIGURE 2. 1 0 (A-C)
lower serratus anterior 6 (PAA 1 20'- 1 50'), mid natus 3 (PAA 90'- 1 20'), teres minor 3 (PAA
dle deltoid 7 (PAA 90'- 1 20'). 9ll'- 1 20'), upper trapezius 4 (PAA 90'-peak),
lower trapezius 5 (PAA 90'-peak).
Horizontal abduction: Internal
Rotation (Fig. 2. / I) Horizontal abduction: External
Rotation (Fig. 2.12)
Starting position: From a standing position,
bend forward at the waist until the upper body Starting position: From a standing position,
approaches parallel to the floor. The weights are bend forward at the waist until the upper body
held in an extended elbow position and inter approaches parallel to the floor. The weights are
nally rotated. Movement: The weights are lifted held in an extended elbow position and exter
to just above the shoulder. Qualified muscles: nally rotated. Movement: The weights are lifted
Posterior deltoid 1 (PAA 90'- 1 20'), middle trape to just above the shoulder. Qllalifled muscles: In
zius 1 (PAA 90'-peak), rhomboids 1 (PAA fraspinatus 1 (PAA 90'- 1 2 0'), posterior deltoid
90'-peak), middle deltoid 2 (PAA 90' -1 20'), leva 2 (PAA 90'- 1 20'), teres minor 2 (PAA 60'-90'),
tor scapulae 2 (PAA at extreme range), infTaspi- middle trapezius 2 (PAA 90'-peak), upper trape-
M USCLE ACTIVITY ELICITEO B Y COMMON SHOULDER C O N D I T I O N I N G E X E R C I S E S 37
A 8
FIGURE 2 . 1 1 (A-C)
zius 3 (PM at extreme range), lower trapezius 3 The weights are lifted back past the hips. Quali
(PM 90°-peak), middle deltoid 3 (PM (ied muscle: Middle trapezius 3 (PM neu
90°_ 1 2 0°), levator capulae 4 (PM at extreme tral-300), posterior deltoid 4 (PM 900- 1 200), le
range). vator scapulae 5 (PM at extreme range).
Starting position: From a standing position, Starting position: From a standing position,
bend forward at the waist until the upper body bend Forward at the waist until the upper body
is close to parallel to the floor. The weights are is close to parallel to the floor. The weights are
held in an extended elbow position. Movement: held in an extended elbow position. Movement:
38 P H Y S I C A L T H E R A PY OF T H E SHOUL DE R
A B
c F I G U R E 2. 1 2 (A-C)
M USCLE ACT I V I T Y ELICITED B Y C O M M O N S H OU L DE R C O N D I T I O N I N G E X E R C I S E S 39
A B
c FIGURE 2 . 1 3 (A-C)
40 P H YSICAL T H E R A P Y OF T H E S H O U L D E R
A
B
c FIGURE 2 . 1 4 (A-C)
M U SCLE ACTIVITY E L I C I T E D B Y COM MON S H OUL DE R CONDIT I O N I N G E X E R C I S E S 41
A C
B FIGURE 2. 1 5 (A-C)
Leading with the elbows, the weights are l i fted Bench press (Fig. 2. 16)
to the chest. Qualified /IlL/scles: Upper trapezius
I (PAA 90'_ 1 20'), levator scapulae I (PAA at ex Slarling position: From a back-lying posi
treme range), lower trapezius 2 (PAA 1 20'_ 1 50'), tion, t.he elbows are at the side and flexed so the
posterior deltoid 3 (PAA 90'_ 1 2 0'), middle trape weights are next to the shoulders. Movemel1l: The
zius 4 (PAA 90'_ 1 20'), rhomboids 4 (PAA at ex weights are pressed into an extended vertical
treme), middle deltoid 6 (PAA 90·- 1 2 0·). arm position. Qualified muscle: None. It is sug
gested that the resistance used in the experimen
tal model may not have been of sufficient weight
HoriZOl1lal adducliol1 (Fig. 2.15) to elicit the necessary response to determ ine
Slartillg POSilioll: From a back-lying posi qualified muscle.
tion, the arms are extended out to the sides to
the height of the shoulders. Movemelll: The
Straighl arm press (Fig. 2. 1 7)
weights are lifted with a slight flexed elbow posi
tion to the midline. Qualified /Iluscle: None. It is Starling POSilioll: From a back-lying posi
suggested that the resistance used in the experi tion, the arms are extended in a vertical position.
mental model may not have been of sufficient Movemel1l: The weights are pressed into an ele
weight to elicit the necessary response to deter vated position with the motion occlll'ing at the
mine qualified muscle. shoulder. Qualified muscles: Not rated.
42 P H Y S I C A L T H E R A P Y O F THE SHO U L DE R
A c
B FIGURE 2. 1 6 (A-C)
MUSCLE ACTIVITY E L I C I T E D B Y C O M M O N SHOULDER C O N O I T I O N I NG E X E R C I SES 43
FIGURE 2. 1 7 (A & B)
FIGURE 2. 1 8 (A-C)
44 PHYSICAL T H E R A PY OF T H E SHOULDER
B c
FIGURE 2 . 1 9 (A-C)
Starting position: From a back-lying posi Starting position: From a sidelying position,
tion, the arms are extended to the vertical, el the elbow is flexed to 90° and Ihe forearm is ex
bows flexed. Movement: The weights are lifted ternally rotated. Movement: The weight is l ifted
to an extended vertical arm positions. Qualified fTom the midline to a vertical position. Qualified
lIIuscles: Not rated. muscles: Teres minor I (PAA 60°_90°), infraspi
natus 2 (PAA 60°_90°), postel;or deltoid 5 (PAA
60°_90°). Note: The extreme range of external ro
Internal rotation (Fig. 2. 1 9) tation should be l imited to avoid anterior trans
lation of the humeral head.
Starting position : From a back-lying posi
tion, the arms are held at the side the elbows
are flexed and externally rotated. Movement: The Press-up (Fig. 2.21)
weights are lifted to the midline maintaining a
flexed elbow. Qualified l1Iuscles: None. It is sug Starting position: From a silting position, the
gested that the resistance used in the experimen hands are placed next to the hips. Moveme,lI: By
tal model may not have been of sufficient weight extending the elbows, the hips are lifted from the
to elicit the necessary response to detelmine sitting position. Qualifying ml/scles: Pectoralis
qualified muscle. Note: To limit external rotation major I (PAA upper half of range), pectoralis
and humeral head translation, this exercise may minor I (PAA at extreme range), lalissimus dorsi
be performed in a sidelying position. I (PAA at exlreme for hold).
A
A B
FIGURE 2 . 2 1 (A & B)
A
47
48 PHYSICAL THERAPY OF T H E SHOULDER
A B
49
50 P H Y S I C A L THE RAPY OF T H E SHOULDER
A B
A B c
Upp e r E xtremity
C onditioning Program
Dote:
WEIGHT AND REPEnTlONS
Forward Flexion
Abduction
Shrug
Scoption @ IR
Scoption @ ER
Military Press
Hor. Abd. @ IR
Hor. Abd. @ ER
Extension
Rowing
Hor. Adduction
Bench Press
Straight Arm Press
Triceps
Internal Rotation
External Rotation
Hor. Abd. XR-lso.
Press-up
Push-up
Push-up plus
Pillow Squeeze
Biceps Curls
Wrist Flexion
Wrist Extension
Pro/Supination
Ulnar Deviation
Radial Deviation
Throwing Level
52
APPENDIX 2.3
This program is designcd for athletes to work at their own pace to develop the necessary al'm
strength to begin throwing fTom a mound. The athlete is to throw two days in a row and then rest
for one day. It is not impol1ant to progress to the next throwing level with each outing. It i preferred
that a number of outings at the same level be completcd before progressing. It is impol1ant to throw
with comfort. which may necessitate moving back a level on occasion.
One 25 25 25 60
Two 25 25 50 60
Three 25 25 75 60
Four 25 25 50 60 25 90
Five 25 25 50 60 25 1 20
Six 25 25 50 60 25 1 50
Seven 25 25 50 60 25 1 80
E;ghl 25 25 50 60 25 210
Nine 25 25 50 60 25 2AO
53
APPEN DIX 2.4
I 25 25 so Mound 25 90
2 25 25 60 Flot 25 1 20
3 25 25 SO Mound 25 I SO
4 25 25 60 Mound 25 120
5 25 25 70 Flot 25 I SO
6 25 25 60 Mound 25 1 80
7 25 25 70 Mound 25 I SO
8 25 25 60 Flot 25 1 80
9 25 25 80 Mound 25 210
10 25 SO 70 Mound 25 240
II 25 SO 80 Mound 25 1 80
12 25 SO 90 Mound 25 210
13 25 SO 90 Mound 25 240
14 25 SO 80 Mound 25 1 80
15 25 SO 1 00 Mound 25 210
16 25 50 1 00 Mound 25 240
17 25 50 <60 Mound
18 25 SO 1 00 Mound 25 240
19 25 SO <60 Mound 25 240
20 Botting practice 1 0 Minutes
21 25 SO <60 Mound 25 240
22 Botting practice 1 5 Minutes
23 25 SO <60 Mound 25 240
24 Game: <60 Mound 45 P;tche.
25 SO Worm up
54
APPEN DIX 2.5
Short-Focus Throwing
Rehabilitation Programs
55
Differential Soft Tissue
Diagnosis
MAR I E A J 0 HAN SON
Efficient and effective patient care is always de Iish the probable irritability level of the problem.
pendent on the clinician's ability to perform a sys The ilTitability level is a measure of how easily
tematic evaluation. The evaluation serves to iden symptoms may be provoked and relieved. I The
tify all tissues involved in dysfu
· nction, two major components of the patient interview
stage and progression of the dysfunction, and the are ( 1) the history of the patient's problem(s),
baseline parameters on which to judge treatment and (2) the location, nature, and behavior of
efficacy. Soft tissue diagnosis of the shoulder symptoms.
joint includes evaluation of the glenohumeral,
stemoclavicular, acromiclavicular, and scapulo HISTORY
thoracic articulations, as well as the cervical
spine and related upper quarter structures. Initially, the clinician must establish the onset
We will discuss each component of the and progression of the patient's problem by ask
shoulder evaluation including the patient inter ing when the problem staned and how it began.
view, cervical screening, observation, mobility, The problem will likely fall into one of two major
musculotendinous strength, palpation, and spe categories: macrotrauma or microlrauma. A ma
cial tests. The soft tissue diagnosis is derived crotrauma is an injury resulting from a specific
from assessment of information obtained fTom trauma. A microtrauma is an injury resulting
each component of the evaluation. The chapter fTom repetitive stress to tissues. and is character
concludes with a case study that illustrates the ized by an insidious onset of symptoms. The ca
ongoing assessment process that accompanies tegorization of macrotraumas and microtrau
each component of the evaluation. mas serves to guide the clinician most efficiently
through the remainder of the history and the
physical exam.
PaI:i.ent Interoiew Whenever a macrotrauma is suspected, the
clinician must determine the mechanism of in
The pUll'oses of the patient interview are to iden jury to aid in the identification of the injured
tify the patient's symptoms, detelTnine the his structure(s). Awareness of possible gross disrup
tory of the patient's Clm·ent problem, identify co tion of tissue (such as fractures and dislocations)
existing medical factors tJ,at may affect either may alert the examiner to exert caution during
the current problem or its treatment, and estab- passive range of motion and special tests,
57
58 PHYSICAL THERAPY OF THE SHOU LDER
TABLE 3 . 1 . Medical cOl1diliol1s Ihal may refer pail1 10 Ihe shoLilder complex
thereby preventing further trauma to injured tis tentially produce pain within the boundaries of
sues. Many postoperative patients may be the patient's pain, whether it be local pain or re
grouped with macrotrauma injuries. fen-ed pain, will need to be considered.
When a microtrauma is suspected, the clini The nature of the pain may assist in identify
cian must identify the patient's daily activities ing the structures at fault, and this can be deter
and postures to determine both intrinsic and ex mined by asking the patient to describe the pain
trinsic factors that may contribute to the prob or symptoms_ Deep, dull, and poorly localized
lem. Intrinsic factors are physical characteristics pain has been attributed to visceral structures as
that predispose an individual to microtrauma in well as deep ligamentous, deep muscular, and
juries, such as a hooked (or type III) acromion bony structures S A superficial pain described as
process2 or strength deficits of the rotator cuff sharp or burning in quality has been attributed
muscles.3.4 Extrinsic factors are external condi to skin, tendon, or bursal tissueS A patient may
tions under which an activity is performed that report "throbbing" or "pulsing" pain when suffer
predispose an individual to microtrauma inju ing fTom a vascular injury_ Reports of such symp
ries, sllch as training en"m"s. toms as paresthesias or numbness may indicate
The patient interview should also identify de irritation or injury of a nerve.
mographic information that may aid in the soft Though subjective reports of the nature of
tissue diagnosis, as well as past and present med pain are not usually reliable enough to be consid
ical conditions that may affect the current prob ered, when combined with the location of pain,
lem or its treatment. Additionally, any current some patterns may assist in the differentiation
medications that may mask pain or otherwise of local and refen-ed pain. Referred pain is sus
affect the patient's current problem should be pected when the patient reports a deep burning
ascertained. Because many disease processes or deep aching pain with indefinite boundaries,
may result in referral of pain to the shoulder re while local pain is suspected when the pain is
gion (most notably, diseases of the cardiovascu superficial with clear boundaries 8
lar, pulmonary, and gastrointestinal systems),5-7 The behavior of pain may assist in identify
the clinician can ill afford exclusion of medical ing injured structures, and it also can predict the
conditions that may explain shoulder pain
irTitability level of the problem. The following
(Table 3.1). Finally, the clinician should estab
questions are routine in exploring the behavior
lish any previous treatment received by the pa
of pain:
tient and its result on the frequency and intensity
of symptoms as well as functional abilities.
I. Is the pain constant?
LOCATION, NATU RE, AND BEHAVIOR OF PAIN 2. What activities or positions provoke or in
Definition of the boundaries of the patient's pain crease the pain?
and other symptoms will establish the extent of 3_ What activities and positions relieve or de
the examination. All injured stnl clures that po- crease the pain?
DIFF E R E N T I A L SOFT TISSUE DIAG N O S I S 59
4. Does the pain level vary with the time of varies throughout the day and is related to activi
day or night? ties or positions. Therefore, constant pain not so
related may alel1the clinician to pain associated
Cyriax' recommends three questions regard with medical disease processes.
ing the location and behavior of pain in order to
establish the i1Titability level of a shoulder dys
function:
Cervical Screening
I . Does it hurt to lie on the affected side at
night? The prevalence of cervical spine problems and
2. Does the pain extend below the elbow? the pain referral patterns of the cervical spine
combine to necessitate the inclusion of routine
3. Is there pain at rest?
screening for cervical pathology during exami
nation of any shoulder patient. Cervical radiculo
According to Cyriax,' affirmative answers to all
pathy due to irritation or compression of the CS
three questions indicates a high in;tability level.
spinal nerve root often results i n referred pain
Affirmative answers to one or two of the ques
over the lateral aspect o[ the proximal arm. Be
tions indicates a moderate i1Titability level, while
cause most glenohumeral joint structures are in
negative answers to all three questions indicates
nervated by the CS and C6 spinal nerves, the lat
a low ilTitability level. The irritability level may
eral proximal aspect of the alTH is also a very
be used to predict the tolerance of the patient to
common pain location for the patient with a
subsequent evaluation and treatment proce
shoulder dysfunction. (A notable exception is the
dures.
acromioclavicular joint, which is i nnervated by
Maitland' recommends a specific set of
the C4 spinal nerve. An injury to this joint usually
questions regarding the behavior of pain to es
results in pain specifically over the AC joint.)
tablish the irritability level of the problem. Once
Therefore, it is imperative to examine every pa
an activity or position that provokes symptoms
tient [or both shoulder and cervical dysf"unction.
has been identified, subsequent queries address
A cervical spine screening begins with active
that specific activity or position:
cervical movements. If active movements are
normal, passive pressures at the ends of active
I . How long can the activity or position be
movement are performed. The clinician deter
maintained before the pain begins or in
mines if pain is produced during these tests, and
creases (time I or T I )?
if so, locates the pain produced. To confirm sus
2. How long can the activity or position be picion of changeable shoulder pain potentially
continued before the pain level becomes un referred from the cervical spine, compression
bearable and the activity or position must and distraction tests of the cervical spine can be
cease (T2)? done. Neurologic screening may further infOl-m
3. How long does it take for the pain to return the examiner of the integrity of the cervical
to its baseline level after cessation of the ac spinal nerves9-11 (Table 3.2) and spinal cord. Ad
tivity or position (T3)? ditionally, palpation of structures within the an
terior and posterior triangles of the cervical
Relatively shOl1 periods [or T I and T2, cou spine may provide information on refen-al of
pled with a relatively long period for T3, indicate pain from muscular struCtures common to the
a high in-itability level. Conversely, relatively cervical spine and shoulder complex, or from
long periods for TI and T2, coupled with a rela cervical articular structures (palpation will be
tively short period for T3, indicate a low irritabil discussed later in the chapter)_ See Chapter 4 for
ity level. further discussion of the inter-relationship of the
Generally, mechanical musculoskeletal pain cervical spine and the shoulder.
60 PHYSICAL THERAPY OF THE SHOULDER
ObservaJ:ion POSTURE
increased backward bending of the upper cervi and 0.85, respectively), and fair intrarater relia
cal spine. 1 2 Forward head posture is more preva bility of the normalized scapula protraction mea
lent in patients with microtrauma shoulder inju surement (ICC of 0.78). However, some contro
ries than in the uninjured population. 1 3 The versy in the literature regarding the reliability of
increase in scapular protracLion that occurs with the normalized scapula protraction measure
forward head posture decreases the subacromial ment has subsequently emerged. Neiers and
space,14 and may predispose an individual to WOITell16 report good to excellent intrarater
some shoulder dysfunctions such as impinge reliability of the scapula width and scapula pro
ment syndrome. traction measurements, but poor inlrarater re
liability of the normalized scapula protraction
measurement (ICC ofO.34). Gibson et al . 1 7 report
Posterior View
excellent intrarater and interrater reliability of
From the posterior view, the clinician can the scapula protraction measurement (ICCs of
again ascertain the position of the head on the 0.9 1 to 0.95), but did not study the normalized
cervical spine and the cervical spine relative to scapula protraction measurement. Greenfield et
the torso in the frontal and transverse planes. a1. 1 3 compared the clinical method of measuring
The positions of the scapulae may be compared normalized scapula protraction descI;bed by Di
as to superior-inferior and medial-lateral place veta et al. 1 5 to identical measurements taken
ment, as well as in degree of "winging." Scapular from radiographs. No statistically significant dif
"winging" is defined as the movement of the me ferences in values obtained between the two
dial border of the scapula away from the chest methods were reported, lending credence to Di
wall. II Some depression of the shoulder gridle veta's clinical nleasurement of normalized scap
on the dominant side is normal, presumably due ular protraction. Greenfield et al. 1 3 also reported
to greater activity of the dominant side resulting excellent intrarater and interrater reliability of
in greater extensibility of the joint capsules and the normalized scapular protraction measure
ligaments. I I The position of the scapula can be ment (ICCs of 0.97 and 0.96, respectively).
further assessed by palpation o[ the bony land The position of the scapula in the [Tontal
marks (see the palpation section later in the plane (relative degree of scapular abduction or
chapter). lateral rotation) can be obtained using the first
of three test positions that comprise the lateral
slide test described by Kibler l " (see the section
Objeclive CIi,·,ical Measures o(
on musculotendinous strength later in the
Scapular Posiliol1
chapter).
Diveta et al.15 evaluate protraction of the
scapulae by taking two linear measurements
with a string (Fig. 3 . 1 ). The distance in centime Mol:ri.lity
ters from the root of the scapular spine to the
inferior angle of the acromion (scapular width) Examination of mobility of the shoulder com
is divided into the distance [rom the third tho plex generally begins with a scrutiny of active
racic segment to the inferior angle of the acro range of motion (AROM) in the cardinal planes,
mion (scapular protraction). The resulting ratio the plane of the scapula, and during functional
provides a measurement of scapular protraction movements, followed by passive range of motion
cOlTected for scapular size (normalized scapular (PROM), and accessory motion. Information de
protraction). A larger ratio indicates a greater de rived from mobility testing includes extensibility
gree of scapular protraction. of contractile and noncontractile tissues, func
Diveta et al. 1 5 report good to excellent in tional capabilities, ilTitability level, and di[feren
trarater reliability of the scapula width and sca tiation of muscle weakness and/or pain from
pula protraction measurements (lCCs of 0.94 joint or muscle restrictions.
62 PHYSICAL THERA P Y OF THE SHOULDER
FIGURE 3 . 1 (A)
Measurement of scapular
width. (B) Measurement
B or scapular protraction.
movements in adjacent joints to compensate for Some oscillation of the scapula is normaljy ob
the restriction of a given joint (see the following served through the first 30° to 60° of motion.
sections on cardinal planes and plane of the sca After 30° to 60°, the scapula should s tabilize
pula). against the thoracic wall and begin to laterally
rotate. Movement of the glenohumeral joint
should exceed movement of the scapulothoracic
Cardinal Plal1es joint through the initial phase of elevation "·22 An
inability to complete the initial phase of eleva
Generally, cardinal plane active movements tion most often indicates severe restrictions of
of the shoulder complex grant less information the glenohumeral joint. severe pain and/or ap
regarding speCific pallerns of joint restrictions prehenSion repol1ed by the patient, and in rare
than do cardinal plane passive movements. How cases may also indicate severe restriction of the
ever, significant decreases in AROM compared sternoclavicular joint.
to PROM in the cardinal planes can distinguish
weakness or pain as a primary functional limita MtDDLE PHA S E O F EL E V A TIO N (60° TO 140°).
tion from true joint restriction. Normal ROM in The middle phase of elevation is clinically the
the carclinal planes is 160° to 180° of flexion, 45° most common phase of dysfcmction. During this
to 60° of extension. 170° to 1 80° of abduction. 70° phase, the amount of scapular rotation exceeds
to 80° of internal rotation, 80° to 90° of external the amount of glenohumeral motion.22 Due to
rotation, 30° to 45° of horizontal abduction, and deltoid muscle activity. upward shear force at
135° to 140° of horizontal adduction. I. the glenohumeral joint peaks, and is counter
Cyriax8 advocated active abduction testing acted by activity of the rotator cuff muscula
to discern the presence of a "painful arc." Cyriax8 ture.23.24 If scapular rotation is decreased on the
defines a painful arc as "pain encountered mid patient's involved side, it may be due to limita
range that disappears before the end of range" tion at the acromioclavicular and/or sternocla
and indicates compression of subacromial struc vicular joints, which restrict clavicular elevation
tures. Painful arcs are often used clinically to as and rotation. A limitation of scapulothoracic ro
sist in the diagnosis of impingement syn tation may also be due to tightness of the levator
dromes.20.2 1 scapula muscle. weakness of the serratus ante
When observing AROM, the examiner must rior and upper and lower trapezius muscles. or
be careful to ident ify abnormal palterns of move both. Weakness of the scapular muscles. or
ment even when the gross quantity of movement "scapular instability," is most often apparent
is normal. For example. a patient may substitute during the eccentric phase of elevation, and may
excessive scapular adduction for active glenohu be observed as winging of the scapula or exces
meral external rotation in 0° of abduction (Fig. sive oscillations of the scapula. This may become
3.2), or substitute excessive scapular elevation more accentuated after multiple repetitions of
and external rotation for glenohumeral elevation elevation.
during active elevation (Fig. 3.3). Excessive scapular rotation on the involved
64 P HYSICAL THERAP Y OF THE SHOUL D E R
0
side may indicate weakness of the rotator cuff F I N A L P H ASE OF E LE V A T I O N ( 1 40 TO 1 BOo).
muscles (inability to counteract the upward During the final phase of elevation, movement
shear force of the deltoid), or restrictions of the of the glenohumeral joint significantly exceeds
anterior and inferior glenohumeral capsule. that of the scapulothoracic joint.22 Therefore, the
During the middle phase of elevation, the pres examiner can observe a "disassociation" of the
ence of a painful arc may indicate impingement humerus [Tom the scapula that requires good ex
of subacromial structures. tensibility of the teres major, subscapularis, pec-
tance sequence in other patient populations is stiffness is the patient's primary problem, pain
unknown. may or may not be encountered before resis
Maitland' also advocates a method to estab tance, but resistance rather than pain will limit
lish irritability level during passive range of mo the motion. When stiffness is the patient's pri
lion testing. The method is somewhat more com mary problem, mobilization and stretching tech
plex and requires the examiner to graph the niques to increase mobility are indicated.
following four OCCU'Tences during PROM
testing:
End-feel
I . The point in the range of motion where re The use and interpretation of end feel is con
sistance is first detected (resistance 1 or R I ) troversial due to individual variation and ques
2 . The point in the range of motion where no tionable reliability.2. Cyriaxs describes 6 end
feels (3 normal and 3 abnormal) and Paris and
further movement can be achieved due to
passive resistance (R2) Loubert" describe 15 end-feels (5 normal and
1 0 abnormal). However, clinicians may more
3. The point in range of motion where pain is simply define a normal end-feel as an expected
first reported by the patient (pain 1 or P I ) resistance of muscle or periarticular tissue at the
4. The point in range of motion where no fur end of full PROM, and define abnormal end-feel
ther movement can be achieved due to pain as an unexpected passive resistance of intra-ar
(P2) ticular or extra-articular stl1.1cture(s), or pain
that limits PROM prior to expected end range.
Maitland' asserts that when pain is the pa
tient's primary problem, P I will precede R I, and Specific Patterns of Restrictiol1s
pain rather than resistance will usually limit the
motion. When pain is the patient's primary prob Several specific patterns of passive restric
lem, mobilization techniques to increase joint tions may assist in the soft tissue diagnosis of
mobility are contraindicated. Conversely, when shoulder problems. Arguably the most often
DIFFERENTI A L S OF T T I SSUE DIAGN OSIS 67
cited is Cyriax's capsular pattern of restriction external rotation, lesser in abduction, and least
that aids in the diagnosis of frozen shoulder (see in internal rotation. The authors have observed
Ch. 1 0)8 a modification of Cyriax's capsular pattern. The
greatest restriction at the glenohumeral joint is
F R OZEN SHOULDER OR A DH E S I V E C A P SU L I external rotation in O· of abduction. Abduction
TIS. As described by Cyriax,' the capsular pat to 90· combined with external rotation is the next
tern of restriction is characterized by a restric most restricted range, and internal rotation at
tion of the glenohumeral joint that is greatest in 90· of abduction the least restricted range of mo-
68 PHYSI C A L THER A P Y OF THE SHOUL DER
A B
FIGURE 3.6 (A) Substitution of glenohumeral extension for glenohumeral il1lemal rotatio/'/ in a
patient with restriction of the posterior capsule. (B) Same pa.tiel1l after extensibility of the
posterior capsule is restored.
wteral slide
F I G U R E 3.7
test. Measurement o{
distance {rom in{erior
angle o{ scapula to tile
nearest thoracic segment.
(A) Patie.7I's anns restil1g
at sides. (B) Patiel1t's
hands on hips (thumbs
poil1ling posteriorly).
B ( Figllre cOll/i.lLles.)
70 P HYSI C A L THERAP Y OF THE SHOU L DER
(Data (row Jallda mid SclimidJ2 and Jill arid Jmlda. JJ)
DIFFER E N TI A L SOFT TISSUE DIAG N O SI S 73
TABLE 3.6. Palpation o( upper quarter stnlCtures
HIP, {onl'ard "ead posltlre; TIS, thoracic it/leI sY,ldrome; TP, ,rigger point.
pie (see the section on special tests later in the ness of the levator scapulae and weakness of the
chapter). selTatus anterior and lower trapezius muscles;
Muscle imbalances are a common intrinsic combined, these limit elevation of the acromion
factor in shoulder microtrauma injuries.3 .4 A and potentially contIibute to an impingement
muscle imbalance may be defined as a weak ago syndrome.
nist, a tight agonist, or a combination of the two.
Janda and Schmid32 and Jull and Janda" believe
SCAPULAR STABILITY TESTS
that muscles respond in a predictable pallern to
an altered state of mechanics in both micro Nonnal function of the shoulder complex de
trauma and macrotrauma. Jull and Janda" de mands adequate scapular stability. Thus, in ad
veloped a classification system of skeletal muscle dition to manual muscle testing, speCific scapu
based on response to dysfunction. M uscles that lar stability tests may assist in soft tissue
shorten and tighten in dysfunction are classified diagnosis.
as postural muscles, while those that lengLhen
and weaken in dysfunction are classified as pha
LlIteral Slide Test
sic muscles. This classification system can expe
dite the evaluation of shoulder musculature by Kibler'S described the lateral slide test to
predicting which muscles to routinely manually evaluate the function of the muscles that stabi
muscle test and which to routinely evaluate for lize and/or externally rotate the scapula (upper
flexibility (Table 3.5). and lower trapezius, serratus anterior, and
A muscle imbalance of the rotator cuff gener rhomboid major and minor). A measurement is
ally involves tightness of the subscapularis and taken from the inferior angle of Lhe scapula to
weakness of the infraspinatus, teres minor, and the nearest thoracic segment in three different
supraspinatus. This results in anteIior instability glenohumeral joint positions (Fig. 3.7). Kibler'S
of Lhe glenohumeral joint when in a position of asserts that a difference of 1 cm or greater in
external rotation and abduction.34 M uscle im the second and third positions is associated with
balance of the scapula often involves both tight- microtrauma injuries of the shoulder. Gibson et
74 P HYSI C A L TH E R A P Y OF TH E SHOUL D E R
FI-JP, forward head posture; TIS, thoracic ill/el SYlldromc; TP, lrigger poilll.
DIFFER EN TIAL S OF T TISSUE D I AGN O S I S 75
al ' 7 studied the reliability of the lateral slide test further information on isokinetic strength
measuring with a stl"ing from the TS segment to testing.
the inferior angle of the scapula, and reported
intrarater ICCs of O.S\ to 0.94 and interrater
ICCs of O. \ S to 0.69. Therefore, although a useful Prapriocepf:i.on and Kinesthesia
measurement for each clinician, the lateraI slide
test may not be suitable for comparison between Until recently, proprioceptive and kinesthetic
clinicians. abilities received more attention in rehabilita
tion of lower extremity injuries than upper ex
Fw,ctional Tests of Scapular tremity injuries. Propl;oception is defined as the
"Winging"
ability to perceive position, weight, and resis
tance of objects in relation to the body. Kinesthe
Direct observation of scapular "winging" is sia is defined as the ability to sense the extent,
not possible in the classic supine position for direction, or weight of body movement. In addi
manual muscle testing of the selTatus anterior tion to visual, vestibular, and cutaneous input,
muscle.3o.3 I The examiner may observe scapular receptors in the joint capsule, ligaments, and la
winging due to weakness of the selTatus anterior brum provide proprioceptive and kinesthetic in
muscle by observing active elevation (see the sec formation.
tion on mobility later in the chapter), wall push Published studies on shoulder propriocep
up (Fig. 3.S), or sitting press-ups (Fig. 3.9). tive and kinesthetic testing have used specialized
testing apparatus."·3. Davies and Dickoff-Hoff
man" advocate clinical angular joint replication
ISOKINETIC TESTING
testing with an electronic digital inclinometer.
Many commercially available isokinetic testing They report for normal males average mean dif
devices are now manufactured and can be uti ferences of plus or minus 2.40 to 3.00 for seven
lized to obtain more specific parameters of shoulder joint positions between known angles
strength. The reader is referred to Chapter \ 6 for and subject replication of known angles.
Because proprioception and kinesthesia are tate an efficient yet comprehensive evaluation.
compromised following anterior shoulder dislo In general, palpation of the anterior and poste
cation,J5·3. exercises designed to improve propri rior cervical triangles may be more important in
oception and kinesthesia seem logical, at least patients with postural abnormalities, while pal
in rehabilitation of macrotraumatic injuries that pation of glenohumeral articular structures may
are likely to disrupt the capsular, ligamentous, be more important when glenohumeral macro
or labral structures. trauma is suspected. Because many structures
of the shoulder complex are normally tender to
palpation, comparison of findings to the unin
volved side is crucial. Additionally, similar pal
PaJ.patiffn pation findings are common to many shoulder
dysfunctions, so palpation may be the least valu
Direct manual palpation of specific structures is able component in diagnosis of soft tissue dys
perfOl-med to evaluate tissue tension, structure function. Structures commonly palpated by re
size, temperature, swelling, static position, cre gion are shown in Tables 3.6 and 3.7, along with
pitus, and provocation of pain. A systematic pro the possible dysfunction(s) when palpation find
cedure for palpation of tissues is advised to facili- ings are positive.
Special Tests
Special tests may be included in evaluation of
the shoulder complex to confirm or exclude the
presence of specific shoulder soft tissue dysfunc
tions. In this section we will describe the more
commonly performed special tests for glenohu
meral instabilities, labral tears, impingement
syndrome, musculotendinous dysfunctions, and
rupture of the transverse humeral ligament.
ApprehCl1siol1 Test
FIGURE 3 . 1 2 Jobe
relocat ion lest.
78 PH YSI C AL THE R A P Y OF THE SHOUL D ER
FIGURE 3. 1 3 Glenohumeral load and shift test. FIGURE 3.14 Sulcus sign.
FIGURE 3. 1 7 Superior
labnll1l anteroposterior
(SLAP) lesiol1 lesl.
IMPINGEMENT TESTS
Impingement tests are designed to approximate
the greater tubercle of the humerus and the acro
mion, thereby compressing the subacromial
structures. Common special tests that assist in
the confirmation of a diagnosis of impingement
syndrome include the locking test, the Neer and
Welsh impingement test, and the Hawkins and
Kennedy impingement test.
Lockil1g Tesl
As described by M aitland!· the examiner
stabilizes and depresses the scapula with the
proximal hand while the distal hand internally
FIGURE 3. 1 9 Neer and Welsh impingemenl leSI. rotates and slightly extends the humerus. The
82 PHYSICAL THE R A P Y OF THE SHOUL D ER
Yergason's Tesl
Drop Arm Test If the patient's arm approaches 90· and "drops,"
the test is positive for a full-thickness rotator cuff
The patient may either be seated or standing. tear.55 . 56
The arm is passively raised above 90· of abduc
tion. The patient then actively lowers the aim to Supraspil1atus Test
90· of abduction in intemal rotation (Fig. 3.24).
The humerus is placed in 90· of elevation in
the plane of the scapula and full internal rotation
(Fig. 3.25). The examiner applies resistance to
elevation while the patient allempts to maintain
the position.57.S8 The examiner then grades the
strength of the supraspinatus muscle and notes
any pain provoked by the test.
FIGURE
3.25 Supraspinalus leSI.
DIFF E R E N T IAL SOFT TISSUE DIAGNOSIS 85
C O N C l U S t O N S BASED O N C E R V I C A L CO e l U S I O N S B A S E D ON
SC R E E N I N G O BS E RVATION
I . Muscle tightness or cervical facet restriction I . Forward head posture sUPPOJ-ts the previous
is likely, limiting right cervical rotation and decision to include evaluation of the upper
right side bending. quarter in the ongoing assessment.
2. Cervical spine tests do not reproduce left 2. Left head tilt supports the previous assess
arm or scapular symptoms. ment of possible left cervical facet or muscu
lar tightness.
3. Palpation of the anterior and posterior lI-ian
gles of the cervical spine should be included 3. The O.s-cm difference in scapular position
in the palpation portion of the examination. is unlikely to be clinically significant.
4. Depression of left scapula is likely nOJ-mal
OBSERVATION OF SYMMETRY AND POSTURE because this is the patient's dominant side.
5. Improper biomechanics of ten.nis strokes
Anteriorly, a slight left head tilt and mild atrophy may be either an extrinsic factor in her dys
of Ihe left deltoid can be observed. Laterally, function or a compensation for the dysfunc
moderate forward head posture, apparent exces tion.
sive protraction of the left scapula, and a slight
anterior position of the left humeral head are MOBILITY
noted in comparison to the right side. Poste
ACTIVE R A N G E O F M O T I O N
riorly, a slight left head tilt, a slight depression
of the left scapula, and mild atrophy of the left Cardinal plane movements exhibit limitation in
infraspinatus and teres minor muscles are ob internal rotation and horizontal adduction to 50'
served. and I I D', respectively, with pain at end ranges
88 P H Y S I C A L T H E R A P Y OF T H E S H O U L D E R
over the lateral arm. A painful arc is present dur terior capsule and a false-positive laxity of the
ing active abduction. In the plane of the scapula, posterior capsule may result. Passive scapular
normal glenohumeral to scapulothoracic distraction is slightly limited on the left.
rhythm is observed during concentric activity
through all three phases of elevation. After 7 to
8 repetitions, some mild "winging" of the left sca C O N C L U S I O N S B A S E D ON M O B I L ITY
pula and some oscillations of the left scapula are
seen in the middle phase of elevation during ec I . Limited active and passive internal rotation
centric activity. and horizontal adduction of the glenohu
Functional movement tests demonstrate the meral joint indicate tightness of the poste
ability of the patient to put her left hand behind rior capsule.
her neck, although there is mild arm discomfort 2. With repeated movements, apparent scapu
during the maneuver. The patient is unable to lar instability during the eccentric phase of
put her hand behind her back (left thumb elevation in the plane of the scapula may in
reaches the sacroiliac joint compared to the T7 dicate weakness of the scapular rotators
segment on the right side), and is unable to put and/or stabilizers.
her left hand on the opposite shoulder. She re
3. Limitations of f"tlllctional movements indi
ports left lateral arm pain dUling both maneu
cate that the patient is unable to perform
vers.
daily activities such as fastening a brassiere,
tucking in blouses posteriorly, or perform
PASSiVE R A N G E O F M O T I O N ing tennis strokes with COITect body me
chanics. The functional movement limita
Cardinal plane PROM of the left glenohumeral
tions correlate to AROM findings of limited
joint exhibits limitation of internal rotation to
glenohumeral internal rotation and horizon
60' and horizontal adduction to I IS'. External
tal adduction.
rotation in 0' of abduction is slightly limited
compared to the light side. Other motions are 4. PROM findings indicate that joint restric
full, with mild left lateral arm pain at the end tion, rather than muscle weakness or pain,
range of external rotation in 90' of abduction. primarily limits glenohumeral internal rota
During passive internal rotation, resistance tion and horizontal adduction. The PROM
is encountered prior to pain, and resistance. not findings correlate to the functional move
pain, prevents further movement. During passive ment limitations.
horizontal adduction, pain and resistance are en 5. IITitability level is low (based on internal ro
countered concurrently at 1 10' and pain/muscle tation PROM) and moderate (based on hori
guarding (rather than joint resistance) are felt to zontal adduction PROM), using the method
further limit movement at l i S'. of assessing irritability from either Cyri
ax'or M aitland. I
ACCESSORY M O B I L I TY 6. Posterior capsule tightness and mild ante
When compared to the right side, anteroposter rior capsule laxity may predispose the pa
ior gliding of the left humerus is mildly restricted tient to an impingement syndrome.2'
and posteroanterior gliding is slightly increased. 7. A muscle imbalance of the rotator cuff is
During accessory mobility testing, caution is likely, due to probable tightness of the sub
taken to begin the tests with the humeral head scapularis muscle (based on the PROM limi
in a neutral position, because the patient's left tation of external rotation in 0' of abduction
humeral head is slightly anteriorly positioned concurrent with full external rotation in 90'
when compared to the right side. If this caution of abduction), as well as the slight restric
is not taken, a raise-positive restriction of the an- tion of passive scapular distraction.
DIFF ER EN T I A L SOFT TISSUE DIAGN OSIS 89
MUSCULOTENDINOUS STRENGTH cle atrophy rather than gross macrotrauma
RESISTIVE TESTS explains the weakness.
2. There is a muscle imbalance of the rotator
Resisted shoulder external rotation and abduc
cuff based on the weakness of the external
tion are weak without pain.
rotators and supraspinatus found with resis
tive tests, manual muscle testing, and isoki
M A N U A L M U S C L E T E S T I N G netic testing, combined with the previous
finding of probable subscapularis muscle
Significant findings during manual muscle test
tightness.
ing are as follows:
left R;ghl
3. The patient exhibits weakness and instabil
ity of the scapular muscles based on the lat
GH external rotators 4 - /5 4 + /5 eral slide test, manual muscle testing, and
GH abductors 4 - /5 Ipo;nl 4/5
previously observed oscillations of the sca
Supraspinatus 3 + /5 Ipo;nl 4/5
pula dUI;ng the middle phase of elevation
Serratus anterior 4 - /5 5/5
lower trapezius
(with repeated testing of eccentric activity).
4 - /5 Ipo;nl 5/5
PALPATION
2. Tenderness over the greater and lesser hu 2 . Intrinsic factors in this patient's micro
meral tubercles, anterior acromion, and trauma injury include muscle imbalance of
long head of the biceps tendon are consis the rotator cuff (weakness of the posterior
tent with impingement syndrome. cuff muscles results in failure to counteract
3. Tightness and tenderness of the levator scap the upward shear forces of the deltoid mus
ulae, anterior and middle scalene, and cle),"·2 4 tightness of the posterior glenohu
upper trapezius on the left are consistent meral capsule and mild laxity of the ante
with forward head posture, left head tilt, rior glenohumeral capsule (decreases the
and limited left cervical rotation and side subacromial space)," and weakness of the
bending, and subjective tightness at the end scapular external rotatol (weakness of the
range of cervical nexion. lower trapezius and serratus anterior mus
cles may alter the plane of the surface of
SPECIAL TESTS the glenoid and change the length-tension
Stability test results are a positive left apprehen relationship of the rotator cuff muscles).
sion test, positive relocation test, and a mildly 3. Extrinsic factors in this patient's micro
positive left antel;or load-shift test. The Neer and trauma injury include initiation of a free
Welshso and Hawkins and Kennedy51 impinge style swimming program (repetitive eleva
ment tests are positive. In this case, the locking tion in internal rotation that may
test'S is deferred due to painfully restricted gle predispose to impingement), recreational
nohumeral internal rotation PROM. The supra tennis (tennis serves involve positioning of
spinatus testS7 . S8 is positive for pain and weak the shoulder in combined abduction and ex
ness . The Gilcrest sign'7.s3 is also positive on the ternal rotation, and combined nexion and
left. internal rotation), and an occupation that re
quires overhead lifting.
C O N C L U S I O N S BASED ON S P E C I A L
T E STS TREATMENT PLAN
I . The previous assessment of slight laxity of Sequential treatment goals and a general treat
the anterior glenohumeral joint capsule i s ment plan to accomplish the goals are shown in
further supported by the load-shift test. Table 3.8. The reader is referred to subsequent
2. Impingement tests are positive. chapters for specific treatment programs.
3. The apprehension and relocation tests sug
gest that the patient's impingement is sec
ondary to a mild antel;or glenohumeral sub
luxation.39-41
Summary
4. Pain and weakness of the supraspinatus sup
As emerging trends in the health care delivery
POl1. the findings of impingement and mus
systems demand greater efficiency from health
cle imbalance of the rotator cuff.
care providers, the need for a thorough evalua
5. Positive Gilcrest sign may suggest the in tion is more vital than ever. A systematic evalua
volvement of both the long head of the bi tion is the most effective tool to establish soft
ceps tendon and the supraspinatus tendon tissue diagnoses and prioritization of the pa
in the impingement syndrome. tient's problems, which can then direct the clini
cian to the most efficient treatment plan. The
ASSESSMENT
components of evaluation for the shoulder com
I. M icrotrauma injury characterized by ante plex have each been discussed, and a case study
rior subluxation of the glenohumeral joint has illustrated the process of assessment based
with secondary impingement.39-4 1 on a specific patient's evaluation findings.
DIFF E R E N T I A L SOFT T I SS U E DIAGN O S I S 91
TABLE 3.8. Sequential treatment goals and treatment plan
Decrease octivity-induced poin and inRammotion Ice following swimming nd therapeutic exercises
Correct scapular muscle imbalance Stretching exercises for the levotor scapulae muscle
Strengthening exercises for the serratus anterior and lower trapezius
muscles
Correct rolator cuff muscle imbalance Stretching exercises for the subscapularis muscle
Strengthening exercises for the supraspinatus, infraspinatus, and teres
minor muscles
Increase strength of shoulder elevators Strengthening exercises for the deltoid muscle
Return to poin-free occupational and Proprioceptive/kinesthetic training
recreational overheod activity Functional exercises
Plyometric exercises
Consult with tennis coach regarding biomechanics of tennis strokes
4. Kamkar A , In'gang JJ, Whitney SL: Nonoperative 1 4 . Solem-Bertoft E, Thuomas KA, Westcrberg CE:
management of secondary shoulder impingement The innuence of scapular retraction and protrac
syndrome. J Orthop Sports Phys Ther 1 7 :2 1 2 , tion on the width of t h e subacromial space. Clin
tion Specialist's Handbook. FA Davis, Philadel bility of the glenohumeral jOint. Am J Sports Med
phia, 1 99 1 1 5: 1 44 , 1 987
20. Hawkins RJ , Abrams JS: Impi ngement syndrome 35. Smith RL, Bll.Inolli J: Shoulder kinesthesia after
in the absence of rotator cuff tCaI' (stages t and anterior glenohumeral joint dislocation. Phys
2). Orthop Clinics Nor Amer 1 8:373, 1 987 Ther 69: 1 06, 1 989
2 1 . Simon ER, Hill JA: Rotator cuff injuries: an up 36. Allegrucci M, Whi tncy SL, Lephal1 SM et al:
date. J Orthop Sports Phys Ther 1 0:394, 1 989 Shoulder Kinesthesia in Healthy Unilateral Ath
22. Bagg SD, Forrest WJ: A biomechanical analysis letes Participating in Upper Extremity SpoI1S. J
of scapular rotation dUling arm abduction in the Orthop SP0l1S Phys Ther 2 1 :220, 1 995
scapular plane. Am J Phys Med Rehab 67:238, 37. Davies GJ, Dickoff-Hoffman S: Neuromuscular
1 988 testing and rehabilitation of the shoulder com
23. Poppen NK, Walker PS: FOI'ccs at the glenohu plex. J Orthop Sports Phys Ther 1 8:449, 1 993
meraijoint in abduction. Clin Orthop Rei Res 1 35 :
38. Lephal1 SM, Borsa PA, Warner JP et al: ProPI;
1 65 , 1 978
oceptive sensation of the shoulder in heahhy. un
24. Sharkey NA, Marder RA: The rotator cuff opposes
stable, surgically repaired shouldcrs. J Should
superior translation of the humeral head. Am J
Elbow Surg 3 : 37 1 , 1 994
Sports Med 23:270, 1 995
39. Davis GJ, Gould JA, Larson RL: Functional exami
25. Abrams JS: Special shoulder problems in the
nation of the shoulder girdle. Phys Spol1smed 6:
throwing athlete: pathology, diagnosis, and non
82, 1 9 8 1
operative management. Clin Sports Med 1 0:839,
40. Yahara M L : Shoulder. p . 1 59. In Richardson JK,
1 99 1
Igharsh ZA (cds): Clinical Orthopaedics Physical
26. Hayes KW. Petersen C, Falconer J : A n examina
Therapy. WB Saunders, Philadelphia, 1 994
tion of Cydax's passive motion tests with patients
4 1 . Kvitne RS, Jobe FW: The diagnosis of anterior
having osteoal1hritis of the knee. Phys Ther 74:
instability in the throwing athlete. Clin 011ho Rei
697, 1 994
Res 29 1 : 1 1 7 , 1 993
27. Paris SV, Loubel1 PV: Foundations of Clinical Or
42. Silliman J, Hawkins RJ: Classification and physi
thopaedics. Institute Press. SI. Augustine, 1 990
cal diagnosis of instability of the shoulder. Clin
28. Hanyman DT, Sidles JA, Clark JM et al: Transla
Ol"thop ReI Res 29 1 :7 , 1 993
tion of the humeral head on the glenoid with pas
43. Gerber C, Ganz R: Clinical assessment of instabil
sive glenohumeral motion. J Bone Jt Surg 72A:
i ty of the shoulder. J Bone Jt Surg 66B:55 1 , 1 984
1 33 2 , 1990
44. Caspari R, Gleisser WB: Arthroscopic manifesta
29. TUI'kcl SJ, Panio MW, Marshall JL et al: Stabiliz
tions of shoulder subluxation and dislocation.
ing mechanisms preventing anterior dislocation
Clin 011hop ReI Res 2 9 1 :54, 1 993
of the glenohumeral joint. J Bone Jt Surg 63A:
1 208, 1 98 1 45. Andrews JR, Gillogly S: Physic.11 examination of
30. Daniels L, W0I1hingham C: Muscle Testing: Tech the shoulder in throwing ath letes. In Zarina 8,
niques of Manual Examination. 4 t h Ed. WB Saun Andrews JR, Carson WG (eds): Injuries to the
T 0 B Y HAL L
Upper quarter pain includes pain perceived in mind is essential, and continued critical assess
variable regions of the neck, upper back, upper ment is necessary.
chest, suprascapular area towards the shoulder, In neuromuscular disorders, identification
shoulder, and arm. Associated headache is a fre of the source of pain is essential prior to adminis
quent accompaniment. In the absence of any tration of physical treatment or prescription of
form of neurologic deficit of the peripheral ner patient-generated treatment programs. Among a
vous sys tem or in the absence of definitive results range of physical evaluation tests to assist in this
from diagnostic tests such as imagery tech task are neural tissue provocation tests. Tests for
niques, diagnoses may ensue as a result of indi use in upper quarter pain disorders, originally
vidual clinician bias. Although diagnostic bias described by Elvey in 1 979, 12 . in recent years
with respect to upper quarter pain syndromes have gained popularity in physical therapy litera
may be due to trends and areas of clinician spe ture.3,4
cialty, it may frequently relate to inadequate
The chapter deals with pain disorders unac
physical examination of the neuromusculoskele
companied by neurologic deficit and without de
tal system.
finitive investigative diagnostic results. This type
In this chapter an aspect of clinical practice
of disorder of the upper quarter is very common
and physical examination is presented that we
in physical therapy and manual therapy prac tice.
have found fundamental to the clinical reason
The most apt descriptive term is cervicobrachia/
ing process, or the logic, necessary to evaluate
pain syndrome or cervicobrachia/ disorder.
upper quarter pain syndromes. Presentation of
the topic in this way should not be construed as The diagnostic term radieu/opalhy, al though
author bias toward regarding neural tissue as a technically incorrect for the cervical spine, is fre
major tissue of origin of pain, or the tissue of quently and loosely used in upper quarter pain
involvement in most upper quarter pain syn disorders when pain radiates as far as the fore
dromes. A detailed examination and assessment aIm or hand. Radiculopathy may tllerefore be
of the findings is required before any clinical hy considered an appropriate term for communica
pothesis or diagnosis regarding neural tissue as tion purposes within the context of neuromuscu
a pain source can be made. Even then, an open losketal pain, but it may also be considered in-
131
132 P H Y S I C A L T H E R A P Y OF T H E S H O U LD E R
correct in the absence of evidence o f neurologic dylosis, frequently no Single traumatic event is
deficit of the peripheral nervous system. recalled, and the clinical picture develops insidi
ously. I I In their review o f cervical radiculopathy,
Ellenberg e t al. 12 reported that 80 to 1 00% of pa
tients present with neck and arm pain, with or
incidence in the Community without motor weakness or paresthesia, gener
ally without preceding trauma or other deter
When m'easured in terms o f lost productivity, minable precipitating cause.
medical treatment costs, and disability insur In summary, cervicobrachial pain and cervi
ance claims, upper quarter pajn in the form o f cal radiculopathy are relatively common; recur
cervicobrachial pain syndrome and cervical rad rent episodes o f cervicobrachial pain and cervi
iculopathy represents a substantial problem for cal radiculopathy increase in incidence with age;
society. In the United States there has been an and there is usually no preCipitating trauma. A
increase o f 45 per cent in the rate o f hospitaliza frequently seen cause o f these disorders is motor
tion for cervical spine surgery between 1 979 and vehicle accidents involving"whiplash"injuries of
1 9905 the cervical spine."
Due to the lack o f population-based studies,
the precise incidence of cervicobrachial pain is
not known.6 However, several investigators have
addressed this problem. Thirty-four percent o f Upper ({u,arter Pain
responders to a cross-sectional questionnaire o f
Norwegian adults reported "neck pain" in the In the evaluation of pain and the various types
previous year. Fourteen percent reported neck o f"pain pallems"that may accompany disorders
pain that lasted more than 1 year.? Lawrence,s o f the upper qual1er, it is essential for the clini
who surveyed 3,950 persons in England, found cian to keep an open mind with respect to any
that 9 percent o f men and 1 2 percent o f women judgement o f the tissue o f origin o f pain. Al
complained of cervicobrachial pain. Further though symptoms such as tingling, burning, pins
more, the mean prevalence o f neck sti ffness and and needles, and numbness are generally ac
arm pain in Swedish working males aged 25 to cepted as an indication o f pathology affecting the
54 years was shown by Hu1l9 to be 5 1 percent. nerve root or peripheral nerve ttunk , unaccom
The maximum prevalence was between the ages panied by paraesthesia, pain may be very di ffi
o f 45 and 49 years. An extensive epidemiologic cult to analyze in terms o f tissue o f origin. The
survey o f cervical radiculopathy was can-ied out pain may be o f the following types:
in Roches ter , Minnesota, between 1 976 and
1990.'0 This survey o f a population o f 70,000 I. Local pain, where it may be an indication
people identified 561 subjects with cervical radi o f pathology o f somatic tissues immediately
culopathy, with a male preponderance. Their underlying the cutaneous area of perceived
ages I-anged from 13 to 91 years, with a mean pain
age o f 38 years for both males and females. The
2. Visceral referred pain, where a visceral dis
average annual age-adjusted incidence rates per
order may cause a perception of pain in cu
1 00,000 were 83 for the total, 1 07 for males, and
taneous tissues distant to the viscera in
64 for females. The age-specific annual inci
volved
dence rate per 1 00,000 population reached a
peak o f 203 for the age group between 50 and 54 3. Somatic refen'ed pain, giving ,-ise to per
years. ceived pain in cutaneous tissues distant to
The onset o f cervicobrachial pain or radicu the somatic tissue
lopathy can either be traumatic or insidious. In 4. Radicular rden'ed and neuropathic referred
the older patient with preexisting cervical spon- pain, where it is again perceived in cuta-
N E UR A L T I S SU E E V A L U A T I ON A ND T R E AT M E N T 133
nerve distribution, depending on the site o f the between referred pain arising from somatic tis
lesion.'· Examples o f projected pain with seg sues and arising from neural tissues.2' The pain
mental distribution are the pain o f radiculopathy and paresthesia that occur in cervical radiculo
caused by herpes zoster or other diseases involv pathy are not well localized anatomically, be
ing the nerve trunk before it divides into its cause a number of roots may cause a similar dis
major peripheral branches. Examples of tribution o f pain or even paraesthesia. In a series
projected pain with peripheral distribution in o f 841 subjects with cervical radiculopathy, Hen
clude trigeminal neuralgia, brachial plexus neu derson et al30 found only 55 percent presented
ralgia, and meralgia paraesthetica.'· with pain following a typical discrete dermato
Two types o f pain following peripheral nerve mal pattern. The remainder presented with dif
injUl)' (neuropathic pain) have been recognized: fuse non dermatomally distributed pain. By con
dysesthetic pain and nerve trunk pain's Dyses trast, Smyth and Wright" stated that lower limb
thetic pain is pain perceived in that part o f the radicular pain is felt along a nalTOW band "no
body served by the damaged axons (Fig. 5.2). more than one and a half inches wide."
This pain has features that are not found in deep
pain arising from either somatic or visceral tis
sues. These include abnormal or unfamiliar sen FJvaJ,uation
sations, frequently having a burning or electrical
quality; pain felt in the region o f sensory deficit; In disorders evaluated for physical therapy inter
pain with a paroxysmal brief shooting or stab vention, combinations o f local pain o f somatic
bing component; and the presence o f allo origin, somatic referred pain, and radicular rc
dynia.'? felTed pain are commonly encountered. Periph
Nerve trunk pain is pain that follows the eral referred neuropathic pain is also seen as a
course o f the nerve trunk. It is commonly de discrete symptom or again, in combination with
scribed as deep and aching, familiar"like a tooth other patterns o f pain.
ache," and made worse with movement, nerve In order to evaluate a disorder for effective
stretch, or palpation.2s manual therapy management, the clinician must
In an individual patient with nerve injury, carry out a physical examination without pre
dysesthetic pain, nerve trunk pain, or both may suming the source o f symptoms and in a manner
be present.28 For this reason it can sometimes that results in a sufficient number o f signs COlTe
be difficult to distinguish, on subjective grounds, lating and supporting each other in the formula
tion o f a clinical hypothesis or diagnosis.
In the physical examination and evaluation
of neural tissue for its possible involvement in
a disorder, clinical experience indicates that a
Perceived pain Site of pathology number o f very specific correlating signs must
(Radiculopathy) be present before any suggestion that neural tis
I sue is involved can be made. This is necessal)'
� for accurate treatment prescription when con
Antidromic sidering a manual therapy approach. Physical
impulses treatment, in the form o f manual therapy, cannot
bc prescribed fTom imagery or nelve conduction
studies, although it may well be strongly influ
enced and be guided by such studies even to the
degree where results of either may contraindi
cate manual therapy.
The physical signs o f neural tissue involve
FIGURE 5.2 Radicular pain. ment include the following:
N E U R A L T I S S U E E V A LU A T I O N A N D TR E A T M E N T 135
but had seen his doctor. He complained o f neck tive to the associated movement o f anatomically
stiffness and a heavy feeling with some pain in sUlToundjng tissue and structures. This means
both upper arms, which was said to extend from that nerve trunks have to adapt to positional
his neck. Because of his previous history o f neck changes of posture with movement of both the
related shoulder symptoms he sought physical trunk and limbs; in other words, they have to be
therapy. The symptoms on all occasions were ac compliant to movement. Therefore nerve trunks
tivity related. can be physically tested in a selective manner.
As in the First example, physical evaluation Should nerve tissue become pathologic and
did not reveal any dysfunction o f the neuromus therefore tender and hyperalgesic, the outcome
culoskeletal system in keeping with his com would be pain associated with any trunk or limb
plaint. He was then referred back to his doctor, movement with which the trunks of that nerve
who referred him for cardiac stress testing. This tissue had to adapt. Due to pain, the nerve trunks
revealed coronary artery insufficiency and he would become noncompliant to movement. This
underwent medical management. non compliance would be demonstrated by pain
O f note were the right upper limb symptoms, ful limitation o f movement, where the limitation
which would relate again to spinal dorsal horn is due to muscle tone and activity in groups of
sensitization including a mechanism o f contra muscles antagonistic to the direction of move
lateral sensitization resulting in the bi lateral re ment. In other words, muscles would be re
fen'ed pain o f visceral origin. cruited via central nervous system processing to
These cases, together with three cases o f tho prevent pain by preventing movement. (See the
racic outlet area tumors also seen in Ollf practice section on EMG responses later in the chapter.)
and referred for treatment for "stiff painful In more severe cases o f pain o f neural tissue
shoulder" syndrome, highlight the need for care origin, the increased tone of muscles becomes
ful evaluation o f presenting signs resulting from widespread and may involve muscles quite dis
accurate di fferential physical tests. With respect tant to the source of pain. In addition, a type
to neural tissue involvement, the signs were o f dystonia may be present, whereby an upper
listed earlier and will be discussed further. quarter pain syndrome o f neural tissue origin
In order to understand the structured may appear as "painful stiff shoulder" or "frozen
scheme o f examination as listed for the presence shoulder." Hence the common clinical presenta
o f specific signs, it is necessary to consider the tion o f tumors of the thoracic outlet region (e.g.,
sensory inner vation o f the connective tissues by Pancoast tumor), when the tumor cells invade
the peripheral nervous system and the relative the nelve trunks resulting in nerve trunk pain, is
dynamiCS o f peripheral nerves. Due to an inher one o f "stiff painful shoulder" or "frozen
enl sensory innervation28 nerves and nerve tis shoulder."
sue, when sensitized by pathologic events, can The signs associated with neural tissue pa
become a source o f pain. When pathologic, nerve thology listed above required very careful and
tissue may cause a projection o f pain to be per precise evaluation, an open mind as to the signif
ceived along the course o f anatomically related icance o f each sign, and an open mind with re
peripheral nerve trunks. The peripheral nerve spect to the formulation of a clinical hypothesis.
trunks in turn become sensitized and thus hyper
algesic. The target cutaneous tissues of the af
ACTIVE MOVEMENT DYSFUNCTION
fected neural tissues become sensitized and
tender.20 Herpes zoster (shingles) and causalgia Previous studies' have shown that a position of
are good examples of these signs attributal to shoulder girdle depression, shoulder abduction!
pathologic neural tissue, nerve as a pain source, lateral rotation, elbow extension, and wrisll Fin
and peripheral nerve trunks that can become hy ger extension with the cervical spine in contralat
peralgesic. eral lateral flexion has the effect of placing the
Peripheral nerve trunks are dynamic, rela- neural tissues of the brachial plexus and related
N E UR A L T I SS U E E V A L U AT I O N A N D TR E A TM E N T 137
cervical neural tissues and peripheral nerve and neural tissue by gently resisting the concur
trunks in the upper limb in a maximum ana rent shoulder girdle elevation occUlTing with ac
tomic lengthened state. tive abduction and at the same time positioning
It has also been demonstrated that any move the patient's head and neck in a position of con
ment of the upper quarter to attain this position tralateral lateral flexion. Should neural tissue be
will influence the same neural tissues to variable involved, the response to active abduction would
degrees. Neural tissues as a structure slide within be more painful and the range of movement fur
the anatomic sUlTounding tissues; or the sur ther limited.
rounding anatomic tissues glide over the neural This is a basic approach to analysis of active
tissues; or both occur, as in functional move movement in the physical evaluation of neural
ment. Hence, in causalgia conditions where a tissue. With some thought to applied anatomy,
nelve i painful, a patient will display active the clinician can examine active movements in
movement dysfunction, as will a patient with different directions and in various ways to sup
shingles when the herpes zoster virus affects a port a clinical hypotheSiS formed at this early
doral root ganglion of the brachial plexus. In the stage of evaluation. For example, a disorder of
same manner, a patient with a Pancoast tumor the C4-5 motion segment may involve the C5
affecting the lower trunk of the brachial plexus nerve roots or spinaJ nerve, which may cause an
will present with a "painful stiff shoulder." observable dysfunction of shoulder abduction
With applied anatomy it becomes clearly evi and movement of the hand behind the back, due
dent that different anatomic positions of the to the increased tension that these movements
shoulder, elbow, and wrist will influence the pe place on the suprascapular and axillary nelve
ripheral trunks of the brachial plexus in different trunks. Contralateral lateral flexion of the head
ways. The median nerve will be in its most and neck would increase the dysfunction.
lengthened state in the position described at the
start of this section. The radial nerve will be in its PASSIVE MOVEMENT DYSFUNCTION
most lengthened position with abduction/medial
rotation of the shoulder, elbow extension, Neural tissue tracts must comply to passive
wrisUfinger flexion in the position of the shoul movement as they do with active movement. If
der girdle depression, and cervical spine contra there is a specific painful active movement dys
lateral lateral flexion. The ulnar nerve will be in function due to a disOl'der involving neural tis
its most lengthened position with abduction/ sues, passive movement in the same directions
lateral rotation of the shoulder, elbow flexion, must also be affected by pain, and as a conse
wrisUfinger extension, and again with the same quence, limitation of range.
common position of the shoulder girdle and cer As with active movement, the clinician works
vical spine. through a differential evaluation process for a
Should any neural tissue tract of the upper determination of possible neural tissue involve
quarter become involved in a painful disorder, ment where there is a painful limitation of range.
various active movements will be affected, de Should passive abduction be painfully limited in
pending on the particular tract involved. Ob range, it would correlate with a painful active
viously active shoulder abduction, with shoulder limitation of range. In addition, the pain would
girdle depression and contralateral flexion of the increase and the range decrease, should passive
cervical spine, will affect all tracts of neural tis shoulder abduction be performed with the shoul
sue from C5 to T I. der girdle fixed in depression or the head and
In testing a disorder to determine the possi neck be positioned in contralateral lateral
bility of neural tissue involvement, active shOltl flexion.
der abduction should be examined in or behind This clinical approach applies to applicable
the coronal plane. If pain is provoked or the passive movements in different directions cOlTe
range of movement is limited, the clinician can lating always with active movement dysfunction.
differentiate between shoulder joint pathology The quadrant position of shoulder joint exami-
138 P H Y S I C A L T H E R A PY O F T H E S H O U L D E R
nation described by Maitland32 is of particular ance enables the clinician to form a hypothesis
interest in passive movement examination. In not only on the possible involvement of neural
the quadrant position the humeral head has an tissue in a disorder but also, importantly, on the
upward fulcrum affect on the overlying neUl·o possible site of involvement. Validity with re
vascular bundle in the region of the axilla (Fig. spect to the clinical implications of such tests as
5.3).' Therefore it is conceivable to use this test described by Elvey'·2 has been demonstrated by
not only as a test of the shoulder but also the Selvaratnam et aI.'
compliance of the neurovascular tissues, and in Provocation tests can only be carried out
the context of this chapter the neural tissues of within the available ranges of passive movement,
the brachial plexus and its proximal and distal which are governed by the severity of pain asso
extensions. To do this, the quadrant test is per ciated with the disorder being evaluated. These
formed as described by Maitland,32 and in addi passive movements are those that would
tion with the shoulder girdle in elevation and lengthen the course over which the neural tissue
depression and with the head and neck in ipsi extends to reach its maximum length capacity. In
lateral and contralateral lateral flexion. more severe painful conditions involving neural
These additional positions subtract or add tissue, it is obvious that passive movements and
distance over which the neural tissues travel, positions, well short of its maximum length ca
thereby affording the clinician the ability to dif pacity, would result in a pain response sufficient
ferentiate the test responses as to whether they to cause limitation of range or inability to gain
may represent neural tissue or shoulder joint a f'unctional position due to the pain and protec
signs. tive muscle.
Therefore it really is unrealistic to document
ADVERSE RESPONSES TO NEURAL TISSUE
a standard form of provocation test technique.
PROVOCATION TESTS
The clinician in practice is required to formulate
Provocation tests are passive tests that are ap a methodology of test technique according to the
plied in a manner of selectivity for the examina presentation of each patient with a unique pre
tion of compliance of different neural tissues to sentation of symptoms and signs.
functional positions. This means that identifying There is a necessary requirement for felllc
a specific type of functional position noncompli- tionaI anatomic knowledge, an appreciation of
N E U R AL T I S S U E E V A LU A T I O N AND T R E A TM E N T 139
the affects of evoked pain and associated muscle I. Via median l1erve. Shoulder abduction lat
activity, and a methodological approach taking eral rotation, with the arm comfortably in a
into account these considerations in the physical position of elbow extension, slight wrist ex
examination of neural tissues. However, in order tension (positions naturally occurring as a
to introduce the physical examination of neural result of the placement of the arm);
tissues by provocation tests, a written fOlmula is head/neck contralateral lateral flexion. In
necessary as a baseline starting point. crease the effect with shoulder girdle depres
sion.
Test Tecill1ique From Distal to
2. Via radial nerve. Shoulder abduction medial
Proximal
rotation, with the arm in a position of
Subject in supine; clinicians hands posi elbow extension, slight wrist flexion (posi
tioned to control shoulder girdle elevation and tions naturally occurring as a result of the
elbow and wrist/finger flexion/extension, and placement of the arm); head/neck contralat
also to be able to alter shoulder rotation, eral lateral flexion. Increase the effect with
head/neck lateral flexion, and forearm
shoulder gil-dIe depression.
pronation/supination.
3. Via ulnar nerve. Shoulder abduction lateral
I. Via median l1elve. Shoulder rotation, elbow and wrist/finger extension,
abduction/lateral rotation, forearm supi forearm pronation, shoulder girdle depres
nated, head/neck neutral, shoulder girdle sion; head/neck contralateral lateral flexion.
neutral; extend elbow. Increase effect of the Increase the effect with increased shoulder
test with incremental, wrist/finger exten girdle depression. As the name implies, with
sion, shoulder girdle depression, and passive neural tissue provocation tests a re
head/neck contralateral lateral flexion. sponse to the test is the clinicians goal. This
2. Via radial ne/ve. Shoulder abduction/medial response should be threefold in the pres
rotation, forearm pronation, head/neck neu ence of sensitization of the neural tissue
tral, shoulder girdle neutral; extend elbow. being examined.
Increase effect with incremental wrist finger a. Clinjcian appreciation of increase in mus
(including thumb) flexion, shoulder girdle cle tone in muscles that are in a position
depression, and head/neck contralateral lat
to prevent further movement in the direc
eral flexion.
tion of the test movement - that is, the
3. Via lIll1ar nerve. Shoulder abduction/lateral antagonists to the movement. This in
rotation, forearm pronation, head/neck neu crease in tone should coincide with the
tral, shoulder girdle depression (due to the first experience of the onset of pain.
different inclination of the lower trunk of
b. The identification of the increa ed mus
the brachial plexus to the upper and middle
cle tone amounts to a first limitation of
trunks, which form the major part of the
range of the passive test movement. This
median and radial nerves); elbow flexion. In
is not a lack of range as might be related
crease the effect with incremental
to tethering or any other form of physi
wrist/finger flexion and head/neck contralat
cal prevention of movement, but one di
eral lateral flexion.
rectly related to an evoked pain response
and resultant muscle activity to prevent
TEST TECHNIQUE FROM PROXIMAL TO further pain via the provoking move
DISTAL ment.
Subject in supine; clinician's hands in a position c. Having produced an initial adverse re
to control head/neck lateral flexion, shoulder gir sponse, the test movement should be
dle elevation and depression, and shoulder ab carefully taken further into range in
duction and rotation. order to attempt to reproduce the pain of
140 P H Y S I C AL T H E R A P Y OF T H E S H O U LD E R
2. The neurovascular bundle of the brachial In disorders of pain involving neural tissue it be
plexus as it travels beneath the coracoid pro comes readily apparent that palpation of tissue
cess. in regions anatomically related to the involved
3. The three major peripheral nerve tnmks of neural tissue will reveal marked tenderness to
the arm at their commencement in the ax the point of being hyperalgesic. These tender
illa, where they may not be identifiable indi- points will be predictably found in areas that ap-
N E UR A L T I S S U E EV A L U A T I ON AN D TR E A T M EN T 141
pear to be target tissues of the involved nerve or sponses in positive tests." The concept of neural
its spinal anatomical segments of origin. tissue provocation testing l 2, has been investi
There is a suggestion that the tender points gated for clinical relevance,' as have the mecha
may represent ectopic pacemaker sites,3S per nisms of muscle responses in positive tests.33
haps terminating cutaneous or subcutaneous E M G activity indicates a mechanosensitivity of
branches of the nerve in question. The most com the perip heral nerve trunks that bear anatomic
mon area found in disorders of the upper quarter relationships to the anatomic levels of spinal rad
such as cervicobrachial syndrome is medial to iculopathy," and also presents a logical reason
the medial border of the scapula. for the clinical signs previously outlined before
a clinical diagnosis of cervicobrachial syndrome
EVALUATION FOR SIGNS OF A LOCAL AREA or radiculopathy can be made. This indicates a
OF PATHOLOGY mechanosensitivity of the peripheral nerve
In pathologic conditions of nerve tissue, all of trunks that bears an anatomic relationship to the
the features d iscussed may readily be found or anatomic level of spinal radiculopathy, and also
determined during a physical evaluation. How presents a logical reason for the clinical signs
ever, this does not mean the condition is one previously outlined that must be present before
suited to manual therapy management. It is a clinical diagnoses of cervicobrachial syndrome
quite possible for a painful diabetic neuropathy, or radiculopathy can be made.
a painf�d neuropathy caused by a tumor infiltra
tion, or carpal tunnel syndrome to cause aU of
the features discussed thus far, including limita
tion of active and passive movement. Therefore Manual Th.erapy Treatment of
the clinician must determine a cause for the neu
ral involvement. N(JUral Tissue
As an example in the upper quarter, disc dis
ease will often result in radicular arm pain and The treatment of neural tissue in manual t herapy
a specific cervical spine motion segment dys involves passive movement techn iques, where
function. This would be manifes ted by passive the anatomic tissues or structures surrounding
sp inal segmental motion palpation for aberant the affected neural tissue are gently mobili zed
movemen t, and by accessory spinal segmental with controlled and gentle oscillatory move
motion palpation where an association between ment. Treatment can be more progressive by
an abnormal pain response and aberanl motion using mobilizing techniques in a similar manner
can be made. An example of this would be evi but involving movement of the surrounding ana
dent where a radiculopathy of C6 resulted in all tomic tissues or structures and the affected neu
of the features discussed and t here was a well ral tissue together in the oscillatory movement.34
defined motion segment dysfunction consisting Passive movement of the pathologic neural
of a painful restriction of passive movement at tissue without movement of its sUITounding ana
the CS-6 motion segment. tomic tissues s hould be avoided, and any stretch
ing of affected neural tissue is absolutely con
traindicated.
EMG Responses to Non-No:r:i.mts With clinician experimentation in treatment
Mechanical Stimul.at:ion of Nerve of neural tissue disorders, it becomes readily ap
Trunks in Cervical parent that the disorder may show acute exacer
bation if the guidelines outlined are not followed .
Ratl.i<:ukrpaihy.
Clinicians report that due to frequent exacerba
The concept of neural tissue provocation test tions of conditions they tend to avoid the use of
ing !·2 has been investigated for clinical rele such techniques. I t becomes obvious that the cli
vance.4 as have the mechanisms of muscle re- nician in these circumstances is not prescribing
142 P H YS I C A L T H E R A PY OF T H E S H O U L D E R
most obvious indicator of successful treatment cal spine and the shoulder joint may require mo
would be an improvement of active hand behind bilizing treatment. The extent of the treatment
the back function. to other tissues and structures would be depen
The amount of time the techniques are per dent on the chronicity of the disorder and its se
formed is variable, depending largely on the ex veri ty.
perience of the clinician, but as in any disorder Self-treatment and management is most im
also on symptom severity and ilTitability. The portant. For neural tissue of the upper quarter,
composure of the patient is a prime considera this can be performed in a variety of ways. A rela
tion with regard to the amount of time devo ted tively simple treatment can be canied out by
to a technique. Should the patient shown any placing the hand of the involved side against a
signs of the beginnings of lack of total relaxation, wall in a comfortable position with a degree of
the technique should be temporarily ceased and elbow flexion, followed by very gentle and con
methods of soft tissue mobilization should be trolled conu'alateral flexion. This should not
employed until composure is regained. cause pain, but a feeling of a pulling sensation
With experience, a clinician will ieam to use in the shoulder and upper arm region would be
different techniques; however, the two just de acceptable.
scribed will serve very well when applied appro The movement is repeated three times once
pliately and correctly. In general, in conditions daily. This may appear insubstantial, but it is es
that are more acu te. the anatomic tissues sur sential to regard tlhe movement as self-treatment
rounding the neural tissue should be mobilized. and not exercise. It becomes very evident to the
In the less acute conditions, or where progres inexperienced that in regarding this technique
sion is required, the neural tissues together with as an exercise rather than a treatment, a condi
the sUITounding anatomic tissues should be mo tion can readily be exacerbated, or a condition
bilized. that has settled to chronicity can readily become
As in so many disorders managed by manual acute. Functional training in the form of exercise
therapy techniques, it is necessary to consider at a time deemed appropriate by the clinician
treatment of tissues affected secondarily and as also becomes essential to the self-management
a consequence of the primary neural tissue pa program.
thology. Treatment would commonly be given
for adaptive shortening that inevitably follows
neuropathy. This shortening mostly involves
CASE STUDY
muscles that have been facilitated and involved
H ISTORY
in tonic reOex activity to prevent movement,
which if it occllITed, would cause pain. In addi Mrs. F.O. was sitting in her s tationary motor ve
tion, long-term lack of movement affects articu hicle when it was struck from behind in February
lar and periarticular tissue mobility, and there 1 991. She sustained a "whiplash" defined injury
fore joint treatment may well be a requirement. to her neck. Her immediate complaint was one
The treatment for these associated dys functions of lef t-sided neck pain extending into her upper
must be chosen at a time when tlhe neural lissue back. Treatment and management consisted of
signs are resolving, and the treatment must be rest, medication, and physical therapy. Mrs. F.O.
can'ied out without any disturbance by stretch continued her work in a nursing home, but due
of the neural tissue. to s teady deterioration of symptoms she was
Commonly in upper qual1er conditions in forced to cease work some months after the acci
volving neural tissue, a time will come in the dent. Bilateral upper arm pain developed and de
treatment program to treat the scalenii and the teriorated to the degree where the left arm pain
shoulder abductors/medial rotators for loss of radiated to the hand into the thumb and index
extensibility and to facilitate the shoulder finger and was accompanied by a sensation of
abductors/lateral rotators. In addition, the cervi- "pins and needles." Plain radiographs identified
144 P H Y S I C A L T H ER A P Y O F T H E S H OU L D E R
ossification of the an terior longitudinal ligament eral flexion demonstrated a further decrease in
at the C4 and C5 levels and prominent ossifica range and increased pain.
tion adjacent to the C6-7 disc. Active left shoul Neural tissue provocation tests could only be
der mobility become so painfully limited that she can;ed out in the ava ilable range of shoulder ab
was said to have developed a "fTozen shoulder." duction of 40°. Consequently, there was a need to
Her symptoms slowly improved through compensate for an inability to reach a sufficient
1 993 to 1 994, but remained significant. Right anatomic length of neural tissue in test positions
shoulder mobility was full range, but left shoul by making max.imum use of maximum shoulder
der mobility and neck mobility remained lim girdle depression and contrala teral lateral flex
ited. All litigation was completed in 1 994. ion of the celvical spine ( Figs. 5.4 and 5.5). Al
In early 1 995 there was a gradual increase in though WI;St extension in shoulder girdle depres
pain, culminating in a severe exacerbation of left sion reproduced symptoms, the shoulder girdle
upper quarter symptoms without reason. In par elevated wrist extension did not reproduce the
ticular she complained of severe lef t shoulder shoulder and arm pain.
pain radiating down the arm to the hand accom Neural tissue provocation tests via the me
panied again by a pins and needles sensation of dian and radian nelves reproduced symptoms,
in the thumb and index finger. Marked restric but testing via the the ulnar nerve did not, thus
tion of shoulder mobility by pain once again indicating a spinal level of involvement from C5
mimicked a frozen shoulder. CT scan of the cer to C7. In testing from proximal to distal, the
vical spine in March 1 995 identified degenerative shoulder could again only be positioned in a
facet changes and at the C5-6 level disc degener small available range of abduction, and the
ation with anterior and posterior os teophytic shoulder girdle therefore had to be fixed in
spurring. cauded depression to compensate for the lack of
In May 1 995, Mrs. F.O. was referred to us by ability to be able to place the neural tissue in a
a consultant physician specializing in assess more maximal length position.
ment for pain management for evaluation and Palpation of particular peripheral nelve
for treatment if we felt it indicated, The working trunks of the left upper quarter produced hyper
d iagnosis at that time was left C6 radiculopa thy. algeSic responses. These responses were not pro
The referring physician's next option of treat duced on palpation of all peripheral nelve
ment was to be a C6 nerve root sleeve block. tnlllks. Hyperalgesic responses were obtained in
the left posterior triangle; with respect to the
PHYSICAL EVALUATION
upper trunks of the brachial plexus, immediately
inferior to the left coracoid process; with respect
At initial evaluation, the left shoulder girdle was to the neurovascular bundle, the axilla; and with
elevated with the arm held in a protective posi respect to the neurovascular bundle and the
tion. Left shoulder [unction was recorded as flex upper arm with respect to the median and radial
ion 80° and abduction 40° (Fig. 5.4). nerves. Palpation over the suprascapular and ax
Although cervical range of motion was lim illary nelves a lso produced hyperalgesic re
ited in all directions, particular note was made sponses.
of greater limitation of right lateral flexion than Palpation of cutaneous and subcutaneous
left lateral flexion. Of further interest was the tissues in regions that had a neuroanatomic rela
fact that active shoulder mobility was more pain tionship to the hyperalgesic upper trunk of the
f�11 and more limited in range when perfomled left brachial plexus also indicated hyperalgesic
with head and neck positions in contralateral lat responses. These areas were particularly evident
eral flexion. Passive left shoulder mobility was medial to the medial border of the scapula, the
limited in range by pain to the same degree as upper chest, shoulder, and upper arm. Re
active mobility. Retesting passive mobility with sponses or a similar nature were not found in
the head and neck positioned in contralateral lat- co n'esponding tissues on the right.
N EU R AL T ISS U E EV A L U A T I O N A N D TR E A T M E N T 145
+
cessory motion palpation indicated a pain and
stiffness relationship at the same levels. In spite
of palpation of shoulder subcutaneous tissues
Trapezius
4-
producing painful responses and active and pas
sive motion being limited in range, accessory
-
movement of the articular surfaces was freely Deltoid -+-
+
available.
EMG RESPONSES
+ t
sponses to upper l imb nerve trunk palpation
were recorded using the protocol described by
Hall and Quintner." EMG responses were �,
�"
recorded from the ipsilateral biceps, triceps, del
toid, and upper trapezius muscles on the side of
the arm being tested. EMG activity in the four
muscles was simultaneously recorded during
gentle deep pa lpation over the anatomic site of
St imulus
t t t
the ipsilateral radial and median nen'e t runks Time / 2 s ec interval
in the upper arm, and of the ulnar nerve trunk
behind the medial epicondyle. Recordings were FIGURE 5.6 EMG responses ill this subject with
also made during gentle palpation of the skin and ceTVical radiculopathy are silllilar to those
subcutaneous tissues overlying each presumed documellted by Hall and Quilltlle,-33 ill a silllilar
tender nerve tnmk; and also, in the case of the case. They foul1d painful respollses to gel1tle
median and radial nerve trunks, dUI-ing palpa palpation over the radial alld mediall IleTVe
tion of the bellies of the adjacent biceps and tri Irullks ill the symptolllalic arm of their patient,
ceps brachii muscles. and recorded widespread (mullisegmel1la/) EMG
A burst of activity was recorded in left biceps, respollses on palpation of these putatively tellder
triceps, and upper trapezius muscles sampled on IteTVe lnlrlks. Neither paill Ilor EMG respollses
the painful side when the radial and median were Iloted during palpatioll, ill turn, of the skill
nerve trunks were palpated (Fig. 5.6). The other and the subcutaneous tissues overlying these
stimuli, including palpation of the ulnar nerve, IteTVe lnlrlks, and of the adjacellt muscle bellies
had no effect upon E MG activity, nor were they of biceps alld lriceps brachii.
painful. On the opposite (asymptomatic side),
there were no EMG responses to nerve trunk pal
pation (Fig. 5.7). index finger and the CT results, a diagnosis of
C6 radiculopathy was a lso loosely supported.
ASSESSMENT
Treatment of choice, with respect to physical
treatment, was therefore using a technique that
The physical findings and the EMG analysis cor indirectIy had a postulated physiologic effect,
related accurately with the subjective complaint and hence a therapeutic affect, on neural tissue.
and supported a disorder categorization of cervi
TR EATMENT
cobrachial pain syndrome, in which there was
strong evidence of neural tissue involvement and Treatment commenced with therapist interven
of it being the major pain source. In view of the tion only. Severity of pain prevented any patient
pins and needles sensation felt in the thumb and generated management at that time. Treatment
N E U R AL T I S S U E EVA L U A T I O N A ND TR E A T M E N T 147
and lateral rotators and to regain nonnal muscle pingement syndrome, to degenerative disease o f
recruitment patterns o f arm elevation. the cervical spine. In such cases, the physical
Treatment was successful at the time of writ evaluation by necessity has to be very precise,
i ng this report. The severity o f pain was reduced with the clinician being skilled e nough to per
and the range o f left shoulder mobility was in form a competent and detailed analytical evalua
creased in unison, as treatment proceeded. The tion not o nly to determine the source(s). The
improvement o f both vadables was o n the order depth o f such an examination must be of a type
of 50 percent, a level of improvement acceptable that will thoroughly evaluate all structures capa
to all parties concer ned when consideri ng the ble o f refelTing pain. O nly then can a working
history and severity o f the disorder. The same diagnostic hypothesis be formed and tested with
medications were continued but decreased in a technique o f treatment prescribed from the ex
quantity, and a nerve root sleeve block was not amination findings.
can"jed oul. Prior to the treatment i ntervention This perspective is quite di fferent from treat
symptomatic deterioration was reported. ment in the form o f anti-inflammatory medica
It is anticipated Mrs. F.O. will continue to tion or management of pain w ith analgesic medi
improve, and with more time progress to an ac calion, transcutaneous electrical nerve
live functionaJ training program. stimulation (TENS), or other forms of modali
ties. In these approaches the physical examina
DISCUSSION
tion needs only to be o f sufficient extent to deter
mine the existence o f an organic musculoskeletal
Many disorders encountered in physical therapy disorder. The examination in that ca e does not
practice have multiple possibilities as to the tis need to be so detailed, and as a result the tissues
sue of origin of pain. A ready example is the pa of origin of pain need only be presumed.
tient refen"ed for treatment for shoulder arm This approach obviously has its success. In
pain, when there are numerous possible sources Mrs. F.O.'s case, unfortu nately, this approach
o f the pain, from lateral epicondylitis, to im- was not successful. A great deal of thought is
N E U R A L T I S S U E E V A L U A T I O N A N D T R EA T M E N T 149
simply because the normal physiologic effects of movement, functional training programs can
associated with movement of tissues in and be implemented.
around the in tervertebral foramen do not occur.
Due to pain and muscle reflex activity directly
resulting from movement transferred to the
pathologic neural tissue, the patient is unable to Summary
perfOlm any movement that would influence the
pathologic tissue favorably in terms of having a As extensive an ou tline as possible of neural tis
therapeutic affect. In other words, s tasis within sue in upper quarter disorders has been given,
the intervertebral segment and mo tion segment although the extent has been governed by the
of involvement would not only exist but persist. consu·aints of a chapter in a clinical text. It is up
In this context, the patient told to exercise to the individual clinician to challenge the con
would be unable to do so with any therapeutic tent of the chap ter in order to gain a full under
influence on the pa thology, and would in fact standing of the role that neural tissue may play
reinforce movement patterns that prevented in the painful dysfunc tions seen daily in the
physiologic movement of the pathologic neural physical therapy clinic. It is also up to the indi
tissue, thus denying the tissue the beneficial ef vidual to maintain an open mind with respect to
fects of movement. implicating neural tissue in a painful disorder
The value of therapist intervention as seen and a very thoughtful approach to techniques of
in the ca e study again can be answered in telms treatment when neural tissue is involved.
of the physiologic benefit of movement. The pa An understanding of neural tissue relative
tient position during treatment is such that dynamics, sensitization, and nociception includ
ing physiologic pain and clinical pain, is essen
movement can be promoted within the interver
tial, and readers are encouraged to s tudy these
tebral foramen and motion segment of the
topics in detail. An understanding of pain mech
pathologic level without evo king pain. In this
anisms will lead to understanding of the move
way, reflex muscle activity is avoided, and the
ment dysfunctions of pathologies such as reflex
therapeutic effects of movement can therefore
sympathetic dystrophy, herpes zoster, Pancoast
be gained. Salter'9 has ou tlined the effects of pas
tumor, and o ther pathologies such as those men
sive movement on pa thologic tissues, and with
tioned at the start of the chap ter that may result
respect to the tissues occupying the in terverte
in " frozen shoulder."
bral foramen i t could be postulated that the same
Many physical signs must be present in order
premises apply. to imply that neUI,,1 tissue is involved. The rea
The advancement from direct therapist in sons why dysfunction of movement will be ap
tervention to patient intervention and eventually parent when neural tissue is sensitized and
functional training therefore lies in the response therefore a source of pain have been outlined,
to passive movement with respect to its pre and postulations have been offered as to why
sumed physiologic influence on the pathologic nonpainful passive movement techniques of
tissue, the therapeutic e ffects of this influence, treatment may be beneficial. It must be readily
and with time a resulting decreased severity of apparent that pain is of the utmost significance
pain. With decreased pain, the patient is able to in guiding both the examination and treatment.
move without prompting reflex muscle activity, Should this be overlooked, it will become very
and thel·erore in a manner more in keeping with obvious why a patient's condition deteriorates
an ability to have a physiologic and remedial in during examination and treatment of neural
fluence on the improving pa thologic neural tis tissue.
sues. At this s tage, patient self-treatment tech The greatest single example of poor tech
niques can be prescribed, and with further time nique, as a result of lack of understanding, is the
and the regaining of normal physiologic ranges use of stretch, either in examination or lreal-
N E U R A L T I S S U E E V A L U A T I O N A N D T R E A T M E N T 151
ment. The credibility of the profession rests with I S . Grieve GP: RcfelTcd pain and other clinical fea
the individual. tures. p. 27 1 . In Boyling JD, Palstanga N (eds):
Grieves Modern Manual Therapy. 2nd Ed.
Churchill Livinstone, Edinburgh, 1 994
1 6 . Bonica JJ, Procacci P: General considerations of
References acute pain. p. 1 59. In Bonica JJ (ed): The Manage
ment of Pain. 2nd Ed. Vol. I . Lea & Febiger, Phila
I . Elvey RL: Brachial plexus tension tests and the delphia, 1 990
pathoanalomical oligin of arm pain. p. 1 05 . [n 1 7. Fields HL: Pain. McGraw-Hill, New York, 1 987
fdczak RM cd: Proceedings. Aspects of Manipula� 18, Inman vr, Saunders IB: RefelTed pain from skel
live Therapy, Lincoln Institute of l-Ieahh Sciences, etal Sln.lctures. J Netv Ment Dis 99:660, 1 994
Melbourne, 1 979 1 9. Foerster 0: The demlatomes in man. Brain 56: t ,
2. Elvey RL: The investigation of arm pain. In Grieve 1 933
GP (ed): Modem Manual Therapy. Churchill Liv 20. Elliot FA: Tender muscles i n sciatica: EMG stud
ingstone. Edinburgh. 1986 ies. Lancet 1 :47, 1 994
3. Butler OS: Mobilisation of the nervous syslcm. 2 1 . Brodal A: Neurological Anatomy in Relation to
Churchill Livi ngstone, Melboume, 1 99 1 Clinical Medicine. 3rd Ed. Oxford Un iversity
4. Selvaratnam PJ, Matyas TA, Glasgow EF: Nonin Press. Oxford. 1 98 1
vasive discrimination of brachial plexus involve� 22. Kellgren JH: On the distdbution o f pain adsing
ment in upper limb pain. Spine 1 9:26, t 994 from deep somatic structures with charts of scg
5. Davis H: Increasing rate of cervical and lumbar mental pain. Clin Science 4:35. 1 939
spine surgery in the United States 1 979- 1 990. 23. Cloward RB: Cervical diskography. A contribu
Spine 1 9: 1 1 1 7. 1 994 tion to the etiology and mechanism of neck, shoul
6. Loeser JD: Celvicobrachial neuralgia. p. 868. In der and arnl pain. Ann Surg 1 50: I 053, 1 959
Bonica JJ (cd): The Management of Pain. 2nd Ed.
24. KJafta LA, Collis JS: The diagnostic inaccurancy
Lea & Febiger. Philadelphia, 1 990
of the pain response in celvical discography. Clcv
7. Bovim G, Schrader H , Sand T: Neck pain i n the
Clin Oual� 36:35, 1 969
general population. Spine 1 9: 1 307, 1 994
25. Dwyer A, Aprill C, Bogduk N : Cervical zygapophy
8. Lawrence JS: Disc degenerat ion. Its frequency
seal joint pain patterns, I : a study of normal vol
and relationship to symptoms. Ann Rheum Dis
Ullleers. Spine 1 5 :453, 1 990
28: 1 2 1 , 1 969
26. Dwyer A, Aprill C, Bogduk N: Celvical zygapophy
9. Huh L: Frequency of symptoms for different age
seal joint pain patterns 2: a clinical evaluation.
groups and professions. p. 1 7 . In Hirsch C, Zolter�
Spine 1 5:458, 1990
man Y (cds): CClvical Pain. Proceedings of the in�
27. Dt'eyfuss P, Michaelson M , Fletcher D: Atlanto
ternational symposium held i n Wcnncr-Gren
occipital and lateral atlanto-axial jOint pain pat
Centre, Stockholm. Pergamon Press, Oxford,
terns, Spine 1 9: 1 1 25, 1 993
1 97 1
2 8 . Asbury AK, Fields HL: Pain due to peripheral
1 0. Radhakrishnan K, Litch WJ, O'Fallon W M , Kur
nerve damage: an hYPOlhesis. Neurology 34: 1 587,
land LT: Epidemiology of cervical radiculopathy:
a populat ion-based study from Rochester, Minne 1 984
sota, through 1990. Brain 1 1 7:325, 1 994 29. Dalton PA, Jull GA: The distribution and charac
1 1 . Connell MD, Wiesel SW: Natural h istory and teristics of neck-arm pain in patients with and
pathogenesis o f celvical disc disease. Orth Clin without a neurological deficit. Aust J Physiother
North Am 23:369, 1 992 35:3, 1 989
1 2 . Ellenberg MR. Honet JC, Treanor WI: Cervical 30. Henderson C M , Hennessy R, Shuey 1-1: Posterior
rad iculopathy. Arch Phys Med Rehab 75:342, lateral foram inolomy for an exclusive operative
1 994 tcchnique for cervical radiculopathy: a review of
1 3 . Spitzer WO et al: Scientific monograph of the 846 consecutively operated cases. J Ncurosurg 1 3 :
Quebcc Task Force on Whiplash-associated Dis 504, 1 983
orders. Spine 20:9, 1 995 3 1 . Smyth MJ, WI-ight V: Sciatica and the intervcl-tc
1 4. Grieve GP: Common Vertebral Joint Problems. bral disc. An experimental study. IBJS 40A: 1 40 I .
2nd Ed. Churchill Livingstone, Edinburgh, 1 988 1 95 8
152 P H Y S ICAL T H E R A PY Of T H E S H O U L D E R
32. Maitland GD: Vertebral Manipulation. 5th Ed. 1 85. In Shacklock M (ed): Moving in on Pain. But
But terworths, London, 1 98 6 terworth-Heineman, Australia, 1 995
3 3 . Hall TM, Quintner ) L : Mechanically evoked elec 36. Yoo IU, ZOll D, Edwards WT et al: Effects of cervi
tromyographic responses in peripheral neuro cal spine motion on ncUtufor-aminal dimension of
pathic pain: a single case study. In: Abstracts of the human cClvical spine. Spine 1 7 : 1 1 3 1 , 1 992
the Australian and New Zealand Rchcumatology 37. Farmer JC, Wisneski RJ: Cervical spine nerve root
Associations Annual Sciemific Meeting. Auck compression: an analysis of neuroforami nal pres
land, 1 995 SUI"CS with varying head and ann positions. Spine
34. Elvey RL: Treatment of arm pain associated with 1 9 : 1 850, 1 994
abnom'\al brachial plexus tension. Aust J Physi 38. Devor M: NeUl·opathic pain and injured nelve: pe
other 32:224, 1 986 ,;pheral mechanisms. BM) 47:619, 1 99 1
35. Vicenzino B: An investigation of the effects of 39. Salter RB: Motion versus rest: Why immobilise
spinal manual therapy on forequaJ1cr pressure joints? pp. 1 - 1 1 . In : Proceedings o f the Manipula
and thelmal pain thresholds and sympathetic ner tive Therapists Association of Australia, Brisbane,
vous system activity in asymptomatic subjects. p. 1 98 5
Neurovascular
Consequences of
Cumulative Trauma
Disorders Affecting the
Thoracic Outlet: A Patient-
Centered Treatment
Approach
PET E R I . EDGELOW
Neurovascular compression syndromes of the In the past [our years in an outpatient or
upper quarter involve a complex and bewildering thopedic clinic, over 500 patients with the diag
set of problems when seen as separate diagnoses, nosis of TOS received physical therapy treat
but interrelationships must be considered. Is· ment. One of the common findings was that
sues related to the cumulative trauma disorder patients often exhibited signs and symptoms in
o[ thoracic outlet syndrome will be presented. multiple areas. These patients presented with se
Thoracic outlet syndrome (TOS) as a diag vere, chronic pain problems that failed all con
nostic entity is receiving increased attention; yet servative treatments and, in some instances.
one must not fall into the trap o[ ignoring other failed multiple surgeries. The patients all had 2
anatomic sites of neurovascular entrapment. or more years of symptoms before being ulti
Therefore, although issues will be presented that mately diagnosed as having TOS. An evaluative
focus on the thoracic outlet and symptoms that procedure and treatment protocol has been the
can derive from this region, one must consider resul t of this clinical experience.
the potential for multiple entrapment sites. A clear understanding of the neural conse-
153
154 P H YSIC A L THE RAPY OF THE S H OU L D E R
quences o f cumulative trauma d isorders (CTDs) the pressure gradient and effect both the local
affecting the thoracic outlet will help the practic neural circulation as well as the venOLiS return
ing physical therapist comprehend the etiology from the whole upper extremity.
of these disorden;. Also, it is necessary to think Relevant signs and symptoms will be intro
of CTDs as multifactoral rather than having a duced that are important indicators leading to
single cause, as the basis for evaluating and de an understanding of the pathology as well as
veloping an effective treatment program. treatment goals and objectives. This information
The guiding principles for effective treat is essential when treating either a single-tunnel
ment of neurovascular entrapment build on the thoracic outlet problem or a multiple-tunnel
Fundamental idea that neurovascular entrap problem when one of the tunnel problems is in
ments occur as a result of trauma to the nervous the anatomic region called the thoracic outlet.
system or vascular system . Such trauma may A case history of a patient with early signs
occur in an individual with few or many preex.ist of a cumulative trauma disorder illustrates the
i ng risk Factors. use of the knowledge presented in this chapter
Three concepts have been developed based in evaluation and treatment. It is my contention
on clinical experience: findings From surgery, hy that if adequately addressed at the time the
pot heses derived From the basic sciences, and symptoms and signs first presented themselves,
logical common sense. problems can be prevented from developing into
The first concept is that patients must be in the kind of unremitting condition being dis
control of their own care in order for treatment cussed.
to be effective and lasting. In the current medical
climate, issues that cannot be controlled by the
patient include the interaction between the
health care practitioner, the patient's employer,
Importance oj Treati1l{J the Wlwle
and the patient's insurance provider. Therefore, Perscm
factors that can be controlled-such as individ
ual risk factors, health habits, daily living de Patient empowerment is an essential ingredient
mands, and belief systems-take on an i ncreas in treatment. It is based on the theory that a suc
ing importance in the trealment process. cessful outcome involves engaging the whole
The second concept is that neurovascular en person in treatment. Although TOS is a physical
trapments are a problem of stenosis. Stenosis problem, it affects the whole person. Simplisti
should not be thought of as a rigid narrowing of cally stated, the impact is to change the person
an anatomic pal-t, but rather a series of events from being in control of their life to being out of
or circumstances, some of which may result in control. This feeling state of being out of control
an irreversible narrowing and others of which negatively affects the body/mind connection. Re
are reversible. For example, the stenosis caused storing the feeling of being in control is one
by the presence of a cervical rib or scalenus min method to have a positive impact on this connec
imus may be irreversible, but the stenosis due to tion.
postural changes or paradoxical breathing pat In order to be empowered, patients must be
terns is reversible. ready to take control of their own care. Once pa
The third concept is that an u nderstanding tients are committed to this process, the physical
of fluid dynamics must complement investiga therapist acts as a coach to guide them through
tions of structural changes. This concept is based recovery as they learn to monitor daily activities
on research concerning fluid dynamics in the and the home treatment program.
carpal tunnel and appears to be equally relevant There are two key issues that facilitate the
for the thoracic outlet. As structural and fluid feeling of being in control: Understanding "what
changes cause restriction in the size of the outlet, is wrong" and "what is the solution." Patients
these changes could contribute to disruption of need to understand why they have the problem
T RA U MA D ISOR DERS AFFECTI N G THE T H ORAC I C O U T LE T 155
and how their actions can help resolve it. This 3. Painlnumbness and tingling that is constant
requires that the therapist is able to translate the but does not stop you from doing what you
pathoanatomic knowledge inherent in the diag have to do = crying.
nosis into a language that empowers the patient. 4. Painlnumbness and tingling that is severe,
This can be done in a number of ways. One constant, and interferes with thought and
method is to give a story that is simple, using action, and cannot be relieved hysteria.
=
2. Pain that comes and goes = whining. cause the body's pain response will be to protect
.......
""
0,
-<
CB Vent. '"
�
ramus
'"
>
Rib # 1 �
-<
0
�
-<
'"
�
V>
'"
0
c:
r
0
�
'"
TRAUMA D ISOR D E RS A F F E C T I N G TH E T H ORACIC O U TLET 157
the neurovascular stmctures. This protective re scapula, with the medial border made up of the
sponse has an adverse affect on healing when the cervical vertebrae and discs with the external
muscle tension reaction is prolonged by ovemse, opening of the intervertebral foramina, and a lat
overtreatment, or recurrent injury. eral border formed by the glenohumeral joint
(Fig. 6. 1 ). Potential risk factors within these
structures are as follows.
<II
FIGURE 6.t Antltomy o( the thoracic oLlflet. The clavicular head o( the stemocleidol11astoid
muscle ha.s been removed to view the anterior scalene muscle with the phrenic nerve crossing
it. The CS, C6, C7, CB, T I ventral roots o( the plexus are visible as they pass in (rol1l o( the
middle scalene muscle. ( @ Peter Edgelow. Used with permission.)
--e::::r-
----
--e::::r- -tD--
T R AU M A D ISORDER S AFFEC T I N G T HE THOR A C IC OUTLET 159
MUSCLES processes or a cervical rib to the first rib
are present in half of the normal popula
The muscular components separate this bony
tion, and fewer than 1 percent develop TOS;
tunnel into two additional "soft-tissue" tunnels.
so these are not considered a primary risk
A medial tunnel is formed by the anterior and
factor but can certainly provide a predisposi
middle scalenes as they pass from their origins
tion for development of symptoms2
to their insertions. The scalenus anterior arises
from the anterior knob of the transverse process 3. Shortening in the muscular elements sec
of each vertebra to insert on the anterior superior ondary to poor posture and traumatic scar
surface of the first rib, and the scalenus medius ring. Scalene muscle trauma fTom injury
arises from the posterior knob of the transverse with resultant inflammation, fibrosis, and
process and inserts to the posterior superior sur contracture as verified by histologic stud
face of the first rib. A lateral muscular tunnel is ies4 The scalene muscles of patients with
formed by the pectoralis minor muscle as it traumatic TOS have shown consistent ab
passes from its origin on the third, fourth, and normalities in fiber type, size distl'ibution,
fifth ribs to the coracoid process of the scapula and amount of connective tissue. Normal
(Fig. 6.1). The anterior bony wall of the tunnel is scalene muscle fibers comprise 50 percent
further reinforced by the presence of a muscular of type I and 50 percent of type II. Type [ fi
component (subclavius), which passes from its bers contract and relax slowly, develop ten
point of origin along the lateral one third of the sion over a narrow range, and are very resis
undersurface of the clavicle to its insertion at the tant to fatigue, making these fibers
medial superior surface of the first rib. specialized for the long-term contraction
Potential risk factors within these structures necessary in the maintenance of posture.
are as follows. Type II fibers are characterized by rapid
contraction and relaxation, develop a wide
I . Nan'owing of the scalene triangle and pec range of tensions, and often fatigue quite
toralis minor contractile tunnels as a result rapidly. They are suited for high-intensity,
of abnormal breathing and overused acces short-duration muscular activity' The TOS
sory breathing muscles, in conditions such samples showed a predominance of type [
as asthma or COPD. Paradoxical breathing (slow) fibers over type II (quick) fibers. TOS
patterns in which the scalenes and pectorals samples averaged 77 percent type 1 to 33
are used as the initiators of each breath, percent type IT. These studies also showed a
rather than assisting the diaphragm and Significant increase in connective tissue.
lower intercostals during a deep inspiration, The normal average amount of connective
could be considered as a reason why the tissue in a healthy muscle is 1 4.5 percent,
scalenes alter their physiology (see #3). and the average amount in TOS samples
2. Anatomic variations of the anterior and mid was 36.6 percent. This suggests that fibrosis
dle scalene muscles, such as unusual prox of the scalene muscles secondary to trauma,
imity, wide distal attachments of the first such as whiplash, may be an important con
rib, distal interdigitations, and the presence tributor to the cause of TOS4
of a scalene minimus muscle2 .3 Fibrous 4. Post-traumatic scarring along the deep cervi
bands that attach lower cervical transverse cal fascia could be another source of dys-
..
FIGURE 6.2 Diagrammatic representation of tunnels within the upper quarter that may be
compromised by acquired, cOl1gel1ital, or postural slel10tic lesions. I ., vertebral canal; 2.,
intelvertebral foramil1a; 3., scalenes; 4., infraclavicular; 5., pectoralis mil1or; 6., cubital tLl/mel;
7., carpal tLl/mel a,.,d calwl of GUYOI1. (@ Peter Edgelow. Used with permission.)
160 PHYSICAL T H E RAPY OF THE SHOULD E R
TRAU M A DISO R O ERS AFFEC TI N G THE T HO R A C I C OUTLET 161
function. The deep cervical fascia is continu gle, which is formed by the anterior and middle
ous with the axillary sheath that encases lhe scalene muscles and the first rib. There they arc
neurovascular bundle.6 Scarring in one area joined by the subclavian vein, which passes in
could lead lO decreased mobililY lhroughoul fTont of the anterior scalene muscle. Distal to the
lhe length of the lissue. first rib, the subclavian vessels are renamed the
axillary artery and vein. Normally, there is "har
NERVES monious coexistence" among these su·uctures.7
However, if the delicate balance is disturbed, the
The brachial plexus comprises the C5 lhrough
osseous or fibromuscular components can cause
T\ nerve roOlS with a conlribution from C4 and
compression on the neurovascular structures.
T2. However, il is the venlral rami of C8 and TI,
giving neurogenic or vascular symptoms (Fig.
as lhey anastomose to form the lower trunk of
6. 1 ).7-10
the brachial plexus, which is of parlicular impor
Potential risk factors within these structures
tance with TOS, because it is lheir relationship
are as follows. Due to the relationship of the ar
with the floor of the lunnel (first rib) thal places
tery and vein to adjacent structures, the vein is
them in jeopardy. The sympathetic supply lO lhe
more susceptible to compromise than the artery.
upper exlremity comes from the stellate ganglion
The first rib, anterior scalene, subclavius, and
which lies on the neck of the firsl rib.(figure I)
clavicle form a tunnel with a variable diameter.
POlenlial risk factors wilhin these slructures are
Narrowing of this space would affect the venous
as follows.
flow more than arterial flow and may be a signifi
I . The possibility of an abnormally large con cant factor in fluid dynamics not only in the tho
lribution of T2 fibers to the TI root, lermed racic outlet but also in the carpal tunnel. Based
a postfixed plexus. The affecl on available on nonnal pressure gradients. any increase in
neural mobility is lO lower the exiling T I vascular congestion would have an immediate
root, resulting in a longer course lO get over effect on the pressure within a tunnel, and this
the firsl rib and inlo the arm. would then initiate a sequence of events that
could ultimately produce nerve damage.
2. Any change in mobility of the plexus or a
The nerves and blood vessels are required to
segment of the plexus as a result of scalTing
traverse both the bony tunnel and the two soft
of the extraneural elements with further
tissue tunnels as the nerves pass from the inter
changes central to the scalTing. Such
vertebral canal to the arm and the blood vessels
change will affect the segment. That is,
fTom the thorax to the arm.
slumped posture increases the length of the
spinal cord, thereby changing the distance
lhe roots have to traverse to get into the FUrther Issues in Uruierstanding
arm.
the PathophysiJJlogy of
BLOOD VESSELS Cumulative Trauma IMorders
The subclavian vessels enter and exit the chest A can be seen, the thoracic outlet tunnel diame
in this region, together with the nerves. The sub ters can be nan'owed by a combination of bony,
clavian artery courses through the scalene trian- soft tissue, neurologic, and traumatic abnormal-
FIGURE 6.3 This overlay o( the tunnels upon Ihe analomy emphasizes the close proximity o( Ihe
il1lerverlebral (oramina, (2) Ihe space belween the amerior al1d middle scalel1e, (3) Ihe course
of the subclavial1 vein passing over the firs I rib and benealh Ihe clavicle betIVeen Ihe l1Iuscular
auachmems oflhe al1lerior scalene (posleriorly) al1d the subclavius (anteriorly), (4) al1d Ihe
space poslerior 10 peclortliis /11;'70r (5). ( @ Peter Edgelow. Used wilh pennissiol1.)
162 PHYSICAL THERAPY OF T HE SHOULDER
ities. In addition, dysfunctional reflexes, fluid volved side. As the first rib elevates due to the
system dynamics, and postural, ergonomic, and abnormal breathing pattern it approaches the
gender factors can further affect the scalene first clavicle and affects the available space for the
rib triangle and interfere with the course of subclavian vein.
the neurovascular structures, causing vascular Further clinical obselvation with these pa
compression. tients reveals the issue of increased tone in the
muscles of the upper quarter and a decrease in
hand temperature and blood flow. This clinical
DYSFUNCTIONAL REFLEXES THAT CAN
observation and its relevance to the perpetuation
AFFECT TUNNEL DIAMETER
of the problem has led to a hypothesiS to try to
There are three reflexes that can affect the diam explain this phenomenon and how to restore the
eter of the thoracic outlet and the blood flow to system to normal.
the upper extremity. In severe neurovascular en The somatic nervous system has a normal
trapments, these reflexes are all pathologic and protective reflex, which is called the flexion with
may worsen if the reflex activity is not normal drawal reflex. Under normal circumstances,
ized. when the extremity experiences a noxiolls timu
An abnormal or paradoxical breathing pat Ius (such as touching a hot stove), the reflex pulls
tern is the most common and frequently over the extremity away fTom the stimulus towards
looked dysfunctional reflex. The common dys the center of the body. Following this reflex, re
functional pattern is the tendency to breathe laxed repeated movements of the extremity will
with the upper thorax with an absence of abdom result in a relaxation respon e of the muscles
inal movement. This could be viewed as a protec that produced the withdrawal. 11
tive response adversely affecting the breathing The autonomic nelvous system also has a
pattern (e.g., gasping and breath holding). This normal protective response: vasoconstriction. I f
protective response acts to elevate the first rib, there i s a traumatic event such as a cut, t h e auto
thereby nan-owing ti,e tunnel. Changing the nomic nervous system causes a vasoconstriction,
breathing pattern to relaxed, diaphragmatic which results in a decrease in blood f1ow allow
breathing would assist in opening the tunnel and ing time for the blood to clot. Following the clot
releasing the resultant muscle tension. The nor ting, there is a reflex vasodilatation, which then
mal breathing reflex is to breathe in the quiet i ncreases blood flow to promote more rapid
mode with tile diaphragm and only use the healing. This vasodilatation response can be
scalene muscles as accessory muscles of breath stimulated by relaxed repeated movements of
ing when the i nspiration deepens. In paradoxical the injured part. The effect of the relaxed re
breathing, the scalenes are used even when peated movements is felt as a warming of the
breathing quietly. The resultant change in the extremity.
normal reflex pattern of breathing then becomes In patients with cumulative trauma disor
conditioned into a "new nOlmal" or pathologic ders, these reflexes become dysfunctional. The
breathing. In treatment it is e sential to decondi somatic nelvous system's flexion withdrawal re
tion this conditioned reflex, because it perpetu flex becomes hyperactive, so that relaxed, re
ates a vicious cycle of pain/spasm and conges peated movements of the extremity cause an in
tion. crease in muscle tension of the flexor muscles
In patients with paradoxical breathing the rather than a softening or release of tension. The
involved scalene begins to contract with the initi autonomic system in the dysfunctional state re
ation of inspiration and contracts through the sults in a decrease rather than an increase in
full inspiratory phase. This pattern of contrac blood flow with relaxed, repeated movements.
tion can be palpated, and note should be made The breathing reflex in the dysf'unctional state is
of the difference in size, time of contraction, and paradoxical. These reflexes (flexion wi thdrawal,
sensitiviLy to pressure as compared to the unin- vasoconstriction, and paradoxical breathing) be-
TRA UMA DISORDERS AFFECTING THE THORAC I C OUTLET 163
come conditioned by repeated noxious stimuli to these systems, the structures they supply, and
respond with persistent cooling, with increased the pumps that maximize the flow necessary for
muscle tension in the extremity, and with in adequate repair and health. Because the key in
creased tension in the scalenes. An important gredients for adequate circulation o f all of the
component in treatment is to decondition these systems involve both movement and diaphrag
abnormal reflexes by training the patient to per matic breathing, bOlh the problem and the solu
form relaxed, repeated movements in a range tion become obvious.
that does not elicit the tension/cooling response, An additional issue is that of pressure and its
but does elicit the relaxation/warming response impact on circulation. The blood supply within
while maintaining relaxed scalenes during quiet a peripheral nerve relies on a pressure gradient
diaphragmatic breathing. system for adequate nutrition. In research on
pressure gradients within the carpal tunnel, the
FLUID DYNAMICS, TISSUE REPAIR AND
pressure in the nutrient arteriole was found to
NEURAL MOBILITY
be greater than the pressure in the capillary,
which was greater than the pressure in the nerve
The traditional paradigm in considering the fascicle, which was greater than the pressure in
musculoskeletal consequences of an injury is to the vein, which was greater than the pressure in
see the consequences as a loss of flexibility, coor the tunnel (Fig. 6.4). Imbalance in the pressure
dination, endurance, and strength. This para gradient due to an increase in the tunnel pres
digm then directs treatment for musculoskeletal sure caused the vein to collapse. creating venous
injury to restoring losses in flexibility, coordina stasis and hypoxia . I f nothing was done to re
tion, endurance, and strength. This paradigm verse this problem then the hypoxia continues,
needs to be expanded to include circulation leading to edema, which ultimately leads to fi
(fluid systems), particularly when considering broblastic activity and scar Formation within the
the cumulative trauma patient population. The nerve fascicle.'·'l From this evolves a hypothesis.
problem in these patients is that the nervous sys Initial trauma around the nerve could lead to ex
tem becomes affected in the injury, and the ensu traneural scalTing without affecting the in
ing pain has a negative impact on both the circu traneural function of the nerve. However, once
lation and the healing process. the pressure gradient changes lead to intraneural
There are six separate fluid systems within fibrosis, then permanent neural change would
the upper quarter. These fluid systems must be occur.
working at their best to maximize healing from Although the pressure gradient research has
trauma to this area. Table 6. 1 briefly summarizes been described For the median nerve in the car
pal tunnel, the model could be generalized to the
entire nervous system, as it is continually housed
TABLE 6.1 Fluid systems within the upper within tunnels of varying structure throughout
quarter the body.'l This is of importance in the thoracic
outlet because, as previously mentioned, struc
CIR CULATORY SYSTEM STRUCTURES PUMP
SUPPLIED tural and dynamic changes cause restriction in
Arteries and veins Muscles, ligaments, Heort
the size of the outlet, which could contribute to
bone disrupting the pressure gradient and affecting
Lymph Fascia Movement the neural circulation. A useful analogy to de
Synovial Auid Joints Movement scribe this situation is to consider a river flowing
Cerebral spinal Auid Duro, meninges, Breathing into a lake and a river flowing out of the lake, in
nerve roots which the inflow equals the outflow. [n this state,
Intervertebral disc Auid Disc Wolk;ng the volume of the lake is constant, the oxygen
Intraneuronal transport Nerve Movemenl content is high, and the pollution content is low.
system
Should there be an obstruction affecting the out-
164 PHYSICAL T HERAPY OF THE SHO U LDER
collapse = venous stasis and hypoxia. (C) Certain occupations that involve constant turn
Neural {lI1d tll/mel fibroblastic respO'1Se: {urcher ing or sustained flexion of the neck (keyboard
increase ;n tunnel pressure and hypoxia, scar jobs), repetitive use of arms (assembly line
tisslle. (A, arteriole; C, capillary; N, l1en'e; T, work), lifting or holding the al-ms above the
tll/mel; V, venule.) (Adapted (rom the work o{ shoulders ( painters, electricians), and working
SLlI1derlal1d, 1976; @ PeCer Edgelow. Used with with vibrating tools seem to predispose people
pennissiol1.) to develop symptoms.' Studies have compared
occupations of heavy industry work (packers and
assembly workers), office work, and cash regis
ter work for incidence of TOS symptoms. In one
TRA U MA DISORDERS A F F ECTING THE THORAC I C O U TLET 165
, -- ..... ....
,
\
\
I
I LRKE = RRM ,
/ I
+ OHYGEN
/ + POLLUTION \
I
I
SWRMP
I
, +OHYGEN
\ tPOLLUTlON
,
...... _- --
FIGURE 6.5 An G/wlogy o( a heallhy lake 10 describe to Ihe paliel1l the possible scel1ario o(
venOLiS stasis leading to congestion (swamp) lIIilhin the ILl/mel(s), al1d hence the l1eed to
decol1gesl Ihe ILl/mel (drain Ihe swamp!) be(ore proceedil1g to other Ireatments. (@ Peter
Edgelolll. Used wilh penllission.)
study, it was found that the awkward work pos of intense sustained highly repetitive physical ac
ture and continuous muscle tension of the cash tivity with high cognitive demand.
register work produced the highest percentage of Another possible cause of symptoms related
TOS symptoms (32% of cash register workers).5 to the thoracic outlet is the narrowing of the cos
Some of these symptoms may be due to postural toclavicular space by a hypomobile, elevated first
stresses, such as the carrying of heavy packs or rib. I. It is suggested that patients with emphy
weights by those unaccustomed to heavy work, sema are predisposed to TOS because the first
or by debilitation and poor posture.7 .14-1• Recent rib is chronically elevated.s Also, a high thoracic
clinical experience has shown that musicians are lordosis lifts the upper ribs towards the clavicle,
another occupational group in which there is a approximating these structures and causing im
significant incidence of CTDs because of periods pingement of the neurovascular contents.'7 It is
166 PHYSICAL T HERAPY OF T HE SHOU LDER
important to remember that anything that af racic outlet may be due to the lower position of
fects the circulation through the thoracic outlet the female sternum, which decreases the angle
could then compromise the nutrition of the between the scalene muscles '>o Another factor
nerve at a distal site. not to overlook is the biomechanical conse
Sleeping postures are often affected, and pa quences of the anatomic fact that women have
tients may awaken with their arm having fallen breasts. Perhaps instead of drooping shoulder
asleep and it may even be momentarily flail and girdles, the problem is chronically contracted
require some passive movements with the aid of pectoral muscles or undue tightness of the
the uninvolved arm to restore circulation and scalene muscle group.6
mobility.
An important fact to appreciate is that the
nervous system is a continuolls tissue tract. As
the effect of specific trauma and age affects the
mobility of the nervous system, certain postures
that place the nervous system in its extreme of Patients are remarkable for lack of objective evi
range can be potentially injurious or in;tating, dence of neurologic injury or radiological find
particularly if they are sustained. For example, ings, and it is the subtle soft-tissue signs of neu
the common position of many seated office ral imtability, vascular abnormalities, changes
workers is slumped. Slump sitting with the in breathing patterns, changes in first .;b and
coccyx/sacrum in a flexed position and a loss of thoracic mobility, and in the quality of muscle
lumbar lordosis when accompanied by a tho contraction that contt;bute to the clinical diag
racic kyphosis has a very profound affect on the nosis.
mobility of the spinal cord caudal to the cervico A complete clinical evaluation should always
thoracic junction. The spinal cord is approach consider conditions that may simulate or coexist
ing its end range of motion. Add to this the use with TOS, such as cervical disc disease or spon
of the arms in an extended position, such as dylosis, angina pectoris, spinal cord neoplasm,
working with a mouse on the computer, and you Pancoast tumor, multiple sclerosis, carpal tun
selectively stress the upper roots of the brachial nel syndrome, ulnar nerve compression at the
plexus compared to the lower roots. The func elbow, orthopedic problems of the shoulder and
tional position of holding a phone to the ear spine, and inflammatory conditions of the joints
would selectively stress the lower roots of the and soft tissues. 2 .2 1
plexus. The information upon which this analy In addition, the T4 syndrome presents symp
sis is based is the pioneering work of Bob Elvey toms of dull pain, aching, and discomfort or par
on the upper limb tension test.'s This knowledge aesthesia in the arm, which do not follow any
is important in analyzing the stresses of ADL as dermatomal pattern and often have a vague feel
well as in examination and treatment, as is men ing of tightness or pressure in the posterior
tioned later in this chapter. mid thoracic region. The signs on palpation of
the T4 syndrome are located between T3 and T6
as differentiated from the supraclavicular ten
GENDER ISSUES
derness associated with TOS ··22
It is not known why the incidence of TOS in Many patients have multiple tunnel issues
women is twice that of men. I t is speculated that involving more than one "tunnel" (termed multi
the increased incidence may be due to less devel ple crush). Sorting out the contribution of each
oped muscles, more horizontal clavicles, or a is challenging. A major contribution to the clari
greater tendency for drooping shoulders; or it fication of ce.vical involvement comes fTom the
may be due to more prevalent congenital anoma work of Dr. Herman Kabat." He has devised a
lies in the thoracic outlet in women. 1 9 simple clinical test to clarify the quality of mus
I t has been suggested that a narrowed tho- cle contraction in two distal arm muscles inner-
T R A UMA D ISOR D E R S AFF E C T I N G THE T H O RACIC O UT L E T 167
vated by the C7 nerve rool. These muscles are affected, fTequently in the hypothenar area and
adductor pollicis and flexor carpi ulnaris. A posi fourth and fifth digits. The pain may radiate to
tive test incriminates the C7 root as a potential the chest wall 6.28.2'
source of irritation, and a significant number of Arterial obstruction produces coolness, cold
patients with TOS also exhibit weakness in ad sensitivity, numbness in the hand, and exertional
ductor pollicis and flexor carpi ulnaris that is re fatigue, Venous obstruction may cause cyanotic
versed by self celvical traction. It is of interest discoloration, arm edema, finger stiffness, and a
to observe that sometimes the motor root prob feeling of heaviness. I '.30-3 2 Venous symptoms
lem is in one arm while the TOS problem is in are more common than arterial ones. Peripheral
the other. embolization can cause gangrene of fingertips
Another challenging diagnostic problem and is an arterial complication of TOS 7 . 33
concerns carpal tunnel syndrome (CTS). True
CTS involves the median nerve only and is often
associated with a Tinel and/or Phalen sign. CTS FUrlctiol1al Profile {or Patiel1ls With
is associated with TOS in 2 1 to 30 percent ofTOS TOS
cases. Ulnar nerve compression at the elbow is
Symptoms are aggravated by dependency of
associated with TOS in 6 to 1 0 percent of
the arm and any use of the arm in lifting, push
cases. 24. 25 The double crush syndrome indicates
ing, pulling, reaching over the head, or repetitive
the existence of more than one area of nerve
activity such as writing, data entry, or playing a
compression in an extremity!6 The presence of
musical instrument. Fine coordination may be
a more proximal lesion does seem to make the
affected, with patients complaining of symptoms
more distal nelve more vulnerable to compres
with sustained upper extremity activity, such as
sion. 27
combing hair, reaching, holding a newspaper,
It is believed that in some cases there can be
telephone or steering wheel, or carrying a heavy
a multiple crush syndrome involving any combi
bag. Pain is often worse after rather than during
nation of cervical spinal nerves, trunks and cords
use, and is refen'ed to as latency. The pain may
of the brachial plexus, ulnar nerve compression
be particularly disturbing at night,30 and symp
at the elbow, and carpal tunnel syndrome .>' In
toms can be bilateral or unilateraJ.1
severe cases of TOS, the author's experience is
Symptoms are eased by avoiding aggrava
that the lower extremity neural tension signs,
ting activity and through support of the involved
such as straight leg raising (SLR) and cord mo
extremity, such as wearing a sling or keeping the
bility, can also be affected.
hand in a pockel.
Past History (or Patients With TOS evoked potentials (SSEP). Positive electrodiag
nostic studies can reveal chronic, severe lower
There may be a history of traumas to the trunk brachial plexopathy. Such tests may indi
head or neck or upper extremity that subse cate an abnormality in nerve function, but do
quenLiy resolved, leaving the patient apparently not give the specific cause. Low-amplitude ulnar
asymptomatic or with minor residuals that did sensory responses are the most widely accepted
not compromise normal function. If this trauma of these studies, but there is disagreement over
affected the diameter of the canal(s) or the flexi the reliability ohhe results. There is a wide range
bility of the nervous system as it traverses the of conduction times found in asymptomatic indi
canals, or caused trauma to the vascular system, viduals, which may be the result of inaccurate
then the trauma may have contributed to the placement of the proximal electrode at Erb's
onset of symptoms. poinI.6.7.24. 37.38 Many TOS patients have normal
electrodiagnostic studies. This may be due to the
TESTS AND MEASURES FOR PATIENTS WITH
intermittent nature of the symptoms, which are
TOS
dependent on certain positions. Instead of test
ing these patients in the anatomic position, they
Specific diagnosis for TOS can be made by radio should be tested in the symptom-provoking posi
graph and computed-tomography (CT) scan. Ra tion.39 Most agree that these studies are helpful
diologic studies identify any bony abnormalities, in ruling out carpal tunnel syndrome and ulnar
degenerative changes, Pancoast tumors, or other nerve entrapment at the elbow.7 .2 4, 32. 37
pulmonary diseases " Previous history of clavic Thermography has been used by some prac
ular fracture picked up on radiography is impor titioners as an aid i n diagnosis of TOS 4o Ther
tant, because it can predispose toward emboliza mography indicates either an increase or de
tion of the subclavian artery . 2S CT and magnetic crease in heat emission secondary to blood flow.
resonance imaging ( M Rl) are often necessary to Alterations in heat emission can be measured by
rule out frank cervical disc disease, spinal steno an increased blood flow, as in venous occlusion,
sis and fibrous bands " or a decreased flow, as in arterial compression
An important finding whose significance is or nerve Hber irritation fTom neurogenic
often not appreciated is the presence of an elon compression. Because pathologies such as cervi
gated transverse process of C7 seen on plain cal radiculopathy, ulnar nerve injury, and reflex
films. It is the experience ofa prominent vascular sympathetic dystrophy can produce similar pat
surgeon who has perfon-ned over 250 thoracic terns, the lack of specificity can make interpreta
outlet decompression surgeries that the presence tion of thermography difficull.37
of an elongated transverse process is a marker A muscle block is another technique used as
for other anomalies within the thoracic outlet, a diagnostic aid. Relief of symptoms after
such as soft-tissue changes within the scalene tri scalene muscle block with lidocaine into the
angle and fibrous bands (R. Stoney, personal muscle belly can implicate the anterior scalene
communication). muscle as the source of pathology. Improvement
Diagnosis for vascular TOS is made by du after the block cOITelates with good response to
plex scanning (ultrasound combined with Dopp surgery "
ler velocity waveforms), angiography, or venog
raphy "·36.37 The infraclavicular area should be
OBJECTIVE EXAMINATION BY PHYSICAL
auscultated for the presence of a bruit with the
ann in various positions. 19.20.33 A bruit indicates
THERAPIST FOR PATIENTS WITH TOS
Stret1gth Testil1g
Relaxed breathing is always paradoxical, I . Adson's test. This has been used to impli
with the scalene muscle active on inspiration cate the anterior scalene muscle's role in ob
from the initiation of inspiration through the full literating the pulse when the muscle is put
inspiratory excursion. The patients often have on stretch.
difficulty breathing with the diaphragm, and
2. The exaggerated military position. This pur
even when they can, it is the inability to quieten
ports to test the costoclavicular component
the scalenes that is the dysfunctional pattern.
of the thoracic outlet by lowering the clavi
cle onto the first rib, causing compression
More Traditiol1al Objective Tests {or there.
Thoracic Outlet SYl1drome
3. Hyperabduction of the arms (alms over
The standard clinical tests to implicate par head with elbows flexed, as assumed in
ticular areas that could be responsible for caus sleep). This produces a pulley effect of the
ing compression to the neurovascular structures neurovascular structures under the pector-
TRAUMA O ISOR O E RS A F F E C TING THE T HOR A C I C OUTL E T 171
alis minor tendon and coracoid process, Compared to the ULTT, these tests involve only
causing compromise at that site. This posi partial tension of the neuromeningeal system.
tion can also nan"ow the costoclavicular However, with the more mild cases, progres
space. Both pulse obliteration and typical sively adding tension up to the limit of the neuro
symptom reproduction are considered posi meningeal system may be required. This may ex
tive for these tests. 1 0. 20 plain why many limes the results of these classic
4. The abduction exte111al rotation test (AER), tests are negative, and why performing the ULTT
commonly called the hands-up test. This is a beller test of the limit to which the compro
has the reputation of being the most relia mised system can be taken. No single test of the
ble of the TOS tests. This postural maneu more traditional tests is speCific enough to elimi
ver involves shoulder abduction and exter nate other potential sources of pathology.
nal rotation to 90°, producing a scissors-like
compression of the neurovascular stnlc
tures by the clavicle on the first rib. It can
be considered positive by reproduction of
Treatment
the patient's symptoms or pulse change. 2 . 7 · 1 9
Positive response for pulse obliteration is GOALS
Identify variance in warming response to re FIGURE 6.7 Relaxed diaphraglllalic brealhillg. (A)
peated movements of the hand, and use this Paliel1l lyil1g supine, kllees flexed wilh (oalll
abnormal cooling response for guidance in wedge posiliol1ed 10 slabilize Ihe shoulder girdle
deconditioning the acquired dysfunctional 011 Ihe affecled side. The ball-oll-a-slick is
pattern. posiliolled superior 10 Ihe scapula al1d close 10
Develop personal control under the guid Ihe spine 10 press agail1sl Ihe firsl rib. Inhale
ance of a professional physical therapist, m·ld arch Ihe lumbar spine allowil1g Ihe chill 10
through monitoring, and teach the patient 110d down as Ihe body shorle/1s relative 10 Ihe
how to use specific active and passive exer pelvis. (B) Exhale alld flallen Ihe lumbar spil1e,
cises and certain assistive devices to effec comracling Ihe abdominal muscles so as 10 pull
tively ( l ) open the tunnel(s) that are nar the ribs dOWIl lowards Ihe pelvis and Ihe firsl rib
rowed and (2 ) assist normalization of the genlly pushes agaillsl lhe ball-on-Ihe-slick, chin
fluid systems through the pumping actions nodding up. ( @ Peler Edgelow. Used lVith
of breathing and movement. Both outcomes permission.)
must be achieved without increasing pain
that the patient perceives as harmf,, 1 . From
a clinical perspective, pain is perceived of
as harmful if one of two responses occurs.
Either a tension response results in the mus
cles being used when a relaxation is the in
tended result, or a cooling response occurs
in the involved extremity when a warming
response is the intended response.
Rib Mobilizer
.
A ....
_ . -
.,'" .. . ..
" . Etha{oam Rollers
/.2. . .
6-il1ch Etha{oam roll. Anns relaxed and
sLipported by belt. Breathe in as balanced in the
.
(R·· ·
cel1ler arId breathe aLit as rolling {rolll side to
side. May per{on" in standil1g i{ supi/,. is too
pain{"l. (@ Peter Edgelow. Used with . . ·· ·
'. .';1"-"J--r--....--..
...
permission.)
to first rib depression during active exhalation." spine and thoracic spine with three inch
Training of this breathing pattern can be pro Etha{oal11 roll. (A) Spilwl extensiorl with il1hale
gressed by doing it with the legs extended and to pain only. Move Lip spine to include all
relaxed and with the legs extended and relaxed segments increasing ra/1ge as tolerated. (B)
during inhalation but with active internal rota Spinal [lexion with exhale. ( @ Peter Edgelow.
tion of the hips during exhalation. This active Used with penn iss ion.)
1 74 PHYSIC A L THERAPY OF T H E SHO U LDER
"
15
� 1 0"
�
FIGURE 6. 1 1 Dimensions of foa m wedges to assist i" relaxed, repeated move/llel1ls of the
cervical spine. (@ Peter Edgelow. Used with pennission.)
rolier, they progress to the 3-inch roller (Fig. addressed is the skill necessary to perform the
6 . 1 0). A word of caution: these exercises must be exercise and control the breathing pattern at Ihe
able to be performed without significant in same time. If the patient cannot quieten the
crease in spinal pain during the exercise. Any in scalenes during the exercise on the roller, then
crease in spinal pain must not be accompanied the patient is not ready to do it. It takes time to
by any arm pain. The other issue that must be decondition a conditioned response.
the wrists. Self-mobilization of the left wrist 8. Pratt NE: Neurovascular entrapment in the re
gions of the shoulder and postel;or triangle of the
cleared that complaint in 24 hours and it
neck, Phys Ther 48: I 894, 1 986
did not return.
9. Karas S: Thoracic outlet syndrome. Clin SPOlts
Progression of treatment through the foam Med 9:297, 1 990
rollers and selF-mobilization of the neural 1 0. Lord !W, Rosati LM: Thoracic-outlet syndromes.
tissues cleared all symptoms, and she has re Clinical Symposia, CrnA Pharmaceutical Com
mained free of any arm symptoms For 6 pany, Summit, N, 1 97 I
months. 1 J . Edgelmv Pl: Thoracic oUllet syndrome: a patient
centered treatment approach. p. 1 32. In
Slight ongoing neck discomfort associated
Shackloch MO (cd): Moving in on Pain. Butter
with stress from data entry is relieved with worth-Heinemann, Sydney, 1 995
the home program. 1 2 . Butler 0: Mobilisation of the Nervous System,
Churchill Livingstone, London, 1 99 1
1 3 . Gi fford L : Fluid movement may partially account
for the behaviorof symptoms associated with noc
Summary iceplion in disc injury and disease. In ShackJock
M (ed): Moving in on Pain. Butterworth-Heine
Even though diagnostic procedures are more man, Sydney, 1 995
thorough and treatment is growing more sophis 1 4 . Nichols H M : Anatomic slnlct ures of the thoracic
ticated, much additional research is needed to outlet. Clin Ol'lhop 207: I 3, 1986
aid in devising improved evaluation and treat 1 5. Peet RM, Hemiksen ro, Anderson TP, Mal1in G M :
Thoracic outlet syndrome. Mayo Clinic Proc 3 1 :
ment procedures for the TOS patient. The ability
2 8 1 , 1 956
to change symptoms and signs early in the
1 6. Lindgren KA, Leino E: Subluxation of the first l'ib:
cOurse of the condition needs to be followed over
A possible thoracic outlet syndrome mechanism.
time to see if early intervention will have a long Arch Phys Med Rehabil 68:692, 1988
term afFect on the course of the pathology. 1 7. Celcgin Z: Thoracic outlet syndrome: What does
it mean for physiotherapists? p. 825. In Proceed
ings of IXth Congress World Confederation for
Physical Therapy, Stockholm, 1 982
References 1 8. Elvey RL: The investigation of arm pain. p. 530.
I n Gl'ieve G (ed): Modem Manual Therapy of the
1 . Sunderland S: Sixth biennial conference proceed Vertebral Column. Churchill Livingstone, New
ings, Manipulative Therapists Association of Aus York, 1 986
tralia. Adelaide, t 989 1 9 . Sallstrom J, Schmidt H: Cervicobrachial disor
2. Roos DB: New concepts of thoracic olltlet syn ders in cCl1ain occupations with special reference
drome that explain etiology, symptoms, diagnosis to compression in the thoracic oUllet. Am J Ind
and treatment. Vase Surg 1 3 :3 1 3 , 1 979 Med 6:45, 1 984
3. Telford ED. Mottershead S: The "costoclavicular 20. Hursh LF, Thanki A: The thoracic outlet syn
syndrome." 1 :325, 1 947 drome. PosIgrad Med 77: 1 97, 1 985
1 78 P H YSICAL T H ER A PY OF T H E S H O ULDER
2 1 . Crawford FA: Thoracic outlet syndrome. Surg 33. Riddell 0 1-1 , Smith 8M: Thoracic and vascular as-
Clin NOI�h Am 60:947, 1 980 peeLs of thoracic outlet syndrome. Clin 011hop
22. Kabat H : Low Back and Leg Pain from Herniated 207:3 I , 1 986
CClvical Disc. St. Louis, Warren H. Green, 1 980 34. Machleder H I : Thoracic olltlet syndromes: New
23. Adson AW: Surgical treatment for symptoms pro- concepts f
rom a century of discovery. Cardiovasc
duccd by cervical ribs and the scalenus anticus Surg 2 : 1 37 , 1 994
muscle. Surg Gynecol 85:687, 1 947 Reprinted in 35. Pascarelli E, Quilter 0 : Repetitive Strain Injury: A
Clin Orthop 207:3, 1 986 Computer User's Guide. John Wiley & Sons, New
24. Wood VE. Twito R. Verska JM: Thoracic outlet York, 1 994
syndrome. The results of first db resection in 1 00 36. Baxter BT, Blackburn 0 , Payne K, Pcarche WH,
patients. Ol1hop Clin North Am 1 9 : t 3 I , 1 988 Vao JST: Noninvasive evaluation of the upper ex-
trcmity. Surg Clin North Am 70:87. 1 990
25. Narakas A, Bonnard C, Egloff DV: The ceravico
37. Sucher 8M: Thoracic outlet syndrome-A myo-
thoracic ouLlet compression syndrome. Analysis
fascial variant, 1. Pathology and diagnosis. JAOA
of surgical treatment. Ann Chir Main 5 : I 95, 1986
90:686, 1 990
26. Upton ARM, McComas AJ: The double crush in
38. Dawson OM, Hallett M, Millender LH: Thoracic
nerve enlrapment syndromes. Lancet 2:359, 1 973
oUllet syndromes i n Entrapment Neuropathies.
27. Osterman AL: The double crush syndrome. 01'-
LiLLIe, Brown, BaSion, 1983
thop Clin North Am 1 9: 1 47 , 1988
39. Chodo.-off G, Dong WLG, Honet JC: Dynamic ap-
28. Liebenson CS: Thoracic outlet syndrome: Diagno-
proach in the diagnosis of thoracic Olillet syn-
sis and conselvative management. J Manipulative
drome using somatosensory evoked responses.
Physiol Ther I I :493, 1 988 Arch Phys Med Rehabil 66:3, 1985
29. Young HA, Hardy DG: Thor'acic outlct syndrome. 40. Pavot AP, Ignacio DR: Value of in frared imaging
Br J Hosp Med 29:457, 1 983 in the diagnosis of thoracic outlet syndrome.
30. Roos DB, Owens JC: Thoracic outlet syndrome. Thcm1ology 1 : 1 42 , 1 986
Arch Surg 93:7 I , 1 966 4 1 . McNair JFS, Maitland GD: Manipulative therapy
3 1 . Et heredge S, Wilbur B, Stoney RJ : Thoracic outlet technique in the management of some thoracic
syndrome. Am J SUl'g 1 3 8 : I 75, 1 979 syndromes. In Grant R (cd). Physical Therapy of
32. Karas S: Thoracic outlet syndrome. Clin Sports the Celvical and Thoracic Spine. Churchill Living-
Med 9:297, 1 990 stone, New York, 1988
Evaluation and Treatment
of Brachial Plexus Lesions
B Rue E H . GREENFIELD
D 0 R I E B • 5 YEN
The brachial plexus supplies both motor and sen- as well as a review of the microscopic anatomy
5011' innervation to the upper extremities and re of the nerve and nerve trunks.
lated shoulder girdle structures. Lesions to the
brachial plexus compromise the neurologic in
SUPERFICIAL ANATOMY
tegrity, and hence the function, of the shoulder
and related upper extremity. Evaluation ofshoul The brachial plexus comprises the anterior pli
der dysfunction should include an assessment of mary divisions of spinal segments C5, C6, C7, C8,
the integrity and functional status of the brachial and TI, as shown in Figure 7.1. The components
plexus. The complex structure of the brachial of the brachial plexus include the following:
plexus requires a thorough understanding of the
multiple i nnervation patterns to the various mus
1. Undivided anterior primary rami
cles. An understanding of the mechanisms of in
juries to the brachial plexus, pathophysiologic 2. Trunks-upper, middle, lower
changes of nerve fibers and nerve roots, and po 3. Divisions of the trunks-anterior and poste
tential for recovery is essential for proper and ef rior
fective clinical management. Therefore, this
4. Cords-lateral, posterior, and medial
chapter provides a review of the anatomy of the
brachial plexus, classification of brachial plexus 5. Branches-peripheral nerves derived fTom
injuries, description of pathomechanical and the cords
pathologic changes to the specific nerve fibers
and nerve roots, and a reviewof a c1arifying evalu The segmental motor innervation of the brachial
ation to assess the nature and extent of brachial plexus to the muscles of the shoulder is shown
plexus lesions. Clinical case studies offer a com in Figure 7.2. The anatomy of the plexus has been
bined physical and occupational therapy man previously descl·ibed. I The fourth celvical nerve
agement ofa patient with a brachial plexus injury. usually gives a branch to the fifth cervical, and
the first thoracic nelve frequently receives one
[Tom the second thoracic. When the branch from
ArwJmny oj the Brachial Plexus
C4 is large, the branch from T2 is frequently ab
The anatomy of the brachial plexus is divided sent and the branch fTOm T I is reduced in size.
into a review of the gross anatomy of the plexus This constitutes the prefixed type of plexus. Con
and its relationship to surrounding structures, versely, when the branch fTom C4 is small or ab-
179
180 P H Y S I C A L T H E R A P Y O F T H E S H O U LDE R
Sponal
Trunk3 Dtvi3ion3 Cord3 Branche3
nervez
tr_-:<:::._-Dor,Sol .3cOopu!or
C·�
SUpro.3caputar
T'I
Long
'-horoCIc
MQ'dlC11
b,.och\ol _
culan.ou.s
/
"Qdlot ...
ante brochlal
cutoneouJl
FIGURE 7.1 Segmental motor innervation o{ the mllscles o{ the shollider. (From Hollinshead,'J
with permission. )
sent, the contribution o f C S i s reduced i n size, sion. The anterior division of the upper and mid
that of T I is larger, and the branch fTom T2 is dle tl1.lnks unite to form a cord, which is situated
always present. This alTangement constitutes on the lateral side of the axillary artery and is
the post fixed type of plexus. called the lateral cord. The anterior division of
The most typical arrangement of the bra the lower tl1.lnk passes downward, first behind
chial plexus is as follows. The fifth and sixth cer and then on the medial side of the axillary artery,
vical nerves unite atlhe lateral border of the sca and forms the medial cord; this cord frequently
lenus medius muscles to form the upper tl1.lnk of receives fibers from the seventh cervical nelve.
the plexus. The eighth cervical and first thoracic The posterior divisions of all three tnmks unite
nerves unite behind the scalenus anterior to fOl-m to form the postel;or cord, which is situated at
the lower tl1.lnk of the plexus, while the seventh first above and then behind the axillary artery. I
cervical nerve itself constitutes the middle tl1.l nk. Autonomic sympathetic nelve fibers are
These three tl1.lnks travel downward and lat present in all parts of the brachial plexus, con
erally and just above or behind the clavicle, each sisting mostly of postganglionic fibers derived
splilling into an anterior and a posterior divi- from the sympathetic ganglionated chain. The
E V A L U A T I O N A N D T R E A T M E N T O F B R A C H I A L P L E X U S L E S I O N S 181
C2 C3 C4 C5 C6 C7 C8 T1
--------- Trapezius - -- ----- -
_____
Supra ____
Spina!us
I
---- Rhomboids--
I
----Infraspinatus - ----
---Deltoid - ---
I
--- Teres Minor ---
I
------Biceps------
I
---- Brachialis ----
I
------Serratus Anterior ------
I ,
------ Subscapularis --------- -- ----- -
,
-
I
------ Pectoralis Mai or------- -- ------- --------
,
------ Pectoralis Minor ------
, 1
Coraco
Brachialis
FIGURE 7.2 Additional segmental motor ilmervation o( the muscles o( the shoulder.
only preganglionic fibers in the brachial plexus fected nerve and predict the affected muscles.
are Lhose of primary ramus TI. ' Because the Topograph ic relationships of the plexus are de
sympathetic supply!o the eye travels through the l ineated in Gray's Anatomy. I
T I nerve roOL, the occurrence of Horner's syn· 1n the neck, the brachial plexus is situated in
drome, characterized by constriction of the pupil the posterior triangle, which is the angle between
and ptosis of the eyelid on the involved side, in the clavicle and the lower posterior border of the
a patient who has sustained a traction injury is stemocleidomastoid muscle. The plexus in this
presumptive evidence of avulsion to that root.2 area is covered by skin, platysma, and deep
fascia.
The plexus emerges between the scalenus an
ANATOMIC RELATIONSHIPS TO THE
terior and scalenus medius muscles, passes be
BRACHIAL PLEXUS
hind the anterior convexity of the medial LWO
The clinician should understand the relationship thirds of the clavicle, and lies on the first digiLa
of the brachial plexus to the anatomic structures tion of the serratus anLerior and subscapularis
about the neck, shoulder girdle, and arms. To muscles. In the axilla, the lateral and posterior
effectively isolate a plexus lesion, especially in cords of the plexus are on the lateral side of the
the presence of open trauma, the clinician must axillary artery and the medial cord is behind the
identify the plexus and its relaLionship to the an· axillary artery. The cords surround the middle
atomic structures. For example, knowledge of part of the axillary artelY on three sides, the me
the portion of plexus that lies between the clavi dial cord lying on the medial side, the posterior
cle and the first rib, in the presence of clavicular cord behind, and the lateral cord on the lateral
fracture, can help the clinician isolate the af- side of the axillary artely. In the lower part of
182 P H Y S I C A L T H E R A P Y OF T H E S H O ULD E R
the axilla, the cord split into the nerves for the
upper limb.
- - � -,
system outward, a dural funnel is drawn lat
erally into the foramen. The dura, al a junction
- - �
of the intervertebral foramen, being cone
� - shaped, plugs the foramen in such a way as to
-_.
-----,
---- �-
' resist further displacement of the nelve (Fig.
---� -- - � 7.5). Second, the fourth, fifth, sixth, and seventh
-� .
--� ----
�
---=...
, cervical nelve roots are securely attached to the
vertebral column. Each nerve root, on leaving
-=---:::�- the foramen, is lodged into the gutter of the
- --=--==:= �
---.�
.-----... - =:
..,. -
--- , corresponding transverse process, bound se
curely by reflections of the prevertebral fascia
and by slips from the dura attachment to the
transverse processess (Fig. 7.5). Sunderland
FIGURE 7.4 Example o( the undulating structure suggests that the significance of this attachment
o( the (uniculi, which contains l1erve fibers o( a emerges on examination of the relative suscepti
l1erve tnll1k to the poi.u o( (ai/ure. (From bility to avulsion injury of the several nelve
Sunderland,3 with penllissiol1)
roots contributing to the brachial plexus. Trac
tion injuries, which do not avulse nerve roots,
more commonly involve the spinal nerveS
neurium, imparts a degree of elasticity in the
where these attachments exist, whereas the in
nerve trunk. Fourth, each pel"ipheral nerve con
cidence of avulsion injuries is much higher in
tains, within the nerve trunk, a large amount
the case of the nerve roots, which do not have
of epineurial connective tissue that separates
the e soft tissue attachments to the transverse
the fasciculi. According to Sunderland,3 values
of epineurial connective tissue of various pe processes.
ripheral nerves range in the body fTom 30 to
75 percent of the cross-sectional area of the
total number of nerve fibers contained in each
nerve trunk. Therefore, the epineurium, by pro
viding a loose matrix for the contained fasciculi,
cushions the nerve fibers against deforming
forces.
CWssijication oj Brachial, Pl£xus ity (root and sheath intact) or IUptured (root in
tact and nerve sheath IUptured).4 Spontaneous
Injuries recovery may occur with the first injury; but
without surgical repair of the IUpture, no recov
Nu merous types of classifications of brachial ery will occur i n the second lesion.
plexus injuries have been proposed (Table 7.1). Finally, the postganglionic avulsion is classi
The majority of brachial plexus lesions result fied as either supraclavicular, which involves Ihe
from trauma, either direct, as if suuck by an in tlUnks and divisions of the plexus, or infraclavic
strument, or indirect, as in a traction lesion to ular, which involves the cords and branches'> [n
the cervical spine or upper extremity.>-12 Lesions a se,-ies of 420 brachial plexus cases that under
may be described as preganglionic or postgangli went operations, Alnot reported that 75 percent
onic. Preganglionic avulsion injuries indicate were supraclavicular lesions and 25 percent were
that the nerve root has been torn from the spinal infTaclavicular lesions.'
cord and preclude the possibility of recovery.
Post ganglionic lesions may be either in continu-
SUPRACLAVICULAR LESION
POSTERIOR CORO LESION ence of a long thoracic nerve injury, during ab
duction or flexion of the arm, results in partial
A posterior cord lesion involves the areas of dis
loss of scapular rotation. The ability of the upper
tribution of the radial, axillary, subscapular, and
and lower trapezius muscles to temporarily com
thoracodorsal nerves. The lesion results in weak
pen ate the loss of the serratus anterior muscle
ness of the extensors in the arm, with impair
to externally rotate the scapula allows For close
ment of medial rotation and elevation of the arm
to full range (180°) flexion and abduction of the
at the shoulder.
arm.17 However, these muscles quickly fatigue
after four or five repetitions, resulting in signifi
PERIPHERAL NERVE LESION cant loss of full active shoulder flexion and ab
duction range of motion.
Common peripheral nerve or branch injuries in
clude, but are not limited to, lesions of the long
thoracic nerve, axillary nerve, dorsal scapular
AXILLARY NERVE LESION
nerve, and suprascapular nerve. I njuries to the
dorsal scapular and suprascapular nerves are re The axillary nerve originates from spinal seg
viewed in Chapter 4 ments C5 and C6, travels to the distal aspect of
the posterior cord of the brachial plexus, and ad
LONG THORACIC NERVE LESION
vances laterally through the axilla. I The nerve
bends around the posterior aspect of the surgical
The long thoracic nerve originates from the ante neck of the humerus to innervate the deltoid
rior primary rami of C5, C6, and C7 nerve roots muscle and the overlying skin, as well as the teres
after these nerves emerge from their respective minor muscle.
intervertebral foramen. The nerve reaches the The most frequent cause of isolated axillary
serratus anterior muscle by traversing the neck nerve lesion is anteromedial shoulder d isloca
behind the brachial plexus cords, entering the tion.5.7 In 80 percent of cases, anteromedial dis
medial aspect of the axilla, and continuing down location results in a neuropraxia of the axillary
ward along the lateral wall of the thorax.I Al nerve, with total recovery in 4 to 6 months.5
though isolated injuries to the long thoracic
Complete lesion to the axillary nerve results
nerve are rare, traumatic wounds or traction in
in loss of active shoulder abduction. Sensory
juries to the neck that result in isolated weakness
changes include an area of anesthesia along the
of the selTatus anterior muscle with winging of
deltoid muscle. However, even in the presence of
the medial border of the scapula are presumptive
a total axillary nerve lesion, some active shoulder
evidence of a long thoracic nerve lesion.2 Normal
abduction and external rotation is possible. Re
shoulder abduction and flexion results from a
synchronized pattern of movements between sidual shoulder abduction results from the ac
scapula rotation and humeral bone elevation. tions of the supraspinatus and infraspinatus
Variations in the scapulohumeral rhythm in the muscles, as well as the biceps muscle. The stabili
l iterature have been repOl·ted.IJ-16 For every 15° zation of the humeral head by the supraspinatus
of abduction of the arm, 10° occurs at the gleno muscle combined with the action of the long
humeral joint and 5° occurs from rotation of the head of the biceps muscle allows, in some cases,
scapula along the posterior thoracic wall. 13 The full overhead abduction. SpeCifically, by exter
rotation of the scapula results from a force cou nally rotating the aim, the patient places the long
ple mechanism combining the upward pull of the head of the biceps muscle in the line of abduction
upper trapezius muscle, the downward pull of pull. However, the strength of abduction under
the lower trapezius muscle, and the outward pull these conditions is poor, and loss of muscle
of the serratus anterior muscle.'6 Therefore, power occurs quickly with repetitive move
palsy of the serratus anterior muscle in the pres- ments.
E V A L U A T I O N A N D T R E A TM E N T OF B R A C HIAL P L EX U S L E S I O N S 187
C'
" ondary to traction 10 the brachial plexus when
an athlele sustains a laleral flexion injury to lhe
neck. Specifically, the syndrome is an abrupt
Fig. C change in the neck and shoulder angle, as experi
The pulley in this case, with arm raised,
enced by football players making a tackle, with
t is the coracoid.
depression of the shoulder and rotation of the
neck to the contralateral shouder.6. 10-1 1 Markey
A - ·· _ ··_··_·· - ·---·
et al reported another common mechanism of
injUl)' due to compression of the fixed brachial
plexus between the shoulder pad and the supe
FIGURE 7.6 Traction apparatus representing rior medial scapula when the pad is pushed into
brachial plexus. (From Stevens, I. with the area of Erb's point. 10 Regardless of the mech
pemlission.j anism of injury, at the time of injury the athlete
188 P H Y SIC A L T H E R APY O F T H E S H O U L D E R
relates a stinging or buming pain, radiating from proximal humeral fTaclures with associates bra
the shoulder into the arm. '0- 12 Location of the chial plexu injuries.'4 Silliman and Dean report
lesion varies, and cervical rool avulsion has been that an associated complication of scapular frac
seen in severe cases. tures around the scapular spine is suprascapular
Most "bumer" injuries are self-limiting and nerve injury.6
resolve within minutes of insult. Potential prob
lems include persistent neck tenderness and
upper extremity weakness. [f these problems
persist, electromyography should be performed Palhophysiolo{Jy of Injury
at 3 to 4 weeks to assess for seriolls nelV'e
damageW-1l The extent of injury to the nerve trunk, ranging
[Tom a nondegenerative nCUI"opraxia to a sever
DISLOCATIONS ance of the nerve or plexus (neurotmesis), will
dictate the course of treatment (surgical versus
Injuries to the brachial plexus can occur as a re
nonsurgical) and the prognosis and relative time
sult of shoulder dislocation. The incidence of
frames for full recovery.
secondary brachial plexus injury after shoulder
Five major degrees of injury are described by
dislocation ranges from 2 to 35 percent in the
Sunderland";
li terature. Guven et al. reported the "unhappy
triad" at the shoulder that included concomitant
shoulder dislocation, rotator cuff tear, and bra 1. First-degree l1erve il1jury. This injury is char
chja] plexus injury.'9 Axillary nerve injury some acterized by interruption of conduction at
times occurs with acute anterior dislocation of the site of injury with preservation of the an
the humeral head. Wang et al. presented a case atomic continuity of all components com
with concomitant mixed brachial plexus injury prising the nerve trunk, including the axon.
in the presence of infel;or dislocation of the gle Clinical features include temporal), loss of
nohumeral joint.2o Travlos et al. classified bra motor function to the affected muscles, but
chial plexus lexions due to shoulder dislocation the presence of electric potential due to axo
into diffuse infraclavicular, posterior cord, lat nal continuity is retained. Cutaneolls sen
eral cord, and medial cord injuries.21 The type SOl)' loss may occur, but will recover in ad
of injury partly depends on the mechanism of vance of motor function. Most patients
injury and the direction of dislocation of the hu recover spontaneously within 6 weeks after
meral head. injury.
2 . Second-degree nerve illjllry. In this injul)',
the axon is severed and fails to survive
FRACTURES
below the level of injlll)' and, for a variable
Traumatic injuries associated with fractures in but shon distance, the axon degenerates
the shoulder girdle and humerus bones have proximal to the point of the lesion. How
been associated with brachial plexus injuries. ever, the endoneurium is presclved within
Della Santa et al. found sixteen cases of costocla the endoneurial tube. Histologic changes to
vicular syndrome related to compression of the the nerve include breakdown of the myelin
subclavian artery and brachial plexus were due sheath, Schwann cell degeneration, and
to callous and scar formation as a result of fTac phagocytic activity with eventual fibrosis.
tures of the c1avicieH Stromquist et al. reported Clinical features include temporal)' com
three cases of injury to the axillary artery and plete loss of motor, sensOl)" and sympa
brachial plexus complicating a displaced proxi thetic functions in the autonomous distribu
mal fracture of the humerus." Blom and Dahl tion of the injured nerve. Several months
back found two cases in a series of 31 cases of will pass before recovel), begins, with proxi-
EVA L U A T I O N A N D TRE A T M E N T O F B R A CH I A L P LEXUS L E S I O N S 189
mal reinnervation occurring before distal re The clinician should use any one of a number of
innervation to the involved muscles. charts for recording results of the physical exam
3. Third-degree l1ellle injury. This condition is ination, as shown in Figure 7.7. Evaluation and
characterized by axonal disintegration, Wal treatment is a conjoint effort by a physical and
lerian degeneration both distal and proxi an occupational therapist who specializes in the
mal to the site of the lesion, and disorgani treatment of hand and upper extremity injuries.
zation of the internal structure of the Knowledge of hand management and rehabilita
endoneural fasciculi. The general fascicular tion is particularly important in lower trunk inju
pattern of the nerve trunk is retained with ries to the brachial plexus. Additionally, in the
minimal damage to both the perineurium presence of fourth-and fifth-degree nerve inju
and epineurium. Because the endoneural ries to the brachial plexus, occupational therapy
tube is destroyed, intrafascicular fibrosis offers strategies for splinting as well as equip
may obviate axonal regeneration. Many ment modification or assurance to assist perma
axons fail to reach their original or function nently dysfunctional individuals.
ally related endoneurial tubes, and are in
stead misdirected into foreign endoneurial
tubes. Clinically, motor, sensory, and sympa Histmy
thetic functions of the related nerves are
lost. The recovery is long, up to 2 to 3 years, MECHANISMS OF INJURY
with a chance of significant residual dys
function. Because mo t brachial plexus injul'ies result
from trauma, a thorough history should include
4. Fourth-degree l1elve il1jury. This type of in
questions concerning the nature and mecha
jury is similar to third-degree nerve injury,
nisms of injury. According to Stevens, the dif
but the perineurium is disrupted. Therefore,
ferent varieties of sU'ess, and the relative posi
the chance for a residual dysfunction due to
tion of the arm and head at the time of the
fibrosis and mixing of regenerating fibers at
stress, make tremendous differences in the
the site of injury, which may distort the nor
kinds of lesions suffered, in the locality of the
mal pattern of innervation, is high.
lesion, and in prognosis. I S The magnitude of
5. Fifth-degree IlelVe injwy. In this injury, the forces, that is, high-speed versus slow-speed in
entire nerve trunk is severed, with resultant juries, is important to ascertain. According to
complete loss of function to the affected Frampton, high-speed, large-impact accidents
structures. Obviously, without surgical graft are commonly associated with preganglionic
ing, recovery is negligible. plexus injuries, while slow-speed, small-impact
accidents are commonly associated with post
ganglionic injul-ies.4 Examples of high-velocity
injuries are those resulting from falls from
speeding motorcycles, while examples of low
CIi1:rifying Eval:uation velocity injuries are those resulting from a fall
down a stairway.
A thorough and systematic clarifying evaluation
is essential for the clinician to accurately assess
PAIN
the nature and extent of the brachial plexus le
sion and to develop an appropriate and effective The area and nature of pain should be docu
treatment plan. Because most brachial plexus le mented. Pain, described as a constant burning,
sions slowly improve over a long period of time, crushing pain with sudden shoots of paroxysms
the clinician must maintain and update accurate of pain, is central in nature. This pain occurs
records concerning the progress of the patient. as a result of deafferentation of the spinal cord
190 P H Y S I C A L THE R A P Y OF THE S H O U L D E R
BRACHIAL PLEXUS
�E __
____
____
____
__ __
__ ___ ROGHT
DATE OF EXAM __
____
____
____
____
__ SUPRAClAVICUl..AA FOSSA ___
____
____
__
DATE OF INJUAY' __
____
____
____
__ _ ��D��' _
__ __
____
____
____
___
OCCUPATION __
____
____
____
____
_ FRACTURES __
____
____
____
____
___
HOANEA 5 SVNOROUE __
__ __
__ __
____
__ VASeutAR STATUS' ___
____
____
____
__
E"G __
____
____
____
____
____
____
____
____
____
____
____
____
_
", - - · C 6 " - - ..
-
C8
.� .. U ·G '" -
� - - - - - - ...
- -
T l.:..........:.
OU
I
. -
"'10(1"" " ..._ .c :> - _ .C 1 . ...
-.... -
... '"
... :.. - -
... -
... �
-- - - - --
...
...
. - - -- - .. .... , - - --
... ....
nll"AT S .... ' [1111 0 '"
- �
'1.[. lI,ruou(·
.. "
- -
, ·n
OJG SUI1..
, '
�� :O � OI� o � ., ,,,,,
'�""'�IS
'"
(U[fOSOII
fl u e,",
"
A' L� [ JO '
I I I 0
'"
•
CUI": r
."
,
'TT"
1.0,,0 'II'Y HY.-o'..
01il4."
"...llIALI'
I f lIT , ,, olelS
""
.
(.T(I'",�
IIO'A'OIIS
suJlou...TO"
0I0 'T" 1,. I ". ' , , , 0
'
La,rs" .,. u, 00" "
.. Ott " I.. J IIAJ "
C l AV ' C U l,..A 1I U[...,, !,.
c-
.. ,
o
, ..
.
HO'
,.,
• ."IST
00"', '·"1.."'.·
.'0'.1,./1,11..10""
FIGURE 7.7 Chart (or recordillg
• THUM' results o( physical examil1atiol1
0' o ..0 .. ( (or brachial plexus il1jury. (Frolll
..
Leffert2, with permission.)
at the damaged root level, leading to undamp ophthalmos, myosis, and ptosis, along wilh a
ened excitation of the cells in the dorsal horn deficit of facial sweating on the affected side,
of the spinal cord. The confused barrage of reOects damage to the TI nerve root. Questions
abnormal firings is received and interpreted concerning the course of events since injury or
centrally as pain and is eventually felt in the a change in the severity of the symptoms estab
derma tomes of the nerve root that is avulsed.2• lish an indication of an improving or worsening
In a series of 188 patients with post-traumatic lesion. A condition that is resolving sponta
brachial plexus lesions, Bruxelle et al found neously may indicate first- or second-degree
that 91 percent experienced pain at least 3 years nerve injuries, while a condition that has not
after injury'>· Pain may also result from second changed across the course of 6 weeks may indi
ary injuries to bones or related soft tissues. The cate at least a third-degree nerve injury, accord
report of any anesthesias or paresthesias should ing to Sunderland's classification.
be noted and documented. The presence of Hor Finally, the clinician should document the
ner's syndrome, which is characterized by en- patient's occupation, handedness, and previous
E V A L U A T I O N A N D T R E A T M E NT O F B R A C H I A L P L EX U S L E S I O N S 191
state of health to assist in establishing feasible cian should obselve the attitude or position of
goals for retum to the patient's premorbid activ the upper extremity and hand. An ann position
ity level. of adduction and intemal rotation can result
from Duchenne-Erb pa"llysis. Pronation of the
forearm with flexion at lhe wrist and metacarpo
phalangeal and proximal i nterphalangeal joints
Physical. FJval.uat:ion can result from injury to the lower trunk of the
brachial plexus.' External deformities along the
The components of the physical evaluation in clavicle, which may indicate fracture, should be
clude: ( I) posture; (2) passive range of motion of noted. Both nonunions and malunions of the
the cervical spine, shoulder, and upper extrem clavicle can result in significant compression of
ity; ( 3 ) motor strength; (4) sensation; (5) palpa the brachial plexus. The supraclavicular fossa is
tion; and (6) special tests. The occupational ther inspected for the presence of swelling or ecchy
apy evaluation includes assessment for ( I ) mosis in those patients with recent injury and for
edema; (2) coordination; ( 3 ) activities of daily nodularity and induration in the brachial plexus
living; and (4) vocational and avocational pur where the injury is 0ld 4 The eyes are obselved
suits. The physical evaluation should be repeated for constriction of the pupils or ptosis of the eye
frequently during the process of rehabilitation to lids, which can indicate the presence of Horner's
carefully assess subtle signs of nerve reinnerva syndrome.2
tion.
POSTURE
The passive range of motion of all joints of the
The patient is obselved from the front, side, and shoulder girdle and upper limb must be assessed
behind. From behind, the clinician observes for and recordecl using a standard goniometer. Defi
muscle atrophy as well as winging of the scapula. cits of joint motion from immobility result in
Winging of the scapula signifies weak.ness of the contractures of joint capsule, adhesions in the
serratus anterior muscle, which may indicate a joints, and shortening of both muscle and ten
lesion of the long thoracic nerve. Ipsilateral atro dons above the affected joints. The classic stud
phy of the supraspinatus or infraspinatus mus ies of Akeson et al demonstrated the deleterious
cles can signify suprascapular nelve entrapment. effects of 9 weeks of immobilization on peria.-ti
Atrophy of the deltoid muscle, in addition to the cular structures, including the loss of water and
supraspinatus and infraspinatus muscles, can glycoaminoglycans, randomization and abnor
indicate an upper trunk plexus lesion, such as mal cross-linking of newly synthesized collagen,
Duchenne-Erb Paralysis of the C5 and C6 nerve and infi ltration in the joint spaces of fatty fibrous
trunks. Isolated atrophy of the deltoid muscle in materials.28
dicates an isolated axillary nelve lesion. From
the side, the clinician should obselve for changes
MOTOR STRENGTH
consistent with a forward head posture: accentu
ated upper thoracic spine kyphosis, protraction Several manuals are available that review proper
and elevation of the scapulae, increased cervical isolation, stabilization, and grading procedures
spine inclination, and backward bending at the for manual muscle testing.29.3o Most grading sys
atlanto-occipital junction. The forward head tems grade muscle for 0 to 5, with 0 being a flac
posture results in muscle imbalances that can cid muscle and 5 representing normal muscle
further result in entrapment of various nerves of strength.29 A complete upper extremity test
the brachial plexus in the area of the thoracic should be perfonned initially to provide the clini
outlet. 21 Thoracic outlet syndrome is discussed cian a data base from which to measure improve
in detail in Chapter 16. From the front, the clini- ment. Therefore, retests should be performed pe-
192 P H Y S I C A L T H E R A P Y OF T H E S H O U L D E R
riodically. A thorough manual muscle test assists teries may occur. Additionally, all patients who
the clinician in pinpointing the site and extent have had a significant nerve injury will have evi
of the plexus lesion. Establishing an appropriate dence of vasomotor changes.' Assessment of the
strengthening program is based on isolating and brachial and radial pulses and inspection for
grading involved muscles. lsokinetic testing can dusky, cool skin indicating venous insufficiency
also assist clinicians in measuring muscle should be performed by the clinician.
strength deficits, usually for peak torque, power,
and work, compared with the uninvolved upper
EDEMA
extremity. Refer to Chapter 16 for a review of
isokinetic testing protocols in the shoulder. Edema must be assessed and treated to prevent
stiffness in the joints. The concept of volumetrics
SENSATION to measure upper extremity edema is well estab
Assessment of sensory loss assists in the diagno lished. The patient's hand is submerged in a lu
sis of the level and extent of the plexus lesion. cite container (Volumeter, Volumeters Unlim
Total avulsion of the plexus results in total anes ited, Idyllwild, CAl, and the amount of water
thesia of the related areas. However, in a mixed displaced is measured using a 500-ml graduated
lesion, and when recovery is OCCUlTing, the sen cylinder. Both extremities should be measured
sory pattern may vary in the arm. The sensory and the results recorded. Circumferential mea
evaluation may include deep pressure, light surements of the hand and forealm are another
touch, temperature, stereognosis, and two-point method of measuring edema. However, this
discrimination, depending on the patient's sta technique is best suited for individual digit swell
tus.4 Sensory changes are documented along ing or in the case of open wounds, which may
dermatomes, as illustrated in Figure 7.7. preclude the patient getting the extremity weI.
Manual palpation is also used to measure edema.
COORDINATION
The severity of the edema is usually rated from
I to 3, with I being minimal and 3 being severe
Loss of sensation and muscle control in the pres or pitting edema.
ence of a brachial plexus injury results in a loss of
gross and fine motor coordination in the affected
upper extremity. There are numerous tests on PALPATION
the market designed to assess an individual's co Manual palpation is used to assess for myofas
ordination. Each requires varying amounts of cial trigger points about the affected shoulder
fine and/or gross motor coordination. The Pur girdle and upper extremity musculature. Trigger
due pegboard (Lafayette Instructional Co .. La points result from tight and contracted muscles
fayette, I N ) , for example, assists the clinician in or from partially denenlated muscles exhibiting
assessing the patient's manual dexterity. Patients poor muscle control and altered movement pat
are requested to place pegs with both the right terns. Active trigger points refer pain into the af
and left hands, singularly and in tandem, and fected upper extremity, as well as the shoulder
to perform a speCific assembly task using pins, girdle, neck, and head.3, .33
collars and washers. These tests are timed and
compared with normative values " The thera
SPECIAL TESTS
pist should determine the most appropriate tests
based on the patient's level of functioning. The presence of Tinel's sign, demonstrated by
tapping over the brachial plexus above the clavi
VASCULAR
cle, can be quite useful in distinguishing rupture
In the presence of severe brachial plexus injuries, from a lesion in continuity '.4 A distal Tinel's sign
particularly with associated fractures of the clav indicates a lesion in continuity whet'e the axonal
icle, disruption of the subclavian or axillary ar- connections within the ner've trunk are intact.
EV A L U A T I O N A N D T R EA T M E N T OF B R A C H I A L P L E X U S L E S I O N S 193
This may con'espond to a first-degree nerve in the patient closely as to premorbid hobbies or
jury or a regenerating second- or third-degree potential areas of interests. Activities of interest
nerve injury, as described by Sunderland. Con are developed that encourage use of the affected
versely, the presence of a localized tenderness to extremity.
tapping above the clavicle indicates a possible
neuroma resulting fTom disruption of part of the
plexus. This type of injury would correspond to
Lahoratory FJual:uJL/:i.ons oj
a fourth- or firth-degree nerve injury.
Brachial Plecus LesWns
ACTIVITIES OF DAILY LIVING
Also included in the overall evaluation of a pa
The patient is questioned regarding all aspects tient with a brachial plexus injury are laboratory
of self-care to identify those specific tasks he or evaluations involving electrodiagnostic testing,
she is not able to perform owing to the extent of myelography, and radiographic assessment.
the brachial plexus injury. Such areas include These evaluations help the clinician diagnose the
self-care skills such as feeding, bathing, groom area and extent of the Ie ion and provide baseline
ing, and dressing, Based on the specific limita
measurements to help evaluate progress.
tions of the patient, the occupational therapist
then determines whether to provide the patient
RADIOGRAPHIC ASSESSMENT
with specific adaptive equipment or to instruct
the patient in one-handed techniques. Every patient who has sustained a significant in
jury to the brachial plexus should have a com
ASSESSMENT FOR SPLINTING plete radiographic series done of the cervical
In the case of a complete brachial plexus injury, spine and involved shoulder grid Ie, including the
the patient is fitted with a nail arm splint that c1avicle.2 Fractures of the clavicle with callus,
allows the patient to use the extremity at home which can impinge on the nerve trunks along the
and at work. The splint is fitted early, to prevent costoclavicular juncture, or fractures of the cer
the patient from relying on one-handed methods vical transverse processes, which can indicate a
as a means of performing specific activities.' In root avulsion, must be ruled out.2,4
the case of a CS-7 injury, the patient might re Magnetic resonance imaging (MRJ) has been
quire a long wrist and finger extension assist used to detect injuries to the brachial plexus. Bil
splint (Fig. 7.8). The patient may also be fitted bey et al evaluated 64 consecutive patients with
with a resting hand splint (Fig. 7.9) to wear at suspected brahial plexus abnormalities of di
night to help maintain the wrist and fingers in a verse causes with MRJ.34 MRJ was found to be
balanced position. 63 percent sensitive, 100 percent specific, and 73
percent accurate in demonstrating the abnor
VOCATIONAL mality in a diverse patient population with multi
ple etiologies of brachial plexus injuries.
A detailed job description is obtained to assess
the patient's potential to return to work. In addi
tion, a functional capacity evaluation can be per MYELOGRAPHY
fOimed later in the rehabilitation process to as Myelography is used to indicate the status of the
sess the patient's physical demand level. nerve roots in the presence of traction injuries
to the brachial plexus. According to Leffert, root
AVOCATIONAl
avulsion can occur in the presence of a normal
Because the brachial plexus-injured patient is myelogram.2 However, a well-documented study
unable to work , avocational pursuits are often by Yeoman indicates the efficacy of myelogra
an important source of much-needed diversional phy as a valuable adjunct to the diagnosis of bra
activity. The occupational therapist questions chial plexus root lesions ]5
194 P H Y S I C A L T H E R A P Y O F T H E S H O U L D E R
for specific treatments are presented, when rele- 30°, and supination measured 50°. The patient
vant. had full pronation and wrist and finger Oexion
and extension.
HISTORY
MOTOR STRENGTH
A 25-year-old right-handed man was involved in
a motor vehicle accident and suffered a traction Motor strength was graded as follows:
lesion to his brachial plexus. Electrodiagnostic
testing indicated an infTaganglionic lesion to his Grade 0 = no contraction
left brachial plexus at Erb's joint, that portion of Grade I trace
the brachial plexus where C5 and C6 unite to join
Grade 2 = poor
the upper trunk. Radiologic studies indicated no
Grade 3 fair
fTactures at the cervical spine or clavicle. The pa
=
left arm. He reported less numbness and in laris 3, extensor carpi radialis longus and bre
=
creased strength in his left arm since the initial vis = 3 , and supinator = 3. His grip strength
injury. was 88 Ib on the right and 1 0 Ib on the left.
VOCATION SENSATION
The patient works as a carpenter. Sensation was impaired to light touch and to
sharp/dull along the lateral aspect of the left
POSTURAUVISUAL INSPECTION shoulder, in the area of the deltoid muscle, and
Atrophy was observed in the deltoid, supraspi along the radial side of the forearm.
natus, and infTaspinalUs muscles on the left com
COORDINATION
pared with the right side. His left arm was held
in internal rotation along his lateral tnmk, with Coordination was assessed using the Purdue
his forearm pronated and his wrist and fingers pegboard and rated as follows: right hand, 14;
in slight Oexion. left hand, 2; both hands, 4; assembly task, 6.
Elevation in the plane of scapula measured 1 20°, The patient had 2 + edema palpated along the
external rotation in adduction measured 30°, ex dorsum of the left fingers at the proximal inter
ternal rotation in 45° abduction measured 60°, phalangeal joints and metacarpal joints and
and external rotation in 90° abduction measured along the dorsum of the left hand. His volumetric
70°. His elbow, forearm, wrist, and hand passive measurements were 482 cc on the right and 525
range of motion were all within normal limits. cc on the left.
Elevation in the plane of scapula measured 60°, Trigger points were palpated in muscle bellies of
external rotation in adduction from full internal the left upper trapezius, left rhomboid, and left
rotation measured 20°, elbow Oexion measured subscapularis muscles.
EVALUATION A N D T R E A T M E N T O F B R A C H I A L P L E X U S L E S I O N S 197
ACTIVITIES OF DAILY LIVING IADL) rotator cuff and deltoid muscles results in in-ita
tion and trigger points in both the left upper tra
The patient was unable to perform the following
pezius and left rhomboid muscles. A trigger
self-care activities:
point palpated in the subscapularis muscle is the
result of the shoulder and arm positioned in in
Feeding-unable to cut his food.
ternal rotation and along the lateral trunk wall,
Bathil1g-unable to wash his right shoulder which maintained the subscapularis muscle in a
and upper ann. shortened position. The contracted subscapu
Groollling-unable to apply deodorant to laris muscle resulted in the greater limitation of
his right underarm. passive external rotation with the ann adducted
along the lateral trunk wall, as opposed to exter
Dressing-unable to tie shoes, bulton shirt,
nal rotation with the arm abducted to 45° or 90°.
zip pants or jacket, or buckle belt.
(R. Donatelli, personal communication.)
The weakness in the left upper extremity and
ASSESSMENT
hand resul t in a loss of normal muscle pumping
This is a patient whose history revealed a trac activity to remove interstitial fluid. In addition,
tion injury to the upper trunk of the brachial the patient tended to keep his arm down at his
plexus involving nerve trunks C5 and C6. Be side. These two factors result in increased edema
cause he demonstrated at least poor muscle con in the left upper extremity, especially the left fin
trol of the affected muscles, which is sponta gers and hand, compared with the right. The
neously improving since the initial injury, the weakness in the left upper extremity, a well as
extent of the injury is classified as between a the patient's decreased manual dexterity, inter
first- and second-degree injury, according to fered with some self-care activities. Fortunately,
Sunderland's c1assification.25 Therefore, one can the patient is right-handed, which will expedite
expect combined resolution of nerve function, his return to employment as a cm-penter.
with full return of function of the left upper ex
tremity. REHABILITATION GOALS AND TREATMENT
Passive range of motion is moderately lim
E A R L Y STAGE
ited in the affected shoulder with restrictions of
the related joint capsule, fascia, tendon, and FIRST GOAL
muscle. Soft tissue limitations are consistent The first goal is to reduce pain.
with the findings of Akeson et al..'8 Tabary et
T R E A T M E N T . Heat, low-voltage surge stimulation,
al.,39 and Cooper" a who studied the affects of
and spray and stretch (see Ch. 1 2) were applied
immobilization on periarticular capsule, tendon,
to the active trigger points in the lefI upper trape
and muscle, respectively. The loss of motor con
zius and left rhomboid muscles in our patient.
trol results in altered scapulohumeral rhythm.
Transcutaneous neuromuscular stimulation,
The rotator cuff muscles, particularly the supra
using a high-rate, low-intensity conventional set
spinatus. infraspinatus, and teres minor mus
ting with dual channels and four electrodes, was
cles, are unable to adequately control gliding of
applied around the left shoulder. The transcuta
the humeral head during elevation of the shoul
neous neuromuscular stimulation device was
der. The resultant weakness, even in the presence
worn 8 hours per day.
of a weak deltoid muscle, results in impingement
of the suprahumeral soft tissues underneath the RATIONALE. According to Travell and Simons, my
unyielding corocoacromial ligament. Chronic ofascia I trigger points in the shoulder girdle
impingement results in inflammation and de muscles refer pain into the left shoulder and arm
generation of the rotator cuff tendons. in a consistent paltern." Therefore, reduction of
Compensation of the scapula muscles to ele trigger point tenderness in the left upper trape
vate the arm in the presence of weakness of the zius and left rhomboid muscles will alleviate part
198 P H Y S I CA L T H E RAPY OF T H E S H O U L D E R
of this patient's pain. The conventional transcu ments, respectively. The scientific literature
taneous neuromuscular stimulation selling indicates no optimum time frames for applying
stimulates large A-beta sensory fibers that modu grade IV manual stretching to the perialticular
late impulses from the small A-delta and C fibers capsule. Clinically, we use three sets of I -minute
in the dorsal horn of the spinal cord.·, ·42 Pain grade IV oscillations into the restricted tissue
impulses along the A-delta and C fibers in this preceded by heat and followed by ice.
patient resulted from irritation of nociceptor
endings in the connective tissue sheaths sur THIRD GOAL
rounding the nerve fibers and trunks, due to the The third goal is to avoid neural dissociation to
traction injury.42 the reinnervating muscles.
SECOND GOAL TREATMENT. High-frequency low-volt muscle
The second goal is to restore full passive range stimulation with a pulse duration of 30 msec was
of motion and soft tissue mobility. applied to the partially denervated muscles. The
TREATMENT. 1n our patient, low-voltage surge preferred duty cycle was 1 0 seconds on and 20
stimulation followed by spray and stretch tech seconds off, for a period of 30 minutes. The pa
niques were applied to the active trigger points tient was instructed to use a home stimulator
in the muscle belly of the subscapulruis. Mobili three to four times daily.
zation techniques, in the grades III and IV range
RATIONALE. According to strength-duration stud
according to Maitland's classification, were ap
ies, muscle stimulation to a partially denervated
plied to the various joints in the left upper ex
muscle requires a higher CLuTent and longer
t remity ·J Special attention was directed at man
pulse duration than does stimulation to a nor
ual distraction of the specific details concerning
mally innervated muscle.J• In addition to main
mobilization techniques at the shoulder com
taining reinnelvating muscle tissue viability,
plex.
electrically i nduced mu cle contractions facili
Patients with this condition are given a pro
tate normal circulation, decrease edema, and
gram of range of motion self-exercises in order
present potential null-itional or tropic skin
to preserve the range of motion at those joints
changes."·45
where there is no, or only limited, active range
of motion. Each patient is given an active range FOURTH GOAL
of motion exercise program for the uninvolved
Reducing edema is the fourth goal.
joints so that these joints do not become re
stricted due to disuse of the extremity in general. TREATMENT. Retrograde massage was applied to
The patient's family should be fam i l iar with the the hand from a distal to proximal direction,
exercise program so that they can encourage the with the patient's hand and forearm elevated
patient to follow through and become active par above his healt.'· In addition, the patient and
ticipants in the patient's rehabilitation. his wife were provided with wrillen instructions
RATIONALE. In our patient, the painful limitation regarding elevation of the arnl, retrograde mas
of external rotation with the shoulder adducted sage, and first pumping to activate muscle
along the lateral trunk wall results from a con pumping action in the hand and forearm.
tracted subscapularis muscle. Therefore, spray Coban (3M Medical-Surgical, St Paul, M N )
and stretch, followed by distraction of the medial i s a gentle elastic wrap used for edema control.
scapula border, elongates the subscapularis It is wrapped diagonally from the fingertips
muscle and improves external rotation with the proximally and should overlap approximately t
shoulder in the adducted position. Mobilization in. The advantages of Coban are thaI it is reusa
techniques at the shoulder are d i rected at the in ble (thus reducing costs), may be worn for pro
ferior and anterior capsules, respectively, to pro longed periods, and allows for full range of mo
mote abduction and external rotation move- tion.47
E V A L U A T I O N A N D T R E A T M E N T O F B R A C H I A L P L E X U S L E S I O N S 199
R A T I O N A L E . Retrograde massage, in a gravity-as M I D D L E STA G E
upward pull of the deltoid muscle. Isokinetic and wrist strength. He was issued therapeutic
strengthening is instituted as soon as the patient putty and instl'llcted in hand-strengthening exer
is actively exercising with \ - or 2-lb weights. cises.
Isokinetic contraction offers the advantage of ac
SECOND GOAL
commodating resistance to maximally load a
contracting muscle throughout the range of mo The second goal is to continue mobilization to
tion SO The patient exercises at preselected the restricted joints.
speeds, beginning with slower speeds, so that he Low-load prolonged stretching using
T R EA T M E N T .
or she can consistently "catch" and maintain the surgical tubing was applied to the restricted peri
speed of the dynamometer. External rotational articular capsules, especially the anterior aspect
strengthening is emphasized early, as previously of the glenohumeral capsule, to promote exter
mentioned, to restore the dynamic glide of the nal rotation. The patient was positioned with his
humeral head along the glenoid [ossa by reestab shoulder in 45° of abduction and his elbow in
lishing strength in the supraspinatus, infraspi 90° flexion. Surgical tubing attached to his wrist
natus, and teres minor muscles. Isokinetic test provided a 30-minute low-load stretch into exter
i ng is performed every 2 to 3 weeks to assess peak nal rotation.
torque and power values of the involved com R A T I O N A L E . Using rat tail tendons, Lehman et al
pared with the uninvolved upper extremity. Iso demonstrated that the optimum method to
kinetic diagonal strengthening patterns are per stretch pericapsular tissue is to use low-load pro
fanned initially supine, to eliminate the affect longed stretch.5I According to Lehman et al the
of the muscles working directly against gravity. prolonged stretching allows the viscoelastic ma
Diagonal patterns are eventually performed with teral in the capsular tissue, including the water
the patient sitting or standing, after bilateral and glycoaminoglycans, to creep or to elongate
strength deficits between the left and light shoul with the tissue.
der rotators are within 20 percenl. Although not
scientifically substantiated, we have obselved THIRD GOAL
that when bilateral shoulder rotational strength If necessary, continue the third goal for edema
deficits are greater than 20 percent, impinge control.
ment of the suprahumeral soft tissues and pain,
FOURTH GOAL
du.-ing active shoulder elevation, occurs.
The fourth goal is to reevaluate the use of assis
OCCUPATIONAL T HERAPY. In occupational therapy. tance-providing devices and to modify the use of
our patient worked on tabletop activities with his these devices.
left upper extremity supported. The activities
F1FfH GOAL
were directed toward strengthening his elbow,
forearm, and wrist musculatul·e. For example, he Increasing coordination is the fifth goal.
transferred pegs from one bucket placed in fTont TREATMENT. As our patient's motor performance
of him to a bucket placed to his far left. This improved, coordination activities became an in
activity required active elbow flexion and exten tegral part of his treatment program. Initially,
sion in a gravity-eliminated position. As his the activities focus on such gross motor skills as
shoulder strength improved, he was able to per placing large pegs into a bucket while being
form this same activity unsupported. Addition timed and, later, placing those same pegs into a
ally, he was able to stack cones, which required pegboard. As he continued to improve, the activi
active shoulder abduction against gravity. He ties required more fine motor skills, such as ma
used light weights to strengthen WTist flexion and nipulating nuts and bolts (graded from large to
extension, supination, and pronation. Elastic small), practicing on an ADL board, turning
I'lIbber tubing, such as Theraband ( Hygenic, coins and so forth. All activities were timed to
Akron, OH), was used at home to improve elbow document progress. Trombly and Scott state that
E V A L U A T I O N A N D T R E A T M E N T OF B R A C H I A L P L E X U S L E S I O N S 201
in order to increase coordination, activities safely and accurately perform his job. At that
should be graded along a continuum rTom gross time, the patient started on woodworking
to rine and that as the patient's coordination im projects that required minimal rine motor tasks
proves, the activities should require faster speeds sanding, staining. At 1 5 months, he progressed
and more accuracy.52 to work.ing on more intricate projects and, at 1 8
months, he returned to work.
LATE STAG E
FIRST GOAL
CASE STUDY 2
The flrst goal in the late stage is to optimize mus
The second case study presents a pattern or in
cle strengthening within the constraints of rein
jury that occured to the lower portion or the bra
nervation.
chial plexus K\umpke. lnitial rindi ngs are deline
TREATMENT. Isokinetic strengthening is contin ated in the clarifying evaluation and should be
ued to all major arrected muscle groups in the compared and contrasted to the findings in Case
left upper extremity. Rotational and diagonal Study I . Goals, phases or treatment, and princi
strengthening at the shoulder is continued. Fast ples of treatment are similar to Case Study I and
speed training, at 1 80·/s, is added when bilateral have been omitted to avoid redundancy.
slow-speed dericits, at 60·,s, are within 20 per
HISTORY A
cent. The patient is instructed in an aggressive
home strengthening program using adjustable 42-year-old male construction worker was work
curf weights. Functional training, including l i rt ing on a scafrold, slipped, and grabbed a ra iling
ing, carrying various-size weights, hammering, with his right hand. The result was a forcer·tli
and sawing activities, is instituted. upward pull or the arm. This injury occured ap
RATIONALE. Strengthening in the clinic is contin proximately 7 weeks ago. The patient reports
ued ir the patient continues to exhibit strength numbness and tingling along the ulnar border or
gains with periodic isokinetic strength retests. his right arm into the fourth and fifth ringers. He
Fast-speed training is instituted to improve mus reports occasional burning pain along the same
cular endurance. Fast-speed training is not insti distribution as well as along the lower portion
tuted until slow-speed bilateral deficits are of his right neck. He l·epol·ts weak.ness in his right
within 20 percent. We have observed clinically grip. He also has slight "drooping" of his right
that, in the presence or slow-speed, bilateral defi eyelid. A neurologist perrOlmed an EMG last
cits greater than 20 percen t, the patient cannot week that indicated increased insertional activ
consistently "catch" and maintain the faster ity within the medial finger and wrist flexors and
speeds or the dynamometer. Functional training intrinsic hand muscles. A diagnosis or a second
ror this particular patient is designed to simulate degree/third-degree lower trunk brachial plexus
the working conditions and motor requirements injury was made. The patient was given nonsteri
or carpentry. odal anti-inflammatory medication and refelTed
to a program of physical and occupational
SECOND GOAL therapy.
Optimizing joint and soft tissue mobility is the
VOCATION
second goal.
The patient is a construction worker and is right
THtRD GOAL
hand dominant.
The third goal is to help the patient return to
work. POSTURAL!VISUAL INSPECTION
TREATMENT. At I year postinjury, a job analysis Mild atrophy was observed in the intrinsic mus
was done to identify those tasks the patient cles of the right hand. A mild c1awhand deror
would need to perrorm in order to be able to mity was observed and characterized by hyper-
202 P H Y S I C A L T H E R A P Y O F T H E S H O U L D E R
extension of the fourth and fifth digits at the eyelid indicated a potential sympathetic compo
metatarsal-phalangeal joints and flexion of the nent (Homer's syndrome) and the
interphalangeal joints. physical/occupational therapist should monitor
the condition carefully for sympathetic dystro
ACTIVE AND PASSIVE RANGE OF MOTION phy in the right hand. Fibrillation potentials with
EMG examination combined with clinical test
Mild to moderate restriction in flexion of fourth
ing that produced a minimum strength grade of
and fifth metatarsal-phalangeal joints and exten
3 in all affected muscle groups indicated a proba
sion of fourth and fifth interphalangeal joints.
ble partial denervation of muscles affected by C8
MOTOR STRENGTH
and T 1 nerve roots. The extent of the injury was
therefore diagnosed as a second degree (rule out
The patient's muscles were graded as follows: third degree) [axonotmesisl with Wallerian deg
flexor carpi ulnaris 3 + , medial half of flexor
=
neration of some muscle fibers but probable
digitorum profundus 3, opponens digiti min
=
preservation of the endoneurial tube. Sponta
imi = 3, abductor digiti minimi 3, flexor digiti
=
neous recovery will occur in case ofaxonotmesis,
minimi = 3, interossei muscles 3, medial lum
=
but axonal outgrowth takes a long time in these
bricales (fourth and fifth digits) 3, flexor pol
=
cases (at least a year) due to the limited growth
Iicis brevis = 3 + , and adductor pollicis brevis rate and the long distance to their target muscles.
= 3. A comprehensive program of both physical and
occupational therapy based on a phased ap
SENSATION
proach outlined in the initial case is indicated;
Sensation was impaired to light touch and as with all lower trunk brachial plexus injuries,
sharp/dull along the ulnar side of the arm, fore a comprehensive hand therapy program should
arm, and hand. Special tests: Froment's sign was be designed by a certified hand therapiSt. Peri
equivocal; the patient was asked to grasp a piece odic electromyographic evaluations should be
of paper between the thumb and index finger. performed to check for reinneravation charac
With full paralysis of the adductor pollicis brevis, terized by pol phasic action potentials. If signs
the thumb would flex; however, only slight flex of recovery fail to appear after 1 year, surgical
ion was produced when the paper was pulled exploration should be performed.
away.
EDEMA
Summary
1 + edema along the dorsum of right hand; the
hand was slightly cool to palpation, but no
The case studies illustrate the problem-solving
trophic changes were noted.
approach to patient treatment. Signs and symp
toms evaluated during the c1a" ifying evaluation
The Purdue peg board indicated coordination
are prioritized in order of their clinical signifi
deficits in the right hand; ADL assessment indi
cance. Treatment is divided into three phases to
cated d i fficulties in self-care similar to those out
allow the clinician to establish appropriate goals
lined in Case Study I .
within the constraints of nerve reinnervation.
The patient is progressed through each phase
ASSESSMENT
based on continued re-evaluation of signs and
The pathomechanics of injury involved an up symptoms. The patient is discharged when clini
ward traction injury of the right limb that af cal tests and evaluation indicate no further im
fected the lower portion of the brachial plexus, provement in motor capabilities. The patient is
as desc,-ibed by Stevens. Lower plexus injuries discharged on a home program and is periodi
affect nerve roots C8 and T I . Ptosis of the right cally reevaluated. Treatment is resumed if re-
E V A L U A T I O N A N O T R E A T M E N T OF B R A C H I A L P L E X U S L E S I O N S 203
evaluation confirms additional signs of mOlOr re movements. A roentgenographic study. J Bone
innervation. A combined physical and Joint Surg 48A: I 503, 1 966
occupational therapy approach recognizes the I S . Poppen NK, Walker PS: Normal and abnOlmal
mOlion of the shoulder. J Bone Joint Surg 58A:
potential of significant long-term dysfunction of
1 95, 1 976
the patient's upper extremity.
1 6. Inman VT, Ralston HJ, Saunders J B et al: Relation
of human electromyograms to muscular tension.
Electroencephalogr Clin Neurophysiol 4: 1 87,
References 1 952
1 7. Kendall HO, Kendall FP, WadsWOI'lh GE: Mus
cles: Testing and Function. 2nd Ed. Williams &
I . Williams PL, Wanvick R: Gray's AnalOmy. 36th
Wilkins, Baltimore, 1 97 1
British Ed. Churchill Livi ngstone, Edinburgh,
1 8. Stevens J H : Brachial plexus paralysis. p. 344. I n
1 980
Codman E A (ed): The Shoulder. Krieger Publish,
2. Leffel·t RD: Clinical diagnosis, testing, and e1ec
ing, Melbourne, 1 937
tromyographic study in brachial plexus traction
1 9 . Guven 0, Akbar Z, Yalcin S, Gundes H: Concomi,
injuries. Clin Orthop Rei Res 237:24, 1 98 8
tant rotator cuff tear and brachial plexus injury
3. Sunderland S: Traumatized nerves, roots and gan·
in association with anterior shoulder dislocation:
glia: musculoskeletal factors and neuropathologi.
unhappy triad of the shoulder. J Ol'lhop Trauma
cal consequences. p. 1 37. In Kon' 1 M (ed): The
Neurobiologic Mechanisms in Manipulative 8:429, 1 994
Therapy. Plenum, New York, 1 978 20. Wang KC, Hsa KY, Shik CH: Brachial plexus in,
4. Framptom VM: Management of brachial plexus jury with erect dislocation of the shoulder. 011hop
S. Alnot JY: Traumatic brachial plexus palsy in the 2 1 . Travlos J, Goldberg I, Boorne RS: Brachial plexus
adult: retro· and infTaclavicular lesions. Clin Or· lesions associated with dislocated shoulder. J
thop Rei Res 237:9, 1 988 Bone Joint Surg 72B: 68, 1 990
6. Silliman JT, Dean MT: Neurovascular injuries to 22. Della Santa D, Narakos A, Bonnard C: Late lesions
the shoulder complex. J Ol1hop SPOl'tS Phys Ther of the brachial plexus after fracture of the clavicle.
1 8:442, 1 993 Ann Chir Main Memb Supcr ( France) 1 0:53 1 ,
7. Comtet JJ, Sedel L, Fredenucci IF: Duchenne-Erb 1 99 1
palsy: experience with direct surgery. Clin Orthop 23. Stromquist Lidgren L, Norgren L , Odenberg S:
Rei Res 237 : 1 7, 1 988 Neurovascular injury complicating displaced
8. Blunelli GA, Blunelli GR: A foul1h type of bra proximal fractures of the humerus. injury 1 8:423,
chial plexus injury: middle lesions (C7). Ital J 01' 1 989
thop Traumatol (Ausllia) 1 8:389, 1 992 24. Blom S, Dahlback LO: Nelve injuries i n disloca
9. Mumenthaler M. Narakas A, Gilliat RW: Brachial tion or the shoulder joint and rractures or the neck
plexus disorders. p. 1 325. In Dyck PJ, Thomas PK. of the humelus. Acta ChiI' Scand 1 36:46 1 , 1 970
Lambel1 EH. Bunge R (eds): Peripheral Neuropa 25. Sunderland S: Nerves and Nerve Injuries. 2nd Ed.
thy. Vol. 2. WB Saunders, Philadelphia, 1 984 Churchill Livi ngstone, Edinburgh, 1 978
1 0 . Markey KL, DiBendello M. Curl WW: Upper llunk 26. Bruxelle J, Travers V , Thiebaut JB: Occun'ence
brachial plexopathy. The sti nger syndrome. Am J and treatment of pain arter brachial plexus injury.
SP0l1S Med 2 1 :650, 1 993 Clin 011hop ReI Res 237:87, 1 988
I I . Hershman EB, Wilbourn AJ. Bergfeld JA: Acute 27. Janda V: Muscles, central nervous motor regula·
brachial neuropathy in athletes. Am J Sports Med tion and back problems. p. 29. In KOIT 1M (cd):
1 7:655, 1 989 The Neurobiologic Mechanisms i n Manipulat ive
1 2. Speer KP, Bassett FH [ 1 1 : The prolonged burner Therapy. Plenum, New York, 1 978
syndrome. Am J Spol1S Med 1 8:59 1 , 1 990 28. Akeson WH, Amiel D, Mechanis GI et al: Collagen
1 3 . Inman VT, Saunders M , Abbot LC: Observations cross-linking alterations in joint contractu res:
on the function of the shoulder joint. J Bone Joint changes in the reducible cross-links in pcTiar1icu·
Surg 26A: I , 1 944 lar connective tissue collagen arter nine weeks or
1 4. Freedman L, Munro RR: Abduction of the arm immobilization. Connect Tissue Res 5: 1 5, 1 977
in the scapulat· plane: scapular and glenohumeral 29. Highet WB: Grading or motOI- and sensory recov·
204 P H Y S I C A L T H E R A P Y O F T H E S H O U L D E R
ery i n nelVe injuries. p. 356. In Seddon HJ (ed): 4 t . Lampe GN, Mannheimer JS: Stimulation Charac
Peripheral Nerve Injuries. Medical Research teristics of T.E.N.S. FA Davis, Phi ladelphia, 1 984
Council Rep0l1 Sel'ies T2 282. Her Majesty's Sta· 42. Guyton AC: Organ Physiology: Structure and
tion..,), Office, London, 1 954 Function of the Nervous System. 2nd Ed. WB
30. Daniels L, W0I1 hingham C: Muscle Testing. Tech· Saunders, Philadelphia, 1 976
niques of Manual Examination. 4th Ed. WB Saun 43. Maitland GD: Peripheral Manipulation. 2nd Ed.
ders, Philadelphia, 1 980 ButienvOl1hs, London, 1 977
3 1 . Hamm NH, Curtis D: Nonnative data for the Pur 44. Gutman E, Guttman L: Effects of electrotherapy
due pegboard on a sample of adult candidates for on denclvatcd muscles i n rabbits. Lancet t : 169,
vocational rehabilitation. Percept MOl Skills 50: 1 942
309, 1980 45. Hatano E et al: Electrical stimulation on dener
32. Travell JG, Simons DG: Myofascial Pain and Dys· vated skeletal muscles. p. 469. In Goria A (cd):
function. The Tr;gger Point Manual. Williams & Posttraumatic Pel-ipheral NClvc Regcneration:
Wilkins, Baltimore, 1 984 Expedmental Basis and Clinical Implications.
33. Janda V: Some aspects of extracranial causes of Raven PI"CSS, New York, 1 98 1
facial pain. J Prosthet Dent 56:4, 1 986 46. Reynold C: The stiff hand. p . 95. In Malick H ,
34. Bil bey JH, Lamond RG, MaLLrey RF: MR imaging Kasch M (cds): Manual o n Management o f Spe
of disorders of the brachial plexus. J Magn Reson cific Hand Problems. AREN Publication, Pitts
burgh, 1 984
Imaging 4 : 1 3 , 1 994
47. Enos L, Lane K, MacDougal B: Brief or new: the
35. Yeoman PM: Cervical myelography i n traction in
use of self-adherent wrap in hand rehabi litalion.
juries of the brachial plexus. J Bone loint Surg
Am J Occup Ther 38:265, 1 984
50B:25, 1 968
48. Trombly C, SCOll A: Occupational Therapy for
36. Bufalini C, Pesalori G: Posterior cervical electro
Physical Dysfunction. Williams & Wilkins. Balti
myography in the diagnosis and prognosis of bra
more, 1 977, p. 7 1
chial plexus injuries. J Bone Joint Surg 5 1 B:627,
49. Saha AK: Dynamic stability o f the glenohumeral
1 969
joint. Acta Ol1hop Scand 42:49 1 , 1 97 1
37. Bonney G, Gilliat RW: Sensory nerve conduction
50. Hislop HJ, Pen;ne JJ: The isokinetic concept of
after t1-aClion lesion of the brachial plexus. PI-OC
exercise. Phys Ther 47: 1 1 4, 1 967
R Soc Med 5 1 :365, 1 95 8 5 1 . Lehman JF, Masock AJ, WalTen CG, Koblanski
38. SCOll P M : Clayton's Electrotherapy a n d Actino· IN: Effect of therapeutic temperaturc on tcndon
t herapy. 7th Ed. Ball iere Tindall, London, 1 975 extensibility. Arch Phys Med Rehabil 5 1 :48, 1 970
39. Tabary JC, Tardieu C, Tardieu G, Tabary C: Exper· 52. Trombly C, SCOll A: Occupational Therapy for
imental rapid sarcomere loss with concom itant Physical Dysfunction. Williams & Wilkins, Balti
hypoextensibility. Muscle Nerve 4: 1 98 , 1 9 8 1 more, 1 984
40. Cooper RR: Alterations during immobilization 53. Hollinshead W: Functional Anatomy of the Limbs
and regeneration of skeletal muscles i n cats. J and Back. 4th Ed. WB Saunders, Philadelphia,
Bone Joint Surg 54:9 1 9, 1 972 1 976.
The Shoulder in
Hemiplegia
SUSAN RYE R SON
KATHRYN LEV J T
Hemiplegia, a paralysis of one side of the body, faclOrs influencing both humeral mobility and
occurs with strokes or cerebrovascular accidents humeral stability in the glenoid fossa:·5 and (3)
involving the cerebral hemisphere or brain stem. the muscular attachments of the shoulder-girdle
Although hemiplegia is Lhe classic and most ob complex."· Because muscles that move the sca
vious sign of neurovascular disease of the brain, pula and humerus have attachments to the cervi
it can also occur as a result of cerebral tumor or cal, thoracic, and lumbar spine, and to Lhe rib
trauma. I cage, a loss of motor control and alignment will
One of the most worrisome physical prob have multiple effects on the shoulder girdle.
lems for clients with hemiplegia is the shoulder. 2
Shoulder pain, subluxation, loss of muscular ac
tivity, and loss of functional use are the most Abrwrmal Bimnechanics
common complainLs. These problems can be
avoided with proper assessment and treatment The loss of motor conLrol of the shoulder in pa
and can be ameliorated if they already exist. This tients with a hemiplegia affects the operation of
chapter reviews biomechanical and motor con normal biomechanical principles. In hemiplegia,
trol impairments and presents a fTamework for three factors prevent normal shoulder biome
the clinical management of Lhese shoulder prob chanical patterns from occurring: loss of muscu
lems in hemiplegia. lar control and the development of abnormal
movement patterns; secondary soft tissue
changes that block motion; and glenohumeral
Normal, SIuru.lder Girdi£ joint subluxations. These Lhree factors combine
to allow at least three distinct types of shoulder
Mechanics and arm dysfunction.
205
206 PHYSICAL THERA PY OF THE SHOULDER
� J..
�
!J
~
�: \ \
�
,
,
�
A
\ \ B
c o
FIGURE 8.4 (A) Nonnal glel10humeral aligl1mel1t. (B) II1{eriol' glel10humeral joil1t sublllxatiol1.
(C) Al1Ierior glel10humeral joint subluxation. (D) Superior glenohumeral joint subluxatioll.
THE SHOULDER IN HEMIPLEGIA 209
into nexion or abduction results in simultaneous humerus in relative abduction. With humeral ab
scapular abduction. duction, the shoulder capsule is lax superiorly,
and the head of the humerus can slide down the
glenoid fossa4
SHOULDER SUBLUXATION
With scapular downward rotation, the gle
Shoulder subluxation occurs in hemiplegia noid fossa orients downward and the passive
when any of the biomechanical factors contrib locking mechanism of the shoulder joint, as de
uting to glenohumeral stability are disturbed. scribed by Basmajian,6 is los!. The loss of this
The most important factor is the position of the mechanism, the loss of postural tone, and the
scapula on the thorax. The scapula is nOl-mally loss of tension of the shoulder capsule result in
held on the thorax at an angle 3D· from the fTon an inferior humeral subluxation of the hemiple
tal plane.' When the slope of the glenOid fossa gic shoulder.
becomes less oblique and no longer faces up When the body is in an upright position, the
ward, the humerus "slides down" the slope of the weight of the paretic arm and upper trunk will
fossa, and inferior subluxation, the subluxation cause the spine to curve with the concavity to
most fTequently mentioned, occurs'·6 the hemiplegic side or to Oex forward (Fig. 8.5).
Two other forms of subluxation exist in the This laterally flexed position of the spine places
hemiplegic shoulder: anterior and superior sub the scapula lower on the thorax, with inferior
luxation. Each of these subluxations have down angle winging. As motion return occurs and the
ward-rotated scapulae, as does the inferior sub upper trapezius and levator scapular become ac
luxation, but the other scapula and humeral tive, an inferior subluxation may be found with
planes of movement vary (Fig. 8.4). These sub an elevated scapula. In either case, the humerus
luxations are discussed in detail in the next sec
tion.
Subluxation is not painful as long as the sca
pula is mobile.7 However, the subluxed shoulder
should not be allowed to progress into a painful
shoulder with loss of passive range of motion
(ROM).
Type 1 Ann
With a severe loss of muscular activity, head
and trunk control are virtually absent. This loss
of trunk control results in increased lateral trunk
Oexion on the hemiplegia side.
The scapula in these patients is downwardly
rotated for one or more of the following reasons.
First, the loss of scapular muscle activity allows
the scapula to lose its normal orientation on the
thorax and rotate downward (the superolateral
angle moves inferiorly). Second, loss of trunk
control results in increased lateral trunk Oexion.
The scapula, moving on this laterally Oexed
trunk, becomes relatively downward rotated,
and the glenoid fossa faces inferiorly.3.4 Third, FIGURE 8.5 Type I, left hemiplegia: fonvard
the weight of the arm, if not supported, will pull flexiol1 of IrLlI1k with flaccid aI'''' influencing
the weakened scapula downward and place the scapLlla position.
210 PHYSICAL THERAPY OF THE SHOULDER
FIGURE B.6 (A) Type I, left hemiplegia: left side o( body (allil7g laterally into gravity, scapula
lower 01'1 thorax. (B) Type I, left hemiplegia: humerus hangs by the side in il'llemal rotatiol7,
elbow extension, and (oreann prO/1Qtiol7.
will hang by the side in internal rotation, the long standing, scapular elevation with humeral
elbow will extend passively, and the forearm will internal rotation may be the only movement
pronate (Fig. 8.6). available.
With an inferior subluxation, the humeral Soft tissue tightness is found in both sections
head is located below the inferior lip of the gle of the pectoral muscles, and posteriorly in the
noid [ossa. As subluxation occurs, the shoulder rotator cuff and the insertion of the latissimus
capsule is vulnerable to stretch, especially when dorsi muscle.
the humerus is hanging by the side of the body.
In this position, the superior portion of the cap R E DUCTION OF INFERIOR SU B L UXATION. To re
sule is taut.' The weight of the dependent hume duce an inferior subluxation, the scapula must
rus will place an immediate stretch on the taut first be upwardly rotated to neutral and moved
capsule. Over time, the superior portion of the to its normal position in the frontal plane (ele
capsule will become permanently lax." vated if low on the rib cage and depressed if high
When subluxation occurs, the movement on the rib cage). The humerus is then moved to
possibilities are limited owing to the mechanical neutral fTom internal rotation and lifted up into
position of the humeral head. Any movement the fossa. Care must be given to keep the spine
that occurs will not follow the rules of scapulo aligned vertically during the subluxation reduc
humeral rhythm. With an inferior subluxation of tion.
THE SHOULDER IN H E MIPLEGIA 211
Biochemical shoulder problems resulting influenced mechanically by this db cage devia
from this type of arm include tion. The downward-rotated scapula begins to
move superiorly on the thorax, and the humerus
I. Downward rotation of the scapula hyperextends with internal rotation. The gleno
2. Vertebral border and/or inferior angle wing humeral joint will sublux anteriorly. With an an
ing of the scapula terior subluxation, the humerus is internally ro
3. Inferior glenohumeral joint subluxation tated and positioned inferior to and forward of
4. Humeral internal rotation the glenoid fossa (Fig. 8.4B). The humeral head
appears aJigned with the acromion in the sagittal
plane, resulting in an apparent shortening of the
length of the clavicle. As the humeral head moves
Type /I Ann forward out of the socket, the distal end of the
The second pattern develops as the trunk humerus moves into hyperextension. Infel-ior
gains more extension control than flexion con angle or vertebral border winging of the scapula
trol. An increase in cervical and lumbar exten will occur.
sion is evident. The head and neck assume a posi This combination of lib cage rotation and
tion of ipsilateral flexion and contralateral humeral hyperextension allows the elbow to flex
rotation. At the thoracic level, this imbalance re and the forearm to pronate (Fig. 8.8). As the sca
sults in a unilateral loss of control of the abdomi pula continues to elevate on the thorax, and the
nals. Therefore, the rib cage loses its abdominal subluxed, internally rotated humerus moves into
"anchor" and will flare laterally and/or rotate stronger hyperextension, the humeral head pro
(Fig. 8.7). The scapula and humerus are strongly trudes forward against the proximal end of the
FIGURE 8.7 (A & B) Type II, left hemiplegia: loss of rib cage al1chor with rib cage rotated
coracoid process in a superior subluxation. The 1110tion available in shoulder elevation, I",meral
humerus is tightly held in internal rotation and abduction, internal rotation, al1d elbow flexion.
abduction, so that the elbow joint lies directly
below the shoulder in the frontal plane but is
abducted away from the rib cage. tion; it must be lowered, rotated upward, and
Passive motion of the glenohumeral joint is adducted. The humerus is externally rotated to
severely limited because the humeral head is neutral, using slight traction if necessary. Exter
lodged under the coracoid process. Although the nal rotation of the humerus is then combined
deltoid and biceps attempt to initiate humeral with horizontal adduction of the distal humerus
motion, no dissociation occurs between the hu as the humeral head is brought back into the
merus and scapula. During attempts to move, fossa.
these patients typically "fire" strongly in this ele Biomechanical shoulder problems resulting
vation-abduction-internal rotation pattern, from this type of arm include
with elbow and wrist flexion (Fig. 8.10). By in
creasing humeral internal rotation, patients can I. Scapula elevation and abduction with verte-
"lock" their elbows into elbow extension. When bral border winging
distal movement exists, it is used to reinforce the 2. Superior subluxation
active shoulder pattern. The wrist assumes a
3. Humeral internal roLation
flexed and radially deviated position. This moves
the forearm from pronation in the direction of 4. Lack of dissociation between scapula and
supination. humerus, and between scapula and rib cage
Soft tissue tightness in the deltoids, pector
als, and rotator cuff are frequent secondary com
plications. Soft tissue tightness in these groups is
often mistaken for atrophy from brachial plexus
Relatiol1ship of Subluxatiol1 to COl1lrol
injury.
The type of shoulder subluxation and the
R E D UCTION OF SUPERIOR SUBLUXATION. The mOlOr control available affect the hemiplegic pa
superior subluxation is the most difficult to re tient's ability to move the arm functionally in
duce. The scapula is returned to a neutral posi- three ways. First, the loss of antigravity postural
214 PHY SICAL THERAPY OF THE SHOULDER
tone ;lnd the subsequent pallerns of moLion re ance or improper movement pallerns. When the
turn will change the relationship of the scapula joint is improperly aligned, passive or active mo
to the trunk and the relationship of the distal tion either with or without weight-bearing will
arm to the scapula. This change in position will result in joint pain. This pain is sharp and stab
alter the anatomic relationship of the jOinls. Sec bing in nature. It is relieved immediately when
ond, the changes in bony alignment will change joint alignment is corrected. At the shoulder,
the resting length and direction of pull of the joint pain occurs when glenohumeral alignment
major muscle groups of the shoulder and arm. and rhythm is not maintained. The most fre
Biomechanically, this will lead to muscle imbal quent reasons for poor al ignment are (t) lack of
ance and problems of motor control. Third , appropriate humeral rotation during forward
changes in muscle excitation and recruitment flexion and (2) improper placement of the hu
pallerns may occur in these muscles, in which meral head in the glenOid fossa.
resting lengths have been altered. Pallerns of Treatment for this type of pain begins with
spasticity or abnormal coaclivation of muscles immediate cessation of the movement pattern.
may result in problems in any or all of these areas Forced motion with pain must never be allowed.
and will contribute to the abnormal and ineffi The movement should STOP; the limb should be
cient motor pallerns associated with hemiplegia. lowered, and the bones must be cOITectly re
Clinically, it is necessary to analyze the patient's aligned before treatment begins again. If soft tis
motor patterns to identify the segments of abnor sue orjoint tightness exists, realignment may not
mal motion. This will facilitate more effective be possible unless soft tissue or joint mobility is
treatment. improved or increased.
MuscuWskeletal C011Si.derations
SHOULDER PAIN
Join' Pain
Joint pain in hemiplegia occurs when a joint
is placed in a biomechanically compromised po FIGURE 8.1 I Left hemiplegia: body moving 0/1
oceptive stimuli. One explanation for its occur and joint contractures. Shoulder-hand syn
rence is that the levels of "tolerance" of the im drome can be prevented by a program that
paired eNS have been reached. The treatment
should stop for that session, and the duration of I. Grades the motor program in stages with in
treatment and the nature of the treatment should creasing sensitivity to movement
be noted. Subsequent treatment should be
2. Gradually but consistently uses weight-bear
graded to allow movement to continue but not ing activities for the entire shoulder girdle
to exceed the patient's sensory tolerance. If treat and upper extremity
ment is stopped completely, these patients may
proceed to shoulder-hand syndrome. 3. Reeducates open-ended activities (non
weight-bearing) with appropriate scapulo
humeral rhythm
Shoulder-Halld Syndrome 4. Prevents edema
Shoulder-hand syndrome begins with dif 5. Teaches patients how to care for their arm
fuse "aching pain" in the shoulder and entire
arm. Because this pain interferes with the desire
to move the arm, the hand soon becomes swollen
and tender. If passive motion is forced on a swol
len wrist and hand, the joints will become
sharply painful. Treat:rnent Pln.nning
The second stage is characterized by de
creased ROM of the shoulder girdle, hand, and The treatment of the deficits in motor control in
fingers. Skin changes are also present because the patient with hemiplegia focuses on the im
of the lack of motion and loss of tactile input. provement of function and the prevention of fur
The syndrome culminates with presence of ther disability from secondary complications. In
atrophied bone and severe soft tissue deformity this section, treatment objectives for the hemi-
THE SHOULDER IN HEMIPLEGIA 217
plegic shoulder will be presented in three major non-weight-bearing palterns, and (4) reeducat
categories. The first category of objectives is de ing distal movement for functional skills.
signed to help the patient releam basic postural
control. The second set of objectives focuses on
Reestablishing Nonnal Alignlllent
the neuromuscular deficits of hemiplegia: loss
of extremity motor control and function. In the It is necessary to reestablish normal align
third category, the objectives for the secondary ment before attempting to reeducate motor con
complications of hemiplegia-subluxation, trol. The shoulder girdle must be properly
pain, loss of motion, and spasticity-will be dis aligned either by lengthening shortened or spas
cussed. tic muscles or by supporting body parts that do
not have sufficient muscular activity.
REESTABLISHMENT OF POSTURAL CONTROL
Establishing Weight-Bearing
The objectives for establishing postural control
include (I) facilitating righting reactions, equi The ability to accept and bear weight on the
librium reactions, and protective reactions; and affected aIm following a stroke is one of the most
(2) providing normal tactile, proprioceptive, and important goals of a therapeutic program. Active
kinesthetic input. Before specific retraining of weight-bearing on either a partially flexed or ex
the shoulder in patients with hemiplegia can tended upper extremity is used as a means of
begin, postural control of the head, neck, and increasing mobility; increasing postural control
trunk must be present. This postural trunk con of the trunk.; improving motor control of the af
trol provides the body with the ability to shift fected arm; introducing and grading tactile pro
weight. The ability of the body to shift and bear prioceptive, and kinesthetic stimulation; and
weight to one side fTees the opposite extremity preventing edema and pain. Positions that pro
for the functions of reaching, grasping, and re vide weight-bearing for a hemiplegia shoulder
leasing. Along with sensory feedback (tactile, and arm include (I) rolling onto the affected side
proprioceptive, kinesthetic, visual, and vestibu in preparation for getting out of bed (Fig. 8.14A
lar), movement requires a base of stability or and B), (2) supporting the forearm on a pillow
base of support, a point of mobility, and a weight placed in the lap or on a lap board or on a table
shift. Weight shift, either anterior, posterior, lat when silting (Fig. 8.14C), and (3) extending the
eral, or diagonal, is followed by one or more of weight-bearing arm down onto a countertop
the following: righting reactions, equilibrium re while standing.
actions, protective reactions, or falling. The es An active weight-bearing program for the pa
tablishment of head and neck control allows the retic arm stresses "active" pattems in the trunk
shoulder girdle to dissociate or move freely from and does not allow the patient to lean or "hang"
the thorax and the humerus to dissociate from on the ligaments of the affected extremity (Fig.
the scapula. To establish good motor control, the 8.1SA and B). This active participation of the
body (trunk) must be able to adjust posture auto trunk. is accomplished by plaCing the upper ex
matically so that an upper extremity movement tremity in an aligned weight-bearing position
may achieve its purpose. and asking the trunk or "body" to move on the
stable arm in anterioposterior, lateral, and rota
tional directions (Fig. 8-1SC to H).
NEUROMUSCULAR DEFICITS
In the acute stage of hemiplegia, when very
Objectives for reestablishing motor control and little postural control is present, upper extremity
function of the hemiplegic arm include (I) rees weight-bearing is used to facilitate proximal
tablishing normal alignment, (2) establishing motor control. When the upper extremities are
normal weight-beal;ng patterns in the upper ex "fixed" onto the supporting surface through fore
tremity, (3) initiating and "holding" proximal arm weight-bearing activities, the arm becomes
218 PHYSICAL THERAPY OF THE SHOULDER
a point or stability ror movements of the trunk rotated, while the other humerus becomes more
and pelvis. As the body moves away from the internally rotated (Fig. 8.17).
arm, scapular protraction and upward rotation, For patients with available but synergistic
humeral nexion, and upper trunk nexion are en movement patlerns, upper extremity weight
couraged (Fig. 8.16A). As the body moves toward bearing can be used to lengthen or inhibit tight
the arm, scapular adduction and trunk extension or spastic muscles while simultaneously racili
are encouraged as the humerus moves into more tating muscles that are not active. When the
extension (Fig. 8.16B). When the pelvis and person sits with hands down and open, a rota
trunk move laterally, the scapulae move in oppo tional movement of the body toward the ar
site directions. one into more abduction and one fected upper extremity will lengthen tight shoul
into more adduction. The humerus on the side or der depressors and downward rotators, tight
the lateral weight shirt becomes more externally humeral internal rolatOl-S, and elbow nexors,
THE SHOULDER IN HEMIPLEGIA 219
while simultaneously activating the opposing taken out or weight-bearing and is asked to move
groups (Fig. 8.18A & B). in space, the demands on the shoulder girdle are
dirferent from weight-bearing demands. The
motor demands on the shoulder for non-weight
iI,itiatil1g and "Holdil1g" Proximal
bearing (open-ended) activities can be divided
Non-Weight-Bearing Paltems
into (I) the ability to hold the weight of the limb
When the hand or arm is placed in a position against gravity; (2) the ability to initiate antigrav
of weight-bearing, the motions of the shoulder ity movement paUerns, including the ability to
girdle occur as a reaction to the body's move switch from glenohumeral to scapulohumeral
ment over the rixed extremity. When the arm is movement as needed; and (3) the ability to recip-
A ur..o:...____
/. . �l., B c
FIGURE B . 1 6 Right hemiplegia: (A) moving body away from weight-bearing ann; (8) moving
Muscle groups that are unable to contract after but efforts to move the ann produce abnormal
the joint has been realigned need to be stimu pallerns, treatment is directed toward establish
lated. The techniques of stimulation have been ing more normal coordination. This may involve
described by Bobath and others. The techniques both inhibiting the abnormal way in which mus
are the same, although they have been ascribed cles are recmited and retraining in the COITect
different names, including joint compression pallern of motor recmitment. Problems in motor
(pressure tapping, joint approximation); resis recmitment can best be addressed by teaching
tance with proper alignment maintained; quick the patient to identify and quiet muscles that are
stretch (inhibitory tapping, "pull-push"); sweep firing inappropriately through techniques of in
tapping (bmshing, icing); and repetition. hibition or biofeedback. The patient is then
When the patient has movement available, taught to allow passive motion of the arm with
out firing muscles inappropriately or allowing
muscle tone in the ann to increase. The patient is
then encouraged to try to "follow" the movement
and finally to perform it actively with less assis
tance from the therapist. Place and hold exer
cises are useful in helping the patient use the
correct muscles at the shoulder girdle without
inappropliately firing distal muscle groups.
While new recmitment pallerns are being estab
lished, the patient is also taught appropriate con
trol of the previously "overused" muscles. Thus,
the patient learns to inhibit biceps activity when
reaching, but to use the biceps appropriately to
bling the hand to the mouth.
Patients who have less spasticity or more
complete motor return have fewer problems
with abnormal recmitment but more problems
FIGURE B. 1 7 Right hemiplegia: weight shifting to with motor control. This category of patients has
right moves right humerus into more external missing components of motor activity. Compen
rOlalion while left htllnerus begins /0 move into satol), motions resembling an abnormal pattern
Ihe direClion of inlernal rOlalion. result. For example, lack of active external rota-
222 PHY SICAL T H ERAPY OF THE SHOULDER
tion of the humenls will lead to a substitution position the hand appropriately for grasp by se
pattern of abduction, internal rotation of the hu lecting appropriate forearm and wrist positions,
menlS, and scapula elevation (Fig. 8.20). If this hold the hand in position while the fingers move,
motor pattern is being used because the patient and sustain grasp while moving proximally.
cannot actively externally rotate the humenls, Problems in any of these areas may inlerfere
the goal of treatment must be to make external with adaptive grasp.
rotation available during active shoulder move As shoulder girdle control builds, the posi
ment and to establish the ability to hold the hu tions and movements of the distal segments must
merus in external rotation while moving distally. be added in treatment so that various distal posi
Similarly, other patients may have difficulties tions are available to the patient to use function
with protraction and upward rotation of the sca ally. As new combinations of motor behavior are
pula. In this case, the therapist must control the learned, the patient should be taught a fllllc
motion of the scapula proximally to facilitate the tional task using this pattern to ensure carry-over
correct motion of the scapula while the patient from exercise into everyday life.
works on upper extremity placing or movement
sequences.
Subluxation
Acutely, if subluxation is not present, treat FIGURE 8.20 Le(t hemiplegia: lack of aClive
ment follows the objectives listed earlier under external rotation results in compensation
"Treatment Planning." If subluxation has oc pallem of humeral abduction and illtemal
cUlTed, treatment must be preceded by caref'ul rotation.
assessmenl, reduction of subluxation, and
proper support.
Proper assessment of subluxation includes Rolyan hemi arm sling, the shoulder saddle
determination of sling, and variations on the axillal)' support as
described by Bobath .'
I . The exact position of the humeral head, sca-
RolyQl1 hemi arm slil1g (Rolyan Smith and
pula, rib cage, and spine
Nephew, Inc., Menomonee Falls, WI): This
2. Mobility or passive range of motion sling has a humeral cuff and a figure eight
3. Tone suspension. It will provide moderate sup
4. Amount and location of motor control port to the humerus and allows the elbow
to be extended. The arm is free to be moved
The assessment will reveal the cause of the and used for support (Fig. 8.21B).
subluxation (loss of motor control of scapula Shoulder saddle sling (Fred Sammons, Inc.,
andior humerus, soft tissue tightness, and hypo Brookfield, IL): This sling has a forearm
tonus or hypertonus). Appropriate treatment can cuff and a shoulder saddle suspension. It
then begin. Treatment of subluxation includes provides maximum support to the entire
the following goals: arm and prevents the arm from "banging"
around during functional activities. This
I. Manual alignment and support of scapula sling is excellent for the naccid limb with
on the thorax and humerus in the glenoid pain. It allows moderate humeral and
fossa during treatment elbow movement (Fig. 8.21C).
Axillary sLipport (All Orthopedic Appliances,
2. Increase in motor control in shoulder girdle
Inc., Miami, FL): This support elevates the
muscle groups
scapula and provides minimal inferior sup
3. Inhibition of spasticity or stretching of soft port for the humerus. It should not be used
tissue tightness in patients with elevated scapulae. It has
4. Maintenance of pain-free ROM with proper been criticized for placing pressure on the
glenohumeral rhythm brachial plexus when inappropriately
5. Prevention of stretching of shoulder capsule donned (Fig. 8.210).
through proper positioning andior shoulder Because no device is available that upwardly
supports rotates the scapula, no shoulder StlPPOlt will cor
rect glenohumeral joint subluxation. Shoulder
Proper positioning can be achieved through supports will help support andior maintain posi
the use of lapboards, tables, armrests, or pillows tion on the I;b cage once the con'ection has been
when sitting; self-assisted motion during func made. Shoulder supports will also prevent the
tional activities; and weight-bearing on the fore naccid arm from banging against the body dur
arm or hand. ing functional activities, thus decreaSing shoul
der joint pain. They also help to relieve down
S HOULDER SUBLUXATION S U P P O R T S . The ward traction on the shoulder capsule caused by
shoulder should be supported in the acute stage the weight of the aim.
of hemiplegia to prevent stretch on the capsule Therapy clinics should have different types
or to eliminate pain. In the I 950s and 19605, or of shoulder SUppOl'tS available and evaluate
thopedic slings were given to patients with hemi which support provides the best protection for
plegia (Fig. 8.21A). These slings held the hume each patient.
rus against the body in internal rotation and kept
the elbow in nexion. The arm was immobilized Pain
and the patient was unable to see the arm or try The causes of shoulder pain have been de
to use the aim even for support. In the 1970s scribed in detail. Treatment of the painful shoul
and 1980s, alternative slings were produced: the der and arm should include
THE SHOULDER IN HEMIPLEGIA 225
A c
B o
FIGURE B.21 (A) Orthopaedic sling. (B) Rolyal7 hemi anll sling. (C) Shoulder saddle sling. (D)
Axillary support.
t . Immediate cessation of any movement or ac (passively) or by the client actively (this in
tivity that causes or increases the pain cludes lengthening or inhibition of the short
2. Removal of edema, if present ened or spastic muscle groups and realign
ment of malaligned joints)
3. Realignment of the shoulder girdle/trunk
complex either by the therapist manually 4. Reeducation of the inactive muscle groups
226 PHY SICA L THERAPY OF THE SHOULDER
Patients with a diagnosis of frozen shoulder are working definition of frozen shoulder; and (3) to
commonly seen in the physical therapy depart present evaluative and treatment procedures for
ment. Unfortunately, frozen shoulder is often a fTozen shoulder. 1 hope that the reader can read
"catch-all diagnosis"I .2 that can imply many ily apply this information to clinical practice,
shoulder problems. In the literature, conf"usion thereby improving patient care.
abounds on the subject of frozen shoulder. First,
there is no consensus on the name of this clinical
entity. Some of the more common terms that are
synonyms for frozen shoulder are adhesive cap lJiterature ReIJiew
sulitis, periarthritis, stiff and painful shoulder,
periarticular adhesions, Duplay's disease, scapu Frozen shoulder is loosely defined as a painful
lohumeral periarthritis, tendinitis of the short stiff shoulder. I This definition appears to be
rotators, adherent subacromial bursitis,3 painful more of a description of symptoms than a diag
stiff shoulder, bicipital tenosynovitis, subdeltoid nosis.' McLaughlin states that frozen shoulder
bursitis, humeroscapular fibrositis, shoulder is a popular medical colloquialism and not a di
portion of shoulder-hand syndrome, bursitis agnosis.' In this literature review, a working defi
calcarea, supraspinatus tendinitis, periarthrosis nition of ["ozen shoulder will be established.
humeroscapularis, and a host of foreign lan
guage terms' PATHOLOGY AND DEFINITION
Confusion in terminology probably reflects
the confusion in the definition, pathology, etiol Historically, Duplay6 in 1872 was first credited
ogy, and treatment of this clinical entity that is with describing the painful stiff shoulder, refer
so evident in the literature. One of the difficulties ring to the condition as hl.ll11eroscapu/ar peri
in reviewing the literature of evaluation and arthritis (periarthritescapulohumerale) second
treatment of frozen shoulder, the main thlUst of ary to subacromial bursitis. In 1934, Cod man 7
this chapter, was that few studies defined frozen coined the term frozen shoulder, attributing the
shoulder in the same way. As a result, inconsis painful stiff shoulder to a short rotator tendini
tencies in patient selection based on their varied tis. Cod man devoted only nine pages of his text
definitions made it difficult to assess the value of book on the shoulder to frozen shoulder, sum
the treatment being examined. In addition, most marizing this condition as difficult to define,
studies did not discuss the evaluative procedures explain, and treat. In 1945, Neviaser' surgically
used to reach the diagnosis of fj'ozen shoulder. explored 10 cases of frozen shoulder, finding ab
The goals of this chapter are (I) to present a liter sence of the glenohumeral synovial nuid and the
ature review of the pathology, etiology, and clini redundant axillary fold of the capsule, as well as
cal features of frozen shoulder; (2) to establish a thickening and contraction of the capsule, which
257
258 P HYSIC A L T H ER A P Y O F T H E S H O UL D E R
had become adherent to the humeral head, thus, shoulder confirmed the above clinical findings,
he used the term adhesive capsLllitis. As Neviaser showing evidence of degeneration of the supra
rotated these shoulders, it appeared at first as if spinatus tendon with hyperemia, a definite in
the humeral head and capsule were glued to flammatory reaction.
gether but could be separated with one or two Similarly, in 1973, Macnab'3 illustrated that
rotational movements, thus freeing joint move degenerative changes in the supraspinatus oc
ment. Microscopic examinations in all 10 cases CUlTed first at the zone of impaired blood supply
revealed reparative inflammatory changes in the where the tendon passes over the humeral head.
capsule. Based on this work, Neviaser suggested This area is relatively avascular, as the humeral
that adhesive capsulitis described ule pathology head pressure on the tendon "wlings out" the
of frozen shoulder. blood vessels. The lack of circulation in this area
In 1938, McLaughlin' reported that in surgi could cause degeneration of the supraspinatus
cal exploration of a number of frozen shoulders, tendon. The degeneration process produces a
he found no histologic evidence of inflammation. local ilTitation of the tendon. In response to tis
He (00 observed a loss of the inferior redundant sue inflammation, the body produces antibodies
fold, but the adhesions between the folds were affecting the adjacent rotator cuff tendons. This
easily separated and separation did not increase autoimmune reaction produces a diffuse capsul
shoulder motion. McLaughlin consistently itis, or frozen shoulder.
found that the rotator cuff tendon was con Lippmann, 1 4 in 1943, confirmed both
tracted and shrunken, holding the humeral head Schrager and Pasteur's theory that bicipital teno
tight in the glenoid and allowing little motion at synovitis preceded frozen shoulder. In examin
this articulation. Although unsupported by ex
ing 12 surgical cases of frozen shoulder, lipp
amination, McLaughlin postulated that the tis
mann conSistently found tenosynovitis of the
sue changes in the cuff were related to collagen
long head of the biceps tendon. The tendon
stiffening. This appeared reasonable, because
sheath was typically thickened and edematous,
McLaughlin observed that prolonged disuse of
and the tendon was roughened and adherent to
the extremity preceded a frozen shoulder. He
the sheath. Lippmann proposed that the progres
recognized that the reason for shoulder disuse
sion of the frozen shoulder could be detel-mined
may be in or removed from the shoulder. Al
by the extent of tendinous adhesion: the more
though many studies cite disuse of the extremity
advanced the condition, the more adherent the
as a contributing [actor, ,·S- 1 i McLaughlin's
tendon. He attributed stiffness of the shoulder
study is one of a few that address collagen
to the upward spread of the tenosynovitis into
changes as a result of immobility in the frozen
the shoulder joint, causing adherence of the in
shoulder. Research documents that changes in
periarticular connective tissue collagen result tracapsular tendon to the capsule and the articu
from i mmobilization. The effects of immobiliza lar surface of the humeral head. Ultimately, the
tion and its relationship to frozen shoulder will intracapsular tendon would disintegrate and
be addressed later. gradual improvement of shoulder function
In 1949, Simmonds , 1 2 like Codman, pro would occur.
posed that patients with frozen shoulder exhib Turek 15 theolized that continual trauma of
ited inflammation in the rotator cuff, particu the rotator cuff and biceps tendon as they are
larly in the supraspinatus tendon. Inflammation forced against the acromial arch results in de
of the supraspinatus tendon is secondary to de generation and edema. The tendons thicken as
generative changes in the tendon caused by im a result, creating a ban-ier to humeral head
paired blood supply, as the tendon is repeatedly movement under the arch. If trauma persists,
traumatized by rubbing against the acromion healing by granulation tissue results in fibrous
process and coracoacromial ligament. Histo adhesions of the biceps tendon, rotator cuff. sub
logic examination of four patients with frozen acromial bursa, capsule, humeral head, and ac-
FROZ E N S H O U L DER 259
romion. The result is loss of motion at the gleno groove. NOImally, the rotator interval contains
humeral joint. elastic membranous tissue. With adhesive cap
DePalma 16 stated that the pathologic process sulitis, both the rotator interval and coracohu
of frozen shoulder primarily involves the fibrous meral ligament are converted into a thick fibrous
capsule. The normally flexible capsule becomes cord, which holds the humeral head tightly
nonelastic and shrunken. The mechanism re against the glenoid fossa, restl;cting humeral
sponsible for these changes is unknown. As the motion. 1 7
condition progresses, the synovial fluid, fascial More recently, several studies of the pathol
covering, rotator cuff, biceps tendon, biceps ten ogy associated with frozen shoulder have used
don sheath, and subacromial bursa can all be the arthroscope for direct viewing of the joint.
come involved. DePalma observed involvement In 1991, Hsu and Chan'o scoped 25 patients with
of these structures in various stages of frozen frozen shoulder. The authors noted synovial hy
shoulder.'6 I n the early stages, the capsule be potrophy in 10 of the cases, obliteration of the
comes contracted, with loss of the inferior capsu inferior recess in 3 cases, rotator cuff tears i n 6,
lar fold. In the later phases, i ncreased capsular and intra-articular adhesions in 4. Many patients
fibrosis occurs. The synovial membrane be had concomitant pathologies.
comes thickened and hypervascular. These tis Uitvlugt et al." in 1993 performed diagnostic
sues lose their elasticity and easily tear as the glenohumeral joint arthroscopy before and im
humerus is rotated or abducted. The coracohu mediately after manipulation on 20 patients with
meral ligament becomes a thick, contracted cord frozen shoulder. The pathologies documented
as it spans the tuberosities to the coracoid pro were vascular synovitis in all cases, with capsular
cess. The subscapularis tendon also becomes fi
contracture primarily in the anterior and infe
brotic, thereby limiting shoulder external rota
I-ior capsule. Unlike Neviasar, there were no
tion. In addition to the subscapula,;s, the
intra-articular adhesions noted. The subacro
supraspinatus and infraspinatus are also tight,
mial bursa was not inspected in this study.
resulting in restricted glenohumeral motion as
Pollock et a1.22 in 1994, inspected 30 fTOzen
the head is held high in the glenoid by these fi
shoulders al ihroscopically and noted subacro
brotic tendons, thereby limiting downward hu
mial bursal adhesions i n all patients. He stated
meral excursion. The biceps tendon was found
that a contracted glenohumeral joint capsule is
to be adhered to the sheath and the groove. Like
the primary structure responsible for frozen
Lippmann, 1 4 DePalma 1 6 speculated that once
shoulder.
the gliding mechanism of the biceps tendon is
In 1991, Wiley'3 treated 37 patients with fro
gone as the tendon becomes anchored to the hu
zen shoulder using ar throscopy. He noted a vas
meruS by adhesions, shoulder function begins to
return. cular reaction around the biceps tendon and the
Like DePalma, Ozaki et al.,'7 Neer et aI., IS subscapularis bursa opening. He found no intra
and Kieras and Matsen" have cited a shortened al iicular adhesions or obliteration of the inferior
coracohumeral ligament as contributing to a fro recess. Noteworthy in this study is the careful
zen shoulder. Ozaki also noted contracture of the patient selection, including only those with "pri
rotator interval and joint capsule in his study but mary" frozen shoulder. Primary frozen shoulder
found no intra-articular adhesions. as defined by Lippmann are those patients with
The rotator interval is a space between the no findings i n the history, clinical examination,
anterior border of the supraspinatus and the su or radiographs that could explain the decreased
perior border of the subscapularis. The coraco range of motion. ' 4 Wiley also used local anes
humeral ligament originates from the coracoid thetic blocks, CT scans, and arthrograms to rule
process and passes forward and downward in the out other pathologies such as rotator cuff tears
rotator interval to insert with the joint capsule or impingement that could be at fault. Patients
into both tuberosities, bridging the bicipital with these later pathologies are classified as hav-
260 P H Y SI C A L T H ER A P Y OF T H E SHOULD ER
ing "secondary" frozen shoulder 1 4 and were ex procedure, Cyriax obser ved that patients with
cluded from this study. "arthritis" causing glenohumeral stifFness have
Rizk et a!. 24 selected 2 1 patients with "idio pain and limitation of movement with active and
pathic adhesive capsulitis" to examine under passive testing only. Resisted testing is negative,
arthrography. Like Lippmann, Rizk classified thereby ruling out any of the contractile struc
these patients as having no history of trauma, no tures previously mentioned as the cause of fro
neurologic, bony, or arthritic condition to ac zen shoulder.
count for the limited and painful shoulder. Dur Limitation in both active and passive gleno
ing arthrography, Rizk noted a loss of joint vol humeral movement has been observed by oth
ume due to a constricted capsule, serr'ations of ers.B·9,26-28 Cyt;ax25 funher clarifies that arthri
the synovium, non filling of the bicipital tendon tis exhibits limitation of passive motion in
sheath, and obliteration of the subscapular or characteristic proportions, which he calls the
axillary recesses. Like Wiley, he found no intra capsular pattern. The capsular pattern of frozen
or extracapsular adhesions. shoulder is most limited in external rotation, fol
Various pathologies have been postulated to lowed by abduction, and then by internal rota
be the cause of frozen shoulder. Both contractile tion. Both Neviaser' and Kozin26 noted limita
and noncontractile structures have been incrimi tions in these same motions. Others observed
nated. Cyriax25 has outlined an examination that loss of glenohumeral movement in all direc
differentiates a contractile from a noncontractile tions I2, 1 5,24.29,30, in external rotation and abduc
element in shoulder dysfunction. Cyriax states tion only," and in abduction, external rotation,
that the term (rozen describes a symptom of stiff and flexion.32.33
ness and not a pathology. According to Cyriax, Reeves" substantiated the capsular pattern
frozen shoulder is arthritis, which implies that in arthrograms of 17 patients with frozen shoul
the entire glenohumeral joint capsule is affected, der. He consistently noted that more contrast
limiting both active and passive movement. dye was deposited posteriorly than in any other
His examination includes selective tension areas of the joint capsule, and that the joint ca
testing of the shoulder complex whereby differ pacity was grossly reduced and the inferior cap
ent structures are stressed by active, passive, and sular fold, subscapularis bursa, and biceps
resisted motions to determine the site of the le sheath were obliterated. Therefore, based on the
sion. Both contractile elements (muscle, tendon, arthrokinematics of shoulder motion, it follows
tendoperiosteal unit, and musculoperiosteal that if the anterior capsule were more contracted
unit) and noncontractile or inert elements (liga than the posterior capsule, external rotation
ments, synovial membrane, jOint capsule, articu would be more limited than internal rotation. In
lar sUlfaces, bursa, dura , Fascia, nerve root, and addition, abduction would be limi ted by the loss
fat pads) are tested. of the inferior redundant fold and limited exter
In the examination, active shoulder motion nal rotation.
in initially tested. Although active motion may Likewise, Ozaki et a!. 1 7 found a diminished
incriminate both contractile and noncontractile joint capacity and restricted inferior axillary fold
elements, the results, when cO ITelated with pas and subscapularis bursa in 17 patients with fro
sive and resistive testing, frequently can give ad zen shoulder due to a shortened coracohumeral
ditional information about the soft tissue lesion. ligament. As mentioned, both Ozaki et al.17 and
Second, passive shoulder motion is tested to Neer et al. 1 8 substantiated that a shortened cora
evaluate the inert tissues, because the contractile cohumeral ligament limits external rotation.
elements are totally relaxed during passive test Without external rotation, abduction is also lim
ing. Last, with resisted shoulder motion, only the ited; hence the capsular pattern.
contractile elements are evaluated, because the Scienti fic research points to many different
tests are performed isometrically, thus prevent structures as the cause of frozen shoulder. One
ing joint movement. Based on this examination common observation is that the capsule be-
FRO Z E N SHOUL D E R 261
comes contracted around the humeral head. The modeling of the collagenous portion of the con
clinical observation of limited and painful active nective tissue. The cause for the increased colla
and passive motion in the capsular pallern sub gen production is unknown.
stantiates that a noncontractile structure is at Ozaki et al.'7 also noted fibrosis in the con
Faull. This, however, does nOt rule out that the tracted coracohumeral ligament and rotator in
patient may have had a contractile structure ini terval in histologic studies of 17 fTOzen shoul
tially involved and that a frozen shoulder is the ders. The end result of i ncreased fibrosis is a
end result of such a lesion. "subsequent loss of biologic properties of the
In closing, the author would like to postulate connective tissue" in the shoulder joint, namely,
a working definition for frozen shoulder as gle "loss of capsular flexibility and toughness.""
nohumeral stiffness resulting from a noncon Therefore, the clinically observed loss of shoul
tractile element. Both active and passive motion der motion resulting from disuse may be the re
is painful and restricted. Passive mobility is lim sult of underlying capsular connective tissue
ited in a capsular pallern, with external rotation changes.
being limited most, followed by abduction, and The third factor associated with the develop
then internal rotation. A frozen shoulder does ment of frozen shoulder is that of the peri
not exhibit objective findings of a contractile le arthritic personality. Some investigatorss .•.9.,.
sion unless the lesion is concurrent with a non state that psychological factors, especially
contractile lesion. depression, apathy, and emotional stress, con
tribute to frozen shoulder. Patients with peri
arthritic personalities have a low pain thresh-
ETIOLOGY
01d9; therefore, any shoulder pain will probably
Although much has been reported on the patho lead to early voluntary immobilization of the ex
genesis of frozen shoulder, its exact cause re tremity. These patients take no active role in any
mains unknown. However, certain faclors treatment, such as exercise for shoulder pain,9
pain, disuse, and a periarthritic personality-are and are therefore more l ikely to develop a more
considered to contribute to the development of severe case of frozen shoulder. Wright and
frozen shoulder. Haq:8 however, tested 1 86 patients with frozen
Pain in the shoulder can result from various shoulder and found no such personality.
intrinsic and extrinsic sources. 1 0.35-37 Whatever
the source, pain usually forces the patient to
CLINICAL FEATURES
protect the arm from use. I m mobilization of
a synovial joint has been shown to have In the literature, a few clinical features appear
detrimental effects on the periarticular connec consistently in patients with frozen shoulder.
tive l issue.38- 46 These common observations include arthro
Lundberg" examined the synovial mem graphic and radiographic findings, age of onset,
brane and fibrous layer of the anterior-inferior type of onset, and course of the condition.
capsule of 14 frozen and 13 normal shoulders. Arthrographic findings appear to be one of
He found an increased amount of hexosamine in the most prevalent characteristics of frozen
the frozen shoulder as compared with normal shoulder. So that the abnormal arthrogram may
shoulders. This difference was caused by an in be beller understood, the nOimal shoulder
crease in the total content of glycosaminoglycans arthrogram is discussed first.
(GAG), namely, an increase in heparan sulfate, The joint capsule consists of relatively loose
chondroitin-6 sulfate, and dermatan sulfate, and connective tissue with a surface area more than
a decrease in hyaluronic acid in the frozen shoul twice that of the humeral head.49 The capsule
ders. These changes in GAG content reflect a pro normally attaches to the humeral head just prox
cess of fibrosis occurring in the tissue. There was imal to the greater tuberosity, and then extends
marked fibroblastic proliferation, indicating re- medially at the level of the anatomic neck of the
262 P H Y SIC A L T H ERA P Y OF T H E SH O U L D ER
......
filling of the subscapularis bursa and bicipital retracted away {rom the ItIberosities (straight
sheath.23,24,52 .53,55,57 arrows). The axillary recess is small, and
Some investigato r s believe that arthrogra extravasation has occurred pn'or to exercise
phy is essential in diagnosing fTozen shoul (curved alTows). (From Goldman, 50 \\lith
der. 56.58-60 Others find it helpful but not essential permission.)
FROZEN SHOULOER 263
Although many studies desc,;be frozen within 2 years from the onset of symptoms, This
shoulder as being self-limiting, 12,27,30,64,65 there success was achieved with treatment of reassur
are very few documented studies of the natural ance, occasional simple analgesics, and hypno
course of frozen shoulder.29,64 Reeves29 studied sis " Lippmann and colleagues61 noted that it
41 patients with frozen shoulder for 5 to 10 years is uncommon to outwait the natural course of
(average, 30 months), always to their greatest re fTozen shoulder wiu,ollt intervention. Simon30
covery, He defined frozen shoulder as an "idio further emphasized that simply outwaiting the
pathic condition of the shoulder characterized condition does not assure the patient a full pain
by the spontaneous onset of pain with restriction less ROM,
of movement in every direction," He noted three In addition to the previously mentioned clin
consecutive stages of frozen shoulder: pain, stiff ical features, others are found with less consis
ne s, and recover y. The total time for greatest tency, Opinion varies on their relationship to the
recovery was between 1 and 4 years after the incidence of frozen shoulder, These features in
onset of symptoms, More than half of the pa clude sex, side involved, occupation (manual ver
tients had permanent loss of shoulder motion, sus sedentary),27,48 the presence of immunologic
as compared with the uninvolved "normal" factors such as H LA_B27,58 . serum IgA lev
shoulder's range of motion (ROM), but had no els,69 raised C-reactive protein and immune com
limitation in any functional activities. plex levels,68 and association with other diseases
Shaffer et al 66 followed 62 patients with id (hemiparesis,3I,48 ischemic heart disease, thy
iopathic frozen shoulder for 2 to 1 1 years (aver roid disease,70,7 1 pulmonary tuberculosis,
age, 7 years), Although 60 percent of the patients chronic bronchitis,48 and diabetes62,72-74.
had restricted ROM only I I percent reported Diabetes and the incidence of fTozen shoul
mild functional limitations due to pain and stiff der have been under closer scrutiny, with some
ness. These studies contradict other research in interesting results, Lequesne et al.62 tested 60
dicating full recovery or slight loss of motion in consecutive patients with fTozen shoulder and
18 to 24 months fTom the onset of symp found that 1 7 of these had diabetes, In a larger
toms. 1 1, 1 5, 27,6 1,64 sample, Bridgman 72 found that more than 10
Cyriax also classified frozen shoulder into percent of 800 diabetics had fTozen shoulder
three stages,25 The first stage exists when the compared with 2 percent of 600 nondiabetic con
pain is confined to the deltoid area or at least trol subjects, These authors contend that the
does not extend distal to the elbow, when the prevalence of diabetes in frozen shoulder is sig
patient can lie on the involved extremity at night, nificant.
when pain is present only with movement, and In summary, the onset of frozen shoulder is
when the end-feel is elastic. The second stage is usually insidious and occurs i n patients more
present if only some of the criteria in the first than 40 years of age. The course of the condition
stage are met. The third stage is characterized has been documented to be as long as 10 years,
by severe pain extending from the shoulder to DlII;ng this time, the level of pain and restriction
the forearm and wrist, inability to lie on the in can vary greatly. Other typical features of frozen
volved extremity at night, pain at rest and great shoulder include abnormal arthrograms with
est at night, and an abrupt end-feel. Treatment marked capsular changes and normal radio
varies according to the stage of the condition and graphs,
will be addressed later,
In a small series of 21 patients with frozen
shoulder, Simmonds ' 2 observed that after 3 Examirwtion
years, only 6 regained normal function, 9 had
weakness and pain, and 6 had either weakness A complete description of the examination of the
or decreased mobility, Gray" noted that 24 of 25 frozen shoulder is beyond the scope of this chap
patients regained normal glenohumeral motion ter, Emphasis will be placed on the phYSical ther-
264 PHY S I C A L THER A P Y OF THE SHOUL D E R
apist's objective as essment and the way in applies to pertinent questioning concerning the
which findings relate to treatment of frozen shoulder complex, cervical spine, and brachial
shoulder. plexus structures, although these areas will be
examined.
SUBJECTIVE FINDINGS
OBJECTIVE FINDINGS
In my clinical experience, most patients with fro
zen shoulder have had the condition for several Initial observation of the patient fTequently re
weeks to several months before seeking treat veals a stooped posture with rounded shoulders;
ment. When referred to physical therapy, the pa the involved extremity is adducted and internally
tient probably has taken or is cUITently taking a rotated, resting in the patient's lap."
course of anti-inflammatory medication and In gait, the arm swing is usually limited or
has used self-treatment with a heating pad absent on the affected side. A therapist obselving
warm showers, aspirin, and rest of the extremity. the patient disrobe will notice that the patient's
Pain motivates the patient to seek medical shirt is usually removed as though the arm were
attention,9.16 as does decreased function in a cast. The uninvolved extremity is removed
of the extremity.75 Subjectively, the patient first, with very little movement of the opposite
complains of a vague, dull pain over the del side. The reverse occurs when the patient
toid that increases with motion2.5 1 .6 1 and disturbs dresses. The patient usually wears shirts that
sleep!9.3I .32.5I.6 1 .76 Functionally, the patient will button down the front and require no overhead
be unable to sleep on the affected side!·6. 1 7.25 action to remove.
hook a brassiere in the back, comb the hair, or The levels of the shoulders are frequently un
reach for a wallet in a back pocket. The patient even, with the involved side usually elevated in
usually cannot recall an injury and [Tequently is a p,"otective manner. As a result of maintaining
unable to determine when the pain and/or loss this posture, there may be tender points along
of function began. If the condition is more ad the ipsilateral upper trapezius, with perceived
vanced, the patient may complain of pain pain along its course to the suboccipital area.
spreading fTom the shoulder down the fore The scapula on the involved side is usually ele
alm,"·25 up to the cervical spine, and into the vated, laterally rotated, and abducted as a re ult
ipsi lateral scapula, and pain at rest. 25 of excessive scapular motion to compensate for
These complaints correspond well to Cyri the impaired glenohumeral motion. The abnor
ax's stages of capsular lesions." Although the mal scapular position can cause stretch weak
study by Reeves29 documents arthrographic ness of the rhomboids77 and levator scapulae
changes in the first and last stages of frozen tightness, giving rise to local pain. If the condi
shoulder, from a practical standpOint Cyriax's di tion is long-standing and there has been a long
vision is more clinically applicable. In the patient period of disuse, muscle atrophy around the in
population that I saw, very few patients were ex volved shoulder and scapula may be evident.
amined arthrographically. It appears that Because celvical spine dysfunction can refer
arthrography was reser ved for those patients pain to the shoulder, this area must be as
who did not respond to a long-tel-m conservative sessed.,o.)s.)6 It is not the objective of this chap
program of physical therapy and medication. ter to outline a complete cervical examination,
Even if arthrography is performed, Cyriax's but a few important tests are mentioned. I f active
stages can also be clinically helpful in treatment cer vical ROM is normal, overpressure should be
.
planning. applied at the end of each range '8 This involves
During the interview, it is also important to a gentle passive movement at the end of the avail
ask questions concerning the patient's general able range. There should be a slight pain-free in
health to assess any other disease process that crease in the ROM. If active ROM and active
may be referring pain to the shoulder. The same ROM with overpressure are negative for provo-
FRO Z E N S H O U L D ER 265
cation of symptoms, the cervical quadrant test Much of the remaining objective assessment
can be performed. This involves guiding the head of the shoulder is based on Cyriax's" examina
into extension toward one side and then adding tion principles. The entire examination is pre
cervical rotation to the same side 78 sented because the negative findings are as im
Individual cervical segmental mobility portant as the positive findings in assessing
should then be tested to ascertain any joint dys frozen shoulder. All examination procedures
function. Physical therapists trained in these mentioned should be performed bilaterally,
methods have a variety of testing techniques that using the uninvolved extremity as "normal" for
can be perfOl-med to check segmental mobility the individual who is being assessed.
in all directions of motion. Cervical compression Twelve movements are included in the exam
and traction tests complete the passive cer vical ination, and the order of their performance is
spine examination. Additional information con important. Active motion assesses both contrac
cerning the cervical influence on the shoulder tile an noncontractile elements, passive motion
pain may be obtained by having the patient ele assesses inert structures, and resisted motion as
vate the involved shoulder while traction is being sesses conlractile str uctures.
applied to the cer vical spine and noting if there
is any improvement in shoulder pain or ROM.35 '- Active elevatiol1. Elevation is movement
Finally, resistive testing of cervical ROM will away from the side in the coronal plane,
provide information concerning the contractile with 180· possible. During active elevation,
structures of the neck. the patient's willingness to move, the mus
The integrity of the brachial plexus must be cular power, and the ROM can be as
evaluated in case of shoulder pain. 35 The stan sessed.
dard Addson, hyperabduction, and costoclavicu 2. Passive elevation. The ROM, the location in
lar tests may not be valid with limited shoulder the range in which pain is produced, and
motion. Elvey's developed a brachial plexus ten the end-feel should be noted. End-feel is
sion test that can be performed adequately de the sensation detected by the examiner at
spite restricted shoulder motion. The reader is the extreme of the passive ROM. 2 5.80 The
encouraged to refer to this text for the details. normal end-feel of the shoulder is capsu
Acromioclavicular, ster noclavicular, and lar, which is similar to the sensation en
scapulothoracic dysfunction and first rib syn countered when two pieces of tough rub
drome can also give rise to shoulder pain.35.79 ber are squeezed togellJer. There is a firm
Acromioclavicular joint pain is usually very lo arrest to movement, but some "give" is
calized and can easily be pinpointed by the pa noted." Both the end-feel and the point in
tient.25 This local pain differs from the diffuse the range where pain is provoked are im
dull pain common with frozen shoulder. Scapu portant i n deciding treatment. This will be
lothoracic dysfunction usually results from ex further discussed in the section on stretch
cessive scapular compensatory motion, and ster ing as treatment.
noclavicular dysfunction usually results from 3. Painful arc. This can only be tested when
abnormal shoulder mechanics. First rib dysfunc 90· of abduction is present actively 01' pas
tion can result from a variety of problems. The sively. Abduction is defined as the amount
mobility of the sternoclavicular, scapulothora of movement between the scapula and hu
cic,3s.79 acromioclavicular, and first rib79 should merus, with 90· being normal. The patient
be tested to rule out their involvement in shoul actively elevates the extremity and notes if
derpain. In summary, careful examination of the there is a painful point in the range bor
cervical spine, brachial plexus, acromioclavicu dered on either side by non painful motion.
lar, sternoclavicular, scapulothoracic joints, and The same arc of pain can be felt as the
first rib is essential in a complete assessment of arm is brought down from the elevated po
shoulder pain. sition or if elevation is pel'formed pas-
266 PH Y S I C A L THER A P Y OF THE S HOUL D E R
sively. A positive finding indicates that a manipulation is the prefen'ed treatment to re
structure is being pinched during the move store joint play.
ment. According to Menne!, there are seven joint
4. Passive scapLllohumeral abduclion. The sca play motions at the glenohumeral joint. He rec
pula is stabilized at its inferior angle as the ognizes that normal glenohumeral movement
therapist passively elevates the extremity, depends on normal acromioclavicular, sterno
noting when the inferior angle begins to clavicular, and scapulothoracic joint movement.
move; 90· is the normal range before the The reader is refer red to Chapter I for review
scapula moves. of this necessary hal-mony. All of the joint play
5. Passive laleral rOlaliol1. As with passive ele molions are actually rolls and glides of the hu
vation, ROM, the point in the range at meral head within the glenOid. In the shoulder,
which pain is provoked, and the end-feel where the convex humeral head is moving on the
should be noted. stationary glenoid, roll and glide occur in oppo
6. Passive medial rOlaliol1. See the comment site directions ·o Any discrepancies in joint play
for 5, above. assessment will direct the therapist with a
Note that all resisted tests are performed knowledge of normal joint mechani s to the in
isometrically. Both pain and muscle weak volved area of the capsule. Furthermore, treat
ness are noted. The resisted tests are the ment can be directed to these specific areas.
following. The normal joint play motions of the gleno
7 . Resisled addLlcliol1. humeral joint are antel;or glide, posterior glide,
8. Resisted abduclion. lateral glide, inferior and posterior glide, lateral
9. Resisted laleral yotaliol1. and posterior glide, external rotation of the hu
1 0. Resisled medial roealiol1. meral head within the glenoid fossa, and poste
I I . Resisled elbow extel1siol1. rior glide of the humeral head within the glenoid
12. Resisted elbow flexion. fossa with the shoulder flexed to 90·,65 Although
the joint play motions mentioned are assessment
As previously mentioned, confusion occurs
when more than one lesion exists. With this con techniques, they are also treatment techniques
cise examination, both contractile and inert that can be used to restore normal shoulder me
structures can be assessed. chanics by stretching the involved portions of the
In summary, because frozen shoulder in capsule. This will be discussed in the treatment
volves a noncontractile slructure, active eleva section.
tion and all passive testing are limited and pain All joint play motions can be quantified
ful. In addition, limitation of passive movement using a scale from 0 to 6.s1 Although the assess
is in a capsular proportion, with most limitation ment of the jOint play is subjective, grading the
in external rotation, followed by abduction, then movement allows easy documentation of the mo
internal rotation. tion. Again, the univolved extremity should be
Further information in detelmining which tested to assess "normal" for the patient. Grade 0
areas of the capsule are involved in frozen shoul indicates no joint movement as in an ankylosed
der can be obtained by assessing motions of gle joint; grade I indicates marked loss of motion;
nohumeral joint play. Mennel79 coined the term grade 2, a slight limitation in motion; grade 3,
joint play and defines it as small, involuntary normal mobility; grade 4, a slight increase in mo
movement essential for normal joint motion. He bility; grade 5, a marked increase in motion; and
based this definition on joint mechanics, i n grade 6, joint instability. In frozen shoulder with
which rotations, glides, and long axis extension capsular restrictions, grades I and 2 will be en
(traction) are nOlmal joint play motions. Joint countered most frequently.
play motion is often not more than Ys inch of A final examination tool is palpation. Cy
movement in any plane. When joint play is lost, riax25 cautions that palpation gives very lillIe in
joint dysfunction exists. Mennel proposes that formation and is ollen irritating to the involved
F R OZEN S H O ULD E R 267
structures. For these reasons, palpation is re local hydrocor-tisone and exercises or infTared ir
served until the very end of the examination. I n radiation and exercises. However, both groups
frozen shoulder, palpatory findings are generally receiving exercises did Significantly beller than
negative. There may be tenderness over the patients receiving analgesics alone. Dacre et aI . ,
acromioclavicular jOint as a result of improper following 66 cases for 6 months, concluded that
shoulder mechanics. In addition, any secondary local steroid injection, physical therapy with mo
muscular involvement resulting rTom posture or bilization, or a combination of both were all ef
abnormal scapular motion may exhibit tender fective in decreaSing pain and increasing shoul
painful points. In a contractile lesion coexisting der function. They also concluded that the
with frozen shoulder, there will probably be ten steroid injection was cost-effective.87
derness over the lesioned str ucture. Biswas et al.75 found that patients receiving
Although this evaluation is lengthy, it is im intra-articular hydrocortisone, short-wave
perative that an accurate assessment of the diathermy, and aspirin as well as active and pas
shoulder lesion be made. Proper treatment is sive mobilization exercises all benefited. Fur
based on an accurate assessment. 34.79.82 thermore, these investigators concluded that ex
ercise is the most important treatment in frozen
shoulder. Liang and Lienss found no difference
in active exercises when combined with inlra
Treatment articular injection and heat (short-wave diath
ermy, ultrasound, or moist heat), with heat
Prevention is the best treatment of frozen shOltl alone, or with injection alone. Similarly, they
der ."·5 1 Although there is little agreement on its concluded that exercises were probably the only
treatment when it occurs, there is agreement on useful treatment for frozen shoulder. Rizk et al.89
the treatment goals; pain relief and restoration of found that transcutaneous electrical nerve stim
normal shoulder movement "5.83 Unfortunately, ulation with prolonged pulley traction was supe
few controlled studies in the literature examine rior to a variety of heat modalities and exercises.
treatment of frozen shoulder. One of the prob
lems in studies of frozen shoulder is the variable
patient selection due to the var-iable definitions TRANSCUTANEOUS ELECT RICAL NERVE
of what constitutes frozen shoulder. Another STIMULATION
problem, so frequently encountered in any
human subject study, is the ethics of the neces Various treatments can be used to achieve the
sity of an untreated control group. goals of pain relief and restoration of mobility,
Hazleman65 studied 130 cases of frozen but documentation of their effectiveness in fro
shoulder retrospectively and found no difference zen shoulder is lacking. Transcutaneous electri
in treatment of local corticosteroid injections, cal nerve stimulation (TENS) can be used to de
physical therapy consisting of pendulum and crease the symptoms of pain in both the early
pulley exercises with short-wave diathermy, or and later stages of frozen shoulder. Figure t 0.3
manipulation under anesthesia. Binder and col illustrates an effective TENS application for fro
leagues" followed 42 patients with forzen sholtl zen shoulder.9 0 The analgesia provided by TENS
der for 8 months and found no long-term differ allows other therapeutic procedures, such as ex
ence in treatment by intra-articular steroids, ercises, to be performed more comfortably. For
Maitland-type passive mobilization, ice, or no maximal effectiveness, TENS should be applied
treatment. Hamer and Kirk8S documented no before and/or during the exercises.9o Decreasing
Significant advantage in ice or ultrasound treat the pain during stretching of the fTozen shoulder
ments, but both were beneficial in decreasing the will gain the confidence of the patient as well as
painful stage and hastening recovery. Lee et al.86 facilitate joint relaxation, which is essential for
found no difference in patients who received passive joint manjpulation.
268 P H Y SI C A L T H ERA P Y OF T H E S H OU L D ER
HEAT
indicated for the patient with frozen shoulder. sition. Without movement, the new collagen is
The three stages as outline by Cyriax, the end laid down in a haphazard manner. Abnormal col
feel, and the pain/resistance sequence are three lagen deposition occurs between the newly syn
such guides.25 A good therapist paces the patient thesized fibril and preexisting collagen fibers,'·
through a graded active and passive exercise pro resulting in a mechanical block to collagen
gram and constantly reassesses the effect of the movement. Multiple adhesions between collagen
program on pain and stiffness. fibrils and fibers is manifested as joint stiffness.
I n addition, with the decrease in hyaluronic acid,
the lubricant between the fibers is lost, contrib
MANIPULATION
uting to further impairment of free collagen
Manipulation, or mobilization as it is frequently movement.
called, is a fOlm of passive exercise designed to Based on these considerations, it seems rea
restore joint play motions of roll, glide, and joint sonable to assume that movement of the joint
separation.79 Very few controlled studies involve will prevent or limit adhesive fOlmation. Al
joinL manipulation in the treatment of frozen though this is not documented, movement to
shoulder. Nicholson9• compared treatment with prevent adhesions is a clinical goal of exercise. I n
mobilization and active exercises to active exer t h e event that capsular adhesions have formed,
cises alone i n 20 patients with frozen shoulder manipulation can be used to break the adhesions
After 4 weeks of treatment, passive abduction and restore joint play. Further research is ob
improved significantly in the mobilization viously needed in this area.
group. There was, however, no significant differ It is beyond the scope of this chapter to out
ence in pain scores between the two groups. Ni line every manipulative technique for frozen
cholson noted that inferior glide of the humerus shoulder. Demonstrations can be found in the
was the most severely restricted motion. texts of Maitland,'· Mennel,79 and Kaltenborn 81
Bulgen et al 99 found no superiority of Mait Techniques for each area of the shoulder cap
land-type manipulative techniques in patients sule, acromioclavicular, sternoclavicular, and
with frozen shoulder for more than I month over scapulothoracic joints are illustrated here. Phys
treatment with ice, intra-articular steroid injec ical therapists benefit by becoming as familiar
tions, or no treatment. I n fact, after 6 weeks of as possible with as many techniques as possible
treatment, the group receiving manipulation had to afford beller treatment to their patients. Any
greater loss of motion than did the other groups. of the techniques illustrated can be adapted as
Bulgen et al. explained that the detrimental ef oscillatory or static stretching techniques and
fect of physical therapy occurred when manipu can be performed in any part of the range. The
lation was perfOl-med during the active stage, an goal of treatment, whether for pain relief or in
eJTor that must be avoided?· creasing ROM, will influence the choice of treat
For normal shoulder function, all areas of ment technique. The mobilization techniques
the capsule must be extensible to allow joint play aJ.., illustrated in Chapter 1 6.
motion. Capsular extensibility depends on fric Cervical as well as shoulder pain may be
tion-free sliding of the collagen fibers within the present . This may result from overuse of the
capsule.3• Hyaluronic acid with water is the lu upper trapezius and levator scapula with exces
bricant between the collagen fibers3•. JOO. J O l that sive scapular elevation to compensate for the loss
allows this free gliding to occur. of glenohumeral motion 77 The upper t rapezius
Lundberg's study of the capsular changes in and levator scapula are usually shortened and
frozen shoulder revealed a marked i ncrease in will need treatment to decrease pain and restore
fibroblastic formation of collagen, a loss of hya normal physiologic length. Any or the physical
luronic acid, and an increase in sulfated GAGs.47 modalities are useful to decrease pain. Massage
The newly formed collagen in the capsule de is relaxing as well as beneficial in moving any
pends on motion for proper alignment and depo- excessive fluid accumulation. It also can assist
FROZEN S H O U L DER 271
the chair. The therapist or a reliable family mem "Muscles cannot be restored to normal if the
ber who has been taught the exercises can de joints which they move are not free to move."79
press the humeral head while using the appara Because there is often excessive scapular mo
tus. Last, the patient can be instructed to keep tion, stabilization exercises to the scapular area
the spine Oat against the chair while performing can be performed before f'ull glenohumeral mo
these exercises. Despite these efforts to i mprove tion is restored. Otherwise, I do not advise
the exercises, Murray77 contends that these ap strengthenjng exercises until near normal ROM
paratuses should be used only when normal glid is achieved. Trus will avoid strengthening a mus
ing is present. cle i n a shortened range that may impede the
Active exercises allow more patient control restoration of mOlion.
than do mechanical exercises. Active exercises Isometric, isotonic (both concentric and ec
are essential in maintaining the capsular extensi centric), and isokinetic exercises, free weights,
bility obtained through manipulation. They are and proprioceptive neuromuscular facilitation
best performed i n a pain-free range to prevent are all useful in restoring muscle strength. Var
any innammatory reaction by forcing joint ious exercise equipment such as Cybex, Univer
movement. The same principles of mechanical sal, and Nautilus is commonplace in many
exercises apply to forced active exercises; that is, health clubs, and individual programs should be
the active range will not be available if normal developed for the patient . After pain abates and
joint play is lacking. ROM is restored, most patients will not continue
Codman or pendulum 7 exercises performed physical therapy for a strengthening program.
with gravity are usually painfree. With the pa Therefore, intermillent follow-up visits should
tient bent at the waist and extremity dangling, be made to review and alter the exercise program
the weight of the extremity produces joint sepa as needed and to assess the patient's progress .
ration and eliminates a fulcrum at the glenoid
or acromion with movement.7 With traction at
OTHER TREATMENTS
the joint, the patient will usually find the exer
cises more comfortable. For additional traction, Cortisone injections, manipulation, joint disten
the patient can grasp a light weight, such as an tion, or a combination of any of these are other
iron. The exercises include forward and back treatments for frozen shoulder. The literature is
ward, medial to lateral, and circular motions filled with arguments for and against manipula
made with the entire extremity. The object is to tion under anesthesia 1 04- 1 1 8 and cortisone injec
have the patient increase the arc of movement lions. S9 , 83 . 1 1 1 - 1 1 6
within a painful ROM. Rizk et al.' 1 6 reported no significant im
Cardinal plane or diagonal active motion can provement in ROM in patients receiving in
be performed as a home program if the necessary trabursal or intra-articular steroid or lidocaine,
joint play movements are available. Home exer or a combination of both. The steroid group
cise programs should be kept simple and to a noted a temporary relief of pain only.
minimum, requiring no speciaJ equipment, so Loyd and Loyd59 advocate the use of arthrog
that the patient will comply with the program, raphy for accurate intra-articular injections as
which in frozen shoulder is usually a long course. opposed to blind clinical injections. They found
The number of repetitions as well as the vigor that a combination of steroid injection followed
will have to be determined for each patient. As by gentle manipulation was useful in treating
mentioned, for their analgeSic effects, prepara frozen shoulder.
tory heat or ice may be used prior to perfor Mulcahy et aJ.33 and Ekelund and Rydell60
mance of exercises. successfully treated fTozen shoulder with a com
Last, muscle reeducation and strengthening bination of al1hrographic joint distention, intra
may be needed to restore normal physiologic bal articular steroid injection, and gentle joint ma
ance to the entire shoulder complex and spine. nipulation. Ekelund and Rydell noted that full
FROZEN S H O U L DER 273
ROM was not always restored with this treat subscapularis, and release the anteroinferior
ment; instead manipulation under general anes capsule.
thesia would be in order. Several nonoperative and operative treat
Rizk'4 advocates capular distention through ments of frozen shoulder have been presented.
arthrography in treating frozen shoulder. He Various manipulative procedures were used in
noted no intra- or extracapsular adhesion in ad many of the treatment studies mentioned. A
hesive capsulitis. In all case , djstention caused short lever arm with gentle force during manipu
the capsule to rupture at particularly const,-icted lation avoids complications, such as a fractured
sites, namely the subacromial or subscapular humerus. Some investigators have reported rota
bursa. tor cuff lea''S following manipulation.55
Sharma et al. ' 1 7 compared joint distention Clinically, if a patient has been treated with
and steroid injections to manipulation under manipulation, it is helpful to know the ROM ob
general anesthesia in treatment of frozen shoul tained and the complications, if any, lhat were
der. Distention gave better results with de encountered during the procedure. I t is very
creased pain and improved ROM. They suggest common for a patient to have less motion follow
distention be performed early in fyozen shoulder ing manipulation even if therapy is initiated im
to expedite recovery. mediately. This may be owing to an acute inflam
Arthroscopy is being employed more re matory reaction and muscle splinting due to
cently in the treatment of frozen shoulder. There pain. Pain is frequently increased for several
is disagreement in the literature about its usef·ul days following manipulation. TENS and ice are
ness, but some feel that it allows visualization very helpful at this stage. Exercises are essential
and treatment of associated pathologies. following manipulation under anesthesia. The
Hsu and Chan'o compared arthroscopic dis therapist frequently sees the patient four times
tention, manipulation under general anesthesia a day in the hospital, beginnjng on the day of the
and physical therapy, and physical t herapy procedure. Reassurance and encouragement are
alone. The first two had better results in pain needed to motivate the patient to exercise in the
reduction and improvement in motion. The au presence of pain.
thors favor distention because it is more control I n the cases of steroid injection treatment,
lable than manipulation and any intra-articular the physical therapist should be aware of the lo
pathology can be seen. cation, number, and frequency of cortisone in
Pollock" advocates arthroscopic examina jections administered to the patient. Because of
tion following manipulation. This allows for reports of spontaneous tendon ruptures follow
joint deb,-idement and treatment of associated ing multiple injection, care should be exercised
pathologies, which may range from acromi with these patients. Knowledge of any procedure
oplasty to sectioning of the coracohumeral liga performed on the patient enhances treatment de
ment. cisions.
Open surgical release is recommended for
patients who have failed to improve with con
servative treatment, including manipulation, or
who have conlraindications to manipulation, Summary
such as significant osteopenia, history of frac
ture or dislocation, or recurrence after manipu This chapter has presented the varied theories
lation." • Several aut hors cite a contracted cora on pathogenesis, definition, etiology, clinical
cohumeral ligament as the source of fyozen features, and treatment of the fyozen shoulder.
shoulder and recommend releasing this liga Physical therapy management for fyozen shoul
ment ' 7- 1 9 In addition to sectioning the cora der may include prepatory modalities to de
cohumeral ligament, I(jeras and Matsen 1 9 crease pain, passive manipulation, muscle reed
also excise subdeltoid adhesions, lengthen the ucation and strengthening, and a home exercise
274 P H Y S I CAL T H ERA P Y OF THE SHOU L D E R
program. The course is long and often tedious progressed, he tolerated grades 3 and 4 of these
to both the patient and therapist, because maneuvers. He was instructed in Codman and
progress is very slow. The goal of treatment is pain-fTee active ROM exercises [or home to be
the restoraLion of normal pain-fTee shoulder done 5 times per day. Postural awareness was
Function. FUliher research in all of the above also emphasized.
areas is needed to prevent and better treat the After 3 weeks of therapy at a fTequency o[ 3
common musculoskeletal complaint of Frozen t imes per week, the patient's active ROM im
shoulder. proved to 55· of extemal rotation, 1 20· of abduc
tion, 65· of intemal rotation, 1 40· of flexion, and
1 0· adduction. I-Ie began a home strengthening
program with tubing to be performed three times
CASE STUDY daily within the pain-free ROM.
A 65-year-old white male presented with a 2-year By the fifth week, the patient's ROM im
history of left shoulder stiffness. Over the past 6 proved to 70· of external rotation, 1 45· of abduc
months, he had noted limitation in Function due tion, 75' of i nternal rotation, 1 60' of flexion, and
to the progressive stiffness with pain at the ex 1 5· of adduction. He noted no functional limita
treme of the available range. His first indication tion and resumed bowling. He voluntarily dis
of loss of Function was the inability to raise the continued treatment, and a follow-up phone call
arm to wash the axilla. Three years prior he had I month later revealed less than full ROM but
stiffness in the right shoulder, which resolved no pain or loss of function.
after a steroid injection. He denied injut)' to In my experience, this patient is typical in
either shoulder. discontinuing treatment as soon as there is no
Objectively, the patient exhibited a Forward pain or loss of [unction, even though lacking full
head posture with the left shoulder intemally ro ROM. The rapid return of motion is atypical For
tated. Active shoulder ROM was 25' of extemal a [Tozen shoulder with a 2-year histOl)'.
rotation, 85' of abduction, 45' of intemal rota
tion, 90' of flexion, and adduction to neutral.
Passive elevation to 85· was painf"tll at the end of
the range with a capsular end-feel. There was Acknowledgments
compensatory scapular motion with active and
passive abduction past 75' and pain at the end I wish to thank Rita K. Owens-Skatl, B.S., P.T.,
of the range. Passive lateral and medial rotation for assistance in the preparation of the manu
met with resistance and then pain at the end of script, and William Boissonnault, M.S., P.T., and
the ROM with a capsular end-feel. All resisted Steve Janos, M.S., P.T., for their assistance with
upper extremity testing was within normal lim the photographs.
its. Joint play motion testing revealed grade 2 for
inferior, antedor, and lateral glides, and extemal
rotation of the humeral head within the fossa.
The remainder of the upper quarter evaluation
References
was unremarkable.
I . Baleman J : The Shoulder and Neck. WB Saun
Treatment included ultrasound to the gleno
ders, Philadelphia. 1 978
humeral joint for 8 minutes at 1 .5 W/cm', soft
2. Neviaser JS: Adhesive capsulitis and the sliff and
tissue mobilization, and joint play manipulation.
painful shoulder. Orthop Clin Norlh Am 1 1 :327,
Initially, the manipulations used included infe 1 980
dor, antet;or, and lateral glide techniques. They 3. Neviaser ]S: Adhesive capsu litis of the shoulder:
were applied as grade 2 oscillatOl), movements study of pathological findings in pedal1hritis of
because the patient had pain only as the end of lhe shoulder. J Bone Joint Surg 27:2 1 1 . 1 945
the range was approached. As the treatments 4. Meulengracht E, SchWaJ1Z M: The course and
F R OZ E N S H O U L DER 2 75
prognosis of perial1hrosis humeroscapulads arthrogr-aphic capsular distention and rupture.
with special regard to cases with general symp Arch Phys Med Rehabil: 75,803, 1994
toms. Acta Med Scand 1 43:350, 1 95 2 25. CYl'iax J: Textbook of Ol�hopaedic Medicine. 7th
5. McLaughlin H L : The "frozen shoulder." C l i n Or Ed. Vol. 1 . Bailliere Tindall, London, 1 978
thop 20: 1 26, 1 96 1 26. Kozin F: Two unique shoulder disorders. Adhe
6 . Ri zk TE, Pinals RS: Frozen shoulder. Semin Ar sive capsulitis and reflex sympathetic dystrophy
thritis Rheum 1 1 :440, 1982 syndrome. Postgrad Med 73:207, 1 983
7. Codman EA: The Shoulder. Kreiger, Malabar, 27. Jayson MV: Frozen shoulder: adhesive capsul
FL, 1934 itis. Br Med J 283 : 1 003, 1 98 1
8. Coventry MB: The pl'Oblem of the painful shoul 2 8 . Morgensen E . Painful shou lder. Aeliological and
der. JAM A 1 5 1 : 1 77 , 1953 pathogenetic problems. Acta Med Scand 1 55 :
gen crosslinking alterations in joint con rigidity of the shoulder joint. Acta Orthop Scand
tractures: changes in reducible crossl inks in per 36:35, 1 965
ial1icular connective tissue collagen after nine 55. Samilson RL, Raphael L, Post L et al: A.1hrogra
weeks of immobil ization. Connect Tissue Res 5 : phy of the shoulder joint. Clin O.1hop 20:2 1 ,
5, 1 977 1 96 1
4 1 . Akeson WH, Amiel 0, Woo S: lmmobility effects 56, Neviaser RJ : The frozen shoulder diagnosis and
of synovial joints: the pal1homechanics of joint management. Clin Orthop 223:59, 1 987
contracture. Biorheology 1 7:95, 1980 57. Neviaser RJ: Al1hrography of the shoulder joint.
42. Enneking W, Horowitz M: The i ntra-articularef Study of the findings i n adhesive capsulitis of
fects of immobili7..alion on the human knee. J the shoulder. J Bone Joint Surg 44A: 1 32 1 , 1 962
Bone Joint Surg 54A:973, 1 972 58. Rizk TE, Christopher RP, Pinals RS et al: Arthro
43. Evans E , Eggers G , Butler J el al: Immobilization graphic studies in painful hemiplegic shoulder.
and rcmobi lization of rats' knee joints. 1 Bone Arch Phys Med Rehabil 65:254, 1 984
Joint Surg 42A:737, 1960 59. Loyd JA, Loyd H M : Adhesive capsulitis of the
44. laVigne A, Watkins R: Preliminary r'csults on shoulder: arthrographic diagnosis and treat
immobilization: induced stiffness of monkey ment. South Med J 76:879, 1 983
knee joints and posterior capsule. I n : PCI"SpeC 60. Ekelund AL, Rydell N : Combiniation treatment
lives in Biomedical Engineering. Proceedings of for adhesive capsulilis of the shoulder, Clin Or
a symposium of Biological Engineering Society, thop 282 : 1 05 , 1992
University of Strathclyde, Glasgow, June 1 972. 6 1 . Lippmann K, Bayley I, Young A: The uppe,· limb.
University Park Pr'ess, Baltimore, 1 973 The frozen shoulder. Br J Hosp Med 25:334, 1 98 1
45. Woo S, Mauhews IV, Akeson WH et al: Connec 62. Lequesne M , Dang N , Bensasson M et al: In
tive tissue response to immobility: cOITelative creased association of diabetes mellitus with
study of biomechanical and biochemical mea capsulitis of the shoulder and shoulder-hand
surements of normal and i m mobilized rabbit syndrome. Scand J Rheumatol 6:53, 1 977
knees. A.,hdtis Rheum 1 8:257, 1 975 63, Reeves B: Experiments on the tensile strength of
46. Scholl meier G , U h thoff HK, Sarkar K et al: Ef the anterior capsular' stl1.1ctut'es of the shoulder
fects of immobilization on the capsule of the ca in man. J Bone Joint Surg 50B:858, 1968
nine glenohumeral joint. Clin Orthop 304:37, 64. Gray RG: The natural history of "idiopathic" fro
1 994 zen shoulder. J Bone Joint Surg 60B:564, 1978
47. Lundberg BJ: Glycosaminoglycansofthe nOlmal 65. Hazleman BL: The painful stiff shoulder.
and frozen shoulder-joint capsule. Clin Orthop Rheumatol Phys Med I I :4 1 3 , 1972
69:279, 1970 66. Shaffer B, Tibone lE, Kerlan RK: Frozen shold
48. Wdght V, Haq AM M M : Pedarthritisofthe shoul de... A long term fol low-up. J Bone Joint Surg
der. Aetiological considerations with particular 74A:738, 1 992
reference to personality factors. Ann RJleum Dis 67. Bulgen DY, Hazleman BL, Voak 0: HLA-B27 and
35 :2 1 3, 1 976 frozen shoulder. Lancet I : I 042, 1 976
49. Anton HA: Frozen shoulder. Can Fam Phys 39: 68. Bulgen DY, Binder A, Hazleman BL et al: Immu
1 773, 1 993 ological studies i n frozen shoulder. J Rheumatol
50. Goldman A: Shoulder Arthrography. Technique, 9:893, 1 982
Diagnosis, and Clinical Con'elation. Little, 69. Bulgen DY, Hazleman B, Ward M et al: Immuno
Brown, Boston, 1 982 logical studies in frozen shoulder, Ann Rheum
5 1 . Neviaser JS: Adhesive capsu lilis of the shoulder Dis 37: 1 35, 1978
(frozen shoulder). Med Times 90:783, 1 962 70. Bowman CA, Jeffcoate WJ, Pattrick M et al: Bi
52. Kaye JJ, Schneider R: Positive contrast shoulder lateral adhesive capsulilis, oligoal1hritis and
a.·thrography p. 1 37 . In Freiberger RH, Kay JJ, prox imal myopathy as presentation of hypothy
Spiller J (eds): Arthrography. Appleton-Century roidism. Br J Rheumatol 27:62, 1 988
Crofts, New York, 1 979 7 1 . Wohlgethan JR: Frozen shoulder in hyperthy
5 3 . Neviaser JS: Arthrography of the Shoulder. The roidism. Arth,;tis Rheum 30:936, 1 987
Diagnosis and Management of the Lesions Visu 72, Bridgman JF: Periat1hritis or the shoulder and
alized. Charles C Thomas, Spdngfield, IL, 1 975 diabetes mellitus. Ann Rheum Dis 3 1 :69, 1 972
54. Lundberg BJ: Arthrography and manipulation in 73, Erhard R: Diabetic capsu litis of the shoulder. p.
FROZEN S H OUL D E R 277
1 0 1 . l n : Proceedings of the 4th International Fed to its management. Arch Phys Med Rehabil 64:
eration of Orthopaedic Manipulative Therapists. 29, 1 983
International Federation of Orthopedic Manipu 90. Mannheimer J, Lampe G: Clinical Transcutane
lative Therapists, Christchurch, New Zealand, ous Electrical Nerve Stimulation. FA Davis. Phil
1980 adelphia, 1 984
74. Fisher L, KUl1Z A, Shipley M : Association be 9 1 . The Academy or Trad itional Ch inese Medicine:
tween cheiro311hropathy and fTozen shoulder i n An Outline of Chinese Acupuncture. Foreign
patients with insuli n-dependent diabetes melli Languages Press, Peking, 1975
tus. Br J Rheumatol 25: 1 4 1 , 1986 92. Yun W, Wei W, Shugin W: Treatment or peri
75. Biswas AK, Sur BN, Gupta CR: Treatment of per arthritis hu meroscapulads with acupuncture
iarthritis shoulder. J Indian Med Assoc 72:276, and acupoint blocking. J Trad Ch inese Med 1 3 :
1 979 262, 1 993
76. Olsson 0: Degenerative changes of the shoulder 93. Pothmann R, Weigel A, Stux G: Frozen shoulder:
joint and their connection with shoulder pain. differential acupuncture therapy with point ST-
Acta Chil' Scand supp\. 1 8 1 : I 04, 1 935 38. A J Acupuncture 8:65, 1 980
77. MunllY W: The chronic frozen shoulder. Phys 94. Leclaire R. BOUl'gouin J: Electromagnetic treat
Ther Rev 40:866, 1 960 ment of shoulder periart hritis: a randomized
78. Maitland GO: Peripheral Manipulation. 2nd Ed. controlled trial of the efficiency and tolerance of
BUlIerworth, Publishers. Boston, 1 977 magnetotherapy. Arch Phys Med Rehabil 7:284,
79. Mennel J : Joint Pain. Diagnosis. Treatment 1991
Using Manipulative Techniques. Litlle, Brown, 9 5 . Mueller E E , Mead S, Schulz B et al: A placebo
Boston, 1964 controlled study of ul trasound treatment for pcr
80. Wanvick R. Williams PL: Gray's Anatomy. 35th iat1hritis. Am J Phys Med 33:3 1 . 1954
British Ed. WB Saunders, Philadelphia 1973 96. Quin CE: Humeroscapular perial1hritis. Obser
8 1 . Kaltenbom FM: Mobilization or the Extremity vations on the effects of x-ray therapy and u l lra
loints. Examination and Basic Treatment Tech sonic therapy in cases of "frozen shoulder." Ann
niques. liar Bokhandel, Oslo, 1 980 Phys Med 1 0:64, 1967
82. Nelson PA: Physical treatment of the painrul arm 97. Hayes KW: Manual ror Physical Agents. 3rd Ed.
and shoulder. JAMA 1 69 : 8 1 4 , 1 959 Northwestern U niversity Press, Ch icago. 1 984
83. Valtonen E: Subacromial betamclhasone ther 98. Nicholson G G : The effects of passive joint mobi
apy. The effect of subacromial injection of beta lization on pain and hypomobility associated
melhasone in cases of painful shoulder resistant with adhesive capsulitis or the shoulder. JOSPT
to physical therapy. Ann Chir Synaecol Fenn, 6:238, 1 985
supp\. 63:5, 1 974 99. Bulgen DY, Binder Al, Hazleman BL et al: Fro
84. Binder AI, Bulgen DY. Hazleman BL et al: Frozen zen shoulder: prospective clinical study with an
shoulder: a long-term prospective study. Ann evaluation of t h ree treatment regimens. Ann
Rheum Dis 43:3 6 1 , 1984 Rheum Dis 43:353, 1 984
85. Hamer J, Ki rk JA: Physiotherapy and the rTozen 1 00 . Ham A, COImack 0: Histology. 8th Ed. JB Lip
shoulder: a comparative tdal of ice and u l tra pincott, Philadelphia, 1 979
sonic t herapy. NZ Med J 83 : 1 9 1 , 1 976 1 0 1 . Swann D. Radin E , Nazimiec M: Role of hyaluro
86. Lee M, Haq AMMM, Wright V et al: Pelial1hritis nic acid in joint lubrication. Ann Rheum Dis 3 3 :
or the shoulder: a controlled tlial or physiot her 3 1 8 , 1 974
apy. Physiotherapy 59:3 1 2 , 1 972 1 02. Wyke BW: Articular neurology-a I'eview. Phys
87. Dacre JE, Beeney N, Scott DL: Injections and iotherapy 58:94 , 1 972
physiot herapy ror the painrul stirr shoulder. Ann 1 03. Liebolt FL: Frozen shoulder. Passive exercises
Rheum Dis 48:322, 1 989 for treatment. NY State J Med 70:2085, 1 970
88. Liang H , Lien I : Comparative study i n the man 1 04 . Haggart GE, Dignam RI, Sullivan TS: Manage
agement of frozen shoulder. J Formosan Med ment of the "frozen" shoulde ... JAMA 1 6 1 : 1 2 1 9,
Assoc 72:243, 1 973 1 956
89. Rizk TE, Chl;stopher RP, Pinals RS et al: Adhe 1 05. SI;vastava KP, Bhan FB, Bhatia IL: Scapulo
sivecapsulitis (frozen shoulder): a new approach humeral perial1hlitis. A clinical study and evalu-
2 78 PHY SI C A L THER A P Y OF THE SHOU L D E R
alian of end results of its treatment. J indian Med 1 1 2. Mumaghem GF. Mcintosh 0: Hydrocol1 isonc in
Assoc 59:275, 1 972 painful shoulder. Lancet 1 :798, 1 95 5
1 06. Quigley TB: Indications for manipulation and 1 1 3 . Roy S , Oldham R : Management o f painful shoul-
cOl1icosteroids in the treatment of stifr shoul· der. Lancet I : 1 322, 1 976
ders. Surg Clin North Am 43: 1 7 1 5 , 1 963 1 1 4. Cyr-iax J . Trosicr 0: Hydrocortisone and sofi lis-
1 07 . Heibig B , Wagner P , Dohler R : Mobilization of sue lesions. Br Med J 2:966, 1 953
frozen shoulder under general anaesthesia. Acta 1 1 5. Cdsp El, Kendall PH: Treatment of pedarthrilis
Orthop Belg 49:267, 1 983
of the shoulder with hydrocort isone. Sr Med J
1 08 . Coombes WN: Frozen shoulder. JR Soc Med 76:
1 : 1 500, 1 95 5
7 1 1 , 1 983
1 1 6. Rizk TE. Pinals RS, Talaiver AS: C0I1icostcroid
1 09. Quigley TB: Treatment of checkrein shoulder by
injections in adhesive capsulitis: investigation of
use of manipulation and cOl1 isonc. JAMA 1 6 1 :
their value and site. Arch Phys Med Rehabil 72:
850, 1 956
20, 1 9 9 1
1 1 0. Weiser HI: Painful pdmary frozen shoulder mo-
bilization under local anesthesia. Arch Phys Med 1 1 7. Shanna RK, Bajekal RA, Shan S: Frozen shoul-
The integral functions of the rotator cuff muscu classification of rotator cuff pathology must first
lature. combined with the large multiplanar be developed.
movement patterns inherent in both activities of
daily living and sport activity in the glenohu
meral joint. make the rotator cuff vulnerable to Etiowgy and Cl.assijicat:Um of
injury. commonly requiring treatment in both
orthopaedic and sports physical therapy. The ro
Rotator Cuff Patlwlogy
tator cuff musculature functions to stabilize the
The etiology of rotator cuff pathology can be de
glenohumeral joint in four primary ways: ( I ) by
scribed along a continuum. ranging at one end
its passive bulk. (2) by developing muscle ten
from overuse microtraumatic tendonosis, to ma
sions that compress the joint surfaces together.
crotraumatic full-thickness rotator cuff tears. A
(3) by moving the humerus with respect to the
second continuum of rotator cuff etiology con
glenoid and thereby tightening the static stabiliz
sists of glenohumeral joint instability and pri
ers (capsular-ligamentous restraints). and (4) by
mary impingement or compressive disease." The
limiting the arc of motion of the glenohumeral
clinical challenge of treating the patient with a
joint by muscle tensions. I As one of the primary rotator cuff i njury begins with a specific evalua
dynamic stabilizing structures of the glenohu tion and clear understanding of the underlying
meral joint. high-intensity concentric and eccen stability and integrity of not only the compo
tric rotator cuff muscular activity has been re nents of the glenohumeral joint. but the entire
ported during simple elevation in the scapular upper extremity kinetic chain.
plane. ' as well as during the tennis serve3-S and There are several w�ys of classifying rotator
throwing motion 6.7 To beller understand the re cuff pathology. One classification method i'
habilitation process required to restore normal based upon the suspected or proposed patho
shoulder joint anhrokinematics and pain-free physiology 9 For the purpose of this chapter. four
glenohumeral joint function. the etiology and classifications of rotator cuff pathology will be
279
280 PHY SICAL THERAPY OF THE SHO U L DER
mm of the anterior acromion with preservation crease the tensile stresses to the I'Otatorcuff mus
of the insertion of the deltoid, and beveling of cle tendon units.··9
approximately 2 cm posteriorly to provide addi
tional space for the inflamed tendons.9 Open re
MACROTRAUMATIC TENDON FAILURE
pairs of associated full-thickness tears of the ro
tator cuff are routinely performed. Unlike the previously mentioned rotator cuff
classifications, cases involving macrotraumatic
tendon failure usually entail a previous or Single
SECONDARY COMPRESSIVE DISEASE
traumatic event in the clinical history.9 Forces
Impingement or compressive symptoms may be encountered during the traumatic event are
secondary to underlying instability of the gleno greater than the nOl-mal tendon can tolerate.
humeral joint.8.9 Allenuation of the static stabi Full-thickness tears of the rotator cuff with bony
lizers of the glenohumeral joint, such as the cap avulsions of the greater tubel'Osity can occur
sular l igaments and labrum fTom the excessive (Tom single traumatic episodes. According to Co
demands incurred in throwing or overhead ac field, 21 normal tendons do not tear, as 30 percent
tivities, can lead to anterior instability of the gle or more of the tendon must be damaged to pro
nohumeral joint. Due to the increased humeral duce a substantial reduction in strength . Al
head translation, the biceps tendon and rotator though a single traumatic event that resulted in
cuff can become impinged secondary to the en tendon failure is often reported by the patient
suing instability.'·9 A progressive loss of gleno in the subjective exam, repeated microtraumatic
humeral joint stability is created when the dy insults and degeneration over time may have cre
namic stabilizing functions of the rotator cuff ated a substantially weakened tendon that ulti
are diminished fTom fatigue and tendon injury.9 mately failed under the heavy load. Full-thick
The effects of secondary impingement can lead ness rotator curr lears require surgical treatment
to rotator cuff tears as the instability and im and aggressive rehabilitation to achieve a posi
pingement continue. 8,9 tive f"llnctional outcome 9.', Further specifics of
rotator cuff surgical treatment will be discussed
later in this chapter.
TENSILE OVERLOAD
insertion " Rathburn and MacNab" reported by Loehr et aI. '·Changes in stability of the gleno
the effects of position on the microvascularity of humeral joint were assessed with selective divi
the rotator cufr. With the glenohumeral joint in sion of the supraspinatus andlor infraspinatus
a position of adduction, a constant area of hypo tendons. Their findings indicated that a one-ten
vascularity was found near the insertion of the don lesion of either the supraspinatus or infra
supraspinatus tendon. This consistent pattern spinatus did not influence the movement pat
was not observed with the a,-m in a position of terns of the glenohumeral joint, whereas a two
abduction. These authors termed this the tendon lesion induced significant changes com
"wringing out phenomenon" and also noticed a patible with instability of the glenohumeral
similar response in the long head tendon of the joint. '· Therefore, patients with full-thickness
biceps. This positional relationship has clinical rotator cuff tears may have additional stress and
ramifications for both exercise positioning and dependence placed on the dynamic stabilizing
immobilization. Brooks et al. 25 found no signifi function of the rotator cuff, due to increased hu
cant difference between the tendinous insertions meral head translation and ensuing instability.
of the supraspinatus and infraspinatus tendons Additional research on full-thickness rotator
with both being hypovascular with quantitative cuff tears has significant clinical ramifications.
histologic analysis. One hundred consecutive patients with Full
Contradictory research published by Swion thickness tears of the rotator cuff were prospec
towski et al. ' 6 does not support this region of tively evaluated to determine the incidence of as
hypovascularity or critical zone. Blood flow was sociated intra-articular pathology by M iller and
greatest in the critical zone in living patients with Savoie." Seventy four of 1 00 patients had one
rotator curr tendonitis from subacromial im or more coexisting intra-articular abnormalities,
pingement measured with Doppler flowmetry. with anterior labral tears occu'Ting in 62, and
biceps tendon tears in 1 6. The results of this
study clearly indicate the importance of a thor
ough clinical examination of the patient with ro
AnaJumic Description of Rotator tator cuff pathology.
OuJTTears A second type of rotator cuff tear is an in
complete or partial-thickness tear. Partial-thick
There are several primary types of rotator cuff ness tears can occuron the superior surface (bur
tears commonly described in the literature. Full sal side) or undersurface (articular side) of the
thickness tears in the rotator cuff consist of tear's rotator cuff. Although both bursal and articular
that comprise the entire thickness (from top to side tears are partial-thickness tears of the rota
bOllom) of the rotator cuff tendon or tendons. tor cuff, significant differences in etiology are
Full-thickness tears are of1en initiated in the crit proposed for each9
ical zone of the supraspinatus tendon and can Neer'o", and Fukoda et al. 30 have both em
extend to include the infraspinatus, teres minor, phasized that superior surface (bursal side) tears
and subscapularis tendons. ' 7 Often associated in the rotator cuff are the result of subacromial
with a tear in the subscapularis tendon is sublux impingement. In the classification scheme listed
ation of the biceps long head tendon from the earlier in this chapter, tears on the superior or
intertubercular groove, or either partial or com bursal side of the rotator cuff are generally asso
plete tears of the bi. ciated with both primary and second31)' com
full-thickness rotator cuff tears show a variety of pressive disease as well as macrotraumatic ten
findings ranging from almost entirely acellular don Failure. The progression of the mechanical
and avascular margins to neovascularization irritation on the superior surface can produce a
with cellular infillrate.' 7 partial-thickness tear that can ultimately
The efFects of a Full-thickness rotator cuff progress to a Full-thickness tear 9 "
tear on glenohumeral joint stability were studied Partial-thickness tears on the undersurface
ROTATOR CUFF PATHOLOGY AND REHAB I LITAT I ON 283
nOl-mal muscular strength, more specific, dy using one hand on the posterior aspect of the
namic, isokinetic testing is indicated to better patient's shoulder. This places tension on the an
identify muscular weakness or u nilateral terior capsule and can produce a subtle anterior
strength imbalances·· subluxation of the humeral head, often repro
ducing the patient's shoulder pain. 8 The reloca
tion portion of the test consists of a posteriorly
directed force produced by the examiner, by
Special Tests placing the heel of the hand over the humeral
head anteriorly. This posterior force centralizes
The classic tests for evaluation of a patient with the humeral head in the glenoid fossa. A positive
rotator cuff pathology are the impingement subluxation/relocation sign consists of provoca
tests. The impingement test reported by tion of the patient's symptoms, with the anterior
Neerlo.11 places the shoulder in full forward translation in the position of 90° of abduction
flexion with overpressure. This places the su and external rotation, with cessation of the
praspinatus under the coracoacromial arch, symptoms with the relocation (posterior central
and can compress the tendon and reproduce ization force).
the patient's symptoms. A second impingement Capsular mobility testing with the patient su
test, reported by Hawkins and Kennedy, 47 in pine at 30°, 60°, and 90° of abduction is also per
volves 90° of forward flexion with full internal formed with both anterior and posterior stresses
rotation. This test passes the rotator cuff under imparted. The anterior stress applied at 30°, 60°,
the coracoacromial arch, with pain and a facial and 90° tests the integrity of the superior, middle,
grimace being indicative of a positive test. A and inferior glenohumeral ligaments, respec
final impingement test is the crossed arm ad tively·8 The degree of translation of the humeral
duction test, which involves horizontally ad head relative to the glenOid, as well as endfeel,
ducting the humerus starting in 90° of elevation. are bilaterally compared and recorded ·"9 Cap
These impingement tests primarily indicate the sular mobility testing with the shoulder in 90° of
presence of rotator cuff injury from compres abduction is particularly important, due to the
sive or impingement etiology.10.48 Tests to de important hammock-like stabilizing function of
termine the i ntegrity of the static stabilizers of the inferior glenohumeral ligament complex.
the glenohumeral joint are a vital part of the The anterior band of the inferior glenohumeral
comprehensive evaluation. 8.9 Rotator cuff in ligament provides critical reinforcement against
jury caused by instability of the glenohumeral anterior translation of the humeral head (sublux
joint is a common occurrence in younger indi ation) with the arm in a position of 90° of abduc
viduals and in overhead athletes. 8.9 tion and 90° of external rotation 48
Clinical tests for instability must be routinely An additional test to determine the degree of
performed on the patient with rotator cuff pa anterior capsular laxity is the Lachman test of
thology, to determine the underlying mobility the shoulder· With the patient supine and the
status and/or degree of instability in the glenohu shoulder abducted 90° with 45° of external rota
meral joint. Clinical tests for instability of the tion, an anterior force is applied to the humeral
glenohumeral joint include the apprehension head to assess anterior translation of the gleno
and M D I sulcus signs, as well as the fulcrum, humeral joint and note the end point of the ante
load and shift, and subluxation relocation tests. rior capsule·
( Further discription of these clinical tests can be The consistent use of these instability tests
found in Chapter 3). The subluxation relocation will provide the clinician with greater insight re
test popularized by Jobe8.32 is performed with garding the relationship, if any, between the pa
the patient supine, with 90° of glenohumeral tient's rotator cuff pathology and glenohumeral
joint abduction and 90° of external rotation. The joint instability. The identification of either ante
examiner pushes the humeral head forward, rior or multidirectional glenohumeral joint lax-
R OTATOR CUFF PATHOLOGY AND REHAB I LITAT I ON 287
the force couple. A force couple consists of a pair Weakness of the rotator cuff, coupled with hy
of forces acting on an object that tends to pro pertrophy or training enhancement of the del
duce rotation, even though the forces may act toid through uneducated exercise prescription
in opposing directionsSO An example of a force by the patient using traditional "large shoulder
couple in the shoulder is the deltoid-rotator cuff muscle group dominant" resistive training exer
force couple outlined by [nOlan et al. 5J The force cises, further perpetuates this force couple im
vector of the deltoid, if contracting unopposed, balance.
is superior. which would create superior migra The coordinated interplay between the rota
tion of the humeral head. 52 The supraspinatus tor cuff and deltoid musculature ic f,!rther dem
muscle has a compressive [unction when con onstrated in EMG analysis by Kronberg et al. 2
tracting, creatingan approximation of the hume This study illustrates that all of the rotator cuff
rus into the glenoid (Fig. 1 1 .4). The infraspi muscles are involved, to some extent, with basic
natus, teres minor, and subscapularis produce a shoulder movements, acting to assist in the
caudal rorce that resists the superior migration movement and counterbalance the micromo
of the humeral head. One factor of key impor tions of the humeral head to keep it stable within
tance when clinically interpreting the force cou the glenoid.
ple concept is the muscle's force potential in rela Additional force couples described in the lit
tion to its physiologic cross-sectional areaso eratureS .50 are the serratus anterior-trapezius
Research shows the subcapularis to have the and internal-external rotator couples. The serra
greatest force potential, followed closely by the tus anterior-trapezius force couple is also impor
infraspinatus-teres minor groupSO The smallest tant in rotator cuff pathology, as it produces up
physiologic cross-sectional area is exhibited by ward rotation of the scapula, ' moving the
the supraspinatus. These small rotator cuff overlying acromion superiorly out of the path of
cross-sectional areas paJe in comparison to the the elevating proximal humerus. The internal-ex
larger force-generating capacities of the deltoid ternal rotator force couple is another commonly
muscle. The presence of a force couple imbal- imbalanced pair in the overhead athlete, due to
288 PHY S I CAL THERAPY OF THE SHOULDER
upper exlremily is also indicated. Commonly ap The Davies modified base pOSItIOn is initially
plied are medicine balls and therapeutic Swiss used for all patients for internal and exlernal ro
balls in exercise pallems that utilize the stretch lation. 3 5.46 Submaximal intensities at speeds
shortening cycle of the scapulolhoracic muscu ranging from 2 1 0· 10 300·/sec are used, wilh spe
lature, such as chest passes, and various throw cific emphasis on the external rolators because
and catch maneuvers that alter the position of of their important role in funclional activilies3 .'.7
the glenohumeral joint 6' and in the mainlenance of dynamic glenohu
Resistive exercises with emphasis on the bi meral joint slability.' ·56
ceps muscle are recommended in rotator cuff re Progression from lhe modified position in
habilitation, due to the glenohumeral joint stabi palients who will reLUm to aggressive overhead
lizing and humeral head depression actions.65- 67 activity is followed, using tissue tolerance as the
Strengthening of the biceps in neutral and 90· of guide. lsokjnetic internal and external rotation
shoulder flexion is recommended, with concen in lhe scapular plane, with 80· to 90· of abduc
tric and eccentric contractions implemented. tion using fasl conlraclile velocilies, has been
The use of isokinelic exercise is warranled successf�llly used as an end-slage rota lor cuff ex
in later stages of both non- and postoperative re ercise, to prepare lhe rolator cuff musculalure
habililation. As patients lolerate medium-resis for the demands of overhead activily (Fig. I 1 .6).
lance surgical tubing exercise and can perform Interprelation of isokinetic tesl dala lypi
isolated rolalor cuFf exercise wilh a 3-pound cally focuses on bilaleral comparisons and uni
weight, they are considered for this progression. lateral strength raoos. 46 Unilaterally dominant
A B
FIGURE 1 ( ,6 (A & B) /sokillelic illlemaliexlenwl rolalion wilh 90·of abdtlClioll il1 l"e scaplllar
plane.
R OTATOR C U FF PATHOLOGY AN D REHAB i l i TAT I ON 291
upper extremity sport athletes often demon subacromial decompression is used to remove a
strate I S to 30 percent greater internal rotation portion o[ the overlying offending structure, and
strength on the dominant arm, with bilaterally provide both protection for the rotator cuff and
symmetrical external rotation strength. 35 .46.53.5 4 prevention of further disease progression follow
Although bilateral comparison does provide im ing its repair.69
portant baseline comparison for the individual, Another commonly used surgical exposure
the unilateral strength ratio may be o[ even for rotator cuff repair is the lateral "deltoid-split
greater importance. J5 ,41,46 The unilateral t i ng" approach. This surgical approach begins
externaliinternal rotation ratio in healthy shoul with a transverse incision through the skin, 4 to
de, has been reported at 66% throughout the 6 cm in length, beginning at the anterolateral
velocity spectrum ·6 Patients with rotator cuff corner of the acromion and continuing poste
impingement and glenohumeral joint instability riorly to the posterolateral corner 70 A straight
have significant alterations o[ this normal 66 longitudinal incision based off the lateral aspect
percent ratio ' ! The unilateral strength ratio is of the acromion, along the line of the deltoid fi
also altered « 66 percent) in the dominant atom bers, is also frequently used. Regardless of the
in overhead throwing and racquet sport athletes orientation of the skin incision, the deltoid is
due to the selective internal rotation strength de then split in line with its fibers near the antero
velopment. 3 5.46.53 .54 Isokinetic exercise and iso lateral corner of the acromion. The deltoid's ori
lated joint testing is an objectively quantifiable gin is protected and not detached. The deltoid is
method to address the force couple imbalances not split further distally than 5 cm to avoid dam
often inherent in the shoulder with rotator cuff age to the axillary nerve. 70
pathology. The type of surgical approach used in an
open rotator cuff repair dictates the progression
of both range of motion and resistance exercise
following surgery. With the anterior deltopect
Specijic Factors Influencing the oral approach ( where the deltoid can be de
RehabiJ,ilaticm oj Rotator Cuff tached from its origin), restrictions regarding the
Tears application of active OJ' resistive exercise are nor
mally given, to allow the deltoid's origin to heal
SURGICAL APPROACH and become viable before the larger stresses in
cUl'red with active or resistive movements are ap
The type of surgical approach used during open
plied. Active-assistive movement following sur
repairs of rotator cuff tears has a considerable
gery with the m ini-arthrotomy technique, using
innuence on several aspects of the rehabilitative
the lateral deltoid splitting approach, can nor
process. Two surgical approaches commonly mally commence on the first postoperative
seen in rehabilitation will be briefly discussed. day. 7o Preservation of the deltoid's origin allows
The "deltopectoral approach" consists of an an more aggressive range of motion and earlier ap
terolateral incision beginning JUSt below the plication of strengthening exercises during the
middle one third of the clavicle, crosses the cora rehabilitation process. This author's protocol for
coid tip, and continues distally in an oblique lat rehabilitation following open rotator cuff repair
eral fashion to the anterior aspect of the hume with a deltoid splitting surgical approach is given
rus "" Nearly all anterior surgical procedures can in Case Study I later in the chapter.
be accomplished using this surgical exposure, in Progression of both range of motion and re
cluding open rotator cuff tears. sistive exercise is much [aster following arthro
In some cases, anterior surgical exposure of scopic rotator cuff debridement (Case Study 2).
the shoulder requires detachment of the deltoid Active, active-assistive, and passive range of mo
origin from the anterior aspect of the acro tion all commence on the first postoperative day
mion "9 This is particularly common i[ an open following artlu'oscoPY unless associated surgical
subacromial decompression is performed. The procedures were performed such as anterior
292 PHY S I CA L THERAPY OF THE SHO U L D E R
capsulorrhaphy, repair of a Bankart lesion with throscopic debridement and subacromial de
suture tacks, laser capsulorrhaphy, or extensive compression are two options frequently dis
subacromial decompression. Submaximal inten cussed. 7 ' - 73 Rockwood and Burkhead7 ' followed
sity resistive exercise is also initiated rapidly, fol 93 patients who underwent open debridement
lowing debridement of pa.-tial rotator cuff tears. and subacromial decompression for irreparable
Because arthroscopic approaches to the shoul rotator cuff tears. Minimal deterioration in func
der do not disturb the deltoid origin or the tra tion and no degenerative changes were repOl�ed
pezo-deltoid fascia, resistive exercise using a with an 8-year average follow-up evaluation.
low-resistance, high-repetition format is recom Burkhart 73 studied 25 patients who undelwent
mended early, to retard atrophy and begin to a1�hroscopic debridement and subacromial de
normalize muscular strength imbalances. 7o compression of massive rotator cuff tears with
an average 30 monlh follow-up. Eighty-eight per
cent of the patients in this series were found to
LENGTH OF IMMOBILIZATION
have good or excellent results, with no deteriora
The degree and length of immobilization of the tion of results over time. Finally, Montgomery et
shoulder following rotator cuff repair can greatly al. 72 compared the results of open surgical repair
affect early rehabilitation emphasis. Traditional to a.�hroscopic debridement in 87 consecutive
immobilization in a sling or sling and swathe for patients with full-thickness rotator cuff tears. A
up to 6 weeks following open rotator cuff repairs 2- to 5-year follow-up revealed that the open sur
results in a capsular pattern of range of motion gical repair group had superior results as com
limitation that requires extensive joint mobiliza pared to the arthroscopic group. The literature
tion and passive stretching. Extensive limitation contains an extensive an-ay of research demon
in active and passive elevation, as well as external strating the efficacy of various surgical proce
rotation of the shoulder, are commonly present dures for rotator cuff pathology which is far be
following this degree and length of immobiliza yond the scope of discussion of this chapter. One
tion. Patients seen following arthroscopic de consistent finding is the important role of physi
bridement of partial rotator cuff tears often re cal therapy in both the conservative treat
ceive no immobilization other than a sling for ment 74 , 75 as well as postoperative management
one to two postoperative days, and hence often of rotator cuff disease.
require minimal accessory mobilization to re
store normal joint arthrokinematics. The com
mon finding of associated instability and capsu
Fa.ctms IrIjl'l.lffl1.(Jing tIw Results oj
lar laxity in the overhead athlete with partial
undersurface rotator cuff tears, coupled with NO'Yl(J[Jerativ e RehahUitation oj
minimal immobilization time following arthro Rotatm Cuff Tears
scopic debridement, often deemphasize the im
portance of accessory joint mobilization, espe Several factors are consistently rep0l1ed in the
cially to the anterior capsule. As stated earlier, literature as having a significant relationship to
the loss of internal rotation range of motion does the outcome of nonoperative treatment of rota
indicate the application of posterior capsular tor cuff disease. Clinical findings and prognostic
mobilization and passive stretching techniques factors associated with unfavorable clinical out
in this population. 39.40 comes in a sample of 1 36 patients with impinge
ment syndrome and rotator cuff disease were ( I )
rotator cuff tear greater in size than 1 .0 cm' , (2)
SURGICAL PROCEDURE
a history of pretreatment symptoms greater than
Debate in the literature regarding the surgical 1 year, and (3) Significant functional impairment
management of rotator cuff tears exists. Open at initial evaluation. 7 5 Itoi and Tabata74 repo.�ed
repair of the tom rotator cuff tendon versus ar- on the clinical outcome of conservative treat-
ROTATOR CUFF PATHOLOGY AN D REHAB I L I TAT I ON 293
ment of 1 24 shoulders with a full-thickness rota ing follow-through of his pitching motion. In ad
tor cuff tear with a follow-up of 3 years. The pri dition to localized anterior left shoulder pain, the
mary factors relating to an unsatisfactory result patient complained of weakness, loss of velocity
were identified in their sample as limited abduc in his throwing performance, and eventually an
tion range of motion and significant abduction inability to tolerate repeated repetitions of over
muscular weakness on initial evaluation of the head activity. His pertinent history includes pre
patient. Factors not associated with clinical out vious bouts of what he calls impingement dating
come included patient age, gender, occupation, back to his high school and collegiate baseball
associated instability, dominance, and chronic years. He denies any dislocations of his left
ity of onset. shoulder. After 2 months of nonoperative treat
ment, including nonsteroidal anti-inflammatory
medication and physical therapy for rotator cuff
and general upper extremity strengthening, he
Summary
was scheduled for further diagnostic testing.
Rehabilitation of rotator cuff pathology requires Diagnostic testing revealed an undersurface
an extensive, objectively based evaluation and (articular side) tear in the supraspinatus tendon.
thorough understanding of the complex bio He underwent an arthroscopic procedure to de
mechanical principles and etiologic factors bride the margins of the partial-thickness tear.
associated with rotator cuff injury. A rehabil He is referred to physical therapy one day follow
itation program aimed at restoring nOlmal ing arthroscopic surgel)'.
joint arthrokinematics and normal muscular INITIAL FINDINGS
strength, endurance, and balance is supported
Examination of the patient postop reveals no ob
by the scientific principles currently present i n
vious atrophy with the exception of a hollowing
th e literature. Isolated treatment and evaluative
in the infraspinous fossa on the left. Passive mo
focus on the rotator cuff and glenohumeral joint
tion on the second day postop is 1 20· in forward
must be combined with a more global upper ex
flexion, 1 00· of abduction, 75· of external rota
tremity kinetic chain approach to comprehen
tion, and 20· of internal rotation. Good distal
sively address rotator cuff pathology.
strength is present, and intact neurologic status
is confirmed. Passive accessory mobility of the
patient's left shoulder reveals a 2 + anterior
CASE STUDY 1 translation at 60· and 90· of abduction, as com
REHABILITATION FOILOWING pared to a 1 + on the right uninjured shoulder.
Posterior and caudal mobility are equal bilater
ARTHROSCOPIC ROTATOR
ally. Additional special tests such as labral and
CUFF DEBRIDEMENT OF AN impingement test are defelTed due to the pa
UNDERSURFACE TEAR OF THE tients acute postoperative nature.
SUPRASPINATUS TREATMENT
The patient is a 27-year-old professional baseball Modalities are applied (electric stimulation and
pitcher who started having left anterior shoulder ice) to decrease pain and swelling, with a pri
pain in early April following a normal, unevent mary goal initially of restoring normal joint mo
ful spring training. Although the patient denies tion. Passive, active assistive and active ROM are
any particular incident of i njury, he reported ini used to telminal ranges as tolerated. Accessory
tially decreased recovery following pitching and mobilization is applied in the posterior and cau
pain in the anterior aspect of his shoulder dUl;ng dal directions to facilitate the return of flexion,
the acceleration phase and continued pain dur- abduction, and internal rotation ROM. Anterior
294 PHY S I CAL THER A P Y OF THE SHOU L D E R
glides are not indicated due to the hypelmobility plied during thi> time frame. Results of the pa
assessed on initial evaluation. Application of iso tients initial isokinetic test show 1 0 to 1 5 percent
metric and manually resisted rotator cuff greater internal rotation strength when com
strengthenjng is initiated along with scapular pared to the uninjured extremity and 5 to 1 0 per
stabilization techniques (rhythmic stabilization, cent weaker external strength at 5 weeks postop.
manual protraction/retraction). At the end of the External/internal rotation ratios range between
rirst postoperative week, the patient has 1 75° of 45 and 50 percent, revealing a relative weakness
forward Oexion and abduction, 90° of external or imbalance of external rotation strength on the
rotation, and 35° of internal rotation measured dominant extremity. A plyomctric program with
with 90° of abduction. medicine balls to simulate functional muscular
contractions and facilitate scapulothoracic
strength is initiated dUI-ing this stage.
WEEKS 2 4
ranges of motion are indicated, with posterior Continued mobilization and PROM to normalize
glides and emphasis on stretching of the poste glenohumeral joint motion are performed, with
rior musculature to increase internal rotation. continued emphasis on the posterior capsule and
Progression of the patient's rotator cufr strength posterior musculature. Isotonic rotalor cuff ex
ening program includes concentric and eccentric ercise is progressed to not more than 5 pounds,
isotonic exercise using the pallerns with high and advancement of the scapular programs in
levels of scientirically documented rotator cuff isotonic, closed-chain . and plyometric venues
activation. Initially a I -pound weight is tolerated continues. Isokinetic testing at 8 to 9 weeks
with progression to 3 pounds by 3 weeks postop. postop shows 25 percent greater internal rota
Advancement of the patient's scapular strength tion strength, and equal external rotation
ening program includes the use of closed-chain strength measured in the modiried position. At
Swiss ball exercise, seated rows, shrugs, and ser this time the patient is progressed to an interval
ratus anterior dominant activities including a Ihrowing program , carried out at the clinic on
protraction punch movement pattern with tub alternate days beginning with tossing at a 30-foot
ing and manual resistance. Distal strengthening distance, progressing over the next 3 to 4 weeks
is of key importance, and bicep/tricep and to 60, 90, and 1 20-foot stages. Once the patient
forealm/wrist isotonics are perfOlmed both in tolerates 1 20 feet with as many as 75 10 1 00 repe
the clinic and in the home program. Continued titions, he is progressed to throwing off the
progress of this patient is documented with mound at 50 percent intensities. The isokinetic
AROM of the left shoulder a t 1 75° of forward strengthening is progressed to a more functional
Oexion and abduction, 95° of external rotation, 90° abducted position in the scapular plane. The
and 40° of internal rotation. continuation of a lotal arm strength program
both in-clinic and at home is followed.
WEEKS 4-8
intelmittent based on his level of activity. One of the elbow, particularly into extension because
month ago the patient was hitting a serve early in of the continued use a sling for immobilization,
a match with minimal warm-up and felt a deep, is i ndicated, as well as the use of grip putty to
sharp pain in the anterolateral aspect of his prevent disuse atrophy of the forearm and wrist
shoulder as his arm was accelerating forward musculature during the immobilization period.
just prior to impacting the ball. He was unable The patients initial range of motion at 1 week
to continue playing, and following the match was status post open rotator cuff repair is 90° of flex
unable abduct or flex his arm more than 90°. ion and abduction, 50° of internal rotation, and
Continuous pain was reported, even with rest 30° of external rotation. During the third postop
and sleeping, and he was evaluated by an or erative week, passive range of motion is pro
thopedic surgeon 2 days later. An M R l was gressed to active-assistive range of motion. The
scheduled, which revealed a full-thickness tear use of overhead pulleys and the upper body er
of the supraspinatus tendon. He subsequently gometer are added within the range of motion
underwent an open surgical repair using a del restrictions listed. Submaximal multiple angle
toid splitting approach, and is refelTed for post isometrics are performed for shoulder IRIER, as
operative rehabilitation 2 days following sur well as manual resistance exercise for the biceps
gery. and triceps, scapular protractors/retractors, and
elevators, and distal forearm and wrist muscula
INITIAL FINDINGS ture.
The patient presents with his right arm immobi PHASE II: TOTAL ARM STRENGTH (WEEKS 6-12)
lized in a sling. Initial orders are for passive
The patient's range of motion is advanced from
range of motion for the initial 2 weeks within the
active assistive to active, and terminal ranges of
limitations of 100° of flexion and abduction, 30°
flexion, abduction, and internal and external ro
to 40° external rotation. The patient has no distal
tation are included. CLm-ent range of motion of
radiation of symptoms and full light touch sensa
the patient is 1 20° of flexion, 1 05° of abduction,
tion and strong distal grip. The initial exam con
60° of external rotation, and 60° of internal rota
sists primarily of a neurologic screening and pas
tion. Continued mobilization of the glenohu
sive range of motion measurement. The patient's
meral joint is combined with end-range passive
contralateral extremity has a 1 ° load and shift
stretching techniques to restore normal joint
and anterior translation. The patient expressly
arlhrokinematics. Initiation of resistive exercise
denies any instability in either shoulder prior to
in the form of isotonic internal and external rota
this injury. Instability or impingement tests are
tion, prone extension, horizontal abduction, and
not performed on the postop shoulder at this
eventually scaption are performed with no resis
time.
tance, progressing the resistance level as toler
ated. Advancement of the scapular strengthening
INITIAL PHASE (lVeeks 0-6)
program to include plyometrics with a Swiss ball
Modalities consisting of electric stimulation and and eventually a medicine ball are included dur
ice are applied as needed to control pain and in ing this time frame. Concentric and eccentric
crease local blood now. Passive range of motion muscular work are performed using surgical tub
is performed using the above guidelines as maxi ing and controlled execution of the resistive exer
mal ranges. Evaluation of the patient's accessory cise patterns with isotonic resistance. At 1 0 days
movement reveals a decreased caudal glide and po top this patient has 1 55° of forward flexion,
posterior glide relative to the contralateral ex 1 45° of abduction, and 85° of external rotation
tremity. Accessory mobilizations are applied with 90° of abduction. Sixty degrees of internal
using the caudal and posterior directions along rotation is present with 90° of abduction. Toler
with passive stretching. Mobilization of the sca ance of 3-pound isolated rotator cuff exercises
pulothoracicjoint is also used. Passive stretching (ment ioned earlier) is demonstrated. The patient
296 P HY S I CAL THERAPY OF THE SHOULDER
is progressed to isokinetic internal and external charge of the patient from formal physical
rotation in the modified base position for a trial therapy.
of submaximal isokinetic exercise. Continued
use of home exercise for the rotator cuff using
tubing as well as the use of tubing and a counter Referenc es
balanced weight for a forearm and wrist pro
gram, to begin to prepare the distal upper ex I . Blaiser RB, Guldberg RE, ROlhman ED: Anterior
stability: Contributions of rotator cuff forces and
tremity for the return to tennis play in the later
the capsular ligaments in a cadaver model. J
stages of rehab.
Shoulder Elbow SlIrg 1 : 1 40, 1 992
2. Kronberg M, Nemeth F, Brostrom LA: Muscle ac
RETURN TO ACTIVITY PHASE (WEEKS /2-/6) tivity and coordination in the nannal shoulder:
An electromyographic sJUdy. Clin Olihop 257:76,
Continued accessory mobilization to achieve full 1 990
ranges of elevation is applied to this patient, as 3. Rhll KN, McCormick J, Jobe FW et al: An electro
well as passive stretching in physiologic range of myographic analysis of shoulder fllnction in ten
motion patterns. An isokinetic test is performed nis players. Am 1 SPOliS Med 1 6:48 1 , 1988
in the modified base position, revealing equal in 4. Vangheluwe B, Hebbelinck M : Muscle actions and
ternal rotation strength bilaterally, with a 35 per ground reaction forces in tennis. lnt J Sports Bio
mechan 2:88, 1 986
cent external rotalion deficit identified. The pa
5. Miyashita M . Tsunoda T, Sakurai S ct al: MusclI
tient's ERlIR ratio is 54 percent, well below the
lar activities in the Lennis serve and overhead
desired 66 percent balance. Range of motion for
throwing. Scand 1 SPOlis Sci 2:52, 1 980
this patient has continued to improve to 1 75° of 6. lobe FW, Maynes DR, Tibone lE et al: An EMG
flexion and 1 60° of abduction, 95° of external ro analysis of the shoulder in pitching. Am J Sports
tation, and 60° of internal rotation. Advancement Med 1 2 :2 1 8, 1 984
of the patient's strengthening program includes 7. Fleisig GS, Andrews JR, Dillman Cl, Escamilla
the 90° abducted position for both isokinetic RF: Kinetics of baseball pitching with impl ica
lRlER and surgical tubing strengthening. Plyo tions about injury mechanisms. Am J Sports Mcd
metric exercise with medicine balls intensifies, 23:233, 1995
as does the entire scapular program, including 8 . lobe FW, Kivitne RS: Shoulder pain in the over
hand or throwing athlete: The relationship of an
the use of closed chain push-ups and step-ups
terior instability and l"Otator cuff impingement.
with emphasis on protraction for serratus
Orthop Rev 28:963, 1989
strengthening. The patient conlinues with reha
9. Andrews JR, Alexander EJ: Rotator cuff injury i n
bilitative exercise and close adherence to a home throwing and racquet sports. Spor1s Med Ar1hros
program to reinforce the concepts of total arm cop Rev 3:30, 1 995
strength in preparalion for the interval return to 1 0. Neer CS: Anterior acromioplasty for the chronic
tennis play. Achievement of greater external ro impingement syndrome in the shoulder. A pre
talion muscular strength and endurance is rec li monary repoli. 1 Bone Joint Surg 54A:4 1 , 1972
ommended before this patient begins the inter I I . Neer CS: Impingement lesions. Clin Orthop 1 73:
val tennis program. The guided return to tennis 70, 1983
will include groundstroke activity initially, with 12. Golding FC: The shoulder: Theforgol lenjoinl. Br
J Radio1 35: 1 49, 1 962
progression to volleys and serving based on toler
1 3 . COllon RE, Rideoul OF: Tears or the humeral ro
ance to the forehand and backhand
tator cuff: a radiological and pathological ne
groundstrokes. Typically the interval program
cropsy survey. 1 Bone Joint Surg 46B:314, 1 964
following an open repajr of a full-thickness rota 1 4. Poppen NK, Walker PS: Forces at the glenohu
tor cuff tear takes up to 6 to 8 weeks before pro meral joint in abduction. Clin Olihop 1 35 : 1 65 ,
tected match play can resume. Emphasis on con 1 978
tinued use a rotator cuff and scapular strength 1 5 . Lucas DB: Biomechanics of the shoulder jOint.
maintenance program is followed upon dis- Arch Surg 1 07:425, 1 973
R O T ATOR CUff PATHOLOGY AND R EHABI L I TAT I ON 297
1 9. Zuckerman JO, Kummer FJ, Cuomo et al: The in 34. Fukuda H, Hamada K, Nakajima T, Tomonaga A:
nuence of coracoacromial arch analOmy on rota Pathology and pathogenesis of the intratendinous
lor cuff Icars. J Shoulde,- Elbow Surg 1 :4 , 1992 teadng of the rotator cuff viewed from en bloc
h istologic sections. Clin O'1hop 304:60, 1 994
20. Nirschl RP: Shoulder lendonilis. In Pelll'onc FP
35. Ellenbecker TS: Rehabililation of shoulder and
(cd): Upper Extremity InjUlies in Athletes. Ameri
elbow injudes in tennis players. Clin Sports Med
can Academy of 011hopaedic Surgeons Sympo
14:87, 1 995
sium. Mosby, Washinglon, DC, 1 988
36. Kibler WB: Role of the scapula i n the overhead
2 1 . Cofield R: Current concepts review of rotator cuff
Ihrowing mOlion. Comemp O'1hop 22:525, 1 99 1
diseasc of Ihc shoulde,-. J Bone Joim Surg 67A:
37. ElienbeckerTS, Roelert E P , Piorkowski P : Shoul
974, 1985
der intel-nal and eXlernal rotation range of motion
22. Codman EA: The Shoulde,·. 2nd Ed. Thomas
of elite junior tennis players: a comparison of two
Todd, Boslon, 1934
protocols, abstracled. J Orthop Spo'1S Phys The,-,
23. Chansky HA, lannolli JP: The vascularilY of Ihe
1 7 :65, 1 993
rolalor cuff. Clin SPO'1S Med 1 0:807, 1 99 1
38. Chandler n, Kibler WB, U h l TL el al: Flexibilily
24. Ralhbull1 JB, MacNab I : The microvascular pal
comparisons of elite junior tennis players to other
lem of Ihe rolalor cuff. J Bone Joinl Surg 52B:
ath leles. Am J Sports Med 1 8 : 1 34 , 1 990
540, 1970
39. Harryman DT, Sidles lA, Clark 1M, et al: Transla
25. Brooks CH, Revell WJ, Headey FW: A quamilalive
tion of the hu meral head on the glenoid with pas
histological study of the vascularity of the rotator
sive glcnohumcral joint motion. J Bone Joint Surg
cuff tendon. J Bone Joinl Surg 74B: l S I , 1 992
72A:1 334, 1 990
26. Swiontowski MF, Iannotti IP, Boulas HJ et al: In
40. Matscn FA Ill, Artnz CT: Subacromial impi nge
traoperative assessment of rotator cuff vascularity
ment. p. 623. In Rockwood CA Jr, Malsen FA I I I
using laser doppler Oowmelry. p. 208. In Post M ,
(eds): T h e Shoulder. W B Saunders, Philadelphia,
Mon'ey BF, Hawkins R J (eds): Surgery o f the 1990
Shoulder. St. Louis, Mosby Vear Book, 1990 4 1 . Warner JJP, Micheli LJ, Arslanian LE, el al: Pal
27. lannolli JP: Lesions of the rotalor cuff: Pathology lems of nexibility, laxity, and strength in normal
and Pathogenesis. In Matsen FA, Fu Fl-!, Hawkins shoulders and shou lders with instability and im
RJ (eds): The Shou lder: A Balance of Mobility and pingement. Am J Sports Med 1 8:366, 1 990
Siabilily. American Academy of Orthopaedic Sur 42. Hoppenfeld S: Physical examination of the spine
geons, Rosemonl, IL, 1 993 and extremities. Prentice-Hall, Norwalk, CT, 1 976
28. Loehr JF, Helmig P, Sojbjerg JO, JungA: Shoulder 43. Saha AK: Mechanism of shoulder movements and
instability caused by I'olator cuff lesions: An in a plea for the recognition of "zero position" of gle
vitro sludy. Clin O'1hop 303:84, 1 994 nohumeral joint (rep,-inled). Clin Orthop 1 73:3,
29. Miller C, Savoie FH: Glenohumeral abnormalilies 1983
associated with full-thickness tears of the rotator 44. Daniels L, Wort hingham C: Muscle Testing: Tech
cuff. O,1hop Rev 23: February 1 994, 1 59 niques of Manual Examination. 5th Ed. WB Saun
30. Fukada H, Hamada K, Vamanaka K: Pathology ders, Philadelphia, 1 986
and pathogenesis of bursal side rotator cuff tears 45. Ellenbecker TS: Muscular slrength relalionship
viewed from en bloc h istologic sections. Clin Or between nOlmal grade manual muscle testing and
thop 254:75, 1 990 isokinctic measurement of the shoulder intemal
3 1 . Nakajima-T, Rokumma N, Kazuloshi H et at: His and extcmal rotators, abstracted. J Ol-lhop Sports
tologic and biomechanical characteristics of the Phys Ther 1 9:72, 1 994
298 PHY S I CAL THERAPY OF THE SHOULDER
46. Davies GJ: A compendium of isokjneLics in c1ini· during a baseball rehabilitation program. Am J
cal usage. 4th Ed. S & S Publishers, LaCrosse, WI. SPOl1S Med 1 9:264, 1 99 1
1 992 6 2 . Fleck 5, Kraemer W: Oesigning Resistance Train
47. Hawkins RJ, Kennedy JC: Impingement syn ing Programs. Human Kinetics, Champaign, IL.
drome in athletes. Am J SP0l1S Med 8: 1 5 1 , 1 980 1987
48. Obrien SJ, Neves MC, Arnoczky SJ et al: The anat 63. Moesley JB, Jobe FW, Pink M : EMG analysis of
omy and histology of the inferior glenohu meral thc scapular muscles dud ng a shoulder rehabi lita
ligament complex of the shoulder. Am J Sports tion program. Am J SpOl·ts Med 20: 1 28, 1 992
Med 1 8 :449, 1 990 64. Wilk KE, Voight ML, Keirns MA et al: Stretch·
49. Altchek OW, Skyhar MJ, WalTen RF: Shoulder ar shortening drills for the upper extremities: theOl),
throscopy fOl' shoulder instability. p. 1 87. In: In· and clinical application. J Ol1hop Sports Phys
structional Course Lectures. The Shoulder. Amer Ther 1 7:225, 1 993
ican Academy of Orthopaedic Surgeons, 65. Glousman R, Jobe FW Tibone JE et al: Dynamic
,
An important component of the inilial or problems, cancer, diabetes, rheumatoid arthri
thopedic evaluation is to differentiate the etiol tis, kidney problems, hepatitis, or heart attack . I
ogy of a patient's pain complaints as neuromus Two imp0l1ant aspects of the orthopedic
culoskeletal in origin versus visceral pathology evaluation that will help detect visceral pathol
or disease. Screening for visceral disease is im ogy or disease are a careful history and palpa
portant for several reasons: ( I ) many diseases tion. A sampling of important questions related
mimic orthopedic pain and symptoms, and a to the history-taking portion of the evaluation is
subsequent delay in diagnosis and treatment listed below2:
may lead to severe morbidity or death; (2) there
I . Describe the first and last time you experi
is a significant increase in the number of patients
enced these same complaints .
over the age of 60 seeking orthopedic medical
care; and (3) there is an increase in the managed 2. Are your symptoms the result of a trauma,
or are they of a gradual or insidious onset?
care environment that encourages fewer refer
rals to specialists, fewer referrals for diagnostic 3. Was it a macrotrauma (motor vehicle acci
testing, and less time given to plimary care phy dent, fall, sports injury) or repeated micro
sicians to make an accurate diagnosis of every trauma (overuse injury, cumulative trauma
patient complaining of musculoskeletal pain. disorder)?
Consequently, the physical therapist in an outpa 4. What was the mechanism of injury?
tient orthopedic selling is evaluating and lreat 5. Do you have any other complaints of pain
ing patients who have greater morbidity and are throughout the rest of your body-head,
more acutely ill than the patients who presented neck, chest, back, abdomen, arms, or legs?
for therapy 1 0 or 1 5 years ago. Recent research 6. Do you have any other symptoms through
has found that approximately 50 percent of all out the rest of your body-headaches, nau
the patients refen'ed for outpatient orthopedic sea, vomiting, dizziness, shortness of
physical therapy have at least one of the follow breath, weakness, fatigue, fever, bowel or
ing diagnoses: high blood pressure, depression, bladder changes, numbness, tingling, pins
asthma, chemical dependency, anemia, thyroid or needles?
299
300 P H Y SI C A L T H E R A P Y OF T H E S H O U L D E R
eral pulses is another important diagnostic tool these nociceptors by sufficient chemical or me
for the orthopedic manual therapist. When pal chanical stimulation, neural information is
pating a pulse, the therapist needs to compare transmitted along small unmyelinated type C
the amplitude and force of pulsations in one ar ne,ve fibers within sympathetic and parasympa
tery with those in the cO'Tesponding vessel on thetic nerves . 3. 1 5- 17
the opposite side.7 Palpation of the artery should This information is subsequently relayed to
be performed with a light pressure and a sensi the mixed spinal nerve, dorsal root, and into the
tive touch. If the pressure is firm, then there is dorsal horn of the spinal cord (Plate 1 2 .2) . Sec
a risk of not being able lO perceive a weak pulse ond-order neurons in the dorsal horn project in
or misinte'-prcting your own pulse as that of the the anterolateral system." Within the anterolat
patient's 7 Pulsations may be recorded as normal eral system, nociceptive impulses ascend in the
(4), slightly (3), moderately (2), or markedly re spinothalamic, spinoreticular, and spinomes
duced ( 1 ), or absent (0).7 Palpate the arterial encephalic tracts." The targets in the brain for
pulses for cardiovascular and peripheral vascu these tracts are the thalamus, recticular forma
lar disease . The arterial pulses may be palpated tion, and midbrain, respectively."
in the upper extremity (axillary 3I1ery in the ax Chemical stimulation of nociceptors may re
illa, brachial artery in the cubital fossa, ulnar and sult from a buildup of metabolic end products,
radial arteries at the wrist) and lower extremity such as bradykinins or proteolytic enzymes, sec
(femoral artery at femoral triangle, popliteal ar ondary to ischemia of the viscus.3 Prolonged
tery at popliteal fossa, posterior tibialis artery spasm or distension of the smooth muscle wall
posterior to medial malleolus, and dorsal pedis of viscera can cause ischemia secondary to a col
arte,), at the base of the first and second metatar lapse of the microvascular network within the
sal bones).'. s·7 •
. viscus.' Chemicals, such as acidk gastric fluid,
Be aware of the easy and common diagnoses can leak through a gastric or duodenal ulcer into
of osteoarthritis, degenerative joint or disc dis the peritoneal cavity, resulting in local abdomi
ease, and spondylosis in the elderly population. nal pain . 3.,s
Many asymptomatic elderly persons have posi Mechanical stimulation of visceral nocicep
tive radiographs for these diseases. Also, the el tors can occur secondary to torsion and traction
derly in our society are at a greater risk for vis of the mesentery, distention of a hollow viscus,
ceral pathology and disease. In addition, old or impaction.J , I I - 14 Distention may result from a
asymptomatic orthopedic injuries may become local obstruction such as a kidney stone or from
symptomatic due to facilitation from a segmen local edema due to infection or innammation .'
tally related visceral organ in a diseased state"" o Spasm of visceral smooth muscle may also be
Pain may be defined as an unpleasant sen a sufficient mechanical stimulus to activate the
so,) , and emotional experience associated with nociceptors of the involved \�SCUS. 3.13 . '8
actual or potential tissue damage" . True visceral Visceral pain is not uncommon in patients
pain can be experienced within the involved vis suffering from neoplastic disease. Pain com
cuS.'·'2 plaints from cancer patients have several origins.
and poorly localized.3.121. 3 There is also a strong Somatic pain occurs as a result of activation of
autonomic reflex phenomenon, including sudo nociceptors in cutaneous and deep tissues
motor (i ncreased sweating) changes, vasomotor (tumor metastasis to bone) and is usually con
(blood vessel) responses, changes in arterial stant and localized." Visceral pain results from
pressure and heart rate, and an intense psychic stretching and distending or from the produc
alarm reaction. I 1 . 12,1 4 Viscera are innervated by tion of an innammatOl), response and the release
nociceptors (Plate 1 2 . 2)3" . These free nerve end of algesic chemicals in the vicinity of nocicep
ings are found in the loose connective tissue tors .' "'. ' 2 Metastatic tumor infiltration of bone
walls of the viscus, including the epithelial and and gastrointestinal and genitourinal), tumors
serous linings, as well as the walls of the local that invade abdominal and pelvic viscera are ve,),
blood vessels in the viscus . 3 After activation of common causes of pain in the cancer pa-
302 P H Y S I CA L T H E R A P Y OF T H E S H O U L D E R
PATIENT QUESTIONNAIRE
AGE . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . .
HEIGHT ....................................... .
WEIGHT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . •
EPISODE OF FAINTING . . . . . . . . . . . . . . . . . . . • . . . . . . .
DIABETIC ..................................... .
PULMONARY
HISTORY OF SMOKING . . . . . . . . . . . . . . . . . . . . . . . • . . . .
SHORTNESS OF BREATH . . . . . . . . . . . . . . . . . . . . . . • . . . .
FATIGUE .......................................
WHEEZING OR PROLONGED COUGH .................. .
CARDIOVASCULAR
HEART MURMUR/HEART VALVE PROBLEM . . . . . . . . . . • . . .
SWELLING IN EXTREMITIES . . . . . . . . . . . . • . . . . . . . • . .
PATIENT QUESTIONNAIRE
PAINFUL URINATION . . . . . . . . . . . . . . . . . . . . . . . . . • . . .
VAGINAL DISCHARGE . . . . . . . . . . . . . . . . . . . . . . . . • . . . .
PAINFUL INTERCOURSE . . . . . . . . . . . . . . . • . . . . . . . • . . .
HISTORY OF INFERTILITY . . . . . . . . . . . . . • . . . . . . . • . .
GASTROINTESTINAL
DIFFICULTY IN SWALLOWING . . . . . . . . . . . . . . . . . . . • . .
NAUSEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HEARTBURN . . . . . . . . . . . . . . . . . • . . . . . . . • . . . . . . . • . . .
VOMITING . . . . . . . . . . . . . . . . • • . . . . . . . . . . . . . . . . • . . .
FOOD INTOLERANCES . . . . . . . . . • . . . . . . . • . . . . . . . • . . .
CONSTIPATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . .
DIARRHEA . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . • • . . .
INDIGESTION .................................. .
IMPOTENCE . . . . . . . . . . . . . . . . . . . . . . • . . . . . . • . . . . . . .
tienl." Deafferentation pain results fTom injury The obselvation has been made that visceral
to the peripheral and/or central nervous system disease produces not only orthopedic pain, but
as a result of tumor compression or infiltration true orthopedic dysfunction.2o2 . I For example,
of peripheral nerve or the spinal cord, or injury pain referred to the T4 spinal segment fTom car
to peripheral nerve as a result of surgery, chemo diac t issue (angina) may cause renex muscle
therapy, or radiation t herapy for canceL" Ex guarding of the muscles supplied by T4, which
amples are metastatic or radiation-induced bra will interfere with the normal mobility of that
chial or lumbosacral plexopathies, epidural segment of the spine. This may then produce
spinal cord and/or cauda equina compression, movement around a nonphysiologic axis at that
and postherpetic neuralgia. I I segment and subsequently lead to joint injury,
Somatic, visceral, and deafferentation pain locking, or hypomobility.
may be complicated by sympathetically main
tained pain, in which efferent sympathetic activ
ity promotes persistent pain, hyperpathia, and Theories on Visceral
vasomotor and sudomotor changes . I I Also, noci Referred Pain
ceptors may be facilitated following injury, lead
ing to lower threshold of activation, greater in I. Referred pain is pain experienced in tissues
tensity of response to injury, and the emergence that are not the site of tissue damage, and
of spontaneous activity within the interneuron whose afferent or efferent neurones are not
9
pool of the dorsal horn . I 1.1 physically involved in any way."
Cerebral Cortex
Thalamus
Spinothalamic
Tract
Cervical Segment
of the Spinal
2. Pain happens within the central nervous sys tors of a viscus are eventually stimulated,
tem, not in the damaged tissue itself. Pains chemically or mechanically, these same sen
do not really happen in hands or feet or sory cortex cells may become stimulated
heads; they happen in the images of heads with the cortex interpreting the origin of
and feet and hands.22 this sensory input based on past experience.
3. Referred pain fTom deep somatic structures The pain, therefore, is perceived to arise
is often indistinguishable fTom visceral re fTom the area of skin that has repeatedly
ferred pain.2J stimulated these cOl-tical cells in the past.
The referred pain may lie within the der
4. Visceral pain fibers constitute less than 1 0
matome of those spinaJ segments that re
percent of the total afferent input to the
ceive sensory information from the visceral
lower thoracic segments of the spinal cord
organ.2 4
and are rarely activated. I S In this way, a vis
ceral stimulus may be mistaken for the 6. Sensory fibers dichotomize as they "leave"
more familiar somatic pain. IS the spinal cord, one branch passing to a vis
ceral organ as the other branch travels to a
5 . Visceral referred pain may be due to misin
site of reference in muscle or skin (Fig.
terpretation by the sensory cortex 24 Over
1 2. 2 ).2 5.2 .
the years, specific cortical cells are repeat
edly stimulated by nociceptive activity fTom 7. Visceral nociceptor activity converges with
a speci fic area of the skin. When nocicep- input from somatic nociceptors into com-
Cerebral Cortex
Thalamus
Spinothalamic Afferent
Tract Nerves
drawing of a visceral
afef r
afferem l7erve converging
Viscera onto the same
spil70thalamic tract cell il7
the dorsal hom of the spil7ai
cord.
306 P H Y S I C AL T H E R A P Y OF T H E S H O UL D E R
mon pools of spinothalamic tract cells i n esophagus. stomach and pancreas) can refer
th e dorsal horn of t he spinal cord. Visceral pain to the shoulder through contact with the
pain is then referred to remote cutaneous diaphragm (Plates 1 2. 1 . 1 2.3. and Fig. 1 2.4)J [n
sites because the brain "misinterprets" the the rat. cervical (C3. C4) dorsal root ganglion
input as coming from a peripheral cuta cells were seen that had collateral nerve fibers
neous source. which normally bombards that emanated fTom both the diagphragm and
the central nervous system with sensory the skin of the shoulder (Fig. 1 2.2)."
stimuli (Fig. 1 2.3).6.11 - 1 5 .2 3.2 7 29
Symploms
Pain in the shoulder is most often felt at the
Viscera Capahle oj ReJerring Pain supel·ior angle of the scapula. in the suprascapu
to the Shoulder lar region. and in the upper trapezius mus
c1e Jo. 3I NOImally there are no complaints of pain
DIAPHRAGM in the region of the diaphragm. unless the patient
The central portion of the diaphragm. which is suffered trauma or a musculoskeletal strain to
the surrounding tissues.
segmentally innervated by cervical nerves C3 to
CS via the phrenic nerve/ 30 can refer pain to
Diagnosis
the shoulder.25 .29- 34 Although the diaphragm is
a musculotendinous strllctUl'e and not a viscus, Local tenderness or shoulder pain during
it is i nteresting in tel·ms of the distance it refers palpation of the diaphragm. Full active and pas
its pain to the shoulder. Also. many viscera (liver. sive shoulder girdle elevation may cause pain.
C4 Seg m en t
the Sp ina l Cord
��=-C4 Affe rent Nerve
because this motion changes the shape of the rest of his body. He reported he was a competi
thoracic cage and subsequently puts tension on tive racquetball and volleyball player. He played
the diaphragm." Shoulder pain is reproduced either sport three to four times a week. The pa
or exacerbated by deep breathing, coughing, or tient reported pain for the 6 days prior to presen
sneezing,32, tation, but denied any trauma. Nine days prior to
evaluation he participated in a 2-day walleyball
(volleyball on a racquetball court) tournament.
Six days prior to presentation the patient was
CASE STUDY 1
involved in two competitive racquetball league
HISTORY
matches .
A 24-year-old right-handed male presented to He reported a constant low-intensity ache
physical therapy (February 1 992) with a diagno that never went away, regardless of what he did.
sis of "left shoulder pain." His only complaint He was able, however, to produce a sudden and
was periodic, and severe, localized left shoulder sharp pain with certain movements. He was able
pain at the acromioclavicular joint (Fig. 1 2.5). to sleep on his left side without much difficulty.
He denied neck pain, headaches, weakness, arm Eating and bowel or bladder activity had no af
pain, or paresthesias. The patient denied any fect on his symptoms. Coughing, laughing, and
other complaints or symptoms throughout the deep inhalation did, however, produce a sudden
sharp pain in the shoulder.
J l PHYSICIAN-ORDERED TESTS
GENERAL HEALTH
CERVICAL SCREEN
FIGURE t 2.5 Paill diagram from a 24 year-old Left shoulder active and passive ROM was WN L
righl-hQ/1ded l1Iale wilh a presellling diagnosis of with minimal discomfort and no reproduction
"Ief l shollider pail1. " of symptoms.
308 P H Y S I C A L T H E R A PY OF T H E S H O U L D E R
PATIENT QUESTIONNAIRE
HEIGHT ....................................... .
WEIGHT (Ibe) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . •
CONSTANT PAIN . x. . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . __
PULMONARY
HISTORY OF SMOKING ........................... .
�
SHORTNESS OF BREATH . . . . . . . . . . . . . . . . . . . . . . . . . • .
x
__
FATIGUE ...................................... .
--X
WHEEZING OR PROLONGED COUGH . . . . . . . . . . . . . . . . . • .
__ x
HISTORY OF ASTHMA, EMPHYSEMA OR COPD ......... .
__ x
HISTORY OF PNEUMONIA OR TUBERCULOSIS . . . . . . . . . •
_x_
CARDIOVASCULAR
HEART MURMUR/HEART VALVE PROBLEM ............. .
__X
HISTORY OF HEART PROBLEMS .................... .
__X
SWEATING WITH PAIN ........................... .
--X
RAPID THROBBING OR FLUTTERING OF HEART . . . . . . . •
__x
HIGH BLOOD PRESSURE . . . . . . . . . . . . . . . . . . . . . . . . . . •
__X
DIZZINESS (SIT TO STAND) . . . . . . . . . . . . . . . . . . . . . •
__ x
SWELLING IN EXTREMITIES . . . . . . • . . . . . . . • . . . . . . . .
--X
HISTORY OF RHEUMATIC FEVER ................... .
__X
ELEVATED CHOLESTEROL LEVEL ................... .
__X
FAMILY HISTORY OF HEART DISEASE . . . . . . . . . . . . . . . __
x
PAIN/SYMPTOMS INCREASE WITH WALKING OR STAIR
CLIMBING AND RELIEVED WITH REST .............. .
__ x
JOINT MOBILITY
THORACIC SPINE AROM AND PROM
Passive nexion with humeral internal rotation Pain and/or rigidity will be noted with ab
( I R) or external rotation (ER) was negative; gle dominal palpation. An upright plain anterior
nohumeral, sternoclavicular, and acromioclavi posterior radiograph will demonstrate free intra
cular joint compression and distraction were peritoneal air under one or both hemidi
negative; upper limb nerve tension tests were aphragms 36 See the associated diagnostic clues
negative. Immediate and sharp left shoulder under "Diaphragm" earlier in the chapter.
310 P H Y S I C A L T H E R A P Y OF T H E S H O U L D E R
Abdominal or vaginal surgery that allows op activItIes can be fatal due to an air embo
erative free air to enter and become trapped Iism.36.37.39- 4 1 To create pneumoperitoneum, air
within the peritoneal cavity, is another source of must first enter the vagina before it passes
refen-ed pain to the shoulder. through a patent os cervix to enter the body cav
ity of the cervix and subsequently travel through
Symptoms the uterine tube prior to escaping into the perito
neal cavity (Fig. 12.7).
Pain in the shoulder. See the associated
symptoms under "Diaphragm." SYl1lptOlltS
Pain in the shoulder. See the associated
Diagnosis symptoms under "Diaphragm."
There will be a history of recent abdominal
Diagnosis
or vaginal surgery. The abdomen is not tender
to palpation and rigidity is absent . An upright There will be a history of current or recent
plain anterior-posterior radiograph will demon pregnancy or recent abdominal or vaginal sur
strate free intraperitoneal air under the dia gery. The abdomen is not tender to palpation and
phragm.3. See the associated diagnostic clues rigidity is absent. An upright plain anterior-pos
under "Diaphragm." terior radiograph will demonstrate free intraper
For females, certain activities during preg itoneal air under the diaphragm. 3• See the asso
nancy, within 6 weeks postpartum, or follOWing ciated diagnostic clues under "Diaphragm."
abdominal or vaginal surgery, can lead to pneu
LUNG
moperitoneum. These include menstruation, ef
fervescent vaginal douching, vigorous sexual in The lung, which is innervated by thoracic nerves
tercourse, orogenital insufflation, and knee to TS to T6,3 is capable of referring pain from two
chest stretching exercises.>··37. 39 .0 The last three
. distinct diseases to the shoulder. 3o . 32 . 33 .35,43- 4.
Diaphragm
Peritoneal Cavity
'------05 Cervix
FIGURE 1 2.7 Schel1latic
The first is pulmonary infarction that is often most common fatal cancer in both men and
secondary to a pulmonary embolism.32 ... The womenso It commonly refers pain to the supra
second is a Pancoast tumor. The most common clavicular fossa, usually on the right siden Pain
cause of pulmonary embolism is a deep venous from a Pancoast tumor may be referred to the
thrombosis (DVT) originating in the proximal shoulder due to the involvement of the upper
deep venous system of the lower legs 46 Risk fac ribs. 5 1 Shoulder and arm pain may also occur
tors for DVT include blood stasis due to bed rest, secondary to contact between the cancerous
endothelial (blood vessel) injury from surge.), or lobes of the lung with the eighth cervical (C8)
trauma, and a state of hypercoagulation 46 Other and first thoracic ( T I ) nerves, resulting in shoul
ri k factors include congestive heart failure, der and upper extremity symptoms similar to
trauma, surgery (especially of the hip, knee, and thoracic outlet syndrome or a C8 radiculopa
prostate), more than 50 years of age, infection, thy 35. 43 .45. The chest wall and subpleural
diabetes, obesity, pregnancy, and oral contracep lymphatiCS are often invaded by the tumor. 5 1
tive use 46 Pain is refen'ed to the shoulder due to Other structures that may be involved include
contact with the central portion of the dia the subclavian artery and vein, inte.-nal jugular
phragm (Plate 1 2.3 and Fig. 1 2.4). 30-32 vein, phrenic nerve, vagus nerve, common ca
rotid artery, recurrent laryngeal nerve, sympa
thetic chain, and stellate ganglion.43. 45. 5 1 Cancer
SYlllptOI11S
can metastasize to the lungs fTom carcinomas in
Pain in the shoulder is most often felt at the the kidney, breast, pancreas, colon, or uterus 46
superior angle of the scapula, in the supraclavic The lung itself is a common source of meta
ular region, and in the upper trapezius mus static cancer to bone, the liver, adrenal glands,
c1e.30 .3I Patients will usually report the relief of and the brain' 6.50 Symptoms associated with
pain when lying on the involved shoulder" cancer of the spine include a deep, dull ache that
Symptoms related directly to the pulmona.) , em may be unrel ieved by rest. so Pain often precedes
bolism may include swollen and painful legs a pathologic fracture.so I f a fracture is present,
with walking, acute dyspnea or tachypnea, chest then the pain may be sharp, localized, and asso
pain, tachycardia, low-grade fever, rales, diffuse ciated with swelling S O Pain will be reproduced
wheezing, decreased breath sounds, persistent with mechanical stress, thereby simulating a
cough, restlessness, and acute anxiety.46- 48 See pure musculoskeletal dysfunction. Neurologic
the associated symptoms under "Diaphragm" signs and symptoms will be present in some pa
earlier in the chapter. tients due to compression of the spinal cord. Pain
is exacerbated by percussion of the spinous pro
cess, with a reflex hammer, of the involved verte
Diagnos;s
brae so
There is a history of recent surge.)'. Chest
radiographs, arterial blood gas studies, pulmo
Symptoms
nary angiography, and ventilation-perfusion
(V/O) scintigraphy are diagnostic tools available Shoulder pain is the presenting symptom in
for the physician.4' Plain radiographs may not over 90 percent of patients with a Pancoast
demonstrate the infarct, however, which may be tumor.43.46 A.m pain is common, often involving
hidden by the dome of the diaphragm.32 This is the medial aspect of the forearm and hand, in
a potentially fatal condition that needs rapid re cluding the fourth and fifth digits.43.4S•
fen'al for emergency medical attention. See the thesias may be felt in the arm and hand due to
associated diagnostic clues under "Diaphragm." compression of the subclavian artery and vein."
The second disease state is a Pancoast tumor Patients will often report relief of pain when
that occurs in the apical portion of the lung lying on the i nvolved shoulder.2 Associated
(Pla te 1 2.4 ) 30 .32. 35.43. 45.46.50 .51 Lung cancer is the symptoms include Horner syndrome (contrac-
312 P H Y S I C A L T H E R A P Y O F T H E S H OUL D E R
Diagnosis
CASE STUDY 2
HtSTORY
severe WIO) right shoulder pain that radiated right-/zGl,ded (elllale IVith a presel1tillg diagnosis
down her arm and along the ulnar border of her o( "(rozell shoulder. "
forearm and hand to include the third through
fifth digits (Fig. 1 2 .8). The patient presented with
a diagnosis of "frozen shoulder." She denied the patient denied any other complaints or symp
neck pain, headaches, or chest pain. About 6 toms throughout her body.
weeks prior to her evaluation she reported an PAST MEDICAL HISTORY
episode in which it felt like her whole right arm
went numb. This symptom did not return. She 1 994: Surgery to R. TMJ (2 months ago) for a
did, however, report periodic mild numbness malignant melanoma.
along the ulnar border of her right hand. On fur 1 99 1 : Fell on right shoulder, no fracture, re
ther discussion she admitted that she forgot to solved in 4 months.
tell her physician about the numbness. The pa 1 975: Lumbar disc surgery.
tient stated that her shoulder pain started gradu
PHYSICIAN-ORDERED TESTS
ally sometime in January 1 994. Her pain was ag
gravated by reaching into the back seat of her Cervical spine and right shoulder radiographs
car from the driver's seat. Relief of pain occurred were negative per physician.
when she lay down on her right side.
GENERAL HEALTH
The patient denied that there was any change
in her symptoms following stair climbing, a The patient questionnaire (Fig. 1 2 .9) revealed a
greasy meal, or a bowel movement. Except for family history of cancer. Her grandmother had
what she described on the patient questionnaire, throat cancer, her father had prostate cancer,
VISC E R A L P A T H O L O GY R E F E R R I N G P A I N TO T H E S H O U L O E R 313
PATIENT QUESTIONNAIRE
HEIGHT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WEIGHT (lbs) . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . .
PULMONARY
H I STORY OF SMOKING . . . . . . . . . . . . . . . . . . . . . . . . • . . . __ X
SHORTNESS OF BREATH . . . . . . . . . . . . . . . . . . . . . • . . . . . __ X
FATIGUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • • . .
__ X
WHEEZING OR PROLONGED COUGH . . . . . . . . . . . . . . . . . . . __ X
HISTORY OF ASTHMA , EMPHYSEMA OR COPD . . . . . . . • . .
--'I
H I STORY OF PNEUMONIA OR TUBERCULOS I S . . . . . . . • . .
__x
CARDIOVASCULAR
HEART MURMUR/HEART VALVE PROBLEM . . . . . . . . . . . • • .
__ X
HISTORY OF HEART PROBLEMS . . . . . . . . . . . . . . . . . . . • .
___x
SWEATING WITH PAIN . . . . . . . . . . . . . . . . . . . . . . . . . . • . __ X
RAPID THROBBING OR FLUTTERING OF HEART . . . . . . • . __ X
HIGH BLOOD PRESSURE . . . . . . . . . . . . . . . . . . . . . . . . . • .
__X
DIZZ INESS ( S IT TO STAND) . . . . . . . . . . . . . . . . . . . . • .
--'I
SWELL I NG IN EXTREMITIES . . . . . • . . . . . . • • . . . . . . . . .
__x
HISTORY OF RHEUMAT I C FEVER . . . . . . . . . . • . . . . . . . . .
__x
ELEVATED CHOLESTEROL LEVEL . . . . . . . . . . . . . . . . . . . .
_x_
FAMILY H ISTORY OF HEART DISEASE . . . . . . . . . . . . . . . --'1- ( 1 )
PAIN/SYMPTOMS INCREASE WITH WALKING OR STAIR
CLIMBING AND RELIEVED WITH REST . . . . . . . . . . . . . . .
MENSTRUAL CRAMPS . . . . . . . . . . . . . . . . . . . . . . . • . . . . . .
and her sister had pancreatic cancer. It also re both cases. Passive right shoulder girdle depres
vealed that she is a 1 00 pack-year smoker (packs sion with cervical left sidebending produced
per day X number of years she smoked). The shoulder and arm pain; brachial plexus tension
pulmonary part of the questionnaire was signifi stretch also reproduced the symptoms. Thoracic
canl. outlet tests were negative.
CERVICAL SCREEN
JOINT MOBILITY
toms include difficulty swallowing, weight loss, The heart, which is innervated by thoracic nerves
and (in the late stages) drooling 47 Symptoms as T I to TS,3 is capable of referring pain to the
sociated with cancer are bloody cough, hoarse shoulder.30-33 .52 .56 Cardiac afferen t fibers have
ness, sore throat, nausea, vomiting, fever, hic shown evidence of convergence with esophageal
cups, and bad breath 47 Symptoms associated afferents and somatic afferents in the upper tho
with renux esophagitis are regurgitation, fTe racic spinal cord B I n fact, esophageal chest pain
quent vomiting, and a dry nocturnal cough ·7 is known to mimic angina pectoris. 54 In addition,
The patient will complain of heartburn that is convergence has been demonstrated between
aggravated by strenuous exercise, or by bending cardiac afferents, abdominal viscera (gallblad
over or lying down, and is relieved by sitting up der, for example) afferents, and somatic affer
or taking antacids ·7 See the associated symp ents in the lower thoracic spinal cordY·53 Con
toms under "Diaphragm" earlier in the chapter. vergence has also been noted with proximal
somatic afferents (shoulder), phrenic (dia
Diagnosis phragm), and cardiopulmonary spinal afferents
Positive 24-hour intraesophageal p H and onto the cetvical spinothalamic tract neurons
pressure recordings, acid perfusion, edropho (Fig. 1 2 . 1 0).'9 This explains how diaphragmatic
nium stimulation, balloon distension, and ergo- disease and cardiac disease are both able to refer
Cerebral Cortex
Thalamus --
Spinothalamic
Tract
Afferent
Cervical Segn)ent Nerves
of the Spinal Cord
(::::hr
cardiopulmollGry afferent nerve
converging onto the same
agm
spinothalamic tract neuron.
316 P H Y S I C A L T H E R A P Y OF T H E S H O U L D E R
Symptoms
Diagnosis
1 993: Arthroscopic surgery to the right knee . No restrictions or hypermobilities were found in
1 993: Fell onto left shoulder, sprained, resolved any of the joints in the shoulder girdle.
in 3 months.
ASSESSMENT
1 985: Lumbar disc surgery.
The patient's symptoms were not reproduced
PHYSICIAN-ORDERED TESTS
dudng a thorough neuromusculoskeletal exami
No radiographs or special lab tests ordered. nation, and therefore his complaints were not
consistent with an orthopedic dysfunction or in
GENERAL HEALTH
jury. A return to the interview process revealed
The patient questionnaire (Fig. 1 2. 1 2 ) was signif that the patient periodically felt a tightness or
icant for the pulmonary and cardiovascular sec pressure on his chest at the same time he felt
tions . At the time of evaluation he was a 35 pack the shoulder pain. Both symptoms rapidly went
year smoker, had a history of heart problems away when he sat down and relaxed. The symp
(palpitations and tachycardia), and both his fa toms were reproduced when he climbed a hill
ther and grandfather died prematurely of heart behind his house.
allacks . Subsequently the patient was referred back
to the physician for follow-up to mle out cardio
CERVICAL SCREEN
pulmonary disease. He was subsequently diag
Active and passive ROM was WNL and painless. nosed with myocardial ischemia with associated
Cervical axial compression and Spurling's quad angina pectoralis. His symptoms disappeared
rant compression tests (see Fig. 4 . 1 6) were nega with nitroglycerin.
live.
Active and passive ROM were WNL and painless. The heart, which is innervated by thoracic nerves
T 1 to T5, is capable of refelTing pain to the shoul
RESISTED TESTING der in cases of pericarditis . 3 .35 .5 7 Pericarditis is
Shoulder girdle muscles were strong 'Ys and pain an inflammation of the sac sUITounding the
less. heart. 35 , 5 7
PALPATION
Symptoms
No Significant musculoskeletal tenderness was
There is usually a sharp burning pain in the
found throughout the shoulder girdle. Palpation
chest or left shoulder.35 .47• 57 Pain may be aggra
of the lymph nodes and the abdomen was nega
vated by deep breathing, coughing, or lying Oat;
tive . Palpation of the arterial pulses in the left
and relieved by sitting up and leaning for
upper extremity revealed that they were of nor
ward s .3 s.. ,.s, Other symptoms include fever,
mal (grade 4) strength.
tachycardia, and dyspnea.47 Symptoms of
NEUROLOGIC EXAMINATION chronic pericarditis include pitting edema of the
arms and legs, serous fluid in the pedtoneal cav
Sensation, deep tendon reOexes, and strength
ity, enlarged liver, distended veins in the neck,
testing of the upper extremities was WNL.
and a decrease in muscle mass . 47
SPECIAL TESTS
Diag'lOsis
Passive Oexion with humeral I R or E R was nega
tive; glenohumeral compression and distraction There will often be a pel-icardial friction rub,
were negative; upper limb nerve tension tests which has different characteristics than a heart
were negative. murmur, noted during auscultations of the
318 P H Y S I CAL T H E R A P Y O F T H E S H O U L D E R
PATIENT QUESTIONNAIRE
CONSTANT PAIN . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . .
_x_
PAIN WORSE AT NIGHT . . . . . . . . . . . . . . . . . . . . . • . . . . .
_x_
PAIN RELIEVED BY REST . . . . . . . . . . . . . . . . . . . • . . . . .
_X_
PULMONARY
H ISTORY OF SMOKING . . . . . . . . . . . . . . . . . . . . . . • . . . . .
__X
SHORTNESS OF BREATH . . . . . . . . . . . . . . . . . . . . . . . . . . . �
FATIGUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . -1L-
WHEEZING OR PROLONGED COUGH . . . . . . . . . . . . . . . . . . .
�
HI STORY OF ASTHMA , EMPHYSEMA OR COPD . . . . • . . . . .
_x_
HI STORY OF PNEUMONIA OR TUBERCULOSIS . . . . . . . . . .
_x_
CARDIOVASCULAR
HEART MURMUR/HEART VALVE PROBLEM . . . . . . . . . • . . . .
_x_
HI STORY OF HEART PROBLEMS . . . . . . . . . . . . . . . . . . . . . �
SWEATING WITH PAIN . . . . . . . . . . . . . . . . . . . . . . . • . . . . �
RAPID THROBBING OR FLUTTERING OF HEART . . • . . . . .
_x_
HIGH BLOOD PRESSURE . . . . . . . . . . . . . . . . . . . . . . • • . . . �
D I Z Z I NESS ( S IT TO STAND) . . . . . . . . . . . . . . . . • . . . . .
_x_
SWELLING I N EXTREMITIES . . . . . . . . . . • . . . . . . . • . . . .
�
HI STORY OF RHEUMAT I C FEVER . . . . . . . . . . . . . . . . . . . .
_x_
ELEVATED CHOLESTEROL LEVEL . . . . . . . . . . . . . . . . . . . . �
FAMILY HI STORY OF HEART D ISEASE . . . . . . . . . . . . . . .
_X_
PAIN/ SYMPTOMS INCREASE WITH WALKING OR STAIR
CLIMBING AND RELIEVED WITH REST . . . . . . . . . . . . . . . __
x
MENSTRUAL CRAMPS . . . . . . . . . . . . . . . . . . . . . . . . . . . • . .
CERVICAL SCREEN
RESISTED TESTING
PALPATION
FIGURE 1 2 . 1 3 Pain diagram (rom a 64-year-old The right sternoclavicular joint was slightly
right-hal1ded (emale with a presel1ling diagl10sis warm and red, with exquisite tenderness noted.
o( "right shoulder pain. " A palpable band of tender tissue was noted in
the right upper trapezius muscle. There was no
tenderness or enlargement noted with palpation
PAST MEDICAL HISTORY of the lymph nodes. Palpation of the abdomen
did not reveal rigidity or viscus enlargement. Pal
1 993: Root canal, 6 weeks ago .
pation of the arterial pulses in the right upper
1 993: Surgery (March) to implant a prosthetic
extremity revealed that they were of normal
heart valve.
(grade 4) strength. There were no petechia or
1 975: Hysterectomy.
Janeway lesions on her skin. Ankle edema was
noted bilaterally.
PHYSICIAN-ORDERED TESTS
NEUROLOGIC EXAMINATION
No imaging studies were ordered.
Upper extremity sensation, DTR, and strength
GENERAL HEALTH were all WNL.
PATIENT QUESTIONNAIRE
PULMONARY
H I STORY OF SMOKING . . . . . . . . . . . . . . . . . . . . . . . . . . . .
----lL-
SHORTNESS OF BREATH . . . . . . . . . . . . . . . . . . . . . . . . . . . __ X
FATIGUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . .
_x
_
MENSTRUAL CRAMPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ASSESSMENT
There will be a prolonged capillar)' refill time
for the fingers, systemic hypotension, and a weak
The patient's signs and symptoms were consis or absent distal pulse . 47 Bilateral dilation of the
tent with an irritable right sternoclavicular joint pupils will occur late.47 A chest radiograph may
with capsular and articular cartilage or meniscus or may not allow visualization of the aneu,),sm.
involvement. The patient's history of prosthetic Arterial occlusion, usually due to atheroscle
valve surgery, recent surger)" shortness of rosis or compression of the subclavian artery, as
breath, fever, chest pain, and sudden onset of in thoracic outlet syndrome, of the shoulder can
pain without trauma were of concern. She was present as a deep constant pain or lead to is
referred back to her primary care physician in chemic pain with exercise . JO.60
order to rule out cardiac disease. The patient was
subsequently diagnosed with bacterial endocar
SYlllptoms
ditis. After a week on antibiotics her shoulder
pain disappeared. Patients will complain of pain in the region
of the shoulder girdle that may mimic a nerve
root compression 6' Other symptoms include
VASCULAR
paresthesias, coldness, weakness, and fatigue in
An aneurysm within a subclavian vessel, or an the involved extremity . 47.6 .
aortic orifice of a subclavian vessel. can result in
pain at the shoulder -'D- 32 .47 .52 This is a poten
Diagnosis
tially dangerous arterial condition.3S An aneu
rysm is an abnormal widening of the arterial wall Systolic blood pressure will be higher while
caused by the destruction of the elastic fibers of diastolic blood pressure remains unchanged in
the middle layer of that wall or due to a tear in the involved extremity.47 Claudication will be
the inner lining of the arterial wall that allows noted with a distal pulse that is weak or ab
blood to flow directly into the wall and subse senl.47 .6• The extremity will be cool, cyanotic,
quently widen it." Aortic aneurysms can enlarge and demonstrate a prolonged capillar), refill
and compress pain-sensitive stnlctures in the time ·7 Tachycardia and angina pectoris may
upper mediastinum, leading to shoulder pain . 3D also be present . 47 Contrast angiography will
They generally occur in the elderly and slowly demonstrate arterial occlusion that is best seen
enlarge over a period of many years . " Rapid with the extremity elevated.6 ' In the case of tho
morbidity or mortality is expected if an aneu racic outlet syndrome, one of the following tests
rysm ruptures,35 will be positive: Adson's, costoclavicular, hyper
abduction, pectoralis minor, or the 3-minutc
flap-arm test 60-62
SY"lploms
Thrombophlebitis of the axillary and subcla
Pain in the shoulder that may include throb vian veins can also cause shoulder pain (Fig.
bing and cramping. The patient may also repo.1 1 2 . 1 5).30. '2 .63 Thrombophlebitis is an inflamma
paresthesias, neck pain, and/or chest pain.47 tion of a vein in the presence of a blood clot. This
Other symptoms include night sweats, pallor, is a Se,"iOllS situation, because an emboli may
V I S C E R A L PATHOLOGY R E F E R R I N G P A I N TO T H E S H O U L D E R 323
FIGURE 1 2. 1 5Thrombosis or
the subclavian vein at the
level or the thoracic outlet.
(From Rohrer:' with
pem7ission.)
break free and travel to the lung, a potentially such as weightlifting ·3 Symptoms of shol'tness
fatal condition. The risk of pulmonary emboliza of breath, pleuritic chest pain, hemoptysis, or a
tion for persons wilh a subclavian thrombosis is new nonproductive cough are suggestive of a
approximately 1 2 percent ·3 Deep vein thrombo pulmonary embolus ·3
sis of the upper extremity is often due to venous
trauma from repetitive motions of the shoulder,
which is refen'ed to as effort thrombosis, in per Diagnosis
sons with an abnonnal thoracic outlet ·3 Other Edema, coldness, and cyanosis will be noted
causes of venous thrombosis include the pres in the fingers, hand, and upper alm,"··3 .•4 Dis
ence of indwelling venous catheters (central tension of the superficial veins is usually seen in
lines or pacemaker leads), local compression, ra the hand, upper arm, shoulder, or anterior chest
diation, or hypercoagulability ·3 wall.·3 .M Effort thrombosis is usually seen in
young, healthy individuals with an athletic phy
Symptoll1s sique,·3 I t is also seen frequently in hikers who
carry backpacks ·3 Exertion of the involved ex
There will be pain in the region of the shoul tremity will lead to a significant exacerbation of
der girdle. Fever and chills may be presenL47 The the pain and swelling,,3 PhYSician-ordered tests
patient may complai n of cold and swollen fin include duplex ultrasound scanning and venog
gers " Patients with effort thrombosis complain raphy.
of the sudden onset of swelling and cyanosis in The shoulder-hand syndrome, also known
volving the entire arm ·' These patients will as reflex sympathetic dystrophy or minor causal
often report a history of upper extremity exertion gia, is another source of shoulder pain and dys-
324 P H Y S I C A L T H E R A P Y O F T H E S H O U L D E R
function from a vascular diso;·der.60 This syn Fig. 1 2 .4).3.•.32.52.•5 Cancer of the liver is more
drome is precipitated by trauma to the upper common in men and women over the age of 50 3
extremity (sprain, laceration, fracture, or rotator The liver is one of the mo t common ites of me
cuff tear), cervical disc disease, cervical spon tastasis from primary cancers elsewhere in the
dylosis, hemiplegia, herpes zoster, and cardio body (colorectal, stomach, pancreas, esophagus,
vascular disease ·o These disorders are responsi lung, and breast cancers) ·' Hepatitis, or inflam
ble for a reflex stimulation of the sympathetic mation of the liver, can range from the subclini
nerve supply to the extremity with a resultant cai to the rapidly progressive and fatal stage ···5
increase in vasomotor tone.60
Symptoms
Symptoms
Right shoulder pain may be acute or spas
Patients will complain of shoulder pain and modic in nature.3 The patient may also complain
tenderness in conjunction with aching, paresthe of headache, myalgias, and arthralgias " Other
sias, swelling, coldness, and stiffness in the hand symptoms include indigestion, nausea, vomit
and fingers ·o The symptoms are constant, even ing, unexplained weight loss, and fatigue.3,.,,7 .•5
at resl.60 Pain fyom cancer of the liver may be described as
deep, gnawing, and poorly localized to the upper
abdomen or back 3 See the associated symptoms
Diagnosis
u nder " Diaphragm" earlier in the chapter.
Limited mobility (active and passive) of the
shoulder, wrist, hand, and fingers will be noted
Diagnosis
in association with cyanosis, coldness, non pit
ting edema, and hyperhidrosis in the hand and There may be an upper abdominal mass, an
fingers ·o Eventually the fingers will demon enlarged liver, or tenderness in the right upper
strate stiffness, weakness, muscular atrophy, quadrant of the abdomen.3 .•.•7.•5 Associated
flexion deformity, and trophic changes of the signs are jaundice, pale skin, purpura, ecchymo
nails . ·o After 6 months, plain radiographs will sis, spider angiomas, palmar erythema, an
show spoLly osteoporosis of the head of the hu orexia, and the accumulation of serous fluid in
merus, carpus, and sometimes the phalanges ·o th e peritoneal cavity.···7 .•5 Refer the patient for
After 9 months, the skin of the hand becomes radiograph, diagnostic ultrasound, CT scan, or
smooth and glossy, and there is atrophy of the M R I of the abdomen.·5 See the associated diag
subclItaneolls tissue and intrinsic muscles. flex nostic clues under "Diaphragm."
ion contractu res of the fingers, and osteoporosis
of the entire extremity . ·o
PANCREAS
Additional diagnostic tests that may be indi
cated for a variety of vascular disorders include The pancreas, which is segmentally innervated
Allen's test, Doppler ultrasonic flow detector, by thoracic nerves T6 to T I 0, can refer pain to
systolic blood pressure, pulse volume recording, the left shoulder through contact with the central
angiography, and auscultation of the major ar portion of the diaphragm (Plate 1 2 . 1 and Fig.
teries.7,62 1 2.4) 3 .•. 30. 52 Shoulder pain is usually at the left
scapula or supraspinous area " Cancer of the
pancreas is more common in men and women
LIVER
over 50 years of age 3 Pancreatic cancer has been
The liver, which is segmentally innervated by linked to diabetes, alcohol use, a history of pan
thoracic nerves T7 to T9, is able to refer pain to creatitis, and a high-fat die! . 42 Pancreatitis, or
the right shoulder through its contact with the inflammation of the pancreas, may be caused by
central portion of the diaphragm (Plate 1 2 . 1 and heavy alcohol use, gallstones, viral infection, or
V I 5C E R A l PAT H 0lOG V R E F" E R R I N G PA I N TO T H E 5 H 0 U lD E R 325
blunt trauma . ···2 Acute pancreatitis can be common in women), pregnancy, oral contracep
rata1." tive use, obesity, diabetes, a high-cholesterol
diet, and liver disease "S Gallbladder cancer is
more commOn in men and women over the age
Symptoms
or 50 ]
Pain in the left shoulder, mid epigastrium,
andior back "··2 Patients with a pancreatic ab
scess, cancer, or pancreatitis may complain of Symptoms
rever, weight loss, jaundice, tachycardia, nausea,
andior vomiting..,··7 In addition, patients with a Cramping pain or a deep, gnawing, poorly
pancreatic abscess may also report an abrupt localized pain in the back or right shoulder may
rise in temperature, dialThea, and hypoten be the first symptoms ]··,47.•S Pain is usually re
sion ·7 Patients with pancreatic cancer may also ferred to the right scapula.J .6··s Other symptoms
complain or ratigue, weakness, and gastrointesti include chronic epigastric or right upper abdom
nal bleeding.47 A patient with pancreatitis will inal pain after meals. nausea, vomiting, and
often bend rorward or bring the knees to the rever ",47 .•S Patients surfering with cholelithiasis,
chest in order to relieve the pain . .,·47 These pa the passage of a stone through the bile or cystic
tients will report an exacerbation of pain with duct, will complain of udden and severe parox
walking or lying supine." In addition, these lat ysmal pain in addition to chills and restless
ter patients will complain of a waxing and wan ness.47
ing pain in the epigastric and left upper quadrant
or the abdomen " Pain will be exacerbated byeat
ing, alcohol intake, or vomiting.· See the associ Diagnosis
ated symptoms under "Diaphragm" earlier in the
Gallbladder cancer is characterized by
chapter.
weight loss, anorexia, andior jaundice.47 .•s Pa
tients with cholecystitis will have a fever, jaun
Diagnosis dice, tenderness over the gallbladder, and ab
dominal rigidity.·7.•s Cholelithiasis will produce
There may be an abdominal mass, enlarged
a low-grade fever in the patient "··7 Fatty or
liver or spleen, or tenderness in the epigastric
area.3.6,47 Diagnostic ultrasound, CT scan, or greasy roods will exacerbate the symptoms or
MRI may be necessary for an accurate diagnosis . gallbladder disease ]··s There will be tenderness,
See the associated diagnostic clues under "Dia and occasionally a palpable mass, in the right
phragm." upper abdominal quadrant.· Rerer ror radio
graph, diagnostic ultrasound, and/or CT scan . ·s
These disorders are more common in obese
GALLBLADDER
women over 40 years of age.3 .•
The gallbladder (Plate 1 2. 1 ), which is i nnervated
by thoracic nerves T7 to T9, is capable Dr rerer
ring pain to the right shoulder.3 .6·30-32 .47 . 52 .• 5 Af
rerent fibers (T6 to T i l ) from the gallbladder CASE STUDY 5
pass into hepatic and coeliac plexuses and then HISTORY
enter the major splanchnic nerves, through
which they pass to the sympathetic chain into A 5 1 -year-old right-handed obese female pre
the spinal cord 27 Common diseases of the gall sented to physical therapy (May 1 995) with a di
bladder include cholecystitis (inflammation) agnosis of "right shoulder strain." She com
and cholelithiasis (stones).3 Risk factors ror the plained of a periodic severe, deep, and
latter include age (increases with age), sex (more generalized ache across the back of her right
326 P H Y S I C A L T H E R A P Y OF T H E S H O U L D E R
PHYSICIAN-ORDERED TESTS
GENERAL HEALTH
PATIENT QUESTIONNAIRE
YES !!Q
NAME Case S tudy '5 DATE 5/21/95
AGE 21
'J:11
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HEIGHT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
S
WEIGHT ( lbs) . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . 17:;
FEVER AND/OR CHILLS . . . . . . . . . . . . • . . . . . . . • . . . . . . __ x
UNEXPLAINED WEIGHT CHANGE . . . . . . . . . . . . . . . . . . . . . __ x
NIGHT PAIN/DI STURBED SLEEP . . . . . . . . . . . . . • . . . . . . __ x
EPI SODE OF FAINTING . . . . . . . . . . . . . . . . . . . . . . . . . . . _x _
HI STORY OF CANCER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __
X
FAMILY HI STORY OF CANCER . . . . . . . . . . . . . . . . . . . . . .
---1L1 1 )
RECENT SURGERY ( DENTAL ALSO) . . . . . . . . . . • . . . . . . . _X
_
CONSTANT PAIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _X
_
GASTROINTESTINAL
DIFFICULTY IN SWALLOWING . . . . . . . . . . . . . . . . . . . . . . _x_
NAUSEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __ X
HEARTBURN . . . . . . . . . . . . . . . . . . . • . . . . . . . • . . . . . . . . . _X_
VOMITING . . . . . . . . . . . . . . . . . . . . • . . . . . . . • . . . . . . . . . _X
_
FOOD INTOLERANCES . . . . . . . . . . . • . . . . . . . • . . . . . . . . . __ X
CONSTI PAT ION . . . . . . . . . . . . . . . . • . . . . . . . • . . . . . . . • . __X
DIARRHEA . . . . . . . . . . . . . . . . . . . • • . . . . . . . . . . . . . . . • . __ X
CHANGE IN COLOR OF STOOLS . . . . . . . . . . . . . . . . . . . . . _X
_
RECTAL BLEEDING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • .
_X
_
HI STORY OF LIVER OR GALLBLADDER PROBLEMS _X _
INDIGESTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . _X
_
LOSS OF APETITE . . . . . . . . . . . . . . . . . . . . . . . . . . . . • • . _X
_
FIGURE 1 2. 1 7 Patiel1t questionnaire (01' Case Study 5, 11l0di{ied to show signi{ical1l portions o(
both pages.
RESISTED TESTING nodes and arterial pulses in the neck and upper
Resistive testing of the muscles throughout the extremity were WNL. Palpation of the abdomen
right shoulder girdJe did not reproduce pain. revealed rigidity and exquisite tenderness in the
right upper abdominal quadrant.
PALPATION
NEUROLOGIC EXAMINATION
Mild tenderness, without reproduction of signifi
cant shoulder pain, was noted in the left upper Increased sensitivity to light touch and pin.prick
trapezius, left middle trapezius and rhomboids, was noted in the left C6 dermatome. Hyperre·
and the right infTaspinatus muscle belly. Lymph flexia (3 + ) was noted for the left brachioradialis
328 P H Y S I C A L T H E R A P Y O F T H E S H O U L D E R
JOINT MOBILITY
Diagnosis
The right acromioclavicular and scapulothoracic
Tenderness will be noted at the costoverte
joints were graded 3, WNL, in mobility. The right
bral angle and, in the case of innammation, there
sternoclavicular joint was hypomobile, grade 2,
will be a fever.47.66 Musculoskeletal pain is rarely
in distraction and inferior gliding. The right gle
the primary complaint. Cancer of the kidney is
nohumeral joint was hypomobile, grade 2, in all
most common between the ages of 55 and 60 s0
directions, probably due to muscle guarding .
It can metastasize to the lung, brain, or liver so
Metastasis to bone occurs late in the disease pro
ASSESSMENT
cess. so
The patient's signs and symptoms were i nconsis In patients with a pel-inephl-ic abscess, there
tent with an active orthopedic injury of the right is no tenderness over the renal areas of the back,
shoulder. Chronic joint dysfunction was noted and only mild distension is noted during abdom
in the right shoulder girdle. The left shoulder and inal palpation . 67 There will be an elevated ESR,
hand symptoms were thought to be secondal), to white cell count, and fever 67 A plain anteropos
a mild and chronic left cervical radiculopathy. terior KUB (view of the kidney, ureters, and blad
The cervical spine did not appear to be a source der) radiograph will demonstrate the following:
of right shoulder symptoms . Of concern was the ( 1 ) difficulty identifying the psoas stripe, (2) ab
patient's history of diabetes, hepatitis, fever, sence of the renal outline, and (3) curvature of
shoulder pain associated with greasy meals, and the spine towards the side of the disease.67 Refer
the exquisite tenderness in the right upper ab for an intravenous pyelogram and/or CT scan.
dominal quadrant. The patient was refen-ed back Kidney stones may produce a severe
to her pl-imary care phYSician to 11.1 Ie out any gas cramping pain .' Chronic kidney disease may be
trointestinal problems. The patient was subse associated with poor calcium deposits in bone,
quently diagnosed with cholecystitis. which will lead to a weak bone structure .' For
all of the diseases of the kidney that have been
discussed, patients may benefit by refelTals for
KIDNEY
diagnostic ultrasound, CT scan, or MRJ .
The k.idney (Plate 1 2- 1 ) , which is innelvated by
thoracic nerves T I 0 to L 1 .3 may refer pain to the
STOMACH
shoulder girdle region.32.66 There are several pa
thologies to consider with respect to the kidney, The stomach, which is segmentally innelvated
including cancer, perinephriC abscess, and other by thoracic nelves T6 to T I O, can refer pain to
disease processes such as kidney stones. Associ the shoulder through contact with the central
ated disorders are pyelonephritis, nephritis, ne portion of the diaphragm (Plate 1 2. 1 .2 and Fig.
phropathy, nephrotic syndrome, renal artery oc 1 2.4).3.30 Cancer of the stomach is more common
clusion, renal failure, renal infarction, and renal in men and women over 50 years of age .' Risk
tuberculosis.47 factors for an ulcer or gastritis include heavy al-
V I S C E R A L PATHOLOGY R E F E R R I N G P A I N TO T H E S H O U L D E R 329
cohol use, smoking, and the use of nonsteroidal drome, spastic colon, obstructive bowel disease,
anti-inflammatory drugs (NSAIDs) 6.42 diverticulitis, and cancer. Colon cancer is the
most frequently diagnosed cancer in the Uni ted
States 6 Cancer in this region is most common
Symptollls
in men and women over the age of 50 J·50 Metas
Pain is most often described in the right tasis to the spine, liver, and lung are common 6. 50
shoulder." The patient may also complain of Smoking, alcohol, NSAIDs, and caffeine may in
epigastric or right upper abdominal quadrant crease the risk of disease. 3 The NSAIDs may also
pain.6,42 Patients with cancer, an ulcer, or gastri mask the symptoms J Other dsk factors include
tis may complain of weight loss, night pain, or a prior history of inflammatory bowel disease,
chronic dyspepsia-painful digestion, a sense of prior·cancer ofanother organ, and benign polyps
fullness after eating, heartburn, nausea, vomit of the colon 6
ing, and a loss of appetite.··42•47 Patients with
stomach cancer may complain of a deep, gnaw Symptoms
ing and poorly localized pain in the upper abdo Pain is referred to the right shoulder from
men or back J Persons with an ulcer may also the hepatic flexure of the colon (Plate 1 2 . 1 ) 68 A
complain of gastrointestinal bleeding and epi cramping pain is often described in the lower
gastric pain I to 2 hours after a meal, which oc midabdominal region 6A2A7 There may also be
curs with vomiting, fullness, or abdominal dis a fluctuation of pain with eating habits, painful
tention.42 .47 Patients with gastritis may also bowel movements, diarrhea, indigestion, nau
report belching, fever, malaise, anorexia, or sea, vomiting, change in bowel habits, bloody
bloody vomi!.47 See the associated symptoms stools, jaundice, and weight loss J ,,7 Irritable
under "Diaphragm" earlier in the chapter. bowel syndrome is the most common gastroin
testinal disorder in Western society.42 Symptoms
are aggravated or precipitated by emotional
Diagl10sis
stress, fatigue, or alcohol, or by eating a large
There may be an abdominal mass or tender meal with fruit, roughage, or a high fat content ·2
ness J .47 Abdominal CT scan or MRl may be nec I n addition to the above symptoms there may be
essary for an accurate diagnosis. See the associ constipation, foul breath, and flatulence.42 The
ated diagnostic clues under "Diaphragm." predominant symptom with ulcerative colitis is
rectal bleeding and dian·hea ·2 With obstructive
bowel disease the patient will complain ofconsti
COLON AND LARGE INTESTINE
pation, rapid heart rate, and short episodes of
The colon and large intestine, which is inner intense cramping pain.47 Diverticulitis, an in
vated by thoracic and lumbar nerves T i l to L t ,3 flammation in the wall of the colon, will produce
is capable of refelTing pain to the right shoulder constant left lower abdominal pain with radia
(Plate 1 2 . 1 ) 68 The gastrointestinal tract (GI) has tion commonly to the low back, pelvis, or left
dual innervation (Plate 12.2). There are afferent leg 6 [n cases of cancer, there may be a change
fibers that join sympathetic nerves and afferent in the frequency of bowel movement, a sense of
fibers that join parasympathetic nerves.·9 Pain incomplete evacuation, bloody stools, unex
from the GI is predominately mediated by affer plained weight loss, weakness, fatigue, exer
ent activity in sympathetic nerves such as the tional dyspnea, and vertig0 6A7 .50
splanchnic and hypogasuic nerves 69 These af
ferent nerve fibers have theircell bodies in thora Diagnosis
columbar spinal ganglia and their central projec Patients may exhibit abdominal distension,
tions enter the spinal cord at levels between T2 abdominal tenderness, rectal bleeding, anorexia,
and L3 69 Disorders relevant to thi region in and abnOlTnal bowel sounds ·7 Diagnosis is con
clude ulcerative colitis, irritable bowel syn- firmed by a positive colonscopy.
330 P H Y S I C A L T H E R A P Y OF T H E S H O U L D E R
POSTVIRAL FATIGUE SYNDROME omega-3 fatty acids have successfully been used
to treat ulcerative colitis.90 Postviral fatigue syn
Postviral fatigue syndrome (PFS) is yet another drome is also known as myalgic encephalomyeli
source of pain in the region of the shoulder gir tis; Epstein-Ba'T virus syndrome; chronic fatigue
dle.30.70-77 Recent research has suggested a rela syndrome; and Iceland, Akureyri, or royal free
tionship between PFS and fibromyalgia.72 .7' The disease.
criteria for a diagnosis of fibromyalgia syndrome
includes neck and shoulder pain as well as a
specific tender point in the supraspinatus Symptoms
muscle.78-8 1 Insidious onset of severe muscle fatigue and
There appears to be an association between myalgia, exacerbated by exercise, ,7.7o Most com
PFS and the abnormal early onset of i ntracellu mon in cervical, thoracic, and shoulder re
lar acidosis during exercise.7 1 .75.7. This is gions.7o There may be associated headaches, diz
thought to represent excessive lactic acid pro ziness, cognitive dysfunction, sore throat, andJor
duction secondary to a problem with metabolic disturbed sleep ·7.70
regulation 7 1 .75-7. It also appears to be a problem
with muscle metabolism.7o.7 ' . 75.77 There is spec
ulation that this d isease is related to destruction Diagl10sis
of the mitochondria within the cell.7I •7' This sub Postviral fatigue syndrome is most common
sequently leads to an inability to perform aerobic in young and middle-aged adults, especially
glycolysis, so that the patient is stuck in perpet women. It always follows a viral infection (cox
ual anaerobic glycolysis, which results in a build sackie, Epstein-Barr, rubella, or varicella) and
up of lactic acid leading to early fatigue and com primarily affects skeletal muscle. There is usu
plaints of muscle soreness.7I·7•.7• M itochondrial ally mild lymphadenopathy and fever.47 Plain ra
damage and fibromyalgia have been associated diographs and laboratory studies, such as ESR,
with the in'itable bowel or "leaky gut" syn are not helpful. Range of motion in the spine or
drome.7•.' 1 .'2 A healthy intestinal wall is coated extremities is usually within normal limits. Mus
with hundreds of different species of microorga cle biopsies are not diagnostic, but abnormalities
nisms. This protective coating of microorga in fatty acid metabolism have been noted 7o.H
nisms acts in concert with the physical ban'ier Single-fiber EMG studies have demonstrated
provided by the cells lining the intestinal tract to prolonged jitter values.7o There may be associ
provide the body with important filter-like pro ated psychological problems, such as depres
tection. Damaging substances like unhealthy sion, in patients with chronic complaints.7 1 -73
bacteria, toxins, chemicals, and wastes are fil Note: The case studies used in this chapter
tered out and eliminated. Persons with "leaky have been modified for instructional purposes.
gut" syndrome, however, are not able to filter out
all of the damaging substances. Subsequently,
unhealthy bacteria, toxins, chemicals, and
wastes leak through the intestinal wall and into Summary
the bloodstream. One very well known risk factor
for the development of intestinal mucosal dam The best way to determine if a patient has vis
age is the use of nonsteroidal anti-inflammatory ceral pathology is to first eliminate all possible
drugs (NSAlDs). 83-.9 neuromusculoskeletal tissues as a source of the
Persons with PFS are more susceptible to vi symptoms. This requires skill, confidence, and
ruses and have a harder time fighting viruses due experience in pel·forming your own orthopedic
to their inability to metabolize essential fatty evaluation. If you cannot reproduce a patient's
acids.7• The essential fatty acids are proposed to symptoms or have difficulty identifying a tissue
have a strong antiviral effect.74 I n addition, in lesion, or if a patient does not respond to treat-
V I S C E R A L PATHOLOGY R E F E R R I N G P A I N TO T H E S H O U L D E R 331
ment, then ruling out visceral pathology be (cd): Examination in Physical Therapy Practice:
comes imperative. An orthopedic patient who Screening for Medical Disease. 2nd Ed. Churchill
demonstrates signs and symptoms of visceral pa Livi ngstone, New York, 1 995
9. Natkin E, HarTington G, Mandel M : Anginal pain
thology can be saved from severe morbidity or
referred to the teeth: report of a case. Oral Surg
death by early referral to the appropriate physi
40:678, 1 975
cian.
1 0. Henry J, Montuschi E: Cardiac pain refen'ed to
site of previously experienced somatic pain. BI'
Med J 9: 1 605, 1978
I I . Payne R: Cancer pain: anatomy, physiology, and
Acknowledgernent.s
pharmacology. Cancel' 63:2266, 1 989
1 2 . Procacci P, Maresca M: Clinical aspects of visceral
I wish to thank Ola Grimsby and Jim Rivard for
pain. Funct NeuroI 4 : 1 9 . 1 989
their contribulions and hard work on Ihe illus
1 3 . Cervero F: Mechanisms of acute visceral pain. Br
trations for this chapter. Med Bull 47:549, 1 9 9 1
1 4 . Gebhart G, Ness T : Central mechanisms o f vis
ceral pain. Can J Physiol PharmacoI 69:627, 1 99 1
1 5. Lynn R: Mechanisms o f esophageal pain. Am J
References Med 9 2 : 1 I S, 1992
I . Boissonnault WG, Koopmeiners MB: Medical his 1 6. Cousins M : Lntroduction to acute and chronic
tOly pronle: orthopaedic physical therapy outpa pain: implications for neural blockade. In Cousins
lients. J Orthop Sports Phys Ther 20:2, 1 994 M, Bridenbaugh P (cds): Neural Blockade in Clini
2. Goodman CC, Snyder TEK: Systemic origins of cal Anesthesia and Management of Pain. JB lip
musculoskeletal pain: associated signs and symp pincott. Philadelphia, 1988
toms. p. 522, In: Di fferential Diagnosis in Physical 1 7. Raj P: PI"ognostic and therapeutic local anesthetic
Therapy. 2nd Ed. WB Saunders, Philadelphia, block. In Cousins M, Bridenbaugh P (cds): Nellral
1 995 Blockade in Clinical Anesthesia and Management
3, Boissonnauh WG, Bass C: Pathological origins of of Pain. 18 Lippincott, Philadelphia. 1 988
trunk and neck pain, 1 . Pelvic and abdominal vis 1 8. Ruch T: Viscera] sensation and refen'ed pain. I n
ceral disorders. J Orthop Spor�s Phys Ther 1 2: 192, Fulton J (ed): Textbook of Physiology. WB Saun
1 990 der'S, Philadelphia, 1 949
4. Goodman CC, SnyderTEK: Introduction to differ 1 9 . Korr 1M: Sustained sympatheticotonia as a factor
ential screening in physical therapy. p. I . In: Dif in disease. p. 229. In Korl' 1M (cd): The NeUl'O
ferential Diagnosis in Physical Therapy. 2nd Ed. biologic Mechanisms in Man ipulative Therapy.
WB Saunders, Philadelphia, 1995 Plenum, New York, 1 978
5. Boissonnauit WG, Janos SC: Screening for medi 20. Lewit K: The contribution of clinical observation
cal disease: physical therapy assessment and to neurobiological mechanisms in manipulative
treatment principles. p. I , In Boissonnault WG therapy. p. 3 . In Korl' 1 M (ed): The Neurobiologic
(cd): Examination in Physical Therapy Practice: Mechanisms in Manipulative Therapy. Plenum.
Screening for Medical Disease. 2nd Ed. Churchill New York. 1 978
LivingsLOne, New York, 1 995 2 1 . Patterson M: A model mechanism for spinal scg·
6, Koopmeiners MB: Screening fOI" gastrointestinal mental facilitation. J Am Osteop Assoc 76:62, 1 976
system disease. p. 1 0 1 . In Boissonnault WG (ed): 22. Gdeve G: Clinical features. p. 1 59. In: Common
Examination in Physical Therapy Practice: Vertebral Joint Problems. Churchill Livingstone,
Screening for Medical Disease. 2nd Ed. Churchill New York, 1 98 1
Livi ngstone, New York, 1 995 23. Lewis T, Kellgren J: Observations relating to rc
7. Abramson 0 1 , Miller OS: Clinical and laboratory fen'ed pain. visceromotor reOexes and other asso
tests of al1crial circulation. p. 5 1 . In: Vascular ciated phenomena. Clin Sci 4:47, 1 939
Problems in Musculoskeletal Disorders of the 24. Cyriax J: Refen'ed pain. p. 22. In: Textbook of 0..-
Limbs. Springer-Verlag, New York, 1 98 1 thopaedic Medicine. Vol. I . Diagnosis of Soft Tis
8 . Michel TH, Downing J : Screening for cardiovas sue Lesions. 8th Ed. Bailliere Tindall, London,
cular system disease. p. 3 1 . In Boissonnault WG 1982
332 P H Y S I C A L T H E R A P Y OF T H E S H O U L D E R
25. Laurberg S, Sorensen K: Cervical danml root gan in the knee chest position. Am J Obstet Gynecol
glion cells with collaterals to both shoulder skin 72:903, 1956
and the diaphragm. A nuorescent double labelling 40. Arons�n M , Nelson P: Fatal air cmbolism i n prcg
study in the ral. A model [or referred pain? Brain nancy resu lting from an unusual sex acl. Obstci
Res 33 1 : 1 60, 1 985 Gyneco1 30: 1 27, 1 967
26. Bahr R, Blum berg H, Janig W: Do dichotomizing 4 1 . Qu igley J, Gaspar 1 : Fatal air embolism on the
afferent fi bers exist which supply visceral organs eighth day of pucrpel'ium. Am J Obstct Gynccol
as well as somatic structures? A contribution to 3 2 : I 054, 1 936
the problem of refclTcd pain. Neurosci Leu 24:25, 42. Goodman CC, Snyder TEK: Overview of gastroin
1 98 1 testinal signs and symptoms. p. 2 1 5 . I n : Di fferen
27. Doran F: The sites to which pain is rcfclTcd from tial Diagnosis in Physical Therapy. 2nd Ed. WE
the common bile-ducl in man and its implication Saunders, Philadelphia, 1 995
for the theory of refelTed pain. Br J Surg 54:599, 43. Vargo M, Flood K: Pancoast tumor presen ting as
latcd to mucosal prostanoids. and plasma drug 88. Bateman ON, Kennedy JG: Non-steroidal anti-in
concentrations in human volunteers. Agents Ac flammatory drugs and elderly patients: the medi
tions 39:C2 1 , 1993 cine may be worse than the disease. Br Med J 3 1 0:
86. H irschowitz 61. Lanas A: NSAID association with 8 1 7 , 1995
gastrointestinal bleeding and peptic ulcer. Agents 89. Nicholson AA, Bennett JR: Case !'ep0l1: radiolog
Actions 35(sllppl):93, 1 99 1 ical appearance or colonic stricture associated
87. Melarange R , Gentry C, O'Connell C et al: Anti with the usc or nonsteroidal anti-i nflammatory
inflammatory efficacy and gastrointestinal irri drugs. Clin Radiol 50:268, 1 995
tancy: comparative I month repeat oral dosestucl 90, Simopoulos AP: Omega-3 fatty acids in health and
ies in the rat with nabumetone. ibuprofen and disease and in growth and developmenl. Am J Clin
diclofenac. AAS 32:33, 1 99 1 Nutr 54:438, 1 99 1
Manual Therapy
Techniques
ROBERT A DONATELLI
TIMOTHY J M cMAHON
The p,;mary goal of the clinician is to optimize Normal joint function includes a dynamic
function, decrease pain, restore proper mechan combination of arthrokinematics (intimate me
ics, facilitate healing, and assist regeneration of chanics of joint surfaces), osteokinematics (the
tissues. Manual therapy has been demonstrated movement of bones), muscle function, fascial ex
clinically to be an important part of rehabilita tensibility, and neurobiomechanics (addressed
tion and assessmenl of restricted joint move in Chap. 6). Dysfunction and pain of the shoulder
ment. Clinical application of manual techniques can result from altered function of any or all of
is based on an understanding of joint mechanics, these systems. A detailed sequential evaluation
tissue histology, and muscle function. Signifi that hypothesizes particular impairments dic
cant advancement has been made in describing tates which particular manual therapy strategies
the benefits of passive movement by such re are appropriate. Please refer to Chapter 3 for
searchers as Akeson, Woo, Mathews, Amie!, and shoulder evaluation procedures. Clearing the
Peacock. 1-3 With this knowledge in hand the cli cervical and thoracic spine and brachial plexus is
nician can apply manual therapy techniques dur reviewed in Chapter 4 and 5. Manual techniques
ing critical stages of wound healing to influence discussed wiu focus on the shoulder complex.
extensibility of scar lissue, reduce the develop
ment of restrictive adhesions, and provide foun
DEFINITIONS
dations of neuromuscular mechanisms to re
store homeostasis. I Through an understanding Several terms must be defined when mobiliza
of the effects of immobilization and sort tissue tion is discussed. Articulation, oscillation, dis
healing constraints we can establish criteria for tractions, manipulation and mobilization all de
phases of manual therapy techniques. scribe a specialized type of passive movement.
This chapter will focus on manual therapy Articulatory techniques are derived [rom the
for the shoulder complex from a basic science osteopathic l iterature. They are defined as pas
and problem-solving approach. Manual therapy sive movement applied in a smooth rhythmic
will be discussed in relation to soft tissue and fashion to stretch contracted muscles, ligaments,
joint mobilization and muscle reeducation. and capsules gradually." They include gentle
Management of the shoulder patient will be dis techniques designed to stretch the joint in each
cussed from a perspective of protective versus of the planes of movement inherent to the joint.'
nonprotective injuries. The force used during articular techniques is
835
336 P H YSI C AL T H E RAP Y OF T H E SH OU LDE R
usually a prolonged stretch into the restriction techniques. The techniques are built on active
or lissue limitation. and passive joint mechanics and are directed at
Oscillatory techniques are best defined by the periarticular structures that have become re
Maitland, who describes oscillations as passive stricted secondary to trauma and immobiliza
movements to the joint, which can be a small or tion. These same techniques can be effective
large amplitude and applied anywhere in a range tools i n assessment of specific joint impair
of movement, and which can be performed while ments.
the joint surfaces are held distracted or com Soft tissue mobilization (STM) for purposes
pressed'- There are four grades of oscillations. of this chapter will be as defined by 10hnson:
Grade I is a small-amplitude movement per "STM is the treatment of soft tissue with consid
formed at the beginning of range. Grade 2 is a eration of layers and depth by initially evaluating
large-amplitude movement performed within and treating superficially proceeding to bony
the range, but not reaching the limit ohhe range. prominence, muscle, tendon, and ligament.'"
Grade 3 is a large-amplitude movement up to
the limit of range. Grade 4 is a small-amplitude
movement performed at the limit of range'
Grades I and 2 are used primarily for neurophys
Effects ojPassive Movmrumt em
iologic effects and do not engage detectable re Scar Tissue: Indications and
sistance. Grades 3 and 4 are designed to initiate Contraindications Jor
mechanical changes i n the tissue and do engage
tissue resistance.
Mobilization
Distraction is defined as "separation of sur
Research indicates that mobilization is most ef
faces of a joint by extension without injul)' or
fective in reversing the changes that occur in
dislocation of the parts. " 6 Distraction techniques
connective tissue following immobilization. I Ad
are designed to separate the joint surface at
ditionally, mobilization after trauma must be
tempting to stress the capsule.
carefully analyzed. When is it safe to apply stress
Manipulation is defined by Dorland's Illus
to scar tissue? How much stress should be ap
trated Medical Dictionary as "skillful or dexterous
plied to the scar in order to promote remodeling?
treatment by the hand. In phYSical therapy, the
What djrection should stress be applied? These
forceful passive movement of a joint beyond its
active limit of motion."7 Maitland describes two important questions must be answered before
manipulative procedures. Manipulation is a sud we can determine the indications for mobiliza
den movement or thrust, of small amplitude, tion of scar tissue. Indications for mobilization
performed at a speed that renders the patient will be discussed in regards to protective and
powerless to prevent itS Manipulation under an non protective categories of shoulder injuries. A
esthesia is a medical procedure used to restore case study EOImat will be used for each categol),
normal joint movement by breaking adhesions. to illustrate changes in treatment and discuss the
Mobilization is defined as "the making of a rationale of each phase.
fixed or ankylosed part movable. Restoration of
motion to ajoint."6 To the clinician, mobilization
is passive movement that is designed to improve CASE STUDY 1
soft tissue and joint mobility. I t can include oscil PROTECTIVE INJURY
lations, articulations, distractions, and thrust
techniques. Protective injuries are £i'om surgery and/or
Mobilization, in this chapter, is defined as trauma with significant soft tissue damage or re
a specialized passive movement, attempting to pair. Examples of protective injuries include an
restore the arthrokinematics and osteokinema terior capsular shift, Bankart repair, rotator cuff
tics of joint movement. Mobilization includes ar repair, and shoulder dislocation. Rehabilitation
ticulations, oscillations, distractions, and thrust for patients with protective injuries is divided
M A N U A L TH E R A PY T E C H N I Q U E S 337
into six phases: maximum protection, protected Palpable tenderness and trigger points on
mobilization, moderate protection, late moder subscapularis, selTatus anterior, levator sca
ate protection, minimum protection, and return pula, pectoralis minor, and lower portions
to function. This case study will illustrate the of longus colli muscles.
concepts of phased rehabilitation in a patient Scapular gliding revealed pectoralis major
with a protective shoulder injury. and minor tightness, and excessive mobility
H ISTORY of the scapula in an anterior direction.
A 16-year-old female basketball player was re Hypermobility of wrist, knee bilaterally,
fen'ed for postoperative rehabilitation of a right and left shoulder joints.
anterior capsulolabral reconstruction. The pro
cedure performed was a mini-open procedure ASSESSMENT
See Table 1 3 . 1 for ROM measurements. Patient was immobilized in a sling postopera
tively for the first 5 to 7 days. AAROM and PROM
Slightly elevated and protracted scapula R in the following protected ranges: Up to 90° of
Decreased fascial mobility of suture, and flexion, 45° of internal rotation, 90· of abduction,
along fascia of inferior clavicle. and neutral external rotation to be started 1 to
WEEKS P
OSTO PER A
T IVELY
2 4 • • I.
PROM (degrees)
Flexion 80 130 140 165 176
Abduction 58 90 102 160 170
External rototion, neutrol position -5 14 25 45 64
Extemol rototion, �5° abd. position -10 18 30 53 75
External rototion, 90" abd. position NT NT 38 56 80
Internal rototion, 450 obd. position 43 63 63 65 70
Extension NT NT 60 69 78
AROM (degrees)
Flexion NT NT 125 160 170
Scaption NT NT 130 165 175
2 weeks postoperatively. Ice and rest with al-m counterstrain an indirect positional release tech
supported for pain reduction. nique" to spinal and rib dysfunctions. PROM
and AAROM in protected positions described in
RATIONALE the previous phase.
ment of tissue tensile strength by helping align tween collagen fibers. Tensile strength has
newly synthesized collagen. Additionally, im reached its first peak, allowing gentle AROM as
proved tensile strength allows for early AROM early as 3 weeksz i n protected positions (rotation
in the next phase. before elevation especially in contractile compo
nent i njuries). STM to sutures and sUI1'ounding
PHASE 3: MODERATE PROTECTION PHASE (3 '0 6 fascial planes facilitates suture scar extensibility
Weeks)
and proper muscle function, and decreases pain.
REEVALUATION An additional goal of rehabilitation for this
phase is to prevent muscle atrophy, inhibition,
See Table \3.2 [or PROM measures. Continued
and effects of immobilization. PNF scapular pat
muscle guarding of subscapularis. Serratus ante
terns with a progression towards resisted pat
rior, first rib, longus colli, and scalenes with lillie
terns during this phase foster activation and res
to no tenderness. Subjective reports of decreas
toration of scapular muscle activity, providing
ing soreness and pain of GH joint at rest. Sutures
dynamic proximal stability. Progressive isomet
have been removed and superficial closure com
ric exercises in protected posi tions can be used
plete. Patient continues with anterior chest mus
around 5 weeks by the patient at home or work to
cle tightness and decreased scapular excursion.
stimulate inhibited muscle and provide dynamic
tension to healing soft tissue.
TREATMENT
P HASES M AXIMUM PROTE CTE D MO DE R ATE LATE MO DER ATE MIN MI UM R ETURN TO
PROTE CT ION MO BILI ZAT ION PROT E CTION PROT E CT ION PROT ECTION FUN CT O
I N
Time 1-10 day, 10 day, to 3 3-6 week, 6-12 weeks 12-16 weeks + 16 weeks
weeks
Stage of heeling InAommotory, Eorly nbroplo,io Fibroplasia, Maturation Maturation AIIoturotion
proliferative maturation
early
fibroplasia
GooI, Protect newly Facilitate Enhonce tensile Stress scar; Some as previous Retum to function
formed scor functional strength of restore phose; progressively
$Cor, seer force increase
aligning couples; strength
new proximol, rototor cuff,
collogen di,tol poroscopulor
fibers; dear muscles
$pinal and
rib
dysfunction
Monual therapy 7-10 day, Joint mobs- As previous, Scopular release PNF UE patterns A, needed for
techniques postwound, grades 1 STM to tech.; PNF with any deficits
grades 1 end 2 suture, UE pottems; signi�cant
and 2 joint progress ta scapular Iow-lood resistance;
mob, 3,4; STM release prolonged low-food
surrounding tech.; PNF streich prolonged
tissue; PNF scapular stretch if
scapular pottems needed
pottems;
protected
PROM
Other Position Home program (odmon lsokinetics in Some os Progressive retum
theropeutic education; of PROM in exercises, protected previous, to sport
interventions onti- protected T-bar, ROM- increasing drill" ligh.
inAommotory ranges Swiss boll, submax; effort and recreational
modolities; foam octive ROM; activities
ice roller; scopular plyoboll
AAROM stabilization throwing
and exercises;
AROM PRE,
exercises
See Table 1 3 . 1 for ROM measurements. Patient The return to function phase begins usually
demonstrating some elevation of scapula with around 1 6 weeks if elements of movement are
late elevation phase; excessive scapula elevation free of abnormal patterns and pain. This phase
increased with resistance. Activities of daily liv happens sooner based on patient response, spe
ing within normal limits. No pain with most ac cific trauma, and level of function requ ired. Ex
tivities and exercises. ercises are more functionally based and maximal
efforts are used. lsokinetic testing of rotator cuff
TREATMENT
muscles infOlm the therapist of any deficits in
particular internal External ratio's, that may in
Continued progression of weights and reps of dicate increased hazard for return to function.
previous phase of exercises. Chest pass throwing Currently reimbursement issues and managed
against plyoLrampoline with 2.5-1 b, ball. STM care policies may not allow physical therapists
performed to apparent remaining fascial restric to follow a patient completely through all phases
tions along the inferior clavicle followed by man of rehabilitation.
ual and PRE strengthening of lower trapezious In summary, protected shoulder injuries can
and sen-atus anterior. PNF resistive patterns per be safely progressed through a phased program
formed close to end-range abduction and exter of rehabilitation based on stages of sofl tissue
nal rotation. healing. Table 1 3.2 summarizes the various
stages. Manual therapy techniques used at spe
cific stages of healing can enhance the strength
RATIONALE
and extensibility of scar, reestablish force cou
Multiple repetitions in unresLricted ROM con ples, and restore functional movement patterns.
tinue to provide sLress to the maturing scar. Man
ual techniques during this phase are used to fur
ther fine-tune function and clear any remaining
restrictions. Neuromuscular control at end CASE STUDY 2
range abduction and external rotation is essen NON PROTECTIVE INJURY
tial to help protect capsular reconstruction and
return to sport. Nonprotective shoulder IIlJuries are primaJ;ly
shoulder dysfunctions that have no significant
PHASE 6: RETURN TO FUNCTION (16 Weeks +) soft tissue healing constraints. Examples of non
protective injuries include postacromioplasty,
REEVALUATION
prolonged immobilization, adhesive capsulitis,
Isokinetic testing reveals externaVinternal rota and impingement syndromes. Often these pa
tors ratio at 8 1 percent and 20 percent stronger tients present with pain, stiffness, and limited
than uninvolved side. function. This case study will illustrate the con-
342 PH Y S I C A L T H ER A P Y OF T H E S H O U L DE R
cepts O r rehabilitation ror a patient with a non along longus colli muscles at C5-6 L, Poste
protective injury. rior aspects or ribs 2-4 L, L subscapula,-;s,
supraspinatus, infraspinatlls, teres minor,
HISTORY and levator scapula
A 46-year-old remale homemaker presents with Capsular testing revealed restricted motion
lert shoulder pain and stirfness. Patient was re in all dil'ections
rerred 5 days postarthroscopic surgery and
closed manipulation. Patient began having pain ASSESSMENT
and stirfness several months prior possibly due
to overworking in her yard. Lert L shoulder be Patient with nonprotective shoulder injury, Ad
came increasingly stiff and painful the 5 to 6 hesive capsulitis with strong muscle guarding
weeks prior to surgery. Diagnosis given was ad and possible adaptive shortening or subscapu
hesive capsulitis. Past medical history: "stirr laris. Unable to fully assess capsular restrictions
neck" 2 to 3 years ago. secondary to muscle guarding or rotator curr and
subscapularis muscles.
T IME INITI A
L 2 WEE KS 4 WEEKS 6 WEEKS 10 WEEKS
PROM Idegree,1
flexion 102 112 140 150 174
Abduction 70 80 120 150 170
External rotation, neutral position -20 5 30 36 62
External rotation, 450 abet position 10 20 45 56 70
External rototion, 900 abel position NT NT 40 46 75
Internol rolotion, 450 abd. position 52 54 52 53 71
Hyperextension 48 50 53 53 71
AROM (degree'l
Scoption 70 90 112 132 155
tion, and education. Patients often will perform pula using theraband and a I -lb weight ini tially
habitual patterns of movement, maintaining cur for 1 0 minutes progressing to 20 minutes over a
rent state of dysfunction. Correction, modifica series of 4 to 5 treatment sessions. High-speed
tion, or cessation of predisposing activities is es (2000/s) isokinetics were initiated for internal
sential. Goals of rehabilitation during this phase and external rotation in the plane of the scapula
are to reduce inOammation and pain, restore in the available ROM. Scapular release tech
proximal stability spine, scapula muscle activity, niques used to mobilize fascial restrictions
and avoid painful positions. Clearing spinal and within subscapularis, se'Tatus anterior, and leva
rib dysfunctions that contribute or are source tor scapula. Joint mobilization, myofascial re
problems for shoulder signs and symptoms is es lease techniques used to address facet joint irri
sential during this phase for an optimal func tation C5-6 and suboccipitally. PNF scapular
tional outcome. patterns progressing from passive to resistive
movements with emphasis on posterior depres
INTERMEDIATE PHASE
sion, as illustrated in Figure 1 3 . 1 .
REEVALUATION
FIGURE 1 3.1
344 P H Y S ICAL T H E R A P Y OF T H E S H O U L DE R
curring at the glenohumeral. Kaltenbom deter showed that there is a increased risk of tissue
mined the appropriate method of applying a glid trauma and injury with rapid stretch rates. Rap
ing mobilization technique by the convex concave idly applied forces will cause material to react
mle. 15 Forexample, slidingofthe convex humeral i n a stiff, brittle fashion, causing tissue tearing.
head an a concave glenoid surface occurs in the Gradually applied loads result in tissue respond
opposite direction of the humems. Therefore, ing i n a more yielding manner with plastic defor
during elevation of the shoulder, the humeral is mation. If the tissue is held under a constant ex
sliding inferiorly as the bone moves superiorly. ternal load and at a constant length, force
However, data are now available that challenge relaxation occurs. 24
the concave-convex mle of arthrokinematic mo In addition to increasing extensibility of GH
tion. capsular and ligamentous stmctures, muscle ex
Poppen and Walkeri. report a movement of tensibility must also be addressed. Clinically the
the humeral head in a superior and inferior di authors have found subscapularis to be com
rection during elevation of the shoulder. Howell monly restricted in shoulder dysfunction. Sub
et al. demonstrated translatory motion of head scapularis is the most stablizing factor during
of the humems to be opposite of that predicted external rotation of the glenohumeral joint in 0°
by the concave-convex mle. Only patients with of abduction. " Additionally, most patients tend
instability demonstrated translation in the direc to guard or immobilize a painful shoulder by ad
tion predicted by the concave-convex mle.17 Soft ducting and intemally rotating the GH joint,
tissue tension capsular, ligament rather than thus shortening subscapulmis.
joint surface geometry may be a greater determi In prolonged immobilization and dysfunc
nant of the arthrokinematics of the GH joint. tions such as adhesive capsulitis, subscapularis
The type and fTequency of force used to mobi may accommodate to a shorten position. Mus
lize depends on the implicated tissue. In this case cles respond to immobilization by degeneration
study, the implicated tissue of restriction is the of myofilaments, change in sacromere alignment
anterior and inferior capsule, GH ligaments, and and configuration, decrease in mitochondria,
subscapularis. The authors advocate the use of and decreased ability to generate tension. 2• Mus
low-load prolonged stretch in addition to oscilla cles accommodate to immobilization in a short
tion techniques ror more signiricant soft tissue re ened position by losing sarcomeres. Tabary et al.
strictions. Connective tissue structures such as found that muscles immobilized in a shortened
ligaments, tendons and capsules respond to me position for 4 weeks had a 40 percent decrease
chanical stress in a time-dependent or viseoelas in total sacromeres and displayed an increased
tic manner. ' 8-21 Viscoelasticity is a mechanical resistance to passive movement. 27 Muscles im
property of materials that describes the tendency mobilized in a lengthened position had 20 per
of a substance to deform at a constant rate. The cent more sacromeres and demonstrated no
rate of deformation is not dependent on speed of change in resislance to passive motion.
the external force applied. If the amount of defor Functionally, limited subscapularis extensi
mation does not exceed the elastic range, the bility may effect functional elevation. Otis et al. 28
structure can return to the original resting length have recently documented the importance of re
after the load is removed. If loading is continued storing rotation to the glenohumeral joint in
into the plastic range, passing the yield point, fail order to facilitate elevation. It was demonstrated
ure of the tissue will occur. Failure is thought to that the contribution of infraspinatus moment
be a function of breaking intermolecular cross arm to abduction is enhanced with internal rota
links rather than mpture of the collagen tissue. 22 tion while that of subscapulmis is enhanced with
If pel-manent increase in ROM is a goal of external rotation. 28 Low-load prolonged stretch
treatment, then manual therapy should be aimed and rotational exercises in the plane of the sca
at producing plastic defOl·mation. Taylor et al. 23 pula in our case study are an atlempt to reverse
M A N U AL T H E R A P Y T E C H N I Q U E S 345
the effects of immobility, increasing the extensi without cervical pain but ROM ce,vical spine
bility and strength of the subscapularis muscle. 3/4 normal SB L and R.
Restrictions of subscapularis tend to also affect
parascapular muscles secondary to the altered
TREATMENT
scapulohumeral rhythm.
Scapular release techniques and STM (de Patient instructed in exercise progressions for
sc,ibed later in the chapter) can be used to re next 2 months with emphasis on rotator cuff and
lease fascial restrictions that have developed as parascapular muscle exercises. Patient allowed
a result of abnormal movement paLlerns. In this to progress back to swimming and gardening ac
particular case, the patient had excessive pro tivities to tolerance.
traction and downward rotation of the scapula
with trigger points in the levator scapula, serra
tus antedor, and pectoralis minor. Warwick and RAT t O N A L E
Williams29 report a possible fusion of the sen·a Once ROM and strength are optimized, a home
tus anterior and levator by their fascial connec program is finalized to further facilitate physio
tion. Excessive tone of pectoralis minor effectly logic changes such as increased sacromeres and
depresses the scapula and restricts the scapular remodeling of periarticular tissues. In the com
rotation necessary for proper elevation. Further petitive and industdal athlete, fonn, technique,
more, the se'Tatus anterior and levator scapula and training error cOITecUon is essential to pre
work as a force couple to rotate the scapula. In vent recurrence of dysfunction.
creasing the extensibility of the fascia of these In summary, rehabilitation of nonprotective
three muscles would allow proper functioning of injUlies depends on the implicated tissues or sys
parascapular force couples during elevation. tems in dysfunction or restriction. Table 1 3.4
RETURN TO FUNCTION PHASE
summarizes the phases of rehabilitation. G H
joint arthrokinematics may be strongly inOu
REEVALUAT t O N
enced by periarticular tissue extensibility and
See Table 1 3.3 for I O-week ROM measurements. muscle function rather than pure joint geometry.
All ADLs without pain and patient has started Manual techniques must comply with the type
working in the yard without limitations. Patient of tissue or system response desired. Continual
PHASES IN T
I A
I L INTERMEDIATE RETURN TO FUNCTION
Signs and Pain at rest; difficulty No poin at rest; poin with resistance; moderate ROM maximized; functional
symptoms sleeping; poin reactivity; limited rot, and elevation; movement poin free;
(reactivity) before weakness of rolator cuff and/or muscle imbalances
resistance poroscopulor muscles resolving
Gools Decrease poin Restore rotation ROM and strength of Retum to Fundion
poroscopulor muscles and rotator cuff
Monuol theropy Grocles 1 and 2 Grades 3 and .4 ioint mobs; STM; scopular Fine-tuning of functional
techniques joint mobs release techniques; PNF scapular and UE pottems with PNF
patterns; Iow·1oad prolonged stretch
Other therapeutic Anti-inRammatory Heat with stretch; isokinetic and isotonics Home program, correct
interventions modalities; working ratation before elevation in POS; technique and training
positioning and isometrics; AAROM with T bars, Swiss errors
activity bolls, loom rollers; GH io;n' ond scopulor
education toping techniques
346 P H Y S ICAL T H E R A P Y OF T H E S H O U L DE R
JOint mobilization can result in the patient demonstrate the elongation of tissue under var
guarding against the mobilization. ied loads. A high-load, shon-duration treatment
( l OS g to 1 65 g for 5 minutes) and a low-load,
long-duration treatment (5 g for 1 5 minutes)
Direction of Movement
were compared.34.35 The results indicated that
The direction of movement of mobilization low-load, long-duration stretch was more effec
should take in account the mechanics of the joint tive in obtaining a permanent elongation of the
mobilized, the aI1hrokinematic and osteokinem tissue. In humans, Bonutti et al.36 determined
atic impairments of the dysfunction, and the cur that the optimal method to obtain plastic defor
rent reactivity of the tissues involved. mation and reestablish ROM is static progressive
The direction of forces to the joint is also de stretch (SPS). One to two 3D-minute sessions per
termined based on the response desired. Neuro day of SPS for I to 3 months produced an overall
muscular relaxation and pain modulation effects average i ncrease in motion of elbow con
will be appreciated if the direction of force is op tractures of 69 percent, with exceUent compli
posite pain. Biomechanical effects will be appre ance by the patients. As previously noted, the au
ciated if forces are directed towards resist but to thors advocate the use of low-load prolonged
patient tolerance. The resistance represents the stretch with heat to facilitate plastic deformation
direction of capsular or joint limitation. Move of shoulder capsular restrictions. Figure 1 3.2 de
ment into the restriction is an attempt to make picts one method of low-load prolonged stretch
mechanical changes within the capsule and the for external rotation. The patient needs to be in
surTounding tissue. The mechanical changes may a subacute stage of reactivity and the stretch is
include breaking up of adhesions, realignment of to patient tolerance. Heat used in conjunction
collagen, or increasing fiber glide. Certain move with the stretch has been found to be more effec
ments stress specific parts of the capsule. For ex tive than stretch alone.37•3• The patient's shoul
ample, arthrogram studies demonstrated that ex der is placed in the plane of the scapula with a
ternal rotation of the glenohumeral joint stresses wedge or tack of towels. The stretch is per
the anterior recess of the capsule.33 formed by theraband resistance to assist with po
sitioning and the use of a hand weight and grav
ity to stretch anterior periarticular Slnlctures.
Body Mechal1ics Duration of stretch can be from 20 to 30 minutes.
Little research has been performed on joint
Proper body mechanics are essential in ap
mobilization to determine the optimum dura
plication of mobilization techniques. The thera
tion of oscillation. Often the duration is deter
pist is able to impart desire direction and force of
mined by the change desired by the therapist.
movement if working from a position of stability.
For example, GH joint mobilization of grades I
The therapist should stand close to the area
or 2 performed to facilitate neuromuscular relax
being mobilized and use weight shifting through
ation could be performed until muscle guarding
legs and trunk to assist movement in the vector
was reduced and ROM increased.
of mobilization. The therapists hands and arms
should be positioned to act as fulcrums and le
vers to fine-tune mobilization. Gherwhurneral Joint Techniqu£s
FIGURE 1 3.3: I N FERIOR GLIDE OF THE
FIGURE 1 3.2
FIGURE 1 3.3
M A N U A L T H E R A P Y T E C H N I Q U E S 349
FIGURE 1 3.4
Patielll Position I
/
Supine, with the involved extremity as close
as possible to the edge of the table.
Therapist Position
HUMERUS
Patient Position
Therapisl POSilioll
HUMERUS
Paliel1l Posilion
Therapist Posiliol1
Sitting on treatment table at 45° tum from FIGURE 1 3.8: ANTERIOR GLIDE OF THE HEAD
sagittal plane. Mobilizing hand is placed on ante OF THE HUMERUS
rior humeral head, with a wedge or rolled towel
Paliel1l Position
under lateral scapula. Assisting hand supports
distal extremity to facilitate relaxation. The mo Prone, with the involved extremity as close
bilization is directed posterior along the plane of as possible to the edge of the table. The head of
the glenoid. This technique is useful for reactive the humerus must be off the table. A wedge or
shoulders with posterior capsule tightness. towel roll is placed just medial to joint line under
the coracoid process. The extremity is abducted
and flexed into the plane of the scapula.
FIGURE 1 3.6: POSTERIOR GLIDE OF
HUMERUS
Therapisl Positiol1
Paliel1l POSi/iol1
Distal to the abducted shoulder facing ceph
Supine with involved shoulder flexed 90° and alad. The outer hand applies slight distraction
horizontal adducted to first tissue resistance. force while the i n ner mobilizing hand glides
M A N U A L T H E R A P Y T E C H N IQ U E S 351
FIGURE 1 3.7
Therapist Position
the head of the humerus anteriorly, stressing
Facing laterally in a silting position, with the
the anterior capsule. The tendon of the subscap
forearm of the involved extremity held between
ularis is also stressed with this technique. The
the therapist's knees. Both hands grasp the head
mobilization can be fine-tuned by changing the
of the humerus and apply anteroposterior move
angle of the anterior force to the area most
ment oscillating the head of the humerus.
restricted.
Grades I and 2 are mainly used with this tech
nique to stimulate mechanoreceptor activity.
FIGURE 1 3.9: ANTERIOR/POSTERIOR GLIDE
FIGURE 1 3. 1 0: ANTERIOR/POSTERIOR GLIDE
OF THE HEAD OF THE HUMERUS
OF THE HEAD OF THE H U M ERUS
Prone, with the involved extremity over the Supine with the involved extremity supported
edge of the table abducted to the desired range. by the table. A towel roll, pillow, or wedge is placed
A strap may be used to stabilize the scapula. under the elbow to hold the arm in the POS.
FIGURE 1 3.8
352 P H Y S ICAL T H E R A P Y OF THE S H O U L DE R
FIGURE 1 3.9
Facing laterally in a sitting posItion. The Facing laterally with caudal mobilizing hand
fingertips hold the head of the humerus while a grasping the distal humerus. the heel ohhe ceph
gentle up-and-down movement is applied. This alad mobilizing hand over the lateral aspect of
technique is used with grades 1 and 2 oscilla the head of the humerus. Force is applied
lions. through both hands. The caudal hand rDiates the
humerus extemally and provides long-axis dis
FIGURE 1 3. 1 1 : EXTERNAL ROTATION OF THE traction while the cephalad hand pushes the
HUMERUS head of the humerus in a posterior direction.
Patient Position
FIGURE 13.10
M A N U AL T H E R A P Y T E C H N I Q U E S 353
FIGURE 1 3 . 1 1
FIGURE 1 3 . 1 2
354 P H Y S I C A L T H E R A P Y O F T H E S H O U L DE R
FIGURE 1 3 . 1 3
FIGURE 1 3 . 1 4
FIGURE 1 3 . 1 6
lengthen during passive elongation .'9 Abnormal TABLE 1 3.5 Treatment hand tecimiq"es
compensations may occur, possibly leading to
breakdown of compensating tissues. Susloined pressure: Pressure applied directly to restricted tissue at
Within the shoulder complex several areas the desired depth and direction of maximol restriction
are importanl to evaluate for fascial restrictions. Directoscillations: Repeoted oscillations on and off a restriction with
uptake of slack as restriction resolves
Scapulothoracic releasing techniques will also
Perpendicular mobilization: Direct oscillations and/or sustained
be described due to the musculotendious and
pressure techniques performed perpendicular to muscle fiber
fascial characteristics of this articulation. The
or soft ti nue play
following is a descl-iption by muscle(s) or space Parallel mobilization: Pressure applied longitudinally to restrictions
between structures to evaluate and mobilize. along Ihe edge of Ihe muscle belly '" along bony conlou"
Table 1 3.5 defines the types of techniques re Perpendiculor (transverse) strumming: Repealed mylhmicol defor
ferred to in the figure legends. mations of a muscle belly to improve muscle play and reduce
tone
Patient Position
Therapist Position
Supine
Facing axilla with mobilizing fingers on
muscle belly of subscapularis. Parallel mobiliza
Therapist Position
tion or perpendicular strumming or direct oscil
lation may be used. Assistive techniques are sus Cephalad hand simultaneously elevates, ex
taining pressure while elevating and adducting ternally rotates, and distracts the involved
the shoulder as in Figure 1 3 . 1 7B. shoulder, while the caudal hand (thenar side)
M A N U A L TH E R A P Y T E C H N IQ U E S 357
FIGURE 1 3. 1 7
FIGURE 1 3. I 8
FIGURE 1 3 . 1 9
M A N U A L T H E R A PY T E C H N I Q U ES 359
FIGURE 1 3.20
FIGURE 1 3.2 1
along rib contours medial to lateral or lateral to FIGURE 1 3.22: INFERIOR CLAVICLE
FIGURE 1 3.22
POSTER I O R APPROACH
Same side as involved shoulder. Palpating
medial to lateral or vice versa along inferior clav Patient Position
icle, look for fascial restrictions and tenderness
especially at the costoclavicular ligament, sub Sidelying as previous bUI closer to posterior
clavius muscle, and the conoid and trapezoid lig edge of table.
aments. This region is important to evaluate and
treat in shoulder patients who have protracted
Therapist Position
and externally rotated scapula with adaptive
shortening of anterior chest musculature. Posterior to patient with therapist's hips in
perpendicular orientation to patient's trunk.
FIGURE 1 3.23: SCAPULAR DISTRACTION Therapist's adjacent leg on the treatment table
with knee bent and placed along midthoracic
Patient Positim,
spine. Outer mobilizing hand grasps the verte
Sidelying close to the edge of the table with bral border of the scapula. Inner hand supports
the involved extremity accessible to the thera the anterior GH joint. Once hand placement is
pist. A pillow may be placed against the patient's achieved, the therapist leans back, distracting
chest to provide anterior support. the scapula away from the thoracic wall. Sus
tained stretch most effective with this technique.
Therapist Positiol1
FIGURE 1 3.25: SCAPULAR EXTERNAL
Facing the patient with caudal hand under
ROTATION
neath inferior angle of the scapula and the ceph
alad hand grasping the vertebral border of the Patient Position
scapula. Both hands tilt the scapula away from
the thoracic wall along with the distraction of Sidelying with the involved extremity acces
the scapula by the therapist leaning backward. sible to the therapist.
M A N U AL TH E R A P Y T E C H N I Q U E S 361
FIGURE 1 3.23
FIGURE 1 3.24
FIGURE 1 3.25
FIGURE 1 3.26
FIGURE 1 3.27: SCAPULA DISTRACTION, hand web space under the inferior angle of the
PRONE scapula. The forces are applied simultaneously.
Patient Position The outer hand lifts the G H joint while the adja
cent hand lifts the inferior angle of the scapula.
Prone with the involved extremity supported
by the table.
Therapist Positiol1
Summary
Facing cephalad. outer hand under the head Rehabilitation of shoulder injUlies using manual
of the humerus and the adjacent mobilizing techniques is based on an understanding of
M A N U A L T H E R A P Y T E C H N I Q U E S 363
FIGURE 1 3.27
stages of sort tissue healing, normal and abnor 2. Peacock EE II': Wound Repair. 3rd Ed. WB Saun
mal arthrokinematics and osteokinematics of ders, Philadelphia, 1984
3. Akeson WH, Amici D, Woo SLY: Immobility ef
the shoulder complex, effects of biomechanical
fects on synovial joints. The pathomechanics of
stress on various tissues, and muscle function.
joint contracture. Biorheology 1 7:95, J 980
The application of manual techniques for the
4. Stoddard A: Manual of Osteopathic Technique.
shoulder is dependent on a thorough sequential
HUlchinson, London, 1959
evaluation and continual reassessment. Indica 5. Maitland GD: Pedpheral Manipulation. Butter·
tions and contraindictions for mobilization are worth Publishers, London, J 970
based on an understanding of the histology of 6. Clayton L (cd): Taber's Cyclopedic Medical Dic
immobilized and traumatized tissues. Clinical lional),. FA Davis, Philadelphia, 1 977
management o[ shoulder i njuries has been dis 7. Friel I (cd): Dorland's Ill ustrated Medical Diction
cussed from a perspective of protective versus al)'. 25th Ed. WB Saundel'S, Philadelphia, 1 974
nonprotective injuries, and phased programs of 8. Johnson GS: Course notes, Functional Or·
rehabilitation have been presented. Research on thopedic 1 , institute for Physical Art, San Fran
cisco, Mal'eh 1 99 1
the efficacy of manual therapy must be advanced
9 . Andriacchi T e t al: Ligament: InjlllY and repair.
and traditional concepts and techniques should
In Woo SLY, Buckwalter J (eds): InjUJ)' and Re
comply with current and future discoveries.
pair of the Musculoskeletal Soft Tissues. Ameri·
can Academy of Orthopaedic Surgeons, 1 99 1
Ackrwwledgements t o. Kellet J : Acute ST injuries, a review o f the litera·
ture. Med Sci SPOI'ts Exel'c 1 8 :5, 1 986
We would like to Ihank Jill Heinzmann, R.P.T. J 1 . Jones LH: Strain and Counterstrain. American
and John Zubal, A.T.C. for their assistance with Academy of Osteopathy, Colorado Spl'ings, 1 9 8 1
the manual technique piclures. 1 2 . Kelly M , Madden JW: Hand surgel), and wound
healing. p. 49. In Wolf011 FG (ed): Acute Hand
References Injuries: A MulLispeciaJty Approach. LillIe,
Brown, Boston, 1 980
I . Frank C, Akeson WH, Woo S el al: Physiology and 1 3 . Cohen KI, McCoy BJ, Dicgclmann RF: An update
therapeutic value of passive joint motion. Clin Or on wound healing. Ann Plast Surg 3:264, 1 979
Ihop 1 85: 1 1 3 , 1984 1 4 . Arem Al, Madden JW: Effects of stress on healing
364 P H Y S ICAL T H E R A P Y O F T H E S H O U L D E R
wounds: intermittent noncyclical tension. J Surg cal and structural changes on the cat soleus mus
Res 20:93, 1 976 cle due to immobili7.ation at di fferent Icngths by
1 5. Kaltenbom FM: Mobilization of the Extremity plaster casts. J Physiol 224:23 1 , 1 972
Joints. Olaf Norris Bokhandel. Oslo, Norway, 28. Otis JC, Jiang CC, Wickicwicz TL et al: Changes in
1980 the movement alms of the rotator cuff and deltoid
1 6. Poppen NK, Walter PS: Normal and abnormal muscles with abduction and rotation. J Bone Joint
motion of the shoulder. J. Bone Joint Surg 58: 1 95 , Surg 76:667, 1 994
1 976 29. Wanvick R, Williams P (eds): Gray's Anatomy,
1 7 . Howell SM, Galinat BJ et al: NOImal and abnor 35th Blitish Ed. WB Saunders, Philadelphia, 1973
mal mechanics of the glenohumeral joint in the 30. Wyke BD: The neurology of joints. Ann R Coli
hOlizontal plane. J Bone Joint Surg 70:227, 1 98 8 Surg Engl 4 1 :25, 1 966
1 8. Vidik A : O n t h e rheology and morphology of soft 3 1 . Wyke BD: Neurological aspects of pain therapy:
collagenous tissue. J Anat 1 05 : 1 84, 1 969 a review of some cun-cnt concepts. p. I . In Swer
dlow M (ed): The Therapy of Pain. MTP Press,
1 9, Reigger LL: Mechanical properties of bone. I n
Lancaster, England, 1 98 1
Davis GJ, Gould JA (eds): Orthopaedic a n d SPOI�S
32. Haldeman S: Modern Developments in the Pdnci
Physical Therapy. CV Mosby, Sl. Louis, 1 985
pies and Practice of Chiropractic. Appleton-Cen
20. Betsch OF, Bauer E: Structure and mechanical
tury-Crofts, East Norwalk, CT, 1 980
propel�ies of rat tail tendon. Biorheology 1 7:84,
33. Kummel BM: Spectrum of lesion of the antedor
1 980
capsulc mechanism of the shoulder. Am J Sports
2 1 . Butler DL, Grood ES, Noyes FR et al: Biomecha
Med 7: 1 1 1 , 1 979
nics of ligament and tendons. Exer SPOl1 Sci Rev
34. WalTen CG, Lehman IF, Koblanski NJ: Elonga
6 : 1 26, 1 979
tion of rat tail tendon: effects of load and tempera
22. Hirsh G: Tensile properties during tendon heal
ture. Arch Phys Med Rehabil 52:465, 1 9 7 1
ing. Acta Orthop Scand, suppJ. 1 53: I , 1 974
3 5 . Warren C G , Lehman JF, Koblanski N J : Heat and
23. Taylor DC, Dalton 10, Seaber AV et al: Viscoelas
stretch tech-procedure: an evaluation using rat
tic properties of musculotendon units: The biome
tail tendon. Arch Phys Med Rehabil 57: 1 22, 1 976
chanical effects of stretching. Am J Sports Med
36. Bonutti PM, Windau BS et al: Stalic progressive
1 8:300, 1 990 stretch to ,-eestablish elbow range of motion. Clin
24. Van Brockl in JD, Follis DG: A study of the me Ol�hop 303: 1 28, 1 994
chanical behavior of loe extenSOl' tendons uncleI' 37. Lehman IF, Masock AJ , WalTen CG, Koblanski
applied stress. Arch Phys Med 46:369, 1965 IN: Effects of therapeutic temperatures on tendon
25. Turkel SJ, Panio MW, Marshall n, Girgis FG: Sta extensibility. Arch Phys Med Rehabil 5 1 :48 1 , 1 970
bilizing mechanisms preventing anledor d isloca 38. Lentell G, Hetherington T, Eag n J , Morgan M: The
tion of glenohumeral joint. J Bone Joint Surg 63: use of thermal agents to innuence the effective
1 208, 1 98 1 ness or a low load prolonged stretch. Ol�hop
26. COOpel' RR: Alterations during immobilization Sports Phys Ther 1 7:200, 1 992
and regeneration of skeletal muscle i n cats. J Bone 39. Johnson GS: Soft tissue mobilization. In Donatelli
Joint Surg 54:9 1 9, 1 972 R, Wooden MJ (cds): Ol�hopaedic Physical Ther
27. Tabary JC, Tabary C, Tardieu C et al: Physiologi- apy, Churchill Livi ngstone, New York, 1 994
Strengthening Exercises
KAREN E DAVIS
ROBERT A DONATELLI
Strengthening is one of the most vital compo cordingly-' Strength training i ncreases the maxi
nents of shoulder rehabilitation. Once sufficient mum strength of tendons and ligaments while
healing occurs and adequate range of motion i s stronger muscles reduce the relative daily stress
obtained, strengthening often becomes the main placed upon joints throughout the body.'
focus of treatment. As the effects of prolonged Strength training i ncreases skeletal muscle
immobilization are becoming more apparent, mass, force-generating capability, and metabolic
early mobilization and strengthening are gaining capacity. Strength training also increases nexi
in popularity. bility, possibly increasing performance and re
The present chapter defines strength, ducing the potential for injury both with work
strength training principles, and exercise pre related and athletic activities.3
scription. Muscles essential to shoulder mobility
and stability are discussed along with specific
strengthening exercises for the shoulder.
The case studies present treatment programs Muscular Endurance
for two shoulder patients. These cases apply
strengthening principles to the rehabilitation "Absolute muscular endurance (AME) i the abil
plans. Incorporating strengthening exercises ity to maintain a given fixed submaximal force
and exercise prescription appropriately to each output during work relying prima,;ly on anaero
patient is as important as any other component bic metabolism until exhaustion."" Factors that
of treatment. This chapter will provide some conu;bute to AM E or anaerobic capacity include
guidelines to follow when designing your own (1) biochemical adaptations, (2) maximal
strengthening regime. strength level , (3) neural adaptations, and (4)
muscle hypertrophy." Muscle endurance has
been described as performing work using mod
erate to heavy loads over a period of time.' Most
Strength clinicians are familiar with the cardiovascular
factors contributing to overall endurance or aer
Strength is defined as the ability to produce force obic capacity. Cardiovascular factors may con
and is often used as a measure of ability.' tdbute to muscle endurance; however, increases
Strength is important in both health and perfor in adenosine triphosphate (ATP), creatinine
mance.' Strength training can positively effect phosphokinase (CP), glycogen stores, myokinase
the entire musculoskeletal system as bone, mus activity, and maximum strength largely com
cle, and associated connective tissue adapt ac- prise anaerobic capacity.' Concentrations of
365
366 PHYSI C AL THER APY OF THE SH OULDER
Plyometrics INT
Plyometrics are high-intensity training bridging Intensity or volume is den pendent on the num
the gap between speed and strength.'7 Plyome ber of sets and repetitions, rest between sets, du
trics are exercises in which a rapid deceleration, ration of workout, and the amount of weight or
368 PHYSICAL THERAPY OF THE SH O U LDER
depending upon the goals of training. Specificity of trammg is the most important
Six or fewer repetitions. with weight based principle in strength training. The rehabilitation
on a low RM (I to 5 RM). provide the most goals will determine the specificity of training
strength and power benefits.20 Weight based on and dictate the intensity. frequency. and dura
6 RM to 1 2 RM provides moderate gains. and tion of the program. The SAID (specific adapta
weight based on 20 RM and above provides mus tions to imposed demands) principle indicates
clllar endurance gains without strength gains. that the body will gradually adapt to the specific
The intensity of training is categorized as high. demands imposed upon it. '4 Thus. the demands
moderate or low with corresponding RMs of 90
•
must be specific to the desired goals and con
percent. 70 to 90 percent and below 70 percent. 20 stantly change for continual adaptations and re
Moderate workloads and moderate volumes of sultant increases in strength.
work are suggested for athletes retraining after
injury. prepubescent athletes. and hypertensive
WARM- U P
populations. The intensity of training in rehabili
tation must consider tissue healing and prior General and specific warm-up methods have
physical activity of the patient and be directed been demonstrated to improve performance as
towards rehabilitation goals. well as reduce the ,-isk of injury from training.'
S T R E N G T H E N ING EX ER C I S ES 369
PERIOOIZA ION
T
10 repetitions pel-formed 2 or 3 days per week anced by the [iring of the rotator cuff dUl;ng ele
with moderate weights. vation.
Townsend et al.25 performed an electromyo
graphic (EMG) analysis of the glenohumeral
muscles. The four rotator cuff muscles and other
Strengthening Exercises for the positioners of the humerus were studied using
Shoulder common shoulder exercises from rehabilitation
programs used by professional baseball clubs.
The muscles of the glenohumeral joint have been Four exercises were found to be the most chal
grollped inLO three functional categories by lenging for every muscle. These exercises were
Saha." The first group, prime movers, include ( I ) elevation in the plane of the scapula with in
the deltoid and clavicular head of the pectoralis ternal rotation (Fig. 1 4 . 1 ) (2) Oexion, (3) prone
major. The second group, steering muscles, in horizontal abduction with the arm externally ro
clude the supraspinatus, subscapularis, and in tated ( Fig. 1 4.2), and (4) press-up (Fig. 1 4.3). The
fraspinatus. This group majntains the humeral plane of the scapula is fun her defined in Chapter
head in the glenoid. Finally, the latissimus dorsi, I.
teres major and minor, and sternal head of the The supraspinatus has been identified as the
pectoralis major are collectively the third group, most frequently injured muscle of the rotator
the depressors. cuff group.2. Jobe and Moynes2• also support
Dynamic glenohumeral stability is provided that the rotator cuff muscles should be evaluated
by the rotaLOr cuff. The rotator cuff muscles are and strengthened individually. They report max
important providers of joint stability as they ap imal supraspinatus muscle activity at 90' of arm
proximate the humeral head in the glenoid abduction, 30' of ho.-izontal Oexion, and full in
fossa.>' The importance of force coupling be ternal rotation in the upright position. Black
tween the rotator cuff and the deltoid is best de burn et al.27 duplicated this test position de
scribed by Inman et al.24 The sheer forces across scribed by Jobe and Moynes2• and analyzed
the joint from the deltoids' upward pull are bal- vm·iolls other exercise positions, reporting the
S T RENG THENING E X ERCIS E S 371
f,mction training baseball pitchers. Isotonic con funcUonal improvements through strength
centdc exercises were used on an isokinetic de training. Several other studies have shown in
vice. The results indicated statistically signifi creases i n power and velocity of movement with
cant increases in throwing velocity and an significant increases in the strength of the legs. I
increase in external rotator torque. Extensive reviews of the physiologic effects of
Ellenbecker et al." compared the effects of resislance and endurance training illustrate the
concentric isokinetic versus eccentric isokinetic effects on performance.36-39 Muscle strength,
exercise on rotator cuff strength and power and endurance, verticle jump, and sprint speed are
on tennis serve velocity. Concentric strength was just a few of the va,;ables increased with resis
significantly improved in both groups after 6 tance and endurance training.
weeks of training. Improvements in eccentric
strength and serve velocity were only found with
the concentric training group; however, not
using a controlled group weakened the results of Summary
this study.
Mont et al.37 performed a study similar to Strength is a measure of human performance.
Ellenbecker's examining strength training isold Strength is a result of the interaction of neural,
netically and functional outcomes using tennis muscular, and mechanical factors. Initial gains
serve velocity. Mont et al. compared isokinetic in muscular strength during the first few weeks
training of the shoulder internal and external ro are secondary to neural adaptations. Increases
tators using concentrically trained, eccentrically in cross-sectional area of muscle contdbute to
trained, and control groups. Slatistically signifi strength gains after the first few weeks of train
cant concentric and eccentric gains were ob ing. The plimary cellular effects of strength
tained with both training groups when com training occur in the fast, type II, muscle fibers.
pared to the control. The increase in serve The type II fibers are responsible for muscle
velocity was greater than I I percent. strength and power and must be recruited dur
All three studies illustrate sport-specific ing training to be hypertrophied. Training with
STREN GTH E NI N G EXERCISES 373
low or moderate weight will not provide this mobility. This is achieved by synchronous activ
stimulus. Strength training must also be specifi ity of the rotator cuff. long head of the biceps,
cally designed to meet the rehabilitation goals. rotators of the scapula, and the deltoid. Fatigue
lncreases in maximum strength allow the or weakness of any of these muscle can lead to
athlete or worker to perform at a smaller per abnOlmal translation of the humeral head."
centage of their maximum effort and thus en Weakness of the rotator cuff is also thought to
dure longer work rates. This ability represents trigger glenohumeral instability.'9 Scapular ro
an overall increase in muscular endurance. Ade tator muscle weakness allows excessive scapular
quate muscle strength and endurance at the movement, contdbuting to poor scapulohum
shoulder complex is necessary to maintain ade eral rhythm. Abnormal humeral head transla
quate physiologic and accessory motion, and tion of the humeral head, or altered scapulohum
thus normal scapulohumeral rhythm. eral rhythm, can contribute to initation of
The muscles at the shoulder complex must adjacent tissues and shoulder pathology."
work together to provide adequate stability and Proprioceptive exercises and eventually plyo-
374 PHYSICAL THERAPY OF THE SHO U L D ER
standing positions, with most activities requir joint. Limits in passive range of motion demon
ing reaching in front and/or overhead. He has strate limits in mobility of the subscapularis and
been performing these job duties for 1 5 years. capsular structures.40.4I Limits in the scapuloth
He reports intermillent shoulder pain during the oracic articulations were also identified. Limits
last 3 to 4 years that has progressively worsened i n active elevation correspond to the passive
over the last 3 to 4 months. He has been referred findings. During this middle phase of elevation
to physical therapy with a diagnosis of "impinge (60· to 1 40·), there is an i ncrease in scapulothor
ment syndrome." acic movement.42 Adequate glenohumeral and
scapular rotator strength is critical, because
INITIAL EVALUATION
maximum shearing forces of the deltoid occur
Radiographic findings did not reveal an abnor at this phase. This middle range is also the range
mal shaped acromion; however, mild bone spur in which this patient performs the majority of
ring was present on the underlying surface of the his work-related tasks. The presence of trigger
AC joint. Visual inspection revealed gross atro points i n the muscle and shoulder complex cor
phy of the right shoulder complex. Gross pos respond to overactivity of these muscles com
tural changes including an increased thoracic pensating for the reduced scapular motion.43
kyphosis, forward head, and rotated humerus All of this patient's findings are contributors
were apparent. Active elevation of the humerus to a reduced suprahumeral space leading to im
in the plane of the scapula was approximately pingement.
80· and limited by pain. The lateral border of
the scapula protracted excessively during active
TREATMENT PLAN AND RATIONALE
elevation. Passive extel11al rotation was limited I N I T IAL P H AS E ( W E E K I)
to 5· at O· of abduction and 20· at 90· of abduc
tion. Accessory glenohumeral motion testing re This patient was placed on light duty at work and
vealed moderate capsular restrictions in anterior his overhead activities were limited during his
and posterior directions for the involved extrem rehabilitation. This patient was seen three times
ity. Overall passive scapular mobility was limited per week during the first 1 2 weeks of physical
in rotation and distraction from the lib cage. therapy. Initial treatments focused on restoring
Isokinetic assessment of the rotator cuff was soft tissue mobility. Heat in conjunction with a
deferred at this point due to limited ROM for low load prolonged stretch into external rotation
rotation; however, gross manual muscle tests re was applied to the shoulder (Fig. 1 4.8). The hu
vealed 4/5 intel11al rotator and 3/5 extel11al rota merus was positioned 30· anterior to the frontal
tor strength. The patient was not able to assume plane and 1- to 3-pound weights were progres
the prone test position for the supraspinatus. Su sively added to patient tolerance for 1 0, 20, and
praspinatus testing standing revealed pain and 30 minutes in consecutive treatment sessions.
weakness. Strength assessments revealed 3 + 15 Elevating tissue temperatures with superficial
muscle grades for the scapular rotators, serratus moist heat in conjunction with a low load pro
anterior, middle and lower trapezius, rhom longed stretch are thought to cause plastic defor
boids, and extel11al glenohumeral rotators. Im mation in connective tissues.44 Soft tissue tech
pingement testing was positive (see Chapter 3). niques to reduce trigger points followed by
Neurologic testing was normal. Palpation re glenohumeral and scapular mobilizations were
vealed trigger points within the subscapularis, then performed.
levator scapulae, and pectoralis major muscles. Active stretching of the antagonistic mus
cles, pectoralis major, upper trapezius, and leva
N
I
tor scapulae was performedTprior to strengthen
ERPRETATION OF FINDINGS
Apparent muscle atrophy and postural and ra ing of the agonistic scapular rotators. Janda (49)
diographic changes may be attlibuted to disuse describes muscle imbalances occurring from
and age-related changes of the glenohumeral tight muscles inhibiting its antagonist. Janda45
376 PHYSICAL T HERA P Y OF THE SHOULDER
stresses the importance of stretching the antago 6. Prone extension with internal rotation (Fig.
nists prior to strengthening the agonists. 1 4. 1 0)
After two visits, improvement in external ro
Eighty percent of an estimated I RM was used
tation reached 45· at O· of abduction and 60· at
as the load for all i otonic scapular rotator exer
90· of abduction. Scapulothoracic rhythm was
cises. Three sets of 1 0 repetitions was preceded
improved, and excessive protrusion of the sca
by a specific warm-up of the exercise without
pula with active movements was reduced. Active
weight. At this time the patient's ability to per
elevation was full; however, a painful arc was
form the exercise through pain-free ROM was
present, implicating impingement of subacro
assessed.
mial tissues. All strengthening movements and
Isok.inetic testing of the glenohumeral rota
daily tasks were limited to 90· of elevation during
tors was performed in the plane of the scapula.
this phase.
Test results indicated a 45 percent deficit of the
A 5- minute general warm-up using an upper
extemal rotators and a 22 percent deficit of the
body ergometer was used prior to active stretch
internal rotators. During the next visit, isokinelic
ing and strengthening exercises (Fig. 1 4.9). strengthening of the rotators was begun u ing
Stretches for both the inferior and posterior rota speeds of 90· and 1 20· per second for 3 sets of
tor cuff were incorporated with 30-second holds, 1 0 repetitions (Fig. 1 4.1 I) Each physical therapy
repeated five times. session concluded with ice to the shoulder for 1 0
Isotonic strengthening exercises included minutes. lee was applied t o prevent any adverse
the following. inOammatory responses secondary to stretching,
to maintain the plastic deformation gained with
I. Elevation in the plane of the scapula with treatment, and to reduce delayed-onset muscle
the arm internally rotated (Fig. 1 4. 1 ) soreness.46
2. Prone horizontal abduction at 1 00· with
arm externally rotated M t D DL E PHAS E ( W E E K S 3 TO 5)
3. Press-up (Fig. 1 4.3) During the following 3 weeks of physical ther
4. Seated rowing (Fig. 1 4.5a) apy, this patient was seen three times per week.
5. Biceps curls (Fig. 1 4.7) Heat with stretch and soft tissue manipulation
S T RENG THENING EXERCI S E S 377
FIGURE 14.9 Upper body ergometer. FIGURE 14. 1 1 Isokil1etics (or internal and extemal
rotation o( the shoulder il1 the plane o( t"e
scapula (30 "anterior to (rol1tal plal1e).
FINAL PHASE ( W E E K 6)
external rotator deficit and a 1 0 percent increase pos i tive impingement sign. Apprehension and
in internal rotator strength. relocation tests were positive. Biceps brachialis
A majntenance program was reviewed prior testing was positive for Speed's test. Posteriorly.
to discharge. This program incorporated all of li mited capsular mobility was detected. Manual
the isotonic strengthening exercises performed muscle testing demonstrated pain and weakness
during therapy. with sidelying internal and ex of the supraspinatus. subscapularis. and infra
ternal rotation exercises replacing the isokinet spinatus/teres minor (315 muscle grades). The
ics for the glenohumeral rotators. The patient scapular rotators (serratus anterior. upper. mid
was instructed to perform three sets of 1 0 repe dle. and lower trapezius. and rhomboids) dem
titions for each exercise 3 days a week for 6 onstrated fair plus (3 + 15 muscle grades)
weeks. A continued program of three sets of strength. but fatigued quickly with repetitive
1 0 repetitions for each exercise was recom testing.
mended to be performed 2 days per week indefi Overall this athlete reported her current
nitely provided this patient was performing the shoulder pain had progressed from intermittent
same job tasks. to constant. and was significantly aggravated by
most activities using the right arm over 90' of
elevation.
Isokinetic testing of the glenohumeral rota
CASE STUDY 2: ROTATOR CUFF
tors was performed in the plane of the scapula.
AND BICIPITAL TENDONITIS Test results i ndicated peak torque. power. and
The focus of the case is to identify the contribut total work deficits of greater than 40 percent for
ing factors to rotator cuff and bicipital tendonitis. the external rotators and greater than 20 percent
initiate the appropriate strengthening program. for the internal rotators when compared to the
and return this athlete to competitive sports. uninvolved side. The peak torque of the external
rotators was 50 percent of the internal rotators.
HISTORY Palpation revealed trigger points within the
subscapularis muscle belly and tenderness along
This case presents a 2 1 -year-old collegiate female
the anteriosuperior aspect of the right shoulder.
tennis player with a complaint of chronic right
shoulder pain. Her prior history for this shoulder
INTERPRETATION OF FINDINGS
includes similar painful episodes. usually occur
ring mid to late season. during the past 3 years. Signs and symptoms indicate a possible second
Previous treatments include the use of oral anti ary impingement and tendonitis as a result of
inflammatories and modality treatments admin abnormal anterior translation of the humeral
istered in the athletic training facility on campus. head. The abnormal or excessive translation may
Her CUITent complaints have not subsided with be secondary andlor contributing to the loss of
these types of conservative treatment and she has dynamic stability from the rotator cuff and bi
been referred for physical therapy evaluation and ceps tendon. evident by the tendonitis.2) The
treatment. Her CUITent medical diagnosis is "ro scapular rotator weakness and posterior capsu
tator cuff and bicipital tendonitis." lar tightness are also predisposing andlor precip
itating factors.
INITIAL EVALUATION
TREATMENT PLAN AND RATIONALE
Radiographic Findings were normal. Visual in
I NITIAL PHASE (WEEK I )
spection revealed moderate right scapular eleva
tion. protraction. and atrophy of the posterior This athlete was restricted from tennis activities
rotator cuff muscles. External rotation was lim during the initial phase of treatment. She did.
ited by 30' in the adducted position. when com however. independently perform lower body
pared to the uninvolved side. She presented with and conditioning workouts. She was seen for
^1
S TR E N G TH E N I N G EXERCI SE S 379
5 consecutive days during this initial phase. of treatment, and the use of the upper-body
Treatment focused on decreasing the reactivity ergometer (UBE) was initiated in an attempt
of the inflamed tissue and restoring normal soft to begin general muscular endurance training.
tissue mobility within the shoulder complex. Rhythmic stabilization exercises for the gleno
Heat was applied to the shoulder joint in humeral and scapulothoracic joints were also
conjunction with low-voltage surged electrical initiated at this point in treatment, manually
stimulation to the subscapularis trigger points performed by the therapist.
to begin treatment. Soft tissue and joint mobili
zations were applied to the glenohumeral and
M I DDLE PHASE (WEEKS 2 TO 6)
scapulothoracic joints to further reduce the
trigger points and improve posterior capsular During week 5-minute warm-up was perfOlmed
mobility. on the UBE prior to active stretching and iso
Low-voltage medium-frequency electrical tonic strengthening exercises as in Case I. Iso
simulation was applied to the supraspinatus tonic exercises included the following.
and posterior rotator cuff while isometric were
performed for external rotation in the plane of I. Elevation in the plane of the scapula (Fig.
the scapula for 1 5 minutes. All treatments dur 1 4. 1 )
ing this initial phase of treatment commenced 2 . Prone horizontal abduction at 1 00° with ex-
with an iontophoresis treatment at the rotator temal rotation (Fig. 1 4.2)
cuff insertion site using dexamethasone sodium 3. Seated rowing (Fig. 1 4.5a)
phosphate followed by a l a-minute application 4. Biceps curls (Fig. 14.7)
of ice. 5. Sen'atus press (Fig. 1 4 . 1 2 )
Overall tissue reactivity and subjective re 6 . Prone extension with internal rotation (Fig.
port of pain were reduced by the fourth day 1 4. 1 0)
A
FIGURE 14.1 z (A & B) SerratLls press. B
380 P
H Y SI C A L TH ERA P Y OF THE SH OU LDER
FI N A L P H A S E ( W E E K S 7 A N D 8 )
S. Sit-ups with a ball toss/catch using a and absolute and relative cndurance. Res Q Exer
slanted minitramp Sport 53: I , 1 982
6. Prone trunk extension with the plyoball 1 2 . Kraemer WJ: Exercise physiology comer: the dy
Physiol 55: 1 00, 1 986 24. Inman VT , Saunders M , Abbot LC: Observations
9. Lieber RL, Bodine-Fowler SC: Skeletal mllscle on the function of the shoulder joint. J Bone Joint
mcchanics: implications for rehabilitation. Phys Surg 26: I , 1 994
Thel' 73:844, 1 993 "25. Townsend H, Jobe FW, Pink M, Pen,), J: EMG
1 0. Dudley GA, Harris RT: Neummuscular adapta analysis of the glenohumeral muscles during a
tions to conditioning. In Baechle, TR (cd): Essen baseball rehabilitation program. Am J Sports Med
tials of Strength Training and Conditioning/Na 20:264, 1 99 1
tional Strength and Conditioning Association. 26. Jobe FW. Moynes DR: Delineation o f diagnostic
Human Kinetics, Champaign, lL, 1 994 criteria and a rehabilitation program for rotator
I I . Andersen T, Kearney JT: Effects of three resis cuff injuries. Am J Spotts Med 1 0:336, 1 982
tance training programs on muscular slrength 27. Blackbul11 TA, McLeod WD, White B Wofford L:
382 P
H YS I C AL THER A P Y OF THE SH O UL DER
E M G analysis of posterior rOlator cuff exercises. training. p. 29. In Bernhardt DB cd: Sports Physi
Athletic Training 25:40, 1 990 cal Therapy. Churchill Livingston, New York,
28. Worrell TW, Corey BJ, York Sl, Santiestaban J: 1 986
An analysis of supraspinatus E M G activity and 38. Kraemer W1, Deschenes MR, Fleck S1: Physiolog
shoulder isometric force developmenl. Med Sci ical adaptations to resistance exercise: Implica
Sports Exer 24:744, 1 992 tions for athletic conditioning. Sports Mcd 6:246,
29. Moseley JB, Jobe FW, Pinks M: EMG analysis of 1 988
the scapular muscles during a shoulder rehabilita 39. Stone MH, Fleck SJ, Triplett NT, Kraemer WJ:
tion program. Am J Sports Med 20: 1 28, 1 992 Health-and pelformance-related potential of re
30. Ha.1 D, Carmichael SW: Biomechanics of the sistancetraining. Spor1s Med 1 1 :2 1 0, 1991
shoulder. J OJ1hop Sports Phys Ther 6:229, 1 985 40. Turkel SJ, Panio MW, Marshall Jl, Grigis FG: Sta
3 1 . Peat M: Functional anatomy of the shoulder com bilizing mechanisms preven ting anterior disloca
plex. Phys Ther 66: 1 855, 1 986 Lion of the glenohumeral joint. J Bone Joint Surg
32. Rodosky MW, Hamer CD, Fu FH: The role of the 63A: 1 208, 1 98 1
long head of the biceps muscle and superior gle 4 1 . Han-yman DT, Sidles lA, Harris Sl, Matsen FA:
noid labrum in anterior stability of the shoulder. The role of the rotalol' cuff intelval capsule in pas
Am J Sports Med 2 2 : 1 2 1 , 1 994 sive motion and stability of the shoulder. J Bone
33. Wooden MJ, Greenfield B, Johanson M et al: Ef Joint Surg 74A:53, 1 992
fects of su-englh training on throwing velocity and 42. Bagg SD, Forest WI: Eleclromyographic study of
shoulder muscle perfonnance on teenage baseball the scapular rotators during ann abduction in the
players. J Orthop SpoJiS Phys Ther 1 5:223, 1 992 scapular plane. Am J Phys Med 65: 1 1 1 , 1 986
34. ElienbeckerTS, Davies GJ, Rowinski MJ: Concen 43. Travell IG, Simons DG: Myofascial Pain and Dys
tric VCI"SliS eccentric isokinetic strengthening of function. The Trigger Point Manual. Williams
the rotator cuff. Am 1 Sports Med 1 6:64, 1 988 Wilkins, Balt imore, 1 984.
35. Mont MA, Cohen DB, Campbell KR et al: Isoki 44. WatTen G, lehman JF, Koblanski IN: Heat and
netic concentric versus eccentric tr-aining of stretch procedures: an evaluation using rat tail
shoulder rotators with functional evaluation of lendon. Ach Phys Med Rehab 57: 1 22 , 1 976
performance enhancement in elite tennis players. 45. Janda V: Central nelvous motor regulation and
Am J Sports Med 22:5 1 3 , 1 994 back problems. In Korr 1 M (ed): The Neurobiolo
36. Kraemer WI: Physiological and cellular effects of gic Mechanisms in Manipulative Therapy.
exercise training. p. 659. In Leadbetter WB, Buck Plenum, New York, 1 97 8
walter lA, Gordon Sl cds: Sp0l1s-Induced Innam 4 6 . Michlovitz S L : Biophysical pdnciples o f heating
malion, Amedcan Academy of Orthopedic Sur and superficial heat agents. In Michlovitz Sl (ed):
geons, Park Ridge, 1 l, 1 990 Thermal Agents in Rehabilitation. FA Davis, Phil
37. Kraemer WJ, Daniels Wl: Physiological effecls of adelphia, 1 986
Myojascial Treatment
DEB 0 RA H SEIDEL COB B
ROB E R T CAN T U
383
384 PHYSICAL THERAPY OF THE SHOULDER
J oint Myofascial
Mobil ization Manipulation
·
FIGURE 15.1 Int
to treatil1g the shoulder.
histologically be considered connective tissue and deep fascia as well as the nerve and muscle
but are not relevant to our discussion of myofas sheaths, ligaments, and tendons.
cia.'5 Connective tissue is comprised of cells,
ground substance, and three fiber types: Colla CLASSIFICATION OF CONNECTIVE TISSUE
gen, elastin, and retinaculin (Table 15.1 ) 5.6 As
therapists, we are concemed with the ordinary Connective tissue can be divided into three types
connective tissue that compdses the superficial based on fiber density and arrangement: dense
regular, dense irregular, and loose regular. Ten
dons and ligaments are comprised primarily of
dense regular connective tissue, which is charac
TABLE 15.1. Components of connective (issue
terized by a high proportion of collagen fibers to
Collagen: Mo�1 tensile of connective tissue fibers ground substance, and a parallel arrangement of
Type I collagen: Ordinary connective tissue (loose and dense)
fibers. These characteristics allow for high ten
Type II collagen: Hyaline cartli oge
sile strength with low extensibility. Dense regu
Type III collogen: lining of arteries and fetal dermis
lar connective tissue has poor vascularity due to
Type IV collagen: Basemenl membranes
Elastin: More elastic then collogen. lining of arteries and ligamen
its compactness. Healing time is therefore signif
tum flovum icantly increased after any trauma (see Fig. 15.4).
Reticulin: Most elastic fiber. Framework of lymph nodes and glands Dense irregular connective tissue is found in
Ground substance: Viscous medium in which cells and connective joint capsule, periosteum, dermis of skin, fascial
tissue lie sheaths, and aponeuroses. A dense multidirec
Mechanical barrier against foreign matter tional fiber atTangement is charactetistic of this
Medium for nutrient ond waste diffusion type of connective tissue. Due to the structure
Maintains spacing between adjacent collagen fibers (interfiber it is able to limit forces in a three-dimensional
distance) to prevent cross-links
manner. As compared to dense regular connec-
MYOFASCIAL TREATMENT 385
tive tissue, it possesses a higher proportion of collagen synthesis and degradation are the same.
ground substance as well as increased vascu After 12 weeks of immobilization, collagen deg
larity. radation exceeds collagen synthesis, resulting in
Loose regular connective tissue is found in a net collagen 10ss. 14
the superficial and deep fascia as well as nerve In a study by Evans et ai, it was found that if
and muscle sheath, endomysium, and the sup rat knees were experimentally immobilized, then
portive structure of the lymph system. This tis manipulated under high velocity, pal·tial joint
sue is the most easily mobilized with myofascial mobility could be restored. If these joints were
techniques .3-5.7 allowed to move prior to manipulation, full mo
bility could then be restored. This held true for
immobilization of less than 30 days. Longer pe
Effects oj immofliJ:ization and riods of immobilization result in less optimal re
turn of mobility.13
MolJilization on Connective Tissue
With an understanding of the normal biomecha
nics and histology of the myofascial tissue, it is
now important to see how these tissues are af Other Physiologic Resprmses To
fected by immobilization, trauma, and remobili MyojasciaJ, Manipulation
zation. This is essential so that realistic goals can
be set in the clinic. [t is important to remember
that most of the available information on the ef Soft tissue mobilization and massage are com
fects of immobilization of connective tissue has monly used interchangeably. Additional effects
come from research done on animals, most of of massage on the body have been well docu
which were normal and nontraumatized. This is mented in the literature. Three secondary effects
fundamentally different from patients typically are on blood now, the basal metabolism, and the
seen in a orthopedic clinic. I autonomic system.
Amiel et al. performed extensive animal Massage has been shown to increase blood
studies on the immobilzation of connective tis now to the extremities. Deep massage strokes in
sue dut;ng the 1960s and I 970S8-13 Their studies crease total blood now in both animal and
typically involved immobilizing a normal animal human subjects. Massage causes capillaries to
knee then analyzing the histologic effects on con dilate in the region of the stroking, resulting in
nective tissue. The authors found fibrofatty infil
increased blood volume and now. Of signifi
trates, primarily in the areas of capsular folds.
cance is the fact that milder massage does not
With longer periods of immobilization greater
produce the same effect. The type and depth of
amounts of infiltrate developed and adhesions
the myofascial technique may alter the effect
began to form in the connective tissue.
produced on the body. IS-17
Under histologic examination, no significant
The autonomic system has also been shown
loss of collagen was found-only loss of ground
to be effected by massage. Ebner reported that
substance (glycosaminoglycans and water).
With the loss of ground substance came a de connective tissue massage stimulates circulation
creased fiber distance, leading to cross-link de in a region of the body, which in turn opens up
velopment between collagen fibers. Immobiliza increased circulatory pathways to other body re
tion leads to a lack of stress being applied to the gions. The mechanical friction created by mas
collagen fibers, causing them to align in a hap sage stimulates the mast cells in connective tis
hazard fashionu This alignment leads to a de sue to produce histamine. Histamine causes
creased tissue extensibility·-13 When immobili vasodilation, resulting in increased blood now
"
zation occurs for less than 12 weeks, the rate of around the body. IS,19,
386 PHYSICAL THERAPY OF THE SHOULDER
MyoJascial EJuai:uation oj the For the shoulder, we must consider the trunk
and neck positions in both silling and standing
Shoulder as well as the relationship of the scapulae relative
to the trunk. The evaluator should be looking for
When evaluating the shoulder, the physical ther areas of muscle or connective tissue asymmetry
apist is looking for acorrelatiol1 of (indil1gs that as well as increased muscle activity. Because fas
might be indicative or a dysfunction. History, as cial planes can be restricted over large areas of
well as the results from visual, movement, and the body, a head to foot evaluation may be
palpatory exams, should be considered. II is im needed. If a leg length discrepancy exists, a pa
portant to remember that connective tissue tient may develop muscle asymmetry due to pro
changes, in the absence or other objective find longed shortening or lengthening or a muscle or
ings, are not necessarily dysr"lmctional. Several group of muscles.
consistent findings are a beller indicator of a Vladamir Janda helped demonstrate the er
problem. For example, consider a patient who fects of myofascial imbalances on postural im
presents with a stiff and painrul shoulder. Exter balances. He looked extenSively at how muscles
nal rotation and abduction are most limited. respond to dysfunction. Janda observed that
Physical evaluation reveals tightness of the inter changes in muscle function play an important
nal rotators and adductors, especially pectoralis role on the pathogenesis of many painful condi
major, latissimus dorsi, and teres major. Postur tions. Janda defined a poslLlral muscle as one that
ally, this patient assumes a protracted position. responds to dysfunction by lightening and a pha
This combination of rindings is indicative of a sic muscle as one that responds to dysfunction
shoulder dysfunction possibly related to postural by weakening. In the upper extremity we see a
abnormalities. The individual findings of pos typical patlem of tightening of the upper trape
ture or tightness were not significant until they zius, levator scapulae, and pectoralis with weak
con'elated with pain and loss or motion. Treat ening of the deep neck flexors and lower scapular
ment must then address all the significant com stabilizers. All or these contribute to the typical
ponents contributing to the dysfunction. kyphotic, protracted posture often seen in the
clinic, (Table 15.2).20.21
HISTORY
Tight muscles tend to act in an inhibitory
way on their antagonist muscles. It does not
History gives valuable insight into patient condi seem reasonable to start a strengthening pro
tions before a hand ever touches them. For exam gram for the weakened antagonist as the first
ple, myorascial pain of nonmechanical origin is step in a rehabilitation program. After stretching
usually dull and nonspecific. Myorascial pain or of the tightened muscles, the strength of the in
mechanical origin is more specific, If a patient hibited muscles may retum without any rurther
reports specific sharp pain that is easily repro treatment. In the case of a fTozen shoulder pa
duced, a more specific pathology may be present. tient, it would make sense to first stretch out the
By knowing the behavior of the patient's pain,
we can begin to isolate the nature of the problem.
We then move on to try to correlate the history TABLE 15.2. Postural vers J.
phasic muscles of
with objective findings. p
the shoulder girdle and LIp eI' thoracic regiol1
POSTURAL PHASIC
POSTURAL EVALUATION
Upper trapezius latissimus dorsi
Body posture can give us clues as to the area of levator scapulae lower trapezius
movement disturbance or where the body may Pectoralis minor Middle traps
have excessive stress placed upon it. The impor Pectoralis major (upper portion) Rhomboids
Cervicol erector spinae Anterior cervical musculature
tance of posture is in how it relates to runction.
MYOFASCIAL TREAT MENT 387
shortened internal rotators and adductors like the layers of tissue perpendicular to the tissues
the subscapulal;s before allempting to as well as moving the perpendicular tissues. The
strengthen the weakened external rotators and examiner should be able to palpate the tendons,
abductors. muscle bellies, muscle sheath, myotendinous
junctions, joint capsule, tenoperiosteal junc
tions, and deep periosteal layers of tissue. To as
MOVEMENT ANALYSIS
Now that posture and movement have been as Maximum effectiveness cannot be achieved if
sessed, the examiner can begin to palpate for the the technique is not efficiently executed. If a
location of the dysfunction. As previously men therapist is not properly positioned, the patient
tioned, palpatOlY findings must also correlate may not be able to relax, or the therapist may
with postural and movement findings to be of be pUlling undue stress on the patient's body.
any significance. The palpatory exam includes Remember to avoid needless body contact with
the myofascial structures by layer and palpation the patient. A pillow between the patient and
of the joint structures. Palpation of the shoulder therapist can provide a mechanical baiTier as
must include the scapular, cervical, thoracic, needed.
and anterior chest wall regions.
Superficial palpation is performed on the
JOINT PROTECTION
skin and superfiCial connective tissues. The ex
aminer should be assessing for temperature, Because the hands are the primary tool of the
moisture,and light touch to determine the exten manual therapist, it is essential to protect them.
sibility of the connective tissues. Tissue rolling Here are a few general suggestions on how a
is one way to check the extensibility of these manual therapist can protect the hands:
Sl!llctures. It involves the lifting away of the su
perficial connective tissue and skin fTom the un J. Avoid hyperflexion or hyperextension of the
derlying structures. joints. This will decrease the problems of
Deep palpation involves palpation through hyperrnobility and early arthritis.
388 PHYSICAL THERA PY OF THE SHOULDER
Palient Position
Therapist Position
Procedure
Ratior/ale
FIGURE 15.2
Tightening of the pectorals is a common
problem found in shoulder patients, especially
2. Use elbows, pisiforms, or fists on patients those with the forward head posture. I n order to
who are too large to safely use your fingers achieve full shoulder range of motion and pos
on. Be creative. tural correction, the extensibility of these mus
cles must be restored.
3. During off hours from work, try to rest your
hands and protect them h'om excessive
strain. Patienl Position
4. Use cold water rinses or short ice massage Supine with the shoulder abducted to 90° to
on your joints if innammation occurs h-om 120° (less nexion with h-ozen shoulders).
vigorous treatment of a patient.
Therapist Position
FIGURE 15.3
FIGURE 15.4
390 PHYSICAL THERAPY OF THE SHOULDER
FIGURE 15.5
FIGURE 15.6
MVOFASCIAl TREATMENT 391
SUBSCAPULARIS TECHNIQUES (FIGS. 15.5, Patient Position
15.6)
Supine with the shoulder elevated 120' to
Rationale 160' depending on the area of restriction.
The subscapularis muscle is often found to
have significant restrictions in patients with de Therapist Position
creased shoulder range of motion due to poor
At the top of the bed, grasping the patient's
posture or immobilization. When [·ull shoulder
arm and providing a gentle upward distraction.
motion cannot be achieved, the therapist should
The palm of the upper arm is placed just below
recheck the subscapularis and the surrounding
the breast line. Be sure of proper draping and
myofascia for trigger points or restrictions.
appropriate hand placement when performing
this technique.
Patient Position
Rationale Procedure
This technique elongates the superficial an The fingers of the lower hand apply a deep
terior fascia, which is often restricted in patients pressure in a sweeping downward motion, while
with a protracted shoulder girdle position. the upper hand retracts the shoulder girdle and
392 PHYSICAL THERAPY OF THE SHOULDER
FIGURE 15.7
FIGURE 15.8
MYOFASCIAL TREATMENT 393
FIGURE 15.9
applies a rotational force through the thoracic then stroke in a downward direction along the
spine. border of the scapula with the lower hand.
SCAPULAR FRAMING (FIGS. 15.9 TO 15. 11) Procedure for Lareral Border
Ratiol1ale
Procedure for Medial Border
To mobilize the scapula off the rib cage in
Place the fingers of the lower hand gently order to stretch the surrounding myofascia. This
along the medial border of the scapula. Gently technique should be done after there has been
retract the shoulder with the upper hand, and preparation of the tissues by scapular flaming.
394 PHYSICAL THERAPY OF THE SHOULDER
FIGURE 15. I 0
FIGURE 15. 1 I
MYOFASCIAL TREATMENT 395
fiGURE 15. 12
SEATED PECTORAL AND ANTERIOR fASCIAL A posterior force towards the patient's head
STRETCHES (FIGS. 15.13 TO 15.15) is applied while the patient takes deep breaths
Rationale
to improve anterior elongation. To incorporate
the lateral fascia and muscles, the patient can be
Sometimes patients are better able to relax asked to lean or rotate to one side while the same
in the seated position. These stretches can be force is applied. The patient's arms may also be
used to elongate the anterior fascia and pectoral fully extended for this technique.
396 PHYSICAL THERAPY OF THE SHOULDER
Proced"re 2
The patient may have only one arm extended
upwards. while the therapist places one hand
along the lateral I-ib cage and the olher just below
the elbow. A traction rorce is then applied in op
posite directions. A rotary component can also
be added using the technique stated above.
RatiO/wle
Patiel1t Positiol1
Supine with the arm abducted 30· and the
elbow bent.
FIGURE 15.14
Tilerapisl POSiliol1
At the patient's side supporting the arm with
the bottom hand. The thumb or the top hand is
in the bicipital groove.
MYOFASCIAL TREA TMENT 397
FIGURE 15.16
PATIENT PROBLEMS
8. Restrictions in the anterior chest wall myo After performing each myofascial technique,
fascia reassess the patient's range of motion to see what
9. Decreased cervical range of motion effect the treatment has made. Large increa es
in range can be achieved through the perfor
From a myofascial standpoint, a good way mance of myofascial techniques without ever
to begin treatment of this patient would be to performing true range of motion or joint mobili
address these components prior to range of mo zation of the glenohumeral joint. Once the myo
tion or strength. The previously discussed tech fascial restrictions are eliminated and the range
niques might be incorporated into treatment of of motion is improved, begin strengthening exer
this patient in the following way. cises if they are still required. Consider each pa
tient's problems individually, continually reas
I. Increased pectoral tone: pectoral muscle sessing the causes of limitation. Use these
play findings to guide your choice of treatment ap
2. Restricted anterior chest wall: anterior fas proach. If one approach is not working, consider
cial elongation with or without a rotary a change in technique. Remember that the afore
componenl mentioned techniques are only a small sample
of available treatments.
3. Peliscapular restlictions: scapular framing,
In the case of this patient, myofascial treat
scapular mobilization, subscapularis release
ment assisted in the ability to isolate the primary
4. Increased tone in upper thoracic problem. On initial evaluation there was too
region/upper trapezius: anterior/posterior much muscle guarding and myofascial restric
lateral elongation of upper thoracic region tions to identify the cause of this patient's pain.
5. Increased tone in paravertebral muscles: ro After 4 treatment sessions using the discussed
tational thoracic laminar release techniques, this patients pain centralized to the
MICHAEL J . WOODEN
Isokinelic exercise has become a popular form of With isotonic equipment or free weights, be
resislive exercise in the physical therapy clinic. cause the speed of movement is not preset, resis
Since the late I960s, the literature has consisted tance to muscle contraction will vary according
primarily of research data and clinical infonna to gravity, positioning, lever aI-m lengths (in the
tion relaling to the knee. However, recenl ad equipment and in the patient's limbs), and cam
vances in equipment have made it possible to use sizes.3 If, because of these factors, effective resis
positioning to apply isokinetics effectively to tance occurs only at a certain point in the range,
most other extremity joints, including the shoul it is possible that the muscle is being strength
der complex. The purposes of this chapter are to ened only at that point. Consequently, isokinetic
list some advantages of isokinetics in shoulder exercise offers the advantage of loading a muscle
evaluation and treatment, to describe the adapt effectively throughout its ROM by fixing the
ability of several dynamometers to shoulder di speed of movement.
agonal patterns, to discuss principles of isoki [sokinetics offers several other clinical ad
netic testing and training with emphasis on vantages, such as the capacity for a wide range
shoulder positioning, and to describe considera of speeds, both for testing muscle function and
tions of test data interpretation. for rehabilitation or strength training ' This al
lows the clinician to determine at what velocities
muscle torque deficits occur: at low speeds (so
called "strength" deficits), or high speeds
Practical Advantages oj Isokinetics ("power" and "endurance" deficits).2 Testing and
training at higher speed attempts to simulate
lsokinelic exercise, unlike isotonic exercise, of normal activities in which angular velocities (as
fers totally accommodating resistance to a mus in walking, nmning, swimming, Ihrowing, and
cular contraction.'-3 Because the speed of move other activities) are far in excess of most isotonic
ment is constant, resistance to the movement speeds.3 Even the highest speeds of the MERAC
varies according to the amount of force applied (Universal Corp., Cedar Rapids, LA), at 500"/s, are
to the resistance arm. Therefore. in a maxirnum not fast enough to ·match many activities, espe
effort isokinetic contraction, the muscle is cially sports activities. However, exercising at
loaded maximally at each point in the range of different speeds may cause quantitative and
motion (ROM).'-3 qualitative recruitment of different muscle fiber
401
402 P H Y SIC A L THERA P Y OF T H E S HO U LD E R
types: therefore, most or all of the muscle can be from clinicians and investigators. 10-1J Isotonic
loadeds-s exercise inco'lJorates eccentric muscle loading;
Increases in speed of isokinetic concentric however, for reasons previously stated, it does
contraction are associated with decreases in not fully accommodate for length-tension
both torque output and electromyographic activ changes nor does it adequately control momen
ity of the muscle.'·s-s Therefore, compressive re llIm or force vector problems. With the advent of
action forces at the joint should also decrease. recent technology in dynamometry, inSlluments
In joints that exhibit an inflamed or painful re such as the Kincom (Chattanooga CO'lJ., Chatta
sponse to exercise, increasing the speed may nooga, TN), Biodex (Biodex, Shirley, NY), and
temporarily "spare the joint" by redUCing joint Lido (Loredan Biomedical, Davi , CAl have the
reaction forces. Whether training solely at high capability of applying eccentric isokinetic load
speeds contributes to an increase of strength at ing with the inherent length-tension accommo
low speeds is controversial, however4.s Never dation. Controversy exists as to the safety of ro
theless, the use of higher speeds is an important botic instruments when applied to human
safety factor in reactive joint conditions, pro subjects, and continued research is needed to
vided that concentric isokinetic contraction is clarify this issue. A key concept to robotic testing
used. and training involves thorough understanding of
Whether at fast or slow speeds, isokinetic re the alterations in the force-velocity curve th . at
sistance will accommodate to pain levels, further are produced by robotics.
ensuring safety, because if the patient needs to Another consideration is that the resistance
decrease or stop the contraction suddenly be mechanism, at least on Cybex equipment, is uni
cause of pain, the resistance will decrease imme axial. Extremity joints, of course, are multiaxial,
diately, because resistance will never exceed the as their instantaneous centers of rotation change
amount of force applied] Unlike isotonic exer constantly through movement.'O-'4 The exten
cise, miminal momentum is produced with isok sive mobility of the shoulder and the multiple
inetics. The use of submaximal effort isokinetics articulations within the shoulder complex fur
also enhances safety in cases of patient pain or ther complicate the appropriate alignment of the
reactive joint inflammation. Decreasing the machine axis with the changing, compromised
force used in isokinetic resistance exercise will, axis of the patient's shoulder.
in turn, decrease joint reaction forces as pro Other practical disadvantages of isokinetics
duced in submaximal eff0l1. Submaximal effort in the clinic include the high cost of equipment,
training may also produce pain reduction selec the amount of floor space required, and the time
tive recruitment of muscle fiber type (slow twitch required to change positions and attachments to
or type I), and improved joint lubrication. In ad test the different movements. The latter is a par
dition to the advantages already discussed, Dav ticular problem with shoulder evaluation, be
ies3 cites many other physiologic and clinical ad cause so many positions and motions are recom
vantages of isokinetics. As with all types (or mended. Testing of diagonal pallerns reduces
modes) of clinical muscle training, isokinetics the time required for multiple dynamometer po
possesses several disadvantages or precautions, sition changes, while assessing multiple muscle
which will be discussed in the next section. For groups.
example, a major physiologic limitation of Cybex The testing and training protocols imple
systems prior to the 6000 model was an inability mented before readiness for diagonal patterns
to exercise and measure muscle eccentrically. require decisions about the positioning of the
Because muscle generates the most amount of glenohumeral joint. To protect injured tissues
tension eccentrically9 and because much of func while maintaining effective strengthening tech
tional movement requires eccentric contraction, niques, several important biomechanical princi
rehabilitation and testing of the glenohumeral ples warrant consideration. The 900 abducted po
joint in an eccentric mode have important appli sition (900 AP) as described in the Cybex manual4
cations and have received increasing emphasis can produce optimal external rotation torque
I SOKI N E T I C E V A L U A T ION A ND T RE A T M EN T 403
and work values.'2. 1S In addition, the proximity EvaJ.uatiJm oj SlurukJer IMg()'l'l()./$
of the position may risk glenohumeral joint im
pingemenl.'5-'8 The 90' AP also involves long The Cybex II manual contains detailed informa
lever arm forces that are contraindicated in cases tion on testing all the cardinal plane movements
of joint instability and Significant rotator cuff of the shoulder.· Photographs and descriptions
weakness.'9 The 90' AP is deleterious when re of positioning and machine settings allow for
stricted internal rotation ROM is present!O as isolated testing of abduction, adduction, flexion,
torsion forces are transmilled from the scapula extension, and internal and external rotation.
through the coracoclavicular ligaments into the These procedures provide excellent information
acromioclavicular joint. on speci(;c muscles or muscle groups and are
In contrast, the neutral position (elbow ad indicated for certain pathologies. The process of
dueted close to the patient's chest wall) produces testing all of these movements as part of a com
the optimal internal rotation torque values as prehensive shoulder evaluation is quite time
well as high external rotation values. Two nega consuming, however, and can be clinically un
tive considerations of this position are the micro manageable. Excessively high charges and ques
vascular wringing out effect,3,2 1 which deprives tionable validity of multiple glenohumeral mus
the active supraspinatus of necessary blood flow, cle measurement pose further arguments against
and stress on the anterior capsular mechanism multiple movement testing. The time manage
with forced stretching of the often inflexible sub ment problem can be solved by evaluating over
scapularis muscle (more often a significant prob all muscle function with two diagonal move
lem in males). ments, thus eliminating several lengthy steps.
Both Hinton 12 and Soderberg and In addition to its practical benefits, diagonal
Blaschak lS suggest the need for multiple posi movement testing may also be more functional
tions for testing and training and, not surpris than cardinal plane movements, which fail to
ingly, that no Single patient or glenohumeral po isolate and measure motion of the acromioclavi
sition is optimal for all clinical purposes, cular, sternoclavicular, and scapulothoracic
However, a compromise position that is safe joints ' Of course, movement of these joints oc
frOI'll both vascular and biomechanical perspec curs throughout the range of glenohumeral mo
tives is the intermediate, or 45', abducted posi tion. Resisted diagonal movement will load
tion. Although Hageman et al.22 found high con muscles that effect movement at all joints in
centric and eccentric torque values for both the shoulder girdle. KnOll and V oss, 25 pioneers
'
external and internal rotation at 45' AP, appro in proprioceptive neuromuscular facilitation
priate protection for both the anterior and poste
(PNF), first described "mass movement patterns"
rior capsular and labral mechanisms also was as being inherently diagonal in nature. These di
found to exist. Interestingly, the 45' AP closely agonals are dictated by anatomy-shapes of
simulates the modified base position advocated joints, lines of muscle pull, and soft tissue restric
by Davies3 and can be readily adapted to con tions-and are those movements observed to be
form to the plane of the scapula, which creates most used in everyday activities.25 The move
low capsular stress and produces peak isokinetic ments to be described in this chapter are similar
rotator cuff torque?3.2. The 45' AP is also simply to the classic upper extremity PNF pallerns,
applied to all dynamometer setup capacities,
with minor patient position or machine adjust
ment . Finally, the 45' AP positions conform
closely to the natural. functional plane of motion Testing Procedure
(the plane of the scapula), and consequently pro
vide a comfortable training position for most pa The first diagonal movement described is the
tients with pain, restl;ctions, and/or rotator cuff combination of extension, abduction, internal
suppression. rotation (ExlfAbdJIR) and flexion, adduction, ex-
404 PHY S I C A L T H E R A PY O F T H E S H O U L D E R
temal rotation (FlexlAddlER). Figure 16. 1A structed to try to keep the elbow Slraight and to
shows the initiation of the ExtlAbdIlR move rotate the arm intemally or eXlemally. depend
ment. and Figure 16. 1 B shows the end of that ing on which movement is being performed. To
same diagonal. blocked manually to prevent hy allow for rotation. a swivel handle is used. It
perextension. Figure 16.1 C illustrates the end po should be pointed out. however. that the rota
sitions for the FlexlAddlER movement. tional component cannot be resisted by the appa
For both movements. the patient is in- ratus. as would be the case if manual J'esistance
I S O KI N E T I C E V A L U AT I O N A N D T RE A T M E N T 405
:'1"
,'
,
Ii ·1·
' . '"
FIGURE 16.2 (A) To rqLle CLlrve s o { uninvo lved shoLllder {o r E xllAbdllR and Fle xJAddlER. (B)
Torque curves o { invo lved sho ulde r {or E xllAbdllR and FlexJAddlER.
were used in PNF,2 5 The dynamometer is tipped son can also be tested at higher speeds as long
forward 15° to account for trunk movement and as measurable torque is being produced. Figure
the forward-inclined plane of the scapula. 23.26 16.2B represents the torque curve for the injured
Figure 16.2A is the normal torque curve for side in the same patient. The lower root-pound
the diagonal ExtlAbdJIR and FlexlAddlER in a readings for the "left involved shoulder" indicate
postanterior dislocation patient who has re strength deficits, at low and high speeds, ranging
covered most of her ROM. The shoulder is tested from 33 to 77 percent. Table 16. 1 gives a sum
at 600/s (low speed) and 1800/s (high speed), the mary of the torque measurements taken [Tom
speeds recommended by Cybex for flexion and Figure 16.2,
extension.' An athlete or unusually strong per- Not only can strength deficits be computed,
406 P HY S ICAL T H ERA P Y O F TH E SHO ULD E R
TABLE 16.1 Summary o( peak lorque de(icils but the shapes of the torque curves in Figure
16.2 can also be compared. The low-speed
DIAGO NAL SPEED RIGHT L EFT DE FICIT
UNINVO L VE D UNINVO L VE D ,'lb, curves (600/s) for the involved shoulder show
(FT -L 8 (FT -L B
a slower "rate of ,;se" than [or the nOlmal )side.
Ext/Abd/IR 60'/. 30 16 47 That is, the weaker side took longer to reach
1 80"/. 26 6 77 its peak torque. In addition, the duration o[
Flex/Acid/ER 60'/. 24 10 58 each ExliAbdlIR and FlexiAddlER contraction
1 80"/. 18 12 33 at low and high speed is shorter, as compared
(D(lw (rom Figure 16.2) with the opposite side, indicating the inability
to sustain tension. These variations in curve
shape are further indications o[ mu cle weak-
ness that should improve after appropriate isok and finish positions for Ext!AddJIR are shown in
inetic training. Last, a comparison of the lower Figure J 6.3A and B, and Figure J 6.4A and B, and
"position angle" scale indicates limitations at initiation of FlexiAbd/ER is shown in Figure
the extremes of ROM, although in this case the J 6.3C. ln this diagonal, the extreme of the Oexion
differences are slight. movement was blocked either manually or, as
This evaluation procedure can also be done shown, using UBXT (Cybex, Ronkonkoma, NY)
[or a second diagonal, the combination of Ext! atlachments. Torque deficit computation and
AddnR and FlexlAbdJER. The sequence of these shape of curve comparisons were done as previ
movements is illustrated in Figure 16.3. The start ously described.
408 P H Y S I C A L T H ERA P Y OF T H E S H O U L D ER
be produced manually or as a function of the TABLE 16.4 Guidelil1e s {or isokine tic spe e d {lI1d
dynamometer with mechanical or electronic pro to col sele ctio n il1 shoulder re habilitatio n
technology. Each patient problem dictates indi
150KN
I ETIC P R OT O C O L.
vidualized blocking; however, anterior glenohu SP EED
greater torque ror intemal rotation and 43 per trained athletes, and expected torque ratios will
cent greater torque ror the adductors in compar more closely conform to predicted levels ror
ing swimmers to nonswimmers, while Alderink nonnals. Tala et al 4 4 demonstrated abduction/
and Kuck round similiar increases of 50 percent adduction ratios of 100 percent to 102 percent
greater adduction in the throwing side for base and external/internal rotation ratios or 78 per
baJJ players compared to nonthrowers.13 Both cent to 87 percent for healthy males and re
Chandler et aL 35 and Brown et al.36 demon males. Joy's found external/internal rotation ra
strated ERIIR ratios in the nondominant side of tios of 65 percent and abduction/adduction
tennis and baseball players despite no dirfer ratios of 70 percent to 81 percent for college
ences in the extemal rotation torque between aged females. Although the variations in exter
sides, which ful"lher demonstrates the torque nal rotation may be explained by the use of
shifts from increased internal rotation/adduc
different dynamometers (Tata et aI., Kincom,
tion torque. Table 16.6 reviews sport-specific
Joy, Biodex), the large variability between ab
normative torque ratios and pertinent informa
duction/adduction ratios may be explained by
tion on the tested populations and patient posi
the test positions used. Tata et al. used plane
tions used in data sampling. Although few stud
of scapular position, while Joy used a [Tontal
ies have reported on horizontal abduction to
plane position. Tata et al.'s study rurther sug
horizontal adduction, Weir et aL 4 3 established a
gested that the scapular plane is more clinically
100 percent ratio in high school-aged wrestlers.
appropriate for testing and training, a view
In addition, Weir et al. demonstrated a signifi
cant increase in torque for both motions at slow point shared by the first author or this chapter
speed as wrestlers aged from freshmen to senior for nonathletic patient cases. Finally, McMaster
years. This trend of increased tOt-que as ages et al.34 round externallinternal rotation ratios
change from 14 to 18 is worthy or further study of 65 to 78 percent and 58 to 74 percent for
ror other sports and certainly would be benericial healthy males and females, respectively.
information for other muscle group torque ra McMaster's abduction/adduction ratios were 65
tios. to 72 percent and 62 percent ror males and
females, respectively. This inrormation, coupled
TORQUE RATIOS IN NORMALS with the data outlined in Tables 16.2 and 16.6,
Normative data for athletes is important, but provides a comprehensive overview of male and
in most orthopedic/sports clinical settings, pa remale nonathletic and athletic norms for the
tients with shoulder complaints are not highly agonist/antagonist ratios that are important pa-
I SO K I N E T I C E V A L U A TI O N A ND T RE A T M E N T 413
rameters of muscle synergy in the shoulder outcome or capacity such as running readiness
complex. after knee injury and throwing readiness after
shoulder injury or surgery. Traditionally, peak
torque at slow speeds 600/s to 900/s has been the
ECCENTRIC TO CONCENTRIC TORQUE
primary clinical factor in readiness decisions.
COMPARISONS
Athletic function for peripheral joints has been
Although important clinical information is man demonstrated to occur at extremely high speeds
isfested by the agonist/antagonist ratios, another (above 2400/s for lower-extremity kinetic chain
isokinetic measurement parameter, the eccen and above 10000/s for the upper extremity ki
tric/concentric torque ratio [rom a single muscle, netic chain) as a result of the summation of
may provide guidelines regarding normal mus momentum through a series of joints. There
cle function versus injury or dysfunction. Al fore, it is apparent that slow-speed peak torque
though extensive additional literature on this measures have limited value in predicting fast
CUITent topic is walTanted, it appears that the joint speed behaviors or most functional activi
relationship of eccentric and concentric function ties.
is important to injury prevention, assessment, Clearly, the prediction of functional athletic
and rehabilitation issues '· Generally, eccentric capacity from isokinetic measures in the lower
torque potentials exceed concent';c torque lev extremity dictates testing peak torque at 240°
els in any given muscle, speed, or position con and faster:s-so which is paralled by the studies
sideration.46 Therefore, the eccentric to concen dealing with isokinetic prediction of upper ex
tric ratio will be expected to be minimally 100 tremity functions. Mont et al.4 7 demonstrated I I
percent. Ng and Kramer'9 found ratios of 1 19 percent increases in both internal and external
percent and 127 percent for internal and exter rotation fTom 1800/s training, which related to I I
nal rotation, while Joy45 found similiar levels percent increases in serving velocity in advanced
of 129 percent and 123 percent, respectively. tennis players. Mont et a!. found both concentric
In addition, Joy delineated ratio of 1 3 1 percent and eccentric training methods to be equally ef
and 1 1 7 percent for abduction and adduction, fective. Wooden et al.5 1 demonstated throwing
respectively. The actual peak performance of velOcity increases in junior and senior high
eccentric torque may not be sampled accurately school baseball players of 2 MPH using 5000/s
at speeds of 180°/5 or slower as in the above individualized dynamic, variable resistance
studies, but due to intrinsic characteristics of (IDVR) on the Merac system. This type of resis
the isokinetic-eccentric loading, patient safety tance is not directly classified as either isokinetic
may preclude testing speeds above 1800/s. Mont or isotonic, but possesses features of both
et al.4 7 determined tennis players' isokinetic modes. Earlier studies have demonstrated
perfOlmance for both external to internal rota throwing and serving velocity increases fTom
tion ratio and eccentric to concentric force ratio isokinetic training of the external and internal
that appears widely variant h·om all other sam rotatorsS . 1 1 and adductors.52 Beach et a!. demon
pled studies and the first author's clinical expe strated 2400/s to be the functional speed for
rience. swimming performance and demonstrated the
predictive value of abductor and external rotator
endurance to shoulder injury in competitive
FUNCTIONAL INFERENCES AND
swimmers.
RELATIONSHIPS
Therefore, although literature on isokinetic
Although controversy exists about functional in validity for common shoulder sport activity is
ferences (or validity) from isokinetic measure scant, the use of peak torque at high speed for
ments, much of the criticism of isokinetics re functional prediction and the value of isokinetic
lates to the common use of peak torque training on sports performance have been estab
measurements in predi<;:ting a certain functional lished.
414 P HY S IC A L T H E R A PY O F T H E S H O ULD ER
TREATMENT
CASE STUDY 1 W E E K I
H I STORY
The problems identified included significant
Patient P.H. is a 53-year-old housewife who was weakness in all directions and limited motion in
involved in a horseback riding accident on March the capsular pattern with moderately high reac
I I , 1995. She was thrown from her horse, sustain tivity and ilTitability. Initially, the treatment con
ing a comminuted fracture of the right proximal sisted of the following modalities.
humerus. Two days later she underwent ORlF for
insertion of an intramodullary rod. Moist heat and interferential stimulation to
promote pain relief and relaxation
INITIAL EVALUATION
Grades I and 2 oscillating mobilizations to
The patient was refen'ed for physical therapy 3 reduce pain and joint reactivity. These in
weeks postsurgery, and presented with com cluded a val-iety of physiologic and acces
plaints of pain, stiffness, and weakness of the sory movements, and were followed by gym
shoulder joint, with mild pain radiating to the ball exercises to increase ROM
forearm, and a general feeling of "heaviness" of
Manual resistance exercises in all planes
the upper extremity. The patient also reported
mild stiffness of the neck, which was resolving. Home exercise program (HEP) including
Functional limitations included moderate diffi pendulum and latex band resistive exercises
culty with dressing and bathjng, and severe limi
tations in housework, gardening and so on. The W E E K 2
patient al 0 could not sleep on the injured side.
Significant findings included the following. Tolerance to treatment was generally good, and
improvements in mobility, strength, and reactiv·
ity were noted. By the end of the second week
the patient's HEP was expanded to include wand
PASSIVIE JOINT MUSCLE
ROM REACTIYIT't' STRENGTH exercises for shoulder flexion and extension; for
flexion, a 2-pound weight was attached. The pa
Flexion 1 400 tv\oderote 2/5 +
Abduction 1 250 High 2/5+ tient was also using a gym ball at home.
External rot. 3S' High 2/5
Internol rot. 72" Moderate 3/5
W E E K 3
Mobilizations were increased to grades 4 to External rotation and abduction were still mod
4 + , respecting reactivity. erately weak, but the patient's function was ap
Concentric isokinetic strengthening for in proaching normal limits. Physical therapy was
ternal and ext�rnal rotation was begun discontinued at this time, but the patient was
within these parameters: 900/s, patient su instructed to continue her HEP indefinitely, and
pine with the shoulder in 30° abduction in to return if any further problems arose.
the plane of the scapula (POS). Submaxi
mum effort contractions were increased
gradually to maximum effort over three
treatment sessions CASE STUDY 2
Progressive resistive exercises (PREs) in HISTORY
6. Mobility
90° PER SECOND 180" PER SECOND
Elevation (supine, assisted) RlL, 78°1 175°
Flexion 1 4° 1 2% Internal rOlalion RlL, L-3fT-6
Extension No deficit No deNcil External rotation (60° elevated, supine)
Abduction 22% 1 9% RlL, ( - 1 5°)/88°
Adduction No deficit No deficit 7. Functional goals-pain-free, normal ADLs
Internal rot. No deficit No deficit and return to work tasks including lifting of
External rot. 24% 26%
boxes above head up to 35 pounds
416 P H Y S I C AL T H E RA P Y O F T H E S H O ULD E R
PROGRAM
MONTH 3
Active assistive ROM: Elevation and external ro-
tation (HEP) PROGRAM
Electrical stimulation: High voltage, surged Begin manual resisted supine shoulder flexion
Pendular exercises (HEP) and external rotation
Shoulder extension isometrics and scapular ad Impulse shoulder extension (standing) with 10
duction (HEP) pounds
SelTatus anledor: Manual resistance in supine Sidelying external rotation exercises with 3
lee massage pounds (HEP)
Plane of scapula Lido isokinetic internal/external
STATUS
rotation (supine), 6 sets of 10 repetitions at
Active external rotation (60° of abduction, su
1200/s, 3 sets of 10 at 180°
pine): 5°
Electrical stimulation 12 minutes with med. fre
Active assisted elevation: 98°
quency, IS/50 contract/rest time
Assisted concentric elevation from 1 10° to 150°,
negative unassisted in reverse range, fol
MONTH 2
lowed by unassisted negative elevation fTOm
PROGRAM 125° to 0°
Passive concentric phase elevation to terminal. Added Impulse "punching" pattern (extended
comfortable limits followed by active as elbow from 90° abducted position) for sen'a
sisted negative phase elevation to I 10° tus anterior and theraband for the same mo
Eagle chest press: 3 plates (elbow below shoulder tion at home (HEP)
height) Impulse shoulder flexion with fixed elbow flex
Increase row to 3 plates, then 4 on Eagle ion "bowling" pattern and theraband simula
Self-administered static External Rotation tion exercise (HEP)
stretch 5 up 10 minute holds (HEP) Eagle pull downs added with 3 plates
Prone shoulder extension (no weight, HEP) Lido continued as above
Grades 2 and 3 inferior glides to humeral head Ann lifts into flexion added with 2 pounds
I S O KI N E T I C E V A L U A T I O N AND T RE A T M E N T 41 7
STATUS closely to normal activity and provide time-sav
Grade 4 supraspinatus ing and practical means of applying isokinetics
Mobility: Elevation 155°, external rotation-R/L to the shoulder. For specific weakness of a mus
= 75°/88° cle or small muscle group (e.g., in rotator cuff
No pain with light lifting and all ADL'sReturned tears), the isolated movements described in the
to light duty work status with physician re isokinetic manual may be more helpful. Simi
striction of no more than 5-pound lifts larly, certain injlll;es or surgical " epairs may ne
cessitate isolation of movement to a cardinal
plane with blocked motion as appropriate.
MONTH 5
Both isokinetic testing and training sessions
PROGRAM should be preceded by warm-up techniques.
Same program with increased effort on Lido Clinical decisions with isokinetics include tim
isokinetics and on inertial patterns as listed ing of application, number of repetitions,
amount of patient effort, and impo,·tantly, the
STATUS
patient and glenohumeral positioning used. Al
Elevation to 165° though both the neutral and 90° AP have specific
Supraspinatus strength: Grade 5 - advantages, it appears that the 45° position offers
Isokinetic testing results: Plane of scapula supine the optimal compromise of physiologic, safety,
internal/external rotation and strengthening goals [or clinical training.
Normative data for the shoulder indicate a
900/s 23% deficit in ER Peak torque strength/torque hierarchy as follows: adductors
52% beller in IR Peak torque and extensors followed by flexors and abductors
44% dencit in ER Total work and, finally, the internal and external rotators.
90% better in IR Total work Side-to-side torque differences tend to be mini
2400/s 4 1 % deficit in E R Peak torque mal unless specific vigorous prefe'Ted activities,
6 % better in L R Peak torque such as baseball pitching, are involved. Peak
33% deficit in ER Total work torque to body weight ratios range from 45 to
61% beller in IR Total work 46 percent for the strongest adductor group to
a variable 8 to 22 percent for the external and
internal rotators, respectively. A clinically im
MONTH 6
portant value for normal shoulder function and
The patient was seen for three visits duIing this synergism is the ERlIR ratio, which should be
month for the same program with continued 60 to 70 percent for most test positions at slow
counseling on the maintenance of his home pro speed.
gram and protection of his arm/shoulder relative Although clinically useful normative data
to safe biomechanics. exist, this new area of isokinetic practice needs
continued research. Similarly, existing clinical
Despite the external/internal rotation torque
protocols and positions require additional re
imbalances and external rotation deficits, the pa
search investigation, with the goal of improved
tient had achieved nearly normal ROM and con
patient care and potentially new uses for isoki
trol. resolved pain, no apprehension with lifting
netic technology as applied to the dynamic stabi
or exertional activities, and was discharged.
lizer system that is so critical to functional ca
pacity of the human upper extremity.
Summary
References
A method of evaluating and treating shoulder t . Moffroid M, Whipple R, Holkosh J el al: A study
girdle muscle weakness and joint dysfunction of isokinetic exercise. Phys Ther 49:735, 1 969
has been described. Diagonal movements relate 2. Laird C, Rozier C; Toward underslanding the ler-
418 P H Y S I C A L T H E R A P Y O F TH E S H O U L D E R
mi nology of exercise mechanics. Phys Ther 59: netic peak torquc and work valucs for the shoul·
287, 1 979 de!'. J Orthop Sports Phys Ther 1 :264, 1 989
3. Davies G: A Compendium of Isokinetics in Clini J 9. Engle RP. Canner GC: Posterior shoulder instabil·
cal Usage: Workshop and Clinical Notes. S & S ity: approach to rehabi litation. J Orthop Sports
Publishers, laCrosse, W I , 1 984 Phys Ther 1 0:488, 1 989
4. Cybex: Isolated Joint Test ing and Exercise: A 20. Kibler WB. Chandler TJ: Functional scapular in
Handbook for Using Cybex IT and the UBXT. stability in throwing athletes. Unpublished study.
Cybex, Ronkokoma, NY, 1 983 Lexington, KY, 1 988
5 . Moffl"Oid M , Whipple R: Specificity of speed of 2 1 . Rathbun JB, McNab I: The micro·vasculature pat
exercise. Phys Ther 50: 1 693, 1 970 tem of the rotator cuff. J Bone Joint Surg 52:540,
6. Barnes WS: The relationship of motor unit activa 1 970
tion (0 isokinctic muscular contraction at differ 22. Hageman PA, Mason OK, Rylund KW, et al: Ef
ent cOnlractile velocities. Phys Ther 60: 1 t 52, fects of position and speed on eccentric and con
centric isokinctic testing of the shoulder rotators.
1 980
J 011hop SPOl1S Phys Ther 1 1 :64, 1 989
7. Thorslensson A, Grimby G, Karlsson J: Force ve
23. Johnston T: The movements of the shoulderjoint.
locity relations and fiber' composition in human
A plea for the plane of the scapula as the plane of
knee extension muscles. J Appl Physiol 40: 1 2 ,
reference for movement occurring at the humel'O
1 976
scapular joint. Br J Surg 2:252, 1 952
8 . Smith M, Melton P: lsokinctic versus isotonic
24. Greenfield B, Donatelli R, Wooden M , Wilkes J:
variable resistance training. Am J Sports Med 9:
Comparison of isokinetic shoulder rotation
275, 1 98 1
strength in plane of scapula vs. frontal plane. Am
9. Rasch P, Burke R: Kinesiology and Applied Anat
J SPOl1S Med 1 8: 1 24 , 1 990
omy. 3rd Ed. Lea & Febiger, Philadelphia, 1 967
25. Knott M , Voss D: Proprioceptive Neuro-muscular
10. Jobe FW, Tibone IE, Perry J , Moynes 0: EMG
Faci litation: Patlel1lS and Techniques. 2nd Ed.
analysis of the shoulder i n pitching. A prel imi nary
Harper & Row, New York, 1 968
1'0 1'011. Am J Sports Med I I :3, 1 983
26. Gardner E, Gray 0, O'Rahilly R: Anatomy: A Re
I I . EllenbeckerTS, Davies GJ, Rowinski MJ: Concen
gional Study of Human Structure. 2nd Ed. WB
tric versus ecccnu-ic isokinetic strengthening of
Saunders, New York, 1 963
the rOlatol- cuff: objective data versus functional
27. Cook EE, Gray VL, Savinar- Nogue E, Medeiros J:
test. Am J SP0l1S Med 1 6:64, 1 989
Shoulder antagonist strength ratios: a compali·
1 2 . Hinton RY: lsoki netic evaluation of shoulder rota·
son between college-level baseball pitchers and
tional strength in high school baseball pitchers.
nonpitchers. J 011hop Sports Phys Ther 8:45 1 ,
Am J SPOl1S Med 1 6:274, 1 988
1 987
1 3. AIdel'ink GJ, Kuck OJ: Isokinetic shoulder
28. Reid DC, Salboe L, BUl11ham R: CUlTent Research
strength of high school and college age baseball of Selected Shoulder Problems. In Donatelli R
pitchers. J 011hop SPOl1S Phys Ther 7 : 1 63 , (ed): Physical Therapy of the Shoulder. Churchill
1 986 Livingstone, New York. 1 987
1 4. Williams P, Warwick R: Gray's Anatomy. 3rd Ed. 29. Ivey FM, Calhoun J H , Rusche K, et al: Isokinetic
WB Saunders, Philadelphia, 1 980 testing of shoulder strength: normal valucs. Arch
1 5. Soderberg GJ, Blaschak MJ: Shoulder intemal Phys Med Rehabil 66:384, 1 985
and extemal rotation peak torque production 30. Coleman AE: Physiological characteristics of
t h rough a velocity speclrum in di ffe!ing positions. major league basebal l players. Phys SPOl1S Med
J Orthop Sports Phys Ther 8:5 1 8, 1 987 1 0: 5 1 , 1 982
1 6. Elsner RC, Pedegrana LR, Lang J: Protocol fOI' 3 1 . Wallace WA, Barton MJ, Mun'lly WA: The power
strength testing and rehabi l i tation of the upper available dul"ing movcment of the shoulder. In
extremity. J 011hop SPOl1S Phys 4:229, 1 983 Bateman, Welsh (cds): Surgery of the Shoulde!'.
17. Einhom AR, Jackson OW: Rehabilitation or the BC Decker, Philadelphia, 1 984
shoulder. p. 1 03. I n Jackson OW (ed): Shoulder 32. Cote C. Si moneau JA, LaGasse P. el al: Isokinetic
Surgery in the Athlete. Techniques in Ot1hoped· sU'cngth training protocols: do t hcy induce skele
ics. Aspen Publications, Rockville, MD, 1 985 lal muscle fiber hypel1rophy? Arch Phys Med Re
1 8. Connelly-Maddux RE, Kibler WB, Uhl T: Isoki- habil 69:28 1 , 1 988
I S O K I N E T I C E V A L U A T I O N A N D T R E A T M E N T 419
33. Loredan Co: Lido isokinetic normative values for 43. Weir JP, Wagner LL, HOllsh TJ el al: Horizontal
shoulders. Unpublished clinical study, Davis, CA, abducti on and adduction strength at the shoulder
1 987 of high school wl..,stlcrs ac!"Oss age. JOSPT 1 5 : 1 83,
34. McMaster WC, Long SC, Caiozzo VJ: Shoulder 1 992
torque changes in the swimming athlete. Am J 44. Tata GE, Ng LR, Kramer IF: Shouldel' antagonist
SP0l1S Med 20:323, 1 992 strength during concentric and eccentric muscle
35. Chandler TJ, Kibler WB, Stracener EC et al: actions in the scapular plane. JOSPT 1 8:654,
Shoulder strength, power, and endurance in col 1 993.
lege tennis players. Am J SPOltS Med 20:455, 45. Toy BJ: Concenu'ic and eccentric shoulder
1 992 strength evaluation of college aged females. JAT
36. Brown LP, N iehues SL, Han-ah A et al: Uppel" ex 30:S37, 1 995
trem ity range of motion and isokinetic strength 46. AlbeIt MS (cd): Eccentric Muscle Training I n
of the internal and external shoulder rotators in Sports and Orthopedics, Churchill-Livingstone,
major league baseball players. Am J SP0l1S Med New York, 1 99 1
1 6:577, 1988 47. Mont MA , Cohen DB, Campbell KR e t al: Isoki
37. Beach ML, Whitney SL, Dickoff-Hoffman SA: Re netic concentdc versus eccentric training o f
lationship of shoulder flexibility, strength and en shoulder rotators with functional evaluation of
durance to shoulder pain in competitive swim performance enhanccment in elite tennis players.
mers. JOSPT 1 6:262, 1 992 Am J Sports Med 22:5 1 3 , 1 994
38. McMaster WC, Long SC, Caiozzo VJ: 1sokinetic 48. Joha nsson C, Lorentzon R, Fagerlund M el al:
torque i m balances in the rOlator cuff of the elite Spl"imers and marathon runners. Doers isokinctic
water po lo player. A m J SP0l1S Med 19:72, 1 9 9 1 knee exte nso," pe rfom1 ance renecl muscle size
39. Ng L R , Kromer JS: Shoulder rotator torques i n and structure.? Acta Phys iol Scand 1 30:663, 1 987
females tennis and non-tennis players. JOSPT 1 3: 49. Kannus P: Peak Torque and total work relation
40, 1 9 9 1 ship in the thigh muscles after an lelior cruciate
40. Wilk KE, Andrews JR, Ar";go CA: The Abductor ligament injUly. JOSPT 1 0:97, 1 988
and adductor strength characteristics of profes 50. Krebs DE: Isokinetic, electrophysiologic and clin
sional baseball pitchers. Am J SPOl1S Med 23:307, ical function relationships following tourniquet
1 995 aided knee alt h rotomy. Phys Ther 69: 1 989
4 1 . Wilk KE, Andrews JR, Ar";go CA et al: The 5 1 . Wooden MJ, Greenfield B, Johanson M : Effects
strength cha racteristi cs of i n ternal and extcrnal of strength training on t h l"owing velocity and
rotator muscles in professi onal baseball pitchers. shoulder muscle perfonnance in teenage baseball
Am J Spo rt s Med 2 1 :6 1 , 1 993 players. JOSPT 1 5 :223, 1 992
42. Wilk KE, Arrigo CA, Andrews JR: 1sokinetic test 52. Bartlett LR, Storey MD, Simons BD: Measure
ing of th e shoulder abductors and adduclors: win ment of upper extremity torque production and
dowed and non-windowed data collection. JOSPT its relationship to throwing speed in the compeli�
1 5: 1 07, 1 994 tive athlete. Am J SP0l1S Mcd 1 7:89, 1 989
Instabilities
ANGELO J . MATTALINO
Evaluation, diagno is, and treatment of shoulder tion when the shoulder is at 90' of abduction.
instability is a complex and constantly evolving Plastic deformation of the glenohumeral liga
process. The quality of diagnostic tests as well ments has been found to contribute to the abnor
as our understanding of its pathology and patho mal translation of the humeral head. Capsular
mechanics have greatly improved in recent lax.ity, insufficiency of the glenoid labrum, and
years. Better diagnostic tools have led to better weakness of the rotator cuff musculature can
presurgical visualization of shoulder pathology. jeopardize glenohumeral joint stability and lead
Arthroscopic evaluation has advanced the un to abnormal humeral head translation and pro
derstanding of the pathology and the dynamics gressive rotator cuff pathology. 3
of shoulder instability. Arthroscopic surgery and The inferior glenohumeral ligament (poste
open surgical techniques to correct shoulder in rior band) is the primary contdbutor to poste,;or
stability patterns are evolving and still im stability of the shoulder when in 90' of abduc
proving. tion· Inferior translation of the glenohumeral
The shoulder joint has great mobility, with joint is affected by the superior glenohumeral
stability throughout its range of motion. Gleno ligament in the adducted position, ' the inferior
humeral stability is maintained via static and dy glenohumeral ligament complex at 45' and 90'
namic influences. Negative intra-articular pres of abduction, and the rotator cuff interval por
sure and dynamic compression forces by tion of the anterior-superior shoulder capsule.6
muscular forces, primarily by the rotator cuff The understanding of these pathomechanics is
musculature, are examples of these influences. crucial in making clinical rehabilitative and sur
It has been estimated that 40 percent of the dy gical decisions.
namic forces are contributed by the rotator cuff
musculature and that removal of the labrum re
duces these forces by half. Rehabilitation ad Pathorn£chanics
dressing neuromuscular conditioning can
strongly influence shoulder stability. ' Surgical There are three categOl;es of stability factors
repair and/or reconstruction of capsulolabral about the glenohumeral joint: anatomic, dy
anatomy can help restore stability. namic, and static. The anatomic category in
Bankhart initially described the detachment cludes the labrum, which adds depth to the gle
of the labrum and the inferior glenohumeral lig noid surface, "changing a saucer to a bowl." The
ament complex from the anterior aspect of the negative atmospheric pressure within the gleno
glenoid.2 Since this initial report, scientific ex humeral joint is another important anatomic
perimentation has further delineated the role of contributor to stability. InjUl)' to the labrum is
the inferior glenohumeral ligament complex as thought to disrupt this atmospheric seal, thus
the primary stabilizer resisting ante";or transla- contributing to instability.
421
422 PHYSICAL THERAPY OF THE SHOULDER
Static support is provided by the capsuloliga mined along with occupational and/or recrea
mentous structure about the glenohumeral joint. tional demands required of the affected shoul
The inferior glenohumeral ligament is most im der. Description and location of symptoms,
portant in preventing anterior and inferior trans frequency, and what activities worsen and re
lation. The middle glenohumeral ligament con lieve the symptoms, should be obtained. Onset
tributes static stability by resisting extemal of the problem and specific description of any
rotation and abduction. The static stabilizing traumatic event should be determined, in partic
structures work in conjunction, each playing ular any history of shoulder dislocation and total
their role during speciric points in the range of number of dislocations and subsequent reduc
motion of the shoulder, and together providing tions.
an encapsulating network throughout glenohu
meral joint range of motion.
The rotator cuff mechanism cont.-ibutes "dy
namic" support by compressing the surfaces of
Objective Examinal.ion
the glenohumeral joint. [n particular the supra
The normal unaffected shoulder should be ex
spinatus and the deltoid musculature are the
amined rirst to use as comparison to discern the
dominate compressive contributors at 90· of ab
level of pathology. Palpation for areas of tender
duction. The subscapularis is considered the
ness is recommended, anteriorly over the long
most important in decreasing displacement, but
head biceps tendon, rotator cuff insertions, and
its dynamic support is negated with the shoulder
bony landmarks of the AC, SC, scapulothoracic,
in abduction and external rOlation, which are in
and glenohumeral joints. A neurologic exam to
herent in the "cocking" phase of throwing.
discem any motor and/or sensory deficits is per
The infraspinatus muscle helps supplement
fOlmed.
this dynamic dericit of the subscapularis, by
Range of motion should be compared, begin
helping to decrease anterior translation of the
ning with forward flexion, abduction, and exten
glenohumeral joint during extremes of extemal
sion. Internal and external rotation should be
rotation. Remember that the long head of biceps
measured at O· and 90· of abduction, both silting
is also felt to cont.-ibute to anterior stability dur
and supine. Noting the vertebral levels reached
ing abduction and external rotation by supplying
by the patient's thumbs is an excellent maneuver
a "strap" effect of the anterior aspect of the gleno
to compare internal rotation. Decreased extemal
humeral joint. 7
rotation is often encountered in shoulder insta
bility patients.
Clinical. Examinati.un Strength levels need to be determined and
compared to the unaffected shoulder. Weakness
Decision making is very dependent upon the secondary to pain should be discemed from true
clinical subjective and objective findings. Physi structural weakness, using local anesthesia if
cal examination in the clinic and operating room necessary. Abduction and rotator cuff strength
under anesthesia dictates the need for and type should be determined as described elsewhere in
of surgery to be performed. The magnitude and this book.
direction of instability paltems can be deter
mined by an astute examiner.
InstaiJility Testing
Patient History
When testing for instability, it is essential to
Listening to the patient is crucial. Certain infor compare bilateral shoulders and check for natu
mation should be obtained if not volunteered by ral laxity in other joints.
the patient. The dominant hand should be deter- The load UI,d shift test can determine both
INSTABILITIES 423
anterior and posterior glenohumeral joint insta and/or pain dissipates with a subsequent force
bility. The patient is placed in the supine posi directed posteriorly.
tion. Axial loading of the glenohumeral joint is Neer has described the Sulcus sign test for
accomplished or provided with one hand at the detection of inferior instability.9 With the patient
elbow (flexed at 90") and the other hand placed in the sitting position, palpate the glenohumeral
just distal to the humeral head, both anteriorly joint laterally and apply an inferiorly directed
and posteriorly. Next, the examiner should feel dislocation force to the humerus. A positive test
for "play" posteriorly and/or anteriorly in the gle will produce a palpable and/or visible divot in
nohumeral joint, much like the Lachman test for the lateral aspect of the shoulder.
the knee. Feel for a "clunk" as the humeral head A thorough and complete musculoskeletal
potentiaJly translates anteriorly and/or poste examination of the neck, cervical spine, and
riorly; a positive "clunk" test can be indicative of elbow should also be performed to rule out re
a labral tear. " Variation in the degree of horizon ferred symptoms.
tal adduction and abduction may allow the ex
aminer to reproduce familiar symptoms for the
patient. This test has a grading system:
Irrwging Studies jor Shoulder
l. Trace, defined as a small amount of hu Instability
meral head translation.
Standard radiographic studies can be taken in
2. Grade l, defined as the humeral head riding
the clinic to evaluate shoulder instability. This
up the glenoid but not over the rim.
author prefers these views: (1) scapular AP view
3. Grade II, defined as the humeral head glid
with the humerus in internal rotation, (2) scapu
ing up and over the glenoid rim and then re lar AP view with the humerus in external rota
ducing with applied stress.
tion, (3) prone axillary view, and (4) Stryker
4. Grade III, defined as the humeral head glid notch view. The AP view with humerus in inter
ing up and over the glenoid rim with persis nal rotation may reveal the Hill-Sachs lesion on
tent dislocation even after the stress is re the posterior lateral aspect of the humeral head,
moved. s usually considered to indicate evidence of p,-ior
episodes of glenohumeral instability and/or
frank dislocation. Either AP view may show evi
The apprehension test is performed by apply dence of subtle changes indicating periosteal
ing abduction and external rotation to the shoul bone build-up in the interior region of the gle
der; then the examiner's hand placed posterior noid. This finding can indicate prior capsular in
to the shoulder applies force in an anterior direc jury at this area. The axillary view can reveal the
tion. One should observe the patient for signs bony Bankhan lesion at the anterior aspect of
of pain and/or apprehension of reproducing the the glenoid rim. 'o Studies have found the Stryker
symptoms of instability. notch view to be very helpful in revealing the
Jobe has described the subluxatiol1 reloca Hill-Sachs defect"
tion test to test for subtle instability of the gleno To funher delineate the extent of pathology
humeral joint. The examiner applies posterior due to shoulder instability, more invasive diag
force to the glenohumeral joint after anterior nostic imaging can be performed. Arthrography
translation has been performed, with the shoul and CT scans have been used in the past with
der in 90" of abduction and 90° of shoulder exter consistency in diagnosing labral pathology, cap
nal rotation. Patients with anterior instability sular redundancy, Bankhart lesions, Hill-Sachs
might report pain or apprehension with the defects, and intra-articular loose bodies. The use
shoulder in external rotation and abduction with of magnetic resonance imaging has been benefi
the anteriorly directed force. This apprehension cial in identifying rotator cuff pathology, but it
424 PHYSICAL THERAPY OF THE SHOULDER
is not as reliable in diagnosing labral pathology. proaches and thus employ them as individually
MRl can underestimate capsulolabral redun indicated. Open reconstructive procedures such
dancy and injury without concurrent effusion. as capsular shift and open Bankhart repair are
In this author's experience, intra-articular gado recommended to individuals who have a history
linium-enhanced MRl has been reliable in evalu of multiple frank dislocations.
ating soft tissue pathology in patients with shoul For the overhand athlete, particularly the
der instability. Gadolinium is injected intra throwing athlete, J favor arthroscopic stabiliza
articularly via fluoroscopy to produce capsular tion. Most recently I have combined the laser
distention and improved labral-capsular con capsulon'aphy technique with anterior stabiliza
trast depicted on MRl images, thus improving tion both done arthroscopically, with good pre
the sensitivity to identification of labral and cap liminary results, when an early, aggressive reha
sular pathology. bilitation protocol is followed (see case study I).
Thus, when deciding which surgical tech
niques to employ, it is crucial to be mindful of a
patient's expectations. I emphasize that a suc
Sur[Jical /nterventiJm for cessful surgical reconstruction is based not only
ShouIiJer /nc;tabil:ity on obtaining stability and a low reOCCUITence
rate, but on the return to preinjury level of activi
The role of surgical intervention in the case of ties, for example, baseball pitching.
shoulder instability is to repair or reconstruct
the pathology and stabilize the glenohumeral
OPEN RECONSTRUCTION TECHNIQUES
joint with minimal surgical morbidity.
As exemplified by the many different surgi More than 100 open surgical procedures have
cal procedures that have evolved over the years, been described in the orthopedic literature. They
no one procedure has consistently con'ected basically involved capsular tightening, muscle
shoulder "instability" without some associated transfer, bone block transfer, and/or osteotomy.
morbidity, that is, limited range of motion. Presently, the two most consistently employed
Though some of these procedures provide con are the open Bankhart reconstruction and the
sistent "stable" results, occasionally patients are anterior capsulolabral reconstruction.
unable to return to their preinjury level of activ
ity due to certain postoperative physical limita
Open Bmlkharl ReCOrISIl1/ct;OIl
tions. The throwing athlete, for example, may
have postoperative stability but may be unable The anatomic repair of the capsular-pel-ios
to regain the external rotation necessary to be teal separation at the anterior glenoid neck is re
an effective pitcher. Thus arises the most recent ferred to as the open Bankhart repair.2 •12 The
controversy of open versus arthroscopic surgical Bankhart reconstruction attempts to anatomi
reconstruction for shoulder instability. Propo cally correct the primary stabilizer of the shoul
nents of open reconstruction state that they can der and the inferior glenohumeral ligamentous
provide more reliable reconstructions than ar complex (Fig. 17.1). The anterior capsule is en
throscopic repair. Open reconstructive proce tered anteriorly in a vertical fashion where the
dures have been traditionally recommended for capsule attaches 10 the glenoid medially. The an
athletes involved in contact sports such as foot terior glenoid neck is debrided to exposed corti
ball and rugby. cal bone. The glenoid periosteal tissue and the
Proponents of arthroscopic stabilization medially and superior shifted capsule are reat
procedures state that they can provide stability tached to the glenoid margin. The attachment is
without compromising range of mOlion, in par classically achieved through drill holes and more
ticular the external rotation needed. recently with other bony fixation devices-bio
I recognize the pros and cons of both ap- absorbable tacs, Suretac transglenoid utures, or
INSTABILITIES 425
I ,
A B
Rop
c o
I ;
suture anchors, according to prererence or the then incised rTom the glenoid margin rOlming a
surgeon. T-shaped incision. Shifting or the inrerior lear
or the capsule obliterates any redundancy or the
capsule. The superior lear is then shirted inferi
Ope/1 Capsular Shift Procedures
orly, and they are both attached to the anterior
The anterior capsulolabral reconstruction is glenoid by various types of fixation devices at the
relt to beller address the capsular redundancy in prererence of the surgeon. More sutures may be
shoulder instability, in particular multidirec added to these redirected leafs ror rurther tight
tional instability. It is also thought to cause less ening ancIJor reinforcement of the repair. Reha
resultant range of motion deficits, in particular, bilitation consists of progressive increases in
less deficiency of external rotation with abduc range or motion and stretching, which allow the
tion, because the subscapularis is not de soft tissues to heal and promote normal joint
tached. 13 Rather than detaching the subscapu arthrokinematics and upper extremity strength
laris tendon, it is split in line within its fibers at (see case study 2).
its upper two thirds and lower one third junc
tions. The capsule is then reflected from the sub Opel/ Repair of Posterior Illstability
scapularis in a medial to lateral direction. The The reconstruction or the posteriorly un
capsule is then split similar to the incision in the stable shoulder can be allempted with an ante
subscapularis tendon ( Fig. 17-2). The capsule is rior surgical approach. This involves more ag-
2. Labrum
A B
FIGURE 17.2 (A) T-shaped incision ill the glenohumeral joil7l capsule alld sYllovial lilling. (B)
Superior shift of the inferior capsular flap and il/ferior shift of the superior capsul",. flap.
(From Jobe et al.}6 with permissioll.)
INSTABILITIES 427
gressive inferior capsule detachment and Examination under anesthesia is the first
superior advancement. The direct posterior ap stage of surgical treatment both open and a,-thro
proach can employ a posterior capsular shift scopic procedures of shoulder instability. With
and/or bony block of the posterior glenoid. The muscular relaxation induced during anesthesia,
infraspinatus is dissected from the posterior cap the surgeon can more accurately discern the ex
sule and cut diagonally fyom its inse,-tion at the tent of instability patterns. The unaffected shold
greater tuberosity. A similar T-shaped capsular del' should be examined first, followed by the
incision is employed approximately 4 to 6 mm pathologic shoulder. The obvious reason is that
from its humeral insertion. patients often have inherent laxity, the extent of
The inferior leaf of capsule is shifted superi which should be determined prior to making sur
orly and the superior leaf is shifted inferiorly, gical decisions on the affected shoulder. The
and then both are allached to roughened bone clinical examinations addressed earlier in this
on the humerus. It has been recommended that chapter should now be repeated on bilateral
the arm should be held in 1 0· to IS· of abduction shoulders, documenting any bilateral discrepan
and external rotation during the posterior capsu cies in anterior, posterior, and inferior insta
lar shift. The patient is placed in an abduction bility.
pillow/brace at about 20· of abduction for 4 to 6 Next the anesthetized patient is positioned
weeks. Rehabilitation following a posterior cap either in the lateral decubitus or "beach-chair"
sular shift to stabilize the patient with posterior silling position. Traction devices using 5 to 15
instability differs from protocols for rehabilita pounds of weight are preferred by many sur
tion following an anterior capsular shift. Internal geons. Diagnostic arthroscopy is then begun in
rotation and horizontal adduction ranges of mo the usual fashion."·'5 Arthroscopic debridement
tion are limited initially, to protect the posterior of labral tears, partial rotator cuff tears, chon
capsule, and the use of a posterior glide mobili dral defects, removal of loose bodies, and/or any
zation is strictly contraindicated in the early other pathology encountered is performed. At
stages of the rehab process. Progression of flex this point, the surgeon must decide that the clini
ion, abduction, and external rotation range of cal diagnosis of any instability pattern has been
motion is followed prior to the progression of confirmed, and if so then proceed with either an
internal rotation and horizontal adduction. arthroscopic or open stabilization procedure.
Strengthening exercises that develop the ante Many different arthroscopic stabilization
rior musculature, such as the subscapularis, are techniques have evolved over the years, starting
emphasized, as well as the scapular stabilizers. with the metal staple introduced by Johnson in
Closed-chain exercise with the shoulder in 90· of the I 980s. 16 Present options for the arthroscopic
flex.ion are not indicated due to the stress im surgeon vary from resorbable tacks, transgle
parted onto the posterior capsule. noid suturing, 17,18 suture anchors,19 metal sta
pling, >o laser capsulorrhaphy. '9 and glenoid
abrasion without internal fixation. "
Regardless of the specific stabilization tech
Arthroscopic Techniques for nique employed by the surgeon, two steps should
Shoulder Instahilil:ies be followed prior to fixation. The first is prepara
tion the capsuloligamentous complex, depend
Arthroscopic evaluation of the shoulder is the ing on the pathology encountered. If the capsule
best diagnostic tool for shoulder instability. La is redundant and/or reattached inferior to the an
bral pathology, partial rotator cuff tears, capsu terior glenoid margin, it should be dissected free
lar redundancy, and/or intra-articular loose bod from its allachments ( Fig. 17.3). Second, de
ies are often not seen on arthrography, CT scan, pending on the fixation technique selected, the
or MRl studies. Arthroscopy can be employed capsuloligamentous complex is grasped and
preceding open stabilization procedures. shifted superiorly and to the glenoid's anterior
428 PHYSICAL THERAPY OF THE SHOULDER
taco After removing the drill, the Suretac is placed over the
guidewire and the Suretac driver is used to seat the Suretac
(A). When tapping the SUI'etac into the glenoid, avoid
overpenetratil?g the ligament (B). The guidewire is thel?
removed through the driver to el?dure easy removal of the
guidewire. A second Suretac is placed more proximally in a
similar manl?er (C). (Courtesy of Dyol1ics Corp., Al1dover,
�.) c
the shoulder with pathologic instability has been rimental effects to the viscoelastic properties of
the primary area of use for the Holmium YAG the capsular tissues. 18
laser. The Holmium YAG laser can "shrink tis I have employed the laser-assisted capsular
sue" found in capsular redundancy and thus also shift technique in conjunction with the Suretac
decrease joint volume. 16 This tissue during ar anterior stabilization technique during shoulder
throscopic observation becomes visibly shorter arthroscopy for patients with shoulder instabil
and causes apparent "tightening" of redundant ity. Early success has been observed in these
capsuloligamentous structures, which can be cases, which are cUITently under clinical study.
controlled by the amount of energy delivered via Fanton had excellent clinical results in 93 per
the Holmium YAG laser. Reports on studies in cent of 41 patients. " I feel that the laser-assisted
volving animal tissue suggest that the Holmium capsular shiftJcapsulorraphy has potential in the
YAG laser energy can shorten glenohumeral liga treatment of certain shoulder instability pat
ments. 14 A study demonstrated that signjficant terns, particularly in the overhand athlete. Fur
capsular shrinkage can be achjeved with the ap ther laboratory and clinical outcome studies are
plication of nonablative laser energy without det- needed to confirm the potential. The procedure
430 PHY SICAL THERAPY OF THE SHOULDER
The patient is an 18-year-old right-handed com Passive and active assistive range of motion or
petitive volleyball player who reports a I-year the left shoulder, gentle manual resistance, and
history of anterior instability in her left shoulder. multiple angle isometrics for shoulder lRlER,
INSTABILITIES 43 1
bicep and tricep, and scapular protraction/re performed in the modified base position re
traction arc emphasized. Range of motion limi vealed 1 5 percent deficits in external rotation at
tations of IDO· of flexion and abduction, and 45· speeds 90·, 21 D·, and 300·/s. Internal rotation
of external rotation. Accessory glenohumeral strength on the left shoulder was only 5 percent
joint mobilization is performed in the posterior weaker when compared to the right dominant
direction; however, anterior glides are not per arm. ERlIR unilateral strength ratios are 55 to 60
formed to protect the anterior capsule. Modali percent, and are approximately 1 0 to 1 5 percent
ties such as electric stimulation and heaUice are below the desired 66 percent standal·d. The pa
used to facilitate ROM and control discomfort. tient continues with rehabilitation on a three
times weekJy basis with continued emphasis on
TREATMENT rotator cuff strengthening, as well as achieving
a full functional range of mOl ion. She is dis
WEEKS 4-10
charged at 1 6 weeks with a home exercise pro
Passive range of motion to terminal ranges of gram of rubber tubing and isotonic rotator cuff
flexion and abduction is now initiated, with ex exercises, and a general scapular program with
ternal rotation slowly progressed to 90·. Specific closed-chain exercises. Her intelval return to vol
emphasis is placed on regaining intemal rotation leyball includes a 2- to 4-week period without
range of motion and joint mobilizations such as overhead hilling or selving, with a gradual pro
the posterior glide. For functional reasons, the gression to these activities after pain-free prac
shoulder is placed into horizontal adduction to tice activity has been demonstrated for the first
f'urther stretch 2 to 4 weeks.
tient's current range of motion at 6 weeks postop
is D· to 1 60· of flexion, D· to 125· of abduction,
D· to 55· of external rotation, and D· to 45· of
internal rotation. Strengthening exercises are
CASE STUDY 2
progressed to isotonic PREs, emphasizing rota
tor cuff-dominant movement pallems and scap REHABILITATION FOLLOWING
ular stabilization. Closed-chain exercises are em OPEN CAPSULAR SIllFT
ployed to enhance scapular co-contraction using
SUBJECTIVE INFORMATION
therapeutic balls and wall push-ups.
The patient is a 30-year-old male who initially
dislocated his shoulder 2 years ago while snow
WEEKS 10-16
boarding. Over the course of a 2-year period, the
Continued use of mobilization and stretching to patient dislocated his right shoulder 1 2 to 1 3
restore full glenohumeral joint range of motion times, with an increase in the ease of dislocation
is combined with strengthening for the rotator and greater difficulty in reducing the shoulder
cuff and scapular musculature. Isokinetic exer over time. The patient denies any neural symp
cise in the modified base position for internal toms postop or preop from the dislocations that
and external rotation is started at 1 2 weeks occurred. He is involved in precarious sporting
postop. Plyometric exercises consisting of chest activities such as skiing, snowboarding, and
passes and medicine ball catches are used to pre mountain biking, and hopes to return to these
pare the shoulder for the rapid concentric and activities following surgery. The injury and sur
eccentric loads inherent in sport activity. At 1 4 gery occurred to his right arm and the patient is
weeks postop, the patient's range of motion is D· right handed. He was immobilized for 2 weeks
to 1 75· of flexion, D· to ISO· of abduction, D· to following surgelY without any movement or
85· of external rotation, and D· to 60· of internal therapy. He presents to physical therapy with his
rotation with 90· of abduction. An isokinetic test shoulder in a sling.
432 PHYS ICAL THERAPY OF THE SHOULDER
WEEKS 12-20
Continued use of passive and now active assistive
and active range of motion is followed. Glenohu The continuation of range of motion and mobili
meral and scapulothoracic joint mobilization is zation is combined with rotator cuff and scapu
used with avoidance of anterior glides to protect lar strengthening isotonk exercises. The initia
the healing anterior capsule. Rhythmic stabiliza tion of isokinetic exercise in the movement
tion with the shoulder in varying degrees of flex pattern of internal and external rOLation in the
ion, with the patient in a supine position, is used modified base position is recommended. The cri
to improve kinesthetic awareness and promote terion for isokineLic exercise progression is the
strength via the co-contraction of scapular mus- tolerance of a minimum of 3-pound isotonic ro-
INSTABILITIES 433
tator cuff exercises. and full range of motion tion to prevent injury to adjoining segments (lack
within the isokinetic training ranges. An isoki of glenohumeral joint ER. thus placing increased
netic test performed at 1 4 weeks postop on this valgus stress on the elbow). a satisfactory clinical
patient shows external rotation strength to be 5 exam with respect to impingement. and instabil
percent weaker on the postop extremity. and cor ity testing (TSE).
responding internal rotation strength to be 20
to 25 percent weaker across the three velocities
tested.
References
WEEKS 2 0 - 2 8 1 . Wilk 1(£, AlTigo C: Current concepts i n the "eha
bilitation of the athletic shoulde... JOSP 1 8:365.
An isokinetic evaluation at week 20 postop shows 1 993
equal external rotation strength and 5 percent 2. Bankhal1 A: The pathology and treatment of re
greater internal rotation strength at the three cun"cnl dislocation orlhe shouldcrjoinl. Br J Surg
testing speeds. Pain-free isotonic and isokinetic 26:22. 1 938
training is cutTently tolerated by the patient. In 3 . Jobe FW. Kivitne RS: Shoulder pain in the over
dependence is gained in the strengthening pro hand or throwing athlete: the relationship of ante
gram. Active range of motion is 1 75° of flexion. dor instability and rotator cuff impingement. 01-·
thop Rev 1 8:963. 1 989
1 65° of abduction. 85° of external rotation. and
4. Sc!nvaT1Z R, O'Brien S: Capsular restraints lO the
65° of internal rotation measured with 90° of in
abducted shoulder: A biomechanical study. Or
ternal rotation.
thop Trans 1 2 :727. 1 988
The patient is discharged to a home exercise 5 . Warner J, DengX, WalTen R el al: Static capsuloli
program. and will lise pulleys and capsular gamentous restraints to supeIior-inferior transla
stretches (cross body for posterior capsule. and tion or the glenohumeral joint. Am J Sports Med
overhead stretching for interior capsule) to 20:675. 1 992
maintain range of motion. Interval sport pro 6. Hanyman D, Sidles J, Matsen F: The role of lhe
grams are normally initiated at this time. Addi rotator i ntelval capsule in passive motion and sta
tional home exercise is given to this patient in bility of the shoulder. J Bone Joint Surg 74:53.
the closed chain such as push-ups. push-ups with 1992
7. Rodosky MW. Harner CD. Fue FH: The role of
a plus. seated press-ups. and wall push-ups with
the long head or the biceps muscle and superior
partner overpressure. to attempt to prepare the
glenoid labral in anterior stability of the shoulder.
patient's extremity for weight bearing and im
Am J SPOl1S Med 22: 1 2 1 . 1 994
pact often incurred in his precarious sport activi 8. Hawkins R, Boker D: Clinical evaluation of shoul
ties such as skiing and snowboarding. No der problems. p. 1 49. I n Rockwood CA. Matsen
amount of preparation will be sufficient for vio FA IU (eds): The Shoulder. WB Saunders. Ph ila
lent trauma often incurred in these sporting ac delphia. 1 990
tivities. However. inclusion of plyometric and 9. NeeI' C. Foster C: inrerior capsular shift ror infe
closed-chain exercise will allow progression of rior and multi-directional instability or the shoul
the patient's strengthening program beyond the der. J Bone Joint Surg 62:897. 1 980
standard open-chain rotator cuff and scapular 1 0. Roukous J. Fegain J . Abbot H: Modified axially
roentgenogram. Clinic On hop 82:84. 1 972
exercises.
I I . Pavlov H, Wan'cn R, Weiss C el al: The roentgeno
Traditional interval return programs. such
graphic evaluation of anterior shoulder instabil
as those for throwing and tennis. are discussed
ity. Clin Orthop 1 94 : 1 53. 1 985
elsewhere in this book. Criteria for progression 1 2 . Bankhart A: Discussion on reCUlTcnt dislocation
of the interval programs are adequate strength the shoulder. J Bone Joint Surg 30B:46. 1 948
to perfOlTn the sport-related movement patterns 1 3 . Rubenstein D, lobe F, Gloosman R et al: An terior
in a pain-free manner without compensation capsulolabral l'econs(l'uction of the shoulder i n
from adjoining segments. adequate range of mo- athletes. J Shoulder Elbow 1 :229. 1 992
434 PHYSICAL THERAPY OF THE SHO ULDER
1 4. Bramhall J, SC31-pinlo D, Andrews JR: Operative 2 1 . Eisenberg J , Redler M . Hecht P: Arthroscopic sta
arthroscopy of the shoulder. p. 1 05 . In Andrews bilization or the chronic subluxaLing or d isloca
JR, Wilke K (cds): The Ath lete's Shoulder. Church tion shoulder without the use or intemal rixation.
ill Livingstone, New York, 1 994 abstracted. Al-t hroscopy 7:3 1 5 , 1 99 1
1 5. Skyhar M , Altchek D, Wan·en R: Shoulder ar 22. Esch J , Baker C : Ante,;or Inslability. p . 99. In:
lhr"Oscopy with the patient in the beach-chair po Surgical Arthroscopy: The Shoulder and Elbow.
sition. AI"lhroscopy 4:256, 1 988 JB Lippincott, Philadelphia, 1 993
1 6. Johnson LL: Symposium on Arthroscopy. Ar 23. Fanton G, Thabit G: orthopaedic uses or a11hros
throscopy Associalion of North America annllal copy and lasers. p. 47. Olthopaedic Knowledge
meeting. San Francisco. March 1 986 Update SPOltS Medicine. MOS, 1 994
1 7 . Caspari R: A11hroscopic reconstruction for ante· 24. Hayashi K, Markel M , Thabit G et al: The effect
dol' shoulder capsulorrhaphy. Techn Orthoped 3: or nonablative Laser energy on joint capsular
59, 1 988 propert ies: art in vitro mechanical study using a
1 8. Maki N: Arthroscopic stabilization: suture tech rabbit model. Am J Sports Mod 23:482, 1 995
nique. Oper Techn Orthop I : 1 80, 1 99 1 25. Hawkins RJ, Bell RH, Lippitt SB: Atlas of Shoul
1 9 . Wolf E : Arthroscopic Bankhart repair using su der Surgery. Mosby-Year Book, St Louis, 1 996
ture anchors. Techn Olthop I : 1 84, 1 99 1 26. Jobe FW, Giangan-a CE, Kvilne RS et al: Ante,;or
20. Warner J , Warren R : Arthroscopic Bankhm'L rc capsulolabral reconstruction or the shoulder in
pair lIsing a cannulated absorbable fixation de athlet.es in overhand Sp011S. Am J Sports Med 1 9:
vice. Oper Techn On hop I : 1 92, 1 99 1 428, 1 99 1
Rotator Cuff Repairs
JOSEPH S . WILKES
The causes of rotator cuff tears are varied and rotator cuff because of repetitive deceleration
depend on the age of the patient as well as the stresses Fig. 18.5. Instability can cause fraying
precipitating activity. They may be traumatic or of either the upper or lower surface of the cuff
degenerative. Because of their locations-the su depending on whether impingement or over
praspinatus primarily, and infraspinatus sec load-type forces are placed on the rotator cuff.
ondarily-they are the most fTequently torn Acute tears of the rotator cuff can occur fTom
muscles of the rotator cuff Fig. 18. 1 . extrinsic overload, such as when a great force is
applied to the abducted arm while the rotator
cuff is active. Another example of extrinsic over
load would be a situation in which a person was
Et:iolo[!Y forced to catch himself during a fall by reaching
overhead, thus placing a large distraction force
Previously it was believed that impingement was on the arm. These mechanisms can injure the
the primary cause of rotator cuff disorders, in capsule and other muscles of the shoulder. An
cluding tears. I Impingement occurs when the acute dislocation of the shoulder can not only
coracoacromial arch causes atlrilion of the ten disrupt the glenohumeral capsule but can tear
don due to nalTowing of the subacromial bursal the muscles about the shoulder, including those
space from either bony encroachment or en of the rotator cuff.
largement of the tendon Fig. 18.2.2 How the rotator cuff tear develops depends on
Impingement is not the only cause of rotator the pattern of the abnormal forces applied to the
cuff tears. Eccentric overload of the rotator cuff rotator cuff. Patients with primary impingement
muscles, resulting in overuse and fatigue, causes have fraying of the upper surface of the rotator
fiberfailureofthe rotator cuff, and is probably the cuff that subsequently leads to rotator cuff tears
most common cause of tears in the young, ath and tendon ruptures Fig. 18.6. The subscapularis
letic patienl.3 Tears in older patients are primar can also be involved in the impingement syn
ily the result of coracoacromial arch abrasion4 drome, and its integrity should be evaluated. The
Instability patterns can also produce impinge subscapularis should be used cautiously in a re
construction procedure. Secondary impinge
ment syndrome, which causes rotator cuff tears
ment causes the same type of wear pattern.
secondarily. Fiber failure can also occur from
chronic tendinitis. Other causes of rotator cuff
tears are calcific tendinitis Fig. 18.3,5 tumors:
and degenerative changes of the coracoacromial
joint that produce inferior spurs Fig. 18.4.7 The diagnosis of a rotator cuff tear can be diffi
Eccentric overload patterns of the rotator cuff cult because the signs and symptoms are similar
usually cause tearing of the undersurface of the to those of acute rotator cuff tendinitis. The c1ini-
435
436 PHYSICAL THERAPY OF THE SHOULDE R
Clavicle
Coracoid process
Acromion
Coracoacromial ligament
��:i-:1� Coracohumeral ligament
Supraspinatus m.
;!i 14�- Infraspinatus m.
r':::����--':��]J-- Subscapularis m.
FIGURE 18.1 Anterior-superior view of the shoulder sliolVs Ihe relatiOl1Ship of the osseous
structures 10the rotator cuff and the coracoacromial arch.
reproduced with Ihe anl1 ill Ihe fully abducted FIGURE 18.3 Calcific deposit lVithil1 the
cal history and physical examination are the shows {rayil1g of the rotator cLIff (grade II).
most important components in making the diag
nosis.8 As part of the initial examination of a pa
tient with a shoulder problem, routine radio should be undertaken to determine the status of
graphs frequently show sclerotic or cystic the rotator cuff.
changes in the area of the greater tuberosity that
may indicate advanced rotator cuff disease. IF DIAGNOSTIC IMAGING TECHNIQUES
FIGURE IS.5 Arthroscopic view o{ the in{erior FIGURE IS.7 Arthrogram of the shoLllder with dye
sLlrface o{ the rotator cLI{f shows {raying o{ the extravasation into (he subacromial bursa
Llnderswface. indicating a lear of the rotator CLiff.
438 PHYSICAL THERAPY OF THE S H OULDER
the compact space under the coracoacromial FIGURE 18.9 Arthroscopic view of the
area and al1 abl10rmal signal in the glel10htlmeral joil1t shows the undersura f ce
su.praspinatus tendon indicating a tellr. the supraspil1afLIs portiol1 of the rotator Cliff
extremely sensitive for full-thickness rotator cuff along with the biceps tendon can be seen arthro
tears, with greater than 90 percent sensitivity
scopically. The rotator cuff can be palpated with
and specificity,'O.11
arthroscopic instruments to determine its integ
cent and an 8 percent incidence of false-negative
rity Fig. 18.9 and to differentiate partial- and full
results.'2 However, it usually cannot provide in
thickness tears from chronic tendinitis. Arthros
formation about incomplete tears, tears on the
copy can also help detect instabilities that may
superior surface, or advanced rotator cuff ten be associated with rotator cuff disorders. During
don disease. AI1hrography requires insertion of
the arthroscopic examination, the integrity of
a needle and dye into the glenohumeral joint.
the anterior labrum and infel;or glenohumeral
Extravasation of dye into the subacromial bursal
ligament should be assessed and the shoulder
area suggests a rupture. Ultrasonography is non
ioint examined £Or instabi\it)'. SLP-P (se'Paralion
invasive and has approximately the same acclI of the superior labrum anterior and poste';or)
racy as the arthrogram.13
lesions of the labrum can indicate glenohumeral
Recently, magnetic resonance imaging MRI
dysfunction.
has become well established in the evaluation of
the rotator cuff tear. With newer technology, the
sensitivity and specificity are greater than 90 per
cent in most studies.13 Magnetic resonance im Surgical. Treatment
aging can detect not only the presence of full
thickness tears, but the presence of partial tears, Initially, most rotator cuff tears should be
their size, and their location with a high degree treated nonoperatively. The indication for surgi
of accuracy as well Fig. 18.8.12. cal treatment is a documented partial- or full
thickness rotator cuff tear that has not re
sponded to treatment and produces symptoms
ARTHROSCOPIC EVALUATION
that interfere with the patient's nOlmal function
AI1hroscopy can also play an important role in ing. However, acute, symptomatic tears in rela
evaluating the rotator cuff for tears. Both the in tively young individuals should probably be re
ferior and superior surfaces of the rotator cuff paired early.15
ROTATOR CUFF RE PAIRS 439
labral abnormalities can also be evaluated at this
time.
Small full-thickness rotator cuff tears « I cm)
can frequently be repaired by an arthroscop
ically assisted method. The same principles of
repair are used as for an open repair. Under ar
throscopic visualization, the greater tuberosity
in the area of the involved tendon is burred down
to a bleeding bony trough. Next, using an intra
articular suturing technique, sutures are passed
through suture anchors in the greater tuberosity,
and the rotator cuff is attached to the bone by
tightening the suture Fig. 18. 1 1.
Lesions larger than I cm should be repaired
by an open technique. These lesions can be sub
divided into small, medium, large, and massive
FIGURE1 8.10Arthroscopic view o(the
tears. Small and medium tears are repaired
glenohumeral joint with an arthroscopic
through a superior lateral incision of the sur
motorized blade tril1ll1lil1g the (rayed rotator cuff
geon's choice Fig. 18.12A. Exposure of the rota
ends.
tor cuff tear is facilitated by a coracoacromial
decompression. Small tears can generally be de
brided and advanced to the bony bed without
Arthroscopic evaluation of the rotator cuff can problems Fig. 12B and C. Medium and large
be combined with the surgical treatment of some tears frequently need moderate mobilization of
tears. The partial-thickness tear with fraying on the muscle bellies by tension to obtain good re
either the inferior or superior surface can be pair to the bony bed, or a V-Y repair can be done
treated with debridement of the involved portion Fig. 18. 13. Massive rotator cuff repairs require
of the tendon Fig. 18.10. The debridement allows extensive mobilization of the muscle bellies and
for freshening of the injured portion of the rota perhaps of the sUITounding muscles, particularly
tor cuff, thus stimulating a healing response. The of the subscapularis or infraspinatus, to allow
remaining fibers hold the cuff in position to heal. coverage of the humeral head. In these patients,
Certainly, a patient with a more advanced par the biceps tendon is usually damaged or rup
tial-thickness tear (more torn fibers) of this type tured severely and a tenodesis can be done at the
should proceed cautiously in the postoperative bicipital groove Fig. 18. 14.7.16-18
period with regard to activities. For a superior
lesion, a coracoacromial decompression proce
dure should also be performed. The rehabilita
tion is similar to that following open repair of
the rotator cuff, but the program is slightly accel
erated. We are able to shorten the rehabilitation The results of rotator cuff repair are variable and
period in these patients because they have intact seem to have a direct relationship to the patient's
fibers remaining to protect the cuffs integrity. age and the severity of the tear. 19 Although it has
During the arthroscopic evaluation, the intra been shown that repair of rotator cuff tears re
articular portion of the biceps tendon should be sults in a significant increase in function for all
examined for injuries associated with rotator patients, the degree of patient satisfaction with
cuff lesions. Frequently, debridement or tenode the repair depends on the size of the tear, associ
sis of the long head of the biceps is indicated ated pathology, and the age of the patient. Pa
when there is a rotator cuff tear. Instability and tients over the age of 65 years have a less favora-
Acromi
Supraspionnatus m.
Supraspinatus m.
D
.....-'-,.,...1=
. ...:- Exposed bone of
humeral head
c
440
R O T A T OR CUFF REPAIRS 441
A B
ble outcome than those under 65, although our office in Apl-il 1995, the patient had full range
symptomatic patients of any age with complete of shoulder motion, but she had a positive im
rotator cuff tears have at least partial relief of pingement sign and some weakness on abduc
their symptoms after a successful rotator cuff re tion at 90°. She had no instability and her neuro
pair.20 vascular examination was intact. Radiographic
examination showed nOl-rnal bony structures
and joint spaces. A review of the M Rl scan
showed a grossly abnormal tendon and a proba
CASE STUDY 1 ble teat· in the supraspinatus of the rotator cufr.
She was scheduled for arthroscopic examination
A 46-year-old woman is a volleyball coach for a of the shoulder.
local college. She has participated in volleyball At surgery, the diagnostic al,hroscopy showed
as an athlete and a coach for over 20 years. In an intact biceps tendon and articular surfaces.
early 1994, she noted increasing pain and dis She had a separation of the anterior superior la
comfort in her right shoulder. She was treated brum, butthe inferior labrum was intact with no
with nonsteroidal anti-inflammatory medica evidence of instability. When its inferior surface
tions and physical therapy without relief. An was viewed, the rotator cuff tendon was found
MRJ was done in the fall of 1994, which showed to be abnormal and to have a tear Fig. 18.15. It
an abnormal supraspinatus tendon with proba was abnormal over a fairly large area, and it was
ble rotator cuff tear. When she first presented to thought that open repair was necessary. There-
442 PHYSICAL THERAPY OF THE SHOULDER
:w.:�\- Supraspinatus
Artiof chumeral
ular surface
head Tearto isshape
V
trimmed
A B
Sutured
creatV
e
Y s cut
effect
Trough --AIM�
Edges
suturedof isupraspi
nto troughnatus FIGURE 18.13 (A) Medium to large tear with
..�oi=����--::::- Inmobi
fraspiliznedatus
Supraspinatus m.
Subscapul
mobilizedaris ������!����subscapularis m.
Humeral head �
Infraspinatus m.
Trough
A B
FIGURE' 8.'4 (A) Massive tear of the rotator wf( with the "bald head" appearance of the
humeral head. Mobilization of the infraspinatus and subscapularis and elevation of the
supraspinalLls mLlscie body to repair the rotator cuff (B) Repaired l1Iassive tear after muscle
mobilization.
fore, an open incision in the anterolateral aspect started on pendulum and passive range-or-mo
of the shoulder was made exposing the rotator tion exercises, which she continued for the first
cuff, where a 2-cm superior tear was identified 4 weeks after surgery. At that time she had Oex
with some retraction of the tendon. The area was ion to 90° and abduction to 60° but minimal ex
freshened, and the rotator cuff was repaired to ternal rotation. She began a structured program
a bony bed with advancement of the tendon back of physical therapy at 4 weeks after surgery and
to the bone Fig. 18.16 . After surgery, she was progressed satisfactorily over the next 6 to 8
weeks to full range of motion and full strength.
At Lhat point, 3 months after surge,y, she was
allowed to resume her normal activities.
CASE STUDY 2
A 4 8-year-old man was seen in the fall of 1994
with insidious right shoulder pain without a
known precipitating injury. He had pain in the
60° LO 120" arc of motion and some pain on
forced abduction at90" but he had good strength.
He had no instability and had full range of mo
tion. He began a trial of physical therapy and
nonsteroidal anti-inOammato,y medications,
FIGURE ' 8.'5 Arthroscopic view of the inferior which allowed him to improve somewhat. He re
sLlra
f ce tumed in the late spring of 1995 with recurrent
444 PHYSICAL THERAPY OF THE SHOULDER
A 8
FIGURE 18.16 {A} Appearance of lite rotalor cLIff lear il1 Case Study / afler exposure by opell
pain in the shoulder. His physical examination Fig. IB.178, which was slightly pulled away fTOm
at that time was essentially unchanged. An MRI the bone. After subacromial decompression, the
scan showed a probable rotator cuff tear. The bony bed on the greater tuberosity was freshened
patient undenvent arthroscopic evaluation and with a mot01-ized arthroscopic blade through a
was found to have no evidence of instability and third portal lateral to the acromion. Two sutures
an intact labrum. However, he had fraying of the were placed through the supraspinatus tendon,
undersurface of the rotator cuff and some fray and after drilling two holes in the greater tuber
ing of the articular side of the subscapularis on osity, the sutll1"es were anchored into the bone
the supel-ior aspect Fig. 18.17A. Examination with plastic suture anchors. With the shoulder in
with the arthroscope in the subacromial bursa the abducted position, the sutures were digitally
showed a I-cm tear of the rotalOr cuff without tied, pulling the rotator cuff tendon back down
retraction. The tear extended through approxi to the bony bed Fig. 1B.1B. Postoperatively, the
mately 80 percent of the supraspinatus tendon patient was started on f"ull passive range-of-mo-
A 8
FIGURE 18.17 {A} Arlhroscopic view of Ihe L111lIersur{ace of Ihe rolalor cufT ill Case Sludy 2. {B}
Arlhroscopic subacromial view of Ihe sLlperior s/.ll{ace of Ihe rOlalor cuff sholVing all
illcomplele lear of Ihe rOlalor ClifT ill Case SlLIdy 2.
ROTATOR CUFF REPAIRS 445
ness rotator cuff tear. J Shouldcl' Elbow Surg 3:
266, 1994
7. Bigliani LU, Rodosky MW: Techniques in repair
of large rotator cuff tears. Tech Orthop 9: I 33,
1994
8. Hawkins RJ, Mohtadi N: Rotalor cuff problems
in athletes. p. 640. In Delee JC, Drez DD Jr. (eds):
Orthopaedic Sports Medicine: Principles and
P.-actice. WB Saunders, Philadelphia, 1994
9. Brems J: Rotalor cuff tear: evaluation and lI--eal
ment. O.1hopedics I I :69, 1988
10. Iannotti JP (ed): Rotator Cuff Disorders: Evalua
tion and Treatment. p. 14. American Academy of
O.1hopaedic Surgeons, Park Ridge, IL, 199 I
I I. Mink JH, HatTis E, Rappaport M: Rotator cuff
FIGURE18.18 Arthroscopic subacromial view or tears: evaluation using double-contrast shoulder
the repaired rotator cuff arthrography. Radiology 157:62 I, 1985
12. Hawkins RJ, MisamoreCW, Hobeika PE: Surgery
for full-thickness rotator-cuff tcars. J Bone Joint
tion exercises. By 6 weeks, he had achieved rull Surg 67A:1349, 1985
range or motion and had started strengthening 13. Burk DL Jr, Karasick D, KUl1Z AS et al: Rotator
exercises. By 10 weeks, he had excellent range or cuff tears: prospective comparison of MR imaging
wilh arthrography, sonography and surgery. Am
motion and was gaining strength with relier or
J Roetgenol 153:87, 1989
postoperative pain. He was started on an in
14. Snyder SJ: Rotator cuff lesions: acute and
creased exercise program.
chronic. Clin Spo.1S Med 10:595, 1991
15. Hawkins RJ, Mohtadi N: Rotator Cliff problems
in athletes. p. 645. In Delee JC, Drez DD (cds):
Ol·thopaedic Spons Medicine: Principles and
References P,·actice. WB Saunders, Philadelphia, 1994
16. Ellman 1-1, HankerC. Baye.- M: Repair of the rota
1. NccrCS II: Anlcrior acromioplasty for the chronic tor cuff. End-result study of faCial'S innuencing
impingement syndrome in the shoulder: a prelim reconstruction. J Bone Joint Surg 68A: 1 t 36, t 986
inary reporl. J Bone Joint Surg 54A:4 I, 1972 t 7. Neviascr JS, Neviaser RJ, Neviaser TJ: The repair
2. Nash HL: Rotator cuff damage: re-examining the of chronic massive ruptures of the rOlatOl" cuff of
causes and treatments. Phys Spol1smed 16: t 29. the shoulder by use of a freeze-dried rotator cuff.
1988 J Bone Joint Surg 60A:68 I, 1978
3. Fowler PJ: Shoulder injuI'ies in the mature ath 18. Packer NP, Calve," PT, Bayley JI, Kessel L: Opera
lete. Adv Spo.1S Med Fitness I :225, 1988 tive treatment of chronic ruptures of the rOlalor
4. Brewer 6J: Aging of the rotator cuff. Am J Spor'ls cuff of the shoulder. J Bone Joint SU'1l 65B: 17 I,
Med 7:102.1979 1983
5. Hsu He, Wu JJ, Jim YF cl al: Calcific tendinitis 19. Haltnlp SJ: ROlator cuff I'epaic relevance of pa
and rotator cuff tearing: a clinical and radio tient age. J Shoulder Elbow Surg 4:95, 1995
graphic study. J Shoulder Elbow Surg 3: I 59, 1994 20. Adamson GJ, Tibone JE: Ten-year assessment of
6. Fallon PJ. Hollinshead RM: Solitary osteochon primal)' rotator Cliff repairs. J Shoulder Elbow
droma of the distal clavicle causing a full-thick- Surg 2:57, 1993
Shoulder Girdle Fractures
MICHAEL J . WOODE N
DA V I D J CONAWAY
Shoulder pain, stiffness, and weakness after frac the hematoma through capillary formation to
ture are common problems presented to the or form a callous of immature bone. Meanwhile,
thopedic physical therapist. Fractures are always osteoclast cells resorb necrotic bone from the
accompanied to some degree by soft tissue in ends of the fTagments. In the remodeling sIage,2
jury, leaving serious implications for rehabilita resorpt.ion and new bone formation continue as
tion well after the fTacture has healed. Even if trabecular bone patterns are laid down in re
the fTacture itself heals solidly, it is the soft tissue sponse to the stress applied. By this time, the
recovery that will determine the ultimate out immobilization, period should be ending so that
come of function. I the necessary "stress" is provided by remobiliza
This chapter presents a brief overview of tion of the limb.
some of the more common shoulder girdle frac The length of time required for each healing
tures. For each, general rehabilitation guidelines stage is influenced by many factors.2 Some of
are offered. The effects of trauma and immobili these include the severity of the trauma, how
zation are also summarized. much bone is lost, the presence of infection,
which bone is fTactured, how effective the immo
bilization is, and the patient's age, general
health, and level of activity.
Stages ojFracture Healing
447
448 PHYSICAL THE RAPY OF THE SHOULDE R
I. Loss of extensibility of capsule, ligaments, one-third (Fig. 19.2) and often in the middle one
tendons, and fascia. Immobilization results third (Fig. 19.3).
in a decrease in water and glycosaminogly The shoulder is immobilized for 14 to 21
can content. This contributes to an increase days, either in a clavicle (or figure eight) brace
in abelTant cross-linking and a loss of move or a sling. Badly comminuted, delayed union, or
ment between fibers4-6 surgically repaired fractures will require more
immobilization.
2. Deposition of fibrofatty infiltrates between
joint structures acting as intra-articular
"glue."7
REHABILITATION
3. Breakdown of hyaline anicular canilage.'
Active range of motion (ROM) exercises should
4. Atrophy and adaptive length changes in
begin within 14 to 21 days. Exercises should in
muscle.9.10
volve the shoulder girdle (elevation, depression,
protraction, and retraction) and the shoulder
Conversely, it has been shown that movement joint (pendulum and wand exercises). In most
tends to prevent or reduce these changes in con cases, a home program is sufficient. In unusual
nective tissue··11 and muscle9•loThe problem for cases of prolonged immobilization and excessive
us, as clinicians, is knowing when to begin active stiffness, passive mobilization may be necessary.
motion and when to progress to passive exercise. Evaluation and treatment should include acces
This requires close communication with the phy sory and physiologic movements of the sterno
sician and an understanding of the stages of soft clavicular, acromioclavicular, glenohumeral,
tissue healing. Evaluation of the direction of re and scapulothoracic joints. The laller is often
striction, pain, and reactivity is essential in deter overlooked, but may be particularly important
mining the readiness of movement.12 because of immobilization in a retracted posi
tion.
Prolonged immobilization can also result in
muscle weakness and even in visible atrophy. Re
Clavicle Fractures sistive exercises can begin when the Fracture ap
pears solidly healed and when pain with move
ment is reduced.
Clavicle r,'actures (Fig. 19.1) most commonly
occur fTom a fall on the lateral aspect of the
shoulder or, less commonly, onto the out
stretched arm. 13 The clavicle typically fractures
at the juncture of the middle one-third and distal Scapu/fJ. Fractures
joint soft tissues have especially significant im ful, limited abduction. 13.14 These are often
plications for rehabilitation. treated surgically with a fixation screw. Addi
tional clearance acromiopla ty or removal of the
acromion may be necessary. Postoperative im
GREATER TUBEROSITY
mobilization is from 14 to 21 days.
Fractures of the greater tuberosity are usually
the result of a fall on the shoulder, most com NECK OF THE HUMERUS
monly in elderly individuals.13 In nondisplaced Humeral neck fractures are caused by a fall on
fractures (Fig. 19.6) splinting should be avoided the outslretched arm or the elbow, often in el
so that active exercise can begin soon. An avulsed derly, osteoporotic women.
and displaced fragment must be reduced to Because shoulder joint stiffness is a common
avoid impingement with the acromion or cor-a complication of humeral neck fractures, early
coacromial ligament, which will result in pain- movement is desirable. The immobilization re-
SHOULDE R GIRDLE FRACTURE S 451
cause some trl.lctures may be more inflamed portions of the capsule. During mobilization,
and painful than others. For example, immobi pain should always be respected. When reactiv
lizing the arm in a sling or in a position of adduc ity is moderate to high, grades I and 11 accessory
tion and internal rotation can result in a "capsu mobilizations are used to reduce pain and pro
lar pattern" Iimitation.'6 In this capsular pattern, mote relaxation. When reactivity is low to mod
all movements at the glenohumeral joint, espe erate, grades III and rv accessory and physio
cially external rotation and abduction, will be re logic mobilizations are used to increase ROM's
stricted.'7 Therefore, mobilization should em Allhough most effort will be concentrated at the
phasize stretching the anterior and inferior glenohumeral joint, other joints in the shoulder
Summary
Fractures of the shoulder girdle are common
and, because of soft tissue U'auma and immobili
zation, often result in stiffness, especially at the
glenohumeral joint. When possible, early move
ment is essential. After a period of immobiliza
tion, all joints of the shoulder complex should be
assessed, regardless of the location of the frac
ture.
CASE STUDY
HISTORY
A 8
FIGURE 19.9 Radiographs o{ spiral/oblique humeral shaft {racture (A) be{ore surgical reduction
duce pain, and was instructed in gentle pendu reactivity continued to lessen, and the patient
lum exercises to be done at home. was more tolerant to passive glenohumeral ROM
and mobilization techniques. To improve de
TREATMENT
creased scapulothoracic mobility, passive scapu
WEEKS I AND 2
lar distraction, elevation/depression, and pro
Combinations of moist heat, nan'ow-pulse elec traction/retraction were begun. To increase
trical stimulation, and oscillations were used to functional muscle strength, glenohumeral and
reduce pain and reactivity, and to promote relax scapular proprioceptive neuromuscular facilita
ation. During this Lime the patient tolerated tion (PNF) was begun. The patienl's home exer
AAROM exercise. By the end of the second week, cise program (HEP) included pendulum and
PROM and muscle trength were as follows. wand exercises in all planes, and low-resistance
PROM REACTIYITY STRENGTH theraband strengthening exercises for shoulder
flexion 6Cf' Moderate 2/5+
elevation, abduction, adduction, and internal
Abduction 42" High 2/5 and external rotation. At the end of the sixth
External rol. 10" High 2/5 week, findings were as follows.
Internal rot. 30" Moderate 3/5
PROM REACTIYITY STRENGTH
WEEKS3T06
flexion 120" low 3/5+
The patient reported gradually decreased pain. Abduction 98' Moderote 3/5
She was better able to dress herself, and was able External rot. 42" Moderate 3/5+
to get comfortable at night. During this time joint Internal rol. 64' low 3/5+
SHOULDE R GIRDLE F RACTURE S 455
Craig EV: Shoulder rractures in the athlete. In Pet Blackwell Scientific Publications, London,
trone FA (cd): Athletic Injuries of the Shoulder. 1987
McGraw-Hili, New York, 1995 Rang M: Children's Fractures. IS Lippincott, Philadel
Crenshaw AH (cd): Campbell's Operative 011hopae phia, 1974
dies. Vol. 3. WB Saunders, Philadelphia, 1970 Rockwood CA, Green DP, Bucholz RW (cds): Frac
Cruess R: AdultOrthopaedics. Churchill Livingstone, tures in Adults, 3rd Ed. JB Lippincott, Philadel
New York, 1984 phia, 1991
DePalma AF: Surgery of the Shoulder. JB LippincolI, Rockwood CA, Matsen FA: The Shoulder. WB Saun
Philadelphia, 1983 ders, Philadelphia, 1991
Mueller KH: Intramedullary Nailing andOther Intra Rodgers LF: Radiology of Skeletal Trauma. Churchill
medullary Osteosyntheses. WB Saunders, Phila Livingstone, New York. 1982
delphia, 1986 Rowe CR: The Shoulder. Churchill Livingstone, New
Park WH, !-Iughes SPF (cds): 011hopaedic Radiology. York, 1988
Total Shoulder
Replacement
G E0 R G E M . MeeL U 5 KEY II I
TIMOTHY U HL
459
460 PHYSI CAL THE RAPY OF THE SHOULDER
patient's motivation and ability to understand bone loss, soft tissue retraction, scan·ing, and
and participate in a postoperative rehabilitation nerve injuries preclude the possibility of signifi
program is crucial. cant functional improvement, and the goals of
The primary indication for a prosthetic re surgery become pain relief and prosthetic stabil
placement is pain. Commonly, patients com ity. These patients are placed in a "limited goals"
plain of night pain, pain at rest, and pain pro rehabilitation program postoperatively.
voked by activities of daily living, work, and
recreation. Shoulder pain at rest is generally tol
PHYSICAL EXAMINATION
erated less well than that of the hip or knee.2 Pain
characteristics-location, character, fTequency, A general physical examination must include a
duration, and radiation-are important to note. detailed examination of both shoulders. A sys
Additional causes of shoulder pain, including tematic method of recording joint motion should
neurologic, cervical, and thoracic causes, should be used. In general, patients with glenohumeral
be investigated. arthl�itis have restricted active and passive
Limitations in motion and shoulder function ranges of shoulder motion with a predominance
are also indications for prosthetic replacement, of scapulothoracic motion. Limited external ro
but they should only be considered secondary tation is more sensitive than forward elevation
indications. Evidence of advanced destructive in detelmining the degree of restricted joint mo
joint disease on radiographs should only support tion in arthritic shoulders.2 Patients with rotator
the clinical diagnosis and decision. It is not in cuff tears may be differentiated from those with
and of itself an indication for surgery in the ab arthritic shoulders because they usually retain
sence of significant pain and dysfunction. For full passive motion while active motion and
most patients who have degenerative lesions, strength are limited.
restoration of shoulder motion and f-unction to Posterior joint line tendel�ness is a character
"near normal" is realistic. In some cases, severe istic finding in patients with glenohumeral arthr-
462 PHYSICAL THE RAPY OF THE SHOULDER
tional improvement. Impingement syndrome shoulder Llsing a Slick IVilh anl1 supporled 011 a
and acromioclavicular joint arthritis must be pillow.
TOTAL SHOUL D E R R E PLACEMENT 463
and injections. Therapy programs should be in
dividualized for each patient and should empha
size good communication between the patient,
surgeon, and therapist. The patient should be in
formed about the diagnosis and goals of rehabili \
tation. Preoperative exercises to maximize pas \
sive range of motion and to condition shoulder \
muscles prepare the patient for postoperative re \
\
habilitation.
\
\
\
\
Indicalifms \
\
,
I
,
,
,
,
110
\
,
I , '-
,
,
,
,
,-_ ...
,
'
r
't
A B
/�
u
� )( E
-�
!
\
.. ,"'-
:-(' .
�
C 0
FIGURE 20,9Five-way isomelrics for Ihe glel10humeral joinl wilh Ihe elbow flexed al 90�
(A) Flexiol1 (B) Exlensiol7 (C) Abduclion (D) Inlemal rolalion (E) Exlemal rotalioll,
465
466 PHYSI CAL THE RAPY OF THE SHOULDE R
I ARTHRITIS OF DISLOCATION
I
I
/ Degenerative arthritis that is the result of recur
rent dislocations of the glenohumeral joint or of
/
/
a surgical procedure for anterior or posterior dis
locations that displaces the humeral head to a po
sition opposite the surgical approach is referred
to as arthritis of dislocation. In most shoulders,
the head subluxates posterioriy following an an
terior approach for a procedure to correct recur
FIGURE 20.10 Active assisted elevation with a rent anterior dislocations. In others, a unidirec
stick in the plane of the scapLila. tional surgical approach was used for a
TOTAL SHOULDER R EPLACEMENT 467
\
\
\
\
\
\
I
I
I
I
I
I
I
(�:C�-_-�:-::"-_I
FIGURE20.12 Beginning
multidirectional instability problem with resid changes in the version of the humeral and gle
ual inferior instability causing persistent symp noid prosthetic components. Modifications in
toms. Most patients in this group are under the the rehabilitation program are made depending
age of 4S at the time of the shoulder replacement. on the degree and direction of instability noted
Special problems encountered duringarthro preoperatively and intraoperatively.
plasty in patients with arthritis of dislocation are Retained hardwal'e is common in shoulders
often related to the initial procedure for instabil that have had previous surgery. Any intra-articu
ity. These problems include previous surgical lar hardware, including any previously placed
scars associated with cutaneous neuromas, scar screws or staples, should be removed.
ring and atrophy of the anterior deltoid, and sub
scapularis contracture that severely restricts ex OSTEONECROSIS
�
--....\
)
--,'
(
�
"
/
../
A B
FIGURE20.13 (A) Ten'llil1al stretching (or elevatiOll. (8) External rotation tvith a Ivall.
(Fig. 20.3). In these patients with an intact gle mechanical factors contribute to this degenera
noid, humeral head replacement alone is indi tive process. Gross instability of the glenohu
cated. Total shoulder replacement is reserved for meral joint develops, and the humeral head mi
patients with stage 4 osteonecrosis, with marked grates cephalad causing wear into the acromion,
degenerative changes of the humeral head and acromioclavicular joint, and coracoid process.
glenoid al1.icular surfaces (Fig. 20.4). The rotator All patients treated with humeral head replace
cuff and biceps tendon are usually intact in these ment or total shoulder replacement along with
patients. rotator cuff repair are placed in a limited goals
rehabilitation program postoperatively with em
phasis on pain reduction and stability instead of
CUFF TEAR ARTHROPATHY
function.
Neer described cuff tear arthropathy in 1975 as
severe destruction of the glenohumeral joint POST-TRAUMATIC ARTHRITIS
with humeral head collapse and a massive rota Arthritis related to previous fractures or frac
tor cuff tear in the absence of other known etio ture-dislocations of the proximal humerus or
logic factorsS A combination of nutritional and glenoid is treated with prosthetic replacement in
)
,f ,
"
'"
" '
, :
1-/
v
,,
"
, /'
469
470 PHYSICAL THE RAPY OF THE SHOULDE R
RelwhiJ:itatUm
\, r\ ,
\
,
-.:,1...
knowledge of the surgical procedure and its post
operative progress is needed. Having this knowl
I edge gives the patient confidence in the thera
, t\
�,�
pist's expertise.
From a technical standpoint, the therapist
and the patient should be in a comfortable posi
F I GURE 20.18 Prone extension is used /0
tion before performing the passive range of mo
strengthen the teres minor and posterior de/wid. tion. Hand placement is also very important. In
I( the patient is LIIwble to lie prone, he or she general, the more proximal placement of the ther
can simply lean (onvard 10 a com(0I1able apist's hand on the patient's arm, the beller. The
positiol7 al7d lean 017 the ,ma((ected patient will sense the therapist has beller control
arm (or support. of his or her arm and will not have a tendency to
actively move it (see Fig. 20.6).
function is not an objective. Frequent communi
cation between the surgeon and therapist is Per(onning Extemal Rota/iol1
needed to determine the appropriate time for re
habilitation to begin. The time frame described in When externally rotating the patient's arm,
Appendix 20.1 C is very conservative and should watch the position of the humerus. If the hume
be modified according to individual needs and re rus is posterior to the midline of the body, the
sponse to the rehabilitation program. amount of external rotation will be lessened and
more painful to achieve. In extension, stress will
CRITICAL POINTS AND TECHNIQUES be placed on the sutures in the anterior struc
C0I1I111UnicQlion tures.
I
I I
I I
I '
I
I I r'
I
I I I
I
I I
, I
I I
FIGURE20.19 Prone I I
\ I
horizolllal abductioll is I I
I ,
used 10 strengthen the I \
Ii �,
supraspilwtus. Watch (or �/ h r\
scapular subs/ilution when
supraspillatus is weak. ���
will want to do more, but it is very easy to i'Titate elastic resistance exercises, or both. On the other
the rotator cuff tendons when initiating passive hand, if a patient is having pain with isometrics,
range of motion, active assisted range of motion, switching to gravity eliminated activities might
and light resistive exercises. The patient's re reduce the pain and still accomplish the goal of
sponse after the first 2 to 3 days of new activities increasing strength and active range of motion.
should serve as a guide for modifying the pro
gram to reach the patient's goals with minimal
Special COl1sideratiol1s
discomfort.
When osteoarthritis is the disorder necessi
tating total shoulder replacement, posterior gle
Resistive Exercise Progression
noid wear and acromioclavicular joint involve
Resistive exercises typically follow this pro ment is common. From a rehabilitation
gression: isometric, gravity eliminated molion . standpoint, glenohumeral elevation in the pure
active assisted range of motion, isometric hold frontal plane (Oexion) is contraindicated be
at end range of active assisted range of motion cause of the chance of posterior shoulder dislo
with eccenlric lowering, active range of malian, cation. Therefore, elevation activities for these
light elastic resistance below shoulder level, light patients are best perfomled in the plane of the
dumbbell resistance, modified activities, and full scapula. Early in the rehabilitation process, ex
relurn to activities. cessive horizontal adduction can cause pain due
Again, the patient's response to the exercises to the freshly shaved ends of the acromion and
determines the progression of the program. For clavicle.
example, if a patient is moving the arm actively, Rheumatoid arthritis patients are generally
comfortably, and biomechanically correctly, it much slower to recover than osteoarthritis pa
would not be inappropriate to move directly tients. Because of the systemic nature of the dis
from isometrics to active range of motion or light ease process, other joints, such as wrist, hand,
474 PHYSICAL THE RAPY OF THE SHOUL DE R
and neck, are involved. Typical exercises for their total shoulder arthroplasty patients. Before
these patients must be modified to avoid aggra such a program can be developed, however, a
vating these other joints. Osteopenia is often thorough understanding of the surgery and the
present, and many patients have rotator cuff purpose of the surgery is needed. Each surgeon
tears. In these patients, rehabilitation must will have his or her own philosophy, and the re
progress slowly and without force. [f the patient habilitation program should reflect that. It is a
is nonambulatory when undergoing total shoul team approach that benefits the patient the
der arthroplasty, transfers should not be done most.
independently for approximately 5 to 6 months.
Avascular necrosis patients who often
undergo a humeral head replacement only, are References
typically younger than the average total shoulder
patient, and their musculotendinous structures I. Pean IE, Bick EM (trans): The classic on pros
are not involved. For these reasons, these pa thetic methods intended to rcpair bone frag
tients often progress rapidly through the rehabil ments. Clin Ol�hop 54:4, 1973
itation process as long as they are motivated and 2. Neer CS: Glenohumeral al�hroplasty. p. 143. In:
no complications arise. Shoulder Reconstruction. WB Saunders. Phila
delphia, 1990
Patients who develop arthritis after disloca
3. Neer CS: Replacement arthroplasty for glenohu
tion also have need of a modified postoperative
meral osteoarthritis. J Bone Joint Surg 56A:1,
program. By the time total shoulder arthroplasty
1974
is indicated in these patients, they have usually
4. Corield RH: Unconstrained total shoulder pros
had I or 2 previous operations. They have shoul thesis. Clin Orthop 173:97, 1983
der stiffness and are apprehensive about un 5. Neer CS, Craig EV, Fukuda H: Cuff-tear arthro
stable positions of the arm. The deltoid and sub pathy. I Bone Joint Surg 65A:1232, 1983
scapularis muscles of their shoulder are 6. Post M, Gdnblat E: Preoperative clinical evalua
predisposed to retears because of the previous tion. p. 41. In Friedman RI (ed): Arthroplasty of
surgery. The surgeon's recommendation that the Shoulder. Thieme, New York, 1994
these structures be protected for a longer period 7. Neer CS, Kirby RM: Revision of the humeral head
and total shoulder arthroplasties. Clin Ol�hop
can delay rehabilitation.
170:189,1982
Cuff tear arthropathy patients have massive
8. Nee,- CS. Welson KC, Stanton FJ: Recent experi.
rotator cuff tears and severe deterioration of the
ence in total shoulder replacement. J Bone Joinl
glenoid and humeral head. Surgeons often have
Surg 64A:319, 1982
to modify the version of the prosthesis and split 9. Friedman RJ: Total shoulder al�hoplasty in rheu
the subscapularis muscle to obtain closure of the matoid arthritis. p. 158. In: Shoulder Reconstruc
rotator cuff. These patients almost always are tion. WB Saunders, Philadelphia. 1990
placed in the limited goals program. 10. Friedman RI, Thornhill TS, Thomas WH, Sledge
CB: Nonconstrained lotal shoulder replacement
in patients who have rheumatoid arthritis and
class TV function. J Bone Ioint Surg 71A:494, 1979
Rehabilitation Programs
Following Total Shoulder
Replacement
Day 1 Arm is pos in c sling. Weeks 4-6 Begin extension and internal rotation stretches
Out of bed. into choir and ambulating. (Fi g. 20.12).
Elbow, wrist, ond hand active range of motion. Terminal stretching for elevation and external
Possive external rotation with 0 slick to poin rototion (Fig. 20.13).
tolerance and not beyond 30" (Fig. 20.5). Light elastic resistance exercises replace
Possive pendulum motions by therapist. isometrics performed with elbOw Rexed to
Days 2-3 Family members ore instructed in technique of 90" and below shoulder level (Fig. 20.14).
passive forward elevation fOr rehabilitation Flexion, extension, and abdudion in the
at home (Fig. 20.6). p)one of the scapula (scoption)
Passive forward elevation in the plene of the Internal and external rotation
scopula. When 1200 of elevation is Assisted elevation of arm with stick, wall, or
possible, the patient begins using 0 rope rope and pulley with isometric hold at end
ond pulley to elevate the arm (Fig. 20.7). range followed by active eccentric
Instruct patient in odivities of doily living. Iowe.-ing to poin toIeronce (Fig . 20.15).
Discharge from hospitol. Weeks light dumbbell program replaces elastic
Home Passive external rotation with stick to 300. 10-12 resistance.
Program Passive forward elevation with family member; $caption-elevation in the plane of the
progression to use of rope and pulley. scapula (Fig. 20.16).
Elbow, wrist, and hand active range of motion. Sidelying or prone external rotation (Fig.
Precautions No lifting with involved orm. 20.17).
Shoulder extension is limited. Elbow not 10 go Prone extension (Fig. 20.18).
behind midline of the body. Prone horizontol obduction (Fig. 20.19).
Weeks 1-2 Review home program and modify as Upon obtaining 85 percent of normal adive
appropriate. range of motion of the shoulder and 0
£
Begin scapular stabilizing exercises within pain manual muscle testing score of ot leost
toleronce (Fig. 20.8). four out of a possible five for anterior
Retraction and deltoid, internal, and external rotators,
Elevation and f ressian modified sport odivities are allowed; short
Begin glenahumera jaint isometrics with elbow irons and pu�ing for golf, and groond
Aexed (Fig. 20.9). strokes in tennis.
Flexion, extensian, abduction Months 5-6 Full return to sport with full odive and passive
Internal and external rotation rang e of motion.
Weeks 2-4 Begin active assisted elevation (Fig. 20.10) or Modified weighrlihing program (elbow does
gravity-eliminated active range of motion not pass midline of body).
in elevation and external rototion (Fig. Continue stretching and strengthening program
20.11). independenrly.
Correct scopulohumerol rhythm should be lsokinetic testing is allowed, if necessary.
maintained during these exercises.
Activities of doily living to tolerance keeping
the arm below shOulder level.
475
476 PHY SIC AL THE RAPY OF THE S H OUL D E R
Abduction of !>houldcr. See {lisa Eleva in total shouldcn-epiacement, 462, in isokinetic excl-cbe
tion of !>houldc,- 464,473 with extcnsionJintcmaJ rotation
in active range of 11101 ion assess Acromioclavicular ligament.10 movement,406[. 407, 40?r
ment,63-65.64f, 136-137 Acromion with flexionlextel11al rotation
biol11cchanic.!. of,3-5, 4f,99-100, in elevation of �houidcr. 280 movement, 406f
100f f,.aclures of. 449. 451 f testing of, 69t,72
arthrokinemmics in.3-5, 4f impingement of humeral grealer Adenosine triphosphate (ATP).
forces in.11-14.12f. 13r.99 tuberosity undel� in hemiple 365-366
muscles in,S,6,7. I tr-13f, gia, 207,207f Adhesions,capsula,", 258
II 14 in impingement syndrome arthrography in,262f
ostcokinematics in, 1-3. 2f, 3f position of,230f,23lf and frozen shouldel� 258,259
in exercise program for throwing role of,231-232,232f in immobilization,formation of,
injuries of shoulder,29,29(, 30. shape of, 234f. 235,235f. 238, 258,270,346
30r. 32,32f, 36-37,37f,38r. 280 manipulation techniques in.270
49f,51 Acromioplasly ADL. See Daily living activities
in isokinctic exercise e.xacerbation of instability in, 243 Adson's test in thoracic outlet svn
with cxtensionlinternal rotation in impingement syndrome. 232, drome,170
movements,403-407,404f, 239 Aerobic training.366
405f,406f Aclive motion Age
with nexionlcxtcrnal rotation in brachial plexus inju1'ies, 196.198 in frozen shouldcl-, 262
movement!.,40M, 407 evaluation of,62-65,64[, 136-137, in impingement syndrome,235, 2361
in scnpulm" plane. 1-2.2[, 3f 387 torque and. 412
in Mrcnglhening c.'(crciscs, 249f, posture in, 387 Agility,relationship to power and
251r. 252f,370f,372f. 473f in fractures of shoulder girdle, 448 strength, 366
lesling or, 691, 72.171 of clavicle. 448 Akureyn disease, referred pain from,
Absolute muscular endurance. of humerus. 450,45 I 330
365-366,373 of scapula, 449 Anaerobic capacity. 365-366. 373
AccessorV' motion in joint mobility,68. in frozen shoulder. 260.265-266 Anatomy of shoulder complex, I, 5-10
72 in exercise program,269-270,272 acromioclavicular joint in.9-10
Acromidchoid mu�clc, in gleno limitations in.reasons for. 62 brachial plexus in,179-184
humeral �tability,8 in postoperative management of glenohumeral joint in, I, 5-6,6f
Acromioclavicular joint, I. 2r instability,430. 431,432 relationship to spine,95-96
in abduction of shoulder,12, 13 predictive value of. 63 scapulothoracic jOint in.10
analomy of,9-10 in protective injuries, 339 slcl11oclavicuial- joint in,9,9f
arthritis of.464,473 in thoracic outlet syndrome. 169, Anesthesia.myofascial mobili7
..ation
in nexion of �hould(.'r, 3 175-176 under,273.336
in frozen shoulder,265 in total shoulder replacement, 466f, in fTozen shoulder, 273
innervation of,59 473 Aneurysms,rcfen-ed pain from, 322
mobili/..3tion techniques involving Acupuncture in frozen shoulder, 268 Angiofibroblastic hyperplasia. 281
antedOI- glide in, 354-355,355f Adduction of shoulder Anti-inflammatory agents, nons-
case �tud.v on, 397-398, 398f in exercise program for throwing teroidal
gapping in. 355, 356f injuries of shoulder,41 ,41f in impingement syndrome,236
in range of motion a�scssmcnl,63 hypov3scuial-ily of rotator cuff dur postviral fatigue syndrome (PFS)
refcn-cd pain to. 319 ing,281-282 and,330
477
478 IN 0 E X
Aplcy'� :,cratch test, 284 in throwing injuries or shoulder. 23, Basal ganglia. in nClIf'Omuscular train
Appcndh:, perforated, pneumoperi· 24 ing, 250
loneum from, 309 AI1icuiation techniques, 335-336 Baseball. throwing injuries or shoul
Apprehension lest in instability of AI1ificial shouldcl' joints, 459-476 der in. 1 9-55
.houldcl·, 22, 75r, 76-77, 286, Assessmenl pnx:edul'CS, See Evalua- Baseball players
423 tion procedures impingement and instability in, 232
AI1criai pulses, palpation of , 300-301 Atherosclerosis. rdelTed pain rrom, isokinetic torque ratios for, 4081.
Arthritis in 10la1 shoulder rcplacemcni 322 4 1 1 -4 1 2 , 4 1 21, 4 1 3
after dblocalion, 463. 466-467, 474 Athletes. See a/so Overhand athletes; muscle activity studies in. 245
glenohumeral. 461 -462. 463 spec/lie sporl results or slI'CngLh training in.
nonopcralivc treatment options for. evaluation or shoulder' problems in, 371 -372
462-463 60 Bench PI'CSS exercise, 41. 42r
oSlcoarthdlis, 460f, 463, 464, 473 impingement syndrome in. 232. Biceps brachii muscle and tendon
post-traumatic, 468, 470 237, 240-253 in frozen shoulder, 258-259
Arthrography isokinetic IOrque ratios ror. 4081, in hemiplegia
in adhesive capsulitis, 262r 4 1 1 -4 1 2 , 412t inappropriate u�e or. 206, 20M
in frozen shoulder. 259-260, 26 1 . predictive value or, 4 1 3 shonening and spa�ticily in.
262, 262r. 264 peripheral nerve entrnpments in. 2 1 2-2 1 3
for �tcroid injections, 272-273 1 17 hypovascularilv or, 2 8 1 -282
in instabilities of shoulder, 423 rotator curr pathology in, 240-242 in impingement syndrome. 81 r. 82.
in rotator cuff tcal'S. 437r. 437-438 strength training improvements in. 231
Arthrokinematics 37 1-372 long head or, 7, 2 3 . BOr
concave--convex mlc of. 344 �ul'gicaJ techniques ror shouldcr in stabilizalion of glenohumeral
definition of. I instabilities in, 424. 429 joint, 422
of glenohumeral joint thmwing injuries or shoulder in. in musculocutaneous ncn'c palsy,
in abduction of shoulder, 4f 1 9-55 1 1 7-1 1 8
role of steerer'S and depressors in. training principles rO I� 368, 369 myorascial mobili7..ation or,
8-9 Autonomic nervOllS system 396-397, 397r
in rOlation of shoulder. 3, 4f. 4-5. impact or myorascial mobili7..3tion in rotalOr curr pathology. 282, 290
I I , J3 on, 385 arthroscopic debridement or, 439
in scaption or shoulder, 4 vasoconstl"iction renex or, 162 tenodesis or. 439, 443r
Iypes or motion. 3 Avascular necrosis in scaption-abduction or shoulder. 5
joint play techniques in assessment etiology or. 467 short head or. 7
or, 266 total shoulder replacement in. 459, in stabilization or glenohumeral
mobili7..31ion techniques in rcstora· 46Ir, 462r, 463, 467-468, 474 joint, 7, 9, 23, 37 1 , 422
tion or, 270, 27 1 A:dll3ry artcf), and vein strengthening c'\:cl'-cises ror. 37 1 , 374r
Ar1hropmhv. posHraumatic, tOlal injury or. 192 tendinitis or
.!>houldcr replaccmcnl in, 463. l'Cren'cd pain rmm, 322-323 case study on. 378-380. 379r.
47 1 , 474 Axillary nerve 380r
Arthroscopy injury or. 1 84, 185, 1 86, 1 88 myorascial mobili7.ation in.
compared to open reconstructive ncumpraxia in, 1 86 396-397 . 397r
�UrgCI)', 424 physical c'\:amination in. 1 9 1 te�ts in evaluation or. 82. 8U, 83.
in rrozcn shoulder, 273 muscles innen·atcd by, 99 83r. 85r. 86
in instabilities or shoulder palsy or. I 1 7 working posture and, 104
as diagnostic tool, 427 Axillary pouch or n.'Ccss. 8 tenosynovitis or, 258
indications ror, 424 Axillary region, pillpation or, 741. 75 lests in evaluation or. 81 [-83r.
laser capsulolT'Uphy in, 424. A.'\:iohumeral and axioscapular mus- 82-83, 85r. 86
428-430 c1cs, response to dysrunction, in throwing movements. 20, 2 1
po�topcr'3live management in, 69t, 7 3 in injured athletes, 2 1
430-431 injur)' or, 23
preoperative steps in, 427-428. in prorcssionals versus amateurs,
428r B 21
as stabilization technique. strengthening exercise ror. 50r. 5 1
427-428, 428r-430r Bacterial endocarditis, referred pain i n lotal shoulder replacement. 464
in I'olator cuff tears. 29 1-292 from,319 Biceps curl exercise. 50r, 5 1 . 374r
a� diagnostic tool, 438. 438r. 443, case study on. 3 1 9-322. 320r. 32 1 r Biceps labral comple'\:. in throwing
443r. 444, 444r Bankhar1lesion. detection or, 423 injUlics or shoulder, 22-23
as surgical treatment. 293-294, Bankhal1 l"Cconstru cl ion, 424-426. Biorccdback techniques in hemiplegia,
439. 439r, 440r. 444. 445r 425r 221
tN0EX 479
Biomechanics of shouldcl' motor strength in. 191-192, Bumcl' syndrome in bl-:lchial plexus
in abduction. 3-5.4f.10f-13f.10-14 194-195.196.202 injuries, 187-188
in brachial plexus injuries. 187.187f myelography in, 193 Bursitis, cervical spine pathology in.
in flexion.3 nClve conduction velocity tests in. 109
in glenohumeral stability. 5-9. ?r. 195
8f.287-288 occupationallherapy in, 189. 193.
in hemiplegia.205-214 195.200 c
in type I ann. 211 pain in. 189-191.196.197
in type II ann. 212 palpation in.192.196 Cancer
in type III aim, 213 passive range of motion in. 191, causes of pain in. 301,304
relationship to spinc.99-100 196.198. 202 rcfCITCd pain from
in rotation.12, 13 patholllechanics of. 187. 187f colon. 329
Body Blade. 25 pathophysiology of. 188-189 gallbladder. 325
Brace�.in clavicle fractures.448 peripheral nerve, 186 kidney.328
Brachialis muscles. in rnu�culocuta- physical e x amination in. liver, 324
neous nerve palsy. I 17-118 191-193.196-197.201-202 lung.3 1 1-314
Brachial plexus.179-203 posterior cord, 186. 188 pancreas, 324-325
anatomy of.99.179-184 posture in. 105.191.196, stomach, 328
in relationship to other struc- 201-202 of spine. symptoms of.31 1
tUl'es, 181-182 radiography in, 193 Capsular fibrosis, in impingement �yn-
in axilla.181-182 rchabilitation in. 193.195. dmmc, 237
components of.179 197-201 Capsular laxitv tests, 286
conis of. 179.180 sensory loss in. 192. 196.202 Capsular lesions. stages of. 264
injury of. 185-186 in shoulder dysfunction , 109-110 Capsular mobility tests, 286
divisions of. 179.180 special tests in. 192-193 Capsula!' pattem, limitation of gleno-
injury of.116. 184-189 splinting in.189. 193.194f humeral movement� in. 67�8.
active range of motion in, 196.202 supraclavicular.184 260-261.452
anatomic features in protection tests in. 192-193 Capsule
from, 182-183 Tinel's sign in, 192-193 of acromioclavicular joint, 10
case study on. 195-203 tdggerpoints in, 192, 197-198 of glcnohumeral joint
chan on results of evaluation in, uppenrunk, 184, 187-188.191 anatomy of. 6
189.190f vascular injuries in, 192 in cClvical ncrve root iiTitation.
c1a))sification of,184, 184t vocational assessment in.193, 108
comparison to hemiplegia, 213 196.201 in frol-en shoulder, 258. 259.270.
as complication of musculoskcle- in neck.181 &e. {lisa FI'Ol-en shoulder
ud injuries, 187-188 neuralgia of.radicular pain in.134 in impingement syndrome.237.
coordination in.192.196.200.202 palpation of nerve trunks and neu- 238.241
daily living activities in.193.196. rovascular bundle of, 140 laxity of.in throwing movements,
199 roots of. anatomic features provid 21
degrees of severity.188-189 ing protection from injuries. mobili7..ation techniques involv
in droopy shoulder syndrome, 183.183f ing.344
105 in segmental innelvation of shoul in range of motion lests.65, 66f.
edema in. 192. 196. 198.202 der muscles, 179.180.180f, 68.68f
electromyography in, 188. 181f in stabili7..ation of joint, 7-8.422
194-195 tests in evaluation of,192-193 stress on, 347
emotional SUpp0l1 in,199 in frol-cn shoulder. 264-265 in throwing movemelllS, 22
evaluation of. 189-195. 196-197, in thoracic outlet syndrome. 157, of sternoclavicular jOint, 9
201-202 161 Capsule-labrum complex. in anhro
history of patient in. 189-191. trunks of.179,180 scopic stabilization of shoul
196.201 ana,omy of. 182f. 182-183. 183f. der. 427-428. 428f
hobby and leisun! activities in. 191 Capsulitis. adhesive, 6. &e also Fl'Olen
193 injury of. 183f. 184-185.191 shoulder; Nonprotective
infraclavicular. 184. 185. 188 Brachial pulse, in br achial plexu� inj uries
laboratory cvaluation of, 193-195 injuries.192 glenohumeral joint in. 67-68. 238
latcral cord,185.188 Breathing pattems in thoracic outlet fibrotic changes in, 109
lower trunk. 185.191 syndrome impingement syndromc in, 238
mechanisms of.189 evaluation of,170, 176 rehabilitation for.case study on,
medial cord, 185, 188 as risk factor. 157. 159, 162-163 342-346
middle trunk.185 treatmcnt of,172f.172-173 use of telm. 258
480 IN 0 E X
Capsulolabral reconstruction, 24. 424 Cervical ncrvc root it,-itation occupatioll4ll. 102-104. 103f
antcr;or. 426,426f evaluation of. 113f,113-116, postural, 100-102, IOIf, 102f
rehabilitation in. 426,431-433 114f-115f rotation of. 122, 124f
poslcdor, 426-427 referred pain in. 113 surgery of. hospitalization for, 132
rehabilitation in. 427 Cervical nelves. 179. ISO lests in evaluation of
Cardiac disease, refcrTcd pain fTom, anatomy of. 97. 97f. 98 compression test. 110. II If. 121
58,58t, 136,315-322 compression of. posture in, 100-101, Spurling's test, 112. I 12f
case studies on,31 M. 316-317, 318r, 10If treatmcnt regimen for,108
319-322, 320f, 321 f injury of. splinting in. IS9 in thoracic outlct syndromt'. 174,
diagnosis of, 316,317,318 initation of 174f
Cardinal plane in reflex sympathetic dystrophy. vasoconstriction of shoulder tissue
in isokinetic exercise. 417 108 initiated by, 108
range of motion tests in,63 in shoulder pathologies,IDS whipl<.l�h injurics of, 132
Cardiovasculal'conditioning, in throw palsy of, 184 Cervical spondylosis
ing injuries of shoulder, 26 Cervical plexus,anatomy of, 99 loss of inhibitory 11lcchanOreceplors
Carpal tunncl syndrome Cervical quadrant tesL. 265 in, 106-107
fluid dynamics in, 154,161 Cervical radiculopathy. See also Cervi shouldcr'-hand syndrome and.
pressure gradient research on, cobrachial pain syndrome 324
163,164f case study on. 143-150. 146f-147f lrealment of, 108
nerve compression in, 167 effect of sensitizcd neurai tissue in, Cervical transvcrsc processes. frac
shoulder' pain 311d. 118 138f tures of. in brachial pll-xus
in thoracic oULlet syndrome. inci EMG rcsponscs lO nervc trunk stim injuries. 193
dence of. 167 ulation in. 141. 146f,147f Cervicobrachial pain syndrome. 131.
Cartilage of glenohumeral joint. frozen shoulder and. 109 See (Ilso Cervical radiculopathy
anatomy of, 6 myofascial neck and shoulder pain c..'lse study on, 143-150, 146f-147f
Causalgia. active movement dysftlnc in, 105, 105f EMG responses to ncrve In.mk stim-
lion in,136,137 pain and paresthesia in, 134 ulation in, 141, 146f. 147f
Cerebellum. in neuromuscular train Celvical region evaluation of. 134-141. 145f. 148
ing. 250 examination of. 59, 60t. S7 local area pathology in, 141
Cervical disc disease referred pain from, 59, 60t need for pn.'cisc examination in.
chronic. intrinsic shoulder pathol- Cervical db, in thoracic outlct syn 134,136,148
ogy from, I 10 drome, 157 pain in
compl'es�ion testing in. 110. 11 l f Cervical spinc, 95-125 incidcncc of. 132
cvaluation of. l lO-IIL I l l f convergence of afferent nerves in, onset of. 132
frozcn shouldcl' and. 109 305f-306f, 305-306,315-316 types of. 133-134
refen-cd pain in, 110 cJ"Oss·�ectional vicws of. 97f palpation in. 140-141
shouldel'-hand disordcrs of. differential diagnosis physical sign� of ncural tis';lIc
Ccrvical faceljoint itTitation of, 118 involvemcnt in. 134-135
ca::;c study on. IIS-124 facilitated segments in, 105-108 self-treatment and managcmcnt in,
ccrvical disc disease and, 112 compared to nonnal �egments. 143
distraction techniqucs in, 121. 122f. 105-106, 10M, 107, 107f lcnderpoint� in, 140-141
l23f effects on nervous system. 108 t,'catmenl of. 141-143, 148f.
evaluation of, 112f. 112-113, etiology of. 106-107 150-151
118-120,119f in frozen shoulder, tcslS in cvalua Cholccystitis. rcfcn-cd pain from,
fncc! joint blocks in, 113 tion of. 264-265 325-328,32M,327f
posture in. 100-101. 10If mechanoreceptor' S in Chronic fatigue svndrome. refcn-ed
refcn'cd pain in, 111-112, 112f, 121 inhibitory. 106-107, IDS pain from. 330
treatment of,12lf-12Sf. 121-124 typcs of, 98 Circulation
usc of pain chal1s in. 133 pathology of impact of mvofasciallllobilil.ution
Cervical fascia rnyofascial neck and shouldcr 011,385
anatomy and function of. 96 pain in,105, 10Sf in thoracic outlet syndromc. 154,
scm1'ing of,in thoracic oUllet syn shoulder symptoms and. 161, 1631",
drome. 159, 161 110-116 in uppcr quurtcr. 163. 163f
Cervical lateral glide technique, in in tendinitis, 109 Clavicle
treatment of neural tissue. 14Sf refcrTcd pain from. 59, 60t in acromioclavicular joint. 10. lOr.
Cervical muscles relationship to shouldel' 13
cieclronlVographv of, in brachial biomechanical, 99-100, 100f fr.lcturc:o. of. 448. 448f
plexus injuries. 195 musculoskeletal. 97-98 brachial plexus injulies in. 185.
response to dv�function,69t, 73 ncurogenic. 97-99 191, 192, 193
IN 0 E X 481
r.ldiographv in,449f. 450f Coracoacromial arch predispositions to trauma and, 58
rehabilitation in,448 abrasion of.in rotator cufT tcm�. 435 range of motion tests for, 65
mobili/.ation techniques involving, relationship of osseous structures in thoracic outlet syndrome.
359-360.360f to.436f 164-166
movements of, 10, 1 0 f Coracoacromial joint, in rotator cuff Decompression. acromial. 231-232
crankshaft effect i n , 1 3 tears Deep venous thrombosis. risk fac to�
in stcl'11oclavicular joint, 1 3 decompression of, 439 for.311
in thoracic outlct �yndl"Omc, 157 osteoarthritis of. 435, 437f Degenerative changes
Closed-chain c:(crcise Coracoacromial ligamcnt, position of, in rotator cuff.235
in impingemcnt �yndromc, in subacromiul space. 230f in supraspinatu� tendon. frol.cn
246-247.250 Coracobrachialis musclc.in musculo shoulder in, 258-259
in postoperative management of cutancous nerve palsy, J 17-1 18 Deltoid muscle
instability,431 Coracoclavicular ligament. anatomy in abduction of shoulder, II, 1 2 ,
in rotator cuff rehabilitation, 289 of. 1 0 1 2 f. 1 3 f
Clunk te�t,79f,8 1 Coracohurneral ligament anatomy of.9
Coban elastic wrap. for edema in anatomy of.8 in axillal) , nerve pab.v. 1 1 7
brachial plexu� injuries. 198 in frozcn shouldel', 259. 273 i n impingement syndrome. 238
Codman exerci�es in fr07.cn shouldcl', in stabilization of glenohumeral manual muscle testing of. 285
272 joint, 7,8 rotator cuff muscles and
Cold applications Coracohumcral space. in impingemcnt in etiology of tcars.283
following isokinetic exercise,409 syndrome. 230 force couple With. 13f. 287,287f
in fnnen shoulder. 267. 269 Coracoid process of scapula in stabilization of glenohumeral
in impingement syndrome.236. fracture of.449, 451f joint. 9. 1 2 . 1 4 . 370.422
239.240. 376 in throwing injlllies of shoulder, 27 strengthening exercises for,
in rolator cuff rehabilitation. 293. position of. in subacromial space. 369f-371f. 370
295 230f tests in evaluation of. 82-83,83f
in tendinitis. 379 Cords of brachial plexus.179.180 in throwing movements, 19. 20, 2 1
in throwing injuries of shoulder, 24 injLII)'of, 185- 1 86 in injur'ed athletes, 2 1
Collagen changes in immobilization. Costoclavicular ligament.anatomy of, 9 in total shouldel' replaccment
346.386 Costoclavicular syndromem, in postopel11tive excrcbes for, 47 1 f,
frozen shoulder in. 258.270 brachial plexus injLII'ics, 188 472f. 475. 476
Colon and large intcstine. rdelTed Costostcmal joint, 2f strength and function of, 462, 463
pain from.329 Costovel1cbrai joint.2f Diabetcs mcllitus, in frozen shoulder.
Compression testing, in cervical spine Crankshaft effect in rotation and cle 263
disorders.110. lllf. 1 21 vation of clavicle.13 Diagnostic bias ror upper qual1cr pain
Compressive impingement. See Creatinc phosphokinase (CP) syndromes. 1 3 1
Impingement. primary anaerobic capacity and, 365, 366 Diagonal movement pattcm3.in i�oki
Computed tomography (Cf) in strength training. 365-366 netic exercise.368, 402.
in cervical spine disorders. I I I . 1 1 3 . Cryotherapy. See Cold applications 403-407. 404f-405f.407f. 417
116 Cumulative trauma disorders (CfO). in brachial ple�us injuries. 1 99-200,
in in�tabilitie� of shoulder, 423 See also Trauma 201
Concentric exercise ergonomic solutions to, 1 01f, 1 03f. Diaphragm
in strength training.367.372.380 104 afferent nelve3 from, convergence
in throwing injuries of shoulder,25 etiology of. 1 02-103 of.306. 306f. 315-3 1 6
Conduction velocity tests. nerve.in pathophysiological issues in, 1 6 1 - 1 66 referred pain from.306-3 1 0 .307f,
brnchial plexus injuries.195 in thoracic outlct. 153-177 3 1 0f
Congenital abnomlalilies in gleno treatment failures in. thoracic outlct diagnosis of. 306-307. 309.310
humeral jOint, 462 dysfunction and.157 pneumoperitoneum and,
Connective tissue. See Myofascial tis Cutaneous tissue, palpation of, 309-3 1 0.310f
suc� 140-141 symptoms of. 306.307f. 309. 310
Conoid ligament, anatomy of. 1 0 Diathelmy in fnnen shoulder. 267,
Coordination 268
in brachial plexus injuries D Diet.in cervical spine dbordcrs.
evaluation of.192.196.202 122-123
improvement of. 200 Daily living activities Discography,in cervical spine disor
in cervical �pine disorde�. exercises in brachial plexus injuries, 193. 196. ders. I I I . 1 16
for. 1 22. 125f 199 Dislocation of shoulder. See also Pro
in hcmiplegia.205-207. 209. limitations in, as indication for total tective injudes
2 1 6-223 shoulder replacement. 461 axillary nen'e injury in. 1 86
482 IN 0 E X
Gender differences. in thoracic outlet dynamic,8-9, 12-13,23.279. Hands·up test,in thoracic outlet syn-
syndrome. 166 287-288,422 drome. 171
Gilcre�l sign lest,82-83. 83f stalic, 5-8,6f,7[' Sf.23. 422 Hawkins sign leM,22
Glenohumeral joint. 1. 2r in thoracic outlet syndrome,hyper Headache. posture and. 100
in abduction of shoulder. forces in. trophy of.157 Head position
11-14, 12f, 13f in throwing injuries. 9,22 and body posture,60-61,100-102,
anatomy or. I. 5-6, 6f in throwing movements, 19-21 10H
3rlhrokincmalic mOlion at,3-5,4f,8 of injured athletes, 21-22 in cumulative trauma disorder,103
cictclminanls of, 344.345 Glenohumcralligamenl.s Healing of fractures,slages of. 447
restoration of. 288 anatomy of. 6 Heart disease. See Cl.ll'diac disease
r01310r's cuff [unction in. mobilization techniques involving, Heat applications
287-288 344 in frozen shoulder,267,268, 269
c�lpsular pattcm of restriction in, in range of motion teslS,68 in impingement syndrome. 375. 37M
67-68 in stabilization of shoulder,6-7, 7f. Hematoma formation in fractlll'es of
capsule.&e Capsule, of gleno 8r.13,421.422 shoulder girdlc,447
hurner...1 joint Glenoid fossa Hemiplegia, 205-226
canilage of, 6 anatomy of. 5-6 alignment of shoulder girdle in
dislocation of. See Dislocation of in stabili1..3tion of glenohumeral in trealment program. 217, 220.
...houlder joint,6, 12f 224,225
in lIexioo of shoulder. 3 Glenoid labl1.lm and weight-bearing,218. 226
in frozen shoulder. 266 anatomy and function of. 5-6,421 biomechanics of shouldel' in,
in hemiplegia anterior capsular rcconstl1.lction of. 205-214
lo�s of mobility, 206-207. 213 24,27,426,426f etiology of. 205
subluxation of. 207,207f. 208f. secondary overload on,241 grasp pallems in, 223
209f-213r. 209-214 tears in loss of muscle control in,205-207.
in humerus fTacturcs. 452 detection of,79f,80f,81 209,212
innervation of, rcfclTed pain and. load and shift test for,423 trcatmenl of,206,207, 216--223,
59 rOLator cuff pathology and,282 226
in isokinctic exercise,positioning undcrlying instability and,242 muscle ::otimulation techniques in,
of,402-403,410,417 throwing injuries of,22, 23, 241 221
join! play motion!'; of,266 in throwing movcments,22 neuromuscular deficits in, 216-223
mobili/.alion techniques involving, Gliding motion open·ended (non-weight·bcaring)
347-354,348f-353f of acromioclavicular joint,354-355, activities in,219-223.
Illu!,cles of 355f 222f-223f
anatomy of,6,8, 9 of humCius. See HUIl1<::rus,gliding place and hold activities in.221
functional categories for,370 motion of posture in. 206. 209, 209f,211f,
peak torque of. 2-3 at joint surfaces,3,4[,11. 13 211-212, 212r.213,213r. 217
in stabilization of joint. 6-7,8-9, of sternoclavicular joint, 354,354[, range of motion in. 226
15,279,422 355f reeducating distal movements in,
..trengthening exercises for, Glycogen. in strength training,365-366 223
369f-374f,370-371 Glycosaminoglycan levels secondary complication:'> in. 223-226
svnchronous activity of. 370. 373 in frozen shoulder,261, 270 shoulder·hand syndrome and, 216.
oslcokinematic motion at,2-3 in immobilization. 346. 385,448 324
palpalion of.741,75 Goniometric measurement,284--285, shoulder pain in,214-216. 220
PCI;;:\llil.:ula.- structures of 285f rrom altered sensitivity,215-216
anatomy of,6 Grasp pallems in hemiplegia,223 in joint. 214
extensibility 0[,4 Gravity eliminated motion,in total in muscle. 214f. 215, 21Sr
in stabilization of joint. 6-8, 10, shoulder replacement,466f, in shouldel'-hand syndrome. 216
11f,422 473 in sublll'C3lion.209
popping 01' clicking of. SLAP lesions ""aunenl of,214,215,216,224-226
and,23 in weight-bearing, 214. 214f. 215,
in range of motion tests,63,64,64[, H 215f
284-285,285f sof1 tissue blocks 10 motion in,
rebTcd pain 10, 319 Hands 206-207,207f,209
in scaption-abduction of shoulder. 3 in hemiplegia,grasp paltems of. spasticity in,206,212. 215,218.
stabilitv or. 3,6-9,10,11 r. 370. 371, 223 220,226
373. See also Stability of in mobili7..nion
' techniques. position sublw(ation of shoulder ill, 207.
shoulder or.346-347,472 209-214
anatomic. 421 protection of. 387-388 a�iIlarv SUPPOl1 for,224.225f
tN 0EX 4&5
treatment of �houlder problems i n . Humeral ligament. tranwerse, t�ts i n size of head i n relation 10 glenoid
2 1 6-226 evaluation of. 85f. 86 fossa, 5
type I ann i n , 209. 209f. 2 1 0f. 2 1 1 Humero�apular periar1hritis. 257 in throwing movements. 20, 2 1
tvpe I I aml in. 2 1 I f. 2 1 1 -2 1 3 . 2 1 2f l-Iumel1Js Ilvaluronic acid levels i n frolen shoul,
tvpe III �lIm i n . 2 1 3f. 2 1 3-2 1 4 anatomy of. in glenohumeral joint. der, 2 6 1 , 270
weight-bearing activities in 1 , 5, M I-I"\'perabduction of a11m., in thoracic
and shoulder pain, 2 1 4, 2 1 4f, 2 1 5. dissociation from scapula i n hemi· outlet syndrome. 170- 1 7 1
2 1 5f plegia, 207, 209 Hvpere1asticity with impingement
in treatment program, 2 1 5, 2 1 6. dist raction of. i n mobilization tech· position in instability continuum.
2 1 M, 2 1 7-2 1 9 , 2 1 8f-222r. 226 niques, 350, 3 5 1 f 243
Ilepatitis. rdclTCd pain from. 324 in external rolation of shoulder. i n throwing injlllies of shoulder', 22
I lcrpcs /.Oster positioning of. 472 Hvperextcnsion of humeru�, in hemi·
acth'e movemerll dysfunction in. fractures of, 449-455. 451 f-456f plcgia and tvpe II arm. 207,
1 36, 1 37 case stud.v on. 453-455, 455f. 2 1 1r. 2 1 1 -2 1 2, 2 1 2 f
referred pain in. 134. 1 3 6 45M Hypermobility o f shoulder, 6 8 , 72
shoulder-hand syndrome and. 324 in greater' tuberosity, 450. 4 5 1 f . 1I)'pomobilitv of shoulder. 68, 72
lIi11·Sachs lesion. detection of. 423 45lr
History taking i n neck, 450-45 I , 45 I f, 452f
in brachial plexus injuries. 1 89-1 9 1 . radiography of, 452f-456f
1 96, 201 rehabilitation in. 4 1 4- 4 1 5 .
i n evaluation fOI' visceral disease. 451-453, 454-455 Icc applications
299-300, 30lr-303f in shan, 45 1 , 45 I f, 454f following isokinetic c'\:crc isc. 409
in frol..e n �houlder. 264 total shoulder replacement i n . in frozen shoulder, 267, 269
in impingement syndrome. 239. 468, 470 in impingement 'iyndrome. 236.
2 5 1 252 gliding motion of 239, 240, 376
information collected during. in abduction of shoulder. 4f. 4-5, i n rotator cuff rehabilitation. 293,
57-58 1 1, 13 295
i n in�tabilitic� of �holiidcr. 422 anterior, in mobilization, in tendinitis, 379
i n myofascial cvaluation, 386 350-35 1 , 35 1 f in throwing injulies of shoulder, 24
in nonproteclive injuries, 342 anterior/posterior, i n mobiliza Iceland di!>e3SC, refen-ed pain from. 330
i n paticllI interview, 57-58 lion, 3 5 1 -352, 35lr Immobilization
i n protective injuries. 337 inferior, i n mobiliz
..
l lion. 347-349.
: collagen changes in, 258. 270, 338,
�elf-admin istered questionnaire in. 348f-349f 339, 385
300, 302f-303f posterior, i n mobili7.3lion. complications from, 344-345, 448
in thoracic outlet syndrome, 349f-350f, 349-350 in fractures of shoulder girdle.
167-168, 1 7 5 i n rotation of shoulder, 4(, 353f, 447-448, 453
i n total shoulder replacement. 459 353-354 of clavicle, 448
Hobby and leisure activities in grcater tuberositv of of humerus. 450, 45 1 , 452
brachial plcxu� injudes, 193. fractul-cs of. 450, 451 f. 452f of scapula, 448. 449
195, 198, 201 impingement undcl' acromion. i n frolcn shoulder i n , 258, 2 6 1 , 270
Holmium VAG laser cap�ulorraph". i n hemiplegia, 207, 207f glycosaminoglycan levels in, 346. 385
instabilitie� of shoulder. position of. in subacrom ial space. impact on myofascial tissue, 385
428-430 230f passive mo\'cment following, 336.
Ilome exercise programs in rOtator cuff disease. 437 338-339
in clavicle fracture�, 448 hvperextension of. in hemiplegia periarticular tissue and muscles in.
in frolen shoulder. 2 7 1 . 272 and type I I aim, 207, 2 1 1 f. 447-448
in humerus fractures. 4 1 4. 4 1 5 . 454 2 1 1-2 1 2 , 2 1 2f i n rotator cuff rehabilitation. 292
in postoperative management of .,
periarticular structures i n stabiliz.
\· I m pingement-in�tabilitv complex. See
instability, 43 1 , 433 lion of. 6-7. 7f, I I also Stability of �houlder
in rOiator cuff tear,.,. 4 1 6 - 4 1 7 i n range of motion tc!o>ts, 64 classification scheme i n , 240,
i n !teapula fractures, 449 retroversion of. 5, 6f 242-243
in throwing injuries of shoulder. 25 rolling motion of, in abduction of in throwing injuries of shoulder, 22
Hooked (or tvpe I I I ) acromion shoulder. 4, 4f. I I . 1 3 Impingement syndrome. See also Non
proces!o>. predi�po!o>ition to rotation of protective i njuries
trauma from, 58 i n abduction of shoulder. 4-5, acromion i n . 230f-232f, 2 3 1 -232.
Ilornel'\ syndrome. 1 8 1 . 1 8 5 , 190, 1 9 1 . 6-7, 7f, 8, 8f 234f-235r. 235, 238
201 in hemiplegia, 2 1 8. 2 2 1 f age relationships in
in brachial plc'\:u� injur-les, J 1 6 i n rotator' cuff pathology. 284 in rotutor cuff degeneration, 235
i n Pancoast tumor, 3 1 1-3 1 2 and scapulohumeral rhythm, 1 0 stages of pathology, 2361
486 IN 0 E X
Impingement syndrome (COIl/iuued) in tensile overload, 241 -242 Lnhibition technique� in hemiplegia,
in athletes. 232, 237, 240-253 tests in evaluation of, 242, 286-287 221
case study on, 374-378 in throwing injudes of shoulder, Innervation o f shoulder muscles,
diagnosis of 22, 26-27 brachial plexus in, 99, 1 79.
painful arcs in, 63, 64, 236, 239 treatment of. 252-253 1 80, 1 80f, 1 8 H
size of subcoracoid space in, 230 underlying instability in. Instability continuum. See a/�o Stabil·
with underlying instabili ty, 243 242-243, 28 1 ity of shoulder
evaluation of, 235-236, 2361, 237, undersurface rotator cuff tears classification scheme in, 240.
238, 238f, 239, 243-244, and, 282-283 242-243
252-253, 286-287, 375 spasticity of muscles in, 236. 237 in throwing injuries of shotlldel� 22
glenohumeral joint in stretching and strengthening exer Instability-related impingement. See
3lt hrokincmatics. 23 1 , 2 3 1 f cises in, 237. 237r. 239, 240, Impingement. secondal),
force couple at, 232-233, 233f, 237 243, 245f-249f, 245-248, 369f, lnterclavicular ligament. anatomy of. 9
rehabiliLation of stabilizing mus· 3 7 1 f, 373f-374f, 375-378, Intel-rcrential stimulation, in impinge
cles in, 244-245, 249-250. 2 5 1 f, 376f-377f ment syndrome, 236
252f, 253, 288-293 subacromial space in, 229-230, 230f Intervertebral forumen, injmv of nClve
in hemiplegia. 207. 2 1 4 subcoracoid, diagnosis of. 230 rOOI S aI, 1 49r. 149-150, 183,
inside o r undcrsUiface tears in, 283f surgical options in. 239 183f
muscle imbalances in, 73. 232-233, tests in evaluation of. 24, 77, 80f, Im'el1.ebral foramina
236, 287 8 1 f, 8 1 -82, 2 3 1 -232, 232f, 242 anatomy of, 97, 97f. 98, 1 60f, 1 6 1
posture and. 233 in throwing injmies of shoulder, 22 doorbell test of, 1 1 3
neuromuscular retraining in. tests in evaluation of, 24 posture and, 1 0 1
249-25 1 throwing movements in, 2 1 Iontophoresis treatment, 379
pain in, reproduction of. 436f i n total shoulder replacement, Lnitability le\'els
pathology of 461 -462 in passive range of motion lests,
cxtdnsic factors, 2 3 1 -234 treatment of, 236t, 236-237, 237f. 65-66
inldnsic factors, 234-235 2371, 238, 243-250, 2 5 1 -253 predictive value of. 57, 59
slages of, 235-239 I mpingement tests Irritable bowel syndrome, refcn-ed
pol:llure in, 233 crossed illm adduction, 286 pain from , 329
precipitating factors in, 233-234 Hawkins and Kennedy, 81 f. 82, 286 Isokinetic exercise, 401-417
predisposition to, 6 1 , 234-235 Neer, 8 1 r, 82, 23 1-232, 232[, 286 abduction/adduction ratio in, 4081,
pl'imary, 235-239. 236t Impulse Inertial Exercise System, 250, 4 1 1 - 4 1 3, 4 1 2 1
case study on, 239-240 252f advantages and disadvantage� of,
in etiology of rotator cuff pathol InOammatory stage in healing of 401-403
ogy, 280, 435 shoulder ginilc fractures, 447 blocking of movements in,
evaluation of. 286 Infraclavicular brachial plexus 409-4 1 0
position in instability continuum, injulies, 184, 1 85. 188 i n brachial plexus injUl;es, 192,
242 Infrahyoid muscles, anatomy and 1 99-200, 201
.Iage I, 236-237, 239-240, 280 function of. 96 case studies on, 4 1 4-4 1 7
S1age II, 237-238, 280 Infraspinatus muscle nnd tendon compared to isotonic excrcise, 40 I ,
S1age III, 238-239, 280 in abduction of shoulder, 5, 1 1 . 1 2 , 402
in throwing injuries of shoulder; 22 1 2 f, 1 4 concentric training in, 372
treatment of. 236t, 236-237. 237f. in brachial plexus injuries, 197. 200 cryotherapy following, 409
2371, 238, 280-281 manual muscle testing of, 285 diagonal movement pallel1lS in,
upper surface rotator cuff teaf'S in scaption of shoulder, S 368, 402, 403-407, 404-405f,
and, 435, 437f in stabili7.ation of shoulder, 7, 1 1 . 407f, 4 1 7
primal"V versus secondal),. 229, 14, 370, 422 in brachial plexus injuries. 192,
243-244 strengthening exercises for. 29. 29[, 1 99-200, 201
secondal)' 30r. 369f-37 I f, 370, 47H eccentric tmining in, 372
case study on. 25 1-253 in suprascapular nerve palsy, 1 J 7 equipment used in, 40 1 . 402. 403,
classification of. 240 tears in, anatomic description of, 282 410
diagno�lic difficulties related to. in tensile overload, 24 1 , 242 extemaVinternal rotation ralio in.
243 in throwing movements, 20, 2 1 408, 4081 , 4 1 7
in etiology of rotator cuff pathol in injured athletes, 2 1 normative data on, 408, 4081,
ogy, 2 8 1 , 435 injury of, 22 4 1 1 - 4 1 3, 4 1 2 1 , 4 1 7
evaluation of. 243-244. 252-253. in professionals versus amateurs, i n fracture!lo of shoulder girdle, 453,
286-287 21 455
rehabilitation issues in, 243-250 strengthening cxercises for. 29, frequency of. 411
surgery in. 242-243 29f, 30f general considerntions in. 4 1 0-41 1
IN 0 E X 487
in impingement :-.yndmmc. 376. concentric and eccentric training in. Lateral glide technique, in t1-eatmcnt
377, 377[ 367, 380 of neural tissue. 142. 1-I8f
maximal crrol1 in. 40 1 . 4 1 1 in impingement syndrome. 369f. Lateral slide test. 70f-7 1 f. 73. 75. 232
mu�le loading in. 40 1 . 402 37 I f. 373[-374[, 376, 377, 377[. i n assessment of scapular posilion, 61
eccentric. 368. 402. 4 1 0 378 Latissimu:, dorsi muscle, 3
rrequency o f training and. 368 in pobloperative management of in abduction of shoulder. 1 2. 1 4
negative respon!>C to. 409 inblability. 43 1 . 432. 433 anatomy and function of. 95-96
in nonprotcctive injuries, 343 in rotator cufr rehabilitation. 289. in stabilization of shoulder. 8. 370
po�itioning of glenohumeral joint 294, 295 strengthening exercises for,
in. 402-403, 4 1 0, 4 1 7 in strength training, 367. 372 369[-37 1 [. 370
i n po�lopcrative managemenl of in tendinitis. 369f. 370r, 373f-374f. in throwing movements. 20, 2 1
in�tabililv, 43 1 , 432-433 377[, 379[, 379-380 i n injured athletes, 2 1
progression of. 409, 4 1 1 in throwing injuries of !;houlder. 25. i n profeSSionals versus amateurs,
propriocepti\'e neuromuscular faeil· 29[-36[, 29-5 1 21
italion in, 403 L:
lxitv of capsule. 6. 1 0
..
Magnetic resonance Imaging (MRJ) Mixed spinal n('I"\-'e, anatomy of. 97. Mu�les. See al.m VJeCI'/i(: ullI_\('le
(Cot//iuued) 97f. 98 i n abduction of shoulder. 2·3.
gadol inium-enhanced, 424 Mobilitv of shoulder. 1 I l f- 1 3f. 1 1 14
in in�t�lbililic� of �houldcr, 423-424 a�
'i essment of. 6 1 -·72. 88-89 i n brachial plc:(us injuries
in rotator cuff tcal"�. ·US. 438f !.Capulohumeral movement in, 10. coordination of. 192, 1 96. 202
Maintenance program� 1 2. 1 3 "renglh of. 1 9 1 192. 194-1 95.
in impingement :.vndrome. 378 ..
Mobili71tion techniques. 335-363. See 196. 199-200. 20 I . 202
�lrc"glh training in. 369-370 also Joint mobilization; complicationlo rmm immobili/ation
Manipuhllion technique!. M"'ofascial mobili7..ation in. 344-345. 346
under anc"Ithesia, 273, 336 under' anesthc"iia. 273. 336 conlrol of
in cClvica! ..pinc dbordcrs, 1 2 1 , 1 2 3 f biomechrmical effcct of. 346 in brachial plc'(u, injuries, 192.
(:ontraindicalion:. for. 346 bodv mechanics in, 347 1 96. 202
definition of. 336 in brachi'll plexus injuries. 198. in hemiplegia. 205-207, 209.
in fro/cn ... houlder. 267. 270-272. 1 99--200 2 1 6-223. 226
2 7 1 1 . 272-273 in complications of immobilil.alion, evalualion of
Manual musdc tC'sting. 691. 72-73 344-345. 346 for almpl1'\>'. 60
in rOialOl' cufr pathology, 284-286. contraindications for, 1 3 5 - 1 36. 346 manUal lC"i1S for. 691. 72 73
285f definition of. 336 ror mobilit\'. 387
Manual (herap,- technique:., 335-363. direction of movcment in, 347 mvofascial. 386-387
Sec llho \pecific tcchnique duration and amplitude in. 347 rcsiloli\'C lesl, for. 7 1 1 ·721. 72
Ma!:>';agc. Set' al.m Mvofascial mobi in fracturc"i of shoulder girdle. 448 fiber IYpes in. 366
li1'<'
1 1 iol1 of claviclc. 448 in thoradc outlel wndrome. 1 59
in brachial plc)ttl!) injuries and of humerus. 45 1 . 452-453. 454, of glenohumeral joinl
edema, 198 455 anatomy or, 6. 8. 9
III c(,l"Vical .!opine diM)rdcn;, 1 2 1 of scapula. 449 in stabili/.ation of joint. 6·7, 8-9
i n (nuen ,houlder, 270-27 1 frequency of. 344 i n hemiplegia
�condarv effects of, 385 in fro7en shouldec 267. 270-272. pain in, 2 1 5
Mcchanorcccplors in celvical spine, 98 2 7 l f. 272-273 I"eCnrilmenl of. 206, 206f. 2 2 1
Medial and lateral pectoral nen'e goals of. 346. 355 'pa,m, of. 206. 2 1 2. 2 1 8. 220. 226
palsy, 1 1 8 hand posilion in. 346-347 spasticity or, 206. 2 1 2. 2 1 8. 220.
Median ncn;c in humcl1.1s fractures. 4 1 4, 4 1 5. 452 226
injUN of. 185 fOI' hypomobililies. 68, 72 slimulation or. 2 2 1
most lengthent-d position or. 1 37 in impingemenl syndrome. 237, hVpel11'ophy of, enduran<':c and. 365
palpation of. 1 40 237f. 375 in impingement 'wndrome
palsv of. 1 85 for glenohumel-al joint capsule. imbalanccs in. 232-233
provocation tC'it via. 1 3 9 237. 238 spa<;ticilY of. 236. 237
Medical c:(erci...e therapy ( M ET). improper lI..'C hniquclo in. I SO- I S I .,trenglhening c'(erciM's for. 237.
121 122 indication"i for, 66 237f. 245f-249f. 245 248
MCI-algia parae..thetica. radicular pain in neurnl ti"ilouc, 1 4 1 143 .,Ircnglh or, 236
in. 1 34 neurophysiologic effeu of. 346 in i-.okinelic c'(crci\C
Metabolism, aerobic and anaerobic. in nonproll..'Ct iv'e injuriclo. 341 ·346 eccentriclconcentlic torque ratio"i
366 principlc!ot of. 346-347 in. 4 1 3
Metacarpalphalangcal joint, referred in protectiH� injuries, 336-341 loadmg of. 4 0 1 . 402. 4 1 0
pain in. 3 1 9 in rotator cuff tear.., 288. 293. 294. Icnglh-tension ,-dationship in. 2 ,
M icrotrallma 295. 296. 4 1 6. 439. 441f 366
caS(' slUdv on, 86-91 "icapuiothorncic mobilil.ation le\:hniquc.. for.
defined, �7 in impingclllt'nt syndromc. 375 344-345. 346. 355-362
head JX)stllfC and. 6 1 . 103 in !otcnpula rractures. 449 morphological relationships of. 95
histolv wldng for. 58 in thoracic out lei svndmmc. motor nen'e inncl'vation"i of.
in overhead "
. POI1.S, 242 172f-173f. 1 7 3- 1 74 1 1 4f 1 1 51
repetltlvt' fOI, trigger poinls. 37�. 379 phasic \'e....u"i
.. poStlll-a1. 691. 73. 386.
in cumulative trauma disorder. 103 IVPC of force u!otcd in. 344 3861
in primalY' tensile overload, 2 4 1 Motor nervc!ot. mlllocJes i n nen'ated by, reeducalion of
MilitalY' position. e:(aggermed, i n tho 1 1 4f I I Sf in brachial plc,(lIlo injurie"i.
racic outlet wndrome. 170 Movement 199 200
Militar. pres... i n (''(crcise program for at joint surfaces. t.vpelo of. 3-4. 4r in rro/en shou lder, 272
throwing injurics. 33. 36. 36f ph\'''iiologic benefil of. 1 50 in hemiplcgia. 206. 2 1 6. 220--2 23,
M i nor causal�ia. referred pain from. planes of, 1 222f-221f. 225. 226
123 124 Muitiple cnrsh wndrome. 1 53. 1 66, 167 in pmt('. (:ti\C mjuric... 3W
tN 0 E X 489
rene'\; activity of. pain and. 1 36. 150 subscapulalis techniques. 390f. Neural tbsue evaluation and treat
rc!oopon�e to nerve trunk stimulation, 391 ment, 1 3 1- 1 5 1 . See al.m CClvi
1 4 1 . 1 4M. 147f thoracic laminar release. cobrachial pain syndrome
in rotation of !.houldcr. 6-7. 7f. 8. 3 9 1 -393. 392f Neurodynamic testing. in thoracic
12. 1 3 upper thoracic region elongation, outlet syndr'Ome. 169-1 70, 1 7 6
i n �aption of 'ihoulder. 2,,3 388. 388f Ncurologic dbeases. i n shoulder dvs
of 'icapulothoracic joint, 1 0 , 1 1 f Mvofascial tissues function. 109- 1 1 0
'ikelelal. c1a,;')irication of. 69t. 73 classification of, 384-385 Neuromuscular deficits i n hemiplegia,
of �ternoclavicuJar joint. anatomy components of, 383, 3841 treatment of, 2 1 6-223
of. 9 in fractures of shoulder girdle. Ncuromu,;cular retraining
in 'itrcngth training. adaptations of. immobilization affect i ng. equipment lI'ied in, 250. 2S I f, 252f
366. 372 447-448. 453 in impingement syndrome. 249-251
MU'iculocutaneous nen:e injUl"'l'. 1 84. in hemiplegia. as block.'> to motion. Neuropathies. in shoulder dysfunc-
1 85. 1 87-188 206-207. 207f. 209 tion. 109- 1 1 0
pah\ in. 1 1 7· 1 1 8 histology of. 383-385 Neuropraxia of a.1(iIlal), nerve, 1 86
MlI'iculo�kelctOlI injulic'i. brachial impact of imlllobili7.ation on, 385 Neurovascular entrapment. 1 53-154
pkxu� injuries as complication in impingement syndrome. mobi, Nonprotecti\"e injulics
of. 187-188 lization and stretching of. 237 evaluation of. 342, 342t. 343, 345
MU'iculotcndinous dysfunction. a.':>M'SS pain in. lOS. 1 05f. 386 examples of, 3 4 1
ment of. 69f-70f. 7 1 1-72t. three-dimensionalil".v of, 383 rehabilitation for
72-75. 82f-85f. 82 86. 89 Mvokinase. anaerobic capacity and, case study on. 3 4 1 -346. 342t, 343f
M\'elograph\ in cervical !'opine dbol' 365. 366 phases of. 345t
dCI";. 1 1 1 . 1 1 6 Mvopathies in shoulder dysfl.lnction. Nonsteroidal anti-innammatorv drugs
Mvocardial b.chcmia. rdcn"t.'CI. pain 1 10 (NSAIDs)
from. 3 1 M. 3 1 6-317. 3 1 8f in impi ngement syndrome. 236
Mvofascial dysfunction po!oo tviral fatigue syndrome (PFS)
in brachial plcxu'i injuries, 192. 197 N and. 330
in workel'"!<.. 103 Nutrition, in cClvical spine diM>rdel�,
Myofascial mobili;
..
mion, 336. 355-362. Neck of humerus, fractul'cs of. 1 22-123
Set' also Joint mobili;.3lion; 450-4 5 1 . 45 l f. 452f
Mobi l i;
....
"ltion techniques Neck pain. See also Cervicobrachial
ca,;e study on. 397-399 pain syndrome o
in cervical !'opine disorders, 1 2 1 mvofascial, 105. 1 05f
definition of. 355. 383 relationship to occup:ltion. Observational examinal ions. compo
goals of. 355 1 0 2 - 1 04 ncnb of. 60--6 1
h,lOd treatment techniques in, 356t syndromes related to, 104-105 Obstructive bowel disease, l'CfclTed
intcrrclation'ihip with joint mobi- Neer impingement test, 81 f. 82, pain from. 329
liJ".alion, 383, 384f 23 1-232. 232f. 286 Occupation
in nonprotective injul'ic'i. 345 Neer' !oo ign test, 22, 423 and cumulative trauma di'iorcier,
patient-therapbt positioning dur NeeI' Slage!:> of impingement, 236t 1 0 1 f. 102-104. 1 03f
ing. 387 Neer unconstrained shoulder prosthe- and return to \vork i n brachial
prolt'ction of hands and joinb in. 'is. 459. 462. 464 ple.xus injuries, 193. 201
387-388 Nephritis, referred pain from. 328 and thoracic outlet syndrome.
in pl"Otective injuries. 339, 341 Nelves. See al.)o Cervical nerves; 1 6 4 - 1 66
to reduce Irigg('I' points, 375 Peripheral nelves Occupational therapy in brachinl
..
econdarv dfech of, 385 in brachial plexus. 1 80-- 1 8 1 plexus injuries, 1 89. 193, 195.
technique'i in. 388-397 conduction velocity tests. in 200
anterior fa'>Cial elongation, 39 1 . brachial plexus injuries. 195 Omega-3 fattv acids. sources of. 1 2 3
392f examination of, 59, 60t Omohyoid mu!ooc lc. anatomy and func-
cf"O!'>.,;-friclion
. of 'iupraspinalus and at intcr\"el1ebral foramen, features tion of. 96
bicep!<. tendon, 396--397. 397f providing protection from Omohyoid wndrome, 104
exten'iibilitv increa!<>e, 344, injuries. 1 49f. 149-150. 1 83. Open chain exerci�, 246-247. 250
355-362 1 83f Open-ended (non-weight-bearing)
pectoral and antelior fOl'icial palpation of. hvperalgesic responses activities in hemiplegia.
stretche'i. 395-396, 396f to, 1 40 2 1 9-223. 222f-223f. 343-345
pectoral mu!oocle pia\". 388, 389f Nelvous system injuries, pain Open recon�tnlctive surgery
!:>capular' fnlllling, 393. 393f-394f response to, I SS. 1 57 anterior capsular shift, 24. 426. 426f
scapular mobilization. 393, 395. Neural adaptations in strength train rehabilitation in. 426. 4 3 1 -433
395f ing. 366. 372 Bankhal1 repair. 424-426, 425f
490 I N0EX
Dlx:n reconstructive surgel)' area and nature of, 1 89 - 1 9 1 in mobility asse��mcnt, 387
(Cont;lIlled) management of. 1 9 6 . 1 9 7 of myofascial structures, 387
compared 10 al1hroscopy. 424 in cancer, causes of, 30 1 , 304 of nerve trunk, 140
indications for. 424 constalll and musculoskeletal, com· in thoracic ouLiet svndrome. 170,
posterior instability rcpail� 426-427 parcd, 59 176
in rolalor cuff tcars, 439, 44 1 . deafferelllation, 304 of upper qual1er stntcturcs. 731.
44 i f-443f. 443 differentiation of local and referred 741, 89-90
results of, 439. 441 problems in. 58, 134-135. 148 Palsy
Oscil kHion techniques, 336 evaluation of. 7 1 t. 72t, 68-7 1 , 83. of cClvical ncrve�, fifth and �ixth.
descriptions of. 3561 84[, 86, 264, 265 1 84
duration in. 347 in frozen shoulder. 257. 261 . 266 E.-bs: 1 84, 1 85, 1 9 1
in mobi l izaL ion , 339, )44 in hemiplegia, 209, 2 1 4- 2 1 6 , 220, of median and ulnar nerves, 1 85
in treatment of I1cuml lissllc. 142-143 224-226 of serratus anterior muscle. t 86
Q:'lcoaI1hl"ilis. lotal shoulder l"Cplacc in impingement syndrome, 236. 239 Pancoast tumor
ment in. 460[, 463. 464, 473 inhibition of. joint mobili/....uion for. "efel1-ed pain and. 3 1 1 -3 1 4
O:,teokincmatics 346 thoracic outlet syndrome in. 1 36,
definition of. I in isokinetic exercise. 40 1 , 4 1 0. 4 1 Ot 1 37
in nexion of shoulder. 3 location of, 58. 59 Pancreas, rcfclTcd pain from. 309.
in scaption-abduclion of shoulder, mapping of. 1 3 3 324-325
1-3, 2[, 3[ myofascial. 1 0 5 , 1 05f. 386 Paralysis. Duchenne·E,·b, 1 84, 185,
Osteonecrosis in neural injurics, 1 34. 1 34f. 1 55. 191
etiology of. 467 1 57 Paravenebral muscle. mobilization of.
10lal shoulder replacement in. 459, in omohyoid syndrome. 104 39 1-393, 392[
46 1 [, 462f. 463, 467-468, 474 pat ient descriptions of. 58 Passive motion
OSlcophytosis. sensory-molor deficits physiology 0[, 1 33[, 1 3 3-134, 1 34[, abuses of, 346
in. 1 1 3. 1 1 3f, 1 1 6 304 in brachial plexus i"jurie�. 1 9 1 . 196.
Overhand athletes projection of. by pcripheml ner'yes. 202
evaluation of rolalor cuff pathology 1 36 restoration of, 198
in, 284-286, 285[ refen·cd. See RcfelTed pain in complications of immobilization.
exercise programs for, 25-26, 53-55 l-eflex aClivity of muscles in, 1 36. 150 346
force couple imbalances in, 287-288 resislance and effectiveness of. 149. 150
rotatOl' cuff rehabili tation in, 288 in frozen ShOllldcl� 269 cnd-feel and, 66
isokinetic exercise in. 290. 290f in passive range of motion tests. evaluation of. 65-68, 66f, 67f. 68f,
surgical techniques for shoulder 65-66 1 38-140, 1 45f. 387
instability in. 424, 429 somatic. 30 1 , 304 in fracl ul-e� of shoulder girdle. 448
Overhand throwing. See (liso Throwing stages of. 263 of clavicle, 448
injuries; Throwing movements sympathetically maintained. 304 of humerus. 4 5 1 . 454. 455
lllu�c1e group� active during. 2 1 syndromes related 10. 104-105 of scapula. 449
i n pmfessionals versus amateurs, in tensile overload. 242 in frozen shoulder. 260. 265-266
21 in thoracic outlet syndrome. 1 55. in exercise program. 269-270.
pain and popping sensation during. 1 57, 167, 1 7 2 , 174, 175 27 1 , 272
23 in throwi ng injuries of shoulder. 22 initabili ty level and. 65-66
in pitching, phases of. 19-21 in total shoulder replacement in mobil ization It'Chniques. 335.
i n r-otalOr cuff dysfunction. 240, 283 as indication, 46 1 . 470 346, See also Mobilil..alion tech
Overuse problems of shoulder dUl'ing l"Chabilitation, 470. 471 niques
in athletes. 240 treatment of. 1 48-149. 267 , 268, in neural tis�uc. 1 4 1 - 1 43, 149. 1 50
in im pingement �yndl'ome. 269, 270, 27 1 , 27 2 in nonprolective injuries, 342. 343
233-234, 236, 240 visceral, 30 1 , 304. See {l/SO Rcfel1"Cd pain and l"Csistance SCQuence in.
throwing injul"ies i n . 1 9 pain, in visceral disease 65-66
i n workcl'S. 240 Painful arc syndrome patterns of restriction� in. 66-68
in frozen shoulder. 265 in poslOpcr"ative management of
in impingement syndrome. 236. 239 instability. 430. 43 1 . 432
p tests for. 63, 64 in protective injuries. 336. 338-339
Palpation. 76 in total shoulder replacement, 462f,
Pain. See (llso Celvicobrachial pain in brachial plex us injuries, 192. 196 463[
syndrome in cervic..'11 spine �crecning. 59 patienHherapist positioning in,
behavior of. 58-59 of cutaneous tissues. 140- 1 4 1 472
in brachial plexus injuries, 1 89- 1 9 1 . deep VCI'SUS supcrlici.tl. 387 in po�Hrnumatic al1hritb. 470
1 92 in frozen shoulder. 266-267 Ir.IlIma
• from, 346
IN D E X 491
Patient contl'Ol, in thoracic outlct syn injury of. 185. 1 86 in lotal shouldcl' replacement.
drome. 1 34-155. 1 57. 1 7 1- 1 72 dysesthetic and nerve lrunk pain 470-474, 475-476
Parient intelview from, 134, 1 34f Post-traumatic anhropathy, in total
assessment of pain in, 58-59 impact on mobility. 1 36 shouldcr replacement, 463.
history taking in, 57-58 sensitized, 136, 1 37, I 38f, 149-150 468, 470, 47 1 , 474
purposes of. 57 evaluation of. 1 37, 139-140, 145f Posture
Pectoralis major muscle, 3 sensory innervation of conncctive assessment of. 60--6 1 , 62f, 87
in abduction of shoulder, 1 4 tissues by. 136 in brachial plcxus injuries. 105, 1 9 1 .
in hemiplegia, 2 1 2-2 1 3 structural features of, 182f 196, 20 1 -202
mobili7..ation technique.!. illVolving Peripheral neul"Opathy. in shoulder celvical spine in. 60--6 1
muscle play in. 388. 389f dysfunction, 109 during elevation of ann, 99- 1 00,
strctching of, 395-396. 39M Peliscapular muscle. mobilization of. 1 00f
nClvc palsy in, 1 1 8 391-393, 392f silting, 100, 1 0 I - I 02, 1 02f
in stabilization of .!.houlder. 9. 370 Personality, in frozen shoulder, 261 standing, 100. 1 0 I f
strengthening exerci.!.es for. Phalen's sign, in carpal tunnel syn i n cumulative tr..l uma disOI'dcl',
369f-37 I f. 370 drome. 167 1 0 i f, 102-104, 103f
in thl'Owing movements, 20. 2 1 Phrenic nerves. convergence with in dorsal scapular nerve palsv.
in injUl"Cd athletes. 2 1 somatic nerves. 306, 306f. 1 1 6-1 1 7
i n profe�sionals versus amateurs. 3 1 5-3 1 6 i n elevation of 3rm, 99-100. 1 00f
21 Physical examination ergonomics and. 1 0 1 f. 103f.
Pectoralis minor mu!>Cle in brachial plexu� injulics. 1 9 1 - 1 93. 1 0 3 - 1 04
mobili7...'ltion tcchniqucs involving. 196-197, 20 1-202 cvaluation of. 60-6 1 . 62f
357. 358f in lotal shoulder replacement, in brachial plexus injuries, 1 9 1 .
muscle plav in. 388, 389f 461-463 1 96
stretching of. 395-396. 396f Pillow �uceze. in excrcise program myofascial, 386-387
nerve palsy in, 1 1 8 for throwing injuries. 50f. 5 1 in rotator cuff pathology, 284
in �tabili7..ation of glenohumeral Pitchers, See Baseball players in thoracic outlet syndrome, 1 9 1
joint, 371 Pilching, See Overhand throwing; in frozen shoulder, 264
strengthening exercises for. 369f. Throwing movements headache and, 100
37 1 , 37 1 f, 373f. 374f Plastic deformation head position in, 60--6 1
Pectoral ncrvc palsy, 1 1 8, 185 mobili7.ation tcchniques in, 344, fOlWard, 100-102, 1 0 I f
Pegboard test of coordination in 347, 348f i n hcmiplegia. 206. 2 1 7
brachial plexu� injuries, 1 92. stretching tcchniqucs in. 375 i n type I arm. 209. 209f
196, 202 Platysma, anatomy and function of, 96 in twe II aim, 2 1 1 f. 2 1 1-2 1 2 .
Pendulum exercise Plyometlic excrcise 2 1 2f
in clavicle fractures, 448, 454 in postoperative managemcnt of in type lIJ arm, 2 1 3 . 2 1 3f
in frozen �houlder� 272 instability, 43 1 , 432 in impingement syndrome. 233
Perial11uitis in rotator cuff I'chabililation, myofascial imbalances and. 386
humero�capular� 257 289-290, 294, 295, 296 nOlmal, alignment of spine in. 1 00,
personality in. 261 in strength training. 367. 373-374. 10If
Pericarditis. refen"Cd pain from. 3 1 7. 380[, 380-381 i n peripheral nerve entrapments.
319 Pneumoperitoneum 1 17
Periodization i n training. 369 creation of. 3 1 0f predisposition to lrauma and. 58
Peripheral nerve entrapment in referred pain to shoulder. 309-3 1 0 sustained, in cumulative trauma
axilialY, 1 1 7 Position of thcrnpist disorder. 103
dorsal scaplllal� 1 1 6- 1 1 7 during elevation of shoulder, 472 in thoracic outlel syndrome
long thoracic, I 1 7 duling mobilization, 387 cvaluation of. 1 69. 1 75, 1 9 1
mcdial and lateral pectoral, 1 1 8 Postfixcd plexus, in thoracic oUllet as risk factor, 1 57. 1 59. 1 6 1 . 1 65.
musculocutaneous. 1 1 7- 1 1 8 syndrome, 1 6 1 166
myofa�cial neck and shouldcl' pain Postoperative peliod Postvin:d fatigue !'.yndrome
in, 105, 105f in an hroscopy. 430-43 1 refcrred pain fTom. 330
suprascapular, I 1 7 in dislocation of shouldcr, 337-341 relationship with fibromyalgia, 330
PCripheral nCIVCS, 179, See also isokinetic exercise in, 409 Power, in speed and sll-cngth training,
'
Nerves in open capsular shift surgery. 366
dynamic!'. of, 136. 137 43 1 -433 Pregnancy, activities during, pneu�
evaluation of. 1 34- 1 4 1 . 1 45f- 1 47f, in rotalor cuff l"Chabililation, 288. moperitoneum from, 3 1 0
148 29 1 , 292, 295-296, 439, 443, Preoperative evaluation i n 10lal
fulcrum effect of humeral head on, 444-445 shoulder rcplacement. 459.
1 38, 1 38f in throwing injuries of shouldel� 24 461 -463
492 IN 0 E X
Rotalor cufr muscles and tendons shoulder-hand syndrome and, 324 ef[ect of posturc on, 1 0 1 - 1 02
(Contil/ued) superior surface. etiology of, 282 evaluation of
manual mu:sc\e testing of. 284-286. tests in evaluation of. 83. 84f in rotator cuff pathology, 284
285f total shoulder replacement in. for slabil ity. 63, 70f-72f. 73
muscle imbalances in, 73. 1 35, 46 1 , 462, 464, 466 for w i nging, 284
287-288 undersutface. 24 1 , 282-283, 283 external rotation of, in mobili7"alion
in primary tensile overload. 2 4 1 vascular predisposition to, 234-235 techniques. 360-36 1 , 362f
rehabilitation of. 288-293. 4 1 5-4 1 7 tendinitis of, 280 fraclul-es of. 448-449, 451 f
biomcchanical concepts in, calcific. 435, 436f in aCl'omion process, 449, 451 f
287-288 case sludy on, 378-380, 379f, 380f in body, 449, 45 1 f
case studies on, 293-296, 443, from cervical spine pathology. 109 i n coracoid process, 449, 451 f
444-445 chronic. 435. 438 in neck, 448. 451 f
immobilization during. 292 tests for impingement of, 8 1 f. 82. rehabilitation in, 449
joint mobilization during. 288. 231-232, 232f, 286 i n hemiplegia, 206-207, 209, 2 1 3
292 in throwing movements. 20. 2 1 i n impingement syndrome, 239.
muscular lraining in. 289-291 in injured athletes. 2 1 244-245
nonopcrative. results of, 292-293 strengthening exercises for, 29. levator muscle of. See Levator
reduction of overload in. 288 29f, 30f scapula muscle
restorat ion of normal joint torque output of. 3 muscle imbalance of, 73, 287
arthrokinematics in, 288 in total shoulder replacement. 464, muscles acting at, 1 0 . 1 1 r, 1 3. 14
:surgery and. 2 9 1 -292 466 myofascial mobili/nion of, 393,
..
.
rclalion:ship of osseous structures ar1hropathy of, 468. 474 395, 395f
10, 436f preoperative assessment of. 46 1 , framing prior- to, 393. 393f-394f
in scaplion of shoulder. 5 462 palpation of, 741. 75
in stabili/.3tion of glenohumeral rehabililalion programs for, 466. position of, 60, 6 1 . 62f
joinl, 279, 370, 422 474, 475-476 in range of motion tests. 63-64, 64f,
strength deficits of. predisposition Rowing exercise 65, 661
to tratlma from, 58 in impingement syndrome, 245. 24M I"efen'ed pain to, 306, 3 1 1 , 324, 325
:;trcngthening exercises fOl� 289. for scapular rotator muscles, 295, release techniques for, 345
289f, 369f-371 f, 370, 376, 377f 2961, 373f in rotation of sholllder� 10. 1 1 f. 1 2.
subluxation of. in throwing injuries, in throwing injuries of shoulder. 37. 1 3, 1 4
22 40f, 4 1
i n rolalor cuff pathology
::.urgcry of Royal free disease, rdcrred pain from ,
compcnsatOl)' actions of. 288
330
ar1hro:scopically assisted repair, evaluation of. 284
439, 440� 444, 445f and scapulohumeral rhythm, 10
ar1hroscopic debddement, 1tion of glenohumeral
i n slabili7..
s
29 1 -292, 293-294, 439, 439f joint. 232
comcoacromial decompression, SAID (specific adaptations to imposed tests in evaluation of. 63, 70f-72f.
439 demands) principle. 368 73, 75
indications for, 438 Scalene muscles in throwing movcments. 20, 2 1 . 22
open repair, 29 1 , 292. 294-296, abnonnalities of. in thomcic outlet winging of, 6 1 . 63. 7 1 f-72f. 75. 239,
439, 44 1 , 441 f-443[, 443 syndrome, 1 59 247, 247f, 248f
results or. 439. 441 anatomy of, I 56f, 1 57. 1 5 8 tests to identify, 284
teat'S in. See also Protective injuries $caption of shoulder Scapular ncrve. dorsal, injur)' of. 186
acromial architecture in. 280 in exercise program for throwing Scapular plane
.culo, 240, 243, 2 8 1 , 435 injuries of shoulder, 33. 34f, 35f appropr-iateness of, 4 1 2
anatomic description of, 282-283 exercises involving. 245f, 369f clinical Significance of. 2
diagnosis of, 229, 435, 437 joint congn.l ity in, 3 elevation in, 1-2, 2f, 3f
eccenll"ic overload and, 435, 437r muscle activity during. 279. 47 1 f exercises in, 369f, 370, 463f. 466f.
eliology of, 279-283, 435 optimal muscle length�tension rcla� 47lf
force couple imbalance and, 287 tionship in. 2 Iilnge o r motion tests in, 63-65, Mf
in impingement syndrome, 238, osteokinematics in. 1-3. 2f, 3f in strength lmining. 3
2381, 280, 281 torque production in, 3 Scapular retraction exercise, 237,
intratendinous or- interstitial, 283 Scapula 237f, 239
nonoperative treatment of, in abduction of shoulder, 1 2 Scapular rotating muscles
292-293, 438 anatomy of, I , 1 0 in stabiliz."J.tion of glenohumeral
pathologic classification of, 240, distmction of, i n rnobili7.ation tech� joint. 3 7 1
279-28 1 niqlles, 360, 361 f, 362, 363f strengthening exercises for. 369f.
i n rheumatoid illthdtis. 464, 466 dyskinesia of, tests to identif)" 284 3 7 1 , 37 1 f, 373f, 374f. 376
IN0EX 495
Scapular stabilizing muscles in impingement syndrome. 244. 245 Splenic infarct or rupture. pneu
manual muscle testing of, 285 in long thoracic nerve palsy. 1 1 7 moperilOneum from. 309
strengthening or. in rolal.or cuff reha mobilization techniques involving. Splinting in brachial plexus injuries,
bilitation. 288. 289, 294. 295 357. 359. 359[ 1 89. 193. 194[
in total shoulder replacement, 464f palsy or. 1 8 6 Sp0l1S. See Athletes
Scapulohumeral a1x!uction, passive, in in rotation of shoulder. 1 2 Spray and stretch techniques. in
frozen shoulder. 266 i n stabilization of shoulder. 1 1 f, brachial plexus injuries. 1 98
Scapulohumcral muscles 371 Spurling's test. 1 1 2 . 1 1 2 f. 1 2 1
anatomy of, 8 strengthening exercises for. 25, 369f. S!..:"'\ bility o f shoulder. I , 1 0 , 42 1 -434.
response to dysfunction. 69t. 73 3 7 1 . 37 1 [. 373[. 37M See also Glenohumeral joint.
Scapulohumeral rhythm, 1 0 in throwing movements. 20. 2 1 stability of
in abduction o f shoulder. 1 2 . 1 3 . 1 4 i n injured athletes, 2 1 clinical examination of. 422
assessment or. 63 injury of. 2 1 . 22 effects of rotator cuff tears on, 282
in hemiplegia. 207. 2 1 0 in professionals versus amateurs. history taking in. 422
ScapuJothoracicjoint. 1 . 2r 21 imaging studies for
analOmy of. 1 0 strengthening exercises for, 25 al1hrography and CT scans, 423
i n flexion of shoulder, 3 Shaking of extremitics. in fTozen anhroscopy, 427. 438
force couple at. 232. 237, 287 shoulder. 27 1 magnetic resonance imaging.
in frozen shouldel'. cxamination of, Shoulder girdle oscillation tcchnique. 423-424
265 in treatment of ncural tissue. radiography. 423
mobilization of, in rotator cuff reha- 142-143 negative atmosphel'ic pn!ssure and.
bilitation, 288 Shoulder-hand syndrome 42 1
in range of Illotion lesLS. 63. 64 cervical spine in, 1 1 0 objective examination of, 422
in scapula fractures. 449 in hemiplegia, 2 1 6 pathomechanics in, 4 2 1 -422
stabilization test for. 284 referred pain fTom. 323-324 periarticular structures affecting. 6-8
Scar tissue after trauma, mobili7.3tion Shoulder saddle sling. for shoulder position of glenOid fossa affecting. 6
techniques in, 338-339 subluxation in hemiplegia. 224, surgery in instabilities
Scientific therapeutic exercise progres 225[ al1hroscopic. 427-428. 428f-430f
sions (STEP). 1 2 1 - 1 2 2 Shrugs, shoulder. in exercise program controver-sy over. 424
Scoliosis. postural relationship of for throwing injuries. 32, 33f laser. 428-430
scapula 10 spine in, 1 0 2 SLAP lesions open reconSll1Jctive. 424-427.
Screening o f cervical region, 59, 60t, 87 in rotator cuff pathology, 438 425r. 4261
Secondary impingement syndrome. in throwing athletes, 23 tests in evaluation of, 75f-79r.
See Impingement syndrome. Slings 76-78. 8 1 . 286-287. 422-423
secondat)' in clavicle fmctures, 448 in throwing athlctes. 22
Secondary tensile overload. 240. in hemiplegia, 224. 225f Stabilization exercises, in cervical
24 1-242 in humenls fTactures. 45 1 , 452 spine disorders. 1 22
Sclf-care. daily living activities in Soft tissue diagnosis. See Evaluation Static progressive stretch (SPS). plas
in brachial plexus injuries. 193. 1 96, procedures tic defomlation from, 347
199 Soft tissue mobilization. See Myofas Sternocln.vicular joint. I . 2f
limitations in. as indicalion for lotal cial mobilization in abduction of shoulder. 1 2 , 1 3
shoulder replacement. 461 Soft tissues. See Myofascial tissues anatomy of. 9 , 9f
in thoracic outiet syndrome, 164-166 Somatic nervous system. flexion with in flcxion of shoulder. 3
Self cer.'icle traction, 1 70, 1 70f, 1 76 drawal reflex of. 162 in frozen shoulder. examination of.
Self-treatment and management. for Spasms in hemiplegia, 206, 2 1 2 265
neural tissue of upper quaneI'. management of, 206, 2 1 8, 220, 226 gliding motion of. in mobilization
143 muscle pain in, 2 1 5 techniques, 354, 354f. 355f
SenSitivity to pain in hemiplegia. Speed training. 366 in range of motion tests, 63
2 1 5-2 1 6 Spinal cord refelTed pain to. 3 1 9
Sensory cortex. misintel-prctalion of anatomy of. 97 stability of. 9
pain in, 305 convergence of afferent nerves in. Stcrnocleidomastoid muscle. anatomy
Sensol), evaluation, in brachial plexus 305[-3061. 305-306 n.nd function of. 96
injulie . 192, 196. 202 examination of. 59. 60t Steroid theraPY in fTozen shoulder.
Sensol), innervation of connective tis Spinal nerve injuries, 1 83, 1 84 267. 272-273
sues, 1 36 Spine. See also Cervical spine Stiffness. mobilization and stretching
Sen'3tus antel'iol' muscle anal.omyof, tunnels in, 1 58r. 160f for. 66
in abduction of shoulder, 1 3 , 1 4 mobili7..ation of. 1 73f. 1 73-174 Stomach. refen-ed pain from, 328-329
force couple with trapezius muscle. motor nerve-muscle con'espon- SlOmmognathic muscles, response to
287 dence in, I 1 4f-1 1 5f dysfunction. 69t, 73
496 IN0EX
Straight aim press, in exercise pm indications and contraindications gual'ding of. in bursitis, 109
gram for throwing injuIies, 4 1 , for, 65, 66 in impingcmcnt syndromc, 435
43f low-load, long-duration, 375, 376f manual muscle testing of, 285
Slmin and counlcrslrain technique, misuse of, 1 50- 1 5 1 mobili7.ation of. 356-357, 357f,
342 i n mobilization, 338. 339, 342, 343. 358[, 390f, 391
Strength 344-345, 347, 348f i n range of motion tests. 65. 671'. 68
definition of, 365 in rotator cuff rehabilitation, 288 in rotation of shouldel', 6-7
endurance and, 365, 368, 373 in throwing injuries of shoulder, 25 in scapt ion of shouldcl', 5
impact of resistive lraining on, 366 for trapezius muscle, in frozen in secondary tensile overload. 242
maximum. 365, 366, 373 shoulder. 2 7 1 f spasms in, 236
musculotendinous, assessment of, Strctch-sh0l1ening exercise, in throw in stnbil i'l..<:ltion of shoulder. 6-7, 7f.
69f-70f, 7 1 t-72t, 68-75, ing injuries, 25 8, 1 1 , 1 2 , 14, 370. 422
82f-85f, 82-86, 89 Strumming techniques, in soft tissue dynamic deficit of. 422
in thoracic outlet syndrome, 1 70, mobilization, 3561 strengthening exercises for,
1 76 Subacromial bursa, in impingement 369f-3 7 1 f, 370
Strengthening exercises, 365-381 syndrome, 237 tCaI'S in. 282
in brachial plexus injuries. 1 99-200, Subacromial impingement, rotator in throwing movement.s. 20, 2 1
201 cufr tears and, 282, 2 9 1 i n injured nthlctcs. 2 1
in frozen shoulder. 272 Subacromial space i n proressionals VCI"'l)US amateurs,
rOl' glenohumeral muscles, in impingement syndrome, 21
369f-3 7 1 [, 37<l-3 7 1 229-230, 230f, 280 trigger points in, 8
for hvpennobilities, 68, 72 measurements or. 280 Subscapular nerves, muscles inner
in impingement syndrome, 237. Subclavian artery and vein vated by, 99
237f, 245f-249f, 245-248, 369f, anatomy of, 1 601', 1 6 1 Sulcus sign tests, 78. 78f. 79f, 8 1 . 286,
37 I f, 373f-374f, 375, 376, 377, injUl'yof. 1 9 2 423
377f. 378 refen'ed pain frol11, 322-323, 3 2 3 f Superior labrum anleroposler-ior
h.okinctic, 367, 376. 377, 377f in thoracic outlet syndromC', 1 6 1 (SLAP) lesion Lest. 80f, 8 1
isomelIic, 367 Subdeltoid joint, anatomy of, 2f Supraclavicular brachial plexus injUl)"
i,otonic, 367, 369f, 37 I f, 373f-374[, Subluxation of shoulder 184
376. 377, 377f, 378 diagnosis of. 229 Supraclavicular region, refcm:d pain
in poMoperativc management of exercise program in, 243 to, 3 1 1
instabil ity. 432 in hemiplegia. 209[-2 1 3f. 209-2 1 4 Suprahumcrnl space, See Subacl'Omial
in protective injUlies, 340. 3 4 1 anteriOl", 207, 208f, 209. 2 1 2-2 1 3 space
for scapular rolator muscles. 245. evaluation of, 223-224 Suprahumeral tissues, in impinge
245f-247[, 369f, 37 1 , 3 7 1 [, inferior, 207, 207f, 209, 250 ment syndrome, edema and
373f-374f pain in, 209 hcmolThagc or, 236
stretching plior to, 375-376 reduction of. 2 1 0. 2 1 2 , 2 1 3 Suprahyoid muscles, anntonw and
in throwing injuries of shouldel� 25 shoulder supports in, 224, 225f function of. 96
i n towl shoulder replacement, superio<; 208f, 209. 2 1 3, 2 Uf Suprascapular ncryc
462f-473f treatment of. 223-224 injury of, 184, 1 86, 188, 1 9 1
Strength training in type I aml, 209, 209[' 2 1 0f, 2 1 1 muscles innervated by. 99
benefits of. 365 in type n ann, 2 1 1 f. 2 1 1-2 1 3 , 2 1 2 f palsy of. 1 1 7
biochemical changes arter, 366 i n type I I I atOm , 2 1 3f, 2 1 3- 2 1 4 Suprascapular region. rcfen'cd pain
impact on perfomlance, 371-372 relocation tests, 286, 423 to, 306
bokinetic exercise in, 401 in lhrowing injudes, 22 Supraspinatlls muscle and tendon
neuromuscular and mechanical case study on, 26-27 in abduction or shoulder. J I . J 2r
changes due to, 366, 372-373 Subscapular bursa in brachial plexlIs injlll'ics, 197, 200
principles of, 368-370 anatomy of. 8 calcific deposits in. 436f
scapular plane in, 3 inflammation of. in frozen shoulder, in frozen shou ldcl� 258-259
speed of movement in, 366 109 hypovasculality of, 234-235, 281 -282
types of contractions in, 367 Subscapu.laris muscle and tcndon impingement of, 80f, 8 1 f, 82
lypes of exercise in, 367 in :lbduction of shoulder. 5, 6-7, 71'. in impingement syndrome, 239
Siretching techniques I I , 12, 14 compression of. 2 3 1
in brachial plexus injUl;es, 198, 199, i n adduclion o f shoulder, 6 , 7f injury of, 234-235
200 anatomy of. 8 strengthening exercises for, 243
in froLen shouldel� 270. 2 7 1 , 2 7 1 f complications from immobilization manual muscle lesting of. 285, 285f
in impingement syndrome, in. mobilization techniques to mobilization of, 396-397, 397f
375-376, 376f reverse. 344-345 in siabilization of shoulder, 7, 1 2 .
mbuse of. 243 in frozen shoulder. 109, 259 370. 422
tN 0 E X 497
strengthening exercbes for, 29, 29[, Swimmers tears i n , 282
30r. 369f-372r. 370-3 7 1 , 47 1 r. isokinetic torque ratios for, in tensile overload. 24 1 , 242
473f 4 1 1-4 1 2, 4 1 21, 4 1 3 in throwing movements, 20, 2 1
in :suprascapular nerve palsy. 1 1 7 muscle activity studies in. 244-245 in professionals ver:sus amatclII"!>.
tears in Symmetry. assessment of. 60. 87 21
anatomic description of. 282 Sympathetic nerves strengthening exercises for. 29,
ca!loe study on, 293-294 in brachial plexus. 180- 1 8 1 29f, 30f
tendinitis of hyperactivity of, 107-108 Tests. See also specific lest
mobilization in, 396-397, 397f Synovial membrane. in frozen shoul in brachial plexus injuries, 192-193
working posture and, 103-104 del� 259 of cOOl-dination, J 9 1 - 1 92, 1 96.
in tensile overload, 24 1 , 242 202
tests in L'valuation of. 73, 80f, 8 1 r. of muscle strenglh. 194-195. 196.
82-83, 83f-85r. 84 T 202
in throwing movcmcnts, 1 9. 20. 2 1 caution during, 57-58
in injured athlt.!les, 2 1 Tender points in cClvical spine screening. 59, 60t
injury of, 22, 23 in cervicobrachial pain syndrome, in frozen shoulder, 260. 264-265
in professionals versus amateurs, 140- 1 4 1 impingement
21 in frozen shoulder, 264, 267 crossed arm adduction. 286
:strengthening exercises for, 29, Tendinitis Hawkins and Kennedy, 81 f, 82.
29r. 30f bicipital, tests in evaluation of, 82, 286
Supraspinalu:s oUllet_ See Subacromial 82f, 83, 83f, 85f, 86 Neer, 8 l f, 82. 2 3 1 -232, 232f, 286
:space cClvical spine pathology in, 109 in instability of shoulder. 75f-79f,
Supra�pinous area, l-efen-ed pain 10. in hemiplegia, 2 1 5 76-78, 8 1 , 286-287,422-423
324 i n impingement syndrome, 237 isokinetic exercise in. 40 I . 402.
Suretac biodcgl'"3dabJe taco in arthro mobili7.3tion in. 396-397. 397r 403-407
scopic stabilization of shoul muscle guarding in. 109 passive range of motion. caution
der, 428, 429f, 430f in rotator cuff tears duting, 57-58
SurgelY calci.hc. 435. 436f in thoracic outlet syndrome. 168.
abdominal or vaginal, pneumoperi- chronic, 435, 438 1 69- 1 7 1
toneum from. 3 1 0 Tennis players i n throwing injuries of shoulder, 22,
i n brachial plexus injuries, 195 isokinetic torque !"atios for, 4 ) I , 23
in frozen shoulder, 273 4 1 2 , 4 1 21, 4 1 3 Thoracic nerves, 1 79. 180
in humerus fractures. 449. 450 muscle activity in, 279 injury of, 185, 186, 1 9 1
in impingement :syndroml.!, 239. results of isokinetic slrength train� palsy in, 1 1 7
242-243, 280-2 8 1 ing in. 372 Thoracic outlct
i n instabilities o f shoulder Tenosynovilis. bicipital. fTozen shoul anatomyof. 1 5M. 1 57-1 6 1 , 1 58f.
arthroscopic, 427-428. der in, 258 1 60f
428f-430f Tensile overload dysfunctional reflexes in. 162-163
controversy over, 424 in etiology of rotator cuff pathology. examination of. 60
laser, 428-430 281 Thoracic outlet syndrome
open reconstruct in" 24, 424-427, pathology or. 240 analogy of lake in. 163-164. 165f
425r. 426f primary, 240, 2 4 1 analogy of orthodontist in. 155. 164
in rotator cuff tears. 241 secondary. 240. 24 1-242 brachial plexus in, 157. 1 6 1
approaches to. 291 undersurface rotator cuff tears and, breathing pallems in
artlu"Oscopically a:.:siSied repair. 282-283 evaluation 0[, 1 70, 176
439, 440r. 444, 445f Teres major muscle and tendon as risk factor, 1 57. 1 59. 1 62-163
arthroscopic debridement, in abduction of shoulder. 1 4 treatment of, 1 72f, 1 72-173
291-292, 293-294, 439, 439f i n stabilization o f shoulder, 8, 370 case study on, 174-177
coracoacromial decompression, strengthening exercises COI-, differential diagnosis of. 166-167
439 369f-37 1 r. 370, 472f dysfunctional reflexes in. 162-163
indication:. for. 438 Teres minor muscle and tendon treatmenL of, 1 72, 1 76
open repail� 29 1 . 292, 294-296, in abduction of shouldel� I I . 1 2 . 1 4 early intelvenlion in, 176-177
439, 44 1 , 44 1 f-443f, 443 i n axillary nelve paby, I 1 7 err0l1 thrombosis in, 323
rehabilitation after, 291-292 i n brachial plexus injuries, 197. 200 evaluation of, 167- 1 7 1
results of. 439. 441 in impingement syndrome, 244. 245 objective, 168- 1 7 1 , 1 75-176
in temile overload. 242 manual muscle testing or. 285 subjective, 167-168. 1 75
in throwing injuries of shoulder, 24 in slabili7.3tion of shoulder, 8. 1 I . 1 4 exercises i n , 1 72f-174f, 1 72-174
tOlal shoulder replacement in. strengthening exercises for. fluid dynamics in, 154, 1 6 1 . 1 63r.
459-476 283f-285r. 284, 472f 1 63-164, 164f
498 IN 0 E X
Thoracic outlet syndl"Ome (Continued) of infraspinatus muscle and tendon. predictive value of. 4 1 3
functional profile in. 167. 1 75 22 relationship t o body \",'eight, 408. 4 1 7
gendel' iss-ues in, 1 6 6 instability continuum in. 22 relationship 1 0 speed. 401 -402. 4 1 3
hislOry o f patient i n , 167-1 68. 1 75 muscle activity in. 2 1 -22. 245 Total shoulder replacement. 459-476
multiple entrapment sites in, 1 53, in musculocutaneous nerve palsy. 1 1 8 communication between surgeon
1 66-167 prevention of. 24 and therapist in, 472
nCUI"Ovascular consequences of, rehabilitation goals in. 24 glenohumeral joint in
1 53-177 of rotator cuff. 240 clastic resistive exercises for,
occupational and ADL issues in, location or. 2 4 1 469f, 473
164-166 pl'imary tensile overload i n . 2 4 1 isometric cxerci�es for. 465f, 470f
pain in o f serratus nntel'ior muscle, 2 1 . 2 2 hislOry taking in, 459. 460
body's response lO, 1 55. 1 57 o f supraspinatus muscle and ten� indications fOI� 463-470
evalualion of, 167, 1 75 don, 22, 23 physical examination in, 461 -463
during treatment, 1 72. 174 surgery in. 24, 424, 429 rehabilitation in
Panco�,sl lumor in, 1 36, 1 3 7 lests in, 22 catcgories of. 470
posture in throwing programs in. 25-26. 53-55 critical points and techniques in.
evaluation of, 169. 1 75. 1 9 1 Throwing movements 472-474
as risk factor, 1 57, 1 59, 1 6 1 , 1 65. acceleration, 20 goals of, 470
166 in injured throwers, 22 limited goals program, 466. 468.
rcfen-cd pain in, 322 muscles active during, 2 1 , 22 471-472, 476
fisk factors for. 1 57, 1 59. 1 6 1 in professional venous amateur rotator cuff and deltoid pro-
scalene muscles in, 1 59 pitchers. 2 1 grams. 470-47 1 . 475
in shouldcr dvsfunction, 1 1 0 stabilization o f glenohumeral limelines in. 47 1 . 472. 475-476
.!ttenosis in, 1 54- 1 6 1 . 1 57 joint duting. 23 Training. See oL..o Strengt h training
symptom control in, 155. t 57 cocking, 1 9-20 combination. 367
teMs in, 168, 1 6 9- 1 7 1 in injured throwers. 2 1 . 22 elTors during. predisposition to
r3lse�positive results of, 1 7 1 l11uscles active during, 2 1 , 22, trauma from, 58
tissue repair in, 1 64 241 isokinetic exercise in. submaximal
treatment of stabilization o f glenohumeral effol1 in, 40 1 . 4 1 0, 4 1 1
case slUcly on, 1 76-177 joint during. 23 plyometl'ic. 367
dcconditioning renexes, 162, 1 72, deceleration. 20-21 spt."'Cificily of, 368
1 76 repetitive microtrauma during. 241 Transcutaneous electrical nerve stimu,
Edgclow protocol fOI� 1 7 1 - 1 72 throwing injuries in. 2 1 -22 lation. See Electrical nerve
goals in, 1 7 1 exercise programs for, 25-26. 53-55 stimulation, transcutaneous
methods to "ell-Olin swamp", 174, follO\v·through, 20-2 1 Transverse muscle plav tcchnique,
1 74f stabilization of glenohumeral 387, 388, 389f
method!> to "open tunnels", joint during, 23 Trapezius muscle
l 72f- 1 73f, 1 72-174 in professionals versus amateurs, in abduction of shoulder, 1 3 . 1 4
patienl comrol in, 1 54-- 1 55, 1 57, 2 1 . 241 anatomy and function or. 95
1 7 1 - 1 72 Windup, 1 9 force couple with sen-atus antel'ior
Thoracic region, mobilization or. 388, Thrust techniques. See Manipulation muscle. 287
388f, 3 9 1 -393, 392f techniques in frozen shoulder. stretching of.
Thoracic spine, segmemaJ mobility or. linel's sign 271, 271f
99 in brachial plexus injudes, 192-193 "eferred pain to. 306, 3 1 1
Thoracodol"'Sal nerve, muscles inner· in carpal lllnnci syndrome. 1 6 7 in rotation of shoulder. 1 2, 1 3
vated by, 99 Torque spasms in. 236
Thrombophlebitis. referred pain from. dudng acceleration ph3se of pitch� in stabili7.ation of shoulder, I I r. 14.
322-32 3, 323f ing, 20 371
Throwing injudes. 1 9-55 age and, 4 1 2 strengthening c:'(crcises fOI� 369f.
a!,throscopy in, 23, 24, 293-294 on dominant compared to non· 37 1 , 37 1 r. 373f, 374f
of biceps muscle and tendon, 23 dominant side, 409 strengthening or. 47 1 f
biomechanics or, 22-23 of intel11allexternal rotators, body in throwing movements, 20, 2 1
clas.<;ification of. 22 planes and. 2-3 Trapezoid ligament. anatomy of. 1 0
in decclemlion phase of pitching, dUling isokinetic exercise. 40Sf Trauma
22 measurement of deficits in. of brachial plexus, 1 84-- 189. See also
dynamic stabilizers and. 9 401-402, 4 1 3 Brachial plexus. injury of
evaluation of, 22-23 normative data on categori7..alion of, 57
exercise programs in, 25-26. for athletes, 408t, 4 1 1 -4 1 2 . 4 1 2t cervical, loss of inhibitory
29f-36f, 29-55 for normals. 408t, 4 1 2-4 1 3 mechanoreceptor"!; in, 106-107
IN 0 E X 499
cumulative. See Cumulative trauma palpation of. 140 lung. 3 1 0-3 1 4
disorden;. palsy of, 185 pancreas, 324-325
fractures of shoulder girdle in, provocation test via, 1 39 stomach, 328-329
447-456 in thoracic outlet syndrome, 167 vascular, 322-324
Olacrotrauma, 57-58, 76 U ltrasonography Viscoelasticity of connective tissue. 344
microlrauma, 57, 58. 6 1 in impingement syndrome, 236, 239 Vitamin and mineral supplements, for
case study on, 86-91 in rOLator cuff tears, 438 muscle, tendon. and collagen
in overhand sports, 240, 24 1 . 242 as therapy, in frozen shoulder, 267, injuries,
in neurovascular entrapmenl, 268-269 Volumetric measurement of edema in
102-103. 1 54 UncovcI1ebrai jOint. anatomy of. 97, 97f brachial plexus injuries. 192.
pa!-.sive movement following. 336 Upper extremities 196
predisposition la, 57, 58 closed chain exer·dses for, 246--247
of rotator cuff. 240, 243, 28 I conditioning program for, 25, 52
scar tissue after, mobilization tech effect of posture on, 1 0 1 w
niques in. 338-339 kineLie chain of. compensatory
Wand exercises
shoulder-hand !ooyndrome and, 324 actions in, 288
total shoulder replacement in. 462, in clavicle fractures. 448, 454
Upper limb tension lests, in thoracic
463. 467 in frozen shoulder, 2 7 1
outlet syndrome. 1 69-170, 1 76
lligger points secondary to. 8 Warm-up
Upper qual1er pain
vascular. in brachial plexus injuries, duration of. in isokinetic exercise.
diagnostic bias in, 1 3 1
192 4 1 0-4 1 1
types or. 1 32-133
Treatment plans. 90. 9 1 1 methods in, 368-369
Triceps brachii muscle. i n e.'(ercise use of ergomeler in, 376. 377f, 379