Physical Therapy of the Shoulder

Physical Therapy of the THIRD EDITION Edited by Robert A. Donatelli, Ph.D., P.T., O.CS. I nsLruclor Divisioll oj Physical T herapy Departmellt oj Rehabilitatioll Medicille EmOlY Ulliversity School oj Medicille At/alita, Georgia Natiollal Director oj Sports Rehabilitatioll Physiotherapy Associates Memphis, Tellllesse CHURCHILL LIVINGSTON' ,-I-JJ New York, Edinburgh, london, Madrid, Melbourne, San Francisco, Tokyo Library of Congress Cataloging-in-Publication Data Physical therapy of the shoulder I edited by Robert A. Donatelli.- 3rd ed. p. em. - (Clinics in physical therapy) Includes bibliographical references and index. ISBN 0-443-07591-3 (alk. paper) I. Shoulder-Wounds and injuries. 2. Shoulder-Wounds and injurics-Treatment. 3. Shoulder-Wounds and injuries-Physical therapy. I. Donatelli, Robert. IT. Series. [DNLM: I. Shoulder-injuries. 2. Shoulder Joinl-injul"ies. 3. Physical Therapy-methods. WE 810 P578 1997) R0557.5.P48 1997 617.5' 72062-de20 DNLM/DLC for Library of Congress 96-29475 CIP €:I Churchill Livingstone Inc_ 1997, 1991,1987 All rights reserved. No pal1 of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying. recording, or otherwise. without prior pennis­ sion of the publisher (Churchill Livingstone, 650 Avenue of the Americas, New York, NY 10011). Distributed in theUnited Kingdom by Churchill Livingstone. Rober1 Steven­ son House, 1-3 Baxter's Place, Leith Walk, Edinburgh EHI 3AF, and by associated companies, branches, and representatives throughout the world. M edical kn owledge is constantly changing. As new infollnation becomes available, changes in treatment, procedures, equipment and the use of drugs become necessary. The editors/authors/contributors and the publishers have, as far as it is possible, taken care to e nsure that the information given in this text is accurate and up to date. However, readers are strongly advised to confirm that the infolmation, especially with regard to drug usage, com­ plies with the latest legislation and standards of practice. 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. Acquisitions Editor: Carol Bader Production Editor: Palll Bemsteill Production Supervisor: Kathleell R. Smith Cover Design: Jeannette Jacobs Printed in the United States of America First published in 1997 7 6 5 4 3 2 I would like 10 dedicate this book to my late father, Revy Donatelli, and 10 my mother, Rose Donatelli. They provided the guidance, motivation, and love 10 help me through my college years, enabling me to pursue a career in physical therapy. I would also like to dedicate the book to my sistel; Linda Schultheiss, and to my brothel; Jerry DonatelliJor their friendship, love, and support. Contributors 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 David J. Conaway, D.O. Robert L. Elvtry, P.T. Associate Clinical Pl'OfessOl; Depal1ment of Senior Lecturer, School of PhYSiotherapy, Orthopaedics, West Virginia College of Osteo­ Curtin University of Technology, Perth, Western pathic Medicine, Lewisburg, West Virginia; Hon­ Australia, Australia oralY Clinical Lnstmctor, Graduate Pl'Ogram in Physical Therapy, Division of Allied Heath Pl'Ofes­ Blanca Zita Gotlw!ez-Kitlg, P. T., e.H.T. sions, Department of Rehabilitation Medicine, Clinic Director, Physiotherapy Associates, EmOlY University School of Medicine; Past Chair­ Jonesboro, Georgia man, Department of Surgery, orthlake Regional Medical Centel� Staff Orthopaedic Surgeon, Jolm e. Gray, P.T. Dekalb Medical Centel; Northlake Regional Med­ Assistant InstmctOl; Ola Grimsby Institute; ical Center, Eastside Medical Center, Atlanta, Clinical Specialist, Department of Physical Georgia; Orthopaedic Surgeon, Killian Hill Therapy, Sharp Rees-Stealy, San Diego, Califor­ Orthopaedic and Sports Medicine Clinic, Lilbull1, nia; Fellow, American Academy of Orthopaedic Georgia Manual Physical Therapists Jeff Cooper, M.S., A.T.e. Bntce H. Greenfield, M.M.Sc., P.T., O.e.S. Athletic Trainel; The Phillies, Philadelphia, Penn­ Instmctor, Division of PhYSical Therapy, Depart­ sylvania; Consultant, Physiotherapy Associates, ment of Rehabilitation Medicine, Emory Uni­ Atlanta, Georgia versity School of Medicine, Atlanta, Georgia Karetl E. Dallis, M.P.T., A.T.C. Ola Grimsby, P.T. Physical Therapist, Physiotherapy Associates, Chailman of the Board, Ola Grimsby institute, Jonesbol'O, Georgia San Diego, Califoll1ia vii viii CONTRIBUTORS Toby Hall, P.T. Susan Ryerson, P.T. Clinical Consultant, School of Physiotherapy, Pal1.ner, Making Progress, Alexandda, Virginia; Curun University of Technology, Perth, Western Adjunct Clinical Faculty, Massachusetts General Australia, Australia Hospital Institute of Health Professions, Boston, Massachusetts, CoordinatorlInstmctOJ; NeUl'ode­ Mari" A. Johanson, M.S., P.T., O.e.S. velopmental Treatment Association, lnc., Clinic Director, Physiotherapy Associates, Chicago, Winois Peachtree City, Georgia Dorie B. Syen, M.S., O.T.R., e.H.T. Rehabilitation Projects Coordinator, Georgia Kathryn L£vil, M.Ed., O.T.R. Baptist Medical Center, Atlanta, Georgia Partnel; Making Progress, Alexandria, Virginia; Adjunct Clinical Faculty, Massachusetts General LoriA. I1lein, M.S., P.T., S.e.S., A.T.e. Hospital Institute of Health Professions, Boston, Associate Lecturer, Depaltment of Kinesiology, Massachusetts; CoordinatorlInstructor, Neurode­ University of Wisconsin School of Educalion; velopmental Treatment Association, Inc., Chicago, Senior Clinical Therapist, SPOl1S Medicine Center, illinois University of Wisconsin Clinics Research Park, Madison, Wisconsin Angelo J. Mattalino, M.D. Medical Director, Southwest Sports Medicine Timothy Uhl, M.S., P.T., A.T.e. and Orthopaedic Surgery Clinic, Ltd., Scottsdale, Director of Physical Therapy, Human Perfor­ Adzona; Medical Director, Baseball Research mance and Rehabililation Center, Columbus, and Rehabilitation Center/Physiotherapy, Tempe, Georgia Adzona Joseph S. Wilkes, M.D. George M. McCluskey III, M.D. Associate Clinical Professor, Depru1ment of Staff Orthopaedic Surgeon, The Hughston Clinic; Orthopaedics, Emory University School of Medi­ Staff Orthopaedic Surgeon, Hughston Sports cine; Orthopedist, The Hughston Clinic; Medical Medicine Hospital, Columbus, Georgia Director, Piedmont Hospital Sports Medicine Institute, Allanta, Georgia; Orthopedic Consul­ Timothy J. McMaJwn, P. T. tant, United Stales Luge Association, Lake Placid, Clinical Instmctor, Division of Physical Therapy, New York Department of Medicine, Emory UniverSity School of Medicine, Atlanta, Georgia; Assistant DirectOJ; Michael J. Wooden, M.S., P.T., O.e.S. Physiotherapy Associates, Lilburn, Georgia [nstmctor, Division of Physical Therapy, DepaJ1- ment of Rehabilitation Medicine, Emory Uni­ Helen Owens, M.S., P.T. versity School of Medicine; National Director, Owner, Orthopedics Physical Therapy Services, Clinical Research, Physiotherapy Associates, Lockport, illinois Memphis, Tennessee Preface 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 M OV E ME NT The Shoulder in Hemiplegia I 205 A N D EV A LU AT I O N Susan Ryerson and Kathryn Levit CHAPTER 1 Functional Anatomy and Mechanics I t S PEC I AL Robert A. Donatelli C O N S I DE R AT I O N S 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 Differential Sofl Tissue Diagnosis I 57 CHAPTER 10 Marie A. Joha>lson and Frozen Shoulder I 257 Blal1ca Zita Gonzalez-Killg Helen Dwel1s NEU R OL O G IC CHAPTER 1 I C O N S I DE R AT I O N S Etiology and Evaluation of Rotator Cuff Pathology and Rehabilitation I 279 CHAPTER 4 Todd S. Ellellbecker IntelTelatiollship of the Spine to Ihe Shoulder Girdle I 95 CHAPTER 12 Dla Grimsby GIld John C. Gray Visceral Pathology Referring Pain to the Shoulder I 299 CHAPTER 5 John C. Gray Neural Tissue Evaluation and Treatment I t 3 t Robert L. Elvey alUl Toby Hall 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 Approach I t 53 Manual Therapy Techniques I 335 Peter I. EdgelolV Robert A. Do/lOtelli and Timothy 1. McMahon CHAPTER 7 Evalualion and Trcalment of Brachial CHAPTER 14 Plexus Lesions I t 79 Strengthening Exercises I 365 Bruce H. Greenfield and Dorie B. Syen Korell E. Davis and Robert A. Donatelli XL� CONTRIBUTORS 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 Color insert follows page 117. CHAPTER 17 Instabilities I 421 Al1gelo J. Mallalil10 CHAPTER 18 Rotator Cuff Repairs I 435 Joseph S. Wilkes Functional Anatomy and Mechanics ROB E R T A . DONATELLI One of the most common peripheral joints to be Osteokinematic and treated in the physical therapy clinic is the shoul­ der joint. The physical therapist must under­ Arthrokinematic Movement stand the anatomy and mechanics of this joint to most effectively evaluate and design a treatment Analysis of shoulder movement emphasizes the program for the patient with shoulder dysfunc­ synchronized movement of four joints: the gle­ tion. This chapter will describe the pertinent nohumeral, scapulothoracic, sternoclavicular, functional anatomy of the shoulder complex and and acromioclavicular joints.,,,·7 relate this anatomy to the h.lBctional move­ rus moves into elevation, movement must OCClIr ments, stability, and muscle activity. at all four joints. Elevation of the arm can be The shoulder joint is beller termed the observed in three planes: the h'ontal plane (ab­ shoulder complex, because a series of articula­ duction), sagittal plane (flexion), and plane of tions are necessary to position the humerus in the scapula (scaption)8,9 Movement of the long space (Fig. 1. 1). Most authors, when describing bones of the arm into elevation is refen'ed to as the shoulder joint, discuss the acromioclavicu­ osteokinematics. Arthrokinematics describes the lar joint, sternoclavicular joint, scapuloLhoracic intricate movement of joint surfaces: rolling, articulation, and glenohumeral joint.'- 4 Demps­ spinning, and sliding.lo ter relates all of these areas by using a concept of links. The integrated and harmonious roles of all of the links are necessary for full normal OSTEOKINEMATIC MOVEMENT mobilityS The glenohumeral joint sacrifices stability Scaplion-Abduclion for mobility. The shoulder is capable of moving in over 16,000 positions, which can be differen­ Abduction of the shoulder in the fTontal tiated by I' in the normal person 6 The mobility or coronal plane has been extensively re­ of the shoulder is dependent upon proximal sta­ searched.4,•. 11-1 7 Poppen and Walker1 5 and bility of the humerus and scapula. The position Johnston,' suggest that the true plane of move­ of the humerus and scapula must change ment in the shoulder joint occurs in the plane throughout each movement in order to maintain of the scapula. The scapula plane (scaption) is stability6 defined as elevation of the shoulder in a range 1 ( 1) Glenohllmeral joilll. 90% of its maximum length. between 30' and 45' anterior to the frontal plane (Figs. (7) Firsl costovertebral joinf. Greenfield et al.27 Soderberg and Blaschak23 and Hell· length·tension relationship of the shoulder ab­ wig and Perrin24 demonstrated no significant ductors and rotators are optimum in this plane differences in the peak IOt'que of the glenohu.. there is a the muscle is fully shortened. Medial tilting angle refers to the oped when the muscle length is approximatel} tilting of the scapula toward the sagillal plane. FIGURE 1. 1 The componenls o( Ihe shoulder joinl cOlI/plex.2o. tested in scaption versus the coronal plane. I. (3) Actol11ioc/avicultlr joilll. (2) SlIbdeltoid joil/I. production of different shoulder muscle groups Several authors believe that the plane o[ the when tested in scaption versus other body scapula is clinically significant because the planesn. respectively. (4) Scapulolhoracic joi11l. Fur- . (5 ) Slemoc/avicular joi/lI. (6) Firsl coslOslemal joinI. 22 the fTontal plane throughout the range of 15 0' Several studies have compared the torque of elevation. IS devised a new method for tak­ FIGURE 1.2 and 1.15 Research has demonstrated that meral rotators between scaption and other body the length of the muscle detelmines the amount planes." reported greater length-tension curves obtained from nOtmal torque production of the external rotators when muscle' show that maximum tension is dcvel. to the frontal plane. when As the medial tilting angle increases. These studies used 45' and 40' anterior of stretch applied to the individual sarcomeres. for the scaption enabling them to exert maximum tension.3).2I Therefore. Convel ely.I9 The test position. the optimal cage. The medial tilting angle was used to de­ scribe scaption.2 Elevatiol'l ill the plalle o( the scapula. I. of elevations. the tension devel· movement of the scapula around the thoracic oped is minimal. ing radiographs to define scaption during eleva­ tion.15 Kondo et al. Kondo et ailS demonstrated that the me· lengthened position of the muscle tendon will fa­ dial tilting angle was constant at 40' anterior to cilitate optimal muscle contraclion.2 PHY S I CAL THERAPY OF THE SHOUL DER 7 3"-_----� . Therefore. and scapulothoracic joints.4) Rolling occurs when various points on a ship. sternoclavic­ rotators are the only muscle group that demon­ ular. Full nexion from 162· to 18 0· is the frontal plane. torque when tested in the scapular plane at 30· and 35· anterior to the frontal plane.. Therefore. allowing for greater joint stability. The pectoralis major and the latissimus ARTHROKINEMATIC MOVEMENT muscles groups are not attached to the scapula. Gliding occurs when one point ferent planes of movement. The third laxeds Poppen and Walkeri' demonstrated that type of arthrokinematic movement. FUNCTIONAL ANATOMY AND MECHANICS 3 Plane of the scapula . not effect the optimal length-tension relation­ 1. avoidance There is little displacement between the two joint of impingement. the internal rotators exhibit no moving surface contact various points on a sta­ change in the torque output when testing in dif­ tionary surface. respec­ Flexiol1 tively. . acromioclavicular. . using a scaption position 35 · anterior to sagittal plane. of which there are tors. surfaces in rotation. for reasons of glenohumeral stability. gliding. I I I . on a moving surface contacts multiple points on In addition to optimal muscle length-tension a stationary surface. it would seen reasonable that when The motion OCCUlTing at Jomt surfaces is comparing the torque output of the internal rota­ arthrokinematic motion. . . I . . and balance of muscle action. I . possible only with synchronous motion in the The studies cited indicate that the external glenohumeral.( w FIGURE 1. . and rotation (Fig. III . " The move­ strated a significant increase in torque produc­ ment is similar to that of abduction.'6 reported higher ratios of trauma is minimal. I . .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. and the most advantageous abduction to adduction and external to internal plane for strength trainjng programs. Whitcomb et al. . When rolling or gliding relationship in the plane of the scapula. there is a Significant change in the contact sular fibers of the glenohumeral joint are re­ area between the two joint surfaces.. Flexion is movement in the planes. I . Thus." . rotation. face contact one point on a stationary surface. thermore. . tion in the scaption plane 30· anterior to the fron­ tal plane. scaption may be the plane in which shoulder All three arthrokinematic movements can .3 Abduction in t"e plane of the scapula. the change in position of the scapula should three types: rolling. Tata et a1. the cap­ occur. oc­ in scaption there is an increase in joint congru­ curs when one or more points on a moving sur­ ity. 4 Arthrokinematic molion occurr. In joints. berosity and the acromion to prevent bone im­ At more than 60°.16 muscle function. Poppen plane.'1g at the glenohumeral joint: rolling..8.' 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. 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. indicating almost pure rota­ essary for full coronal abduction even after the tion.'• Saha investigated the contact area be­ muscles. 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.4 PHYSICAL THERAPY OF THE SHOULDER Gleno-Humeral Jt. demonstrated automatic external rotation . indicating rolling or gliding. and gliding.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. and often between 30° and 60°.IO. A stiff shoulder has limited cap­ Rajendran. tuberosity to clear the acromion and the cora­ in the first 30°. indicating a rotation movement. occur at the glenohumeral joint. Rotation Gliding FIGURE 1.4. extensibility. there was minimal movement pingement. coacromial ligament. and restore the normal balance of face. rolation. and integrity and meral head from impinging on the glenoid rim.1 4.28 using cadaveric glenohumeral sular nexibility and altered muscle function. 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. but they do not order to reestablish harmonious movement occur in equal proportions.·2. External rotation also remains nec­ of the humems. FUNCTIONAL ANATOMY AND MECHANICS 5 of the humerus is an essential component of ac­ aments. responds to the forward inclination of the sca­ enhancing the ability of the muscle to participate pula. elevation may increase rotator cuff compression.-ia­ tation of the humerus. the radius of the three-dimensional orientation of the hume­ curvature of the humeral head was greater than rus with respect to the scapula.3• The disability. dense fibrous connective tissue but generally de- . Brems" repo'is that external rotation is with various movements. An increase in the moment arm enhances the and the poste. and is retroverted 20· to 30. In the remaining 30 percent. This articular surface is in­ erally. 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. functional Significance of the lab. rotation of the humerus increases the moment This retroversion of the head of the humerus cor­ a. especially on the tion.3 The retroversion. 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. Most authors agree that the labrum is Static SWiJilizers of the a weak supporting structure.or tilt of the head of the humerus ability of the superior fibers of the subscapularis to participate in scaption.37 . 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. 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. tion. Flatow et al.um is wedgeshaped when the glenohumeral allows glenohumeral elevation to move to com­ joint is in a resting position. 1 . Oti et al.'·3.'· Saha'· further for the calculation of glenohumeral joint rota­ described the joint surfaces.m of the superior fibers of the infraspinatus. 5 ) .34 The glenohumeral joint contributes the through abduction. so that fTee pendulum movements of the in scaption. The greater tuberosity and the glenoid labrum. Conversely.39 The function of the labrum has also been described as a "chock Glerwhumeral Joint block" preventing humeral head translation. and posterior. Saha35 arch and glenohumeral muscles. me­ sertion of the subscapularis tendon to move lat­ dial. Conditions limiting external rotation or bulation. which in turn at a given time. internal and the glenoid. the ordinate transformations were then performed joint was not a true enarthrosis. cultivate joint stability (Fig. and lab. Appropriate co­ the radius of curvature of the glenoid.s. 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.'· This CO'Te­ in closest proximity between 60· and 120· of ele­ sponds to the natural arm swing evident in am­ vation. glenohumeral lig. An Kn et humeral articulation in 70 percent of his speci­ al.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.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. to be very i'Tegular and to to the scapular plane required external axial ro­ demonstrate a great amount of individual va.um is ques­ tionable.29 used a magnetic tracking system to monitor mens.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. The glenoid fossa is a shallow prevents tendon impingement between the structure deepened by the glenoid labrum. and the bony gle­ tive as well as passive elevation of the arm noid. and changes shape pletion. Maximum elevation in all planes anterior head of the humerus. capsular ligaments. The head of the humerus is large in relation Rajendran and Kwek" described how the course to the glenoid fossa. Furthermore.. external rota­ confirmed the ball and socket joint of the gleno­ tion of the humerus was spontaneous. Thus. which per­ sive external rotation in the adducted position mits the glenoid to conform and seal to the hu­ more than any other anterior structure (Fig. Turkel et al. This inferior pOltion of the capsule lies in folds when the arm is adducted. causing weakness of this por­ tion of the capsule." The A capsule is reinforced anteriorly and postetiorly by ligaments and muscles.8 percent of the shoulders that they studied with radiographs. attaching on the anatomi­ cal neck. mid- . The cartilage is the thickest at the pe­ riphery on the glenoid fossa and at the center of the humeral head.6 PHYSICAL THERAPY OF THE SHOULDER The compressive load is provided by dynamic muscle contraction. rotation was resisted by the subscapularis.'6 The capsule and ligaments reinforce the gle­ nohumeral joint. Also.6) meral head. 4° retrotilt of the glenoid in 73. range of motion an average of 27046 Turkel et portance of an intact glenoid labrum in estab­ al.45 demonstrated at 45° abduction that external lishing a concavity compression stabilization. sistent structure. The glenoid fossa faces laterally. J . The inferior glenohumeral liga­ The glenohumeral joint has been described ment attaches to the glenOid labrum. A negative intra-ar­ cation of the shoulder. Saha" found a 7. these ligaments are not consistently present in each individual. (B) Retroversion of the hUl11erus as aments lend to the capsule is insignificant 44 seen frol11 above. The subscapularis resisted pas­ ated flexibility of the glenoid surface. The sUPPOtt that these lig­ epicol1dyies. surgical release of the ticular joint pressure is produced by the limited subscapularis increased the external rotation joint volume. The retrotilt is a stabilizing factor to the glenohumeral joint.5 (A) Rumenls with marker through The anterior capsule is reinforced by the gle­ the head-I1eck al1d a secol1d marker through the nohumeral ligaments. Both the humeral and glenOid articular surfaces are lined with alticular cartilage. and Munro" found that the glenoid faced down­ ward in 80.5 percent of nOlmal subjects. Turkel ct by Matsen et al40 as a "suction cup" because of al.. The capsule is a lax structure. This phenomenon is caused by the gradu­ ferent positions.45 determined the relative contribution to an­ the seal of the labrum and glenoid to the humeral terior stability by testing external rotation in dif­ head.45 described the inferior gleno­ void of cartilage except in a small zone near its humeral ligament as the thickest and most con­ osseous attachment. the head of the humerus can be distracted one-half inch when the shoulder is in a relaxed position. B The redundant portion of the capsule adheres to itself and limits motion in adhesive capsulitisJ6 FIGURE 1. The capsule attaches around the glenoid rim and forms a sleeve around the head of the humerus. Compression of the head into the In patients with internal rotation contracture socket expels the synovial fluid to create a suc­ and pain after anterior repair for recurrent dislo­ tion that resists distraction. There is no additional support inferiorly.1 Matson et al. Iigamel1ls and subscapularis muscle. rior and posterior portions. supraspinatus.8). At 90° of ab­ appeared to have no significant suspensory role. Stimulation of the posterior axillary ar- . duction. The coracohumeral ligament of the inferior ligament (Fig. glenohumeral ligament to be the main static sta­ the biceps (LI-lB) and short head of the biceps bilizers resisting infel'ior translation. of the Hoi et al. muscles.6 Exlernal rolalion of the humerus in FIGURE 1. Stimulation of the anterior capsuloligamentous restraints to superior and and the inferior axillary articular nerves elicited inferior translation o[ the glenohumeral joint. external rotation was restricted by the Abduction to 45° and 90° demon trated the ante­ inferior glenohumeral ligament (Fig. and infraspinatus the adducted shoulder was the superior glenohu.7 Exlernal rOlaliol1 o f Ihe humerus al Ihe adducled posilion. die glenohumeral ligament. J . A abduction and external rotation. Furthermore. and superior fibers meral ligament. 7). Warner et aJ48 studied the joint was identified. The mosl slabilizing struclLlres structure 10 this movement is the subscapularis for Ihis movemel11 are Ihe middle alld il1(erior muscle. The mosl stabilizing 45°abduclion. respectively. J . 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. The primary restraint to inferior translation of subscapularis. electromyographic (EMG) activity in the biceps. (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. FUNCTIONAL ANATOMY ANO MECHAN I C S 7 FIGURE 1. 'o Release of the dorsi.'o The scribed as steerers of the head of the humeills coracohumeral ligament limits external rotation on the glenoid. the amount and direction of translation de- . and teres minor act as hu­ coracohumeral ligament increased external rota­ meral depressors.5I Dtfnamic Stabilizers of the Glenohumeral JCJint The major muscles that act on the glenohumeral and scapulothoracic joints may be grouped into the scapulohumeral. The infe­ rior recess is referred to as the axillary pouch. The muscles of the scapulohum­ eral group. and sliding) of the glenohu­ 90' of abduction.5I The superior in most shoulder disorders. and satellite trigger points. Travell and ticular nerve elicited EMG activity in the acromi­ Simons" believe that a trigger point within the odeltoid muscle. The rotator cuff muscles insert on the tuberosities and along the upper two-thirds of the humeral anatomic neck. latissimus and elevation of the humerus. spinning. At the glenohumeral recess is the subscapular bursa. leading to major re­ Fibers of the capsule and coracohumeral liga­ strictions in glenohumeral jointmotion. 165. subscapularis may sensitize the other shoulder The coracohumeral ligament is the strongest girdle musculature into developing secondary supporting ligament of the glenohumeral joint.'o meral joint result from the action of the steerers Between the supporting ligaments and mus­ and the depressors of the humeral head. Arthrograms of frozen shoulders in relatively early stages. ary to trauma or microtrauma. ment blend together and insert into the borders The rotator cuff muscles have been de­ of the supraspinatus and subscapularis. resulting in re­ strictions in external rotation in neutral and lim­ ited glenohumeral elevation. axiohumeral.10 The subscapularis muscle is often overlooked in shoulder dysfunc­ tion. teres major. Anteriorly tion of the humeral head is of clinical interest there are three distinct recesses.8Extemai rotatio" of the humerus at subscapularis muscle. Transla­ cles lie synovial bursa or recesses. and axiosca­ pular muscles.8 PHYSICAL THERAPY OF THE SHOULDER communicates with the shoulder joint. and the middle synovial recess lies posterior to the subscapularis tendon. Many times trigger points 90·abduction. It has the largest amount of muscle mass of the four rotator cuff muscles4 As previously noted. 1 6 The subscapularis. The most stabilizing structure for develop within the subscapularis muscle second­ this movement is the inferior ligamem. before gleno­ humeral abduction is completely restricted. passive external rotation range of motion with the ann neutral (adducted) is resisted by the FIGURE 1. show obliteration of the anterior glenoidal bursa. which normally joint. originate on the scapula and insert on the humerus. 3 The arthrokinematics tion both with the arm held in adduction and at (rolling. which include the rotator cuff mus­ cles. 9).4 Michiels and Bodem57 demonstrated that deltoid muscle action is not restricted to the gen­ eration of an abducting moment in the shoulder joint. Thi active control of the translation lation that binds the shoulder girdle to the axial forces provides dynamic stability to the glenohu­ skeleton (Fig. and reinforcing mus­ Abnormal glenohumeral translation is ob­ c1es.'8 on the shaft of the humenrs at the deltoid tuber­ cle. SS The disc binds the joint together and di­ served most often in overhead throwing athletes.orly. ligaments. tween 20' and 90' averaged 9 mm supel. Perry55 describe 17 muscle groups sternal articulating surface greater than the cla­ providing a dynamic interactive stabilization of vicular surface. This is a sellar joint. and first rib. The section of the capsule may produce microtraumatic injuries and possi­ from the disc to the clavicle is more lax. Further allowing more mobility here than between the examination of the dynamic stabilizers in the disc. FUNCTIONAL ANATOMY AND MECHANICS 9 fine the type of instability.4 The deltoid At the other end of the clavicle is the acromioclav­ is a multipennate and fatigue-resistant muscle. sternohyoid. ligament reinforces the capsule anteriorly and The deltoid muscle makes up 41 % of the infel. vides the joint into two cavities. and arises from the clavicle. espe­ mion process and the spine of the scapula. therefore bly instability of the glenohumeral joint. 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. with the meral joint.4 This muscle. sternum. The mechanical advantage of the deltoid is enhanced by the distal insertion and the evolu­ Acromioclavicular JrJint tion of a larger acromion process.orly and 4.eI1iscus and upper and lower ligaments or force was significantly decreased by both the the sternoclavicular joint. The costoclavicular ligament con­ scapulohumeral muscle mass. joint capsule. providing stability to the joint. The capsule sur­ Loss of coordinated balance between accelerat­ rounds the joint and is thickest on the anterior ing. in nectS the clavicle to the first rib. 10 the composite movement of the thoraco-scapu­ The joint is also stabilized by its articular disc.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. 10 The interclavicular throwing athlete will be discussed in Chapter 2.9 The upper and lower allachmel1ls or placement of the humeral head under 1. 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 . decelerating.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. lar-humeral articulation. . Wuelker et al.4 mm anteriorly. The clavicular and scapular regions of the deltoid muscle group afford stability to the gle­ nohumeral joint. icular (AC) joint. The anterior dis­ FIGURE 1.5 kg the lII. This articulation is character­ This may explain its rare involvement in shoul­ ized byvariability in size and shape of the c1avicu- der pathology. and stabilizing muscle function and posterior aspects. also cially the sternoclydomastoid. 10 The SC joint addition to its proximal attachment on the acro­ gains increased stability fTom muscles.5 . 1. The distal insertion is sternothyroid. trapezoid.1. articulating with a muscle function and joint kinematics allow nor­ convex girdle. (From Schenkmal1 and Ru go de Cartaya!S with permissiol7. The middle or "critical phase" is 60' to joint. 1 1). and it can occur in an infinite number of body planes. at the AC joint. 10) are all controlled and facilitated by the conoid. Steindlel. It is through the is largely dependent on the relationship of the conoid and trapezoid ligaments that scapula mo­ scapula and the humerus. except meniscus. vertical axis for protrac­ tion and retraction. but it is an important physiologic joint that 140'. 1. contributing to marily stabilized by muscles.41 ScapukJtJwracic Jaint Shoulder elevation can be divided into three phases. 1. the acromioclavicular ligament. 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. The importance of the increased incidence of dislocations. (c) HoriZOl1lal axis (or elevatiol1 and depression. (h) Vertical axis (or protraction and retraction. The scapula is concave. The stable base.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 initial phase of elevation is 0' to 60' The scapulothoracic joint is not an anatomic degrees. and lectively called the coracoclavicular ligament and therefore the mobility of the glenohumeral joint. The stemal end o( the scapula is on the le(t. thus a greater degree of and coracoacromial ligament. fined as the movement of the humerus away from the side. adds considerably to motion of the shoulder gir­ Specific to each phase of movement. (a) Lon gitudinal axis o( rotatioYl. and horizontal axis for eleva­ Punctional Bimnechanics tion and depression (Fig.55 The scapula is without bony mal pain-free motion.10 PHYSICAL THERAPY OF THE SHOULDER b a FIGURE 1. Lon­ gitudinal axial rotation. and As previously noted. The scapula is pri­ movement occun.10 Axes o( l11otio/1 o( the clavicle. The final phase of elevation is 140' to 180'.) lar facets and the presence of an intra-articular or ligamentous connections to the thorax. The conoid and trapezoid ligaments are col­ and stability (Fig. precise dle.59 maintain stability6 joint rotation occun'ing around three axes. Analysis of the precise . shoulder elevation is de­ acromioclavicular ligaments.5 8 The AC joint capsule is more lax than for its attachments at the acromioclavicular joint the sternoclavicular joint. Poppen and Walker14 stages of abduction. infraspinatus.SJ re­ equal proportions. The deltoid muscle also demonstrates EMG ° INITIAL PHASE OF ELEVATION: 0 TO 60 ° activity in the initial phase of elevation. The sub­ scapularis. the head of of the deltoid muscle produces an upward shear the humerus moved superiorly in the glenoid by of the humeral head. port EMG activity of the upper and lower por­ spin.' Kadaba et al. The EMG activity of the su. the loading vector is beyond also studied the instant centers of rotation for the upper edge of the glenoid. force of lower lrapezius. FLT.) components critical for each phase of shoulder praspinatus muscle indicates an early rise in ten­ elevation will determine the success of clinical sion. 1 1 30� (8) Axis o{ scapular rOlalion {rol1l 30°10 60° (FUT' (orce o{ upper lrapezius.65 wilh perl11issiol1. while that in the lower subscapularis in­ with elevaLion in abduction and in scaption.15 In the early superiorly 1. These movements-roll. 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. the pull orten between 30· 60· of abduction.·2 abduction. but they do not occur in the initial phase of elevation.' 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. They reported that in the first 30· and During the initial stage of elevation. humeral joint surface.'· Saha·o and Sharkey phase of elevation. producing a compressive force to the gleno­ management of shoulder dysfunction. 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. The creased as the elevation reached 90·.5 mm by 120°. transverse compressive [orees of the rotator cuff .) (Modified (rol11 Schel1kl11al1 al1d Ruga de Cartaya. F SA force o{ serralus anlerior. 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." 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. and teres minor mus­ All three arthrokinematic movements occur at cles are important stabilizers of the humerus in the glenohumeral joint. The forces at the abduction and maintains a plateau level of activ­ glenohumeral joint were recorded and applied ity.4 infraspi"atus (I) lIIuscies.53 The deltoid muscle 1. 22 percent (Fig.. to scapulothoracic mobility during the initial The resultant acting forces."3 The initial phase of arm elevation is refelTed to by Poppen and elevation: deltoid. scapular rotation during the early phase of arm the resultant force and the shearing forces of the abduction. Bagg and For­ tion.3 Supraspinatus EMG activity peaks at 100° to the shoulder muscles at a constant ratio ap­ of elevation and rapidly diminishes thereafter. dynamic stability must be initiated be­ The middle or critical phase of elevation is initi­ fore further progression of pain-fTee movement ated by excessive force at the glenohumeral joint. Shoulder ab­ duction is accompanied by clavicular elevation. ity at 90° of abduction. Wuelker et al. In the early part of the criti­ 60° TO 1000 cal phase.15 The subscapularis. 2 .12). 26 percent.1S The primary function of the sub­ scapularis muscle is to depress the humeral . Movement of the scapula is permitted by movement in the AC and SC joints.54 simulated muscle forces reaches maximum EMG activity at about 110° of under the coracoacromial vault. The resu/talll reactive The instantaneous center of rotation (lCR) force (R) is therefore 1II0re favorably placed of the scapula during the initial phase of eleva­ within the glenoid fossa for joint stability.6 times the limb weight or 0. and infra­ occurs about the lower midportion. 43 percent supraspinatus. the shearing force of the del­ of the subscapularis muscle showed more activ­ toid muscle is maximum at 60° elevation (Fig..53 At 60° (abduction). The subscapularis activity decreases substan- . 1.'·1S Dynamic stability of the glenohumeral joint is established by the balance of shearing and MIDDLE OR CRITICAL PHASE OF ELEVATION: compressive forces.3. counteracting the superior migrating force of the deltoid. and latissimus dorsi muscle have small lever arms that form 90° angles to the glenoid face. the down­ ward (short rotator) force was maximal at 9." head. which are stabi­ phase of elevation. can occur.3 with shear and compressive forces equal"' es ary rotatory force couple to produce upward As the arm reaches the end of the critical phase. Peak contribution fTom scapular rotation dUl.12 PHY S I CAL THERAPY OF THE SHOULDER muscles. The relative spinatus/teres minor. As previously noted. scapula rotation percent.ng the forces under the coracoacromical vault OCCUlTed initial phase of elevation is considerably less between 51° and 82° of glenohumeral joint eleva­ than from glenohumeral motion. These force values may represent the patho­ est"3 estimated a 3. There are localed outside the glel10id fossa. tion is located at or near the root of the scapula spine in line with the SC joint. infraspinatus. the deltoid reactive force (D) is ing the initial phase of aim elevation. This force is 4° SC movement for each 10° of shoulder abduc­ counteracted by (he transverse compressive tion' The acromioclavicular joint moves pri­ forces of the supraspinatus (S) and marily before 30° and after 135°.42 times the body weight.' proximating physiologic conditions of shouldel. 9 Walkerls as the selling phase. are maximum at 90° of eleva­ lower serratus antedor muscles provide the nec­ tion.13).12 [" the early stages of glenohumeral Sternoclavicular elevation is most evident dur­ abduction."3 deltoid are almost zero.29 to I ratio of glenohumeral mechanics of shoulder impingement. FIGURE 1. subscapularis. produc­ ing compressive forces to the joint. the lower fibers As previously noted. The upper trapezius and lizing to the joint. 63 DUling the middle phase olher auI. FUNCTIONAL ANATOMY AND MECHANICS 13 humeral motion to every degree of scapular mo­ tion from 20. The rotation of the scapula The head of the humerus demonstrates an about the AC joint is initiated between 60° and excursion of I to 2 mm of a superior and inferior 90' of elevation63 Clavicular elevation is com­ glide on the glenoid surface. At and glide is occun·ing in opposite directions. lrallslatory (orce o( tion about the SC joint. migrate towards the AC joint. lower trapezius. ( FRR rolalOlY (orce o( rolator cuff. Therefore. The most common paltern had 3.. the ratio of eral movement. aClirlg all Opposile these two joints changes throughout the range sides o( axis o( malian. and lower serratus anterior muscles. coupled with scapular deltoid. translatory force of rotator cuff." proposed that the sig­ nificant role of the scapular rotators during the critical phase of elevation is secondary to the rel­ atively long moment arms of the upper trapezius. The relative contribution of cuff muscles. I' The movement of pleted between 120° and 150° of humeral abduc­ the humeral head in a superior and inferior di­ tion63 Clavicular elevation at the AC joint per­ rection after 60' of elevation indicates that a roll mits maximum scapular rotation.' tion at the AC end.29' of motion63 The ICR of the scapula has relocated .) {Modified (rom Schenkmal1 and de rotation about the AC joint.8' scaption. the greatest relative amount of scapular rotation occurs be­ tween 80° and 140' of arm abduction63 The ratio of glenohumeral to scapulothoracic motion has been calculated to be 0.71 to I during the middle phase of elevation. of abduction.71' for scaption be­ tween 81. because of the clavicular rotation around tially after 130° of elevation.'2 along with Freedman and Munro. Motion can occur at the AC joint with less movement occuning at the SC joint. indicating relatively more glenohumeral ment.49 with varying ratios of humeral to scapular move­ to I. FRO.) scapular mobility. Movement of the scapula is permitted by movement of the acromioclavicular and sterno­ FIGURE 1. The humeral component decreased to 0. facilitates normal Carlaya.8° and 139. the scapula rotators provide an impor­ tant contribution to elevation of the humerus in the plane of the scapula. As previously noted.63 external rotation of the humerus is critical for elevation (abduction) of the arm. during the middle phase of elevation. the ICR of the scapula begins to FTR. Clavicular eleva­ rolalory (orce o( delloid. Each pattern had three phases glenohumeral to scapulothoracic motion is 3.8' to 8 1. Trallslalory (orces cancel each of rotation (ICR) lies.64 Doody et al. 0 0 FINAL PHASE OF ELEVATION: 140 TO 180 8agg and Fon·est63 evaluated 20 subjects and found three distinctive patterns of scapulohum­ During the final phase of elevation.13 Force cOl/pie o( deltoid al1d rotalor clavicular joints.' The double-curved clavicle acts cept that antelior ligament stability is critical be­ like a crankshaft permitting elevation and rota­ yond 130° of elevation.65 wilh pemlissioll. supporting the con­ its long axis. FTO. Therefore. re­ approximately ISO' of elevation the ICR of the sulting in a spin of the bone. scapula is in line with the AC joint.1°. combine 10 produce of motion depending on where the instant center upward rOlaliol1. ROlalory (orces. observation of limited passive the humerus away fTom the scapula. Good extensibility of the latissimus. scapulothoracic movement shifts. infra­ the laller. providing stability. 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. Lack of elongation of these muscles pre­ movement is once again dominated by the gleno­ vents the normally dominant movement of the humeral joint. Most studies involving shoulder anatomy and bi­ Summary oj SIuruJJJ. The activity the upper trapezius muscle has reduced in of the supraspinatus. The early phase during the final phase of elevation. 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. As the humerus elevates towards the end of The middle phase of elevation is referred to the elevation range of motion. The rotatory force arm of ing force at the glenohumeral joint. The physical therapist should keep this variation in mind The initial phase of elevation occurs predomi­ when treating an individual patient. or a combination in the initial phase of elevation. the pula. as an inferior and superior glide of 1. 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. standing of the anatomy and biomechanics of this joint can help provide the physical therapist with a rationale for evaluation and treatment. with the majority of movement OCCUlTing upper and middle trapezius. humeral elevation may exhibit elevation of the chest cavity. teres minor. An under­ mobility in passive terminal elevation. At the beginning of the criti­ itself fTom the scapula. teres minor. The ratio of glenohumeral to is 3. teres minor. with various joint surfaces adding to . nantly at the glenohumeral joint.er Phases oj omechanics reveal a common pallem along with Mavenumt a wide variation among subjects. Good extensibility of the latissi­ humerus at the end of the elevation range. The shoulder is an inherently mobile the deltoid muscle produces this superior shear. movement will occur at both ends. acting as an of scapula movement is described as the selling upward rotator and opposing the forces of the phase. or both. secondary to increased protraction of the sca­ During the final phase of elevation. maxjmum shearing forces of the del­ ratio of glenohu meral to scapulothoracic motion toid muscle occur. teres major.63 at the glenohumeral joint. complex. If muscles connecting the humerus and rib cage are not Ilexible enough.49 to I . The activity of of the two. The increased scapula movement is spinatus. pectoralis major. teres major. ciate itself from the scapula. length. it must disengage as the critical phase.14 PHYS I CA L THERAPY OF THE S H OULDER upward and laterally. As previously noted. emphasizing pectoralis major. A 3-mm supe­ Treatment may be directed toward restoring rior glide of the humeral head has been observed mobility.5 mm. l often mus. The latissimus and pec­ Summary toralis major muscles connect the humerus to the rib cage. the cal phase. The bulge is usually the inferior angle. a bulge of the scapula is noted the humerus on the glenoid has been observed laterally. Often with passive The arthrokinematic movement of the head of humeral elevation. observe tightness of the subscapularis muscle. and subscapularis muscles is necessary to allow teres major muscle. 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. infraspinatus. 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. the increased and unconstrained movement of Furthermore. SalTafian SK: Gross and functional anatomy of tensibility in children with cerebral palsy. WB Saunders. Williams P (eds): Gray's Anatomy. Poppen NK. A review. Nearly 20 1 4. 1 980 the traditional frontal plane versus the plane o f 8. Tardieu C et al: Physiologi­ I . Br J Surg 25:252. Welsh RP (eds): Surgery of the Shoulder. Thomas Dodd. ner. 1 987 gram. Soderberg GJ. Arch Phys Med Rehabil 46A:49. Perrin DH: A comparison of two posi­ 7. 1 970 lies on various stabilizing mechanisms. At times.). J Orthop 1 0. Blaschak MJ: Shoulder in.h British Ed. 1 976 1 6 . J Ana. Ng L. Wilkes reference for movements occUlTing at humero­ J: lsokinetic evaluation of shoulder rotational scapula joint. J Bone Joint 22. Clini­ the shoulder.elli R . Abbotl LC: Observations Med Rehabil 63:97. Waterland JC: Shoulder movements during abduction in the scapular curs at the expense of stability. Am J Spo. Kent BE: Functional anatomy of the shoulder cal and structural changes in the cat's soleus mus­ complex. Williams PE. 1 978 20. the arm. FA Davis. Freedman L. Charles C Thomas. and joint. 1 99 1 muscle actions in the scapular plane. 1 993 35. Clin Ol1hop 1 35: 1 65 . Saha AK: Mechanics of elevation or glenohumeral ing shapes of joint surfaces. Sports Phys Ther 1 8:654. Arch plaste. 1 990 graphic analysis of the glenohumeral muscles 26. Am J strength I"alios dudng concentric and eccentric Sports Med 1 9:264. Walker PS: Forces at the glenohu­ muscles act on this joint complex in some man­ meral joint in abduction. 1 983 cal and experimental observations. CV Mosby. Kelley MJ. I . Goldspink G: Changes in sarcomere Icngth and physiological propcl-tics in immobi­ References lized muscle. Arch Surg 26A: 1 . Kondo M. Wooden MJ. The shoulder re­ plane. Leiper CI: A comparison . 1 95 .· casts. Greenfield BH. 1 973 27. 1 992 24. muscles dllling a shoulder rehabilitation pro­ J Orthop Sports Phys Ther 8:5 1 8 . Philadelphia. Harmonious actions of these 1 5 .1S Med 20: 1 28. 1 982 on the function of the shouldcrjoinl. FUNCTION A L ANA TOMY AND M E C H A N I CS 15 the freedom of movement. Acta Orthop Scand 44: 6688.ernal ment. Walker PS: Normal and abnormal muscles are necessary for the full function of this motion or the shoulder. Moseley JB et al: EMG analysis of the scapular through a velocity spcCl!um in di ffering positions. 1 97 1 cle due (0 immobilization at di fferent lengths by 2 . Tabu. Tardieu C . 1 99 1 plea ror use of "plane of the scapula" as plane or 25. Jobe F. includ­ 1 3 . this vast mobility oc­ 1 2 .eman JE. Poppen NK. Taba. 1 27 : 459. JohnsLOn TB: Movements or the shoulder joint: . 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. C. Pen). Codman EA: The Shoulder. [sokin Exerc Sci 1 : 202. Wa. In Ga. Dona. ligaments. Hellwig EV. 1 973 muscles to prevent excessive motion. Dempster Wf: Mechanism of shoulder move­ 23. 1 973 2 1 . 1 937 strength between the plane of the scapula and the 9.). Philadelphia. Philadelphia. Clin Orthop Rei Res 1 73 : II . 1 944 Surg 1 07:425.wick R. Arch Phys Med Rehabil 5 1 d : 595. Whitcomb W. Tata EG. Kramer IF: Shoulder antagonistic during a baseball rehabilitation program. 1 965 and external rotation peak torque production 6. Bos­ 'on. Phys Ther 5 I :867. Huet E. The shallow glenoid I I . with its flexible labrum and large humeral head 1 966 provides mobility. Arch Phys 4. J Bone Joint Surg 58A: joint. 1 934 1 8. 1 96 1 1 7.he scapula. Lucas 0: Biomechanics orthe shoulder joint.1S Med 1 8: 1 24. Am J SpO. J Physiol 224:23 1 . 1 984 1 9. 1 972 Surg 1 07:425. Pink M . Spring­ field. Clin Or­ tions for assessing shoulder rotator peak torque: thop 1 46:37. Lucas 0: Biomechanics o f the shoulderjoint. JC. Saunders M . Bechtol C: Biomechanics of the shoulder. Doody SG. and at variolls limes can be both prime mov­ 1 978 ers and stabilizers. Townsend H . BreL M D et a l : Muscle hypoex­ 3. Calliet R: Shoulder Pain. Tazoe S. Saha AK: TheOl)' of Shoulder Mechanism: De­ scriptive and Applied. 1 973 5. J : Electromyo­ fTontal plane. Inman VT. I L . Pagnani MJ. 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. Am J SpOJ<S Med 20:675. Churchill Living­ 4 1 . Miniaci 3 1 . J Bone Joint Surg muscles with abduction and rotation. Knatt T. MacDonald PS. Hanyman DT. (eds): 1 994 Practical Evaluation and Management of the 55. 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. Torzilli PA: 34. Basmajian J : The surgical anatomy and function sional kinematics of glenohumeral elevation. 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. Flatow EL. The stabiliz­ Static capsuloligamentolls rcstraints to supc­ ing function of passive shoulder restraints. 1 993 static translation experiments. An KN. simulated active elevation. Cole MF. Turkel SI. In Matson FA. 1 9 9 1 cular wire electromyography of the subscapularis. Warner JJ. Singapore Med J 33:493. Edinburgh. Itoi E. Panio MW. WB Saunders. Fowler PJ. tice. Philadelphia. Am J Spons Med 22:779. 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. 1 992 32. Slides JA et al. I n Shoulder.'ccun'cm antedor dislocation of the shoulder. Fl'eedman L. Kuechle DK. Vol 1 . TefT). 1 963 3 0 . Brems JJ: Rehabilitation following lOlal shoulder 75:546. Am J dor-infel-ior translation of the glenohu meral Sports Med 1 99 1 . Clin Ol1hop 307:70. 1 7 . Churchill Livingstone. Travel l I. WB Saunders. Clin Sports Med 53. J Or­ of the aml-tnmk mechanism. J Boneloint 63A: 1 208. Browne AO. 1 994 48. Rajendran K: The rotary innucnce of articular 43. Am J Sports Med 23: 1 995 Ed. In DeLee IC. Wuclker N. Kadaba M P . Drez D. Wooten P et al: [ntramus­ 1 0:757. liang CC. 1 992 1 970 29. 1 9 9 1 43 : 1 475. 1 992 with special reference to the glenoid labrum and 5 1 . A roentgenographic study. 1 988 meral instability. 1 993 Am I Phys Med 60: 1 1 1 . Moseley I-IP. Schmotzer H. 1 9:26-34 joint. 1 97 1 ergistic action of the capsule and the shoulder 36. 1 98 1 . p. Am and the long head or the biceps. Korinek S et al: Three-dimen­ 44. Churchill Livingstone. Hammon D. Saha AK: Dynamic stability of the glenohumeral 49. Soslowsky U. Singapore Med Koy et al: Stabilizing function of the biceps in sta­ 1 32:242. Matsen FA.16 PHYSICAL THERAPY O F THE S H O UL D E R o f torque production during dynamic strength 42. 1 986 SO. Baltimore. 2nd muscles. J Bone Joint the shouJder: mm'phological and clinical studies Surg 74A:53. Williams & shoulder stability based on selective CUlling and Wilkins. Warren RF. 1 966 28. Sidles JA. WalTen RF. GC. 1 968 aJ: Translation of the glenohu meral joint with 40. Deng XH. J Bone Joint Surg 50B:858. Limb. Thren K. Bowen MK. (cds): Or­ 56. Glenohu­ stone. Kwek BH: glenohumeral abduction 47. Korell M et i n man. 1 99 1 ble and unstable shoulders. New York. 1 995 Joint Surg 48A: 1 503. Lippitt SB. 39. Guanche C. Clin Orthop 309: 1 93 . Russell FW: Ligamentous control of function. Thc T'. Hagberg M: Electromyographic signs of shouldcr thopaedic Sports Medicine: Principles and Prac­ muscula. Am J Sports 9 1 3 . New York. Slidies IA et al: Stability. 1 993 Rowe CR (cd): T h e Shou lder. 1 994 46. Matsen FA: 37. J 1 994 Bone Ioint Surg 74A:734. Acta 011hop Scand 42:49 1 .gger Point Manual. I Ol1hop SpOl<S Phys movements. Girgis FG: Sta­ J C . 1 98 1 Surg 76-A:667. Pen')' I: Muscle control or the shoulder. Kessell L: Clinical Disocders or t h e Shoulder. Philadelphia. Solomonow M et al: The syn­ joint. France P et al. J Bone Joint SlIrg Br 33. 1 993 arthroplasty. Simons D: Myorascial Pain and Dys­ 38. 1 979 52. Marshall JL. J Bone Ther 2 1 :227. .Upper contours during passive glenohumeral abduction.' fatigue in two elevated arm positions. MUlTey BF. Surg Clin North Am thop Res 9: 1 43 . 1 992 the an terior capsular structures o f t h e shoulder 54. Hawkins RJ. Galinat BJ. J Bone Joint Surg 448: capsular mechanism of the shoulder. Lippitt SB. Reeves B : Expcdmcnts i n t h e tensile strength o f I OJ<hop Res 1 0:394. KlImmeil BM: Spectrum of lesions of the anterior glenohumeral ligaments. 1 962 Med 7 : 1 1 1 . Kapanji [A: The Physiology or the Joints. Han-is SL. 1 992 35. Rajendran K. Newman SR. Oti 45. 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. 1 983 65. CV Mosby. Clin Ol1hop 1 73:3. 1 95 5 64. Michiels I . Bagg DS. duction in val"ious body POStUI-eS. 1 986 nohumeral joint. Moseley HF: The clavicle: its anatomy and func­ 63. Under NOlmal and Pathological Conditions. 1 995 . J Orthop Sports Phys superior translation of the humeral head. Steindler A: Kinesiology of the Human Body scapular plane. 1 968 or scapular rotation during arm abduction in the 59. lnt Orthop 1 6: In Bateman S. Schcnkman M. Clin Orthop Res 58: 1 7 . Am J Ther 8:438. 1 988 Charles C Thomas. St. 1 992 Shoulder. Louis. 1 984 58. Springfield. 1 987 SP0l1S Med 23:270. IL. Rugo de Cartaya V: Kinesiology 6 1 . FOITest WJ: A biomechanica1 analysis tion. FOITest WJ: Electromyographicstudyof 6 0 . Sharkey NA. FUN C T IONAL ANA T O M Y AND MECHANICS 17 57. Himeno S. Am J Phys Med 65: I I I . Tsumura H: The role of the rOlatal' lromyographical analysis of its activity in arm ab­ cuff as a stabilizing mechanism or the shoulder. Welch P (cds): Surgery of the 268. Marder RA: The rotaLOr cuff opposes of the shoulder complex. Am J Phys Med Rehabil 67:238. Bagg DS. Bodem F: The deltoid muscle: an elec­ 62. These disa­ phases: ( I ) windup. and ends when the forward foot makes 19 . p. '-'o aSSigned task. Electromyographic sequence activity ap­ muscular system and have invested many hours pears fairly consistent regardless of generated of sport-specific training. Its purpose is to organize the body be­ bicipital tendon. (4) acceleration. they represent a very small percentage ward by the deltoid and supraspinatus. (3) late bilities include neurologic entrapments and cocking. Those who have accomplished are less than those produced in a competitive this skill often demonstrate a heightened neuro­ arena. insta­ WINDUP bilities due to derangement of the glenoid. The windup is an activity that is highly individu­ subdeltoid bursitis. fracture of the hu­ form in sequential links to enable the hand to be merus. sec­ ondary impingement due to instabilities. 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.-imary impingement . first 3D· of elevation as the arm is brought up­ however. SLAP (superior labrum anterior to posterior) lesions. subluxing alized. As with tor cuff. The hand can be placed in an infi­ Injury to the glenohumeral complex as a re­ nite number of localities. and (5) follow­ compression syndromes.ing. fTacture of the coricoid. This unique athletic velocities. it is vital that the body per­ lesions of the humeral head. Through­ of the disabilities associated with the overhand out the windup phase there is no consistent pat­ throw. Throwing Injuries J EF F COO PER To throw a baseball with high velocity and with in a controlled environment. OuerlU1:nd Throwing EARLY COCKING 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. all overarm activities. undersurface tears of the rota­ neath the arm to form a stable platform. tern of muscle activity due to these many individual styles. It is assumed that great accuracy is a skill that escapes the majority the forces recorded during these data collections of the population. full-thickness tears of the rotator cuff. posterior capsu­ in the correct position in space to complete the lar syndrome. (2) early cock. and muscle imbalances. 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. The causes the healing process to fall behind that of drawing of the humerus into the moment center the rate of stress. Chronic overuse mum setting for the task of propulsion. joint degeneration. Macrotrauma injuries such as of the glenoid fossa is accomplished during the fractures of the humerus have been reported. acromioclavicular through. biceps tendinitis. This torque develops 27 . Follow-through is the time beginning with the It remains active until the completion of late release of the ball. At the end as the arm is decelerated. The hand follows the ball Supraspinatus. and ends when the humerus begins in­ der. ward flexion and is marked by a maximum inter­ As the body moves fOr\vard. The lattismus dorsi and mately 30° of horizontal extension.0000/s. brum. the humerus is nal rotation of the humerus.20 PHYSI CAL THE R A P Y OF T H E SHOULDER contact with the mound. with a minimal external rotation of approximately 50°. 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.'6 reported peak accelerations approaching Late cocking is the interval in the throwing mo­ 600. " 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. Deceleration FOLLOW-THROUGH of the externally rotating humerus is accom­ pl ished by the contraction of the subscapularis.000 inch tion when the foot makes contact with the pounds of rotatory torque produced at the shoul­ mound. The forces developed in this instant reflect the body's amazing ability to develop power and encase itself in a protective mechanism. 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. During this time the humerus is kinetic energy in the humerus. At this time pectoralis major develop the power to the for­ the static stability of the humeral head becomes ward-moving shoulder. 5 reported 1 4. notably the inferior glenohumeral liga­ into medial rotation. This is a aids in maintaining the humerus in the glenoid very active phase for all glenohumeral muscles by producing compressive axial load. 1 98°/s.000 inch pounds of ternal rotation. The biceps brachii before finishing in internal rotation. The extreme of external ro­ humerus is positioned slightly behind the for­ tation. Pappas LATE COCKtNG et al. of external rotation. Gainor et al. '6 The scapula is protracted and ro­ meral head in the glenoid. Within the first tenth of a sec­ cocking. ratus anterior. supra- . 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. This is accomplished with the Acceleration is a ballistic action lasting less than activation of the anterior. minor are active in this phase but become quiet once external rotation is achieved. 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 infraspinatus. The ball is accelerated deltoid. The subscapularis activ­ dependent upon the ante!ior margin of the gle­ ity is at maximum levels as the humerus travels noid. The scapula is retracted the biceps. 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. middle. when the with the upper body. teres minor. The arm continues into for­ essary angle of the elbow. 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. and teres after release and is unable to apply further force. and posterior one-tenth of a second. The humerus is brought into posi­ tion of 90° of abduction and horizontal exten­ ACCELERATION sion. i nfraspinatus. The triceps develops strong ment and the inferior portion of the glenoid la­ action in accelerating the extension of the elbow. 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. The capsule becomes wound tight in and maintained against the chest wall by the ser­ preparation of acceleration. infraspinatus. Professional cocking phase. 's During the second phase The deltoid. consisting of the subscapularis. 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. These muscles are necessary to protract cocking. the internal rotators. pectoralis major. pectoralis major. poses a traction force within the glenohumeral jOint. supra­ of throwing. . Gowan et al. that the mildly increased activity of the biceps the windup. had de­ activity in the supraspinatus. early and late cocking. 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. '2 conducted a study to determine supraspinatus. The professional pitchers had decreased toralis major. " 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. uninjured throwers. and latissimus dorsi had de­ nally rotate the humerus. This series '9 tested the activity of the biceps. creased activity. Activ­ centric loads are produced. There was As noted with the impingement group. the inter­ also increased activity in the serratus anterior nal rotators. There were and supraspinatus may be compensatory for the no significant differences in the follow-through. trapezius. infraspinatus. They their electromyographic studies compared with are least active during the acceleration phase. spinatus developed a pattern of activity during During the acceleration phase. During early cocking and late eration. rized that the combination of these differences and triceps brachii. The authors suggest were noted in the first three phase of the pitch. sen'a­ t1. professional early cocking. The serratus anterior followed This group consists of the subscapularis. early and late cocking. tion. and biceps continued deltoid activity while the healthy ath­ brachii comprise this first group. if the muscle-fjring sequence of professional subscapularis. infraspinatus. Noted were differences in every muscle amateur pitchers. Versus Amateur by glenohumeral instabilities were compared to Pitchers normal athletes in a similar fashion. accel­ this time period. )atlismus dorsi. superior is not included in either group due to its nonspe­ humeral migration. and creased activity. The serratus anterior showed de­ pitchers used the subscapularis predominately creased activity as well. teres minor. latissimus dorsi. external rotators. middle deltoid. 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. the injured athletes spinatus. It was theo­ llis anterior. The first phase of throwing may lead to increased external rotation.is pattern and was less effective. subscapularis. early cocking. and again increasing in the follow-through. letes had deceased deltoid activity. Throwing athletes who have been hampered ProfessimwJ. laxity present in the anterior capsule. T H R O WI N G INJU R I E S 21 spinatus. No significant differences except the middle deltoid. 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. toralis major and lattisimus dorsi. and serratus an­ pitchers was S ignificantly different from that of terior. and extend the elbow. The infra­ where muscle activity was described as general. horizontal forward flex and inter­ petoralis major. and impaired scapular rota­ cific generalized activity. the scapula. and subscapularis are all active as ec­ during acceleration and internal rOlation. reduced activity during late cock­ pitchers recorded increased activity of the pec­ ing. and lattisimus dorsi. pec­ muscle. which was marked in the early teres minor during the acceleration. Group I presents pure sor." . The scapular rotators react nohumeral joint. stabilizer and decelerator. when tre­ thumb to the forearm andior the ability to hyper­ mendous eccentric forces are developed.23 A positive impinge­ The /nstaiJility Continuum ment sign will be presented but the athletes will not be apprehensive when tested. 2 1 mechanism. we have gained a new prehension test for instability. ity is defined as the ability to passively touch the pa. 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. lizers may be the most damaging pathology to Group 4 present instability without impinge­ the throwing athlete. They will test positive for a Neer or Hawkins since the shoulder has been thoroughly investi­ sign. fested as anterior shoulder pain.1. They have acquired their instability from occult anterior translations of the humerus upon a traumatic event-a dislocation. Group 2 includes appreciation for' this structure. 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.icularly in the deceleration phase. [n the last decade. Lack of hyperelasticity with impingement. and pain relief with relocation. 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. sively overwhelmed. the rotator cuff attempts to These athletes are often unaware of the subtle compensate for the loss of stability. or for both. The metacaro­ pophalangeal joint can hyperextend more than 90° and the interphalangeal joint can hyperex­ tended in excess of 60°. scribed by lobe and Pink as one of instability permitting subluxation. 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.or translations occuring within their gle­ eventually overcome. it was recognized for its role as an elbow impingement without a detectable instability. become i nnervated out of sequence. Hyperelastic­ flexibility can be a factor leading to disability. They are antel. 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. Their complaint is usually that to provide a stable base for the glenohumeral of pain upon the transition fTom late cocking to joint. They prove negative to an ap­ gated via the athroscope. positive ap­ ation has a cumulative effect most often mani­ prehension test. failing to become active in the proper sequence Group 3 athletes present instability due to during the distinct phases of throwing. extend the elbow more than 1 0°. 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. As the anterior Groups 2 and 3 comprise the majority of stabilizers of the glenohumeral joint are progres­ throwing athletes with anterior shoulder pain. These athletes will present stress upon the labrum and capsule.'o This pattern of disability is de­ of general shoulder weakness.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. increasing the fraspinatus muscles. These athletes the glenoid during late cocking and early acceler­ have a negative impingement test. Their pain will be relieved with the aid in the stabilizing of the glenohumeral joint or relocation test. and acceleration or a loss of velocity with a feeling begin to fail. Their pain is Repetitive stretching of the anterior static stabi­ relieved with the relocation test. . The development of small ment. Only about one-third demonstrated a posi­ mechanism. this tent stress upon the inferior glenohumeral liga­ instability does not exist anatomically. the popping was evident in the meral ligament was significantly increased. sisting the rotation. No clinical exam was consid­ cases among the general population. Because there is no clear imaging tive biceps tension test. 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. 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. . Of these glenohumeral joint and can reproduce these shoulders. and follow-through tor cuff or biceps tendon. this lesion thrower. 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. bility. than two to one. ligament. Ninety-one percent of this group was long head of the biceps becomes a larger player male. On the strain produced upon the inferior glenohu­ physical exam. overhand throw and 45 percent of the population When a surgical SLAP lesion was created.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. Andrews et al. the population. This lesion gives the phases. 24 suggest that the No radiographic findings could be correlated SLAP lesion occurs in a very limited number of to the pathology. acceleration. The involvement of the dominant shoulder in the attempt to achieve stabilization to the gle­ versus the nondominant shoulder was greater nohumeral joint. 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. however. 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. ered to be specific for the superior labrum. None of the population demon­ dynamic stability to the glenohumeral joint in strated a significant weakness of either the rota­ the cocking. or clinical test for this lesion.375 arthoscopic vider of axial tension as a protective mechanism evaluated shoulders. ment. T H R OW I N G I N JUR I E S 23 Andrews et al. Snyder et al. which was consistent with Andrews shoulder problems due to the theoretical injury et al. Once the integrity of the glenohumeral These represented only 6 percent of the sample joint is reduced due to occulant subluxations. 2 examined a population of 73 Rodosky et al. The long head acts as a continuum pro­ In a retrospective totaling 2. 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. 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. duction position. it is presently diag­ Fifty-five percent of these shoulders were nosed via the arthoscope. 24 reported 1 40 for the humerus and the inferior glenohumeral cases with superior glenoid labrum injuries. only 28 percent were isolated fTom a symptoms in the forward-flexed and extreme ab­ rotator cuff injury or other labral problems. external rotation as experienced by the overhand In a subgroup of baseball pitchers. 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. This dynamic stability ensures a consis­ athlete a sensation of instability. This position of f. reported a popping or catching sensation. However. The data of Snyder et al. predisposing themselves to injury. 6 (86 percent ) returned to a day. Of this group. horizontal extension. Included and encased in ice for a period of 20 minutes. 48 percent had a positive Hawk­ anterior and posterior joint line to develop the ins sign. As the sur­ A distinct factor on examination is that those geon's knowledge expands and it is supported who continue to have pain when subjected to the with the technical tools necessary to repair previ­ relocation test suffer from impingement. Of his population of 36 baseball players. ously cast aside due to interarticular structural Rubenstein et al. 23 reported the results of an damage can now entertain surgical options once anterior capsular labrum reconstruction proce­ a period or conservative care has proven fnlit­ dure. diovascular conditioning. and at no point should they think modified Rowe test score that included return to they have obtained a cure. Clinical examina­ The surface electrodes should be large and tion revealed 44 percent of the athletes had a pos­ should be placed in a fashion to course both the itive Neer sign. and protocols have made not only a significant im­ external rotation. These of 90° of abduction. and 1 00 percent demonstrated a desired effect within the glenohumeral joint. Those players who began and pain.dement. of 1 3 professional pitchers yielded 6 who had ex­ cellent results. Athletes must understand that return to play 20 were pitchers. (3) an increase in strength and endurance. A subgroup cure.on). in the group of pitchers were 7 of professional This protocol is often repeated four to six times ranks.. The positive relocation test. Three of facilitation patterns. An important rehabilitation issue related in The goals of the rehabilitation process this study was the time between surgery and the should i nclude ( I ) the reduction of inflammation return to throwing.24 P H VS I C A L THERAPY OF THE SHOULDER Anterior Capsular Lahrum RehaiJiJ:itatWn Rec011. Of this group. and (6) a progressive Montgomery and Jobe" reported the results return to throwing. of an advanced surgical procedure comprised of Clinically the control of inflammation and a horizontal capsulotomy and suture anchors. a whole generation letes with instability will tolerate maximum ex­ of athletes have been given a second 0PPOliunity. 9 re­ shoulder is placed in the loose packed position turned to their previous level of play. they will reven to the previous stress cycle.StructWn The knowledge gained over the past decade in The relocation test places stress in a direction the rehabilitation of the overhand throwing ath­ posterior to the humeral head when the glenohu­ lete has allowed the athletic trainer/therapist to meral joint is place in the apprehension position design improved preventative protocols. (2) the return of normal shoulder mo­ their throwing program at 5 months postsurgery tion. less. their previous level of professional baseball. verity and time loss by the athlete. ternal rotation without discomfort during this Overhand-throwing athletes who were previ­ maneuver. This maneuver relieves the pact in the prevention of disabilitie but have stress on the anterior structures and is consid­ played an important role in the reduction of se­ ered positive when the athlete's pain is relieved. If athletes anticipate a previous level of play as a crite. (5) car­ 7 months. had a better outcome than those who began at (4) a reestablished synchrony of motion. angles and rotations necessary for the active . 15 were deter­ demands that the rehabilitation will be a contin­ mined to have excellent results (measured by the uing process. Of the 1 3 pitchers. Ath­ ously undiagnosed lesions. pain is often aided by the combined use of sub­ Thirty-two subjects were included in this study threshold electrical muscle stimulation and ice. Six­ Normal shoulder motion is established by teen percent" of the entire study group reported the use of passive proprioceptive neuromuscular posterior postoperative shoulder pain. This provides the additional these athletes returned for an m-throscopic la­ benefit of educating the athlete on the expected brum deb". with a subgroup of 1 3 pitchers. and resistive cords into ec­ ratus is not often trained in an endurance mode. 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 progression of lower kinetic chain to that of the upper extremity these exercises always begins with bilateral rou­ cheat a solid. The sequence of muscle strengthening Body Blade ( Hymanson. the strengthening should progress ening exercises. tines before allempting single-extremity exer­ The isotonic program in Appendix 2. The act be apparent. and eccentric exercises. of long throwing builds arm strength by over­ First. a goal of any rehabilita­ to the humeral positioners. Often an allempt ally instituted in the same general time frame as to apply the accelerated lessons leamed from the an early throwing program.3). conditioning the upper extremity i s an excellent isotonics. 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. 2.2). The majority of the exercises qualify element of deceleration in a slightly longer form . Fourth. trainer/therapist provides the concentric compo­ lobe and Pink" have suggested that the se­ nent of the exercise. and to some extent stretch-shOltening become active. a less than adequate resistance is em­ shortening associated with the overhand ployed to elicit the desired muscular response. cess at the beginning of each treatment. Progression into the tors or the muscles of the rotator cuff are stretch-shortening exercises is preceded by PNF. T H R O WI N G I NJU R I E S 25 phase. Playa Del Rey. Particular attention is paid to stretching at the extremes of the available range of motion. 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. include this component of the rehabilitation pro­ As shoulder rehabilitation builds upon PNF. and externally rotated posi­ tion and the peak activity arc for each. It scapular pivoters and glenohumeral protectors. The use of the voters. CAl in and endurance usually progresses through PNF. and therefore it is important to themselves to be measured outside of the clinic. 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. and then to the pro­ tion program is to make the patient or athlete peller muscles or accelerators. the posterior capsule to regain the adaptive Second.17 Moseley. the resistance of the eccen­ quence of muscle strengthening begin with the u. tool to aid in the transition to the more dynamic concentric isokinetics. When the athletic ing the day. system. exercises. concentrideccentric resistive cords. or deceleration program. the exercises can be placed in an independent arena. The glenohumeral protec­ training (Appendix 2. 1 is in­ cises. 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. strengthened in association with the scapular pi­ isotonics. Stretch-shortening exercises are usu­ to stretch-shortening exercises. resis­ g1ides2• taught passively in the ROM phase now tive cords. the use of a high repetition program has gram is instituted via an over-the-door pulley not been explored using these exercises. The scapular independent. methodical isotonic strength base. the experimental model used light weights at low The reestablishment of synchrony of motion intensity and low speed. The ser­ isotonic dumbbells. Because tion. thrower.c component can be significantly increased. As noted in the EMG data. Fifth.27 A home range-of-motion (ROM) pro­ Third. and eccentric isokinelics. sen-atus anterior is active throughout most of the Isotonic exercises are easily monitored and lend overhand throw. hori­ and allempted to establish specific muscle func­ zontally extended. centric loading. Extreme care must be take to protect the cluded for a reference. Long throwing provides an the plane. Townsend. the full benefit of this is developed through a throwing program that element of the rehabilitation program may not emphases long throwing (Appendix 2. Isotonic dumbbell exercises. His posterior capsule remained restricted in spite of the active stretching. He presented a positive Hawkins sign.7 percent of the velocity developed by After completing 42 throws with discomfort. game due to a lack of velocity.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. a negative apprehension sign. This failure LO per­ game without difficulty and reported no difficul­ fo. only a L2 dominant compared to T4 nondomi­ nant. A radiograph MRJ was performed. the additional stress is ular allention paid Lo the scapular glides and di­ applied at a consistent rate. the entire sys­ five innings totaling 5 5 pitches in a minor league tem becomes less efficient. An undersurface cuff tear was seen in the generative cysts present in the humeral head. The player's inflammaLion was controlled debrided. it the throwing arm is developed by the lower body was necessary LO place him on a disabled list. which is necessary to develop the re­ tion. His prophylaLic conditioning quired eccentrics applied upon the glenohu­ program was adjusted to below-plane exercises meral joint. conditioning of these segments as part of the en­ Eleven days postinjury the player again at­ lire rehabilitation process. supraspinatus. At this time his forward flexion was re­ a shorter focus in relation to return to play. 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. and abnormalities of and bone scan were conducted and they were the infe. There was no joint laxity. There was a popping sensation reduced internal rotation that was accompanied with pain when he was abducted with external with pain. Fourteen days postinjury the player pitched fail in their conversion of oxygen. man rotation until again complaining or similar Appendix 2. Be­ throw on the side to determine his roster status. his range of motion demonstrated a subtle anterior subluxation for was within normal limits. There was a trough defect on the . agonal pallerns with a shortened lever. which was small.-ior aspect of the anterior glenoid were intcllJreted as normal. also debrided. By progressively increasing the dis­ and supplemented with a PNF series with parLic­ tances of throwing. com­ and 2 . and continued in the five­ hand-throwing athlete to a level o[ competition. rotation and forced into extension. EMS. N i neteen days from the original complaint. cause 46. and the following were of 1 3 months earlier. Ap­ duced by 1 0" in his dominant arm. His pos­ Cardiovascular conditioning should be an terior capsule stretching was accelerated. After an uneventful 5-week spring training con­ The pitcher made one more start. however. Upon examination. aspect of the rehabilitation process continued Five days postinjury the pitcher allempted to and buill upon from the preinjury protocol. and de­ and Lhere was evidence of posLerior capsular lax­ brided. His external pendix 2. Upon examination he pain. and a CASE STUDY 1 negative relocation sign. cycle. but he left the from his first game after five completed innings. and ice.-m compounds the sLresses in the recovery ties the following day.3o it is important to focus upon the which removed him from the active rOSLer. Two days later He complained of nonspecific anterior shoulder he was unable to throw. There were also small de­ nOLed. the pitcher removed himself he pitched into the sixth inning. with the exception of the first time. The anterior labrum was frayed and also iLY. presenting ditioning program. linear. in which ditioning period.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). this was consistent with an MRJ tion was performed. Two programs are provided (Appendices 2. An arthroscopic examina­ noted. and trunk. If the lower extremities forI.5 represents a more aggressive proto­ anterior shoulder pain after six starting assign­ col and can be used in rehabilitations that have ments.4 the player st3l1ed a major league game. The posterior labrum was frayed and with nonsteroidal anLi-inflammatory medica. 5 D and E) [or the progression of the over­ pleted five innings. The athlete to comelitive pitching: a case study. His throwing activi­ ties increased. Othopaed Rev 18:963. he was again able to return to a major roscopic labral debridement: a three-year follow­ league mound. 1992 or abduct his arm. compete for a period of II days. Bone scans were repealed al 2. Hill JA: Rotator cuff injuries: an up­ ing day by the attending orthopedist and a bone date. scapular glides. 7. Simon ER.1h WP. tive range of motion. 1987 but was prescribed a course of general therapy. sports. and 7 months. and to pitch in the minor leagues on a 5-day rotation. This test t'esulted in the dis. 1992 necessary velocity to be competitive. He had pro­ 2. but was unable to develop the up study. Allman Fl. Fleisig GS. The following season the athlete repeated the cycle of early season difficulties and lack of ve­ locity associated with an anteriorly unstable References shoulder. At one participated in every scheduled start. WickiewiczTLet a1: Arh­ bilitation. After another extended period of reha­ 1. There was innammation about the bi­ process. Lombanlo JA: Suprascapular nerve in­ juries with isolated paralysis of the infraspinatus. Kvitne RS: Shoulder pain in the over­ Due to scheduling. At 1 2 weeks photography. Andrews JR. ceps tendon but no evidence of a SLAP lesion. Branch T. indicating anterior sub­ covery of an avulsion fracture of the coracoid luxation. 3. The subacromional space was normal. Mottola M F: Biome­ days lalLer. 11. Gainor 8J. PhD. Ga. Am J Spot1S Med 18:225. compiling month postinjury the player began a two days a total of 230 innings. Am J Spot1S Med 15:579. Am J SpOl�S Med 20:702. Canham PB. one day off throwing program in an aILempt to return to the mound. 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. Andr'cws JR: Biomccha- . Am J be forced to decide if he will undergo an anterior Sports Med 13:337. Schachtet' Cl. 1990 pitched well into the game. ATe. which yielded no concise diagnosis. he was ready to retum to the major league roster. for their assistance with the building arm strength and velocity. and iso­ Ten days post injury his range of motion was tonic exercises. related to the long head of the biceps. He was examined by the aILending or­ tedor subluxations of the shoulder in noncontact thopedist. 1985 capsular labrum reconstruction or retire. the pitcher did not have to hand or throwing athlete. Piotrowski G et al: The throw: bio­ season a starting pitcher complained of discom­ mechanics and acute injury. At-mslrong WS: Occult an­ line. J Orlhop SPOt1S Phys Ther 10:394. on. Ahchek OW. Am J Spo. Treihafl M et al: Suprascapular neu­ he was able to perform without reservation and ropathy in pitchers. he threw a pitch in the fourth innjng chanical factors affecting Dave Dravecky's l-clu. On his next start 1989 8. J Ol1hop was immediately unable to actively forward £lex Sports Phys Ther 16:2. AJSM 8:114. He was examined the follow­ 10.-n that resulted in tremendous pain. 1989 scan was ordered. Carson WG Cl al: Glenoid labnlO1 gressed into the instability continuum and will lean.1980 fort in his throwing shoulder medial to the joint 6. Black KP. The following season the athlete motion had increased by four vertebrae. within normal limits and his internal range of 5. He continued J would like to thank Jim Richards. lobe FW. Ten days later he threw 40 pitches fl'om the mound. Am J Spot1S Mcd 18:80. Wan'en RF. In his next start 6 9. Ringel SP. Dillman el. 1990 4.1S Med 20:468. T H R OW I N G I NJ U R I E S 27 posterior humeral head. which included throwing baILing practice at 7 weeks and pitching in a minor league contest in the ninth week. Pal1in C el a1: Spontaneous fractures CASE STUDY 2 of the humcnls during pitching: a ser-ics of 12 cases. 1992 During the fourth month of the championship S. Dan Elkins. Anlonelli Dl. JSES 4:243. Pappas AM. Un iversity Park capsulolabral reconstruction of the shoulder i n Press. Jobe FW. Am J 21. Jobe F. 22. 1991 the glenohumeral joint: a dynamic model. Pink M: Classification and treatment of SPO'1S Med 15:144. 1985 Spons Med 19:264. Hoshi kawa T. 29. Am J SP0l1S Mcd 19: 3 I . Jobe FW. Am J SPOt1S Med 15:586. Gowan !D. Engle RP. Am J SPOl1S Med during a baseball rehabi litation program. Moynes DR. Tibone 1 et al: Dynamic Elec­ tion prog. 1990 17. Rubenstein DL. 1984 1995 15. Glousman R. JSES I :229. Blackburn TA. p. Pappas AM. Am J Sports Med 22: I 2 I .. Harner CD. Moynes DR. 169. Cain PR. 1988 mance. Snyder Sl. 1985 Training 25:40. lobe F. m. Fu FH: The role of Ihe tive eleclromyographic analysis of the shoulder long head of the biceps muscle and superior gle­ during pilching. Rodosky MW. J Bone Joint Surg Conllibution of the body pans to throwing perfor­ 70A:220. Pen"). 1993 Onhop Sports Phys Ther 18:427. 13. Am 1 SPO'1S Med 20: I 28. While B el al: EMG nics of baseball pitching: a prel iminary report. lobe FW Tibone l E . po" . Jobe FW Tibone J E el al: A compara­ . Balitimore. 1. Montgomery WM. Biomechanics. 741. Townsend H. Louis. In Nicholas 1. 1986 reconslruclion. McLeod WD. McMal1hy CF: Rehabil­ graphic analysis of the glenohumeral muscles itation of the pitching shoulder. Zawacki RM.or slabililY of 428. 1987 noid labrum in anterior stability of the shoulder. MorehouseCA (cds): 20. Hershman E ily: ApP"oach to rehabililalion. Jobe FW: Functional outcomes tromyographic and motion of the upperextremity in athletes after modified anterior capsulolabral in sporls. J emalics. Zawacki RM. Jobe F. 1987 . Jobe FW. 1990 t he scapular muscles during a shoulder rehabilita­ 19. I n Nelson RC. Am analysis of posterior rotator cuff exercises. JOBST 18:402. lobe FW: Elec­ 25. Vol. Tibone lE. Pen"). Jobe FW Giangana CE. Toyoshima S. 1994 16. Am J 14:223. Kvitne RS Cl al: Anterior . 1994 23. Am J SPOl-IS Med I I :3. Banas MP. CannerGC: Posle"ior shoulder inslabil­ 18. 4. Am J SPO'1S Med 12:2 I 8. J: An EMG 24. Miller L eI al: p. Am J Spons Med 22:352. Pink M cI al: EMG analysis of Mosby. Pink M el al: Eleclromyo­ 27. SI. Miyashila M et al: with glenohumeral instability. Sullivan. J Ol1hop SPOI1S Phys Ther lune 1989:488 (eds): The Upper Extremity in SPOt1S Medicine. 1993 12. Glousman RE et al: An­ analysis of the shoulder in throwing and pitching: terior capsulolabral reconstnlction of the shoul­ a preliminary reporl . 1983 de. Moseley J. 1974 athletes i n overhand spor1s..1992 14.28 PHYSICA L THERAPY OF THE SHOULDER nics of pitching with emphasis upon shoulder kin­ shoulder dysfunction in the overhead athlete.. 1992 tromyographic analysis of the throwing shoulder 30. Karzcl RP: An analysis of analysis of the shoulder i n pitching: a second re­ 140 injudes to the superior labrum. Phys Ther 66: I 90S. Moynes D: An EMG . TJ: Biomecha­ 26. Athl J Spons Med 14:216. PelTY l. 1991 28.. Mutschler TA el al: Ante.in athleles. Spe­ Independently. infraspinatus.3) cufL 3 1 Blackburn et al. 2. Prol1e Horizol1tal Abductiol1 at lOa· By coupling electromyography and ci nematog­ with Extenlal Rotatiol1 (Fig. 1 Muscle Activity E licited by Common S houlder Conditioning E xercises The anterior stability of the glenohumeral joint Prone Extension 'vv.rh Exlenlai is enhanced by the dynamics of the rotator ROll/tiol1 (Fig.2) that of a manual muscle test. 2. They demonstrated that externally ro­ 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. 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. '7 Moseley. 2. Each movement FIGURE 2 . 1 29 . and cific to the teres minor. They compared the active signal to with Extenlal Rotatiol1 (Fig.4) tating the humelUs during prone exercise in­ creased EMG activity to the highest levels. 2. Townsend. routines most commonly instituted for condi­ tioning of the shoulder in the throwing athlete. ann extension with their associates examined the dynamic exercise external rotation produced the best isolation.26 examined the supraspi­ natus. ApPEN D I X 2. 3 FIGURE 2.2 F I G U R E 2.30 P H Y S I CA L THERAPY OF THE SHOULDER FIGURE 2.4 . M USCLE ACTIVITY ELICITED B Y COMMON SHOULDER CONDITION I N G EXERCISES 31 A B c FIGURE 2.5 (A-C) . lift the weights away [yom the sides to a height above the shoul­ der. The press-up and shrug motion was divided into two halves of upward motion.or deltoid 5 (PAA 90'_ 1 20').5) Starring position: A standing posture with the weights in hands with palms to the sides.32 P H Y SICAL THERAPY OF THE SHOULDER was divided into 30' arcs of motion. Quali­ (ied l1Iuscles: Middle serratus anterior I (PAA 1 20'_ 1 50'). Each peak activity al'c (PAA) was also noted. anterior deltoid 3 ( PAA 1 20-1 50'). it had to develop EMG activity greater than 50 percent of the manual muscle test. The results of these studies are incorporated in the descriptions of the movements that follow. middle serratus anterior I (PAA Starting position: A standing posture with the 1 20'_1 50'). Quali(ied spinatus 4 (PAA 90'_ 1 20'). Apply traction for the primary im­ 8. 2.6 (A-C) Movement: With elbows straight. lift the weights [or­ B ward until they are above shoulder height. lower serratus anterior 3 ( 1 20'-1 50'). supraspinatus 3 ( PAA 90'_ 1 20'). middle deltoid 4 ( PAA 90'_ 1 20'). A up range was based on the amount of elbow flex­ ion beginning with ful l extension to 30' of flexion and descending in 30' arcs. and this activity would have to occur over three consecutive arcs of motion. This criterion held true for aLI tested motions except the press­ up. Note: Avoid for the multidirectional insta­ upper trapezius 6 ( PAA 90'_ 1 20'). infra­ Movemem: The shoulders are elevated. lower serratus anterior 2 (PAA weights in the hands with palms to the sides. Move­ l1Iel1l: With elbows straight. 2. and two halves of the downward motion.1 50'). For a muscle to qualify for a movement. 1 20'_ 1 50'). shrug.6) Starting position: A standing posture with the c weights in the hands with palms to the sides. lower trapezius 4 (PAA 1 20. three seconds of a end range hold. Abduction (Fig. FIGURE 2. and push-up. 2. pingeI'. range). in­ fraspinatus 5 ( PAA 90'_ 1 20'). rhomboids 3 (PAA 90'_ 1 50'). Fonvard FlexiDlI (Fig. subscapularis 3 (PAA 1 20'_1 50'). subscapularis 4 (PAA muscles: Levator scapulae 3 ( PAA at extreme 1 20'_ 1 50'). antel. middle deltoid bility patient. 7) 90'_ 1 50'). The push. Quali(ied muscles: Lower trapezius I (PAA Shrug (Fig. . of the range of motion. su­ praspinatus 2 (PM 90°_ 1 20°). Military Press (Fig. Qualified l1Iuscles: Anterior del­ deg. ward thighs. Qualified the thighs. levator scapulae 6 (PM 1 20°_1 50°). 2. 1 0) Starling position : A standing posture with Scaption: Extemal RotatiOll (Fig.8) serratus ante. upper trapezius 2 (PM of 30° forward of vertical. Lift to the height above 90°_ 1 20°).1 50 the shoulders.9) weights in hand positioned at the height of the Starting position: A standing posture with shoulders. l1Iuscles: Supraspinatus I (PM 0°_90°). 2. lower trapezius 6 (PM 1 20°. middle deltoid 5 (PM 90°_ 1 20°). Lift to the completion 1 50°-peak). anterior deltoid 2 (PM Starting position: A standing posture with 90°_ 1 20°). supraspinatus 4 (PM 90°_ 1 20°). Movement: Press weights upward to weight in hand with thumbs turned away from the completion of the range of motion. anterior deltoid 4 (PM 60°_90°). M USCLE ACTIVITY ELICITED B Y COMMON SHOULDER CONDITION I N G E X E R C I S ES 33 A B FIGURE 2. infraspinatus 6 (PM of 30° forward of vertical.7 (A & B) Scaption: Intemal Rotation (Fig. subscapularis 1 (PM 1 20°_ 1 50°). toid 1 (PM 90°_ 1 50°). 2. middle deltoid 1 (PM 90°_ 1 20°).). upper trapezius lift the weights in a manner to maintain a plane 5 (PM 1 2 0°.1 50°).-ior 1 (PM 1 2 0°_ 1 50°). Movement: With elbows straight. middle serratus anterior 3 (PM weights in hand with the thumbs turned in to­ 1 2 0°_ 1 50°). Qualified muscles: Lower middle selTatus anterior 4 (PM 1 50°-peak). subscap­ lift the weights in a manner to maintain a plane ularis 2 (PAA 60°_90°). Movement: With the elbows straight. . rhomboids 2 (PM 1 20°_ 1 50°). 34 PHYSICAL THERAPY OF T H E SHOULDER A B c FIGURE 2.B (A-C) . M USCLE ACT I V I TY ELICITED BY C O M M O N SHOULDER C O N D I T I O N I N G E X E R C I S E S 35 A B c FIGURE 2.9 (A-C) . teres minor 2 (PAA 60'-90'). The weights are nally rotated. Qllalifled muscles: In­ zius 1 (PAA 90'-peak). leva­ 2 (PAA 90'. upper trape- .1 20'). infTaspi.1 20').1 20'). 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. middle trape­ to just above the shoulder. Movement: The weights are lifted held in an extended elbow position and exter­ to just above the shoulder.1 20'). lower trapezius 5 (PAA 90'-peak). / I) Horizontal abduction: External Rotation (Fig. 2. 2. tor scapulae 2 (PAA at extreme range). 1 0 (A-C) lower serratus anterior 6 (PAA 1 20'. Qualified muscles: nally rotated.12) Starting position: From a standing position.1 20').1 50'). teres minor 3 (PAA dle deltoid 7 (PAA 90'.1 2 0'). rhomboids 1 (PAA fraspinatus 1 (PAA 90'. mid­ natus 3 (PAA 90'. upper trapezius 4 (PAA 90'-peak). middle trapezius 2 (PAA 90'-peak). middle deltoid 2 (PAA 90' -1 20'). Movement: The weights are lifted Posterior deltoid 1 (PAA 90'. posterior deltoid 90'-peak). approaches parallel to the floor. bend forward at the waist until the upper body Starting position: From a standing position.36 P H Y SICAL T H ERAP Y OF T H E SHOULDER A B c FIGURE 2. 9ll'. Horizontal abduction: Internal Rotation (Fig. posterior deltoid 4 (PM 900. The weights are is close to parallel to the floor. Movement: . The weights are held in an extended elbow position./4) Starting position: From a standing position. Movement: held in an extended elbow position. 2. 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 . le­ range). 1 1 (A-C) zius 3 (PM at extreme range). 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. Ext""siol1 (Fig. levator capulae 4 (PM at extreme tral-300). Starting position: From a standing position. 2. Quali­ (PM 90°-peak). lower trapezius 3 The weights are lifted back past the hips./3) Rowing (Fig.1 200). middle deltoid 3 (PM (ied muscle: Middle trapezius 3 (PM neu­ 90°_ 1 2 0°). vator scapulae 5 (PM at extreme range). 1 2 (A-C) .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 3 (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 . 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) . t. . arm position. 16) to the chest. 1 7) weights are lifted with a slight flexed elbow posi­ tion to the midline. the arms are extended in a vertical position. 1 5 (A-C) Leading with the elbows. middle deltoid 6 (PAA 90·. levator scapulae I (PAA at ex­ Slarling position: From a back-lying posi­ treme range). 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. Qualified /IlL/scles: Upper trapezius I (PAA 90'_ 1 20'). Qualified muscles: Not rated. lower trapezius 2 (PAA 1 20'_ 1 50'). It is sug­ gested that the resistance used in the experimen­ tal model may not have been of sufficient weight HoriZOl1lal adducliol1 (Fig. 2. the weights are l i fted Bench press (Fig. tion.1 2 0·). 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. It is Starling POSilioll: From a back-lying posi­ suggested that the resistance used in the experi­ tion. tion. middle trape­ weights are next to the shoulders.15) to elicit the necessary response to determ ine Slartillg POSilioll: From a back-lying posi­ qualified muscle. Movemelll: The Straighl arm press (Fig.he elbows are at the side and flexed so the posterior deltoid 3 (PAA 90'_ 1 2 0'). the arms are extended out to the sides to the height of the shoulders. 2. Qualified muscle: None. rhomboids 4 (PAA at ex­ weights are pressed into an extended vertical treme). 2. Movemel1l: The zius 4 (PAA 90'_ 1 20'). Qualified /Iluscle: None. 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) . 1 7 (A & B) C FIGURE 2. 1 8 (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 A A B B FIGURE 2. Note: The extreme range of external ro­ Internal rotation (Fig. the gested that the resistance used in the experimen­ hands are placed next to the hips. the arms are held at the side the elbows are flexed and externally rotated. el­ the elbow is flexed to 90° and Ihe forearm is ex­ bows flexed. . muscles: Teres minor I (PAA 60°_90°). lalissimus dorsi be performed in a sidelying position. Qualified fTom the midline to a vertical position. the arms are extended to the vertical. Qualified lIIuscles: Not rated. this exercise may minor I (PAA at extreme range). Note: To limit external rotation major I (PAA upper half of range). the hips are lifted from the to elicit the necessary response to detelmine sitting position.or deltoid 5 (PAA 60°_90°).18) External rotation (Fig. tion. 2.21) weights are lifted to the midline maintaining a flexed elbow. Qualifying ml/scles: Pectoralis qualified muscle. 1 9) tation should be l imited to avoid anterior trans­ lation of the humeral head. postel. 2. I (PAA at exlreme for hold).20) Starting position: From a back-lying posi­ Starting position: From a sidelying position. 1 9 (A-C) Triceps (Fig. Starting position : From a back-lying posi­ tion. Movement: The weights are lifted ternally rotated. infraspi­ natus 2 (PAA 60°_90°).44 PHYSICAL T H E R A PY OF T H E SHOULDER A B c FIGURE 2 . 2. Movement: The Press-up (Fig. Moveme. Qualified l1Iuscles: None. 2.lI: By tal model may not have been of sufficient weight extending the elbows. It is sug­ Starting position: From a silting position. Movement: The weight is l ifted to an extended vertical arm positions. pectoralis and humeral head translation. A B c FIGURE 2.20 (A-C) . 46 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 A B FIGURE 2 . 2 1 (A & B) . 22 (A-C) 47 .A B c FIGURE 2. the body natus 8 (PM 90°_60°). 2. lower serratus anterior 5 ment).23) Starting position: In a prone position. Movemem: By extending the el­ bows.23 (A-C) Push-up (Fig.48 PHYSICAL THERAPY OF T H E SHOULDER A B c FIGURE 2. the body is elevated from the surface. movement). elbows flexed. the hands are placed at the width of the shoulders.22) Push-up plus (Fig. (hands apart): Pectoralis is furthered elevated at the shoulder. bows. Quali{ted muscles (hands together): Infraspi­ Upon completion of elbow extension. pectoralis minor 3 (PM muscles: Pectoralis minor 2 (PM plus move­ second to last arc). Movement: By extending the el­ elbows flexed. hands are placed at the width of the shoulders. middle serratus anterior 5 (PM plus lUs anterior 6 (PM last arc). lower serratus anterior 3 (PM beginning (PM isometric to chest near floor). the Starting position: In a prone pOSItIOn. the body is elevated from the surface. Quali{ted major 2 (PM 60°_30°). middle serra­ movement). 2. . A B c FIGURE 2.24 (A-C) 49 . 26 (A-C) .25 (A & B) A B c FIGURE 2.50 P H Y S I C A L THE RAPY OF T H E SHOULDER A B FIGURE 2. against chest wall. the upper arms are brought into the horizontal with the weights in hand with palms to the sides.24) tween the upper arm and the chest wall. The weights are Biceps curl (Fig. weights toward the shoulders. . abducted position. 2. and then the weights are Movemellt: The elbows are nexed. Startillg positioll: From a standing position.25) Horizo/!tal abductio/!: Extemal Startillg positioll: Place a rigid pillow be­ rotatiordsolated: (Fig.26) held in an extended elbow position in a neutral position. 2. bend forward al the waist until the upper body approaches parallel to the noor. bringing the brought into the externally rotated position. 2. Move­ mel11: Squeeze the pillows with the upper arm Startillg positioll: From a standing position. Movemelll: Leading with the elbows. MUSCLE ACTIVITY E L I C I T E D B Y COMMON SHOULDER C O N D I T I O N I N G E X E RCISES 51 ADDITIONAL EXERCISES Pillow squeeze (Fig. Adduction Bench Press Straight Arm Press Triceps Internal Rotation External Rotation Hor. Abd. 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 .2 Upp e r E xtremity C onditioning Program Dote: WEIGHT AND REPEnTlONS Forward Flexion Abduction Shrug Scoption @ IR Scoption @ ER Military Press Hor. APPEN DIX 2. Abd. @ IR Hor. @ ER Extension Rowing Hor. 3 Nine. It is not impol1ant to progress to the next throwing level with each outing. It is impol1ant to throw with comfort. It i preferred that a number of outings at the same level be completcd before progressing. which may necessitate moving back a level on occasion.Level Rehabilitation Throwing Program 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. APPENDIX 2. LEVEL THROWS/FEET THROWS/FEET THROWS/FEET 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 . The athlete is to throw two days in a row and then rest for one day. APPEN DIX 2. 25 SO Worm up 54 .4 Rehab il itation Pitching Program LEVELS THROWsJFEET THROWS/MOUND/FLAT THROWS/FEET 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. APPEN DIX 2.5 Short-Focus Throwing Rehabilitation Programs I . 2 5 at 60 ft, 2 5 at 90 ft, 1 5 at 60 ft. 3. 5 min. long toss, 7 min. mound, aer­ 2. 25 at 90 ft, 25 at 1 20 ft, 1 5 at 90 ft. obic-bike. 3. 3 min. at 90 ft, 3 min. at 1 20 ft, 3 min. at 4. Aerobic work-I 0 min. bike, 1 0 sprints, 1 2 1 50 ft, 3 min. at 90 ft. min. bike. 4. 2 min. at 90 ft, 2 min. at 1 20 ft, 3 min. at 5. 5 min. long toss, 1 0 min. mound, ael'­ 1 50 ft, 2 min. at 1 2 0 ft, 2 min. at 90 ft. obic-bike. 5. 2 min. at 90 ft, 2 min. at 1 20 [t, I min. at 6. Aerobic work - I 0 min. bike, 1 0 sprints, 1 5 1 50 ft, 2 min. at 1 20 ft, 2 min. at 90 ft. min. bike. 6. 2 min. at 90 ft, 2 min. at 1 20 ft, 2 min. at 1 50 ft, I min. at 1 80 ft, 2 min. at 1 50 ft, 2 7. 5 min. long toss, 1 2 min. mound, aer- min. at 1 20 ft, 2 min. at 90 ft. obic-bike. 8. Day off. THROWING MOUND PROGRAM 9. Batting practice-2 innings (30 pitches). I . 5 min. long toss, S min. mound, aer­ obic-bike. 1 0 . Aerobic work-I 0 sprints, 20 min. bike. 2. Aerobic work-I 0 min. bike, 1 0 sprints, 1 0 I I . Normal day. min. bike. 55 Differential Soft Tissue Diagnosis MAR I E A J 0 HAN SON BLANCA Z TA GONZALEZ - KING 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 BODY SYSTEM RIGHT SHOULDER LEFT SHOULDER RIGHT OR LEFT SHOULOER Cardiovascular Typical angina pectoralis Atypical angina pectoralis Myocardial infarction (rarely may refer Pericarditis to right shoulder) Pulmonary Pleurisy Gastrointestinal Gallstones Pancreatitis Pulmonary neoplasm Acute or chronic cholecystitis Pancreatic carcinoma Hepatitis Hiatal hernia 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 TABLE 3.2. Neurologic scremil1g of cervical spilwl l1erves SEGMENT MOTOR SENSORY REFLEX (1-2 Neck Rexion Skull None (3 Neck side bending lateral neck and jew None (4 Scapular elevation Top of shoulder None (5 Shoulder abduction, elbow Rexion Proximal lateral arm Biceps (6 Elbow Rexion, wrist extension Thumb and index finger Brochiorodiolis C7 Finger extension, elbow extension Middle �nger Trieeps (8 Finger Rexion Ulnar aspect of forearm and hond None Tl Finger obduction Medial arm None ObservaJ:ion POSTURE An assessment of posture includes scrutiny of the Observation of the patient in both static and dy­ anterior, posterior, and lateral views in the namic situations can reveal information about standing position, as well as identification of the the patient's condition. The three basic compo­ patient's silting and sleeping postures. nents of examination by observation are assess­ ment of ( I ) symmetry, (2) posture, and (3) dy­ Anlen'or View namic activities of daily living (ADL), sports, and work activities. From an anterior view, the clinician can as­ sess the position of the head on the neck in the frontal and transverse planes (cervical side bend­ SYMMETRY ing or rotation) and the superior-inferior posi­ An assessment of symmetry can give clues La tion of the glenohumeral joint. A relative inferior areas of dysfunction, although the clinician must position of the humeral head on one side may be aware that some degree of asymmetry is nor­ be seen from this view, although atrophy of the mal. In fact, significant degrees of asymmetry deltoid can give a false impression of inferior can be perfectly normal for some individuals, subluxation. such as athletes in one-handed sports. " Gener­ ally, an assessment of symmetry includes both Lateral View soft tissue and bony contours. Anteriorly, the clinician can observe changes From the lateral side, the positions of the in the thoracic inlet area (such as bony abnor­ head on the ce,vical spine and of the cervical malities of the clavicle, acromioclavicular or spine relative to the torso may be seen, the degree stemoclavicular joint, or areas of ecchymosis or of thoracic spine kyphOSis assessed, and sagittal edema in the supraclavicular fossa), and in the plane position of the glenohumeral joint ob­ muscle contours of the deltoid and pectoral mus­ served (anteroposterior position of the humeral cle groups. Posteriorly, muscle atrophy of the su­ head). Two common problems most easily seen praspinatus, infraspinatus, and teres minor may from this view are an anteriorly displaced posi­ be seen, and gross differences in the position of tion of the humeral head and forward head pos­ the scapula may be noted. Due to specific SpO,1s ture. Forward head posture is characterized by activities, some individuals may have hypertro­ excessively protracted and laterally rotated scap­ phied muscles on their dominant side, resulting ulae, internal rotation of the glenohumeral joint, in the appearance of muscle atrophy on the non­ increased kyphosis of the upper thoracic spine, dominant side. decreased lordosis of the midcervical spine, and DIFF E R E N T IAL SOFT TI S SU E DIAGN O S I S 61 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 A FIGURE 3 . 1 (A) Measurement of scapular width. (B) Measurement B or scapular protraction. ACTIVE RANGE OF MOTION the motion due to pain, apprehension, or other reasons. Therefore, diagnosis of soft tissue dys­ The evaluation of active range of motion encom­ function at the shoulder from active movements passes multiple components of function. When alone is difficult, as the examiner is unable to AROM is limited. one or more of the following isolate the contribution of specific muscle is possible: limited joint mobility. muscle weak­ groups and joints of the shoulder complex to the ness, or unwillingness of the patient to complete limitation in movement. DIFFER E N T I A L SOFT TISSUE DIAGNOSIS 63 Active range of motion can reveal abnormal Plal1e of {he Scapula movement patterns, and can predict for the ex­ Active elevation in the plane of the scapula aminer what functional abilities and disabilities offers an excellent assessment of scapulohum­ the patient is likely to exhibit. eral rhythm and scapular stability. The move­ Generally, AROM of the involved side is com­ ment can be grossly obselved through the three pared to the uninvolved side. although some de­ phases of elevation (see Ch. I) for symmetry and gree of asymmetry may be normal. Often, the the expected biomechanical events. dominant side will exhibit less AROM than the nondominant side. II Conversely. apparent sym­ metry in AROM may be achieved by excessive I N I T I A L P H A S E O F E L E V A T I O N (0° TO 60°). 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 FIGURE 3.2 Excessive left scapular adduction exhibited by a patient with limited leli glel10humeral external rotatioYl at O'or abduction during active range of motion testing. 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- FIGURE 3.3 Excessive lert scapular elevation al1d external rotation exhibited by a patient with limited glenohu meral eleva!ion during active range or motion testing. DIFFER ENTIAL SOFT TISSUE DIAGNOSIS 65 toraHs major, latissimus dorsi, teres minor, and in the selection of initial stretching or strength­ infraspinatus muscles. ening techniques. Although differences in PROM between the involved and uninvolved sides are generally good Functiol1Ol Movements indications of abnormal mobility, the clinician Three functional movements can predict the needs to be aware that some asymmetries may patient's ability to perform the act.ivities of daily be normal. For example, high-level baseball living. As with AROM, active functional move­ pitchers are expected to exhibit greater external ments conculTently test joint mobility, muscle rotation PROM and lesser internal rotation strength, and willingness of the patient to com­ PROM of their dominant shoulder.2S plete the motion. As with AROM, the examiner must be alert for motions of the involved side that only appear HANDS B EH I ND N ECK. Combined glenohumeral to have full mobility because of excessive motion elevation and external rotation, and scapular ro­ at adjacent joints. For example, when the sub­ tation into the middle phase of elevation are re­ scapularis, pectoralis major, and latissimus quired to complete this movement. Inability to dorsi muscles lack flexibiHty or when the inferior perform this movement indicates inability to glenohumeral capsule is restricted, the patient groom, inability to shave the axilla, inability to may substitute excessive lateral rotation of the manipulate objects overhead, and inability to scapula (Fig. 3.4) or excessive extension of the throw. trunk (Fig. 3.5) to achieve full shoulder elevation. Passive glenohumeral extension may also ob­ HANDS B EH I ND B ACK. Combined glenohumeral scure a limitation in passive glenohumeral inter­ extension, adduction and internal rotation, and nal rotation at 90· of abduction (Fig. 3.6). scapular distraction are required to complete this movement. Limitation indicates inability to Irritability Level fasten a brassiere, zipper clothes, or tuck in shirts or blouses posteriorly, and reach back Cyriax· advocates use of the sequence of pain pockets. and resistance during passive movement testing to establish indications and contraindications Combined gle­ HAND TO O P P O SITE SHO U LD E R . for stretching of a joint. If pain is encountered nohumeral flexion and horizontal adduction are in the range of motion prior to resistance, a high required to complete this movement. Limitation level of irritability is likely, and stretching is con­ indicates an inability to manipulate objects traindicated. If pain and resistance are encoun­ across the body or provide adequate follow­ tered at the same time, a moderate irritability through with many sports maneuvers such as a level is likely, and any stretching should be per­ golf swing, tennis forehand, or baseball pitch. formed gently and with caution. I f resistance oc­ curs during passive movement before pain, or if no pain is encountered, then a low irritability PASSIVE RANGE OF MOTION level is likely and the patient is expected to toler­ Passive range of motion allows the examiner to ate stretching well. The clinical use of Cyriax's identify specific restrictions at each joint, to dis­ sequence of pain and resistance has not been tinguish muscle restliction from restriction of well studied. One recent study of the use of the noncontractile tissue, to evaluate the quality of sequence in patients diagnosed with osteoarthri­ resistance at the end of the range of motion (en­ tis of the knee showed poor reliability. The au­ dfeel), and to discem patterns of restrictions that thors attributed this to very short intervals be­ may indicate specific soft tissue problems. Addi­ tween onset of pain and resistance, which tionally, the probable irritability level of the pa­ precluded clinical measurement through man­ tient can be established and serve as one guide ual palpation.26 Reliability of the pain and resis- Arguably the most often . Conversely. 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. but resistance rather than pain will limit lish irritability level during passive range of mo­ the motion. clinicians may more 3. pain unknown.4 Excessive lateral rotation (lateral "bulge") of the right scapula during passive range or motion testing in abductiol1 exhibited by a patiel1l with glelwhLlll1eral capsular restriction. P I will precede R I. may or may not be encountered before resis­ Maitland' also advocates a method to estab­ tance. When stiffness is the patient's pri­ lion testing. 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. following four OCCU'Tences during PROM testing: End-feel I . and Specific Patterns of Restrictiol1s pain rather than resistance will usually limit the motion. mobilization techniques to increase joint tions may assist in the soft tissue diagnosis of mobility are contraindicated. 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). tance sequence in other patient populations is stiffness is the patient's primary problem.2. mobilization and stretching tech­ plex and requires the examiner to graph the niques to increase mobility are indicated. The method is somewhat more com­ mary problem.1cture(s). or pain that limits PROM prior to expected end range. when shoulder problems. Maitland' asserts that when pain is the pa­ tient's primary problem. The point in the range of motion where no tionable reliability. When pain is the patient's primary prob­ Several specific patterns of passive restric­ lem. 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 range of motion where no fur­ end of full PROM.66 PHYSICAL THER A P Y Of THE SHOULD ER FIGURE 3. However. The authors have observed Ch. and least that aids in the diagnosis of frozen shoulder (see in internal rotation. lesser in abduction. 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. (B) Same patie..5 (A) Excessive extension of the trunk during passive elevation testi"g in a patient with subscapularis muscle tighll7ess./ after exte"sibility of the subscapularis is restored. and internal rotation at tion of the glenohumeral joint that is greatest in 90· of abduction the least restricted range of mo- . As described by Cyriax. Abduction TIS.' the capsular pat­ to 90· combined with external rotation is the next tern of restriction is characterized by a restric­ most restricted range. 1 0)8 a modification of Cyriax's capsular pattern. B cited is Cyriax's capsular pattern of restriction external rotation. DIFFERENTI A L S OF T T I SSUE DIAGN OSIS 67 A FIGURE 3. tation of glenohumeral external rotation in O· of abduction than in 45· to 90· of abduction. Limited glenohu­ TIG H T P OS T E R I O R C A P S U L E . for hypermobilities. 29 MWiculiJtendinous Strength M I D D L E A N D I N F E R I O R G L E N O H U M E R A L LIGA­ MENT TI GHTNESS. mobilization tech­ with secondary impingemenl. 14). and glenohumeral joints identifies the presence meral internal rotation and horizontal adduction and direction of hypomobilities and hypermobil­ indicate a restriction of the posterior capsule. (B) Same pa. strengthening S U B S C A P U L A RIS M USCLE T I G H T N E S S . Sub­ exercises to improve joint stability may be em­ scapularis tightness will result in a greater limi­ ployed (see Ch. See Chapter 1 for further discussion of ana­ ACCESSORY M OT I ON tomic restrictions at the glenohumeral joint. This is particularly true of the gleno­ meral external rotation in 45· to 90· of abduction humeral and scapulothoracic joints. scapulothoracic.28 niques to restore the mobility may be employed (see Ch. tion.68 PHYSI C A L THER A P Y OF THE SHOUL DER A B FIGURE 3. because than in O· of abduction.6 (A) Substitution of glenohumeral extension for glenohumeral il1lemal rotatio/'/ in a patient with restriction of the posterior capsule. When hy­ tients with anterior glenohumeral instability pomobilities are identified.tiel1l after extensibility of the posterior capsule is restored.29 they function with little stability provided by . 15). acromioclavicular. ities of the noncontractile structures (primarily Posterior capsule tightness is often found in pa­ the capsule and ligaments) of a joint. An assessment of accessory motion at the sterno­ clavicular. Restriction of the middle A careful assessment of the musculotendinous and inferior glenohumeral ligaments and cap­ structures is of vital importance for soft tissue sule will result in greater Hmitation of glenohu­ diagnosis. B ( Figllre cOll/i. (B) Patiel1t's hands on hips (thumbs poil1ling posteriorly). Measurement o{ distance {rom in{erior angle o{ scapula to tile nearest thoracic segment.7I's anns restil1g at sides. (A) Patie.7 test. DIFFERENTI A L SOFT T ISSUE DIAGN O S I S 69 A wteral slide F I G U R E 3.lLles.) . c FIGURE 3.8 Wall push-tip.70 P HYSI C A L THERAP Y OF THE SHOU L DER FIGURE 3. . Paliel1! with mild left serratus anterior muscle lVeakl1ess exhibits mild '\vil1gil1g" of left scapula.7 (comil1t1ed) (C) Clel10hwlleral joims 90oabdtlc!ed mid imemally rolared. 5. Idelllification of specific /IIuse/e/telldon lesion with resistive tests POSITIVERESISTIVETEST MUSCLEITENOON FINDING S OF ADDITIONAL RESISTIVE TESTS Shoulder abductioo Deltoid Positive Aexion (anterior deltoid) Positive extension (posterior deltoid) Supro�inotus Negative Aexion Negative extension Shoulder adduction Pectoralis mojor Positive Aexion Positive horizontal adduction Teres minor Positive external rotation latissimus dorsi Positive extension Positive intemol rotation Teres major Positive extension Positive internol rotation Shoulder externol rototion Teres minor Positive adduction Infrmpinotus Negative adduction Supraspinatus Positive olxluction Shoulder intemol rotation Subscapularis Negative adduction Pectoralis mojor Positive adduction Positive horizontal adduction latissimus dorsi Positive adduction Positive extension Teres major Positive oddudion Positive extension (Modified (row CyrillX.8 wilh pe..sl1Iissioll. langus copitus Scaleni Infrahyaid Suprahyoid (Data (row Jallda mid SclimidJ2 and Jill arid Jmlda. Respol1se of specific upper quarter lYIuse/es 10 dysful1ctiol1 MUSCLE G ROUP POSTURAL MUSCLES (TIGHTEN) PHASIC MUSCLES (WEAKEN) Axioscapular muscles Upper tropezius Rhomboid mojor and minor levator scopulae Middle trapezius Pectoralis minor lower trapezius Serratus anterior Scapulohumeral muscles Subscapularis Deltoid Supraspinatus Infraspinatus Teres minor Axiohumerol muscles Pectoralis major (clavicular portion) Cervical and stomotognathic muscles Sternocleidomastoid longus colli Suboccipitol.) TABLE 3. JJ) .72 P HYS I C A L THERAP Y OF THE SHOUL D E R TABLE 3.4. 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. TIS. Palpation o( upper quarter stnlCtures REGIO N STRUCTURE SOFT TISSUEI NJ URY FINDI NG OR POSTURAL FAULT Anterior cervical triangle Suprahyoid muscles FHP Tight. Jull and Janda" de­ mands adequate scapular stability. or a combination of the two. Thus.4 A and potentially contIibute to an impingement muscle imbalance may be defined as a weak ago­ syndrome. TP'. TP'. speCific scapu­ based on response to dysfunction. Cervical facet joints Facet stroin Tender. Gibson et . 3. Scapular instability Tight.7). as postural muscles.rigger point. . TP'. M uscles that lar stability tests may assist in soft tissue shorten and tighten in dysfunction are classified diagnosis. and the nearest thoracic segment in three different supraspinatus. This results in anteIior instability glenohumeral joint positions (Fig. Muscle imbalances are a common intrinsic combined. and lower trapezius. {onl'ard "ead posltlre.34 M uscle im­ the second and third positions is associated with balance of the scapula often involves both tight. serratus anterior. tender.6. Anterior and middle scalene muscles FHP Tight. A measurement is ally involves tightness of the subscapularis and taken from the inferior angle of Lhe scapula to weakness of the infraspinatus. TIS Tight. tender Upper trapezius muscle fHP Tight. teres minor. Infrohyoid muscles FHP TP'. Posterior cervical lriangle Sternocleidomastoid muscle FHP Tight. 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.5). these limit elevation of the acromion factor in shoulder microtrauma injuries. selTatus anterior and lower trapezius muscles. a tight agonist. thickened Posterior tubercles of transverse processes fHP Tender (aHachment of levator scopulae muscles) Clavicle Scapular protraction Elevated HIP. microtrauma injuries of the shoulder. 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. DIFFER E N TI A L SOFT TISSUE DIAG N O SI S 73 TABLE 3. Anterior tubercles of transverse processes FHP Tender (insertion of anterior scalene) longus colli FHP TP'. in ad­ veloped a classification system of skeletal muscle dition to manual muscle testing. TP. edema First rib FHP Elevated. while those that lengLhen and weaken in dysfunction are classified as pha­ LlIteral Slide Test sic muscles. and A muscle imbalance of the rotator cuff gener­ rhomboid major and minor). TP'.3 . thoracic it/leI sY. edema. TP'. pie (see the section on special tests later in the ness of the levator scapulae and weakness of the chapter). nist.ldrome. 74 P HYSI C A L TH E R A P Y OF TH E SHOUL D E R TABLE 3. edema. thickened Supraspinatus or infraspinatus Tender. thickened FI-JP. tender. thickened tendonitis long head bicep. muscles lower trapezius muscle Scapular instability A�ophy Axillary region Pectoralis major muscle Scapular protraction Tight Frozen shoulder Tight Pectoralis minor muscle Scapular protraction Tight. TP. TIS. TP's Corocoid proces Scapular protraction Tender (insertion of pectoralis minor) TIS Tender Subscapularis muscle Muscle imbalonce rotator cuff Tight. tender. . Palpatiol1 of structures ofthe shoulder complex RE GIO N ST RUCTURE SOFTTISSUEI NJ URYO R FINDI N G POSTURAL FAULT Scopulor region Acromion process Impingement syndrome Tender Scopular elevation or protraction Elevated Inferior angle of scopulo Scopulor obduction lateral Scapular protraction Elevated Suprascapular notch Suprascapular nerve entrapment Tender Spine of scopula Scapular protraction Excessively angled in frontal plane levotor scapulae insertion FHP Tight. thickened Subacromial bursitis Tender. on scopulo Cervical strain Tight. TP'. forward head posture. Decreased scapular rotation Tight Supraspinatus muscle All rotator cuff pathologies A�ophy Suprascapular nerve entrapment Atrophy Anterior instability A�ophy Infraspinatus and teres All rotator cuR pathologies A�ophy minor muscles Supraspinatus nerve entrapment A�ophy {infra>pinotu. thoracic ill/el SYlldromc.} Anterior instability A�ophy Quadrangular space Axillary nerve entrapment Tender Rhomboid major/minor Scapular instability A�ophy. TP'. TP's Articulor structures Sternoclavicular joint Dislocation Malalignment Sprain Tender Acromioclavicular lAC) joint Dislocation Malalignment Sprain Tender Corocoocromiol ligament 1mpingement syndrome Tender AC joint sprain Tender Coracoclavicular ligaments AC joint sproin Tender Humeral head Anterior subluxation Positioned anteriorly Tight posterior copsule Positioned anteriorly lesser tubercle humerus Tight subscapularis Tender Subscapularis bursitis Tender Greater tubercle humerus 1mpingement syndrome Tender. tendon Bicipital tendonitis Tender. lrigger poilll. edema. TP'.7. and resis­ tance of objects in relation to the body.94 and interrater ICCs of O."·3. 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. muscle. 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 2.3o.40 to 3. vestibular. 3. wall push­ Published studies on shoulder propriocep­ up (Fig. The reader is referred to Chapter \ 6 for and subject replication of known angles. proprioceptive and kinesthetic clinicians.69. 3. tion on mobility later in the chapter). In addi­ manual muscle testing of the selTatus anterior tion to visual. and cutaneous input. Therefore.10 Apprehension test.9).on and Kinesthesia measurement for each clinician.oception is defined as the "Winging" ability to perceive position. abilities received more attention in rehabilita­ tion of lower extremity injuries than upper ex­ Fw. Propl. or sitting press-ups (Fig. . 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.3 I The examiner may observe scapular receptors in the joint capsule. although a useful Prapriocepf:i.ctional Tests of Scapular tremity injuries. \ S to 0. and reported intrarater ICCs of O. or weight of body movement. Kinesthe­ Direct observation of scapular "winging" is sia is defined as the ability to sense the extent. the lateraI slide test may not be suitable for comparison between Until recently. FIGURE 3. not possible in the classic supine position for direction. the inferior angle of the scapula.S\ to 0. ligaments. tive and kinesthetic testing have used specialized testing apparatus. weight.00 for seven lized to obtain more specific parameters of shoulder joint positions between known angles strength.S). Davies and Dickoff-Hoff­ man" advocate clinical angular joint replication ISOKINETIC TESTING testing with an electronic digital inclinometer. Because many structures of the shoulder complex are normally tender to palpation. GLENOHUMERAL STABILITY TESTS Glenohumeral stability tests are performed to as­ sess the integrity of the capsular and ligamen­ tous structures.7. compromised following anterior shoulder dislo­ In general. trauma is suspected. comparison of findings to the unin­ volved side is crucial. Additionally. palpation of the anterior and poste­ cation.1 1 lobe subluxation test. ApprehCl1siol1 Test The patient is placed in a supine posllton. Provocation of pain and apprehension in­ dicate anterior instability.J5·3. The tests may be used to confilm both unidirectional and multidirectional insta­ bilities. 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. temperature. and rupture of the transverse humeral ligament. musculotendinous dysfunctions. sitting position. In this section we will describe the more commonly performed special tests for glenohu­ meral instabilities.patiffn pation findings are common to many shoulder dysfunctions. Structures commonly palpated by re­ size. along with pitus. 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. 3. ligamentous.6 and 3. swelling. and provocation of pain. be more important when glenohumeral macro­ or labral structures. . 10).76 PHYS I C A L THE R A P Y O F THE S HOUL D E R Because proprioception and kinesthesia are tate an efficient yet comprehensive evaluation. structure function. static position. impingement syndrome. similar pal­ PaJ. The examiner provides overpressure into external ro­ tation. while pal­ in rehabilitation of macrotraumatic injuries that pation of glenohumeral articular structures may are likely to disrupt the capsular. The shoulder is then positioned in 90· of abduc­ tion and full external rotation (Fig. labral tears. at least patients with postural abnormalities. cre­ gion are shown in Tables 3. A systematic pro­ the possible dysfunction(s) when palpation find­ cedure for palpation of tissues is advised to facili.39Ao The apprehension test may also be performed with the patient in a FIGURE 3. exercises designed to improve propri­ rior cervical triangles may be more important in oception and kinesthesia seem logical. aminer then applies a posteriorly directed force 2. 1 2 Jobe relocat ion lest. 13). sidered a positive test. The examiner grasps the pa­ tient's forearm with one hand to maintain the Glel10humerai Load al1d Shift Test test position and the posterior humeral head The patient is seated and the examiner is with the other hand. the ex­ over the rim. but not If pain and apprehension are provoked. OIFF ER E N TI A L SOFT TISS U E DIAGN O S I S 77 Jobe Subluxatiol1 Test 3. terior instability with secondary impingemenl. but FIGURE 3 . The hu­ Provocation of pain without apprehension may meral head is directed superiorly and medially denote either primary impingement or mild an­ to approximate the glenoid fossa ("loaded"). 12). 1 1). head rides up and over the glenoid rim. 3 .4I Whjle maintaining the "loaded" position. Reduction of pain and apprehension while "relocating" the humeral head posteriorly is con­ The patient is placed in a supine position. both anterior and posterior stresses are applied and Jobe Reiocaliol1 Test the amount of translation is noted '2 Abnormal This test may aid i n the differentiation of a displacement of the humerus may be catego­ primary impingement from a primary instability rized as follows: with a secondary impingement41 The shoulder is positioned in 90' of abduction and 90° of exter­ I . The examiner then gently positioned behind the patient on the ipsilateral applies an anteriorly directed force to the poste­ side (Fig. identical to the apprehension test. . The examiner stabilizes the rior humeral head. 3. head rides up the glenoid slope. Pain and apprehension i ndi­ scapula with the proximal hand and grasps the cate a positive test for anterior instability " humeral head with the distal hand. 5 1o /0 111111 of dispiacel11el1l: the humeral nal rotation. and indicates primary an­ The aIm is then positioned off the edge of the terior instability rather than primary impinge­ examining table and the glenohumeral joint menlo placed in 90' of abduction and 90° of external rOlation (Fig. /0 10 /5 111m of dispiacel1lel1l: the humeral to the antelior aspect of the humeral head (Fig. 3. The anterior or superior labrum. 3. and the rim and remains dislocated when the stress aim is abducted to 90· and placed on the exam­ is removed. . The common labral sulcus sign i s indicative of multidirectional in­ integrity tests are the clunk test and the SLAP stability and is reported in centimeters of hu. moved. 1 3 Glenohumeral load and shift test. 1 5). FIGURE 3.14 Sulcus sign. Excessive inferior translation with the sul­ The patient is seated with the arm at the side cus defect between the humeral head and acro­ in a neutral position (Fig. The examiner mion constituLes a positive test and indicates applies a distraction force to the humerus. 14).78 PH YSI C AL THE R A P Y OF THE SHOUL D ER FIGURE 3. The examiner applies a caudally directed force to the proximal hume­ StllcLlS Sign rus. More than J 5 111 m of displacement: the hu­ SulcLlS Sign a t 90· meral head rides up and over the glenoid The patient is in a seated position. The patient may report a Labra1 tests are perfol-med to detect tears in the subjective response of subluxation as well." Ex­ inferior glenohumeral instability " cessive inferior translation with a sulcus defect between the acromion and humeral head indi­ LABRAL INTEGRITY TESTS cates a positive test. (superior labrum anteroposterior) lesion test. meral head displacement from the inferior sur­ spontaneously reduces when stress i s re­ face of the acromion. iner's shoulder (Fig. 3. 16 CII/llk lesl. . 1 5 Sulcus sigll al 90� FIGURE 3. D IFF E R E N T I A L SOFT TISSUE DIAGNOSIS 79 FIGURE 3. 1 8 Lockil1g lesl. . FIGURE 3 .80 PHYS ICAL THER A P Y OF T H E S HOUL D E R FIGURE 3. 1 7 Superior labnll1l anteroposterior (SLAP) lesiol1 lesl. DI F F ER E N T I A L S OFT TI S SU E D I A GN O S I S 81 Clunk Tesl The patient is supine and the humerus is shifted anteriorly and posteriorly while simul­ taneously circumducting the humerus and bringing the humerus into full abduction (Fig. are positive clinical signs of a Bankart lesion. rotates and slightly extends the humerus. 16). pseudo-catching may implicate a SLAP lesion with a possible tear of the long head of the biceps tendon. Common special tests that assist in the confirmation of a diagnosis of impingement syndrome include the locking test. a "clunk" sound. 1 9 Neer and Welsh impingemenl leSI. 3. and the Hawkins and Kennedy impingement test. a "clunk" sound and pain.44. thereby compressing the subacromial structures.4S"· Superior LAbrum Ameroposlerior (SLAP) Lesiol1 TeSI The patient is sitting with the humerus in 90' of abduction. Lockil1g Tesl As described by M aitland!· the examiner stabilizes and depresses the scapula with the proximal hand while the distal hand internally FIGURE 3.47 IMPINGEMENT TESTS Impingement tests are designed to approximate the greater tubercle of the humerus and the acro­ mion. 1 7).ion is ap­ plied (Fig. During these maneuvers. or FIGURE 3.20 Hawkins and Kel1nedy impil1gemenl lesl. and the forearm fully supinated. The . usually located between 90' of abduction and full abduction (anteroinferior as­ pect of glenohumeral joint). Resistance to abduct. 3 . the elbow extended. the Neer and Welsh impingement test. Pain. The Gilcrest sign and the Drop Arm test both assess the f"unction of multiple muscles and tendons. Gilcrest Sig n humerus is then abducted until firm joint resis­ The Gilcrest sign evaluates the eccentric ac­ tance is detected (Fig.47.82 PHYSICAL THE R A P Y OF THE SHOUL D ER is accomplished by exe. The supraspinatus tests serve as resistive tests. FIGURE 3. Provocation of pain tivity of the biceps. Yergason's Tesl The patient is seated. and then lowers the arm in the fTontal plane in an externally rotated position NeeI' and Welsh Impingemenl Test (Fig. 3.54 . thereby evaluating both musculotendinous strength and pain provocation.20) 47. MUSCULOTENDINOUS UNIT TESTS M usculotendinous unit tests are designed to identify dysf"unction of specific muscles and ten­ dons. 3.47. The patient Tesl contracts the biceps muscle isometrically by The patient may either be sitting or standing. supraspinatus.2 1 ).23). The examiner palpates the long head of the biceps tendon with the proximal hand while resisting supination and elbow flexion with the distal hand.S3 arm in forced flexion. the supraspinatus. pressing the hand against the head. The patient's hand is placed on top of the head forCing the glenohumeral joint into abduc­ Hawkins and Kennedy Impingel1lent tion and external rotation (Fig. Ludington's Test 3 . 3. Tests specifically for bicipital tendinitis in­ clude Yergason's test and Ludington's tes!.21 Yergason's lesl. the elbow is placed in 90° of flexion.-ting force through the forearm to bring the distal glenohumeral joint into internal rotation. Pain implicates supraspi­ natus tendon impingement. 1 9). Pain and inability to control the arm The patient is seated while the examiner motion is a positive sign of dysfunction of the stands. The patient fully flexes the arm while supraspinatus tendon '9 holding 5 pounds.22). 3. and deltoid indicates a positive test for impingement of the muscles. or the with one hand while the other hand raises the deltoid muscle. causing approximation of the greater tuberosity and the acromjon (Fig. Symptom The humerus is placed in 90° of flexion and then reproduction in the bicipital groove is a positive internally rotated (Fig. 3.47•52 Provocation of pain over the anteromedial aspect of the shoulder is a positive sign of bicipital tendinitis. Scapular external rotation is blocked long head of the biceps. 1 8).50 Pain implicates impingement of the su­ praspinatus and long head of the biceps tendons.51 The maneuver sign for bicipital lendinitis. and the forearm is pronated (Fig. 24). One FIGURE 3.25). Alternate Supraspinatus Test The patient is prone with the arm to be tested resting off the side of the plinth.55 .26).S8 The examiner then grades the strength of the supraspinatus muscle and notes any pain provoked by the test. The humerus is placed in 90· of elevation in the plane of the scapula and full internal rotation (Fig. 56 The arm is passively raised above 90· of abduc­ tion. Drop Arm Test If the patient's arm approaches 90· and "drops.23 Ludil1gton's lest. The examiner applies resistance to elevation while the patient allempts to maintain the position." the test is positive for a full-thickness rotator cuff The patient may either be seated or standing. . 3.­ zontally abducts the arm at 100· of abduction in external rotation and the examiner applies resis­ tance at the end of range (Fig 3. 3.22 Gilcrest sig l1. common test is the Lippman test.59 The exam­ iner then grades the strength of the supraspi­ natus muscle.57. The patient hOl. DIFFER ENTIAL SOFT TISSUE DIAGNOSIS 83 FIGURE 3. TRANSVERSE HUMERAL LIGAMENT TESTS Special tests are also described to identify rup­ tures of the transverse humeral ligament. The patient then actively lowers the aim to Supraspil1atus Test 90· of abduction in intemal rotation (Fig. tear. FIGURE 3. .24 Drop ami test.25 Supraspinalus leSI.84 P HYSI C A L THER A P Y OF THE S H OUL D E R FIGURE 3. FIGURE 3. DIFF E R E N T IAL SOFT TISSUE DIAGNOSIS 85 FIGURE 3.27 Lippman test. .26 Allemale supraSpil1QrUS test. does not cross mid­ component of evaluation on a specific patient. The patient I . The patient reports pain over the lateral aspect of the proximal half of the arm.86 P HYSI C AL THE R A P Y OF THE SHOUL D E R Lippl1wl1 Test COEXISTING PROBLEMS The patient has a 20-year histOlY of i'Titable The patient's elbow is placed in flexion and bowel syndrome for which she takes an antispas­ the examiner palpates the long head of the biceps modic medication (Bentyl). This case study demonstrates the use of each proximally to the CS level. reaching behind her back. beginning approximately 4 months ago. The pain never extends below the elbow or above the subacro­ CASE STUDY mial area. and therefore a summary strokes in tennis. and because she re­ medication. but does not stop her H I ST O R Y from finishing. medial manual forces to the tendon. ports a relatively long T I . No other problems are head of the biceps tendon by exerting lateral and reported. The patient is a 47-year-old flight attendant. based moved to a new home with a swimming pool 6 on the history of the problem's onset and months ago and began swimming laps (freestyle) the introduction of a new activity (swim­ two or three times per week. the pain begins towards the end of her 30 minute swim. Her routine activities include carrying and C O N C L U S I O N S B A S E D ON PATIE T t N T E R V t E W storing luggage as a part of her occupation. and recreational tennis and swimming. The coexisting medical problem of irritable is married and has two teenaged children. and of ongoing assessments is included following lifting luggage overhead for storage while work­ each portion of the evaluation. She reports waking with aching in the left arm after sleeping on the shoulder. casional bilateral neck pain and stiffness. Some discomfort in the medial left scapular area extends distally to the T4 level. During free­ PATIENT INTERVIEW style swimming. and extends laterally to the acromial area general plan of care concludes the case study. ing. She 3. The arm pain is intelmittenl. the shoulder and is unlikely to need further . no T2. and rela­ DEMOGRAPHlC INFORMATION tively short T3. the reader is refe'Ted to subsequent The patient describes the a1'm pain as aching chapters for more specific descriptions of treat­ in nature and the scapular pain as tightness and ment programs. She also reports oc­ tendon within the bicipital groove (Fig. She is unable to identify a specific mechanism of in­ jury. N ATU R E . based on Maitland's' Cl'iteria. serving and backhand is an ongoing process. The pain withheld until the exam is complete. 3. and reports patient meets only one of Cyriax's" three crite­ some improvement in her symptoms with this ria for high irritability. Resting the arm by the side eases The patient reports an onsel of left shoulder pain the pain after about 1 0 minutes. She is currently tak­ ming) 2 months prior to the onset of pain. The pain stems fTom microtrauma. " Ability to displace the tendon fTom the bicipital groove in­ dicates a rupture of the transverse humeral liga­ LOCATI O N . Irritability level is generally low because the (Daypro) for her shoulder problem. for The examiner then attempts to displace the long which she takes Advil. however. She bowel syndrome is not known to refer pain to is left-hand dominant. A line. of the scapula. Although specific diagnoses are soreness. assessment is provoked by swimming. ing a nonsteroidal antiinflammatory medication 2. A N D BE HAVIOR ment.27). A sharp pain without tendon displacement OF P A I N indicates bicipital tendinitis. The O. demonstrates a O. Cervical compression does demonstrates lack of follow-through on her ten­ not provoke pain. but no left tape of her tennis lessons taken by her coach arm or scapular pain.nis strokes Anteriorly. sive protraction of the left scapula. limiting right cervical rotation and decision to include evaluation of the upper right side bending. Muscle tightness or cervical facet restriction I . a slight left head tilt and mild atrophy may be either an extrinsic factor in her dys­ of Ihe left deltoid can be observed. Coexisting cervical symptoms C L I N I C A L M EA S U R E O F S C A P U L A R P O S I T I O N will need special allention during the subse­ quent examination. ing on the right and left sides with the arm in cervical right rotation and right side bending are an adducted position. 3. 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 . greater on the left side. are common in the patient's age group. Forward head posture sUPPOJ-ts the previous is likely. and I I D'. nis forehand and poor positioning for her back­ hand. and backward bending. Arm swing end range. with reports of stiffness at end mostly on the right side because she wakes with range. apparent exces­ tion. 3. with pain at end ranges . Forward bending is full with stiffness at discomfort when in left sidelying. 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. during ambulation is normal. She now attempts to stay slightly limited. ment of possible left cervical facet or muscu­ lar tightness.s-cm difference in scapular position in the palpation portion of the examination. Progressive degenerative joint dysfunctions protraction. Improper biomechanics of ten. D I FF E R E NTIAL S OF T T I SS U E DIAGN O SI S 87 consideration. 1 ) involvement in upper quarter dysfunctions. A video­ comfort in the left midcervical region. 2. The patient keeps and left side bending are within normal limits the left shoulder near its neutral position when (WNL). left rotation. quarter in the ongoing assessment. Laterally. Passive overpressures into cervical right donning or doffing clothing to avoid a combina­ rotation and right side bending provoke mild dis­ tion of abduction and external rotation. respectively. 4. Left head tilt supports the previous assess­ arm or scapular symptoms. due to common referral A measurement of scapular protraction using the of pain to the shoulder region and common method described by Diveta et ai l s (see Fig. Palpation of the anterior and posterior lI-ian­ gles of the cervical spine should be included 3.s-cm difference in scapular 4. 5. is unlikely to be clinically significant. O T H E R P O S I T I O N S A N D A C T I V I T I ES CERVICAL SCREENING The patient normally alternates between sleep­ Compared to left rotation and left side bending. a slight depression of the left scapula. Cervical spine tests do not reproduce left 2. Depression of left scapula is likely nOJ-mal OBSERVATION OF SYMMETRY AND POSTURE because this is the patient's dominant side. function or a compensation for the dysfunc­ moderate forward head posture. 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. With repeated movements. posterior capsule may result. In the plane of the scapula. 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. 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'. or perform­ PASSiVE R A N G E O F M O T I O N ing tennis strokes with COITect body me­ chanics. and is unable to put and/or stabilizers. She re­ 3. her neck. 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. During passive ment limitations. pain and resistance are en­ 5. 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). range of external rotation in 90' of abduction. 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. PROM findings indicate that joint restric­ full. rotation in 0' of abduction is slightly limited compared to the light side.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. rhythm is observed during concentric activity through all three phases of elevation. as well as the slight restric­ is not taken. daily activities such as fastening a brassiere. although there is mild arm discomfort 2. . horizontal adduction. primarily limits glenohumeral internal rota­ During passive internal rotation. tion of passive scapular distraction. tucking in blouses posteriorly. A painful arc is present dur­ terior capsule and a false-positive laxity of the ing active abduction. Other motions are 4. rather than muscle weakness or pain. a raise-positive restriction of the an. A muscle imbalance of the rotator cuff is During accessory mobility testing. and resistance. Limited active and passive internal rotation centric activity. The PROM is encountered prior to pain. prevents further movement. 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). Passive scapular normal glenohumeral to scapulothoracic distraction is slightly limited on the left. her left hand on the opposite shoulder. using the method further limit movement at l i S'. I ACCESSORY M O B I L I TY 6. Limitations of f"tlllctional movements indi­ ports left lateral arm pain dUling both maneu­ cate that the patient is unable to perform vers. External tal adduction. apparent scapu­ during the maneuver. with mild left lateral arm pain at the end tion. anteroposter­ rior capsule laxity may predispose the pa­ ior gliding of the left humerus is mildly restricted tient to an impingement syndrome. 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 . Posterior capsule tightness and mild ante­ When compared to the right side. After 7 to 8 repetitions. 7. caution is likely. not findings correlate to the functional move­ pain. resistance tion and horizontal adduction. If this caution of abduction).2' and posteroanterior gliding is slightly increased. of assessing irritability from either Cyri­ ax'or M aitland. 2. During palpation of the scapular region.ng the middle phase of elevation Serratus anterior 4 . Palpation of the articular SlIuctures shows tenderness over the anterior as­ pect of the left acromion. 3. pos­ The shoulder external and internal rotators are itive findings include a depressed left acromion tested in 30· of elevation in the plane of the sca­ and inferior angle of the scapula. manual muscle testing.S-cm greater measurement is obtained of the cervical spine reveals tightness and tender­ on the left side (see Fig. The peak torque left supraspinatus. based on this patient's gener­ ally low ilTitability level and relatively high I ./5 4 + /5 eral slide test. However. and atrophy of the 180· per second are chosen.ghl 3. and trigger points at the insertion of the tested in 90· of abduction. Mild left scapular ness of the left anterior and middle scalene mus­ "winging" is obselved during wall push-ups (see cles. 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. and tenderness of the left pos­ terior tubercles of the transverse processes of C3 I S O K I N E T I C T E S T I N G and C4. and isoki­ M A N U A L M U S C L E T E S T I N G netic testing. ing are as follows: left R. rotators and supraspinatus found with resis­ tive tests. The patient exhibits weakness and instabil­ ity of the scapular muscles based on the lat­ GH external rotators 4 . sistive tests indicate a muscle or tendon rup­ ture or neurologic dysfunction (see Table C O N C L U S t O N S B A S E D O N P A L P A T I O N 3. infraspinatus. At the axillary region. ten­ pula to avoid pain that may be encountered if derness. The findings support previous conclusions functional level. 18 a I . and tenderness over the left long head of the bi­ I .7). tenderness over the TEST I N G lesser and greater tubercles of the left humerus.nl 5/5 PALPATION SCA P U L A R STAB I L I TY T E S T I N G There are no significant findings to palpation of the structures within the anterior triangle of the During the third component of the lateral slide celvical spine. manual muscle testing. and GH abductors 4 . According to Cyriax.nl 4/5 pula dUI./5 Ipo.8 weak and painless re­ ceps tendon. and teres ratio of the external rotators to internal rotators minor muscles.8). tightness.nl 4/5 previously observed oscillations of the sca­ Supraspinatus 3 + /5 Ipo. 4 . Test speeds of 60· and left levator scapulae muscle.3). meral head. Palpation of the posterior triangle test. a slightly anteriorly po­ CONCLUSIONS BASED O N M U SCULOT E N D I N O U S STRENGTH sitioned left humeral head. . tightness and trigger points of the left upper Fig. mild tight­ is 40% on the left and 60% on the right at 60· ness and trigger points are palpable over the left per second./5 5/5 lower trapezius (with repeated testing of eccentric activity). and that mus. trapezius muscle. it is most likely that the of imbalance of the rotator cuff muscles neutral position for resistive testing does and mild anterior subluxation of the left hu­ not provoke the patient's pain. 3. combined with the previous finding of probable subscapularis muscle Significant findings during manual muscle test­ tightness. subscapularis muscle./5 Ipo. 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. left head tilt. The reader is referred to subsequent 2.39-4 1 on a specific patient's evaluation findings. and combined nexion and left. 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. 3.39-41 Summary 4. the locking tion in internal rotation that may test'S is deferred due to painfully restricted gle­ predispose to impingement).or glenohumeral sub­ luxation. 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. and a case study rior subluxation of the glenohumeral joint has illustrated the process of assessment based with secondary impingement. S8 is positive for pain and weak­ the shoulder in combined abduction and ex­ ness . the need for a thorough evalua­ 5. and an occupation that re­ quires overhead lifting.or load-shift test. sion test. 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. 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. cuff muscles results in failure to counteract 3. 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). Positive Gilcrest sign may suggest the in­ tion is more vital than ever. The ASSESSMENT components of evaluation for the shoulder com­ I. The Gilcrest sign'7.s3 is also positive on the ternal rotation. and a mildly 3. Impingement tests are positive. The apprehension and relocation tests sug­ gest that the patient's impingement is sec­ ondary to a mild antel. positive relocation test. care providers. Extrinsic factors in this patient's micro­ positive left antel. tient's problems. In this case. internal rotation). The supra­ tennis (tennis serves involve positioning of spinatus testS7 . which can then direct the clini­ cian to the most efficient treatment plan. Tenderness over the greater and lesser hu­ 2 . the findings of impingement and mus­ systems demand greater efficiency from health cle imbalance of the rotator cuff. and cle). Intrinsic factors in this patient's micro­ meral tubercles. Tightness and tenderness of the levator scap­ the upward shear forces of the deltoid mus­ ulae."·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. Pain and weakness of the supraspinatus sup­ As emerging trends in the health care delivery POl1. ." and weakness of the bending. anterior and middle scalene. chapters for specific treatment programs. M icrotrauma injury characterized by ante­ plex have each been discussed. and subjective tightness at the end scapular external rotatol (weakness of the range of cervical nexion.90 P HYSI C AL THE RAP Y OF THE SHOUL D ER 2. 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 . anterior acromion. recreational nohumeral internal rotation PROM. rior glenohumeral capsule (decreases the and limited left cervical rotation and side subacromial space).8. Greenfield B: Upperqllal'tcl'evaluation: structural relationships and interdependence. 1 989 phology of the acromion and its relationship to 1 3 . Phys Ther 2 1 : I 00. Berkow R. Whitney SL: Nonoperative 1 4 . Westcrberg CE: management of secondary shoulder impingement The innuence of scapular retraction and protrac­ syndrome. J O. Roy SH. 6 . Fletcher AJ: The Mcrck Manual of Di­ Phys Ther 70:470. Skibinski B: Relalionship apy Practice: Screen ing for Medical Disease. 1 5L h Ed.8. Rothstein J M . 1 990 agnosis and Therapy. 1 995 4. WB Saunders. 1 986 in patients w i t h shouldcl" ovenJse injuries and 3. Thuomas KA. Bigliani LU. Coats PW et al: PoslUre rotato. Wolf SL: The Rehabilita- . between pCI-formance of selected scapular mus­ Churchill Livingstone. 5 t h Ed. Fu FH. Lippi ncott-Raven Phi ladel­ phia. Kibler WE: Role of the scapula in t h e overhead 8. Orthop Trans 1 0:2 1 6. London.· cuff tcars. London. Mailland GO: Vertebral Manipulation. Diveta J. New 2 . In Do­ I . Fletcher AJ: The Merck Manual of Di­ bility study of measurement techniques to detcr­ agnosis and Thcrapy. Hoppenfeld S: Physical Examination of the Spine for her very valuable editorial assistance. 1·lamer CD. Won"ell TW: Assessment of scapular po­ Sharp and Dohme Research Laboratories. Goebel GV. 1 982 1 9. Vol I . Greenfield B. tion on the width of t h e subacromial space. Klein AI-!: Shoulder impi nge­ healthy individuals. 1 5t h Ed. Appleton-Century-Crofts.1hop 22:525. Wooden MJ (eds): Orthopaedic Physical Blil lerworths. CT. 43. Baill iere Tindall.1S Rehabil 2:20. 1 986 Therapy. In'gang JJ.1s Phys Ther ment synciT'ome: a critical review. NJ. Neiers L. 1 99 1 Ed. April EW: The mor­ York. 1 995 1987 1 8. infraspinatus. Rahway. Panjabi MM: Clinical Biomechanics or Aclowwl£dgments the Spine. Churchill Livi ngstone. 1 990 The authors wish to thank Marie-Joselle Murray 1 0. Catlin PA. Rah­ siLion. 1 99 1 cles and scapular abduction in standing subjects. Walker ML. Vol. Boissonnaull WG: Examination in Physical Ther­ 1 5 . 1 993 way. J SpO. I. NJ 1 987 1 7. 2nd Ed. 8th t h rowing motion. Nor­ walk. natelli R. New York. 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 9. 1 976 1 1 . and Extremities. Clin Ol1hop Rei Res 269: 1 62. White AA. Morrison OS. 2nd Ed. Clin 1 993 Orthop Rei Res 296:99. DIFF E R E N T I A L SOFT T I SS U E DIAGN O S I S 91 TABLE 3. 1 992 References 1 2 . Con temp O. J Orthop Sports Phys Ther 1 7 :2 1 2 . Philadelphia. Berkow R. Jordan TM et al: A relia­ 7 . Merck 1 6. 1 99 1 2 1 :287. Gibson M H . Kamkar A . I SL Ed. Magee OJ: Ot1hopaedic Physical Assessment. Vol 2. Sequential treatment goals and treatment plan TREATME NT GOAL TRE ATMENT P LAN 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. J Ol1hop Sports and Oohme Research Laboratories. 1 993 5. Cyriax J: Textbook of OrLhopaedic Medicine. Merck Sharp mine static scapular position.1hop Spo. p. Solem-Bertoft E. Clin Sports Med 1 0:839. Paris SV. London. 1 978 oceptive sensation of the shoulder in heahhy. Hawkins RJ: Classification and physi­ thopaedics. Petersen C. Abrams JS: Impi ngement syndrome 35. Buttcrw0I1hs. Philadelphia. Kendall FP. Janda V. 1 993 meraijoint in abduction. Phys Spol1smed 6: throwing athlete: pathology. 1 984 1 33 2 . 1 990 cal diagnosis of instability of the shoulder. 1 993 New York. 1 995 39. Carson WG (eds): Injuries to the ders Company. Borsa PA. 1 59. Hill JA: Rotator cuff injuries: an up­ 36. Abrams JS: Special shoulder problems in the nation of the shoulder girdle. SI. Provance PG: Muscles: 46. Augustine. diagnosis. Williams & Wil­ athlete. Yahara M L : Shoulder. Walker PS: FOI'ccs at the glenohu­ plex. 1 989 kins. Ganz R: Clinical assessment of instabil­ sive glenohumeral motion. 1 989 2 1 . Paper presented at the 4th con­ Home Study Course. Gillogly S: Physic. Res 1 73:70. Am J Sports Med phia.11 examination of 30. Mut. 1990 44. Marshall JL et al: Stabiliz­ tions of shoulder subluxation and dislocation. evalua­ 33. Balti more. Sidles JA. Davis GJ. Poppen NK. Larson RL: Functional exami­ 25. Clin 011ho Rei 697. Smith RL. 1 989 Shoulder Kinesthesia in Healthy Unilateral Ath­ 22. Caspari R. Philadelphia. 1 989 50. Clark JM et al: Transla­ Ol"thop ReI Res 29 1 :7 . 1 993 of the glenohumeral joint. 1 995 scapular plane. WB Saunders. 1 987 20. 2nd Ed. Andrews JR. J of scapular rotation dUling arm abduction in the Orthop SP0l1S Phys Ther 2 1 :220. New vical and Thoracic Spine. ing mechanisms preventing anterior dislocation Clin 011hop ReI Res 2 9 1 :54. 2nd Ed. J Bone Jt Surg 66B:55 1 . SP0l1S Physical Therapy Session. Philadelphia. Cain PR. Jobe FW: The diagnosis of anterior having osteoal1hritis of the knee. Gleisser WB: Arthroscopic manifesta­ 29. p . 1 995 ference of the International Federation of Manip­ 48. In Richardson JK. J Orthop Sports Phys Ther 1 0:394. Kvitne RS.92 PHYS I C A L THER A P Y OF THE SHO U L DER tion Specialist's Handbook. Marder RA: The rotator cuff opposes stable. 1983 . Am J Elbow Surg 3 : 37 1 . Clin Ol"lhop ReI 34. Fu FH et al: Antedorsta. Davies G D . Schmid HJ: Muscles as a pathogenic fac­ der complex. WB Saunders. Loubel1 PV: Foundations of Clinical Or­ 42. surgically repaired shouldcrs. FA Davis. Maitland GD: Pedpheral Manipulation. SPOl1S Med Update 4:24. Allegrucci M. Clin Orthop Rei Res 1 35 : 38. Jull GA. Panio MW. tor in back pain. 1 987 Ther 69: 1 06. 1 993 47. DeCarlo M: Examination of the shoul­ 32. and non­ 82. 4th Ed. Bll. Forrest WJ: A biomechanical analysis letes Participating in Upper Extremity SpoI1S. McCreary EK. Hawkins RJ . Warner JP et al: ProPI. p. Lephal1 SM et al: date. Orthop Clinics Nor Amer 1 8:373. Janda V: Muscles and motor control i n tion. Institute Press. Hanyman DT. NeerCS Ill: Impi ngement lesions. 1 993 27. York.Inolli J: Shoulder kinesthesia after in the absence of rotator cuff tCaI' (stages t and anterior glenohumeral joint dislocation. Silliman J. 1 99 1 Igharsh ZA (cds): Clinical Orthopaedics Physical 26. Boissomault WG. ulative Therapy. niques of Manual Examination. 1 977 1 988 49. Wooden MJ (eds): 011hopaedic Physical 253. 1 994 Res 29 1 : 1 1 7 . p. J Bone Jt Surg 72A: i ty of the shoulder. Sharkey NA. W0I1hingham C: Muscle Testing: Tech­ the shoulder in throwing ath letes. Gould JA. Am J Phys Med Rehab 67:238. Phys 2). 1 9 8 1 operative management. 4 t h Ed. 40. 1 993 tion of the humeral head on the glenoid with pas­ 43.schlerTA. Lephal1 SM. Whi tncy SL. Phys Ther 74: instability in the throwing athlete.­ 1 65 . In Do­ low back pain: assessment and management. Churchill Livingstone. Falconer J : A n examina­ Therapy. 1 69. New Zealand. WB Saun­ Andrews JR. 1 980 Throwing Mm. Daniels L. 1 985 3 1 . 1 994 Sports Med 23:270. Hayes KW. J Should superior translation of the humeral head. 1 994 tion of Cydax's passive motion tests with patients 4 1 . natelli R. Simon ER. Christchurch. TUI'kcl SJ. 1 98 1 45. In Zarina 8. J Bone Jt Surg 63A: 1 208. Churchill Livi ngstone. Dickoff-Hoffman S: Neuromuscular 1 988 testing and rehabilitation of the shoulder com­ 23. and treatment of the shoulder. Philadel­ bility of the glenohumeral jOint. In Grant R (ed): Physical Therapy of the Cer­ Therapy. 1 99 1 1 5: 1 44 . Walsh DA: Shoulder evaluation of the throwing Testing and Function. Davies GJ. J Orthop Sports Phys Ther 1 8:449. Bagg SD. Clin 28. Janos S: Dysfunction. un­ 24. 37. Gerber C. Davis GJ. Ludington NA: Rupture of the long head of the shoulder. Clin Sym­ metric force development: Med Sci Sports Exerc posia 1 2 : 1 . J . J Bone Jt Surg 1 3 : walk. 1-loppcnfeld S: Physical Examination of the Spine drome in athletes. Kennedy JC: lmpi ngement syn­ 56. Tebone J E . Mosely HF: Disorders of the shoulder. CT 1 976 1 60. Jobe FW. WOITell TW. 1 980 and Extremities. Larson RL: Functional exami­ analysis of the shoulder i n throwing and pitching. Pen). Hawkins RJ. 1 960 24:744. York SL et al: An analysis 1 923 of supraspinatus EMG activity and shoulder iso­ 55. Crofts. 1 983 82. Appleton-CcntUl). Ann Surg 77:358. Am J SPOltS Med 8: 1 5 1 . Clin Orthop Rei Res 1 73: 1 1 7 . COI-ey BJ. Jobe FW. 1 93 1 57. 1 992 . 1 98 1 58. Yergason RM: Supination sign. 1 983 biceps ncxor cubitc muscle. O I F FEREN T I A L S OF T T I S SU E DIAGN O S I S 93 5 1 . Jobe C: Painful athletic injuJies of the 54. Phys Spoltsl11ed 6: Am J SPOltS Med 1 1 :3. 59. Maynes D: An EMG 53. Nor­ 52. nation of the shoulder girdle. Gould JA. . . . . . FIGURE 4.3 Elevation of the arm. . now demonstrating the effect of poor posture on elevation of the arm. (B) Same person. (A) Person with good postural alignment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195. Shoulder and Neck. 1972 . phia. Bateman JE: Lesions producing shoulder pain The authors would like to thank Jim Rivard for predominately. p.Acknowledgement References 1. Philadel- trations in this chapter for publication. WB. In Bateman JE (ed): The his invaluable assistance in preparing the illus. Saunders. . . . . 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. diagnoses may ensue as a result of indi­ use in upper quarter pain disorders. identification shoulder. finitive investigative diagnostic results. 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. Although diagnostic bias described by Elvey in 1 979. Tests for niques. and arm. necessary to evaluate pain syndrome or cervicobrachia/ disorder. In neuromuscular disorders. al though author bias toward regarding neural tissue as a technically incorrect for the cervical spine. 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. upper quarter pain syndromes. is fre­ major tissue of origin of pain. In the absence of any tration of physical treatment or prescription of form of neurologic deficit of the peripheral ner­ patient-generated treatment programs. upper ment is necessary. upper back.Neural Tissue Evaluation and Treatment R OB E R T L E L V E Y T 0 B Y HAL L Upper quarter pain includes pain perceived in mind is essential. Even then.4 cialty. suprascapular area towards the shoulder.3. but it may also be considered in- 131 . A detailed examination and assessment aIm or hand. 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. or the logic. 12 . 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. and continued critical assess­ variable regions of the neck. have found fundamental to the clinical reason­ The most apt descriptive term is cervicobrachia/ ing process. an open losketal 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. Associated headache is a fre­ of the source of pain is essential prior to adminis­ quent accompaniment. chest. originally vidual clinician bias. Presentation of the topic in this way should not be construed as The diagnostic term radieu/opalhy. -ise to per­ years. 1 07 for males. medical treatment costs. giving . Visceral referred pain.s o f the upper qual1er. with or incidence in the Community without motor weakness or paresthesia. 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. it is essential for the clini­ who surveyed 3. The 2.'0 This survey o f a population o f 70.132 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. Further­ though symptoms such as tingling. In 4. pins more. where a visceral dis­ average annual age-adjusted incidence rates per order may cause a perception of pain in cu­ 1 00. several investigators have addressed this problem." Due to the lack o f population-based studies. I I In their review o f cervical radiculopathy. unaccom­ The maximum prevalence was between the ages panied by paraesthesia. pain. 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. where it is again perceived in cuta- . with a male preponderance. Minnesota. Their underlying the cutaneous area of perceived ages I-anged from 13 to 91 years. upper quarter pajn in the form o f cal radiculopathy are relatively common. Local pain. The survey o f cervical radiculopathy was can-ied out pain may be o f the following types: in Roches ter . minable precipitating cause. pain may be very di ffi­ o f 45 and 49 years.000 I. Thirty-four percent o f Upper ({u. Somatic refen'ed pain. the precise incidence of cervicobrachial pain is not known. 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. 12 reported that 80 to 1 00% of pa­ tients present with neck and arm pain.? Lawrence.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.950 persons in England. between 1 976 and 1990.6 However. The age-specific annual inci­ volved dence rate per 1 00. burning. the mean prevalence o f neck sti ffness and and needles. where it may be an indication people identified 561 subjects with cervical radi­ o f pathology o f somatic tissues immediately culopathy. with a mean pain age o f 38 years for both males and females. nerve root or peripheral nerve ttunk . Al­ complained of cervicobrachial pain. recalled. and the clinical picture develops insidi­ ously.000 were 83 for the total. 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. An extensive epidemiologic cult to analyze in terms o f tissue o f origin. Radicular rden'ed and neuropathic referred the older patient with preexisting cervical spon. Fourteen percent reported neck o f"pain pallems"that may accompany disorders pain that lasted more than 1 year. and disability insur­ In summary. society. cervicobrachial pain and cervi­ ance claims.000 population reached a peak o f 203 for the age group between 50 and 54 3. Ellenberg e t al. In the United States there has been an and there is usually no preCipitating trauma. frequently no Single traumatic event is deficit of the peripheral nervous system. 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. gener­ ally without preceding trauma or other deter­ When m'easured in terms o f lost productivity. and taneous tissues distant to the viscera in­ 64 for females. 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 neous tissues that may be distant fTom pathologic neural tissue 5.\ illustrates one of the location of the symptomatic joint(s) in patients physiologic mechanisms thought responsible for with cervical zygapophyseal joint pain.2o." Cloward. ' 4 The cutaneous sensation mapped by Foerster. ment. These findings have experimental evidence. which is suppolted by sound of the upper trunk and arm.24 strate for somatic refen'ed pain is the conver­ pain patterns associated with cervical zygapo­ gence of afferent neurons from one body region physeal joint stimulation have been investi­ onto central nervous system neurons that also gated25-27 The results have vindicated the use of receive afferents from topographically separate pain charts to accurately predict the segmental body tissues. tomatic vertebral segments and soft tissues. but usually within the same spinal seg­ refen'al patterns during cervical discography.15 Two types of refelTed bly conform. a brief outline will be given to help gain an under­ standing of the topic Site of pathology FIGURE S. is that the anatomic sub­ subsequently not been supported.1 A physiologic mechanism (or somatic REFERRED PAIN re{erred pain. sclerotomal.15 Figure 5." One theOl)'. of both the tissue involved as patterns to which referred pain must invaria­ and the segmental leve!. and myotomal charts one patient is inadequate as a Single factor in published in standard texts should not be taken differential diagnosis.' 6 A number of theoretical models have His findings prompted him to assert that pain been put forward to explain somatic referred radiated almost exclusively into the dorsal aspect pain. nerve either with a segmental or a peripheral . pain. ceived to be transmitted along the course of a Inman and Saunders'• put forward the con. It is a frequent cept of myotomes and sclerotomes to explain source of difficulty in the identification of symp­ segmentally referred pain from deep structures. 19 Der­ topography and nature of referred pain in any matomal. its site of Inman and Saunders. or at a distance from.'8 Cloward23 studied pain origin.23 and area adjacent to. The phenomenon of referred pain is well recog­ nized but not well understood. visceral. There is known to be wide variation pain are recognized: somatic refelTed pain and between individuals in the pattel-ns of refelTed radicular pain. Landmarks in the study of refelTed pain are the Somatic rererred pain is pain perceived in an investigations by Kellgren.26 somatic referred pain. and a concept similar to that of the dermatomes for therefore in con'ectly localizing treatment. In this case there is affer­ ent input from an intervertebral disc converging RADICULAR PAIN on the same neuron in the dorsal horn as neu­ rons from the skin in a topographically separate Radicular or projected pain is that pain per­ area. Variable combinations of the preceding Although detailed descriptions of nocicep­ tion-the physiology of pain and the mecha­ nisms of somatic.21 There have been numerous studies of re­ felTed pain patterns following noxious stimula­ SOMATIC REFERRED PAIN tion of different tissues in the cervical spine. and radicular refelTal of pain-are beyond the scope of this chapter. 28 For this reason it can sometimes that results in a sufficient number o f signs COlTe­ be difficult to distinguish. The physical signs o f neural tissue involve­ FIGURE 5. In a series projected pain with peripheral distribution in­ o f 841 subjects with cervical radiculopathy. cannot bc prescribed fTom imagery or nelve conduction studies. brachial plexus neu­ derson et al30 found only 55 percent presented ralgia. 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. frequently having a burning or electrical quality.uation sations. combinations o f local pain o f somatic bing component. in combination with scribed as deep and aching.134 P H Y S I C AL THERAPY OF T H E S H O U LD E R nerve distribution. or both may suming the source o f symptoms and in a manner be present. 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.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. It is commonly de­ discrete symptom or again. Hen­ clude trigeminal neuralgia. lating and supporting each other in the formula­ tion o f a clinical hypothesis or diagnosis.2s manual therapy management. Physical impulses treatment. and the presence o f allo­ origin. 5. and meralgia paraesthetica. Periph­ Nerve trunk pain is pain that follows the eral referred neuropathic pain is also seen as a course o f the nerve trunk. This is necessal)' � for accurate treatment prescription when con­ Antidromic sidering a manual therapy approach. and radicular rc­ dynia. the clinician must In an individual patient with nerve injury. in the form o f manual therapy. ache. carry out a physical examination without pre­ dysesthetic pain. These include abnormal or unfamiliar sen­ FJvaJ. ment include the following: . depending on the site o f the between referred pain arising from somatic tis­ lesion. The remainder presented with dif­ injUl)' (neuropathic pain) have been recognized: fuse non dermatomally distributed pain.2).'· with pain following a typical discrete dermato­ Two types o f pain following peripheral nerve mal pattern. 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.'· Examples o f projected pain with seg­ sues and arising from neural tissues. on subjective grounds. nerve trunk pain. or palpation. 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.'? felTed pain are commonly encountered. nerve In order to evaluate a disorder for effective stretch. In the physical examination and evaluation of neural tissue for its possible involvement in a disorder." and made worse with movement. In disorders evaluated for physical therapy inter­ pain with a paroxysmal brief shooting or stab­ vention. familiar"like a tooth­ other patterns o f pain.2 Radicular pain. 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. pain felt in the region o f sensory deficit. somatic referred pain. and heart are viscera disorder with resultant diaphragm irritation. In addi­ for the physical therapist. We specifically and anatomically to I to 3. although palpation of the right upper ab­ ceral conditions are readily diagnosed during a dominal quadrant was extremely painful locally. Active movement dysfunction. were not happy with the situation and contacted the refen'ing doctor. in stfiction. These findings excluded in the past year. pain and sensitization of the upper trunk of the We have seen examples of this need twice right brachial plexus. Should a it also caused pain to be perceived in the right condition of viscera be accompanied by strong neck. 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 del' pain. and reproduction of both shoulder and ceral referred pain. Adverse responses to neural tissue provo· mal. and the plain radiographs indicated mild cation tests. Hyperalgesic responses to palpation of treatment with the thought that her chest pain specific nerve trunks. right shoul. Evidence in the physical examination of evaluation findings to suggest a muscular or neu­ a local area of pathology. routine medical. Her doctor I. there may be some difficulty in making particular any spinal dysfunction. which must relate was either somatic or radicular referred. [f any suspicion or rones resulting in perceived shoulder and arm doubt exists. medical opinion must be sought. diaphragm. which relate specifi­ Iivel' disease. Obviously medical referral of chest pain on provocation tests of the right upper patients should overcome this potential problem limb when involving the upper trunk. requiring particular consideration when the phrenic nerve sensitization. cally and anatomically to 4 and 6. including ultraso­ nography of the liver and plain radiographs of 2. She was very Involvement tender on palpation of the right upper abdominal quadrant and the mid thoracic spine. in keeping a diagnosis clinically that would involve viscera. which the thoracic spine. which she said radiated from her mid­ neck and bilateral shoulder pain upon referral by back region. however. who investigated the patient 5. T he ultrasonography was reported as nor­ 3. referred her for investigations. upper arm pain. The result culminated in a diagnosis of cutaneous tissues. which must relate specifi­ degenerative changes evident in the midthroacic cally and anatomically to I and 2. pain on palpation of the anterior surface of the right scalenus anterior muscle. reproduction of shoulder pain on palpation of the upper trunk of the bra­ The physical therapist involved in treating disor­ chial plexus in the right pos terior triangle of the ders of the upper quarter must also consider vis­ neck. not all vis­ tion. clinical evaluation. must con'e1ate specifically with I. which would romusculoskeletal disorder. we postulated a liver The liver. She had right neck pain. levels. which the phre­ nic nerve travels over. Passive movement dysfunction. his doctor. doctor because of increasing severity of pain in A second example was a middle-aged man the right lower chest and upper fight abdominal who had received physical therapy in the past for quadrant. In addition. Hyperalgesic responses to palpation of further. with the severity of the pain. She was referred for physical therapy for 4. shoulder pain and active shoulder movement re­ In the absence of other physical findings. Of concern to us was the paucity of physical 6. On this occasion he was not refen'ed . and subsequent fa­ physical therapist is suspicious of the possibility cilitation of the related cervical dorsal horn neu­ of visceral refefTed pain. and difficulty elevating Physical Signs of Neural Tissue her arm above s houlder level. we were involve the neural tissue showing the re­ concerned by reproduction of right lower chest sponses in 3 to 5. The first example was a liver physical therapy as a treatment option and she disorder in a middle-aged woman who saw her was treated by a physician. the nerve trunks revealed coronary artery insufficiency and he would become noncompliant to movement. cruited via central nervous system processing to These cases. rela." Hence the common clinical presenta­ o f specific signs. can be physically tested in a selective manner. the outcome culoskeletal system in keeping with his com­ would be pain associated with any trunk or limb plaint. non compliance would be demonstrated by pain­ O f note were the right upper limb symptoms. elbow extension. highlight the need for care­ origin. a type to neural tissue involvement. and wrisll Fin­ and peripheral nerve trunks that can become hy­ ger extension with the cervical spine in contralat­ peralgesic. The peripheral nerve spect to the formulation of a clinical hypothesis. Due to an inher­ one o f "stiff painful shoulder" or "frozen enl sensory innervation28 nerves and nerve tis­ shoulder. neural tissues of the brachial plexus and related . In other words. can The signs associated with neural tissue pa­ become a source o f pain. He was then referred back to his doctor. With respect tant to the source of pain. shoulder abduction! pathologic neural tissue. when sensitized by pathologic events.) and referred for treatment for "stiff painful In more severe cases o f pain o f neural tissue shoulder" syndrome. physical evaluation Should nerve tissue become pathologic and did not reveal any dysfunction o f the neuromus­ therefore tender and hyperalgesic. whereby an upper listed earlier and will be discussed further. This means both upper arms. they have to be therapy. The symptoms on all occasions were ac­ compliant to movement. nerve as a pain source.136 P H Y S I C A L T H E R A P Y OF T H E S H OU L D E R but had seen his doctor. Therefore nerve trunks tivity related. The target cutaneous tissues of the af­ ACTIVE MOVEMENT DYSFUNCTION fected neural tissues become sensitized and tender. (See the racic outlet area tumors also seen in Ollf practice section on EMG responses later in the chapter. muscles would be re­ fen'ed pain o f visceral origin.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. Due to pain.g. eral lateral flexion has the effect of placing the Peripheral nerve trunks are dynamic. As in the First example. when the tumor cells invade the peripheral nervous system and the relative the nelve trunks resulting in nerve trunk pain. sensory inner vation o f the connective tissues by Pancoast tumor). together with three cases o f tho­ prevent pain by preventing movement. nerve thology listed above required very careful and tissue may cause a projection o f pain to be per­ precise evaluation. 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.. it is necessary to consider the tion o f tumors of the thoracic outlet region (e. 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." sue. When pathologic. ful limitation o f movement. This underwent medical management. 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. movement with which the trunks of that nerve who referred him for cardiac stress testing. 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. trunks in turn become sensitized and thus hyper­ algesic. This tissue had to adapt. lateral rotation. in other words. the signs were o f dystonia may be present. and an open mind with re­ peripheral nerve trunks. which was said to extend from that nerve trunks have to adapt to positional his neck. is dynamiCS o f peripheral nerves. In addition. 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. an open mind as to the signif­ ceived along the course o f anatomically related icance o f each sign. With some thought to applied anatomy. Hence. must also be affected by pain. The radial nerve will be in its PASSIVE MOVEMENT DYSFUNCTION most lengthened position with abduction/medial rotation of the shoulder. limitation of range. In the stage of evaluation. de­ Should passive abduction be painfully limited in pending on the particular tract involved. and as a conse­ wrisUfinger extension. The median nerve will be in its most and neck would increase the dysfunction. as in functional move­ movement in the physical evaluation of neural ment. and cervical spine contra­ there is a specific painful active movement dys­ lateral lateral flexion. and again with the same quence. elbow. 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. common position of the shoulder girdle and cer­ As with active movement. For example. Contralateral lateral flexion of the head ways. In addition. 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. elbow extension. If pain is provoked or the passive movements in different directions cOlTe­ range of movement is limited. a patient will display active the clinician can examine active movements in movement dysfunction. elbow flexion. The ulnar nerve will be in function due to a disOl'der involving neural tis­ its most lengthened position with abduction/ sues. ment where there is a painful limitation of range. or the sur­ ther limited. should passive cervical spine. der abduction should be examined in or behind This clinical approach applies to applicable the coronal plane. 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. and wrist will influence the pe­ place on the suprascapular and axillary nelve ripheral trunks of the brachial plexus in different trunks. with shoulder limitation of range. 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. Ob­ range. the clinician works vical spine. Should neural tissue be will influence the same neural tissues to variable involved. the clinician can lating always with active movement dysfunction. a disorder of same manner. various active movements will be affected. will affect all tracts of neural tis­ shoulder abduction be performed with the shoul­ sue from C5 to T I. Neural tissues as a structure slide within be more painful and the range of movement fur­ the anatomic sUlTounding tissues. If der girdle depression. 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." observable dysfunction of shoulder abduction With applied anatomy it becomes clearly evi­ and movement of the hand behind the back. Neural tissue tracts must comply to passive wrisUfinger flexion in the position of the shoul­ movement as they do with active movement. it would correlate with a painful active viously active shoulder abduction. which may cause an will present with a "painful stiff shoulder. nelve i painful. in causalgia conditions where a tissue. or both occur. the pain would girdle depression and contralateral flexion of the increase and the range decrease. active shOltl­ flexion. the response to active abduction would degrees. passive movement in the same directions lateral rotation of the shoulder. lengthened state in the position described at the start of this section. 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. differentiate between shoulder joint pathology The quadrant position of shoulder joint exami- . rounding anatomic tissues glide over the neural This is a basic approach to analysis of active tissues. due dent that different anatomic positions of the to the increased tension that these movements shoulder. more severe painful conditions involving neural These additional positions subtract or add tissue.' 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. To do this. importantly. as may be Ihe case ill radiCLIlopalhy. the quadrant test is per­ ciated with the disorder being evaluated.' compliance of the neurovascular tissues. on the upward fulcrum affect on the overlying neUl·o­ possible site of involvement. it is obvious that passive movements and distance over which the neural tissues travel. 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. 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. This means that identifying There is a necessary requirement for felllc­ a specific type of functional position noncompli. M. nation described by Maitland32 is of particular ance enables the clinician to form a hypothesis interest in passive movement examination. laleral cord of Ihe brachial plexus. the brachial plexus and its proximal and distal which are governed by the severity of pain asso­ extensions. These formed as described by Maitland.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 FIGURE 5. L. H. functional positions. This il7dicales how shoulder 11101i0/1 l11ay be afe f cled neural lissue. well short of its maximum length ca­ thereby affording the clinician the ability to dif­ pacity. an appreciation of .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 not only on the possible involvement of neural the quadrant position the humeral head has an tissue in a disorder but also. Validity with re­ vascular bundle in the region of the axilla (Fig.3 Cadaver study al autopsy demollslralillg Ihe fulcnll11 afe f cl humeral head 0/1 Ilellral lissue al Ihe level of Ihe shoulder 11Iilh abdLlcliol1llaleral rolalioll. In lateral and contralateral lateral flexion. 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. positions. spect to the clinical implications of such tests as 5. tive muscle. tionaI anatomic knowledge. head of Ihe hLlmenlS.3). Therefore it really is unrealistic to document ADVERSE RESPONSES TO NEURAL TISSUE a standard form of provocation test technique. mediall l1erve slreched over a {illger. 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. slight wrist ex­ examination of neural tissues. Increase effect of the Increase the effect with increased shoulder test with incremental. crease the effect with shoulder girdle depres­ sion. Increase the effect with head/neck lateral flexion. Via median l1erve. clinician's hands in a position c. This in­ rotation. 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. Increase effect with incremental wrist finger a. Via median l1elve. order to attempt to reproduce the pain of . Shoulder abduction lateral I. 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. This 2. Via radial nerve. with the arm comfortably in a into account these considerations in the physical position of elbow extension. This median and radial nerves). a written fOlmula is head/neck contralateral lateral flexion. the 3. head/neck contralateral lateral flexion. extend elbow. elbow and wrist/finger extension. being examined. tissues by provocation tests. head/neck contralat­ also to be able to alter shoulder rotation. shoulder girdle depression (due to the first experience of the onset of pain. head/neck neutral. Subject in supine. neutral. Shoulder abduction lat­ activity. shoulder girdle depression. different inclination of the lower trunk of b. Shoulder abduction medial Proximal rotation. head/neck neu­ ence of sensitization of the neural tissue tral. which form the major part of the range of the passive test movement. forearm pronation. 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. with sion. Having produced an initial adverse re­ to control head/neck lateral flexion. shoulder girdle cle tone in muscles that are in a position depression. head/neck neu­ crease in tone should coincide with the tral. and shoulder ab­ carefully taken further into range in duction and rotation. in order tension (positions naturally occurring as a to introduce the physical examination of neural result of the placement of the arm). Via lIll1ar nerve. shoulder girdle sion. wrist/finger exten­ girdle depression. sponse to the test is the clinicians goal. As the name implies. Via radial ne/ve. Shoulder abduction/lateral antagonists to the movement. and a methodological approach taking eral rotation. Shoulder rotation. and forearm shoulder gil-dIe depression. and passive neural tissue provocation tests a re­ head/neck contralateral lateral flexion. the test movement should be dle elevation and depression. but one di­ eral lateral flexion. eral lateral flexion. extend elbow. forearm pronation. Clinjcian appreciation of increase in mus­ (including thumb) flexion. pronation/supination. Via ulnar nerve. Shoulder abduction/medial response should be threefold in the pres­ rotation. abduction/lateral rotation. shoulder gir­ sponse. The identification of the increa ed mus­ the brachial plexus to the upper and middle cle tone amounts to a first limitation of trunks. However. Test Tecill1ique From Distal to 2. and placement of the arm). and head/neck contralateral lat­ to prevent further movement in the direc­ eral flexion.that is. shoulder girdle depres­ nated. In­ necessary as a baseline starting point. forearm supi­ forearm pronation. tion of the test movement . clinicians hands posi­ elbow extension. shoulder girdle neutral. 3. elbow flexion. with the arm in a position of Subject in supine. gradually apply­ I. The axillary nerve. Palpation of neural where it cannot be identified as a structure. or the upper qual-ter of least se­ able. in the lower third of the tion is suited to a physical treatment. and in some regions mus­ cle tissues. 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. lateral margins of scalenus anterior and me­ dius towards the mid third of the clavicle HYPERALGESIC RESPONSES TO PALPATION and hence the first rib. medial upper arm. The radial nelve. ining fTom cranial to caudal and fTom the where it cannot be identified. and at the antcromedial aspect of the verity. through trapezius ing increasing pressure until deamed sufficient on the superior border of the sca pular.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 complaint. tient to make a comparison and in order for a correct interpretation of a perception of hyperal­ gesia to be made. The nelve sult of nelve trunk palpation. The dorsal scapular nerve. gesia. where it cannot be identified as TRUNK PALPATION a structure. to complete the examination. pect of the deltoid and on the upper lateral Nerve Trunk Palpation in Supil7e Lying border of the scapula as it enters teres minor. in the posterolateral as­ pathologic process responds with a painful reac­ pect of the upper ann. points will be predictably found in areas that ap- . where it can be identi­ fied as a structure. and the response cannot be identified as a structure at the lat­ when adverse or abnormal is one of hyperal­ LeI' sites. the forearm below the elbow. but where they can certainly be always a requirement in manual therapy identified as nerve trunks. If neural tissue sensitized due to some form of 5. The trunks of the brachial plexus in the pos­ 3. Nerve trunks are selectively palpated. and over the This stimulus in the physical evaluation is a re­ posterolateral region of the wrist. The suprascapular nelve. where it is readily identifi­ upper quarter. Reproduction of symptoms is vidually. Selectively exam­ rhomboids and medial to the scapula. 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. tissue of the upper quaner is done in the follow­ 2. where they may not be identifiable indi. The nelve is unidentifiable as a struc­ Position lure at either site. it must also follow that there upper arm. such as with active or the lower third of the lateral aspect of the passive movement. and anterior at the level HYPERALGESIC RESPONSES TO NERVE of the wrist. thl-ough the posterior as­ ing way. The 6. at the lateral aspect of ulus applied directly over or to the nelve trunk. These tender illa. The ulnar nelve. I. gently and preCisely. in regions anatomically related to the involved 3. Nerve Tnmk Palpation in Prone Lying Nerve trunks are palpated through cuta­ Position neous. subcutaneous. where in some indi­ tion to a stimulus applied through its length in viduals it can be identified as a structure. evaluation in order to assume a condi­ 4. OF CUTANEOUS TISSUES 2. at the posteromedial as­ nerve trunks or neural tissues of the uninvolved pect of the elbow. is palpated first in order to allow the pa­ wrist. at a longitudinal manner. through the terior triangle of the neck. where it crosses into the ante­ would be a painful reaction or response to a stim­ rior compartment. The median nerve. where function.3S per­ nisms of muscle responses in positive tests. and by accessory spinal segmental with controlled and gentle oscillatory move­ motion palpation where an association between ment. including limita­ tion of active and passive movement. 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. This indicates a OF PATHOLOGY mechanosensitivity of the peripheral nerve In pathologic conditions of nerve tissue. N(JUral Tissue As an example in the upper quarter. tissue provocation testing l 2. this does not mean the condition is one previously outlined that must be present before suited to manual therapy management.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. and also determined during a physical evaluation.at:ion of Nerve of neural tissue disorders. 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." and also presents a logical reason the medial border of the scapula.33 haps terminating cutaneous or subcutaneous E M G activity indicates a mechanosensitivity of branches of the nerve in question. or radiculopathy can be made. and any stretch­ ing of affected neural tissue is absolutely con­ traindicated. nician in these circumstances is not prescribing . 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. all of trunks that bears an anatomic relationship to the the features d iscussed may readily be found or anatomic level of spinal radiculopathy. It is a clinical diagnoses of cervicobrachial syndrome quite possible for a painful diabetic neuropathy. it becomes readily ap­ Trunks in Cervical parent that the disorder may show acute exacer­ bation if the guidelines outlined are not followed . 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. EMG Responses to Non-No:r:i. 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. or carpal tunnel syndrome to cause aU of the features discussed thus far.4 as have the mechanisms of muscle re.erapy Treatment of the clinician must determine a cause for the neu­ ral involvement. 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. has been investi­ There is a suggestion that the tender points gated for clinical relevance. tomic tissues s hould be avoided.i<:ukrpaihy. 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. Treatment can be more progressive by an abnormal pain response and aberanl motion using mobilizing techniques in a similar manner can be made. I t becomes obvious that the cli­ vance. How­ presents a logical reason for the clinical signs ever.' as have the mecha­ may represent ectopic pacemaker sites. Ratl. Therefore Manual Th.mts With clinician experimentation in treatment Mechanical Stimul." The concept of neural its spinal anatomical segments of origin. a painf�d neuropathy caused by a tumor infiltra­ tion. another fOlm of treat­ mons trable improvement. two treatment techniques. forehead resting o n the palm type.35 tion. undue stimulation of i t will cause fuether hand while comfortably holding and supporting sensitization and exacerbate the condition. barrier. but only when indicated by a de­ If they are not present. The arm must be fully supported on pain. This the head and neck. or in the more commonly seen presenta­ the treatment couch at all times. acute conditions additional support should be To meet this requirement. it is essential that given with the use of a pillow. with a few degrees of medial rotation. Technique: Gentle controlled is the fundamental reason for the muscle activity lateral glide to the contl'alateral side in a slow that results from provoking manouevers-to oscillating manner up to a point in range where prevent further and undue stimulation of already the first resistance in the form of antagonistic sensitized neural tissue. the In general manual therapy terms. guided at all times by an appreciation of protec­ The first resistance represents the treatment tive muscle activity. these signs creased amounts of abduction. amounts of hand behind the back position. It chest or abdomen. pal1icu larly where there are central ner­ of the hand of the uni nvolved side. where it is the dominant tissue of origin. the involved vous system mechanisms of pain and sympathet­ arm supported by the clinician in a position of ically maintai ned pain syndromes. by performing the lat­ ment. treatment patient's arm position should be changed. would eral glide with the shoulder in gradually in· have to be considered. all the signs previously listed aee present in the The technique progresses on subsequent physical evaluation of the disorder to be treated. Should this balTier not be reached. shoulder slightly abducted or commonly is mobilizing neural tissue solely. a s tudy presently being conducted gives the acromial area.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 treatment according to the physical signs dem­ Cervical Lateral Glide o ns trated o n evaluation. The clinician gently supports s tands to reason that if neural tissue is sensi­ the shoulder over the acromial region with one tized. The clinician must be muscle activity occurs. This represents the treatment barrier and With eegard to treatment of the upper is the commencement of increased muscle tone. In addition. will be de­ treatment sessions and when indicated by per­ scribed: cervical lateral glide and shoulder girdle forming the oscillation in gradually increased oscillation. which have The technique progresses o n subsequent been found to be the most useful. nique would be an improvement of active shoul­ The authors have used passive movement der abduction. Although to comfort towards a posi tion of hand behind the date. elbow nex­ rather than with the surrou nding anatomic tis­ ion to about 90· such that the hand rests on the sues. treatment days. techniques in the treatment of neural tissue dis­ orders for many years with excellent results when a disorder has not developed on a patho­ Shoulder Girdle Oscil/ation logic basis to o ne of a more severe neuropathic Patient prone. directed to tissue o ther than neural. The most obvious must dominate over signs of other tissue or indicator of successful treatment using this tech­ structure involvement. This of neueal tissue is i ndicated when the physical would involve more abduction or possibly ex­ evaluation demonstrates that neural tissue is the tending the elbow with the shoulder position tissue of origin of the subjective complai nt of maintained. quarter. support for such treatment ou tcome is an­ back. is treating too strongly. The clinician places the o ther hand over cedotal. The range of oscillation is governed by disorders i nvolvi ng neural tissue with passive the onset of first resistance in the caudad direc­ movement techniques. and therefore producing a stretch effect. Technique: Gentle oscillation suppOl1 in its early results and therefore is dem­ of the shoulder girdle i n a caudad cephalad di­ onstrating the validation of treating appropriate rection. and in more tions. The . Patient supine. was sitting in her s tationary motor ve­ tion. 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. the anatomic tissues sur­ sential to regard tlhe movement as self-treatment rounding the neural tissue should be mobilized. the neural tissues together with as an exercise rather than a treatment. 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." Plain radiographs identified . that has settled to chronicity can readily become As in so many disorders managed by manual acute. She sustained a "whiplash" defined injury fore joint treatment may well be a requirement. and physical therapy. In general. a condi­ the sUITounding anatomic tissues should be mo­ tion can readily be exacerbated. the cervi. which if it occllITed. composure of the patient is a prime considera­ this can be performed in a variety of ways. or where progres­ inexperienced that in regarding this technique sion is required.O. 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. F. Mrs. cause pain. followed by very gentle and con­ methods of soft tissue mobilization should be trolled conu'alateral flexion. The extent of the treatment the back function. a clinician will ieam to use in the shoulder and upper arm region would be different techniques. but due of the neural tissue. This may appear insubstantial. a time will come in the dent. would cause pain. Functional training in the form of exercise therapy techniques. long-term lack of movement affects articu­ hicle when it was struck from behind in February lar and periarticular tissue mobility. in conditions daily. medication. This should not employed until composure is regained. but a feeling of a pulling sensation With experience. and there­ 1 991. For neural tissue of the upper quarter. and the treatment must be rest. and not exercise. but as in any disorder Self-treatment and management is most im­ also on symptom severity and ilTitability. F. can'ied out without any disturbance by stretch continued her work in a nursing home. 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. In addi­ Mrs. N E URAL T I S S U E EVA L U A T I O N A N D TR E A T M E N T 143 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. wall in a comfortable position with a degree of the technique should be temporarily ceased and elbow flexion. The portant. This shortening mostly involves CASE STUDY muscles that have been facilitated and involved H ISTORY in tonic reOex activity to prevent movement. thology. It becomes very evident to the In the less acute conditions. "pins and needles. Treatment would commonly be given for adaptive shortening that inevitably follows neuropathy. but it is es­ that are more acu te. Should the patient shown any placing the hand of the involved side against a signs of the beginnings of lack of total relaxation. however. to her neck. the two just de­ acceptable. scribed will serve very well when applied appro­ The movement is repeated three times once pliately and correctly. In addition. 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.O. depending largely on the ex­ veri ty. A rela­ tion with regard to the amount of time devo ted tively simple treatment can be canied out by to a technique. perience of the clinician. Treatment and management consisted of signs are resolving. or a condition bilized. tnlllks. 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.4 and 5. immediately inferior to the left coracoid process. the left shoulder girdle was to the neurovascular bundle. 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. Mrs. tion adjacent to the C6-7 disc." duction of 40°. particular note was made sponses. Active left shoul­ Neural tissue provocation tests could only be der mobility become so painfully limited that she can. shoulder. All litigation was completed in 1 994.St extension in shoulder girdle depres­ pain. and upper arm.5). 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. culminating in a severe exacerbation of left sion reproduced symptoms.O. co n'esponding tissues on the right. nerves. 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.ed out in the ava ilable range of shoulder ab­ was said to have developed a "fTozen shoulder. there was a need to Her symptoms slowly improved through compensate for an inability to reach a sufficient 1 993 to 1 994. Consequently. F. Passive left shoulder mobility was medial to the medial border of the scapula. and with elevated with the arm held in a protective posi­ respect to the neurovascular bundle and the tion. in the thumb and index finger. 5. 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. and the ation with anterior and posterior os teophytic shoulder girdle therefore had to be fixed in spurring. CT scan of the cer­ to C7. The working trunks of the left upper quarter produced hyper­ d iagnosis at that time was left C6 radiculopa thy. Right anatomic length of neural tissue in test positions shoulder mobility was full range. but left shoul­ by making max. ion of the celvical spine ( Figs. with respect to the PHYSICAL EVALUATION upper trunks of the brachial plexus. Hyperalgesic responses were obtained in the left posterior triangle. thus tion of shoulder mobility by pain once again indicating a spinal level of involvement from C5 mimicked a frozen shoulder. of greater limitation of right lateral flexion than Palpation of cutaneous and subcutaneous left lateral flexion. cauded depression to compensate for the lack of In May 1 995. In testing from proximal to distal. algeSic responses. the limited in range by pain to the same degree as upper chest.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. the axilla. the shoulder girdle upper quarter symptoms without reason. Marked restric­ but testing via the the ulnar nerve did not. Palpation over the suprascapular and ax­ Although cervical range of motion was lim­ illary nelves a lso produced hyperalgesic re­ ited in all directions. but remained significant.4). These areas were particularly evident eral flexion.imum use of maximum shoulder der mobility and neck mobility remained lim­ girdle depression and contrala teral lateral flex­ ited. Retesting passive mobility with sponses or a similar nature were not found in the head and neck positioned in contralateral lat. 5. Re­ active mobility. Left shoulder [unction was recorded as flex­ upper arm with respect to the median and radial ion 80° and abduction 40° (Fig. ment for pain management for evaluation and Palpation of particular peripheral nelve for treatment if we felt it indicated. Al­ In early 1 995 there was a gradual increase in though WI. . In par­ elevated wrist extension did not reproduce the ticular she complained of severe lef t shoulder shoulder and arm pain. with respect At initial evaluation. 4 Mrs. influencing the median nerve. Note should be made of Ihe sl1lall pillow elevaling Ihe ami from Ihe couch.. F. Ihe palienl was unable 10 lie supine with rhe arm resling on Ihe couch by her side. brachial plexus.. 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 FIGURE 5. AI Ihe lime of inilial evaluGtion due to shoulder and ann paill. .ilalio/1 of aClive range shoulder mOlion due 10 sensitization of neural tissues.. FIGURE 5. Wrist exlension pey{omred in maximum available range of shoulder abduclion. demOllSlraliol1 of gross 1i/. and '''Iimalely Ihe cervical nelve roots.o.5 Neural [issue provocation lest. and of the ulnar nerve trunk behind the medial epicondyle. was therefore using a technique that The physical findings and the EMG analysis cor­ indirectIy had a postulated physiologic effect." EMG responses were �. ceps brachii muscles. Ac­ + cessory motion palpation indicated a pain and stiffness relationship at the same levels. triceps. in which there was strong evidence of neural tissue involvement and Treatment commenced with therapist interven­ of it being the major pain source. in the case of the case. index finger and the CT results.146 P H Y S I C A L T H E R APY O F T H E SHO U L D E R Motion palpation of the cervical spine re­ Median Radial Ulnar vealed restricted motion at C5-6 and C6-7. respollses on palpation of these putatively tellder triceps.-33 ill a silllilar tender nerve tnmk. Recordings were FIGURE 5. Neither paill Ilor EMG respollses the painful side when the radial and median were Iloted during palpatioll. a diagnosis of C6 radiculopathy was a lso loosely supported. In spite of palpation of shoulder subcutaneous tissues Trapezius 4- producing painful responses and active and pas­ sive motion being limited in range.7). and recorded widespread (mullisegmel1la/) EMG A burst of activity was recorded in left biceps. ill turn. The other and the subcutaneous tissues overlying these stimuli. del­ toid. IteTVe lnlrlks. with respect to physical treatment. EMG re­ Biceps + + t sponses to upper l imb nerve trunk palpation were recorded using the protocol described by Hall and Quintner. nor were they of biceps alld lriceps brachii. �" recorded from the ipsilateral biceps. 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. including palpation of the ulnar nerve. 5. Severity of pain prevented any patient­ pins and needles sensation felt in the thumb and generated management at that time. ASSESSMENT Treatment of choice. 5. and supported a disorder categorization of cervi­ TR EATMENT cobrachial pain syndrome. painful. In view of the tion only.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. of the skill nerve trunks were palpated (Fig. related accurately with the subjective complaint and hence a therapeutic affect. there were no EMG responses to nerve trunk pal­ pation (Fig. accessory - movement of the articular surfaces was freely Deltoid -+- + available.6). and also. 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. on neural tissue. On the opposite (asymptomatic side). Treatment . and of the adjacellt muscle bellies had no effect upon E MG activity. and upper trapezius muscles on the side of the arm being tested. EMG RESPONSES For the subject in this case history. and upper trapezius muscles sampled on IteTVe lnlrlks. Assessment of treatment was calTied came more stable. and it was explained to her and accepted that improvement would be ex­ Deltoid tremely slow and that i t would be at lea t 2 mon ths before the true value of the treatment approach would be known. Treatment initially was carried out An active abduction was then perfOlmed to take three times per week. forming a right lateral glide of C5 on C6. commenced her own treatment consisted of gentle. F. deltoid. a program of left shoulder ab­ out by reevaluation of active left shoulder mobil­ ductor and lateral rotation was begun.O. treatment was s tepped up Triceps to involve techniques to facilitate the shoulder abductors and lateral rotators. and while walking. Mrs. niques stimulating the abductors and lateral ro­ tators. was given a complete understand­ ing of the disorder. tion when sitting. Biceps With some subjective improvement occur­ ring after 2 weeks and a knowledge that the dis­ order was stabilizing. This was repeated six times with measures were taken to shorten the course over the same relaxation between lifts. MI . remained unchanged. median. This was done in supine lying with con­ triceps. The This consisted of the method described earlier. 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 Median Radial Ulnar to overcome the provocation affect of the drag on sensitized neural tissue by the weight of the shoulder girdle. This in­ ity. At the support the shoulder girdle in a degree of eleva­ same time the shoulder girdle was not elevating. and upper trapezius lIIuscies trolled isometric hold relax techniques supple­ during palpation or the radial. as judged by maintenance of improved function. controlled oscilla tion of the neck from the midline towards the right by per­ program involving neural tissue after 4 weeks. This was also accept­ able to her referring physician. The aim of which the brachial plexus traveled and therefore these techniques was to stimulate the abductors . She was asked to refrain from This was repeated six times. was instructed the weight of the arm only. the function of which a ppeared inhibited. Due to the severity of the condition.O. left arm was supported in the position shown in As the condition improved and the symptoms be­ Figure 5.7 EMG activity or the right biceps. and followed by lift­ anything causing depression or caudad s tress to ing the forearm from the pillow wi thout lifting the shoulder girdle.O. F. small volved sitting sideways a t a table with the left fTlictional improvements of range were deemed arm supported on a pillow to give 90· abduction. and mented as time went on with proprioceptive neu­ ttlnar nerves il1 the upper arm/elbow or the romuscular facilitation PNF patterning tech­ asymptomatic side. These techniques were performed in pain­ less positions. FIGURE 5. presumably due to Stimulus t t t pain. acceptable. Medications and medical advice Trapeziu . These the shoulder. to use a thin pillow but firm under the axilla to and then relaxed back onto the pillow.8. F. which appeared facilitated presumably as a protective Time / 2 sec interval measure to prevent pain. to place the elbow as a maneuver of la teral rotation of her hand in the waistband of her clothing. Mrs. and to inhibit the abnormal excessive influ­ ence of the adductors and medial rotators. held for 2 seconds. as treatment proceeded. The tion not o nly to determine the source(s). the physical Treatment was successful at the time of writ­ evaluation by necessity has to be very precise. and with more time progress to an ac­ calion. 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.'s case. O nly then can a working history and severity o f the disorder.O. or other forms of modali­ ties. 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. A ready example is the pa­ of origin of pain need only be presumed. this approach o f the pain. transcutaneous electrical nerve live functionaJ training program. Note again the pillow lIl1der the anll. The ann is in a position to sltorten (he course over �vh. The technique is ol1e o( a passive lateral glide to the right il1 arl oscillatory manner. The shoulder girdle is supported lightly by the therapist's left hm1d.O. 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. tient refen"ed for treatment for shoulder arm This approach obviously has its success. the cervical spine. and as a result the tissues sue of origin of pain. will continue to tion or management of pain w ith analgesic medi­ improve. and lateral rotators and to regain nonnal muscle pingement syndrome. to im. F. The examination in that ca e does not practice have multiple possibilities as to the tis­ need to be so detailed. unfortu nately. stimulation (TENS).8 Neural /issue [realment technique. was not successful. can"jed oul. i ng this report. when there are numerous possible sources Mrs. 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. In pain.148 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 FIGURE 5. In such cases. 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. ment in the form o f anti-inflammatory medica­ It is anticipated Mrs. F. and a nerve root sleeve block was not amination findings. while the right il1dex (il1ger is at C5 with the head m1d l1eck (ully SlIppoYted. A great deal of thought is . Prior to the treatment i ntervention This perspective is quite di fferent from treat­ symptomatic deterioration was reported.ch neural /issue travels il1 the upper quarter. from lateral epicondylitis. to degenerative disease o f recruitment patterns o f arm elevation. that the condition resolves with great difficulty . To speculate on the reason for im­ provement from a therapist's intervention in the form of passive movement. If this was the case. but it may be that the tissues causing the symptoms were not receiving any therapeutic form of stimulus to promote a decrease in peripheral afferent neural discharge. and by the demonstration of spinal speculated that this sensitization would result in mo tion segment dysfunction.36 It is a lso known that this reduction in lumen has an associated affect of increased pressure within the intervertebral fo­ ramen. the tissues those signs related to. or at the least sensitization. and the evolving pathologic events thereafter. Should a high-velocity decrease in the di­ ameter of the intervertebral foramen occur. as a result of pain caused through movement and rela tive dynamics asso­ ciated with function. Studies by Tay­ foramen (A) and intraneurally (8) as a result of lor and Twomey (personal communication. pain of a radicular type and associated neuro­ Further speculation can be made based on musculoskeletal dysfunction. [t is known that ex tension of the cervical spine reduces the lumen or diameter of the inter­ vertebral foramen. Perth Pail1 Management Centre') [n addition to many additional possible sources of pain. 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 needed to understand why it was not. by positive neural tis­ traneural pathology or indirectly in the case of sue provocation tests. it could be speculated that b leed­ ing of this nature may indicate neural tissue sen­ ment limitation when movement affected the sitization either directly in the case of the in­ neural tissue in question. (Courtesy o( Professor James within the intervertebral foramen. by hyperalgesic responses the extraneural pathology. can be of­ fered. The physical evaluation findings clear ly indi­ cated neural tissue at the major pain source. the mode of possible in­ volvement of the same tissues at the time of the rear-end collision in 1 991.9 fyom their cadaver dissection studies sensitization and irence painful limitation of shows both intraneural and extraneural bleeding shoulder Illation. there may well be a concussion a fect f involving tissues FIGURE 5. a motor vehicle accident. pathology that may result in neural tissue Figure 5. The physical evaluation a lso showed that there was a direct rela tionship. some expla­ nation for the possible cause of neural tissue pa­ thology. some consideration needs to be given to the physical signs. between those same neural tissues and the active movement dysfunction demonstrated. This indicates 1 999) have demonstrated this very possibility.9 Saggital slice of a cervical spine within the confines of the intervertebral foramen showing bleeding within the intervertebral resulting in injury and bleeding. I t could further be to palpation. This dys function the known facts of active movement dys function might have resulted in active and passive move. as appears to happen in whiplash injuries. Taylor. 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. move without prompting reflex muscle activity. and with tioned at the start of the chap ter that may result respect to the tissues occupying the in terverte­ in " frozen shoulder. sues. 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.150 P H V S I C A L T H E R A P Y O F T H E S H O U LD E R simply because the normal physiologic effects of movement. and o ther pathologies such as those men­ sive movement on pa thologic tissues. It must be readily and with time a resulting decreased severity of apparent that pain is of the utmost significance pain. An understanding of pain mech­ pathologic level without evo king pain. is essen­ movement can be promoted within the interver­ tial. 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. thus denying the tissue the beneficial ef­ vidual to maintain an open mind with respect to fects of movement. and readers are encouraged to s tudy these tebral foramen and motion segment of the topics in detail. and with further time nique. It is also up to the indi­ tissue. herpes zoster." bral foramen i t could be postulated that the same Many physical signs must be present in order premises apply.1 tissue is involved. the intervertebral segment and mo tion segment although the extent has been governed by the of involvement would not only exist but persist. Salter'9 has ou tlined the effects of pas­ tumor. In other words. is the and the regaining of normal physiologic ranges use of stretch. It is up In this context. treatment may be beneficial. Due to pain and muscle reflex activity directly resulting from movement transferred to the pathologic neural tissue. patient self-treatment tech­ The greatest single example of poor tech­ niques can be prescribed. In this anisms will lead to understanding of the move­ way. either in examination or lreal- . 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.. functional training programs can associated with movement of tissues in and be implemented. consu·aints of a chapter in a clinical text. sensitization. as a result of lack of understanding. At this s tage. 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. the therapeutic e ffects of this influence. With decreased pain. Should this be overlooked. and nociception includ­ ing physiologic pain and clinical pain. the patient is able to in guiding both the examination and treatment. reflex muscle activity is avoided. Pancoast be gained. 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. to imply that neUI. 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. and the ment dysfunctions of pathologies such as reflex therapeutic effects of movement can therefore sympathetic dystrophy. s tasis within sue in upper quarter disorders has been given. around the in tervertebral foramen do not occur. 27 1 . Brain 56: t . t 994 from deep somatic structures with charts of scg­ 5. Oxford Un iversity 4. Treanor WI: Cervical 30. Ann Surg 1 50: I 053. 1 993 1 97 1 2 8 . Matyas TA. Elvey RL: The investigation of arm pain. 3rd Ed. [n 1 7. 1 995 3 1 . 1 98 1 vasive discrimination of brachial plexus involve� 22. Schrader H . Aust J Physiother North Am 23:369. Aprill C. 1 994 29. 1990 man Y (cds): CClvical Pain. Dwyer A. O'Fallon W M . Clcv 7. J Ncurosurg 1 3 : Quebcc Task Force on Whiplash-associated Dis­ 504. New York. Stockholm. p. 1 994 Melbourne. tures. Churchill Liv­ 20. 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. 1 969 general population. Spine 20:9. Fletcher D: Atlanto­ ternational symposium held i n Wcnncr-Gren occipital and lateral atlanto-axial jOint pain pat­ Centre. bral disc. Lincoln Institute of l-Ieahh Sciences. Brodal A: Neurological Anatomy in Relation to Churchill Livi ngstone. Michaelson M . Churchill Livinstone. p. 2nd Ed. Neurology 34: 1 587. p. Kellgren JH: On the distdbution o f pain adsing ment in upper limb pain. Elliot FA: Tender muscles i n sciatica: EMG stud­ ingstone. 1986 ies. through 1990. Foerster 0: The demlatomes in man. Bogduk N: Celvical zygapophy­ 9. Smyth MJ. An experimental study. Glasgow EF: Nonin­ Press. In Bonica JJ (ed): The Manage­ ment of Pain. Henderson C M . Connell MD. 1 988 1 95 8 . Sand T: Neck pain i n the Clin Oual� 36:35. J Netv Ment Dis 99:660. Shuey 1-1: Posterior rad iculopathy. 1 59. Davis H: Increasing rate of cervical and lumbar mental pain. Wiesel SW: Natural h istory and teristics of neck-arm pain in patients with and pathogenesis o f celvical disc disease. Aprill C. Loeser JD: Celvicobrachial neuralgia. land LT: Epidemiology of cervical radiculopathy: a populat ion-based study from Rochester. 1 994 3. Philadelphia. 1 994 tion to the etiology and mechanism of neck. Phila­ I . IBJS 40A: 1 40 I . I : a study of normal vol­ and relationship to symptoms. Jull GA: The distribution and charac­ 1 1 . 1 979 1 9. Edinburgh. 1 994 25.lctures. Selvaratnam PJ. 1 969 26. Proceedings of the in� 27. The credibility of the profession rests with I S . WI-ight V: Sciatica and the intervcl-tc­ 1 4. lateral foram inolomy for an exclusive operative 1 994 tcchnique for cervical radiculopathy: a review of 1 3 . 1 992 35:3. 2 1 . 2. Spine 1 9:26. 1 990 pathoanalomical oligin of arm pain. Dalton PA. Arch Phys Med Rehab 75:342. Bonica JJ. I . KJafta LA. Litch WJ. Oxford. Lawrence JS: Disc degenerat ion. 1 990 28: 1 2 1 . Asbury AK. shoul­ 6. Fields HL: Pain. Spitzer WO et al: Scientific monograph of the 846 consecutively operated cases. 1 99 1 Clinical Medicine. Churchill Livingstone. Inman vr. In Grieve 1 933 GP (ed): Modem Manual Therapy. Oxford. Pergamon Press. p. Lancet 1 :47. Spine 1 9: 1 307. 1 959 Bonica JJ (cd): The Management of Pain. Brain 1 1 7:325. 1 7 . Butler OS: Mobilisation of the nervous syslcm. In Hirsch C.1 990. Zolter� Spine 1 5:458. 1 05 . terns. Clin Science 4:35. Procacci P: General considerations of References acute pain. groups and professions. Grieve GP: Common Vertebral Joint Problems. 2nd Ed. p. Ann Rheum Dis Ullleers. 1 989 1 2 . In Boyling JD. Spine 1 9: 1 1 25. 1 939 spine surgery in the United States 1 979. Elvey RL: Brachial plexus tension tests and the delphia. Dt'eyfuss P. Melboume. Aspects of Manipula� 18. 1 987 fdczak RM cd: Proceedings. Huh L: Frequency of symptoms for different age seal joint pain patterns 2: a clinical evaluation. 23. Orth Clin without a neurological deficit. Bogduk N : Cervical zygapophy­ 8. Its frequency seal joint pain patterns. Hennessy R. McGraw-Hill. Honet JC. Grieve GP: RcfelTcd pain and other clinical fea­ the individual. Saunders IB: RefelTed pain from skel­ live Therapy. 24. Fields HL: Pain due to peripheral 1 0. Radhakrishnan K. 2nd Ed. Edinburgh. Kur­ nerve damage: an hYPOlhesis. Edinburgh. etal Sln. Bovim G. 868. In der and arnl pain. 1 990 of the pain response in celvical discography. Dwyer A. 1 994 1 6 . 1 983 orders. Minne­ 1 984 sota. Vol. Lea & Febiger. A contribu­ Spine 1 9: 1 1 1 7. Palstanga N (eds): Grieves Modern Manual Therapy. 2nd Ed. Ellenberg MR. Spine 1 5 :453. Collis JS: The diagnostic inaccurancy Lea & Febiger. Cloward RB: Cervical diskography. Australia. 1 85. 1 992 the Australian and New Zealand Rchcumatology 37. Farmer JC. 1 995 SUI"CS with varying head and ann positions. 1 . Spine 1 7 : 1 1 3 1 . London. 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. Vicenzino B: An investigation of the effects of 39. vous system activity in asymptomatic subjects. Quintner ) L : Mechanically evoked elec­ 36. Yoo IU. Devor M: NeUl·opathic pain and injured nelve: pe­ other 32:224. 1 994 abnom'\al brachial plexus tension. 5th Ed. BM) 47:619. 1 986 . Aust J Physi­ 38. 1 99 1 35.152 P H Y S ICAL T H E R A PY Of T H E S H O U L D E R 32. p. But­ But terworths. 1 995 3 3 . 1 98 5 . 1 98 6 terworth-Heineman. Maitland GD: Vertebral Manipulation. Wisneski RJ: Cervical spine nerve root Associations Annual Sciemific Meeting. Brisbane.. Elvey RL: Treatment of arm pain associated with 1 9 : 1 850. Auck­ compression: an analysis of neuroforami nal pres­ land.pheral mechanisms. In: Abstracts of the human cClvical spine.1 1 . In : Proceedings o f the Manipula­ and thelmal pain thresholds and sympathetic ner­ tive Therapists Association of Australia. Salter RB: Motion versus rest: Why immobilise spinal manual therapy on forequaJ1cr pressure joints? pp. Spine 34. Hall TM. In Shacklock M (ed): Moving in on Pain. ZOll D. A clear understanding of the neural conse- 153 . Is· ment. the potential for multiple entrapment sites. nosis of TOS received physical therapy treat­ but interrelationships must be considered. An evaluative focus on the thoracic outlet and symptoms that procedure and treatment protocol has been the can derive from this region. in some instances. one must not fall into the trap o[ ignoring other failed multiple surgeries. multiple areas. These patients presented with se­ Thoracic outlet syndrome (TOS) as a diag­ vere. yet servative treatments and. although issues will be presented that mately diagnosed as having TOS. over 500 patients with the diag­ set of problems when seen as separate diagnoses. The patients all had 2 anatomic sites of neurovascular entrapment. one must consider resul t of this clinical experience. chronic pain problems that failed all con­ nostic entity is receiving increased attention.Neurovascular Consequences of Cumulative Trauma Disorders Affecting the Thoracic Outlet: A Patient- Centered Treatment Approach PET E R I . 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. EDGELOW Neurovascular compression syndromes of the In the past [our years in an outpatient or­ upper quarter involve a complex and bewildering thopedic clinic. or more years of symptoms before being ulti­ Therefore. ready to take control of their own care. as the basis for evaluating and de­ an understanding of the pathology as well as veloping an effective treatment program. health habits." Patients these changes could contribute to disruption of need to understand why they have the problem . to be effective and lasting. Importance oj Treati1l{J the Wlwle and the patient's insurance provider. As structural and fluid feeling of being in control: Understanding "what changes cause restriction in the size of the outlet. Therefore. This feeling state of being out of control an irreversible narrowing and others of which negatively affects the body/mind connection. and symptoms and signs first presented themselves. Re­ are reversible. Perscm factors that can be controlled-such as individ­ ual risk factors. the physical of fluid dynamics must complement investiga­ therapist acts as a coach to guide them through tions of structural changes. system or vascular system .ist­ of a cumulative trauma disorder illustrates the i ng risk Factors. postural changes or paradoxical breathing pat­ In order to be empowered. In the current medical climate. cessful outcome involves engaging the whole The second concept is that neurovascular en­ person in treatment. treatment goals and objectives. it affects the whole person. Simplisti­ should not be thought of as a rigid narrowing of cally stated. Once pa­ The third concept is that an u nderstanding tients are committed to this process. Also. and belief systems-take on an i ncreas­ in treatment.. but the stenosis due to tion. 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 concept is based recovery as they learn to monitor daily activities on research concerning fluid dynamics in the and the home treatment program.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. logical common sense. of these disorden. 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. the impact is to change the person an anatomic pal-t. carpal tunnel and appears to be equally relevant There are two key issues that facilitate the for the thoracic outlet. use of the knowledge presented in this chapter Three concepts have been developed based in evaluation and treatment. Stenosis problem. is wrong" and "what is the solution. 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. Such trauma may A case history of a patient with early signs occur in an individual with few or many preex. 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. It is based on the theory that a suc­ ing importance in the trealment process. issues that cannot be controlled by the patient include the interaction between the health care practitioner. 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. Although TOS is a physical trapments are a problem of stenosis. hy­ that if adequately addressed at the time the pot heses derived From the basic sciences. patients must be terns is reversible. daily living de­ Patient empowerment is an essential ingredient mands. the patient's employer. It is my contention on clinical experience: findings From surgery. " I[ we ignore tension. nosis into a language that empowers the patient. a negative belief sys­ cance of symptoms and cause and effect . For this reason. the belief painlwhine. and then one might consider the [ollowing transla­ they must be cautioned that treatment will not tion. If we ignore tient's feeling o[ control. 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. Tension excited awareness. However. either. and interferes with thought and method is to give a story that is simple. then i t will become will have a negative impact on everything that is so severe that change is not readily apparent and done to help. It is this be­ therefore it cannot "talk. Awareness and he said that he could fix them immediately is the first step to solving a problem. This can be done in a number of ways. 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. sustained gression o[ treatment will be to reverse the pro­ change. "pay attention to tension and blow it away" is an Learning to listen to the language of the body example of the use of words that are descriptive is a critical concept. This means and took out a pair of pl iers. no gain" II' one thought of symptoms as body language. For example. be thought of as 1V0rds to l isten and respond to. and cannot be relieved hysteria. Patients who fit the profile of this belief by fixing the problem. This idea can be expressed to the pa­ the risks and rewards of paying close attention tient by using the analogy of the orthodontist. This is par­ ticularly important with injuries to the nervous t. it is my topic have usually failed other treatment ap­ experience that there is no quick fix for severe proaches. The first step in resolution can take 3 cess and go from a stage of hysteria to crying to months before enough stability and positive re­ whining to tension. Even if you don't wish to wear braces for but learning how much is necessary to support 2 years to have a beautiful smile. tem can sabotage initial treatment efforts if not It i s important for the patient t o understand addressed. Painlnumbness and tingling that is severe. I f that nothing can be done to correct a problem w e ignore constanUcrying. understanding the stand that you might look for another practi­ solution. This process will offer the sults have been obtained for the patient to feel patient an opportunity to understand the signi fi­ in control. 4. system as well as the musculoskeletal system. This 3. teeth. significance of their symptoms. and doing what it takes for the rest of tioner. Common sense and experience has one's l ife to minimize the problem. cause the body's pain response will be to protect . ogy is that it may have a negative connotation In the hysterical state i t is unable to change. = analogies to guide rather than using medical ter­ minology. but not enough Therefore the understanding and commit­ to be able to resolve the problem. at least you the body in stressful situations. Pain and muscle tension can of both the problem and the solution. Pain that comes and goes = whining. one could under­ understanding the problem. They may have tried to understand the neurovascular entrapments. then i t becomes constantJclying. be­ = 2. The problem with medical terminol­ The body speaks to us by symptom change. I f to symptoms-not to become a hypochondriac you went t o the orthodontist with crooked teeth. Not to the taught us that there is no quick fix for crooked extent of dominating one's life with treatment. One constant. and based in the patient's belief system. The common statement o["no pain. but not to deny the problem. Therefore in ment on the part of the patient to an'ive at a satis­ treatment it is important to realize that the pro­ factory outcome involves a significant. lief system that can increase or decrease the pa­ then it becomes painlwhine. be successful if the pain response is not "l istened to" and used as a guide to treatment. [ f there was a quick fix to this issue we have no easy way to be lead along the path then the therapist could overpower this negative of healing. has no place in the treatment of patients. The statement know that it is the best available answer. using action. Anterior scalene � 8. n Stellate > Middle scalene. "" 0. Subclavius __ ---. r -< CB Vent.. ... '" � ramus '" > Rib # 1 � -< 0 � -< '" � V> '" 0 c: r 0 � '" .. phrenic '" -< Brachial Plexus 8. V> Axillary vessles Posterior scalene .... T I ventral roots o( the plexus are visible as they pass in (rol1l o( the middle scalene muscle. 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. acromioclavicular these diagrams to be of assistance in explaining joints and the first rib occur as a result of the problem to the patient. The relationship of the clavicle can af­ The bony tunnel comprises a floor consisting of fect the costoclavicular space and therefore the first through fifth ribs.butor to the high incidence of population. 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. The anterior wall is the potential for changing the vascular flow formed by the clavicle. and Figure 6. ( @ Peter Edgelow. eral border formed by the glenohumeral joint (Fig.s been removed to view the anterior scalene muscle with the phrenic nerve crossing it. The concept of tunnels is an mation following fTacture of the clavicle or essential perspective to understand the problem first rib. that exhibits dysfunction as a result of pathologic which might include the size of the trans­ reflexes secondary to other sites of entrapment. Stmctures that can affect the pathway the lower roots of the brachial plexus must tra­ A review of the anatomy and potential risk fac­ verse to reach the extremity (the breadth of tors will focus on the thoracic outlet. which can Figure 6.2 shows a diagrammatic representation contribute to trauma of the neurovascular of the major tunnels of the spine and upper ex­ bundle during arm movements. is a source of symptoms secondary to congenital 2. This area the first rib). I with CTDs of the upper extremity. The clavicular head o( the stemocleidol11astoid muscle ha. The CS. 6.) .b to then join C8 and pass into the BONES aim. The author has found the sternoclavicular. an arthritic glenohumeral joint. These include callus for­ tunnels (Fig. Used with permission. Factors that can affect the diameter of the considered as tunnels made up of bones and tunnel based on trauma in the past or fTom muscles. opening of the intervertebral foramina. or recurrent injury. Stmctures that can affect the diameter of factors and/or trauma and is the primary region the tunnel based on congenital factors. The posterior wall is the through that space. 6. and a lat­ overtreatment. verse process of C7. the distance traveled to pass from the inter­ vertebral foramina of T I up and over the first I. Functional changes such as the mobility of tunnels on the anatomy. C7. postural changes or dysfunctional breathing The basic anatomic stmctures will briefly be patterns. C6. I tremity. CB. The nerves and blood vessels may be­ the injury that immediately preceded the come compromised within one or more of these onset of symptoms.3 shows an overlay of the 4. and the presence of a cervical rib. Al­ addressing dysfunction in the thoracic outlet though present in less than I percent of the may be a conu. This protective re­ scapula. <II FIGURE 6. These changes affect the course of discussed together with the potential risk factors the lower roots of the plexus by increasing within these structures. 1 ). 1 ) . a cervical rib occurs in 5 per­ failure in conservative management of patients cent of TOS patients. Anatomy I . the length of the clavi­ Early evidence points to the fact that neglect in cle. The anatomy of the thoracic outlet might be 3. Potential risk factors within these structures are as follows.t Antltomy o( the thoracic oLlflet. and degenerative hypertrophy of associated with TOS and the proposed solutions. -tD-- .--e::::r- ---- --e::::r. I . Used with permission.. imity. This suggests that fibrosis dle scalene muscles. and fewer than 1 percent develop TOS. 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. Type II fibers are characterized by rapid contraction and relaxation. TOS patterns in which the scalenes and pectorals samples averaged 77 percent type 1 to 33 are used as the initiators of each breath.d calwl of GUYOI1. pectoralis mil1or.. are as follows. and normalities in fiber type. such as unusual prox­ of the scalene muscles secondary to trauma. intelvertebral foramil1a. These studies also showed a rather than assisting the diaphragm and Significant increase in connective tissue. and the presence tributor to the cause of TOS4 of a scalene minimus muscle2 . tunnel into two additional "soft-tissue" tunnels.) . wide distal attachments of the first such as whiplash. 2. fifth ribs to the coracoid process of the scapula and amount of connective tissue. 6. which passes from its bers contract and relax slowly. Anatomic variations of the anterior and mid­ was 36. fourth... may be an important con­ rib. scalenes alter their physiology (see #3). scalenes.. 5.6 percent. 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. lower intercostals during a deep inspiration. Post-traumatic scarring along the deep cervi­ bands that attach lower cervical transverse cal fascia could be another source of dys- . Nan'owing of the scalene triangle and pec­ range of tensions. 3. Normal (Fig. 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. cubital tLl/mel. of abnormal breathing and overused acces­ short-duration muscular activity' The TOS sory breathing muscles. 4.2 Diagrammatic representation of tunnels within the upper quarter that may be compromised by acquired. The scalenus anterior arises from the anterior knob of the transverse process 3. making these fibers medial superior surface of the first rib. 6. 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.. in conditions such samples showed a predominance of type [ as asthma or COPD. infraclavicular. vertebral canal.3 Fibrous 4. and are very resis­ undersurface of the clavicle to its insertion at the tant to fatigue. and the scalenus medius ring. fibrosis.. and process and inserts to the posterior superior sur­ contracture as verified by histologic stud­ face of the first rib. carpal tLl/mel a. Paradoxical breathing (slow) fibers over type II (quick) fibers. cOl1gel1ital. develop a wide I . specialized for the long-term contraction Potential risk factors within these structures necessary in the maintenance of posture. Type [ fi­ component (subclavius). Scalene muscle trauma fTom injury arises from the posterior knob of the transverse with resultant inflammation. distal interdigitations. size distl'ibution.. 7. They are suited for high-intensity. FIGURE 6. or postural slel10tic lesions. and the average amount in TOS samples 2.1). and often fatigue quite toralis minor contractile tunnels as a result rapidly.5 percent.. percent type IT. develop ten­ point of origin along the lateral one third of the sion over a narrow range. (@ Peter Edgelow. The normal average amount of connective could be considered as a reason why the tissue in a healthy muscle is 1 4. 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.. 160 PHYSICAL T H E RAPY OF THE SHOULD E R . The affecl on available on nonnal pressure gradients. The sub­ ters can be nan'owed by a combination of bony. ( @ Peter Edgelow. resulting in a longer course lO get over effect on the pressure within a tunnel. anterior scalene. because it is lheir relationship are as follows. and which lies on the neck of the firsl rib. TRAU M A DISO R O ERS AFFEC TI N G THE T HO R A C I C OUTLET 161 function. if the delicate balance is disturbed. The deep cervical fascia is continu­ gle. 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. 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. The sympathetic supply lO lhe more susceptible to compromise than the artery. 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.) . Used wilh pennissiol1. There they arc neurovascular bundle. Based a postfixed plexus. 2. would then initiate a sequence of events that could ultimately produce nerve damage. lermed racic outlet but also in the carpal tunnel. subclavius. clavian artery courses through the scalene trian.7 However. the PathophysiJJlogy of BLOOD VESSELS Cumulative Trauma IMorders The subclavian vessels enter and exit the chest A can be seen. il is the venlral rami of C8 and TI. any increase in neural mobility is lO lower the exiling T I vascular congestion would have an immediate root.7-10 the brachial plexus.6 Scarring in one area joined by the subclavian vein. slumped posture increases the length of the spinal cord.'70r (5). However. neurologic. which is formed by the anterior and middle ous with the axillary sheath that encases lhe scalene muscles and the first rib. first rib. together with the nerves. and traumatic abnormal- FIGURE 6. Such vertebral canal to the arm and the blood vessels change will affect the segment. there is "har­ NERVES monious coexistence" among these su·uctures. 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. fTom the thorax to the arm. the thoracic outlet tunnel diame­ in this region. soft tissue. (2) Ihe space belween the amerior al1d middle scalel1e. giving neurogenic or vascular symptoms (Fig. which passes in could lead lO decreased mobililY lhroughoul fTont of the anterior scalene muscle. That is. 1 ). which is of parlicular impor­ Potential risk factors within these structures tance with TOS. Distal to the lhe length of the lissue. thereby changing the distance lhe roots have to traverse to get into the FUrther Issues in Uruierstanding arm. as lhey anastomose to form the lower trunk of 6. T2. (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). Normally.3 This overlay o( the tunnels upon Ihe analomy emphasizes the close proximity o( Ihe il1lerverlebral (oramina. (4) al1d Ihe space poslerior 10 peclortliis /11.(figure I) clavicle form a tunnel with a variable diameter. the subclavian vessels are renamed the axillary artery and vein. upper exlremity comes from the stellate ganglion The first rib. flow more than arterial flow and may be a signifi­ I . POlenlial risk factors wilhin these slructures are Narrowing of this space would affect the venous as follows. and this the firsl rib and inlo the arm. which is called the flexion with­ may worsen if the reflex activity is not normal­ drawal reflex. 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. This normal protective response: vasoconstriction. the reflex pulls tern is the most common and frequently over­ the extremity away fTom the stimulus towards looked dysfunctional reflex. t h e auto­ thereby nan-owing ti. dysfunctional reflexes.g. so that relaxed. 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 resultant change in the extremity. The effect of the relaxed re­ breathing.e tunnel. repeated movements. Following the clot­ releasing the resultant muscle tension. crease in muscle tension of the flexor muscles In patients with paradoxical breathing the rather than a softening or release of tension. there i s a traumatic event such as a cut. time of contraction. sensitiviLy to pressure as compared to the unin. tion can be palpated.. 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. normal reflex pattern of breathing then becomes In patients with cumulative trauma disor­ conditioned into a "new nOlmal" or pathologic ders. these reflexes are all pathologic and protective reflex. because it perpetu­ flex becomes hyperactive. vasoconstriction. 11 tive response adversely affecting the breathing The autonomic nelvous system also has a pattern (e. Following this reflex. As the first rib elevates due to the system dynamics. the neurovascular structures. I f protective response acts to elevate the first rib. This vasodilatation response can be scalene muscles as accessory muscles of breath­ stimulated by relaxed repeated movements of ing when the i nspiration deepens. Under normal circumstances. these reflexes become dysfunctional. In addition. The common dys­ the center of the body. causing vascular Further clinical obselvation with these pa­ compression. and paradoxical. ized. tients reveals the issue of increased tone in the muscles of the upper quarter and a decrease in hand temperature and blood flow. and paradoxical breathing) be- . when the extremity experiences a noxiolls timu­ An abnormal or paradoxical breathing pat­ Ius (such as touching a hot stove).162 PHYSICAL THERAPY OF T HE SHOULDER ities. 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. the scalenes are used even when peated movements is felt as a warming of the breathing quietly. These reflexes (flexion wi thdrawal. and postural. breathing pattern to relaxed. the upper extremity. ergonomic. gasping and breath holding). Changing the nomic nervous system causes a vasoconstriction. re­ ates a vicious cycle of pain/spasm and conges­ peated movements of the extremity cause an in­ tion. This could be viewed as a protec­ that produced the withdrawal. The breathing. This pattern of contrac­ blood flow with relaxed. In treatment it is e sential to decondi­ somatic nelvous system's flexion withdrawal re­ tion this conditioned reflex. The nor­ ting. 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. there is a reflex vasodilatation. In severe neurovascular en­ The somatic nervous system has a normal trapments. fluid volved side. 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. and note should be made The breathing reflex in the dysf'unctional state is of the difference in size. In paradoxical the injured part. 1 briefly summarizes been described For the median nerve in the car­ pal tunnel. 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. as it is continually housed TABLE 6. These fluid systems must be occur.4). The blood supply within while maintaining relaxed scalenes during quiet a peripheral nerve relies on a pressure gradient diaphragmatic breathing. once lation and the healing process. repeated movements in a range tion become obvious. Table 6. the FLUID DYNAMICS. and the ensu­ traneural scalTing without affecting the in­ ing pain has a negative impact on both the circu­ traneural function of the nerve. the structures they supply. Intervertebral disc Auid Disc Wolk. ligaments. Breathing into a lake and a river flowing out of the lake. However. [n this state. 6. that does not elicit the tension/cooling response. which was greater than the pressure in see the consequences as a loss of flexibility. A useful analogy to de­ Synovial Auid Joints Movement scribe this situation is to consider a river flowing Cerebral spinal Auid Duro. In research on pressure gradients within the carpal tunnel. endurance. coor­ the tunnel (Fig. endurance.ng the volume of the lake is constant. and strength. I f nothing was done to re­ tion.'l This is of importance in the thoracic outlet because. This paradigm verse this problem then the hypoxia continues. which was greater than the pressure in the nerve The traditional paradigm in considering the fascicle. system for adequate nutrition. then permanent neural change would the upper quarter.'·'l From this evolves a hypothesis. coordina­ stasis and hypoxia . struc­ CIR CULATORY SYSTEM STRUCTURES PUMP SUPPLIED tural and dynamic changes cause restriction in Arteries and veins Muscles. the pressure gradient changes lead to intraneural There are six separate fluid systems within fibrosis. The nerve fascicle. and with in­ adequate repair and health. in nerve roots which the inflow equals the outflow. which could contribute to bone disrupting the pressure gradient and affecting Lymph Fascia Movement the neural circulation. This para­ gradient due to an increase in the tunnel pres­ digm then directs treatment for musculoskeletal sure caused the vein to collapse.1 Fluid systems within the upper within tunnels of varying structure throughout quarter the body. the oxygen Intraneuronal transport Nerve Movemenl content is high. needs to be expanded to include circulation leading to edema. working at their best to maximize healing from Although the pressure gradient research has trauma to this area. which ultimately leads to fi­ (fluid systems). TRA UMA DISORDERS AFFECTING THE THORAC I C OUTLET 163 come conditioned by repeated noxious stimuli to these systems. An additional issue is that of pressure and its but does elicit the relaxation/warming response impact on circulation. the model could be generalized to the entire nervous system. system Should there be an obstruction affecting the out- . meninges. 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 strength. as previously mentioned. and respond with persistent cooling. and the pollution content is low. creating venous injury to restoring losses in flexibility. which was greater than the pressure in musculoskeletal consequences of an injury is to the vein. TISSUE REPAIR AND pressure in the nutrient arteriole was found to NEURAL MOBILITY be greater than the pressure in the capillary. Imbalance in the pressure dination. Heort the size of the outlet. Because the key in­ creased tension in the scalenes. particularly when considering broblastic activity and scar Formation within the the cumulative trauma patient population. with increased the pumps that maximize the flow necessary for muscle tension in the extremity. bOlh the problem and the solu­ form relaxed. With post-traumatic cumula­ fiGURE 6.) (Adapted (rom the work o{ shoulders ( painters.4 Representation o{ the pressure tive trauma patients. (A. The forces must be small enough not to elicit Significant pain. N. The major factor in this step is a function of time. and working SLlI1derlal1d. lifting or holding the al-ms above the tll/mel. In one . capillary. (B) Hypoxic and edematous 1£1I1I1el al1d LIVING ISSUES nerve: increased tunnel pressure) venule = collapse = venous stasis and hypoxia. An awareness of this issue helps to understand how normal injury and repair can be interfered with in the thoracic outlet region and upper quarter. This idea can be expressed to the pa­ tient by using the analogy of the orthodontist and how he is able to remodel crooked teeth with the use of braces and small forces in the form of elastic bands.) to develop symptoms. For maximum repair and restoration of function. repetitive use of arms (assembly line tisslle.13 Because the blood flow to and from the upper extremity passes through the tunnel of the thoracic outlet. the concept of narrowing of the tunnel can be a mechanical explanation for the circulation problem. arteriole. 1976. (C) Certain occupations that involve constant turn­ Neural {lI1d tll/mel fibroblastic respO'1Se: {urcher ing or sustained flexion of the neck (keyboard increase . l1en'e. For nerve and the application of small forces are also simplicity. and cash regis­ ter work for incidence of TOS symptoms. one nerve fiber il1 a fascicle is important considerations in the healing process.164 PHYSICAL T HERAPY OF THE SHO U LDER flow.' Studies have compared occupations of heavy industry work (packers and assembly workers). C. and stress stimu­ lates adequate remodeling so that the repaired t issue can be as close to the pre-injured slate as possible. office work. Normal repair requires an ade­ quate amount of circulation and stress. (A) Nonnal tunnel pressure gradiel1t: artelY) capillary) l1erve) vel1ule) OCCUPATIONAL AND ACTIVITIES Of DAILY tll/mel. scar jobs). electricians).5). @ PeCer Edgelow. Circula­ tion feeds the healing tissues. microstresses are re­ quired to stimulate both structural strength and flexibility. 6. This condition would be called a swamp (Fig. T. represented. A further issue following injury involves the repair process itself. Used with with vibrating tools seem to predispose people pennissiol1. but sustained enough to allow for the tissues to accommodate to the stress. venule. and the pol­ lution would increase. V. the factor of time taken to gradiel11s in tlze carpal tUl1l1el and the stages that remodel the extraneural components of the {allow alteration o{ the pressure gradients. the oxygen content would decrease.n tunnel pressure and hypoxia. then the volume of the lake would increase. work). '7 It is .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. -. ..14-1• Recent rib is chronically elevated... (@ Peter Edgelolll.7 .s Also. +OHYGEN \ tPOLLUTlON . Used wilh penllission. _. It is suggested that patients with emphy­ weights by those unaccustomed to heavy work. elevated first stresses. I. ..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. register work produced the highest percentage of Another possible cause of symptoms related TOS symptoms (32% of cash register workers)..) study. / I + OHYGEN / + POLLUTION \ I I SWRMP I . 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. TRA U MA DISORDERS A F F ECTING THE THORAC I C O U TLET 165 .. 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.... a high thoracic clinical experience has shown that musicians are lordosis lifts the upper ribs towards the clavicle.-- FIGURE 6. sema are predisposed to TOS because the first or by debilitation and poor posture... such as the carrying of heavy packs or rib.. \ \ I I LRKE = RRM . .. 2 1 plexus. and discomfort or par­ on the upper limb tension test. working with a mouse on the computer. and inflammatory conditions of the joints would selectively stress the lower roots of the and soft tissues. 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. and in the quality of muscle lumbar lordosis when accompanied by a tho­ contraction that contt. 2 . changes in first . cle contraction in two distal arm muscles inner- . such as cervical disc disease or spon­ of the arms in an extended position. orthopedic problems of the shoulder and tional position of holding a phone to the ear spine.b and coccyx/sacrum in a flexed position and a loss of thoracic mobility..tating. 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.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. I t is speculated that involving more than one "tunnel" (termed multi­ the increased incidence may be due to less devel­ ple crush). and you Pancoast tumor. 1 9 simple clinical test to clarify the quality of mus­ I t has been suggested that a narrowed tho. which decreases the angle could then compromise the nutrition of the between the scalene muscles '>o Another factor nerve at a distal site. aching. The spinal cord is approach­ consider conditions that may simulate or coexist ing its end range of motion.'s This knowledge aesthesia in the arm. spinal cord neoplasm. angina pectoris. vascular abnormalities. A major contribution to the clari­ greater tendency for drooping shoulders. such as dylosis. changes workers is slumped. more horizontal clavicles. Perhaps instead of drooping shoulder asleep and it may even be momentarily flail and girdles. Slump sitting with the in breathing patterns. 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.6 mobility." He has devised a lies in the thoracic outlet in women. or it fication of ce. The func­ elbow. as is men­ ing of tightness or pressure in the posterior tioned later in this chapter.bute to the clinical diag­ racic kyphosis has a very profound affect on the nosis. 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.vical involvement comes fTom the may be due to more prevalent congenital anoma­ work of Dr. Add to this the use with TOS. or a is challenging. mid thoracic region. the T4 syndrome presents symp­ sis is based is the pioneering work of Bob Elvey toms of dull pain. carpal tun­ selectively stress the upper roots of the brachial nel syndrome. and it is the subtle soft-tissue signs of neu­ the common position of many seated office ral imtability. multiple sclerosis. For example. As the effect of specific trauma and age affects the mobility of the nervous system. An important fact to appreciate is that the nervous system is a continuolls tissue tract. Herman Kabat. not to overlook is the biomechanical conse­ Sleeping postures are often affected. Sorting out the contribution of each oped muscles. ulnar nerve compression at the plexus compared to the lower roots. mobility of the spinal cord caudal to the cervico­ A complete clinical evaluation should always thoracic junction. The information upon which this analy­ In addition. and pa­ quences of the anatomic fact that women have tients may awaken with their arm having fallen breasts. dence of neurologic injury or radiological find­ particularly if they are sustained. ings. often followed by the passage of time Complaints may include pat'esthesia (numb­ and/or a job involving large amounts of static use ness and tingling). CTS FUrlctiol1al Profile {or Patiel1ls With is associated with TOS in 2 1 to 30 percent ofTOS TOS cases. and a to observe that sometimes the motor root prob­ feeling of heaviness. finger stiffness. 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. or playing a compression in an extremity!6 The presence of musical instrument. 7. push­ cases. with patients complaining of symptoms more distal nelve more vulnerable to compres­ with sustained upper extremity activity. such as sion. and exertional ductor pollicis and flexor carpi ulnaris that is re­ fatigue. The pain may radiate to tive test incriminates the C7 root as a potential the chest wall 6. True CTS involves the median nerve only and is often associated with a Tinel and/or Phalen sign. data entry.2' source of irritation. The most SYlllptO/1/ Pattems {or Patiel1ts With common traumatic event was a motor vehicle TOS accident. 3S . Aching pain is noted as hands . I '. and carpal tunnel syndrome .30-3 2 Venous symptoms lem is in one arm while the TOS problem is in are more common than arterial ones. It is of interest discoloration. cold patients with TOS also exhibit weakness in ad­ sensitivity. embolization can cause gangrene of fingertips Another challenging diagnostic problem and is an arterial complication of TOS 7 . 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. reaching. fTequently in the hypothenar area and adductor pollicis and flexor carpi ulnaris. 24. Venous obstruction may cause cyanotic versed by self celvical traction. It is believed that in some cases there can be telephone or steering wheel. pulling. and is refen'ed to as latency. The pain may of the brachial plexus. su­ quiring sustained hand activity under high cog­ praclavicular area. the author's experience is Symptoms are eased by avoiding aggrava­ that the lower extremity neural tension signs. pain (aching or sharp). These muscles are affected.>' In toms can be bilateral or unilateraJ. or carrying a heavy a multiple crush syndrome involving any combi­ bag. with repetitive use of the sensory and motor loss. Fine coordination may be a more proximal lesion does seem to make the affected. and a significant number of Arterial obstruction produces coolness.2 1 Pain i s fre­ prolonged stress to the hand in occupations re­ quently felt in the lateral aspect of the neck. ulnar nerve compression be particularly disturbing at night. holding a newspaper. Presel1l History {or Patiel1ts With TOS Examirwtion Findings I n the TOS patients referred to the author. SUBJECTIVE SYMPTOMS there was a high incidence of trauma. such as wearing a sling or keeping the bility. or repetitive the existence of more than one area of nerve activity such as writing.28. hand in a pockel. 33 concerns carpal tunnel syndrome (CTS). 25 The double crush syndrome indicates ing. numbness in the hand. 27 combing hair. ting activity and through support of the involved such as straight leg raising (SLR) and cord mo­ extremity. shoulder area. The trauma could be sudden or insidious. I •. can also be affected. trunks and cords use. and the area njtive demand and with either poor work station of the arm con'esponding to the dermatome(s) design or poor hand/arm/neck use . arm edema.30 and symp­ at the elbow.34 Insidious onset oCCULTed following the most common symptom . and of the upper extremity.1 severe cases of TOS. Peripheral the other. reaching over the head. A posi­ fourth and fifth digits. Pain is often worse after rather than during nation of cervical spinal nerves. Because pathologies such as cervi­ gated transverse process of C7 seen on plain cal radiculopathy. spinal steno­ an increased blood flow. 19.33 A bruit indicates THERAPIST FOR PATIENTS WITH TOS an arterial lumen nan-owing. 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. a diagnostic aid.38 Many TOS patients have normal electrodiagnostic studies. muscle as the source of pathology.37 of an elongated transverse process is a marker A muscle block is another technique used as for other anomalies within the thoracic outlet. leaving the patient apparently not give the specific cause. the lack of specificity can make interpreta­ outlet decompression surgeries that the presence tion of thermography difficull. Ra­ tion. ulnar nerve injury. in ruling out carpal tunnel syndrome and ulnar degenerative changes. 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. Positive electrodiag­ nostic studies can reveal chronic.20. 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. 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.2 4.168 PHYSICAL THERA P Y OF THE SHOU LDER Past History (or Patients With TOS evoked potentials (SSEP). Pancoast tumors. angiography. they Specific diagnosis for TOS can be made by radio­ should be tested in the symptom-provoking posi­ graph and computed-tomography (CT) scan.37 The infraclavicular area should be OBJECTIVE EXAMINATION BY PHYSICAL auscultated for the presence of a bruit with the ann in various positions. 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). because it can predispose toward emboliza­ mography indicates either an increase or de­ tion of the subclavian artery . or caused trauma to the vascular system. poinI. Ac­ duction velocities ( NCV).39 Most agree that these studies are helpful diologic studies identify any bony abnormalities. sis and fibrous bands " or a decreased flow.7. but there is disagreement over affected the diameter of the canal(s) or the flexi­ the reliability ohhe results. which are TOS dependent on certain positions. due raphy ( E M G). resonance imaging ( M Rl) are often necessary to Alterations in heat emission can be measured by rule out frank cervical disc disease. and somatosensory live movements of the celvical spine are exam- . or other nerve entrapment at the elbow.7 . but do quenLiy resolved. 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. or venog­ raphy "·36. and reflex films. viduals. 2S CT and magnetic crease in heat emission secondary to blood flow. This may be due to the TESTS AND MEASURES FOR PATIENTS WITH intermittent nature of the symptoms. Stoney.6. 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. late F-wave responses. It is the experience ofa prominent vascular sympathetic dystrophy can produce similar pat­ surgeon who has perfon-ned over 250 thoracic terns. 32.24. 37. Instead of test­ ing these patients in the anatomic position. nerve con­ to respect for the ilTitability of the condition. There is a wide range bility of the nervous system as it traverses the of conduction times found in asymptomatic indi­ canals. as in venous occlusion.' The objective examination is limited in the tradi­ Electrodiagnostic tests include electromyog­ tional scope and range of motion examined. personal muscle belly can implicate the anterior scalene communication). ) [ n the Active Movements author's expel-ience the ULIT I is positive and symptomatic on all patients. ULIT 2 has two variations that more se­ particularly for prominence in the cervical tho­ lectively bias the medial and radial nerves and racic junction. C6. T RA UMA D ISORD E R S A F F E C TING THE T HORAC I C O U TL E T 169 ined to the point of onset or increase of symp­ The patient is asked to move the extremity to the toms only. as a refinement in the examination or progres- . when examining point of onset of symptoms. Functional examina­ to the stage that the ULIT I is improved and no tion is to have the patient elevate the arm with longer initable. This difference tension test. and because all movements These tests are discussed in detail in Chapter 5. for the ulnar nelve and nerve root levels C8-T I . or formed to the left. The evalua­ towards the median nerve and nerve root levels tor should also look for forward head posture. This is the point at the neural mobility. An important fea­ Full active motion testing is not performed ture of these patients is the irritability of the neu­ initially. The cervical ranges of flexion. tingling. and C7 nelve roots. This is before the of the brachial plexus or upper limb tension test. core of the problem. exten­ sion. and peripheral nelves. C6. To examine them into the range in in the right scalene region when rotation is per­ which symptoms such as numbness. i t is essential to examine to the ini­ in range between elbow flexion and extension tial ban'ier or point at which involuntary muscle range is compared with the specific examination guarding comes into play. For this reason. Observatiol1 trunks. need to be examined to the initial point of muscle There are four tests deSigned to test the ex­ tension. is a general hold the extremity in a fully flexed posture much base test for the brachial plexus with a slight bias like the posture seen in hemiplegia. one must examine it to the which tension is felt. There will most commonly be a latent flare. and tension be elicited. which may NeLlrodynalllic Testing take hours or days to subside. to have tension in the left scalene region when Otherwise the pathologic withdrawal reflex will rotation is performed to the right. Each one biases a different aspect of the cervical roots. of the spine and extremities have a biomechani­ and so only a brief description will be given here cal effect on the nervous system. pain are produced is to overexamine them. If this pre­ In my experience. When examining the upper limb point of increase in tension only. then ULIT 2 or 3 may be used the elbow extended and with the elbow flexed. The common restriction is point of muscle tension or muscle guarding. tensibility of the neural structures. In more extreme cases the patient may The first of these tests. This can manifest in movement. all movements to highlight their importance. Tn less in·itable The nervous system is examined both func­ conditions or when the patient has progressed tionally and speCifically. range in which symptoms are elicited. The resulting abnormal amount of subtle protraction and elevation of the shoulder tension will produce a positive ULIT 4 1 girdle. With TOS. 5 for a description o f these tests. and bilateral rotation are assessed to the ral structures. Once this has been done it is too late to back up. compression of the neural structures provides a Typical postural deviations to look for in site of tensile stress concentration and limits the these patients involve protective positioning of normal mobility and exten ibility necessary to the upper quarter to reduce stress on the neural accommodate to the stresses of neck and atm and vascular structures. 1 2 (See Ch. the upper limb tension caution is not adhered to. the risk of a latent flair tests ( U LITs) to evaluate and treat abnormal of ymptoms is heightened. as well as soft-tissue fullness in the C5. It is the irritability neural dynamics in the brachial plexus are the of the nervous system which is at the physiologic most valuable tests for the neurogenic tissues. ULIT I . C5. ULIT 3 is biased the supraclavicular area. 6. I . This produces a pulley effect of the ing compression to the neurovascular structures neurovascular structures under the pector- . This pur­ even when they can. Adson's test. The patients often have on stretch. 2o FIGURE 6. Reflexes usually remain intact. If the strength tests are found sustailled {or 1 5 seconds and t/tel1 slowly to demonstrate weakness and this weakness is released.7 . Retestillg o{ the weak muse/es should reversed with self cervical traction (Fig. (j Palpatiol1 In patients with neurogenic TOS there may be pain with direct pressure over the scalene muscles and also on the brachial plexus." are sometimes equivocal.24.170 P HYSICA L THE R A P Y or T H E SHO U LD E R sion in treatment. the Kabat protocol is used to determine flexor carpi uhwris. is mild and in­ volves most commonly the t henar. it is the inability to quieten ports to test the costoclavicular component the scalenes that is the dysfunctional pattern. This decision is based on clini­ cal judgment. Among the more com­ mon diagnostic tests are the following: Breathil1g Pattern Relaxed breathing is always paradoxical.3o Tenderness in the region of the subclavius muscle as it inserts into the first rib is also common. demonstrate immediate increase in lIlolor then this technique of selF-treatment is incorpo­ power.6). The exaggerated military position.) this protocol the identified path of least resis­ tance is used to guide the patient in modifying activitie of daily living . Stret1gth Testil1g Muscle weakness. if present. as assumed in ticular areas that could be responsible for caus­ sleep). causing compression More Traditiol1al Objective Tests {or there. Kabat's lIIet/tod o{ performing sel{ In the case of a specific C7 motor root weak­ cervicle traction as a method o{ reversing ness (adductor pollicis and/or flexor carpi ul­ identified weakness il1 addllctor pollicis alld/or naris). Hyp­ esthesia may occur in the C8-TI dermatomes. 23 (@ Peter Edgelow. There may also be a positive Tinel sign over the supra­ clavicular area at the i nsertion of the anterior scalene muscle. hypothenar. 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. Hyperabduction of the arms (alms over­ The standard clinical tests to implicate par­ head with elbows flexed. difficulty breathing with the diaphragm. Used with rated into the treatment protocol.20. Thoracic Outlet SYl1drome 3. and 2. and interosseous muscles innervated by the ulnar nerve.6 Dr. 2 3 Based on permission. of the thoracic outlet by lowering the clavi­ cle onto the first rib. The tractiol1 {orce is its significance. 1 0. and why performing the ULTT commonly called the hands-up test. This may ex­ tive for these tests. 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. to types of TOS due to compression by the po­ mention a few of the influencing factors. The abduction exte111al rotation test (AER). nal rotation to 90°. the emo­ changes with the maneuvers. It is the basic premise of this ap­ ously an obliteration of the arm pulses and proach that the patient learns through the ability reproduction of neurologic symptoms. No single test of the ble of the TOS tests. and recognize when treatment is effective. the tests have shown too many false­ lected and individualized therapeutic proce­ positive resulLs to be reliable. progres­ space. and an intellectual understanding of is a more reliable sign of thoracic outlet syn­ the issues related to causes. This test will evaluate all three fits as determjned by insurers and employers. towards the solution. An additional claudication test added to the ment program for patients with thoracic outlet AER position.'" Ab­ duction and exte111al rotation of the arm. to feel the change that occurs while performing Each of these standard TOS tests has compo­ the exerci es to both understand the problem nents of the ULTT within them. This postural maneu­ more traditional tests is speCific enough to elimi­ ver involves shoulder abduction and exter­ nate other potential sources of pathology. the risks and benefits This is called the elevated arm stress test as viewed by the patients. producing a scissors-like compression of the neurovascular stnlc­ tures by the clavicle on the first rib. the general goals of the treatment program The problem with these traditional tests is are to teach the patient to control the problem that when pulse obliteration is used as the criti­ and prevent recurrence by taking control of se­ cal sign.' these factors acknowledged as ongoing param­ eters. methods for prevent­ drome. This is achieved through training and ity of asymptomatic individuals have pulse monitoring of the physical problems. position causes a "drag on the nerve roots. 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. tests are negative. intellectual. 2 . tion can also nan"ow the costoclavicular However.' There are many outcomes that influence a treat­ 5. places a traction force on the brachial plexus and is further exaggerated by the hyper­ Identify physical. With sition and the added stress of exercise . during which a patient opens syndrome. 2o The hyperabduction and costoclavicu­ ing. It can be considered positive by reproduction of Treatment the patient's symptoms or pulse change. This posi­ partial tension of the neuromeningeal system. with the more mild cases. and the cost and bene­ (EAST). Compared to the ULTT. by the change in relevant symp­ the shoulder girdle or the exaggerated military toms. and emo­ abduction maneuver " Adson's test involves lat­ tional issues that contribute to the problem eral flexion of the head to the contra'lateral side.' Reproduction of tional response to the disabling and painful the patient's symptoms using these test positions problem. experience of the therapist. these tests involve only causing compromise at that site. Depression of and to be guided. 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. or the THE EDGELOW PROTOCOL AER test. . They can reflect the education and and closes the hands for up to 3 minutes. because the major­ dures. and the personal lar maneuvers are positive if there is simultane­ role in each. 20 plain why many limes the results of these classic 4. 7 · 1 9 Positive response for pulse obliteration is GOALS only 5 to 1 0 percent in nO I·mals. and curing the disOl'der. Used lVith of breathing and movement. TREATMENT METHODS TO "OPEN THE TUNNELS" Breathing FIGURE 6.. Identify variance in normal quiet breathing and decondition the acquired dysfunctional pattern. The ball-oll-a-slick is pattern.7). From a clinical perspective. and teach the patient 110d down as Ihe body shorle/1s relative 10 Ihe how to use specific active and passive exer­ pelvis.8 Use o( Ihe ball-on-a-slick 10 apply self Relaxed diaphragmatic breathing is taught mobilizalion 10 each rib articulalion while Iyillg with the patient lying supine with hips and knees supil1e. pennission. physically. posiliolled superior 10 Ihe scapula al1d close 10 Develop personal control under the guid­ Ihe spine 10 press agail1sl Ihe firsl rib. A flexes. Used \IIilh bent (Fig. The inhalation phase is coordi. or a cooling response occurs in the involved extremity when a warming response is the intended response.7 Relaxed diaphraglllalic brealhillg. Both outcomes permission. ( @ Peler Edgelow.j . (@ Peler EdgelolV. and emo­ tionally. Appreciate that by training the pa­ tient to recognize (pay attention to the ten­ sion) and reverse the dysfunctional reflexes. and use this abnormal tension response for guid­ ance in deconditioning the acquired dys­ functional pattern.) must be achieved without increasing pain that the patient perceives as harmf. Recognize and reverse dysfunctional re. Identify variance in relaxation response to repeated movements of the hand. intellectually. 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. B Identify variance in warming response to re­ FIGURE 6. 1 . and use this Paliel1l lyil1g supine. Either a tension response results in the mus­ cles being used when a relaxation is the in­ tended result. (B) Exhale alld flallen Ihe lumbar spil1e. (A) peated movements of the hand. pain is perceived of as harmful if one of two responses occurs. 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. 6. m·ld arch Ihe lumbar spine allowil1g Ihe chill 10 through monitoring. they are gaining the control that will guide them to a state of maximum f�mction.172 P H YSIC A L T HER A P Y OF THE SHOUL D ER Recognize the interdependence of the whole person. Inhale ance of a professional physical therapist. ) nated with spinal extension. relaxation of the abdomen that occurs with lumbar extension allows for full diaphragmatic excursion.. _ .. Used with . (A) Spilwl extensiorl with il1hale gressed by doing it with the legs extended and to pain only. (R·· · cel1ler arId breathe aLit as rolling {rolll side to side. de­ pressing the rib cage. . 1 0 Patient mobilizing the pelvis..2. is too pain{"l. contraction of the abdo­ men that occurs with spinal flexion reinforces exhalation while depressing the sternum and rib cage.. and the exhalation phase is coordinated with spinal flexion.. 6. Etha{oam Rollers Six-inch and 3-inch Ethafoam rollers are used to mobilize the spine and rib cage with the emphasis on increasing spinal extension. facilitating spinal stabil iza­ tion and coordination with controlled breathing patterns. With the end of the stick stabilized against a wall this provides a very simple assist fiGURE 6. tion of the hips during exhalation.9 (A & B) Patieo71 lyil1g supine on the /. TRAUMA 0 JSOR O ER 5 A F FECTIN G TH E T H OR A C I C OUT LET 173 contraction of the hip rotators facilitates hip flexor relaxation and scalene relaxation as well. May per{on" in standil1g i{ supi/. assists rib depression. . Move Lip spine to include all relaxed and with the legs extended and relaxed segments increasing ra/1ge as tolerated. This active Used with penn iss ion. Rolling to the side. permission. . (@ Peter Edgelow. . .9).) ... The spinal motion affects a movement of the rib away from the ball during inhalation and a movement towards the ball with B exhalation..--. (B) during inhalation but with active internal rota­ Spinal [lexion with exhale. Rib Mobilizer The ball on the stick is used to mobilize each rib al1iculation (Fig." spine and thoracic spine with three inch Training of this breathing pattern can be pro­ Etha{oal11 roll.. and placing the ball paraspinally and rolling back J onto it while exhaling. .8). ( @ Peter Edgelow. Breathe in as balanced in the ..'" .'. A further modification is to place a ball on a stick up against the posterior aspect of the elevated first rib. In this A �-- way.1"-"J--r--. Anns relaxed and sLipported by belt. ·· · '. A belt is used to assist relaxation of the pectoralis minor muscle (Fig. lumbar to first rib depression during active exhalation... . . " . 6-il1ch Etha{oam roll.. Once patients B have achieved increased mobility with the 6-inch fiGURE 6. - . 6. Conversely. A . 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. The other pillow is placed on the slope to act as L- _ ___. The patient lies supine with the head on one slope of the double-ended pillow and slowly relaxes the neck and lets it roll downhill. elbow. METHODS TO "DRAIN THE SWAMP" Relaxed Repeated Movemelll I have designed two pillows that aliow re­ laxed. Used with pennission. 1 0).. --'" to assess change in hand temperature. It takes time to by any arm pain. right-handed billing clerk devel­ response. Any in­ scalenes during the exercise on the roller. they progress to the 3-inch roller (Fig. The other issue that must be decondition a conditioned response. _ ___ FIGURE 6 . and wrist. Patients are taught to assess their own neural tension and then per­ form relaxed repeated movements of the neck.J.. addressed is the skill necessary to perform the 6 . Used with oped right wrist pain on 1 0/26/95 while doing permission. They are also taught to use a handheld thermometer L. 1 2 The stabilization belt is used to assist patients in checking their own brachial plexus tensiol1. repeated movements of the cervical spine (Fig. Each movement is performed 1 0 times and then the neural tension is reas­ sessed. 6. a SLOp to prevent movement into a range that results in tension or pain. 1 1 Dimensions of foa m wedges to assist i" relaxed. The exercise involves perfonning CASE STUDY HISTORY relaxed repeated movements of the neck. 6. If there is a relaxation response. repeated move/llel1ls of the cervical spine. elbow. (@ Peter Edgelow. 1 2). then crease in spinal pain must not be accompanied the patient is not ready to do it.) computer entl)'. (@ Peter Edgelow. and wn'SI 10 obtain a reiaxationlwanlling A 2 5-year-old. then the patient repeats the movements (Fig.1 74 PHYSIC A L THERAPY OF T H E SHO U LDER " 15 � 1 0" � FIGURE 6. Over the next 2 days the symp- .) rolier. I I ). If the patient cannot quieten the crease in spinal pain during the exercise. She denies any symptoms in the left upper shoulders level. which is intermiLlent and 5. She reponed no prior ann symptoms ease of reading the case study. spine. 50 percent of the time at I . wrist. one in 1 989 and one Tested to initial point of pain/increase only. head with loss of normal pos­ lion in the neck on the right.th area of pain is a soreness in the right upper arm and tender points to palpa­ Posture forward. Driving to and fTom work is uncomfortable in the neck and shoulder blade and she The patient had been working overtime 6 days a feels tight in the right supraclavicular re­ week. T R A U MA D ISOR D ERS A F F E C T I N G THE T H O R A C IC O U TLET 175 toms spread from the wrist up the forearm to the board and vise versa for the first few sec­ elbow and down into the hand. The fOUl. OBSERVATION 4. Forearm supination (900 = full supination) forearm/elbow. the following ab­ but occasional neck pain that responded to mas­ breviation will be used: sage. Glenohumeral external rotation 2. For in 1 99 1 . She worked out at the gym for the OBJECTIVE prior 6 weeks. "The hand feels as if it doesn't want 2 days the pain remained constant and did not to work. She uses (R). Lifting weights at the gym or boxes at work increases her neck pain. The third area of symptoms is intermittent 6. Apparent "step oW' at C71T I . Glenohumeral abduction best 3. Wrist extension (85 to 900 = full wrist exten­ rated as 61 1 0 at worst.t and 31 1 0. 2 . The second area of symptoms in decreasing order of intensity is the right 4. packing records in preparation [or a move. She wears glasses and C. slight slowness in finger dexterity noted Extension: Full range. sion) and fifth digit. and rest. right roller blades for fun. Her normal work commute was 45 minutes twice a day. sion) 3. weight: 1 50 pounds. Her greatest pain is in the area of the right tions involved in the ULTI is as follows. CERVICAL FUNCTIONAL PROFILE ( B Y REPORT) Flexion: 3" chin fTom sternum. Shouldel' girdle depression wors. StGNtFtCANT PAST H tSTORY 3. ULTI. and 6 weeks ago fell on out­ (L). tural alignment. pulls cervical I . Despite rest for onds. upper limb tension test wnl. Aggravated by data entry repetition and spine R > L. but was "OK" within 2 days. Elbow extension ( 1 800 = full elbow exten­ pain in the right thumb. She had two auto accidents. gion. thenar eminence. 25 percent of the time at 2. within normal limits PAtN PATTERN ( BY REPORT) [n addition. left stretched hands with sprain of the left wrist. the recording of the sequence of mo­ I . \vh ich she describes as a constant pain rated at 71 1 0. Pulls anterior cervical when switches fTom 1 0 key entry to key." subside. Height: 5'9". cervical has to "peer at the screen" when tired. self-mobilization. lifting weight up to 60 pounds. . 5. She has had mild asthma since age 1 6. extremity. arm to thumb. I . with ele­ vated first rib on the right and left ancl para­ S H O U L D E R F L E X I O N doxical breathing pattern. U P P E R L I M B T E N S I O N T EST 2. awareness of posture. no lifting. they dis­ appear rapidly. There is much yet to learn through the top of the head. (L) 515. Train in protective body mechanics to mini­ mize stress from work. lnitial modification of work sched ule. problem that clearly involved the cervical . Posture instruction. 3/30°. Pulls right cervical spine and pain left trap. ing. 4/wnl. 4. ." with these problems. 3/45°. 2/60°. The pollicis: (R) 4/5. TREATMENT PLAN (L) (with elbow flexion): 1 35° pulling into the upper arm. When the patient can T R A C T I O N (KABAT) also see the relationship between the findings Results in increase strength of right thumb and and their ability to change those findings. 2.I. no overtime. feet flat on PALPATION noor. 5/wnl. 5. Rotation: (L): 80°. B R E A T H I N G PATT E R N 4. RESULTS AND DISCUSSION This case history was chosen to illustrate that S T R E N G T H findings present in severe cases of neurovascular Flexor carpi ulnaris: (R) 4/5. (L) (with elbow extension): 1 1 0° pulling whole arm to thumb. Cervical and upper thoracic dysfunction in (R) (with elbow flexion): 1 80°. (R) (with elbow extension): 1 35° pulling whole 3. this ulnar wrist flexion. Instruct in "what is wrong" and use home kit for treating upper quarter neurovascular entrapments. beginning with the Kabat protocol and pro­ (R): I/wnl. I f addressed early. Testing reveals that the me­ reinforces the issues they need to address to gel chanical sensitivity is from compression well and stay well. right more than left. cervical spine. Sensitive scalenes on right compared to the left. C37 motor root irritability on the right. 2/80°. 6/1 20° with gressing through the diaphragmatic brealh­ pull in right thumb. and rib cage: Pos­ tural dysfunction in flexion with elevated first Was this an example of a progression of a rib bilateral. Adductor entrapment are evident early in the history. right greater than left. no sitting with legs crossed. flexion. Progress through the home program ap­ Recorded in sequence of examination to tension proach to dealing with these dysfunctions point. Paradoxical with early scalene contraction on quiet inspiration. problem is that if they are not looked for they will often be missed. Findings suggestive of plexus irritability bi­ laterally. 5/wnl. 4/wnl. thoracic and rib mobilization.176 PHYS I CAL THERAPY OF THE SHO U LDER Rotation: (R): Full range. (L): I /wnl. response during repeated movements of the upper extremity. Restoration of the relaxation and warming pull in left arm. For example: Thoracic spine. (L) 515. Pulls L supraclavicular ASSESSMENT region. and one has a clear picture of the E F F E C T O F T R I A L S E L F C E RVICAL relevance of these findings. 61 1 50° with 3. Postural factors influencing the problem. and she has re­ Clinical Symposia. much additional research is needed to outlet.or triangle of the cleared that complaint in 24 hours and it neck. 1 990 The initial treatment involved self cervical 5. Clin Ol'lhop 207: I 3. 1 947 drome. Self-mobilization of the left wrist 8. London. Manipulative Therapists Association of Aus­ York. 1 995 thorough and treatment is growing more sophis­ 1 4 . Schwal1 z J H : Plinciples of Neural Sci­ traction (Fig. but now she complained of left wrist drome. 1 979 Med 6:45. Mayo Clinic Proc 3 1 : ment procedures for the TOS patient. Thanki A: The thoracic outlet syn­ syndrome. New ings. 530. The ability 2 8 1 . Churchill Liv­ for self-traction. 1 59:23 I . Sydney. 1 99 1 1 3 . London. 6. Phys Ther 48: I 894. Churchill Livingstone. Phillips H. Anderson TP. Sunderland S: Sixth biennial conference proceed­ Vertebral Column. 1 32. Sanders J. Celcgin Z: Thoracic outlet syndrome: What does it mean for physiotherapists? p. TR A U M A D ISOR D ERS A F F EC T I N G THE T H OR A C I C O U T LET 177 spine following the auto accidents but now 4. 1 986 did not return. 9. 359.6) and breathing. Telford ED. In Grieve G (cd): Modern Manual pain due to using the leFt wrist and hand Therapy of Ihe Vel1ebral Column. I n Gl'ieve G (ed): Modem Manual Therapy of the 1 . 1 2 . Nichols H M : Anatomic slnlct ures of the thoracic ticated. tissues cleared all symptoms. Edgelmv Pl: Thoracic oUllet syndrome: a patient centered treatment approach. In ShackJock M (ed): Moving in on Pain. Examination of the left ingslone. was involving other tunnels as well? Pearce WH: Scalene muscle abnolmalities i n trau­ matic lhoracic outlet syndrome. Sydney. Lindgren KA. Roos DB: New concepts of thoracic olltlet syn­ ders in cCl1ain occupations with special reference drome that explain etiology. Vase Surg 1 3 :3 1 3 . 1 956 to change symptoms and signs early in the 1 6. N. New York. 1 99 I the wrists. Mal1in G M : Thoracic outlet syndrome. 1986 aid in devising improved evaluation and treat­ 1 5." 1 :325. 1 7. 1 97 I months. Lord !W. The result ence. p. symptoms. p. Peet RM. Grieve GP: The thoracic outlet syn­ pain. 825. In Slight ongoing neck discomfort associated Shackloch MO (cd): Moving in on Pain. Butler 0: Mobilisation of the Nervous System. Butter­ with stress from data entry is relieved with worth-Heinemann. Adelaide. 1 98 I in 24 hours was to abolish the right wrist 6. Elvey RL: The investigation of arm pain. 1 985 . time to see if early intervention will have a long­ Arch Phys Med Rehabil 68:692. Schmidt H: Cervicobrachial disor­ 2. Butterworth-Heine­ Even though diagnostic procedures are more man. Kandel ER. Hursh LF. Gi fford L : Fluid movement may partially account for the behaviorof symptoms associated with noc­ Summary iceplion in disc injury and disease. Summit. PosIgrad Med 77: 1 97. Leino E: Subluxation of the first l'ib: cOurse of the condition needs to be followed over A possible thoracic outlet syndrome mechanism. 1988 term afFect on the course of the pathology. Am J Ind and treatment. Churchill Livingstone. JB Lippincott. 1 J . Banchero N. secondary to the recent rollerblade Fall on Philadelphia. Stockholm. 1 984 3. t 989 1 9 . 1986 wrist uncovered slight carpal dysfunction 7. Rosati LM: Thoracic-outlet syndromes. Haug CE: Thoracic OUllet Syndrome. Edward Arnold. Ratzin Jackson CG. Hemiksen ro. 1 982 References 1 8. In Proceed­ ings of IXth Congress World Confederation for Physical Therapy. Karas S: Thoracic outlet syndrome. diagnosis to compression in the thoracic oUllet. Pratt NE: Neurovascular entrapment in the re­ gions of the shoulder and postel. CrnA Pharmaceutical Com­ mained free of any arm symptoms For 6 pany. p. 1 986 tralia. Sallstrom J. 1 990 rollers and selF-mobilization of the neural 1 0. Mottershead S: The "costoclavicular 20. Sanders RJ. Clin SPOlts Progression of treatment through the foam Med 9:297. 1 995 the home program. Wilbur B. Lancet 2:359. Dawson OM. Green. Brown. 1 990 26. Millender LH: Thoracic nerve enlrapment syndromes. 1 980 peeLs of thoracic outlet syndrome. 1 947 Reprinted in 35. 1 986 Arch Surg 93:7 I . concepts f rom a century of discovery. 1 988 Vao JST: Noninvasive evaluation of the upper ex- trcmity. 1. John Wiley & Sons. Louis. Egloff DV: The ceravico 37. 27. Crawford FA: Thoracic outlet syndrome.1 78 P H YSICAL T H ER A PY OF T H E S H O ULDER 2 1 . Pcarche WH. Kabat H : Low Back and Leg Pain from Herniated 207:3 I . Bonnard C. Machleder H I : Thoracic olltlet syndromes: New 23. Pathology and diagnosis. Hardy DG: Thor'acic outlct syndrome. 1985 29. 1988 39. Narakas A. 1 994 muscle. 1 986 CClvical Disc. Quilter 0 : Repetitive Strain Injury: A Clin Orthop 207:3. 1 986 Computer User's Guide. McNair JFS. Smith 8M: Thoracic and vascular as- Clin NOI�h Am 60:947. 01'- LiLLIe. Karas S: Thoracic outlet syndrome. Young HA. Osterman AL: The double crush syndrome. 1 980 34. 30. 1 990 stone. 1986 90:686. Owens JC: Thoracic outlet syndrome. Clin Sports the Celvical and Thoracic Spine.-off G. Surg 33. Ol1hop Clin North Am 1 9 : t 3 I . Clin 011hop 22. Am J SUl'g 1 3 8 : I 75. 1983 thop Clin North Am 1 9: 1 47 . J Manipulative drome using somatosensory evoked responses. 1 983 in the diagnosis of thoracic outlet syndrome. New York. McComas AJ: The double crush in 38. Physiol Ther I I :493. 1988 . JAOA of surgical treatment. BaSion. Honet JC: Dynamic ap- 28. 1 994 syndrome. St. Wood VE. Adson AW: Surgical treatment for symptoms pro. 1 990 25. New 24. Upton ARM. Physical Therapy of 32. Roos DB. Liebenson CS: Thoracic outlet syndrome: Diagno- proach in the diagnosis of thoracic Olillet syn- sis and conselvative management. In Grant R (cd). Dong WLG. 1 979 syndromes. 1 973 oUllet syndromes i n Entrapment Neuropathies. Stoney RJ : Thoracic outlet technique in the management of some thoracic syndrome. Churchill Living- Med 9:297. Thcm1ology 1 : 1 42 . Warren H. Ignacio DR: Value of in frared imaging Br J Hosp Med 29:457. Baxter BT. Pavot AP. 1 966 4 1 . Hallett M. Sucher 8M: Thoracic outlet syndrome-A myo- thoracic ouLlet compression syndrome. Ann Chir Main 5 : I 95. Maitland GD: Manipulative therapy 3 1 . Surg Clin North Am 70:87. Analysis fascial variant. Blackburn 0 . Riddell 0 1-1 . The results of first db resection in 1 00 36. Et heredge S. Twito R. 40. patients. Pascarelli E. Verska JM: Thoracic outlet York. Cardiovasc duccd by cervical ribs and the scalenus anticus Surg 2 : 1 37 . 1 988 Arch Phys Med Rehabil 66:3. Payne K. Chodo. Surg Gynecol 85:687. posterior. the integrity and functional status of the brachial and TI. Branches-peripheral nerves derived fTom injuries. description of pathomechanical and the cords pathologic changes to the specific nerve fibers and nerve roots. versely. C8. and medial chapter provides a review of the anatomy of the brachial plexus. 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. and the first thoracic nelve frequently receives one [Tom the second thoracic. pathophysiologic 2. into a review of the gross anatomy of the plexus This constitutes the prefixed type of plexus. middle. as shown in Figure 7. Therefore. An understanding of the mechanisms of in­ juries to the brachial plexus. lower changes of nerve fibers and nerve roots. and hence the function. 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. classification of brachial plexus 5.2. of the shoulder and related upper extremity. The anatomy of the plexus has been bined physical and occupational therapy man­ previously descl·ibed. Divisions of the trunks-anterior and poste­ tential for recovery is essential for proper and ef­ rior fective clinical management. Evaluation and Treatment of Brachial Plexus Lesions B Rue E H . this 4. When the branch from ArwJmny oj the Brachial Plexus C4 is large. I The fourth celvical nerve agement ofa patient with a brachial plexus injury. Evaluation ofshoul­ The brachial plexus comprises the anterior pli­ der dysfunction should include an assessment of mary divisions of spinal segments C5. Trunks-upper. C7. lated shoulder girdle structures. Undivided anterior primary rami cles. Lesions to the brachial plexus compromise the neurologic in­ SUPERFICIAL ANATOMY tegrity. GREENFIELD D 0 R I E B • 5 YEN The brachial plexus supplies both motor and sen. Cords-lateral. The components plexus. and po­ 3. usually gives a branch to the fifth cervical. as well as a review of the microscopic anatomy 5011' innervation to the upper extremities and re­ of the nerve and nerve trunks.1. Con­ and its relationship to surrounding structures. C6. when the branch fTom C4 is small or ab- 179 . 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. l nk. the contribution o f C S i s reduced i n size. first behind chial plexus is as follows. The fifth and sixth cer­ and then on the medial side of the axillary artery. ante brochlal cutoneouJl FIGURE 7. Autonomic sympathetic nelve fibers are These three tl1.ou.lnks unite to form a cord. con­ erally and just above or behind the clavicle.1 Segmental motor innervation o{ the mllscles o{ the shollider. (From Hollinshead.lnk passes downward. sion. 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. This alTangement constitutes on the lateral side of the axillary artery and is the post fixed type of plexus. which is situated at the lower tl1._-Dor. which is situated always present. Long '-horoCIc MQ'dlC11 b. called the lateral cord. this cord frequently lenus medius muscles to form the upper tl1. ) sent.och\ol _ culan.lnk of receives fibers from the seventh cervical nelve.lnk of the plexus. vical nerves unite atlhe lateral border of the sca­ and forms the medial cord. The anterior division of the upper and mid­ that of T I is larger. The anterior division of The most typical arrangement of the bra­ the lower tl1..s / "Qdlot . from the sympathetic ganglionated chain. I cervical nerve itself constitutes the middle tl1. and the branch fTom T2 is dle tl1.or cord.3caputar C·o Lalt'r'at pf'cloral �---- T'I ..lnks travel downward and lat­ present in all parts of the brachial plexus. each sisting mostly of postganglionic fibers derived splilling into an anterior and a posterior divi.'J with permission.Sol .3cOopu!or C·� SUpro.. The . while the seventh first above and then behind the axillary artery.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_-:<:::. passes be­ BRACHIAL PLEXUS hind the anterior convexity of the medial LWO­ The clinician should understand the relationship thirds of the clavicle. In the axilla. The plexus emerges between the scalenus an­ ANATOMIC RELATIONSHIPS TO THE terior and scalenus medius muscles. -----. shoulder girdle.Rhomboids-- I ----Infraspinatus . ------- _ . _____ Supra ____ Spina!us I ---.Teres Minor --- I ------Biceps------ I ---. and arms. can help the clinician isolate the af. The plexus in this presumptive evidence of avulsion to that root.2 Additional segmental motor ilmervation o( the muscles o( the shoulder. .Subscapularis --------. and the lateral cord on the lateral fracture. the me­ the portion of plexus that lies between the clavi­ dial cord lying on the medial side.--- I --. in the presence of clavicular cord behind. The cords surround the middle atomic structures.Brachialis ---- I ------Serratus Anterior ------ I . the clinician must axillary artery and the medial cord is behind the identify the plexus and its relaLionship to the an· axillary artery. -------- . platysma. - I -----. Trapezius .----.- . which is the angle between and ptosis of the eyelid on the involved side. To muscles. and deep fascia.2 area is covered by skin. in the clavicle and the lower posterior border of the a patient who has sustained a traction injury is stemocleidomastoid muscle.------. the brachial plexus is situated in drome. are Lhose of primary ramus TI. -. I T I nerve roOL. and lies on the first digiLa­ of the brachial plexus to the anatomic structures tion of the serratus anLerior and subscapularis about the neck. knowledge of part of the axillary artelY on three sides. -----.- -Levator scapulae.----. characterized by constriction of the pupil the posterior triangle.-. especially in cords of the plexus are on the lateral side of the the presence of open trauma. ---. For example. side of the axillary artely. only preganglionic fibers in the brachial plexus fected nerve and predict the affected muscles.Latissimus dorsi ----- FIGURE 7. 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 --------.-.Teres Minor --- . the lateral and posterior effectively isolate a plexus lesion. ---- ---Deltoid . the posterior cle and the first rib. In the lower part of .Pectoralis Minor ------ . the occurrence of Horner's syn· 1n the neck.Pectoralis Mai or------. 1 Coraco Brachialis ---. ' Because the Topograph ic relationships of the plexus are de­ sympathetic supply!o the eye travels through the l ineated in Gray's Anatomy. as well as protective cushions for the nerve fibers. The spaces be­ tween nerve fibers are penetrated by a loose delicate connective tissue network. These connective tissue sheaths serve as planes of access for the vasculature of pe­ ripheral nerves. sholVil1g a the limb is conSiderably greater than the dis­ large number o( (asciculi.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. A dense irregular connective tissue sheath. First. large number o( netve fibers. with two notable ex­ ceptions. the nelve trunks cross the flexor aspect of joints. This means that the length FIGURE 7. which each contain a tance between those points. Because extension is more limited in range than flexion. ANATOMY OF THE NERVE TRUNKS The nerve trunks and their branches are com­ posed of parallel bundles of nerve fibers com­ prising the efferent and afferent axons and their ensheathing Schwann ceils.3. the funiculi run an undulating course in the epineurium.4. the nerve trunk runs an undulating course in its bed. each of which contains from a few to many hundreds of nerve fibers. I with permission. the ulnar nerve at the elbow and the sciatic nerve at the hip. surrounds the whole trunk.3 Structural (eatures o( peripheral nerve of nelve fibers between any two fixed points on fibers and a nerve Inll1k cut away. the endo­ neurium. as shown in Figure 7.) virtue of a relatively large amount of elastic fibers compared with the endoneul-ium and epi- . and a similar but less fibrous perineurium encloses each fasciculus of nerve fibers. I The fibers are grouped together within trunks in a number of fasciculi. Second. during traction. by and Warwick. which in some cases contain myelin sheaths. the cord split into the nerves for the upper limb. Features o( Nerve Trunks Providing Protection (rom Physical De(ormation Several factors protect the brachial plexus and related nelve tlunks from both traction and deformation injuries. the perineurium. the epineurium. the nelves are subjected to less tension during limb move­ ments. (From Williams Third. and the nerve fibers run an undulating course inside the funiculi. The architec­ ture of the nerve trunk is shown in Figure 7. -----. which do not have of epineurial connective tissue that separates the e soft tissue attachments to the transverse the fasciculi.� . E V A L U A T I ON AND T R E A T M ENT O F B R A C H I A L P L E X U S L E S I ONS 183 nerve roots by transmitted forces generated in this manner is normally prevented by the follow­ ing factors. . the foramen. more commonly involve the spinal nerveS neurium. each pel"ipheral nerve con­ cidence of avulsion injuries is much higher in tains. a large amount the case of the nerve roots. --� ---- � ---=. al a junction . =: . which contains l1erve fibers o( a emerges on examination of the relative suscepti­ l1erve tnll1k to the poi. system outward. The dura. Overstretching of (From Sunderland. the epineurium.5).. According to Sunderland. Trac­ tion injuries. . is lodged into the gutter of the .4 Example o( the undulating structure suggests that the significance of this attachment o( the (uniculi. fifth. --=--==:= � ---. on leaving -=---:::�. cushions the nerve fibers against deforming forces.5). ---. 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. being cone­ � . . and shoulder motions. Sunderland FIGURE 7. girdle...3 wilh penl1issiOll) . within the nerve trunk. a dural funnel is drawn lat­ erally into the foramen. FealLlres o( the Nerve Rools Providing Prolection (rom iI*"y The nerve roots at the intervertebral foramen possess several mechanisms that protect them FIGURE 7. imparts a degree of elasticity in the where these attachments exist.3 values of epineurial connective tissue of various pe­ processes.u o( (ai/ure. � -.5 Displacement o( the nerve complex from traction injury. bound se­ curely by reflections of the prevertebral fascia and by slips from the dura attachment to the transverse processess (Fig. . � 7.3 with penllissiol1) roots contributing to the brachial plexus.. - --.. Each nerve root. corresponding transverse process. as well as Ihe plexus dul"ing nOImal cervical spine. Therefore. by pro­ viding a loose matrix for the contained fasciculi. the dura is adherent to and pan of the nelve complex at the level of the intelvertebral foramen. whereas the in­ nerve trunk. and seventh -� . plugs the foramen in such a way as to -_..-----. ---� -. �- ' resist further displacement of the nelve (Fig. .3 Repetitive strains are lalerally Ihrough the (oramen is resisted by placed on the nerve roots forming the brachial plugging the (unnel-shaped dura. 7.. which do not avulse nerve roots. Second. so that when traction pulls the entire . sixth. . (From bility to avulsion injury of the several nelve Sunderland. the fourth. Fourth.� of the intervertebral foramen. shaped. shoulder dural allachment 10 Ihe transverse process. First. cervical nelve roots are securely attached to the vertebral column. as in a traction lesion to ular.>-6 local vascular processes or lesions Participation in generalized vasculopothies (e. either direct. inAammatory. this injury causes Genetic predisposition severe restriction of movement at the shoulder Cryptogenic and elbow joints. affecting two Uunks. levator scapula.-ies of 420 brachial plexus cases that under­ may be described as preganglionic or postgangli­ went operations. or the suprascapular nerve in the su­ Secondary involvement of plexus by tumors of surrounding tissues prascapular notch of the scapula is entrapped Vascular and torn .9 with penuissioll. biceps.1). polyarteritis no· doso and lupus erythematosus) UPPER TRUNK LESION Physical fadars Radiotherapy Palsy of the C5 and C6 roots of the brachial Electric shock plexus is known as Erb's palsy or Duchenne-Erb Infectious. TABLE 7.. Alnot reported that 75 percent onic.) or externally rotate the shoulder. the postganglionic avulsion is classi­ The majority of brachial plexus lesions result fied as either supraclavicular. plexus il1juries as related to the shoulder and However.1. and toxic processes paralysis. or indirect.184 P H Y S I C AL T H E R A P Y OF T H E S H O U L D E R CWssijication oj Brachial. and serratus anterior. or lower llUnks of the brachial plexus. Finally. plexus injuries have been proposed (Table 7. according to Alnot. brachia lis. infraspinatus. but without surgical repair of the IUpture. The patient is unable to abduct (Modified (rom Mwuellflwier el al. the musculocuta­ Anatomic predisposition (sometimes isolated branches) neous nerve (which is tightly attached near the Genetically determined (sometimes isolated branches) origin of the coracobrachialis muscle). or com­ Traumatic bined supraclavicular and infraclavicular le­ Open injuries Fractures sions. Therefore. which involves Ihe from trauma.4 Spontaneous Injuries recovery may occur with the first injury. the axil­ Posture (muscle imbalances/spasms) lary nerve in the quadrilateral space behind the Tumors Primory tumors of brachial plexus shoulder. These lesions occur when the arm is forced Closed injuries violently into abduction and the middle part of Fractures the plexus is blocked temporarily in the coracoid Obstetric region. shoulder dislocations) Compression Ihe head is jerked violently to the opposite side. Terminal branches are torn away and Postnatal exogenous concomitant supraclavicular lesions occur when Sports injuries (e. 'bumer' syndrome. in his series of pa­ cervical spine tients. Etiologic classificatiol1 of brachial middle. supraspi­ Viral or infectious Cryptogenic (neuralgic amyotrophy) natus. Pl£xus ity (root and sheath intact) or IUptured (root in­ tact and nerve sheath IUptured). The patient . Post ganglionic lesions may be either in continu- SUPRACLAVICULAR LESION Isolated supraclavicular lesions affect the upper. Exogenous (sometimes isolated branches) Lower down in the plexus.g. which involves the cords and branches'> [n the cervical spine or upper extremity.>-12 Lesions a se. or infraclavic­ strument. 15 percent of the supraclavicular lesions were double level. and Related to serum therapy supinator muscles. no recov­ Nu merous types of classifications of brachial ery will occur i n the second lesion.g. Preganglionic avulsion injuries indicate were supraclavicular lesions and 25 percent were that the nerve root has been torn from the spinal infTaclavicular lesions. Also usually in­ Para infectious volved are the rhomboids.' cord and preclude the possibility of recovery.' The muscles affecled include the del­ Involvement of local sepsis toid. as if suuck by an in­ tlUnks and divisions of the plexus. There­ fore. Therefore. which caused most of MIDDLE TRUNK LESION the isolated lesions of the axillary nerve and the The middle trunk receives innervation from the posterior cord.' The causes included (l) anteromed­ ial shoulder dislocation. LOWER TRUNK LESION Sensory deficit is localized at the foreann and at The lower trunk of the brachial plexus receives the thumb level. forearm. Partial palsy of the lower portion of the ulnar border of the arm. (15 to 30 years of age) after car or motorcycle accidents. middle trtlOk 8 Middle trunk lesions were pro­ associated with a deficit of muscle pronators of duced by trauma to the shoulder in an anteropos­ the foreal'm and wrist and finger flexors. Brunelli and rare. Sensory involve­ TI are injured.term reha­ with infTaclavicular brachial plexus injuries. Upper medio-ulnar palsy results in injury that is The intrinsic muscles of the hand are only total in the distribution of the ulnar nerve and slightly affected in a lesion involving a prefixed only partial in the distribution of the median plexus. The delay between the injury and re­ cords or the individual peripheral nerves of the innervation of the con'esponding muscle varies brachial plexus. the lesion is proximal. long. (2) violent downward and back­ C7 nerve root and courses distally to form a ward movement of the shoulder. According to Comtet INFRACLAVICULAR LESION et al. The extent of disability is determined Isolated injury to the medial cord is also rare.7 partial or total spontaneous recovery of traumatic Duchenne-Erb paralysis is a frequent Infraclavicular lesions include injuries to the occurrence. a lesion affecting the or upper extremity of the humerus. Therefore. scapula. which middle trunk of the brachial plexus weakens the caused more diffused lesions affecting multiple extensor muscles of the arm and forearm. cluding the brachioradialis. which caused major portion of the posterior cord" The middle stretching of the plexus. innervation from nerve roots C7 and Tl. which receives pri­ mary innervation from the C6 nerve rool. the flexor pollicis longus muscle. affects motor control in the fingers and wrisl. and the hand and forearm occur in a lesion to a post fixed flexor digitorum profundus muscle of the index plexus'" Sensory deficit is present along the finger. and hand.' injury to the lateral cord is dorsal radial aspect of the hand. Sen­ LATERAL CORD LESION sory deficit occurs along the radial d istribution of the posterior arm and forearm and along the According to Alnot. injury to the lower trunk known as Dejerine MEDIAL CORD LESION KJumpke. When terior direction.s . In Alnot's series of 105 patients From 3 to 24 months. cle and along the distribution of the musculocutaneous nerve. Because the musculocutaneous nerve and Brunelli found I 1 percent of a total series of bra­ the lateral head of the median nerve are affected. ex­ cords and terminal branches. the lateral pectoral nerve is injured. whereas paralysis of the flexors of the nerve. and (3) complex trauma trunk offers a major neural contribution to the with multiple fractures of the clavicle.' The sympathetic fibers of Tl ment is usually confined along the deltoid mus­ provide motor control to the eye. E V A L U AT I O N A N D T R E AT M E N T O F B R A C H I A L P L E X U S L ES I O N S 185 cannot supinate the forearm because of weak­ contained within the anterior primary ramus of ness of the supinator muscle. radial nerve. by whether the plexus is prefixed or postfixed. chial plexus injuries were isolated lesions to the motor deficit consists of palsy of elbow flexion. Hor­ pectoralis muscle results in injury to the medial ner's syndrome occurs if the sympathetic fibers pectoral nerve. resulting in partial or total palsy of the upper portion of the pectoralis major muscle. 90 bilitation with periods of reevaluations is imper­ percent of the cases were seen in young people ative. power occurs quickly with repetitive move­ palsy of the serratus anterior muscle in the pres.I Al­ nerve. even in the presence of the medial border of the scapula are presumptive a total axillary nerve lesion. and suprascapular nerve.186 P H Y S I C A L T HE R A P Y OF T HE S H O U L DE R POSTERIOR CORO LESION ence of a long thoracic nerve injury. However. the downward pull of pull. The lesion results in weak­ pen ate the loss of the serratus anterior muscle ness of the extensors in the arm. and the outward pull these conditions is poor. 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. dorsal scapular AXILLARY NERVE LESION nerve. anteromedial dis­ medial aspect of the axilla. tions of the supraspinatus and infraspinatus Variations in the scapulohumeral rhythm in the muscles. 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. entering the tion. SpeCifically. Common peripheral nerve or branch injuries in­ clude. arm. subscapular. axillary. and and lower trapezius muscles to temporarily com­ thoracodorsal nerves. and loss of muscle of the serratus anterior muscle. as well as the biceps muscle. scapula along the posterior thoracic wall. However. lesions of the long thoracic nerve. 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. axillary nerve. these muscles quickly fatigue after four or five repetitions. 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. some active shoulder evidence of a long thoracic nerve lesion. by exter­ rotation of the scapula results from a force cou­ nally rotating the aim. travels to the distal aspect of the posterior cord of the brachial plexus. and ad­ LONG THORACIC NERVE LESION vances laterally through the axilla. in some cases. 13 The full overhead abduction.IJ-16 For every 15° zation of the humeral head by the supraspinatus of abduction of the arm. ments. The stabili­ l iterature have been repOl·ted. but are not limited to.2 Normal abduction and external rotation is possible. resulting in signifi­ PERIPHERAL NERVE LESION cant loss of full active shoulder flexion and ab­ duction range of motion.7 In 80 percent of cases.'6 Therefore. 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. 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.17 However. 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. with total recovery in 4 to 6 months. and C7 nerve roots muscle and the overlying skin. during ab­ duction or flexion of the arm.5 though isolated injuries to the long thoracic Complete lesion to the axillary nerve results nerve are rare. C6. 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. as well as the teres after these nerves emerge from their respective minor muscle.5. traumatic wounds or traction in­ in loss of active shoulder abduction. and continuing down­ location results in a neuropraxia of the axillary ward along the lateral wall of the thorax. the strength of abduction under the lower trapezius muscle. 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. with arm raised.6) '· Therefore." ." . enced by football players making a tackle. the transverse processes proximally and tal. the syndrome is an abrupt Fig. as experi­ The pulley in this case. points of auachment firmly snubbed al the trans­ diclateS the area and extenl of injUl)' to the bra­ verse processes..6. 10 Regardless of the mech­ pemlission.6 Traction apparatus representing rior medial scapula when the pad is pushed into brachial plexus. ' A This injury often has been thought to occur sec­ . I. Specifically. as shown in Figure 7. Specifically..S most common type of sports injuries lhat occur E �D' J C""""'. if tension is im­ upper axilla. G I: to the upper trunk of lhe brachial plexus··lo-I> . A amples of these injuries include the so-called A "burner syndrome. 0' 0 The "burner" or "stinger" syndrome i one of the Fig."-'. A slight deviation ["om this neutral axis creates an unequal pull to Injuries to the NfmJes one side or the other of the apparatus. the relative zontal position. when the arm is at the hori­ chial plexus (Fig. the traction is equally Musculoskeletal Injuries borne by all part of the apparatus. and and I'l�"". When lhe force of traction falls through this neutral center of axis at the C7 vertebra. Stevens compares the cords of the parted to an arm depressed below the horizontal.". 7. Conversely. in the brachial plexus.·---· 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. The brachial plexus is cords on the other side. as well as the magnitude of the forces." shoulder dislocalions. a traclion apparatus mUSl have a neutral axis and a line of resistance."--' .' . I.----�-�� fractures. C Pulley centered on its base to show that its purpose is only to change the direction of application of tension-but must "BURNER" SYNDROME L-_-' be centered. Therefore. plexus as a traction apparatus with a neutral axis slress is increased to the upper roots of the bra­ at the C7 vertebra. depression of the shoulder and rotation of the neck to the contralateral shouder. 10-1 1 Markey A . at the time of injury the athlete .·· _ ··_··_·· . Accord­ chial plexus. That is. ing to Stevens. if the line of traclion falls outside the neutral axis According to Stevens. 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 PaIlwrnechanics oj TraurrwJ:ic by nelve roOts C5 through T I. (From Stevens. if tension is stretched between twO firm points of allach­ imparted to an alTn elevated above the hOl-izon­ ment. the entire force is transmitted fyom the injuries to the brachial plexus results in traclion neulral axis and all tension is released on lhe or tensile strains. he compares the posilion of the shoulder and neck at the time of brachial plexus as a single cord with five separate injury.6. with the area of Erb's point. and occur as a complication of musculoskeletal injuries. the majority of traumatic of C7. slress is increased to the lower rools of lhe the c1avopectoral fascial junction distally. with t is the coracoid. C' " ondary to traction 10 the brachial plexus when an athlele sustains a laleral flexion injury to lhe neck. represented As previously mentioned. C change in the neck and shoulder angle. Ex­ Fig. a majority of brachial plexus injuries result from trauma.j anism of injury. ever. Potential prob­ lems include persistent neck tenderness and upper extremity weakness. Cutaneolls sen­ eral cord. Wang et al. 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. in the presence of infel. but will recover in ad­ of injury partly depends on the mechanism of vance of motor function.21 The type SOl)' loss may occur. How­ been associated with brachial plexus injuries. radiating from proximal humeral fTaclures with associates bra­ the shoulder into the arm. tures around the scapular spine is suprascapular Most "bumer" injuries are self-limiting and nerve injury.or dislocation of the gle­ Clinical features include temporal). including the axon. reported the "unhappy triad" at the shoulder that included concomitant shoulder dislocation. In this injul)'.12 Location of the chial plexu injuries.'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. Most patients injury and the direction of dislocation of the hu­ recover spontaneously within 6 weeks after meral head. posterior cord. Several months back found two cases in a series of 31 cases of will pass before recovel). but chial plexus lexions due to shoulder dislocation the presence of electric potential due to axo­ into diffuse infraclavicular. First-degree l1erve il1jury. '0. ranging [Tom a nondegenerative nCUI"opraxia to a sever­ DISLOCATIONS ance of the nerve or plexus (neurotmesis). and medial cord injuries. the axon degenerates the shoulder girdle and humerus bones have proximal to the point of the lesion. 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. and cervical rool avulsion has been that an associated complication of scapular frac­ seen in severe cases. the axon is severed and fails to survive FRACTURES below the level of injlll)' and. The incidence of frames for full recovery. and to callous and scar formation as a result of fTac­ phagocytic activity with eventual fibrosis. lat­ nal continuity is retained. injury. rotator cuff tear. [f these problems persist. found sixteen cases of costocla­ the endoneurial tube. the endoneurium is presclved within Della Santa et al. with proxi- . This injury is char­ chja] plexus injury.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. 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. reported Clinical features include temporal)' com­ three cases of injury to the axillary artery and plete loss of motor. secondary brachial plexus injury after shoulder Five major degrees of injury are described by dislocation ranges from 2 to 35 percent in the Sunderland".'4 Silliman and Dean report lesion varies. and bra­ 1. Second-degree nerve illjllry. sensOl)" and sympa­ brachial plexus complicating a displaced proxi­ thetic functions in the autonomous distribu­ mal fracture of the humerus.6 resolve within minutes of insult. loss of nohumeral joint. Schwann cell degeneration.2o Travlos et al. presented a case atomic continuity of all components com­ with concomitant mixed brachial plexus injury prising the nerve trunk. classified bra­ motor function to the affected muscles. Guven et al. begins." Blom and Dahl­ tion of the injured nerve. 2 . tures of the c1avicieH Stromquist et al. li terature. for a variable Traumatic injuries associated with fractures in but shon distance. described as a constant burning. lesion. without surgical graft­ are commonly associated with preganglionic ing. is central in nature. Therefore. ally related endoneurial tubes. Pain. According to complete loss of function to the affected Frampton. This pain occurs records concerning the progress of the patient. which may distort the nor­ kinds of lesions suffered. 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. Obviously. ferent varieties of sU'ess. The recovery is long. in the locality of the mal pattern of innervation. Third-degree l1ellle injury. nisms of injury. Evaluation and characterized by axonal disintegration. Because mo t brachial plexus injul'ies result from trauma. with resultant juries. motor. while slow-speed. Because the endoneural ries to the brachial plexus. occupational therapy tube is destroyed. is high. up to 2 to 3 years. intrafascicular fibrosis offers strategies for splinting as well as equip­ may obviate axonal regeneration. recovery is negligible. small-impact accidents are commonly associated with post­ ganglionic injul-ies. high-speed. and are in­ stead misdirected into foreign endoneurial tubes. 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.7. In this injury. The general fascicular tion is particularly important in lower trunk inju­ pattern of the nerve trunk is retained with ries to the brachial plexus. MECHANISMS OF INJURY with a chance of significant residual dys­ function. I S The magnitude of 5. Clinically. that is. 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. the dif­ but the perineurium is disrupted. make tremendous differences in the the site of injury. high-speed versus slow-speed in­ entire nerve trunk is severed. Fifth-degree IlelVe injwy. According to Stevens. a thorough history should include 4. This condition is ination. and sympa­ Histmy thetic functions of the related nerves are lost. the forces. Because most brachial plexus le­ mented. and disorgani­ treatment of hand and upper extremity injuries. is important to ascertain. and in prognosis. in the minimal damage to both the perineurium presence of fourth-and fifth-degree nerve inju­ and epineurium. as shown in Figure 7. Additionally. zation of the internal structure of the Knowledge of hand management and rehabilita­ endoneural fasciculi. crushing pain with sudden shoots of paroxysms the clinician must maintain and update accurate of pain. plexus injuries. 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. Fourth-degree l1elve il1jury.4 Examples of high-velocity injuries are those resulting from falls from speeding motorcycles. large-impact accidents structures. sensory. charts for recording results of the physical exam­ 3. Many ment modification or assurance to assist perma­ axons fail to reach their original or function­ nently dysfunctional individuals. sions slowly improve over a long period of time. This type of in­ questions concerning the nature and mecha­ jury is similar to third-degree nerve injury. as a result of deafferentation of the spinal cord . . nll"AT S . . c- . .1.... patient's occupation..""... '�""'�IS '" (U[fOSOII fl u e. ' .. HO' ..[ N'S • '0111["111101 . A condition that is resolving sponta­ brachial plexus lesions.... - C8 ....... .... 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.." l"IoC"1O (n OIG ('.rs" . leading to undamp­ ophthalmos. myosis. o .. U ·G '" - � .TO" 0I0 'T" 1... _ .. '·"1. lI.. Leffert2.T(I'"..0 'II'Y HY.. - "'10(1"" " . ..AA FOSSA ___ ____ ____ __ DATE OF INJUAY' __ ____ ____ ____ __ _ ��D��' _ __ __ ____ ____ ____ ___ OCCUPATION __ ____ ____ ____ ____ _ FRACTURES __ ____ ____ ____ ____ ___ HOANEA 5 SVNOROUE __ __ __ __ __ ____ __ VASeutAR STATUS' ___ ____ ____ ____ __ MYELOGRAM C. u."oI.. .... ____ e. ' iIIIIII ' . - ..2• lish an indication of an improving or worsening In a series of 188 patients with post-traumatic lesion. -.11.7 Chart (or recordillg • THUM' results o( physical examil1atiol1 0' o .. .. and previous . '" . 0 ' La.. -- . - . I "..."IST 00"'.I N CO. Ott " I.... . (../1. . :. The cate at least a third-degree nerve injury.ruou(· .I'... 'LU 011 ••0' I SU"'·".C 1 ..10"" FIGURE 7. J IIAJ " C l AV ' C U l... .. .... OU I .. . .� '1.. along wilh a ened excitation of the cells in the dorsal horn deficit of facial sweating on the affected side. the clinician should document the ner's syndrome.. 'TT" 1. " A' L� [ JO ' I I I 0 '" • CUI": r .. ·n OJG SUI1. � -... .) at the damaged root level.fUS ". with permission. ____ "'____ e'____ 08____ . .. . olelS "" .. The confused barrage of reOects damage to the TI nerve root. .... and ptosis. of the spinal cord._ .� IIO'A'OIIS suJlou. 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......:.... • ." ... .'0'.. .. __ __ E"G __ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ _ ".0 .."'..... . . ____ . . .... 00" " . .llIALI' I f lIT ... 01il4.[.or second-degree that 91 percent experienced pain at least 3 years nerve injuries.. ( (or brachial plexus il1jury. ..:.- . O' g '" 0 . ' D ' 0 ' '[NUllO'" iIt"NG[ Of< WOTION • SHOUlD(" \GHI . (Frolll . be noted and documented. . -...· .. accord­ report of any anesthesias or paresthesias should ing to Sunderland's classification. -- . ' �� :O � OI� o � . !.... which is characterized by en. Bruxelle et al found neously may indicate first.- .-o'. .".� .. ' [1111 0 '" . ' .. handedness... The presence of Hor­ Finally.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.· C 6 " ..0.. . - T l.A 1I U[..c :> . I'"UtG(III I S . " ... (5) palpa­ the brachial plexus. The physical evaluation should be repeated for constriction of the pupils or ptosis of the eye­ frequently during the process of rehabilitation to lids.3o Most grading sys­ atlanto-occipital junction. which can indicate the presence of Horner's carefully assess subtle signs of nerve reinnerva­ syndrome. Isolated atrophy of the deltoid muscle in­ materials. and shortening of both muscle and ten­ lesion of the long thoracic nerve. the clini. The forward head tems grade muscle for 0 to 5. From the side. ( 3 ) activities of daily nodularity and induration in the brachial plexus living. FJval.uat:ion can result from injury to the lower trunk of the brachial plexus. Both nonunions and malunions of the the cervical spine. cits of joint motion from immobility result in Winging of the scapula signifies weak. and backward bending at the for manual muscle testing. Therefore. such as mal cross-linking of newly synthesized collagen. From the front. 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.29 A complete upper extremity test the brachial plexus in the area of the thoracic should be perfonned initially to provide the clini­ outlet. The supraclavicular fossa is tion. including the loss of water and supraspinatus and infraspinatus muscles. side. (2) passive range of motion of noted. stabilization. PASSIVE RANGE OF MOTION POSTURE The passive range of motion of all joints of the The patient is obselved from the front. retests should be performed pe- . and shoulder girdle and upper limb must be assessed behind. An ann position ity level. and (4) vocational and avocational pur­ where the injury is 0ld 4 The eyes are obselved suits. Duchenne-Erb Paralysis of the C5 and C6 nerve and infi ltration in the joint spaces of fatty fibrous trunks. and (6) special tests.' External deformities along the The components of the physical evaluation in­ clavicle.ness of the contractures of joint capsule. 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. shoulder. 21 Thoracic outlet syndrome is discussed cian a data base from which to measure improve­ in detail in Chapter 16. (4) sensation. ( 3 ) motor strength. Defi­ muscle atrophy as well as winging of the scapula. of adduction and intemal rotation can result from Duchenne-Erb pa"llysis. protraction Several manuals are available that review proper and elevation of the scapulae. randomization and abnor­ indicate an upper trunk plexus lesion.28 dicates an isolated axillary nelve lesion. increased cervical isolation. and grading procedures spine inclination. which may indicate fracture. should be clude: ( I) posture. the clinician observes for and recordecl using a standard goniometer. ment. effects of 9 weeks of immobilization on peria. can glycoaminoglycans. The classic stud­ phy of the supraspinatus or infraspinatus mus­ ies of Akeson et al demonstrated the deleterious cles can signify suprascapular nelve entrapment. adhesions in the serratus anterior muscle. Ipsilateral atro­ dons above the affected joints. 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. (2) coordination.-ti­ Atrophy of the deltoid muscle. and upper extrem­ clavicle can result in significant compression of ity.29. From behind. Pronation of the forearm with flexion at lhe wrist and metacarpo­ phalangeal and proximal i nterphalangeal joints Physical.2 tion. in addition to the cular structures. which may indicate a joints. the clinician should obselve for changes MOTOR STRENGTH consistent with a forward head posture: accentu­ ated upper thoracic spine kyphosis. ence of a brachial plexus injury results in a loss of gross and fine motor coordination in the affected upper extremity. Idyllwild. and head. depending on the patient's sta­ technique is best suited for individual digit swell­ tus. preclude the patient getting the extremity weI.4 A distal Tinel's sign particularly with associated fractures of the clav­ indicates a lesion in continuity whet'e the axonal icle. There are numerous tests on PALPATION the market designed to assess an individual's co­ Manual palpation is used to assess for myofas­ ordination. and two-point method of measuring edema. Volumeters Unlim­ Total avulsion of the plexus results in total anes­ ited. 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. Manual palpation is also used to measure edema. can be quite useful in distinguishing rupture In the presence of severe brachial plexus injuries. .33 collars and washers. Trigger due pegboard (Lafayette Instructional Co . and when recovery is OCCUlTing. The patient's hand is submerged in a lu­ sis of the level and extent of the plexus lesion. demonstrated by tapping over the brachial plexus above the clavi­ VASCULAR cle. usually for peak torque. I N ) . and fected upper extremity. The concept of volumetrics SENSATION to measure upper extremity edema is well estab­ Assessment of sensory loss assists in the diagno­ lished.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. compared with the uninvolved upper EDEMA extremity. . 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. from a lesion in continuity '. which may dermatomes. disruption of the subclavian or axillary ar.4 Sensory changes are documented along ing or in the case of open wounds. all patients who the clinician in pinpointing the site and extent have had a significant nerve injury will have evi­ of the plexus lesion. temperature. light surements of the hand and forealm are another touch.3. 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. for example. COORDINATION The severity of the edema is usually rated from I to 3. strength deficits. The presence of Tinel's sign. and work. as illustrated in Figure 7. cool skin indicating venous insufficiency also assist clinicians in measuring muscle should be performed by the clinician. The sensory and the results recorded. Edema must be assessed and treated to prevent stiffness in the joints. as well as the shoulder to perform a speCific assembly task using pins. this discrimination. connections within the ner've trunk are intact. Refer to Chapter 16 for a review of isokinetic testing protocols in the shoulder. and the amount of water thesia of the related areas. lsokinetic testing can dusky. Additionally. A thorough manual muscle test assists teries may occur. cite container (Volumeter. in a mixed displaced is measured using a 500-ml graduated lesion. However. Both extremities should be measured sory pattern may vary in the arm. The Pur­ girdle and upper extremity musculature. stereognosis. with I being minimal and 3 being severe Loss of sensation and muscle control in the pres­ or pitting edema. However.. Circumferential mea­ evaluation may include deep pressure.7. assists the clinician in or from partially denenlated muscles exhibiting assessing the patient's manual dexterity. Each requires varying amounts of cial trigger points about the affected shoulder fine and/or gross motor coordination. CAl. girdle. the sen­ cylinder. singularly and in tandem. power. neck. La­ points result from tight and contracted muscles fayette. allows the patient to use the extremity at home which can impinge on the nerve trunks along the and at work. Based on the specific limita­ measurements to help evaluate progress. to prevent costoclavicular juncture. Bil­ splint (Fig.or firth-degree nerve 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.2 However. This type of injury would correspond to Lahoratory FJual:uJL/:i. as described by Sunderland. she is not able to perform owing to the extent of myelography. A detailed job description is obtained to assess the patient's potential to return to work. which can indicate a as a means of performing specific activities. 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.or third-degree potential areas of interests. The splint is fitted early.2. 63 percent sensitive. bathing. and dressing.4 the case of a CS-7 injury. tions of the patient. In addi­ tion. the brachial plexus injury. 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. According to Leffert.9) to wear at suspected brahial plexus abnormalities of di­ night to help maintain the wrist and fingers in a verse causes with MRJ. and 73 percent accurate in demonstrating the abnor­ VOCATIONAL mality in a diverse patient population with multi­ ple etiologies of brachial plexus injuries. 100 percent specific. tapping above the clavicle indicates a possible neuroma resulting fTom disruption of part of the plexus. Activities of interest nerve injury. or fractures of the cer­ the patient from relying on one-handed methods vical transverse processes. The patient may also be fitted bey et al evaluated 64 consecutive patients with with a resting hand splint (Fig. nerve roots in the presence of traction injuries to the brachial plexus.34 MRJ was found to be balanced position. root AVOCATIONAl avulsion can occur in the presence of a normal Because the brachial plexus-injured patient is myelogram. 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. Con­ are developed that encourage use of the affected versely. groom­ area and extent of the Ie ion and provide baseline ing. 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.2 Fractures of the clavicle with callus. including the the patient is fitted with a nail arm splint that c1avicle. The occupational therapist questions chial plexus root lesions ]5 . 7. and radiographic assessment. spine and involved shoulder grid Ie.8). 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. the presence of a localized tenderness to extremity.' In root avulsion. 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. 7. a well-documented study unable to work .ons oj a fourth. Such areas include These evaluations help the clinician diagnose the self-care skills such as feeding. must be ruled out. . while normally innelvated signal the onset of Wallel-ian degeneration of a FIGURE 7. able small potentials ( fibrillations) or large po­ knowledge and assessment of these electric tentials (sharp waves).8 A lOl!g melacarpophaiQ/lgeal extension splint used 1-VEtil a patient who has weak wrist extension and trace {iflger extension.9 A resling hand sp/il!! used rol/oIVil1g a brachial plexus lesiol! 10 prevel1l overslre!c/ling or weak and {tl!ger exl€/1sor lIluscies by lIlail1laillil1g Ihe l-vrist in approximately 20" or dorsif/exiol!. which are the hallmark charges can be used to provide information con­ of denervation. ELECTROMYOGRAPHY muscle exhibits no spontaneous electric activity at rest when examined with needle electrodes. Because the loss of axonal continuity results in denervated muscle produces readily recogniz­ predictable.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 FIGURE 7. time-related electric charges. These electric discharges usually cerning muscle denelvation and reinnelvation.2 appear 3 weeks following injury to the plexus and For example. when fected upper extremity from cervical interverte­ recovery is occun-ing and intensive reeducation bral disc protrusion. this is a late reaction that potentially results from the back­ firing of antidromically activated anterior horn cells. and education Nerve conduction velocity tests may be used to concerning passive movement and self-care of help distinguish muscular weakness in the af­ the affected extremity. lasting as long as 3 years. neurovascular repair. antel. Denervation of the Therefore. tromyogram is positive for the muscles inner­ Surgical grafting in the presence of fourth­ and fifth-degree nerve injuries necessitates. consisting of diagnosis. ment of velocity of conduction. whatever possi­ healing constraints.or horn cell disease. muscle strength and uation of the po terior cervical musculature. on vated by the anterior primary rami but not for the pal-t of the therapist. Serial strength­ clarifying evaluation. The time sions do not in(]uence nerve conduction latency. E V A L U A T I O N A N D TR 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 195 specific nerve. function within the constraint of the nerve in­ The posterior cervical muscles are segmentally jury. when a root avulsion is sus­ pected in a patient who has sustained a traction The approach to rehabilitation for brachial injury of the brachial plexus. Goals. and rationales for the Another type of electrodiagnostic testing is treatments for each stage of rehabilitation are the F response.38 and occupational therapy approach. and function. Because regeneration is ex­ innervated by the posterior primary rami of the cruciatingly slow. rami to form the plexus. patient and family education. Conversely. Initial findings are delineated in the normally innervated muscle. may be indicated. as well deep posterior cervical muscles is highly corre­ as home exercise programs. treatments. Rationales . the clinician plexus lesions is directed at maintaining or im­ should also peform an electromyographic eval­ proving soft tissue mobility. frames and extent of each phase are predicted the clinician can be certain that a proximal nelve based on the extent of the lesion and the individ­ conduction delay is a result of a brachial plexus ual's own motivation and recuperative capabili­ lesion 37 ties. are an integral com­ lated with root avulsion.36 cases requires vocational and avocational re­ training. the middle stage. as well as occupational therapy inter­ vention for assistance-providing devices and splints.J8 A denervated or partially denervated injury affecting the shoulder and upper extrem­ muscle requires more time and current than a ity function. and the late stage. The relatively high chance ble damage exists is presumed to be infragangli­ of residual upper extremity dysfunction in some onic in nature. if the elec­ ponent of treatment. Because anterior future recovery is expected and assessment for horn cell diseases and intervertebral disc protru­ reconstructive surgery can take place. an outgrowth of the measure­ exemplified in the case study presented below. Electrical stimulation of motor points as­ CASE STUDY 1 sesses the strength-duration cUlves of affected This case study presents a typical brachial plexus muscles. when no or a brachial plexus lesion. The clinician is able to localize Rehabil:itation Goals and the lesion by sampling muscles innervated by dif­ ferent nerves and root levels.m Stuilies According to Framptom: rehabilitation falls into three stages: the early stage. knowledge of soft tissue the posterior cervical muscles. The goals and phases of duration testing therefore allows the clinician treatment are presented as a combined physical to assess neuromuscular recovery. rehabilitation in severe cases spinal nerves that provide the anterior primary is a long-term process. Nerve Coruiucl:ii. Treatment Additionally. that portion of Grade I trace the brachial plexus where C5 and C6 unite to join Grade 2 = poor the upper trunk. wrist. biceps brachii = 2. subscapu­ = left arm. teres minor = 2. in slight Oexion. and hand. and Atrophy was observed in the deltoid. and weakness in The patient's muscles were graded as fol­ his left shoulder. VOCATION SENSATION The patient works as a carpenter. serratus anterior = 5. ACTIVE RANGE OF MOTION PALPATION Elevation in the plane of scapula measured 60°.196 P H Y S I CA 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. left hand. cc on the left. PASSIVE RANGE OF MOTION EDEMA Elevation in the plane of scapula measured 1 20°. The patient had 2 + edema palpated along the external rotation in adduction measured 30°. and supinator = 3. neck made worse with attempted elevation of his brachialis 2. His volumetric 70°. 30°. in fraspi­ ports intermillent pain in his left shoulder and natus = 3. with Coordination was assessed using the Purdue his forearm pronated and his wrist and fingers pegboard and rated as follows: right hand. left rhomboid. and hand passive measurements were 482 cc on the right and 525 range of motion were all within normal limits. natus. phalangeal joints and metacarpal joints and and external rotation in 90° abduction measured along the dorsum of the left hand. and supination measured 50°. and infTaspinalUs muscles on the left com­ COORDINATION pared with the right side. elbow Oexion measured subscapularis muscles. 4. The pa­ = tient was referred to physical and occupational Grade 4 = good therapy 4 weeks after the initial injury. He re­ lows: deltoid = 2. Grade 5 = nOI111al The patient reported numbness and tingling along the lateral aspect of his left shoulder. 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. was 88 Ib on the right and 1 0 Ib on the left. Trigger points were palpated in muscle bellies of external rotation in adduction from full internal the left upper trapezius. extensor carpi radialis longus and bre­ = creased strength in his left arm since the initial vis = 3 . 14. Sensation was impaired to light touch and to sharp/dull along the lateral aspect of the left POSTURAUVISUAL INSPECTION shoulder. supraspinatus = 3. 2. He reported less numbness and in­ laris 3. 6. wrist. assembly task. both hands. when rele. . His elbow. ex­ dorsum of the left fingers at the proximal inter­ ternal rotation in 45° abduction measured 60°. in the area of the deltoid muscle. His left arm was held in internal rotation along his lateral tnmk. Electrodiagnostic testing indicated an infTaganglionic lesion to his Grade 0 = no contraction left brachial plexus at Erb's joint. forearm. Radiologic studies indicated no Grade 3 fair fTactures at the cervical spine or clavicle. supraspi­ along the radial side of the forearm. The patient vant. in the area of the deltoid muscle. His grip strength injury. and left rotation measured 20°. had full pronation and wrist and finger Oexion and extension. elbow. bulton shirt. 1 2) were applied immobilization on periarticular capsule.. infraspinatus. 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.25 Therefore. Donatelli. low-voltage surge stimulation. The resultant weakness. and teres minor mus­ ting with dual channels and four electrodes. results in impingement of the suprahumeral soft tissues underneath the RATIONALE. according to fered with some self-care activities. one can the patient is right-handed. which will expedite expect combined resolution of nerve function. nal rotation with the arm abducted to 45° or 90°. the weakness in the left upper extremity. and FIRST GOAL muscle. especially the left fin­ trol of the affected muscles. Fortunately. The rotator cuff muscles. inter­ first. tendon. even in the presence worn 8 hours per day. According to Travell and Simons. Transcutaneous neuromuscular stimulation. to the active trigger points in the lefI upper trape­ and muscle. The neously improving since the initial injury. The transcuta­ the humeral head during elevation of the shoul­ neous neuromuscular stimulation device was der. particularly the supra­ using a high-rate. was cles. zip pants or jacket. Be­ side. tendon.. 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 . The loss of motor con­ zius and left rhomboid muscles in our patient. The contracted subscapu­ Groollling-unable to apply deodorant to laris muscle resulted in the greater limitation of his right underarm. 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. 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. Heat. shortened position. with the findings of Akeson et al. as opposed to exter­ Dressing-unable to tie shoes. These two factors result in increased edema cause he demonstrated at least poor muscle con­ in the left upper extremity. personal communication. a well as extent of the injury is classified as between a the patient's decreased manual dexterity. low-intensity conventional set­ spinatus. passive external rotation with the ann adducted along the lateral trunk wall. are unable to adequately control gliding of applied around the left shoulder. Soft tissue limitations are consistent The first goal is to reduce pain.'8 Tabary et T R E A T M E N T . 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. 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. of a weak deltoid muscle. In addition." Therefore.and second-degree injury. fascia. respectively. Sunderland's c1assification. compared with the right. my­ unyielding corocoacromial ligament. his return to employment as a cm-penter. trol results in altered scapulohumeral rhythm. al. which is sponta­ gers and hand. (R. with full return of function of the left upper ex­ tremity. 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. or buckle belt.) 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.39 and Cooper" a who studied the affects of and spray and stretch (see Ch. in a consistent paltern. followed by distraction of the medial i s a gentle elastic wrap used for edema control.42 the reinnervating muscles. 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. 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. 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.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. tracted subscapularis muscle. to pro­ longed periods. in the grades III and IV range RATIONALE. The advantages of Coban are thaI it is reusa­ techniques at the shoulder are d i rected at the in­ ble (thus reducing costs). TREATMENT. active range of motion.47 .·. respectively. and first pumping to activate muscle along the lateral trunk wall results from a con­ pumping action in the hand and forearm. his wife were provided with wrillen instructions RATIONALE. the painful limitation regarding elevation of the arnl. 1n our patient. Therefore. tion. According to strength-duration stud­ according to Maitland's classification."·45 where there is no. and allows for full range of mo­ mote abduction and external rotation move. due to the The third goal is to avoid neural dissociation to traction injury. 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. ·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. electrically i nduced mu cle contractions facili­ Patients with this condition are given a pro­ tate normal circulation. patient resulted from irritation of nociceptor endings in the connective tissue sheaths sur­ THIRD GOAL rounding the nerve fibers and trunks. 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. zation techniques. St Paul. joints so that these joints do not become re­ stricted due to disuse of the extremity in general. plex. Mobilization in. respectively. In our patient. low-voltage surge preferred duty cycle was 1 0 seconds on and 20 stimulation followed by spray and stretch tech­ seconds off. The TREATMENT. 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. were ap­ ies. decrease edema. 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. SECOND GOAL TREATMENT.J• In addition to main­ mobilization techniques at the shoulder com­ taining reinnelvating muscle tissue viability. the patient and ticipants in the patient's rehabilitation. M N ) and stretch. applied to the partially denervated muscles. may be worn for pro­ ferior and anterior capsules. or only limited. Clinically.'· In addition. we use three sets of I -minute in the dorsal horn of the spinal cord. Each patient is given an active range FOURTH GOAL of motion exercise program for the uninvolved Reducing edema is the fourth goal. spray Coban (3M Medical-Surgical. 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. Mobili­ three to four times daily. for a period of 30 minutes. The conventional transcu­ ments. retrograde mas­ of external rotation with the shoulder adducted sage. The therapist should be an active listener poseful activities if motor learning is to take and recognize the normal process of emotional place '· Biofeedback and neuromuscular electri­ recovery in patients with severe disability. Light-weight isotonic strengthening was independence. Early isotonic strengthening is directed cannot stress enough the importance of involv­ at restoring strength in the shoulder rotator cuff ing the patient's family in the rehabilitation pro­ muscles. Financial issues may restore. As strength improved. Manual proprioceptive neuromuscu­ patient is educated as to the nature and extent lar facilitation diagonals allow the clinician to of the injury. and teres minor muscles. normal balance between these muscles and the . Retrograde massage. resulting in alternate contraction and reinnervating muscles. Fear cal stimulation are used on selected weak mus­ is a major component and compounds a patient's cles to facililate muscle reeducational strength. A patient's emotional stimuli can evoke desired muscular responses. Manual proprioceptive neuromus­ heart. Patient and family education and within 20 percent. he was issued a rocker ments at the elbow and pronation and supina­ knife to help him cut his meat and a button hook tion at the forearm. shoulder. anxiety. as measured in peak torque. cular facilitation techniques emphasizing diago­ nal patterns. added to the program . during elevation of the shoulder. and depression associated with a severe ing functional activities. the dy­ become a source of wony and concern for all namic steering mechanism of the rotator cuff involved. he was patient was progressed to isokinetic strengthen­ instructed in specific one-handed methods of ing at slow speeds of approximately 600/s. Fist The first goal in the middle stage is to reeducate pumping. the course assess early subtle strength changes across treat­ of therapy. Refer to Chapter 3 for isoki­ psychological referral were used to accomplish netic testing and strengthening strategies for the the sixth goal. em­ performing certain tasks. used while the patient is exercising or perform­ anger. The patient was progressed to isoki­ netic diagonal movement patterns in the supine SIXTH GOAL position when isokinetic testing indicated a dif­ Providing emotional support education is the ference of left to light external rotation strength. 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 . state will affect his or her pelformance in ther­ and this stimulation must be followed by pur­ apy. specifically the supraspinatus. the therapist must help Modalities such as vibration and tapping are the patient through the initial stages of denial. This anxiety can often be reduced if the RATIONALE. were begun FIFTH GOAL at approximately 3 weeks after the initial evalua­ The fifth goal is to increase the patient's ADL tion. with the patient supine. Family relationships often become strained natus. relaxation of the musculature in the hand and forearm. The patient was issued adaptive cuffs. the course of recovery. in a gravity-as­ M I D D L E STA G E sisted position. In certain instances. The goal is to as a result of serious injury. Appropriate sensory brachial plexus injury. For example. The family members may need as muscles on the humeral head 49 The restoration much SUpp0l1 as the patient and will also benefit of rotator cuff muscle strength reestablishes the from the education process. sixth goal. the to help him button his shirt. and the prognosis for recovery. promotes venous blood return to the TREATMENT. shoulder. In addition. such as tying his shoe phasizing rotational movement palterns in the laces. and power was TREATMENT. infraspi­ cess. One ments. using adjustable-weight T R E A T M E N T . facilitates the reabsorption of in­ FIRST GOAL terstitial fluids into the lymphatic system. Initial isotonic strengthening emphasized equipment to increase his self-care independ­ external rotation movement patterns at the ence until he exhibited a greater degree of motor shoulder as well as flexion and extension move­ control. and teres minor muscles. Initially. to promote exter­ mentioned. OH). so that he Low-load prolonged stretching using T R EA T M E N T . he was able to per­ placing large pegs into a bucket while being form this same activity unsupported. As his the activities focus on such gross motor skills as shoulder strength improved. forearm. For example. He was issued therapeutic strengthening is instituted as soon as the patient putty and instl'llcted in hand-strengthening exer­ is actively exercising with \ . Elastic small). or she can consistently "catch" and maintain the surgical tubing was applied to the restricted peri­ speed of the dynamometer. All activities were timed to Akron. after bilateral and glycoaminoglycans. and pronation. and wrist musculatul·e. He ties required more fine motor skills. As our patient's motor performance of him to a bucket placed to his far left. 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.or 2-lb weights. Surgical tubing attached to his wrist natus.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. especially the anterior aspect strengthening is emphasized early. transferred pegs from one bucket placed in fTont TREATMENT. the activi­ active shoulder abduction against gravity. to restore the dynamic glide of the nal rotation. to creep or to elongate strength deficits between the left and light shoul­ with the tissue. including the water the patient sitting or standing. 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. Addition­ timed and. turning I'lIbber tubing. coins and so forth. left upper extremity supported. to eliminate the affect longed stretch. tance-providing devices and to modify the use of our patient worked on tabletop activities with his these devices. Trombly and Scott state that . FOURTH GOAL du. ment of the suprahumeral soft tissues and pain. The fourth goal is to reevaluate the use of assis­ OCCUPATIONAL T HERAPY. 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. such as Theraband ( Hygenic. he was able to stack cones. he Increasing coordination is the fifth goal.200 P H Y S I C A L T H E R APY O F T H E S H O U L D E R upward pull of the deltoid muscle.-ing active shoulder elevation. supination. Isokinetic and wrist strength. such as ma­ used light weights to strengthen WTist flexion and nipulating nuts and bolts (graded from large to extension. placing those same pegs into a ally. was used at home to improve elbow document progress. infraspi­ 90° flexion. as previously of the glenohumeral capsule. As he continued to improve. continue the third goal for edema deficits are greater than 20 percent. Using rat tail tendons. which required pegboard. sion in a gravity-eliminated position. practicing on an ADL board. External rotational articular capsules. impinge­ control. cises. 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. coordination activities became an in­ activity required active elbow flexion and exten­ tegral part of his treatment program. Although not scientifically substantiated. In occupational therapy. The activities F1FfH GOAL were directed toward strengthening his elbow. speeds. occurs. later. torque and power values of the involved com­ R A T I O N A L E . This improved. beginning with slower speeds. Lehman et al pared with the uninvolved upper extremity. der rotators are within 20 percenl. we have obselved THIRD GOAL that when bilateral shoulder rotational strength If necessary. he progressed and more accuracy. lnitial rindi ngs are deline­ TREATMENT. 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.ing on more intricate projects and. is added when bilateral have been omitted to avoid redundancy. At 1 5 months. At I year postinjury. This injury occured ap­ RATIONALE. at 1 80·/s. and princi­ strengthening at the shoulder is continued. are within 20 per­ HISTORY A cent. The third goal is to help the patient return to work. Rotational and diagonal Study I .ness in his right within 20 percent. At that should be graded along a continuum rTom gross time. staining. carrying various-size weights. at 60·. and grabbed a ra iling ing. in the presence or slow-speed. The patient is a construction worker and is right­ THtRD GOAL hand dominant. Functional training. 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. Optimizing joint and soft tissue mobility is the VOCATION second goal. Strengthening in the clinic is contin­ proximately 7 weeks ago. is instituted. 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. A mild c1awhand deror­ would need to perrorm in order to be able to mity was observed and characterized by hyper- . The result was a forcer·tli and sawing activities. the activities should require faster speeds sanding. He Fast-speed training is instituted to improve mus­ reports occasional burning pain along the same cular endurance. a job analysis Mild atrophy was observed in the intrinsic mus­ was done to identify those tasks the patient cles of the right hand. He also has slight "drooping" of his right that. A neurologist perrOlmed an EMG last cits greater than 20 percen t.s. The patient is instructed in an aggressive home strengthening program using adjustable 42-year-old male construction worker was work­ curf weights. 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. slipped. POSTURAL!VISUAL INSPECTION TREATMENT. at 1 8 months. We have observed clinically grip. bilateral defi­ eyelid. the patient started on woodworking to rine and that as the patient's coordination im­ projects that required minimal rine motor tasks proves. 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. activities safely and accurately perform his job. his right arm into the fourth and fifth ringers. 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. slow-speed dericits. chial plexus K\umpke. The patient was given nonsteri­ or carpentry. odal anti-inflammatory medication and refelTed to a program of physical and occupational SECOND GOAL therapy. Goals. including l i rt­ ing on a scafrold. he returned to work. with his right hand. 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. He l·epol·ts weak. phases or treatment. Fast­ ples of treatment are similar to Case Study I and speed training. hammering.52 to work. Functional training intrinsic hand muscles. upward pull or the arm. ble partial denervation of muscles affected by C8 MOTOR STRENGTH and T 1 nerve roots. Peri­ equivocal. Sponta­ imi = 3.202 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. The patient is progressed through each phase ASSESSMENT based on continued re-evaluation of signs and The pathomechanics of injury involved an up­ symptoms. but no The case studies illustrate the problem-solving trophic changes were noted. and adductor pollicis brevis rate and the long distance to their target muscles. Special tests: Froment's sign was be designed by a certified hand therapiSt. flexor pol­ = cases (at least a year) due to the limited growth Iicis brevis = 3 + . If signs the thumb would flex. The patient is as desc. Treatment is resumed if re- . away. the hand was slightly cool to palpation. A comprehensive program of both physical and occupational therapy based on a phased ap­ SENSATION proach outlined in the initial case is indicated. within the constraints of nerve reinnervation. 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. Ptosis of the right cally reevaluated. ADL assessment indi­ cance. abductor digiti minimi 3. 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. Lower plexus injuries discharged on a home program and is periodi­ affect nerve roots C8 and T I . = 3. 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 . interossei muscles 3. the patient was asked to grasp a piece odic electromyographic evaluations should be of paper between the thumb and index finger. minimi = 3. provement in motor capabilities. 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 + .-ibed by Stevens. fore­ a comprehensive hand therapy program should arm. sharp/dull along the ulnar side of the arm. performed to check for reinneravation charac­ With full paralysis of the adductor pollicis brevis. medial half of flexor = neration of some muscle fibers but probable digitorum profundus 3. only slight flex­ of recovery fail to appear after 1 year. EDEMA Summary 1 + edema along the dorsum of right hand. and hand. however. opponens digiti min­ = preservation of the endoneurial tube. medial lum­ = but axonal outgrowth takes a long time in these bricales (fourth and fifth digits) 3. Sensation was impaired to light touch and as with all lower trunk brachial plexus injuries. surgical ion was produced when the paper was pulled exploration should be performed. approach to patient treatment. 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. terized by pol phasic action potentials. flexor digiti = neous recovery will occur in case ofaxonotmesis. Clin Orthop Rei Res 237:24. Bunge R (eds): Peripheral Neuropa­ 25. 1 988 Rev 2 1 : 1 345. Sedel L. 1 37. Guven 0. Travers V . I n 1 980 Codman E A (ed): The Shoulder. roots and gan· in association with anterior shoulder dislocation: glia: musculoskeletal factors and neuropathologi. Bonnard C: Late lesions the shoulder complex. Silliman JT. Connect Tissue Res 5: 1 5. Dahlback LO: Nelve injuries i n disloca­ 9. p. Markey KL. Travlos J. Blom S. Thomas PK. testing. p. 36th Wilkins. In Kon' 1 M (ed): The Neurobiologic Mechanisms in Manipulative 8:429. 1 978 1 0 . Ralston HJ. of the humelus. p. thy. unhappy triad of the shoulder. Blunelli GR: A foul1h type of bra­ proximal fractures of the humerus. J Ol1hop SPOl'tS Phys Ther of the brachial plexus after fracture of the clavicle. 1 978 syndrome. Janda V: Muscles. Yalcin S. Amiel D. In KOIT 1M (cd): 1 7:655. Bassett FH [ 1 1 : The prolonged burner Therapy. Wanvick R: Gray's AnalOmy. Leffel·t RD: Clinical diagnosis. Hershman EB. 1 988 Bone Joint Surg 72B: 68. Kendall FP. central nervous motor regula· brachial neuropathy in athletes. 1 988 I I . J Bone innervation. p. Poppen NK. 1 977 in the scapulat· plane: scapular and glenohumeral 29. Baltimore. Della Santa D. Shik CH: Brachial plexus in. Gundes H: Concomi. Sunderland S: Nerves and Nerve Injuries. Odenberg S: Rei Res 237 : 1 7. Comtet JJ. New York. Saunders M . Highet WB: Grading or motOI. J Bone Joint Surg 58A: potential of significant long-term dysfunction of 1 95. Krieger Publish. 1 8:442. Electroencephalogr Clin Neurophysiol 4: 1 87. Edinburgh. Plenum. Plenum. J thop Rei Res 237:9. injuries. 1 992 24. Abbot LC: Observations cross-linking alterations in joint contractu res: on the function of the shoulder joint. Clin Orthop 23. Speer KP. 1 970 Lambel1 EH. WadsWOI'lh GE: Mus­ cles: Testing and Function. 011hop lesions. 4. 1 6. Wilbourn AJ. chial plexus injury: middle lesions (C7). 29. Mumenthaler M. Goldberg I. Am J and treatment of pain arter brachial plexus injury. Alnot JY: Traumatic brachial plexus palsy in the 2 1 . 2nd Ed. 1 994 Therapy. 1 325. 1 978 20. 1 990 6. Freedman L. 1 8. Inman VT. Melbourne. A roentgenographic study. 7. The sti nger syndrome. Stevens J H : Brachial plexus paralysis. Wang KC. 1 984 Churchill Livi ngstone. 1 976 the patient's upper extremity. 1 966 occupational therapy approach recognizes the I S . Williams PL. Framptom VM: Management of brachial plexus jury with erect dislocation of the shoulder. Akbar Z. J Ol'lhop Trauma cal consequences. and e1ec­ ing. Mechanis GI et al: Collagen 1 3 . New York. Fredenucci IF: Duchenne-Erb 1 99 1 palsy: experience with direct surgery. SP0l1S Med 2 1 :650. Hsa KY. Blunelli GA. Narakas A. 1 989 The Neurobiologic Mechanisms i n Manipulat ive 1 2. Narakos A. 1 937 tromyographic study in brachial plexus traction 1 9 . In Dyck PJ. Clin Or· lesions associated with dislocated shoulder. 1 944 lar connective tissue collagen arter nine weeks or 1 4. Acta ChiI' Scand 1 36:46 1 . Edinburgh. 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. 1 98 8 tant rotator cuff tear and brachial plexus injury 3. WB Saunders. Sunderland S: Traumatized nerves. Dean MT: Neurovascular injuries to 22. Am J Spol1S Med 1 8:59 1 . Kendall HO. 2nd Ed. 1 990 28.and sensory recov· . 1 993 Clin 011hop ReI Res 237:87. 2. 2. Bruxelle J. Vol. Inman VT. 1 97 1 British Ed. Curl WW: Upper llunk 26. 344. 1 988 Neurovascular injury complicating displaced 8. 1 993 Ann Chir Main Memb Supcr ( France) 1 0:53 1 . Akeson WH. References 1 952 1 7. A combined physical and Joint Surg 48A: I 503. injury 1 8:423. Philadelphia. Stromquist Lidgren L. J Bone Joint changes in the reducible cross-links in pcTiar1icu· Surg 26A: I . Saunders J B et al: Relation of human electromyograms to muscular tension. Churchill Livi ngstone. Thiebaut JB: Occun'ence brachial plexopathy. Walker PS: Normal and abnOlmal mOlion of the shoulder. Bergfeld JA: Acute 27. Norgren L . Munro RR: Abduction of the arm immobilization. Ital J 01'­ 1 989 thop Traumatol (Ausllia) 1 8:389. DiBendello M. Gilliat RW: Brachial tion or the shoulder joint and rractures or the neck plexus disorders. Boorne RS: Brachial plexus adult: retro· and infTaclavicular lesions. J Hand Ther 1 1 5: 1 20. Williams & I . 1 992 S. Am J Sports Med tion and back problems. Arch Phys Med Rehabil 5 1 :48.N. Acta Ol1hop Scand 42:49 1 . J Prosthet Dent 56:4. Tardieu C. 95. 4th Ed. Masock AJ. juries of the brachial plexus. 1 986 46. Tabary C: Exper· 52. MaLLrey RF: MR imaging Kasch M (cds): Manual o n Management o f Spe­ of disorders of the brachial plexus. Simons DG: Myofascial Pain and Dys· vated skeletal muscles. Maitland GD: Peripheral Manipulation. 1 984 40. Williams & Wilkins. London. Hollinshead W: Functional Anatomy of the Limbs and regeneration of skeletal muscles i n cats. AREN Publication. Janda V: Some aspects of extracranial causes of Raven PI"CSS. Guttman L: Effects of electrotherapy due pegboard on a sample of adult candidates for on denclvatcd muscles i n rabbits. Philadelphia. 1 977 3 1 . 1 9 8 1 more. Philadelphia. MacDougal B: Brief or new: the 35. Medical Research teristics of T. Yeoman PM: Cervical myelography i n traction in­ use of self-adherent wrap in hand rehabi litalion. SCOll A: Occupational Therapy for imental rapid sarcomere loss with concom itant Physical Dysfunction. SCOll P M : Clayton's Electrotherapy a n d Actino· IN: Effect of therapeutic temperaturc on tcndon t herapy. J Magn Reson cific Hand Problems. Lehman JF. p . 1 976 niques of Manual Examination. Balti­ hypoextensibility. SCOll A: Occupational Therapy for 36. Hislop HJ. Tardieu G.ne JJ: The isokinetic concept of after t1-aClion lesion of the brachial plexus. Philadelphia. WB 30. vocational rehabilitation. J and Back. 1 975 extensibility. Hatano E et al: Electrical stimulation on dener­ 32. PI-OC exercise. Lancet t : 169. 7 1 chial plexus injuries. W0I1 hingham C: Muscle Testing. Balti­ myography in the diagnosis and prognosis of bra­ more. Gutman E. Curtis D: Nonnative data for the Pur­ 44. 7th Ed. 356. Trombly C. Gilliat RW: Sensory nerve conduction 50. Office. 1 98 1 facial pain. In Malick H . Her Majesty's Sta· 42. 1 977. ders.. New York. Phi ladelphia. 1 984 Expedmental Basis and Clinical Implications. Bone Joint Surg 54:9 1 9.. FA Davis. 2nd Ed. Bil bey JH. J Bone loint Surg Am J Occup Ther 38:265. Muscle Nerve 4: 1 98 . 1 967 R Soc Med 5 1 :365. In Seddon HJ (ed): 4 t . WB Saunders. Daniels L. . Williams & Wilkins. Tabary JC. London. p. 4th Ed.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. 1980 45. 49. J Bone Joint Surg 5 1 B:627. In Goria A (cd): function. 1 97 1 37. 1 980 ButienvOl1hs. London. 1 954 Function of the Nervous System.gger Point Manual. 1 984 Council Rep0l1 Sel'ies T2 282. Guyton AC: Organ Physiology: Structure and tion. Pen. Lane K. Hamm NH. Enos L. 34. Bonney G. 469. WalTen CG. Bufalini C. Trombly C. Baltimore. 1 994 47. Pesalori G: Posterior cervical electro­ Physical Dysfunction. Lamond RG. Reynold C: The stiff hand. 33. Tech· Saunders.S. p. Lampe GN. Phys Ther 47: 1 1 4. Percept MOl Skills 50: 1 942 309. Koblanski 38. Mannheimer JS: Stimulation Charac­ Peripheral Nerve Injuries. Saha AK: Dynamic stability o f the glenohumeral 1 969 joint. Ball iere Tindall. Pitts­ burgh. 1 968 48.). 1 970 39. 2nd Ed. 1 984 50B:25.E. Williams & Posttraumatic Pel-ipheral NClvc Regcneration: Wilkins. The Tr. WB Saun­ 43. Cooper RR: Alterations during immobilization 53. 1 95 8 5 1 . 1 972 1 976. 1 984 Imaging 4 : 1 3 . Travell JG. These Lhree factors combine to allow at least three distinct types of shoulder Mechanics and arm dysfunction. lar control and the development of abnormal movement patterns. lems for clients with hemiplegia is the shoulder. 2 Shoulder pain. loss of muscular ac­ tivity. SIuru. a loss of motor control and alignment will One of the most worrisome physical prob­ have multiple effects on the shoulder girdle. The Shoulder in Hemiplegia SUSAN RYE R SON KATHRYN LEV J T Hemiplegia."· Because muscles that move the sca­ vious sign of neurovascular disease of the brain. it is important to review the nor­ DEVELOPMENT OF ABNORMAL MOVEMENT mal mechanics of the shoulder (see eh. 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. The length of the lower tone state var- 205 . and glenohumeral Normal. a paralysis of one side of the body. pula and humerus have attachments to the cervi­ it can also occur as a result of cerebral tumor or cal. In hemiplegia. the muscular attachments of the shoulder-girdle Although hemiplegia is Lhe classic and most ob­ complex. subluxation. Before beginning a study of the shoulder girdle LOSS OF MUSCULAR CONTROL AND in hemiplegia. thoracic. This tients with a hemiplegia affects the operation of chapter reviews biomechanical and motor con­ normal biomechanical principles. Three areas of normal shoulder mechanics should be Following the onset of a cerebrovascular acci­ emphasized: (I) the mobility of the scapula on dent with hemiplegia. and lumbar spine. 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. and to Lhe rib trauma. and loss of functional use are the most Abrwrmal Bimnechanics common complainLs. secondary soft tissue changes that block motion. a low tone or flaccid state the thorax.lder Girdi£ joint subluxations.' (2) scapulohumeral rhythm and the is present. I). I cage. 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. leading to muscle shortening. rotation. the biceps and ciate the scapula and hume. trunk. 8. As the scapula assumes a position stant muscle firing in these shortened groups can that combines elements of elevation. This results in lengthening or mechani­ flexors recruited to help move shoLilder. and loss of the ability to disso­ mal weakness. The con­ treatment. and extremities. a more constant state of gravity. Be­ cause the shortened muscles are available to the patient to use actively. However. The loss of wrist flexors may be recruited to help lift the scapular stability on the thorax occurs in all but weight of the arm during shoulder flexion while the most minor slrokes. loss of gleno­ appears to be an attempt to substitute for proxi­ humeral mobility. Spinal extensor control becomes more evident than spinal flexor control. and is influenced ini­ no contraction of the deltoid can be palpated tially by such factors as the pull of the arm into (Fig. These patients get re­ tionships of the bones.1). As an example. abnormal movement components. The emergence of spasticity will pe'-petu. inhibition of shortened groups is reinforced cortically with spasticity alone will not produce a functional the attempt to move the aml. downward quickly pull the carpal bones out of alignment. This state is character­ ized by a decrease in active postural tone and a loss of motor control in the musculature of the head. the pattern of control is imbalanced. Early patterns of motor return pull the scapula and arm into ab­ normal postures. the development of postural asymmetry. Over time. state. excitation develops in the biceps and wrist flexor and the influence of pattems of motor retum and muscles. individual muscles gradually become stronger. wrist. the position of the sca­ leading to deformities in the forearm.1 Left hemiplegia: biceps a17d wrist ranges. soft tissue stretching may turn in both flexor and extensor muscle groups. and pula prevents forward flexion of the arm past 60' hand. and abduction. and ab­ A third pattem of motor dysfunction in pa­ normal joint alignment to restore normal move­ tients is characterized by abnormal coactivation ment. as motor return occurs. Because upward rotation is not available . to 80'.us. In other patients. these distal Soft tissue blocks to motion can be catego­ muscle groups are recruited abnormally in what rized as loss of scapular mobility. certain muscle groups are positioned in shortened F'GURE 8. However. Initially.206 PHYSICAL THERA PY OF THE SHOULDER ies from a short period of hours or days to a pe­ riod of weeks or months. Motor reeducation must be directed toward these groups may also be reinforced by associ­ both the recruitment or strengthening of absent ated movements7 Thus. Thus. To restore the normal mechanical rela­ of limb or trunk muscles. These patients also have the ability to re­ cruit distal muscle groups. be necessa ry. As motor return occurs. no movement i s possible. but have difficulty integrating the firing pattems to produce lateral or rotational movement pat­ Soft TissLie Blocks to Motio17 terns. neck. Muscle firing in arm. muscle activity in these ate abnormal alignment. When the scapula and hume­ 'us are pulled severely out of alignment. not all muscles around a joint retum at the same strength. ity are maintained in an almost constant state of treatment must address the abnormal tonal excitation. cal disadvantage in opposing muscle groups. "functional spasticity" or weak muscle groups and the retraining of can develop when muscles of the upper extrem­ available muscles to fire appropriately. carrying. but any movement of the humerus . the humeral greater tubercle will impinge under the coracoid process (Fig. The loss of this scapular com­ ponent. Changes in scapula position will alter the ori- FtGURE 8. and upper extremity weight-bearing. In pa­ tients with an elevated. the scapula has mobility on the thorax and the humerus retains mobility in the FtGURE 8. glenoid fossa. entation of the glenoid fossa and affect the rest­ ing position of the humerus. the humerus is always positioned in some degree of intemal rotation. consisting of scapular abduction and up­ ward rotation. The goal in treatment is to re­ store the normal resting position of the scapula on the thorax and to regain mobility and motor control in all planes of motion. 8. abducted scapula and a hume­ rus that postures in abduction and intemal rota­ Lion. In patients with an elevated. loss of scapu­ lar adduction and depression has equal func­ tional importance for resistive tasks such as lift­ ing. but its position relative to the glenoid fossa will depend on the alignment of the scapula. pushing. With a downward-ro­ tated and depressed scapula. glenohumeral movement greater than 60· is not possible. The loss of scapula upward rotation and protraction is important f1Jnction­ ally because it is necessary for reach and pain­ fTee elevation of the arm. inferior subluxa­ tion and internal rotation result (Fig.3). abducted scapula and a hyperextended humerus. results in the substitution of scapula elevation.2). In cases of chronic hemiplegia. the humeral head will be positioned anteriorly in the fossa. [n this case. THE SHOULDER IN HEMIPL EGIA 207 for the scapula. However. Without treatment.2 Left hemiplegia: inferior subluxation. Loss of dissociation of the humerus from the scapula is the third block to nOlmal movement.3 Left hemiplegia: impingement of humeral greater tuberosity beneath acromion. 8. the scapula loses its mo­ bility on the thorax and becomes fixed. thus eliminating the scapular component of scapulo­ humeral rhythm. � !J ~ �: \ \ � . . . � A \ \ B c o FIGURE 8.208 P H Y 5 IC A L THER A P Y 0F THE 5 H 0 UL 0 ER � J.. (D) Superior glenohumeral joint subluxatioll.4 (A) Nonnal glel10humeral aligl1mel1t. (B) II1{eriol' glel10humeral joil1t sublllxatiol1. (C) Al1Ierior glel10humeral joint subluxation. as de­ uting to glenohumeral stability are disturbed. 8. the ward. Type 1 Ann With a severe loss of muscular activity. With humeral ab­ scapular abduction. The scapula.' When the slope of the glenOid fossa gic shoulder. the humerus luxations are discussed in detail in the next sec­ tion. moving on this laterally Oexed trunk. scribed by Basmajian. Each of these subluxations have down­ angle winging.3. if not supported.5). as does the inferior sub­ upper trapezius and levator scapular become ac­ luxation. Second. 8. 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. 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).4). the subluxed shoulder should not be allowed to progress into a painful shoulder with loss of passive range of motion (ROM). the subluxation cause the spine to curve with the concavity to most fTequently mentioned. First. As motion return occurs and the ward-rotated scapulae. and the head of the humerus can slide down the glenoid fossa4 SHOULDER SUBLUXATION With scapular downward rotation. and the scapula on the thorax. 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.6 is los!. The loss of this The most important factor is the position of the mechanism. occurs'·6 the hemiplegic side or to Oex forward (Fig.5 Type I. THE SHOULDER IN HEMIPLEGIA 209 into nexion or abduction results in simultaneous humerus in relative abduction. the shoulder capsule is lax superiorly. These sub­ an elevated scapula. 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. . the humerus "slides down" the slope of the weight of the paretic arm and upper trunk will fossa. 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. Subluxation is not painful as long as the sca­ pula is mobile. the loss of postural tone. duction.7 However. will pull flexiol1 of IrLlI1k with flaccid aI'''' influencing the weakened scapula downward and place the scapLlla position. with inferior luxation. head and trunk control are virtually absent.4 Third. becomes less oblique and no longer faces up­ When the body is in an upright position. an inferior subluxation may be found with planes of movement vary (Fig. loss of trunk control results in increased lateral trunk Oexion. In either case. and the glenoid fossa faces inferiorly. but the other scapula and humeral tive. and inferior subluxation. becomes relatively downward rotated. FIGURE 8. left hemiplegia: fonvard the weight of the arm. the shoulder rotator cuff and the insertion of the latissimus capsule is vulnerable to stretch. Any movement the fossa. . the humerus is hanging by the side of the body.210 PHYSICAL THERAPY OF THE SHOULDER FIGURE B.6). With an inferior subluxation. (B) Type I. To re­ sule is taut. 8. and posteriorly in the noid [ossa. Over time. and (oreann prO/1Qtiol7. the superior portion of the to its normal position in the frontal plane (ele­ capsule will become permanently lax. With an inferior subluxation of tion. available. In this position." vated if low on the rib cage and depressed if high When subluxation occurs. scapula lower 01'1 thorax.6 (A) Type I. especially when dorsi muscle. the scapula must rus will place an immediate stretch on the taut first be upwardly rotated to neutral and moved capsule. As subluxation occurs. scapular elevation with humeral elbow will extend passively.' The weight of the dependent hume­ duce an inferior subluxation. 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. 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 the forearm will internal rotation may be the only movement pronate (Fig. the long standing. will hang by the side in internal rotation. left hemiplegia: left side o( body (allil7g laterally into gravity. the superior portion of the cap­ R E DUCTION OF INFERIOR SU B L UXATION. 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. left hemiplegia: humerus hangs by the side in il'llemal rotatiol7. the movement on the rib cage). elbow extension. With an an­ ing of the scapula terior subluxation. As the humeral head moves Type /I Ann forward out of the socket. Inferior glenohumeral joint subluxation tated and positioned inferior to and forward of 4. The scapula and humerus are strongly trudes forward against the proximal end of the FIGURE 8. the humeral head pro­ (Fig. the humerus is internally ro­ 3.8). The humeral head appears aJigned with the acromion in the sagittal plane. left hemiplegia: loss of rib cage al1chor with rib cage rotated bachvard and humeral hyperextension with internal rotalion. .7). An increase in cervical and lumbar exten­ will occur. The downward-rotated scapula begins to move superiorly on the thorax. Downward rotation of the scapula hyperextends with internal rotation. 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. Therefore. 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. sion is evident. and the nals. 8. and the humerus I. the distal end of the The second pattern develops as the trunk humerus moves into hyperextension. 8. The gleno­ 2. At the thoracic level. the rib cage loses its abdominal subluxed. this imbalance re­ and the forearm to pronate (Fig.7 (A & B) Type II. 8. Infel-ior gains more extension control than flexion con­ angle or vertebral border winging of the scapula trol.4B). internally rotated humerus moves into "anchor" and will flare laterally and/or rotate stronger hyperextension. resulting in an apparent shortening of the length of the clavicle. Humeral internal rotation the glenoid fossa (Fig. Vertebral border and/or inferior angle wing­ humeral joint will sublux anteriorly. As the sca­ sults in a unilateral loss of control of the abdomi­ pula continues to elevate on the thorax. In chronic cases of anterior subluxation. Anterior subluxation will be the movement pattern available. R E D UCTION OF ANTERIOR SUBLUXATION. forearm. Shorten­ and spinal alignment is cOiTected. The wrist may ap­ from this type of arm include pear to be less flexed as the carpals move dorso­ laterally. If the patient is asked to lift der winging the arm. This forward pressure of the hu­ of the huments is brought forward out of hyper­ ments against the already shortened biceps ten­ extension. While stabilizing the scapula FIGURE 8. the huments is moved hyperextensiol7 with (oreann pronatiol7. it must be moved down from its elevated position and upwardly rotated to neutral.on 3.9 Type II. can then be realigned on the rib cage. right hemiplegia: . biceps. I. left hemiplegia: h«meral in its corrected position. shoulder elevation with humeral inter­ nal rotation.. the scapula ing and spasticity in pectoral and biceps groups .8 Type II. 8. from internal rotation to neutral. To elbow flexion becomes more dominant and the con'ect this subluxation. Humeral internal rotation Soft tissue tightness will be present in the pectoral muscle groups. 4.. the rib cage is derotated forealTn adducts across the abdomen.9). and hand. The humeral head can then be moved back as the distal end biceps tendon. and elbow f1ex. don will mechanically move the forearm into a Biomechanical shoulder problems resulting supinated position (Fig.tllieral hyperextension with (orearm S«pilwtioll. and then lifted up into the fossa. Downward rotation and elevation of the sca­ This anterior subluxation will limit move­ pula ments that require the huments and hand to be 2. To realign the scapula on the rib cage. hyperextension. Scapular inferior angle andior vertebral bor­ in front of the body.212 PHYSICAL THERAPY OF THE SHOULDER FIGURE 8. rotator cuff. This gives an appearance of "mass" flexion in the hemiplegic upper extremity. it must be lowered. 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. and Passive motion of the glenohumeral joint is adducted. abduction. three ways.meral humerus is tightly held in internal rotation and abduction. The sca­ pula is usually elevated and abducted on the thorax. pector­ als. I".10). When bral border winging distal movement exists. The scapula moves superiorly and tilts anteriorly. During attempts to move. Superior subluxation active shoulder pattern. patients can I. The humerus is externally rotated to severely limited because the humeral head is neutral. First. This moves the forearm from pronation in the direction of 4. Soft tissue tightness in these groups is often mistaken for atrophy from brachial plexus Relatiol1ship of Subluxatiol1 to COl1lrol injury. from this type of arm include with elbow and wrist flexion (Fig. Type /II Ann The third type of arm pattern is character­ ized by abnormal coactivation of the limb mus­ cles. The control patterns are not sufficiently integrated to allow selective combinations of movement. The scapula is returned to a neutral posi. these patients typically "fire" strongly in this ele­ Biomechanical shoulder problems resulting vation-abduction-internal rotation pattern. and rib cage f1airing accompanies ac­ tive movement of the hemiplegic arm. and the scapula loses mobility in the direction of depression and upward rotation. THE SHOULDER IN HEMIPLEGIA 213 may develop. 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. no dissociation occurs between the hu­ as the humeral head is brought back into the merus and scapula.iplegia: active coracoid process in a superior subluxation. Humeral internal roLation flexed and radially deviated position. Lack of dissociation between scapula and supination. al1d elbow flexion. left hem. The wrist assumes a 3. the loss of antigravity postural . rotated upward. humerus. 8. and rotator cuff are frequent secondary com­ plications. fossa. causing the humerus to lie under the FIGURE 8. so that the elbow joint lies directly below the shoulder in the frontal plane but is abducted away from the rib cage.10 Type If{. and between scapula and rib cage Soft tissue tightness in the deltoids. By in­ creasing humeral internal rotation. tion. Scapula elevation and abduction with verte- "lock" their elbows into elbow extension. The 1110tion available in shoulder elevation. The neck and tnmk control in clients with this upper extremity pattern contain elements of both flexion and ex­ tension. it is used to reinforce the 2. internal rotation. Exter­ lodged under the coracoid process. using slight traction if necessary. The type of shoulder subluxation and the R E D UCTION OF SUPERIOR SUBLUXATION. The most fre­ Biomechanically. Third . Four categories of shoulder pain can be identified: joint pain. improper mus­ cle stretching. At the shoulder. . the precise anatomic location of the pain. and will contribute to the abnormal and ineffi­ The movement should STOP. or hy­ posensitivity.' Pain occurs in the hemiplegic shoulder as a result of muscle imbalance with 10 s of joint range. It is relieved immediately when ond. If soft tis­ motor patterns to identify the segments of abnor­ sue orjoint tightness exists. and rhythm is not maintained. hypersensitivity. tendinitis. and shoulder-hand pain syndrome. 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.214 PHY SICAL THERAPY OF THE SHOULDER tone . realignment may not mal motion. impingement of the shoulder capsule during improper ROM. the nature of the pain. the limb should be cient motor pallerns associated with hemiplegia. may result in problems in any or all of these areas Forced motion with pain must never be allowed. Pallerns of Treatment for this type of pain begins with spasticity or abnormal coaclivation of muscles immediate cessation of the movement pattern.derations SHOULDER PAIN Shoulder pain is one of the major problem areas in hemiplegia. and the body posi­ tion during the movement that causes the pain must be assessed. 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. muscle pain. the changes in bony alignment will change joint alignment is corrected. resting lengths have been altered. in which meral head in the glenOid fossa. When the turn will change the relationship of the scapula joint is improperly aligned. This pain is sharp and stab­ alter the anatomic relationship of the jOinls. MuscuWskeletal C011Si. Sec­ bing in nature.lnd the subsequent pallerns of moLion re­ ance or improper movement pallerns. weight-bearing upper extremity. lowered. pain from altered sensitivity. this will lead to muscle imbal­ quent reasons for poor al ignment are (t) lack of ance and problems of motor control. This change in position will result in joint pain. the resting length and direction of pull of the joint pain occurs when glenohumeral alignment major muscle groups of the shoulder and arm.1 I Left hemiplegia: body moving 0/1 sition as a result of either shoulder muscle imbal. and the bones must be cOITectly re­ Clinically. To plan a treatment program. improved or increased. Join' Pain Joint pain in hemiplegia occurs when a joint is placed in a biomechanically compromised po­ FIGURE 8. pain also is caused by sympathetic changes. the duration of the pain. it is necessary to analyze the patient's aligned before treatment begins again. This will facilitate more effective be possible unless soft tissue or joint mobility is treatment. 13). The pain is immediately relieved if the should be stopped until the pain subsides. rollowed by overaggressive weight-bearing with This pain occurs in the upper extremity. Treatment Altered Sensitivity can proceed with careful attention given to speed and progression or movement. along with an inac­ body on the limb (Fig. and propri- FIGURE 8. Because lengthening shortened muscles is care should be given to proper joint alignment a goal or treatment.11). 8. THE SHOULDER IN HEMIPLEGIA 215 Muscle Pain extremity. ceived as a "pulling" sensation and is localized 8. The inappropriate is "accustomed. Overstretching or a limb muscle ery following an insult. sensory." Often. When amount or severe stretch is decreased a few de­ weight-beru. It typically occurs arter the weight-bearing is stopped. move back to the shortened range. The pain that occurs because or altered sen­ The pain that accompanies tendinitis is re­ sitivity of the central nervous system (eNS) to lated to muscle pain . Muscle pain is per­ tive trunk and "leaning" on a weak scapula (Fig. to the region or the muscle belly that is being The weight-bearing extended arm activity stretched. this type of pain occurs weight-bearing pattern that leads to tendinitis in when the upper extremity is in a weight-bearing these cases is severe humeral internal rotation position and the patient is asked to move the with forced elbow extension.12 Le(t hemiplegia: weight-bearing with improper alignment. particular grees. 8. and is re­ during the middle or a treatment session that has rerred to other locations. kinesthetic. . and bicipital tendinitis muscle is lengthened too fast or lengthened be­ across the elbow with pain referred down the yond the range to which the shortened muscle volar aspect of the forearm. In the hemiplegic upper included tactile .ng treatment is resumed. the muscle is not allowed to and active trunk scapular pattern (Fig. the two most common types are bicip­ ital groove tendinitis with pain referred down Muscle pain occurs as a shortened or spastic into the muscle belly. and poor jOint alignment results in tendinitis. [or it is caused by the same sensory input is found at the acute stage of recov­ mechanisms. The is described as both diffuse and aching and local­ pain is described as aching or sharp.12). remains ized to the shoulder and sharp. but is allowed to shorten until the pain is relieved. 3.216 PHY SICAL THER APY OF THE SHOULDER FIGURE 8. and the duration of I. treatment objectives for the hemi- . Reeducates open-ended activities (non­ weight-bearing) with appropriate scapulo­ humeral rhythm Shoulder-Halld Syndrome 4. these patients may proceed to shoulder-hand syndrome. Prevents edema Shoulder-hand syndrome begins with dif­ 5. the hand soon becomes swollen and tender. and The treatment of the deficits in motor control in fingers.nning The second stage is characterized by de­ creased ROM of the shoulder girdle. Because this pain interferes with the desire to move the arm. Skin changes are also present because the patient with hemiplegia focuses on the im­ of the lack of motion and loss of tactile input. Subsequent treatment should be 2. hand. If treat­ and upper extremity ment is stopped completely. 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.1 3 Left hemiplegia: weight-bearil1g with proper alignment. the joints will become sharply painful. provement of function and the prevention of fur­ The syndrome culminates with presence of ther disability from secondary complications. One explanation for its occur­ and joint contractures. oceptive stimuli. Grades the motor program in stages with in­ treatment and the nature of the treatment should creasing sensitivity to movement be noted. In atrophied bone and severe soft tissue deformity this section. The treatment should stop for that session. 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. If passive motion is forced on a swol­ len wrist and hand. Teaches patients how to care for their arm fuse "aching pain" in the shoulder and entire arm. Treat:rnent Pln. or falling. 8-1SC to H).14C). posterior. and vestibu­ in preparation for getting out of bed (Fig. postural control of the head. and increasing mobility. REESTABLISHMENT OF POSTURAL CONTROL Establishing Weight-Bearing The objectives for establishing postural control include (I) facilitating righting reactions. When the upper extremities are normal weight-beal. and kinesthetic stimulation. a point of mobility. Weight shift. kinesthetic. Along with sensory feedback (tactile. and affected aIm following a stroke is one of the most (2) providing normal tactile. improving motor control of the af­ trol provides the body with the ability to shift fected arm. THE SHOULDER IN HEMIPLEGIA 217 plegic shoulder will be presented in three major non-weight-bearing palterns. and protective reactions. grasping. To establish good motor control. This postural trunk con­ of the trunk. 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. The second set of objectives focuses on Reestablishing Nonnal Alignlllent the neuromuscular deficits of hemiplegia: loss of extremity motor control and function. neck. proprioceptive. This active participation of the body (trunk) must be able to adjust posture auto­ trunk. or diagonal. equi­ The ability to accept and bear weight on the librium reactions. equilibrium re­ while standing. when very Objectives for reestablishing motor control and little postural control is present. and important goals of a therapeutic program. and (3) extending the eral. movement requires a base of stability or and B). increasing postural control trunk must be present. In the It is necessary to reestablish normal align­ third category. visual.ng patterns in the upper ex­ "fixed" onto the supporting surface through fore­ tremity. loss of motion.. lateral. (2) supporting the forearm on a pillow base of support. The shoulder girdle must be properly pain. either anterior. Positions that pro­ for the functions of reaching. and re­ vide weight-bearing for a hemiplegia shoulder leasing. and asking the trunk or "body" to move on the stable arm in anterioposterior. the objectives for the secondary ment before attempting to reeducate motor con­ complications of hemiplegia-subluxation.1SA and B). and weight to one side fTees the opposite extremity preventing edema and pain. 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. actions. NEUROMUSCULAR DEFICITS In the acute stage of hemiplegia. lat­ when silting (Fig. is followed by one or more of weight-bearing arm down onto a countertop the following: righting reactions.14A lar). (3) initiating and "holding" proximal arm weight-bearing activities. and (4) reeducat­ categories. introducing and grading tactile pro­ weight. 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. (2) establishing motor control. protective reactions. 8. tic muscles or by supporting body parts that do not have sufficient muscular activity. and arm include (I) rolling onto the affected side proprioceptive. the arm becomes . trol. The ability of the body to shift and bear prioceptive. the 8. The first category of objectives is de­ ing distal movement for functional skills. the scapula. 8. and spasticity-will be dis­ aligned either by lengthening shortened or spas­ cussed. upper extremity function of the hemiplegic arm include (I) rees­ weight-bearing is used to facilitate proximal tablishing normal alignment. Active kinesthetic input. signed to help the patient releam basic postural control. and a weight placed in the lap or on a lap board or on a table shift. and rota­ tional directions (Fig. arm. and upper trunk nexion are en­ movement patlerns. 8. and elbow nexors. tight the lateral weight shirt becomes more externally humeral internal rolatOl-S.17). 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 pelvis and person sits with hands down and open. 8. one into more abduction and one fected upper extremity will lengthen tight shoul­ into more adduction. .14 Weight-bearing positions (or the LIpper extremity. As the body moves away from the internally rotated (Fig. For patients with available but synergistic humeral nexion. The humerus on the side or der depressors and downward rotators.218 PHYSICAL THERAPY OF THE SHOULDER FIGURE 8. a point or stability ror movements of the trunk rotated.16A). upper extremity weight­ couraged (Fig. while the other humerus becomes more and pelvis. (A) Left hemiplegia: rolling onto afef cted hemiplegia: //loving onto affected sLlpporting (oreann 011 table. the scapulae move in oppo­ tional movement of the body toward the ar­ site directions. scapular protraction and upward rotation.16B). 8. a rota­ trunk move laterally. When the extension (Fig. When the arm is movement as needed. �l. including the ability to girdle occur as a reaction to the body's move­ switch from glenohumeral to scapulohumeral ment over the rixed extremity. (Figure continues) .. . (2) the ability to initiate antigrav­ of weight-bearing. t 5 (A) Right hemiplegia: improper lI'eight­ bearil1g 011 extended anl1-"hal1gil1g" 011 shoulder a l1d mechal1ically 10ckil1g elbow. and (3) the ability to recip- • J A ur. B c FIGURE B.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. the motions of the shoulder ity movement paUerns. (C-H) Establishing extended­ arm weight-bearing il1 silting. 8. Therapist aligl?S palients left shoulder while she practices combining trunk and arm D E nlovements.. the demands on the shoulder girdle are dirferent from weight-bearing demands.o:.____ /.. in space. The motor demands on the shoulder for non-weight­ iI.. THE SHOULDER IN HEMIPLEGIA 219 while simultaneously activating the opposing taken out or weight-bearing and is asked to move groups (Fig.18A & B). (8) Right hemiplegia: extended arm weight-bearing. 8. 19A). or malalign­ ment. Techniques for managing pain and spas­ ticity are discussed under ''Treatment of Second­ my Complications" later in the chapter and should be used before treatment of motor con­ F trol proceeds. In these cases. in sitting positions until the patient develops con­ trol of the arm in various combinations of sca­ pula and humeral patterns (Fig. the types and combinations of movement can be increased. it is frequently impossible within a treatment ses­ sion to reposition the scapula or humerus in nor­ mal alignment before proceeding with move­ ment reeducation. Orthopedic changes. followed immediately by a movement pattern that uses this new mobility. Over successive treatments. the goal is to gain some increase in mobility in the direction of normal alignment. later. and malalignment of the shoulder joints are not problems. teaching the patient to manage the weight of the arm against gravity is the first stage of motor control to be introduced. as soh tissue mobil­ ity is increased and passive resting positions be­ come closer to normal alignment. . This is done by teaching the patient to "hold" the scapula and humerus in an anti­ gravity position (Fig. This H is done by moving the hemiplegic ann in many functional patterns combined with strong sen­ FIGURE S. When the con­ cept of holding has been achieved. represent a particu­ lar treatment challenge because although ortho­ paedic malalignment at the shoulder will neces­ sitale compensation or abnormal movement. The patient is then taught to move actively within his or her range of control. the patient is asked to initiate patterns at the shoulder. particularly those that are long standing.220 PHYSICAL THERAPY OF THE SHOULDER rocate and coordinate the combinations of mo­ bility and stability needed for reaching. Motor reeducation aimed at training the hemiplegic arm to move against gravity will vary according to the patterns of return present and variables such as pain.7. spasticity. treatment can be directed immediately to improving motor control.19B and C).15 (Conril1ued) sory stimulation during each treatment session. grasping. When pain. in the acute stage. carrying. spasticity. and releasing. 8. in which muscle tone is low and little motion is present.9 "Place and hold" activities are practiced in supine and. quick the patient to identify and quiet muscles that are stretch (inhibitory tapping. Compen­ rOlalion while left htllnerus begins /0 move into satol). including joint compression pallern of motor recmitment. taught to allow passive motion of the arm with­ out firing muscles inappropriately or allowing muscle tone in the ann to increase. This category of patients has right moves right humerus into more external missing components of motor activity. Thus. lack of active external rota- . motions resembling an abnormal pattern Ihe direClion of inlernal rOlalion. hibition or biofeedback. treatment is directed toward establish­ lated. 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. Patients who have less spasticity or more complete motor return have fewer problems with abnormal recmitment but more problems FIGURE B. (8) moving body toward weight-bearing arm. The patient is then encouraged to try to "follow" the movement and finally to perform it actively with less assis­ tance from the therapist. 1 6 Right hemiplegia: (A) moving body away from weight-bearing ann. Problems in motor (pressure tapping. The patient is then When the patient has movement available. but to use the biceps appropriately to bling the hand to the mouth. the patient is also taught appropriate con­ trol of the previously "overused" muscles. and repetition. The techniques of stimulation have been ing more normal coordination. result. resis­ recmitment can best be addressed by teaching tance with proper alignment maintained. sweep firing inappropriately through techniques of in­ tapping (bmshing. This may involve described by Bobath and others. joint approximation). For example. 1 7 Right hemiplegia: weight shifting to with motor control. "pull-push"). icing). although they have been ascribed cles are recmited and retraining in the COITect different names. While new recmitment pallerns are being estab­ lished. THE SHOULDER I N HEMIP L E G I A 221 • B FIGURE B . the patient learns to inhibit biceps activity when reaching. 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. The techniques both inhibiting the abnormal way in which mus­ are the same. If this hold the hand in position while the fingers move. must be based on normal patterns of mobility and stabil­ ity in the scapula and glenohumeral joint. motor pattern is being used because the patient and sustain grasp while moving proximally. 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. Problems in any of these areas may inlerfere the goal of treatment must be to make external with adaptive grasp. (Figure continues. works on upper extremity placing or movement sequences. the therapist must control the learned.) . menlS. tion of the humenls will lead to a substitution position the hand appropriately for grasp by se­ pattern of abduction. other patients may have difficulties tions are available to the patient to use function­ with protraction and upward rotation of the sca­ ally. To use the hand functionally for grasping. nlpO'ir. I B (A & B ) urt hemiplegia: rotational body movements over a weigh/­ A B bearing upper exrremity. the patient must learn to add combinations of elbow position and forearm rotation to the A control established at the shoulder. to be accurate. 1 9 (A) u{t hemiplegia: place and hold Ip:.20). As new combinations of motor behavior are pula.'I <:: ina I h p h p m . 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. Once the patient can initiate normal motion at the gle­ nohumeral and scapulothoracic joints and can maintain the shoulder in positions against grav­ ity.I hp ahlp I n position.222 PHY SICAL T H ERAPY OF THE SHOULDER FIGURE B. In this case.n�fipnt m i l ". Reedllcating Distal Movemel1lS Distal motor control. carrying. internal rotation of the hu­ lecting appropriate forearm and wrist positions. be added in treatment so that various distal posi­ Similarly. cannot actively externally rotate the humenls. and re­ FIGURE B. 8. rotation available during active shoulder move­ As shoulder girdle control builds. and scapula elevation (Fig. forearm. When the hemiplegic patient has biome­ chanical shoulder girdle problems. and wrist as a precur­ sor of success. and spasticity-are discussed separately." If subluxation has oc­ pallem of humeral abduction and illtemal cUlTed. elbow. In addition.20 Le(t hemiplegia: lack of aClive ment follows the objectives listed earlier under external rotation results in compensation "Treatment Planning. assessmenl. the transition from grasp to manipulation involves the addition of complex fine motor patlerns that are often task specific. treatment must be preceded by caref'ul rotation. loss of motion. Subluxation Acutely. reduction of subluxation. accurate po­ sitioning of the hand for function is difficult as the patient attempts to hold the shoulder against gravity and initiate appropriate antigravity movement pallerns. . treat­ FIGURE 8. Improving the level of hand function is thus a separate treatment pro­ cess that requires good motor control of the shoulder. FIGURE 8. THE SHOULDER IN HEMIPLEGIA 223 Different grasp patlerns require varying wrist and forearm positions. 10 TREATMENT OF SECONDARY COMPLICATIONS The objectives for each of the secondary compli­ cations-subluxation pain. if subluxation is not present.19 (Continued) ( B & C) Therapist con'ects alignment and helps patient iean7 to move his le(t arlll ill a variety of B C pal/ems. and proper support. b cage once the con'ection has been when sitting. the shoulder saddle determination of sling. FL): This support elevates the muscle groups scapula and provides minimal inferior sup­ 3. self-assisted motion during func­ made. 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 .21B). Miami. Appropriate treatment can cuff and a shoulder saddle suspension. and spine Nephew. ing functional activities. no shoulder StlPPOlt will cor­ rect glenohumeral joint subluxation. The ward traction on the shoulder capsule caused by shoulder should be supported in the acute stage the weight of the aim.. armrests. This I. through proper positioning andior shoulder Because no device is available that upwardly supports rotates the scapula. They also help to relieve down­ S HOULDER SUBLUXATION S U P P O R T S . Prevention of stretching of shoulder capsule donned (Fig. In the I 950s and 19605. thus decreaSing shoul­ der joint pain. It then begin. 8.210).. Shoulder supports will also prevent the tional activities. rus against the body in internal rotation and kept the elbow in nexion. Manual alignment and support of scapula sling is excellent for the naccid limb with on the thorax and humerus in the glenoid pain. Increase in motor control in shoulder girdle Inc. 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. or pillows tion on the I. Menomonee Falls. These slings held the hume­ each patient.. Inc. Maintenance of pain-free ROM with proper been criticized for placing pressure on the glenohumeral rhythm brachial plexus when inappropriately 5. The arm is free to be moved The assessment will reveal the cause of the and used for support (Fig. It allows moderate humeral and fossa during treatment elbow movement (Fig. Amount and location of motor control port to the humerus and allows the elbow to be extended. Mobility or passive range of motion sling has a humeral cuff and a figure eight 3. Treatment of subluxation includes provides maximum support to the entire the following goals: arm and prevents the arm from "banging" around during functional activities. and variations on the axillal)' support as described by Bobath . It should not be used tissue tightness in patients with elevated scapulae. Inc. sca- RolyQl1 hemi arm slil1g (Rolyan Smith and pula.224 PHYS I C A L T H ER A PY OF THE S H O U LDER Proper assessment of subluxation includes Rolyan hemi arm sling. and weight-bearing on the fore­ naccid arm from banging against the body dur­ arm or hand. tables.21C). Tone suspension. 8. The exact position of the humeral head. and hypo­ Brookfield. IL): This sling has a forearm tonus or hypertonus). andior humerus. of hemiplegia to prevent stretch on the capsule Therapy clinics should have different types or to eliminate pain.21A). It will provide moderate sup­ 4. rib cage.' I . Shoulder Proper positioning can be achieved through supports will help support andior maintain posi­ the use of lapboards. 8. Inhibition of spasticity or stretching of soft port for the humerus. It has 4. 2. soft tissue tightness. subluxation (loss of motor control of scapula Shoulder saddle sling (Fred Sammons. Axillary sLipport (All Orthopedic Appliances. WI): This 2. 8. 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. Realignment of the shoulder girdle/trunk complex either by the therapist manually 4. t . if present ened or spastic muscle groups and realign­ ment of malaligned joints) 3. (C) Shoulder saddle sling.21 (A) Orthopaedic sling. (D) Axillary support. THE SHOULDER IN HEMIPLEGIA 225 A c B o FIGURE B. Removal of edema. (B) Rolyal7 hemi anll sling. Reeducation of the inactive muscle groups . Bel" lower extremity in transitional movements and lin. Basmajian N: Muscles Al ive. ef­ Loss or Range fective treatment can guide motor return and prevent the development of abnormal mOlOr pat­ Loss of ROM at the shoulder can lead to de­ terns. The presence and distribution of spas­ I . ticity in the upper extremity is often influenced McGraw-Hili. From a 6. existing spasticity in Balt imore. Thomas Todd. and hand of shortened muscle groups. Be­ cause the abnormal motor patterns of hemiple­ gia can arise from a combination of abnormal Spasticity alignment. Kapandji lA: The Physiology of the Joints: Upper in standing and walking. " · " Spasticity is one of the positive symp­ thorough understanding of the interrelation­ toms of hemiplegia along with clonus and ships between orthopedic and neurologic fac­ disinhibition of primitive reflexes. New York. unbalanced motor return. FA Davis. de­ positive results of any treatment regimen will ul­ layed initiation of movement. 1 3 evaluation and skill in implementing appropri­ Although inhibition o f spasticity alone will ate treatment of the shoulder girdle complex. Bos· motor control. 7 . and abnor­ The importance of spasticity in the treat­ mal patterns of muscle recitation and reCl'1. and pathologic co­ timately depend on the clinician's systematic contraction of muscles must also be addressed. Philadelphia.1it­ ment of hemiplegia is a controversial sub­ menl. the negative fore neuromuscular reeducation can begin. Churchill Livingstone. (2) activation of the trunk musculature through upper extremity weight-bearing. 1 985 3. We believe that in stroke patients who have not developed spasticity. Cailliet R: The Shoulder in Hemiplegia. forearm. slow maintained stretching or elongation through weight-bearing (functional stretching in The importance of identifying the exact location conjunction with retraining motor control) is and nature of shoulder girdle dysfunction in more effective. or (3) reeducation of the pelvis and lower extremity. Limb. Davis PM: Steps to Follow. Adams RD. movement point of view. Bobath 8: Adult Hemiplegia: Evaluation and . loss of force production. 1 979 the upper extremity can be inhibited by ( I ) main. A graded program of weight-bearing tained elongation or lengthening in the pattern through the shoulder. the development of abnormal compensatol). The symptoms. Codman EA: The Shoulder. Williams & Wilkins. 1 970 Campbell I I hypothesizes that by preventing 4. creased arm function and impaired balance in patients with hemiplegia. It is only when tone is inhibited that a true assess­ References ment of the patient's motor abilities can be per­ formed. The presence of subluxation and pain are spasticity must be dealt with during the treat­ additional problems that must be addressed be­ ment of the hemiplegic shoulder. not result in a functional upper extremity.226 PHY SICA L THERAPY OF THE SHOULDER 5. SpI·inger·Yerlag. Although classic stretching procedUl-es (non-weight-bearing) are often used for loss of shoulder motion in hemi­ Summary plegia. treatment strategies must be based on a jecl. the rapists may decrease or even ton. Yictor M: Principles of Neurology. 1 98 1 by the patient's ability to control the trunk and 2 . paresis. t 980 motor patterns through activation of normal 5. persis­ tent muscle activity or muscle shortening will block nOl-mal movements from occurring. Although lOrs. Edinburgh. hemiplegia has been stressed in this chapter. 1 934 prevent the development of spasticity. I I . Rubiana R: Examination o f the Hand and Upper and movement : Robert Wartenberg Icctul+e. Campbell S: Pedialric Neurologic Physical Ther­ 1979 apy. THE SHOULDER IN HEMI PLEGIA 227 Treatmenl. New York. Carr J H . Jensen M: The hemiplegic shoulder. Ann Neurol 2:460. William Hcinncman. 1 984 rology 30: 1 303. Neu­ Limb. Sahrmann S. 1 980 . Lance JW: The control or muscle tone. 1 977 gramme for Stroke. 1 980 untary movement to spasticity in the upper motor 9. reflexes 1 0. 7: 1 1 3 . 1 983 1 3 . Shepherd R: A Moto. SLlPPi. 2nd Ed. Philadelphia. Churchill Livingstone. NOJ1on BJ: The relationship of vol­ habil Med.' Relearning Pro. Aspen Systems. 1 984 8. neuron syndrome. WB Saunders. London. Scand J Re· 1 2. London. . . . . . . . . . . . . . . . . . . . but still a significant. . closer scrutiny can provide the therapist sionally such an activity is too strenuous for the with a wealth of information to guide rehabilita. 9. a different perspective is fitting. Occa- 30 d i e . choices that may be more appropriate.11. other exercises tested would be or painful. pro- the preset criteria. the data from Townsend et a l . individual recovering from an injury or surgery.tion. Although the assumption is less. scaption in external rotation requires more appropriate. muscle. and (4) press-up (Figs. amount of supraspi- made that the exercise with the greatest EMG natus activity. Again. 9. 72 tion. when EMG activity was noted vide the therapist with a number of different only in the pectoralis major and latissimus dorsi.15. As with the data from Moseley and Gol. and activity should be chosen to strengthen a specific 9. if scaption in internal rotation is too weak rotator cuff.8. 9.16). the press-up was included owing to In this case. For ex- For the therapist wanting to selectively train the ample. . . . . . . . . shoulder problems.' McLaughlin states that frozen shoulder bursitis. As a result. periarticular adhesions. and (3) to commonly seen in the physical therapy depart­ present evaluative and treatment procedures for ment. periarthrosis nition of ["ozen shoulder will be established. Duplay6 in 1872 was first credited ogy. First. One of the difficulties ring to the condition as hl. explored 10 cases of frozen shoulder.Frozen Shoulder H E LEN OWEN 5 Patients with a diagnosis of frozen shoulder are working definition of frozen shoulder.2 that can imply many ily apply this information to clinical practice. frozen shoulder is often a fTozen shoulder. scapu­ Frozen shoulder is loosely defined as a painful lohumeral periarthritis. abounds on the subject of frozen shoulder. humeroscapular fibrositis. In the literature. conf"usion thereby improving patient care. studies did not discuss the evaluative procedures explain. a working defi­ calcarea. In addition. Duplay's disease. I This definition appears to be rotators. most marizing this condition as difficult to define. periarthritis. sum­ the treatment being examined. humeroscapularis. 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. In 1934. In 1945. shoulder is a popular medical colloquialism and not a di­ portion of shoulder-hand syndrome. as well as cal features of frozen shoulder. supraspinatus tendinitis. was that few studies defined frozen coined the term frozen shoulder. refer­ so evident in the literature. and clini­ redundant axillary fold of the capsule. which 257 . (2) to establish a thickening and contraction of the capsule. Cod man 7 this chapter. etiology. pathology. tendinitis of the short stiff shoulder.' In this literature review. inconsis­ painful stiff shoulder to a short rotator tendini­ tencies in patient selection based on their varied tis. bursitis agnosis. bicipital tenosynovitis. Some of the more common terms that are synonyms for frozen shoulder are adhesive cap­ lJiterature ReIJiew sulitis. subdeltoid nosis. Unfortunately. and a host of foreign lan­ guage terms' PATHOLOGY AND DEFINITION Confusion in terminology probably reflects the confusion in the definition. and treat. the main thlUst of ary to subacromial bursitis. stiff and painful shoulder. Neviaser' surgically used to reach the diagnosis of fj'ozen shoulder.ll11eroscapu/ar peri­ in reviewing the literature of evaluation and arthritis (periarthritescapulohumerale) second­ treatment of frozen shoulder.3 painful more of a description of symptoms than a diag­ stiff shoulder. etiol­ Historically. 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. there is no consensus on the name of this clinical entity. attributing the shoulder in the same way. adherent subacromial bursitis. and treatment of this clinical entity that is with describing the painful stiff shoulder. 1 hope that the reader can read­ "catch-all diagnosis"I . posed that patients with frozen shoulder exhib­ Turek 15 theolized that continual trauma of ited inflammation in the rotator cuff. This appeared reasonable. traumatized by rubbing against the acromion healing by granulation tissue results in fibrous process and coracoacromial ligament. as the tendon is repeatedly movement under the arch. pro­ would occur. gether but could be separated with one or two Similarly. The effects of immobiliza­ lar surface of the humeral head. because sheath was typically thickened and edematous. 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. The lack of circulation in this area In 1938. the more adherent the as a contributing [actor. confirmed both tracted and shrunken. humeral head.·S. sub­ logic examination of four patients with frozen acromial bursa. This easily separated and separation did not increase autoimmune reaction produces a diffuse capsul­ shoulder motion. local ilTitation of the tendon. causing adherence of the in­ shoulder. capsule. thus. found that the rotator cuff tendon was con­ Lippmann. rotator cuff. 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. 1 2 like Codman. thus freeing joint move­ degenerative changes in the supraspinatus oc­ ment. creating a ban-ier to humeral head paired blood supply. 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. lipp­ amination. gradual improvement of shoulder function In 1949. and ac- . blood vessels. Simmonds . a definite in­ the humeral head and capsule were glued to­ flammatory reaction. If trauma persists. McLaughlin' reported that in surgi­ could cause degeneration of the supraspinatus cal exploration of a number of frozen shoulders. Based on this work. he used the term adhesive capsLllitis. shoulder confirmed the above clinical findings.1 i McLaughlin's tendon. particu­ the rotator cuff and biceps tendon as they are larly in the supraspinatus tendon. Research documents that changes in periarticular connective tissue collagen result tracapsular tendon to the capsule and the articu­ from i mmobilization. In examin­ this articulation. tendon. Histo­ adhesions of the biceps tendon. In response to tis­ He (00 observed a loss of the inferior redundant sue inflammation. 1 4 in 1943. Inflammation forced against the acromial arch results in de­ of the supraspinatus tendon is secondary to de­ generation and edema. or frozen shoulder. in 1973. Al­ by the extent of tendinous adhesion: the more though many studies cite disuse of the extremity advanced the condition. it appeared at first as if spinatus tendon with hyperemia. but the adhesions between the folds were affecting the adjacent rotator cuff tendons. capsule. The tendons thicken as generative changes in the tendon caused by im­ a result. the tion and its relationship to frozen shoulder will intracapsular tendon would disintegrate and be addressed later. The tendon stiffening. McLaughlin observed that prolonged disuse of and the tendon was roughened and adherent to the extremity preceded a frozen shoulder. Ultimately. Although unsupported by ex­ ing 12 surgical cases of frozen shoulder. 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. McLaughlin consistently itis. the body produces antibodies fold.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. 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. 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. Macnab'3 illustrated that rotational movements. As Neviaser showing evidence of degeneration of the supra­ rotated these shoulders. He the sheath. The degeneration process produces a he found no histologic evidence of inflammation. . The pathologies documented as it spans the tuberosities to the coracoid pro­ were vascular synovitis in all cases. The coraco­ range of motion. obliteration of the comes contracted. thereby limiting downward hu­ mial bursal adhesions i n all patients. Unlike Neviasar. In the later phases. shoulder function begins to return. In addition to the subscapula. Ozaki also noted contracture of the patient selection.'7 Neer et aI. The authors noted synovial hy­ shoulder. FROZ E N S H O U L DER 259 romion. elastic membranous tissue. the gliding mechanism of the biceps tendon is In 1991. as defined by Lippmann are those patients with The rotator interval is a space between the no findings i n the history. The mechanism re­ against the glenoid fossa. thereby limiting shoulder external rota­ I-ior capsule. Wiley'3 treated 37 patients with fro­ gone as the tendon becomes anchored to the hu­ zen shoulder using ar throscopy. restl.cting humeral sponsible for these changes is unknown. both the rotator interval and coracohu­ of frozen shoulder primarily involves the fibrous meral ligament are converted into a thick fibrous capsule.s. inspected 30 fTOzen the head is held high in the glenoid by these fi­ shoulders al ihroscopically and noted subacro­ brotic tendons. and subacromial bursa can all be­ the arthroscope for direct viewing of the joint. the rotator interval contains humeral joint. 1 4 DePalma 1 6 speculated that once shoulder. the intra-articular adhesions noted. rotator cuff tears i n 6. rotator cuff. 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. anterior border of the supraspinatus and the su­ or radiographs that could explain the decreased perior border of the subscapularis.22 in 1994. contracted cord frozen shoulder. 1 7 condition progresses. there were no tion. The result is loss of motion at the gleno­ groove. bridging the bicipital with these later pathologies are classified as hav- . the synovial fluid. Patients into both tuberosities. with capsular cess. The subscapularis tendon also becomes fi­ contracture primarily in the anterior and infe­ brotic. biceps ten­ ogy associated with frozen shoulder have used don sheath. i ncreased capsular and intra-articular adhesions in 4. ' 4 Wiley also used local anes­ humeral ligament originates from the coracoid thetic blocks. lar fold. Primary frozen shoulder found no intra-articular adhesions. NOImally.. come involved." in 1993 performed diagnostic sues lose their elasticity and easily tear as the glenohumeral joint arthroscopy before and im­ humerus is rotated or abducted. mial bursa was not inspected in this study. The coracohu­ mediately after manipulation on 20 patients with meral ligament becomes a thick. clinical examination.'6 I n the early stages. The biceps tendon was found that a contracted glenohumeral joint capsule is to be adhered to the sheath and the groove. He noted a vas­ meruS by adhesions. with loss of the inferior capsu­ inferior recess in 3 cases. These tis­ Uitvlugt et al. the capsule be­ potrophy in 10 of the cases. Ozaki et al. comes thickened and hypervascular. The synovial membrane be­ had concomitant pathologies. Hsu and Chan'o scoped 25 patients with of these structures in various stages of frozen frozen shoulder. Like the primary structure responsible for frozen Lippmann. CT scans.. IS subscapularis bursa opening. cular reaction around the biceps tendon and the Like DePalma. The normally flexible capsule becomes cord. With adhesive cap­ DePalma 16 stated that the pathologic process sulitis. 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. biceps tendon. Noteworthy in this study is the careful zen shoulder. several studies of the pathol­ covering. resulting in restricted glenohumeral motion as Pollock et a1. which holds the humeral head tightly nonelastic and shrunken. The subacro­ supraspinatus and infraspinatus are also tight.. As the motion. DePalma observed involvement In 1991. He stated meral excursion. Many patients fibrosis occurs. including only those with "pri­ rotator interval and joint capsule in his study but mary" frozen shoulder. fascial More recently. and sular fold. "arthritis" causing glenohumeral stifFness have Rizk et a!. Both contractile tion. and then by internal rota­ be the cause of frozen shoulder. Last.ax25 funher clarifies that arthri­ the synovium. of the inferior redundant fold and limited exter­ In the examination.30. Based on this examination common observation is that the capsule be- . active shoulder motion nal rotation. subscapularis bursa. and biceps resisted motions to determine the site of the le­ sheath were obliterated. The capsular pattern of frozen or extracapsular adhesions. 1 5. abduction is also lim­ ing. According to Cyriax. synovial membrane. and obliteration of the subscapular or characteristic proportions. Cyriax25 has outlined an examination that loss of glenohumeral movement in all direc­ differentiates a contractile from a noncontractile tions I2. abduction would be limi ted by the loss fat pads) are tested. Cyriax states tion only. external rotation ments. Ozaki et a!. passive shoulder motion is tested to Neer et al. Cyriax obser ved that patients with cluded from this study. shoulder is most limited in external rotation. Both Neviaser' and Kozin26 noted limita­ and noncontractile structures have been incrimi­ tions in these same motions.24. Fascia. in external rotation and abduc­ element in shoulder dysfunction. Rizk noted a loss of joint vol­ humeral movement has been observed by oth­ ume due to a constricted capsule. As mentioned.29. jOint capsule. contractile elements are evaluated. serr'ations of ers. fol­ Various pathologies have been postulated to lowed by abduction. One ing joint movement. the results. tendon. Therefore. because the contractile cohumeral ligament limits external rotation. articu­ would be more limited than internal rotation. He consistently noted that more contrast limiting both active and passive movement. and musculoperiosteal that if the anterior capsule were more contracted unit) and noncontractile or inert elements (liga­ than the posterior capsule. only the ited. 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. dye was deposited posteriorly than in any other His examination includes selective tension areas of the joint capsule. passive. Although active motion may Likewise. Resisted testing is negative. non filling of the bicipital tendon tis exhibits limitation of passive motion in sheath. or arthritic condition to ac­ zen shoulder. 1 8 substantiated that a shortened cora­ evaluate the inert tissues.32. In lar sUlfaces. bony. ligament.33 ness and not a pathology. and addition. arthrography. based on the sion. der. nerve root. it follows tendoperiosteal unit. elements are totally relaxed during passive test­ Without external rotation. 1 7 found a diminished incriminate both contractile and noncontractile joint capacity and restricted inferior axillary fold elements.17 and Second. in initially tested. thus prevent­ structures as the cause of frozen shoulder. Like Wiley. arthrokinematics of shoulder motion.26-28 Cyt. both Ozaki et al." and in abduction.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. Both contractile elements (muscle.B·9. no tures previously mentioned as the cause of fro­ neurologic. bursa. 24 selected 2 1 patients with "idio­ pain and limitation of movement with active and pathic adhesive capsulitis" to examine under passive testing only. dura . because the Scienti fic research points to many different tests are performed isometrically. that the term (rozen describes a symptom of stiff­ and flexion. when cO ITelated with pas­ and subscapularis bursa in 17 patients with fro­ sive and resistive testing. hence the capsular pattern. which he calls the axillary recesses. Others observed nated. Rizk classified thereby ruling out any of the contractile struc­ these patients as having no history of trauma. frequently can give ad­ zen shoulder due to a shortened coracohumeral ditional information about the soft tissue lesion. which implies that in arthrograms of 17 patients with frozen shoul­ the entire glenohumeral joint capsule is affected. external rotation. with resisted shoulder motion. Like Lippmann. count for the limited and painful shoulder. he found no intra­ capsular pattern. Reeves" substantiated the capsular pattern frozen shoulder is arthritis. Dur­ Limitation in both active and passive gleno­ ing arthrography. "" nohumeral stiffness resulting from a noncon­ Therefore. FRO Z E N SHOUL D E R 261 comes contracted around the humeral head. being limited most. Wright and frozen shoulder. followed by abduction.35-37 Whatever the source. Haq:8 however. brane and fibrous layer of the anterior-inferior type of onset. especially contractile lesion. and then extends marked fibroblastic proliferation. The modeling of the collagenous portion of the con­ clinical observation of limited and painful active nective tissue. However. a working definition for frozen shoulder as gle­ "loss of capsular flexibility and toughness. namely. con­ tribute to frozen shoulder. the author would like to postulate connective tissue" in the shoulder joint. a few clinical features appear detrimental effects on the periarticular connec­ consistently in patients with frozen shoulder.'7 also noted fibrosis in the con­ Faull. Patients with peri­ arthritic personalities have a low pain thresh- ETIOLOGY 01d9. (GAG). Both active and passive motion der motion resulting from disuse may be the re­ is painful and restricted. 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. namely. There was imal to the greater tuberosity. tested 1 86 patients with frozen Pain in the shoulder can result from various shoulder and found no such personality. 1 0. 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. with external rotation changes. such as exercise for shoulder pain. 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. certain faclors­ treatment. and connective tissue with a surface area more than a decrease in hyaluronic acid in the frozen shoul­ twice that of the humeral head. and dermatan sulfate. So that the abnormal arthrogram may shoulders. The joint capsule consists of relatively loose chondroitin-6 sulfate.9. intrinsic and extrinsic sources. the nOimal shoulder crease in the total content of glycosaminoglycans arthrogram is discussed first.. indicating re. sion unless the lesion is concurrent with a non­ state that psychological factors. therefore. The cause for the increased colla­ and passive motion in the capsular pallern sub­ gen production is unknown. 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. an increase in heparan sulfate. Some investigatorss . This difference was caused by an in­ be beller understood. age of onset. capsule of 14 frozen and 13 normal shoulders. I m mobilization of a synovial joint has been shown to have In the literature. "subsequent loss of biologic properties of the In closing. the clinically observed loss of shoul­ tractile element. stantiates that a noncontractile structure is at Ozaki et al. and The third factor associated with the develop­ then internal rotation. and emotional stress. pain usually forces the patient to CLINICAL FEATURES protect the arm from use. however. These patients take no active role in any mains unknown.49 The capsule ders.. and course of the condition. apathy. its exact cause re­ tremity.46 These common observations include arthro­ Lundberg" examined the synovial mem­ graphic and radiographic findings. tive l issue.9 pain. Passive mobility is lim­ sult of underlying capsular connective tissue ited in a capsular pallern. A frozen shoulder does ment of frozen shoulder is that of the peri­ not exhibit objective findings of a contractile le­ arthritic personality.•. The end result of i ncreased fibrosis is a end result of such a lesion. This.38. These changes in GAG content reflect a pro­ normally attaches to the humeral head just prox­ cess of fibrosis occurring in the tissue. medially at the level of the anatomic neck of the . disuse. depression. 16.5o The redundant fold of the capsule hangs in the axilla (Fig. gives no clues to what initiates the cap­ sulaI' changes. however.53 Arthrography. especially in the fihh decade. the contrast dye is injected posteriorly. Plain film findings in frozen shoulder are usually negative..5I Abnormal findings include retrac­ tion of the joint capsule away from the greater tuberosity (Fig..1Sertion has a sionally recalled by some patients. (From Goldman. and inferiorly. In addition. and pain is usually experienced as the capacity is reached.58-60 Others find it helpful but not essential permission. Some investi­ gators associate frozen shoulder with the post­ FIGURE 10.5 2 a ragged and irregular outline of the capsule. with 1 6 ml of contrast fluid allowing the best viewing of the nOl-mal join!. The axillary recess is small.5 0 In fTozen shoulder arthrograms.. humerus and inserts into the bony rim of the glenoid. anteriorly.262 P H Y SIC A L T H ERA P Y OF T H E SH O U L D ER to rule out other shoulder lesions in addition to confirming frozen shoulder.57 arrows). Frequently. 1).2). and Some investigato r s believe that arthrogra­ extravasation has occurred pn'or to exercise phy is essential in diagnosing fTozen shoul­ (curved alTows).50. 50 \\lith der. 1 0.48.30 . the shoulder joint can accept 28 to 35 ml of solution. arrows).or-inferior /' capsule and capsular ligament decreases with . 59. the axillary recess (straight zen shoulder consider the onset to be insidious.55.24. Reeves' study63 con­ firms that the strength of the antel .5o. 1 0./ age. and the subscapularis bursa (curved Trauma including minor injuries was only occa­ aITow).. '7.62 Seldom is frozen shoulder encountered f in a patient less than 40 years of age. 10. because the capsule is usually contracted superiorly. Most studies of fro­ the humeral neck. (From Goldman.2). 56.23.) . except that they occasionally show some osteoporosis from disuse.) .52 and absence of the axillary redundant fold (Fig. 5 0.51.1 Nomlal shoulder arthrogram. An menopausal stage.50 with pemlission. when hormonal changes may extenta/ rotation view shows the insertion along alter connective tissue also. smooth contour. 32.5 2.2 Adhesive capsulitis.52 .61 Wright and Haq·8 and DePalma 16 speculate that this age coincides with normal degenerative changes of connective tissue. there is no FIGURE 10.50.·· 1 1 .61.53 -56 The joint volume is markedly decreased to less than 1 0 ml. The capsule is filling of the subscapularis bursa and bicipital retracted away {rom the ItIberosities (straight sheath. a factor that may precipitate frozen shoulder. Note that the capsular i..53. Emphasis will be placed on the phYSical ther- . and recover y.ollt intervention. 9 had weakness and pain.27. 1 1. occupation (manual ver­ tients had permanent loss of shoulder motion. The third stage is characterized has been documented to be as long as 10 years. Bridgman 72 found that more than 10 Cyriax also classified frozen shoulder into percent of 800 diabetics had fTozen shoulder three stages.6 1.64. Lequesne et al.70.25 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.64 sample.69 raised C-reactive protein and immune com­ limitation in any functional activities.27. nificant.3I. These features in­ onset of symptoms. This shoulder as being self-limiting.48 the presence of immunologic as compared with the uninvolved "normal" factors such as H LA_B27. others are found with less consis­ ne s. FROZEN SHOULOER 263 Although many studies desc. and an abrupt end-feel. with some ness. Opinion varies on their relationship to the recovery was between 1 and 4 years after the incidence of frozen shoulder. plex levels. Treatment marked capsular changes and normal radio­ varies according to the stage of the condition and graphs. side involved. by severe pain extending from the shoulder to DlII.58 .48 ischemic heart disease. These studies contradict other research in­ interesting results. when the prevalence of diabetes in frozen shoulder is sig­ patient can lie on the involved extremity at night. 27. inability to lie on the in­ can vary greatly.29. thy­ iopathic frozen shoulder for 2 to 1 1 years (aver­ roid disease. Although 60 percent of the patients chronic bronchitis. The total time for greatest tency. More than half of the pa­ clude sex. 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. 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. 30 months). of movement in every direction." He noted three In addition to the previously mentioned clin­ consecutive stages of frozen shoulder: pain. Simmonds ' 2 observed that after 3 Examirwtion years.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. 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. when pain is present only with movement. only 6 regained normal function. the onset of frozen shoulder is when the end-feel is elastic. pain at rest and great­ shoulder include abnormal arthrograms with est at night. always to their greatest re­ fTozen shoulder wiu.be frozen within 2 years from the onset of symptoms. age. serum IgA lev­ shoulder's range of motion (ROM). In a small series of 21 patients with frozen shoulder. 1 5. stiff­ ical features.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. and 6 had either weakness A complete description of the examination of the or decreased mobility.68 and association with other diseases Shaffer et al 66 followed 62 patients with id­ (hemiparesis.72-74. Simon30 covery.65 there success was achieved with treatment of reassur­ are very few documented studies of the natural ance. and In summary. Gray" noted that 24 of 25 frozen shoulder is beyond the scope of this chap­ patients regained normal glenohumeral motion ter.30. the level of pain and restriction the forearm and wrist.48 and diabetes62. 7 years). and hypno­ course of frozen shoulder. sus sedentary).ng this time. but had no els. The course of the condition stage are met. Other typical features of frozen volved extremity at night. In a larger toms. These authors contend that the does not extend distal to the elbow. 12.. will be addressed later. occasional simple analgesics.7 1 pulmonary tuberculosis. applied at the end of each range '8 This involves During the interview. laterally rotated. dull pain over the del­ side. It appears that Because celvical spine dysfunction can refer arthrography was reser ved for those patients pain to the shoulder. A therapist obselving warm showers. The patient usually wears shirts that sleep!9. amined arthrographically." 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.)s. although these areas will be examined. If the condi­ shoulder. Cyriax's but a few important tests are mentioned. plexus structures.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.25 action to remove. 1 7.3I . with perceived vanced. the arm swing is usually limited or has used self-treatment with a heating pad absent on the affected side. with the involved side usually elevated in usually cannot recall an injury and [Tequently is a p. this area must be as­ who did not respond to a long-tel-m conservative sessed. If the condition is more ad­ the ipsilateral upper trapezius. from a practical standpOint Cyriax's di­ tion is long-standing and there has been a long vision is more clinically applicable.5 1 . the patient may complain of pain pain along its course to the suboccipital area. SUBJECTIVE FINDINGS OBJECTIVE FINDINGS In my clinical experience.75 Subjectively." course of anti-inflammatory medication and In gait. muscle atrophy around the in­ population that I saw.16 as does decreased function in a cast.32. giving rise to local pain. If active ROM and active may be referring pain to the shoulder. and abducted as a re ult ipsi lateral scapula. In the patient period of disuse. very few patients were ex­ volved shoulder and scapula may be evident. As a result of maintaining unable to determine when the pain and/or loss this posture. and brachial shoulder. 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.)6 It is not the objective of this chap­ program of physical therapy and medication. and rest of the extremity."·25 up to the cervical spine. The abnor­ ax's stages of capsular lesions.. The reverse occurs when the patient toid that increases with motion2. When referred to physical therapy. comb the hair. aspirin. the pa­ the involved extremity is adducted and internally tient probably has taken or is cUITently taking a rotated. it is also important to a gentle passive movement at the end of the avail­ ask questions concerning the patient's general able range. ter to outline a complete cervical examination.6 1 . 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."otective manner. The uninvolved extremity is removed of the extremity. The patient even. spreading fTom the shoulder down the fore­ The scapula on the involved side is usually ele­ alm. and pain at rest.76 Functionally. with very little movement of the opposite complains of a vague. cervical spine. There should be a slight pain-free in­ health to assess any other disease process that crease in the ROM. The same ROM with overpressure are negative for provo- . there may be tender points along of function began. or The levels of the shoulders are frequently un­ reach for a wallet in a back pocket. overpressure should be .o.6 1 and disturbs dresses.9. ment. Even if arthrography is performed. resting in the patient's lap. I f active stages can also be clinically helpful in treatment cer vical ROM is normal. and into the vated. planning. the patient will button down the front and require no overhead be unable to sleep on the affected side!·6.5I. hook a brassiere in the back. the patient first. 25 of excessive scapular motion to compensate for These complaints correspond well to Cyri­ the impaired glenohumeral motion. and the order of their performance is spine examination.80 The encouraged to refer to this text for the details.79 acromioclavicular. sition or if elevation is pel'formed pas- . resistive testing of cervical ROM will away from the side in the coronal plane. 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. Scapu­ portant i n deciding treatment. 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.35. the mus­ The integrity of the brachial plexus must be cular power.79 ber are squeezed togellJer. but some "give" is calized and can easily be pinpointed by the pa­ noted. and first rib79 should merus. 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. First rib dysfunc­ 90· of abduction is present actively 01' pas­ tion can result from a variety of problems. careful examination of the there is a painful point in the range bor­ cervical spine. the patient's willingness to move. The ROM. and motion. 2 5. passive motion pain may be obtained by having the patient ele­ assesses inert structures. and lar. Physical therapists trained in these mentioned should be performed bilaterally. Passive elevation.35 '. in all directions of motion. and costoclavicu­ 2. the location in lar tests may not be valid with limited shoulder the range in which pain is produced. The reader is the extreme of the passive ROM.3s. scapulothoracic joints. There is a firm Acromioclavicular joint pain is usually very lo­ arrest to movement. During active elevation. End-feel is sion test that can be performed adequately de­ the sensation detected by the examiner at spite restricted shoulder motion. applied to the cer vical spine and noting if there is any improvement in shoulder pain or ROM. structures of the neck. 35 The stan­ sessed. scapulothora­ of movement between the scapula and hu­ cic. FRO Z E N S H O U L D ER 265 cation of symptoms. and the ROM can be as­ evaluated in case of shoulder pain. This can only be tested when abnormal shoulder mechanics. lar. noclavicular dysfunction usually results from 3.25 This local pain differs from the diffuse the range where pain is provoked are im­ dull pain common with frozen shoulder. This will be lothoracic dysfunction usually results from ex­ further discussed in the section on stretch­ cessive scapular compensatory motion. Active motion assesses both contrac­ cerning the cervical influence on the shoulder tile an noncontractile elements. The sively. hyperabduction. Additional information con­ important. ster noclavicular. brachial plexus. Abduction is defined as the amount mobility of the sternoclavicular. Elevation is movement Finally. 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. normal end-feel of the shoulder is capsu­ Acromioclavicular. dard Addson. The patient be tested to rule out their involvement in shoul­ actively elevates the extremity and notes if derpain." Both the end-feel and the point in tient. In summary. provide information concerning the contractile with 180· possible. Painful arc. This involves guiding the head of the shoulder is based on Cyriax's" examina­ into extension toward one side and then adding tion principles. with 90· being normal. acromioclavicu­ dered on either side by non painful motion. and ster­ ing as treatment. Cervical compression Twelve movements are included in the exam­ and traction tests complete the passive cer vical ination. Elvey's developed a brachial plexus ten­ the end-feel should be noted. and resisted motion as­ vate the involved shoulder while traction is being sesses conlractile str uctures.Active elevatiol1. the cervical quadrant test Much of the remaining objective assessment can be performed. sternoclavicular. Joint countered most frequently. In the shoulder. tion. and based this definition on joint mechanics. a marked increase in motion. depends on normal acromioclavicular. joint play and defines it as small. A positive finding indicates that a manipulation is the prefen'ed treatment to re­ structure is being pinched during the move­ store joint play. Both pain and muscle weak­ volved area of the capsule. involuntary normal mobility. following. With this con­ techniques. According to Menne!. and the end-feel where the convex humeral head is moving on the should be noted. i n grade 6. riax25 cautions that palpation gives very lillIe in­ joint dysfunction exists. See the comment site directions ·o Any discrepancies in joint play for 5. roll and glide occur in oppo­ 6. meral head within the glenoid fossa. grading the in external rotation. and long axis extension capsular restrictions. The resisted tests are the ment can be directed to these specific areas. The normal joint play motions of the gleno­ 7 . they are also treatment techniques cise examination. 8. fossa with the shoulder flexed to 90·. which pain is provoked. Mennel proposes that formation and is ollen irritating to the involved . and poste­ I I . Resisled elbow extel1siol1. assessment will direct the therapist with a Note that all resisted tests are performed knowledge of normal joint mechani s to the in­ isometrically. 90· is the normal range before the The reader is refer red to Chapter I for review scapula moves. glides. the univolved extremity should be Further information in detelmining which tested to assess "normal" for the patient. posterior glide. limitation of passive movement using a scale from 0 to 6. external rotation of the hu­ 1 0. the point in the range at meral head within the glenOid. Cy­ movement in any plane. a slight limitation in motion. of this necessary hal-mony. Resisled medial roealiol1. sterno­ noting when the inferior angle begins to clavicular. play motion is often not more than Ys inch of A final examination tool is palpation. He rec­ pula is stabilized at its inferior angle as the ognizes that normal glenohumeral movement therapist passively elevates the extremity. there are seven joint 4. active eleva­ section. above. then movement allows easy documentation of the mo­ internal rotation. tion and all passive testing are limited and pain­ All joint play motions can be quantified ful. Resisled addLlcliol1. humeral joint are antel.or glide. rior glide of the humeral head within the glenoid 12. chanics by stretching the involved portions of the In summary. confusion occurs when more than one lesion exists. Passive medial rOlaliol1. and scapulothoracic joint movement. grade 4. Furthermore. ROM. Again. grades I and 2 will be en­ (traction) are nOlmal joint play motions. He bility. Resisted elbow flexion. inferior and posterior glide. When joint play is lost. All of the joint play 5. Passive scapLllohumeral abduclion. The sca­ play motions at the glenohumeral joint. Resisted abduclion. a slight increase in mo­ movement essential for normal joint motion. As with passive ele­ molions are actually rolls and glides of the hu­ vation. move. In frozen shoulder with which rotations. 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. joint instability. Mennel79 coined the term grade 2.s1 Although the assess­ is in a capsular proportion. treat­ ness are noted.65 Although the joint play motions mentioned are assessment As previously mentioned. followed by abduction. grade 5. Passive laleral rOlaliol1.266 PH Y S I C A L THER A P Y OF THE S HOUL D E R sively. lateral 9. grade 3. Resisted laleral yotaliol1. lateral glide. because frozen shoulder in­ capsule. nohumeral joint play. stationary glenoid. In addition. with most limitation ment of the jOint play is subjective. grade I indicates marked loss of motion. This will be discussed in the treatment volves a noncontractile slructure. and posterior glide. both contractile and inert that can be used to restore normal shoulder me­ structures can be assessed. ment. palpatory findings are generally receiving exercises did Significantly beller than negative. I n radiation and exercises. ice. They also concluded that the with frozen shoulder. it is im­ intra-articular hydrocortisone. so frequently encountered in any human subject study. Fur­ based on an accurate assessment. such as ex­ ence in treatment by intra-articular steroids. short-wave perative that an accurate assessment of the diathermy.75 found that patients receiving Although this evaluation is lengthy. Figure t 0. which is essential for found no difference in patients who received passive joint manjpulation. they der . ercises.87 derness over the lesioned str ucture. any secondary local steroid injection. . is the ethics of the neces­ Various treatments can be used to achieve the sity of an untreated control group. For Maitland-type passive mobilization. Hamer and Kirk8S documented no before and/or during the exercises. or with injection alone. or and later stages of frozen shoulder. or a combination of both were all ef­ abnormal scapular motion may exhibit tender fective in decreaSing pain and increasing shoul­ painful points. Biswas et al.9 0 The analgesia provided by TENS der for 8 months and found no long-term differ­ allows other therapeutic procedures. Another STIMULATION problem. .86 facilitate joint relaxation. For these reasons. physical therapy with mo­ muscular involvement resulting rTom posture or bilization. Dacre et aI . to be performed more comfortably. Proper treatment is sive mobilization exercises all benefited. 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.3 manipulation under anesthesia. ulation with prolonged pulley traction was supe­ few controlled studies in the literature examine rior to a variety of heat modalities and exercises. Liang and Lienss found no difference in active exercises when combined with inlra­ Treatment articular injection and heat (short-wave diath­ ermy. In addition. 34. palpation is re­ local hydrocor-tisone and exercises or infTared ir­ served until the very end of the examination. Binder and col­ illustrates an effective TENS application for fro­ leagues" followed 42 patients with forzen sholtl­ zen shoulder. but both were beneficial in decreasing the will gain the confidence of the patient as well as painful stage and hastening recovery. Similarly."·5 1 Although there is little agreement on its concluded that exercises were probably the only treatment when it occurs. Transcutaneous electri­ in treatment of local corticosteroid injections. treatment of frozen shoulder. there will probably be ten­ steroid injection was cost-effective. Hazleman65 studied 130 cases of frozen but documentation of their effectiveness in fro­ shoulder retrospectively and found no difference zen shoulder is lacking. or no maximal effectiveness. Lee et al. 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. There may be tenderness over the patients receiving analgesics alone. or moist heat). pain relief and restoration of found that transcutaneous electrical nerve stim­ normal shoulder movement "5. these investigators concluded that ex­ ercise is the most important treatment in frozen shoulder. However.83 Unfortunately. acromioclavicular jOint as a result of improper following 66 cases for 6 months.82 thermore. Rizk et al.79. goals of pain relief and restoration of mobility. there is agreement on useful treatment for frozen shoulder. In a contractile lesion coexisting der function. TENS should be applied treatment. and aspirin as well as active and pas­ shoulder lesion be made. concluded that shoulder mechanics.89 the treatment goals. both groups frozen shoulder. with heat Prevention is the best treatment of frozen shOltl­ alone. ultrasound.9o Decreasing Significant advantage in ice or ultrasound treat­ the pain during stretching of the fTozen shoulder ments. F R OZEN S H O ULD E R 267 structures. (2b) In depression was not beneficial in treating frozen shoulder below acromion posten·orly. tends to be tempo­ rary. Such is ference i n groups receiving ul trasound at 0. found that one acupuncture treatment of ST 38 cured acute frozen shoulder. Mueller and colleagues9' found that ul­ ducing the acute pain.268 P H Y SI C A L T H ERA P Y OF T H E S H OU L D ER followed for 2 years " Pothmann et al.90 with pennission. TENS is an trasound at 2 W/cm2 was of no value in treating excellent treatment choice when the patient is in subacute frozen shoulder. and exercises.) HEAT Heat application is a very common treatment used to decrease pain and increase soft tissue extensibility.ncture point TW 14 (c hDl1l1el 2). Because the sound waves are so bination o[ ST 38 and UB 57 or a combination focal. acupu. and infrared in'adiation.94 compared patients receiving shoulder. acupuncture poil1l L/ 14 (channel I). ( l a) In depression bordered by the hot packs. passive joint stretching. ercises to patients receiving these same treat­ and clavicle anteriorly. Adapted (1'0111 Mannheime/' and LlIInpe.90 Other investigators recommend heating the joint capsule prior to stretching. the target tissue!' With the in[el"ior capsule so found acupuncture or novocaine blocking at G B frequently involved in fTozen shoulder.3 TENS electrode placement (or (rozen Leclaire el al.90 Therefore. create hyperthermia in the tissue. A variety of modalities. GB 34. spil1e o( scapula posterior/y. (1 b) IrlSertion o( deltoid at lateral a spect o( there was no difference between either group in ann.93 (See reference 9 1 for exact point location. however." The analgesic effect. Quin9• found no d if­ too acute a stage for active treatment.5 WI the case i n stage 3 of frozen shoulder as defined cm2 and exercises and those receiving diathermy by Cyriax. the therapist must be very specific as to of Ll 1 5. and pulley ex­ acromion laterally.90 FIGURE 10. ultra­ sound. After 12 weeks 16. the ex­ 34 t o b e 93 to 9 6 percent effective in eliminating tremity may need to be positioned in abduction pain and restol"ing full mobility in 60 patients and external rotation to reach the inferior por- . and Ll J J 9 1 Yun et al. including short-wave and microwave diathermy. SI l O. paraffin baths. the patient will use the extremity more and prob­ Clinically. because the increased circulation acts as an analgesic. ROM. (2a) the pain scores.) ULTRASOUND Ultrasound research in fTozen shoulder began in the 1 950s when ultrasound was a new form of TENS is significanLly more effective in re­ therapy. In depression below acromion anteriorly. ultrasound is used for its thermal ably avoid the stiffening results of disuse. whirlpools.9• In frozen Other useful acupuncture points that can be shoulder." I f TENS can reduce the discomfort. moist packs. or functional status. acupuncture point LI ments plus magnetotherapy. Leclaire concluded that electromagnetic therapy actupuncture poil1l L/ 15. it is often used prior to stretching of used as electrode sides [or TENS include a com­ the capsule.9o The result of hyperthermia is in­ creased circulation and vasodilation to the tis­ sues. and mechanical effects on tissue. Last. both the loca­ Ice packs can be easily constructed at home tion of pain in the range and the end-feel are with a plastic bag. In the sub­ cise with less discomfort. both active and passive warm moist compresses are easily applied. With the There is. tient perform with less pain. certain factors can help the extremity and prevent subsequent stiffness. exercises will edema. subsides. Similarly. i f l here is a concurTent lesion. fective cold treatments. an initial vasoconstriction limi ted range of frozen shoulder. FRO Z E N S H O ULDER 269 tion effectively. like heat application. Most of us have seen the amount and vigor of exercises. Watm showers and acute stage or stage 2. like heat. therapist determine when and what exercises are . Pain after exercises During this situation. ice massage. A good physical therapist the patient should be strictly instructed to apply must be able to judge when to initiate exerci e. if the end of the limited range is synovitis. Heat­ exercises may be cautiously initiated. especially those with a moist head fea­ tient's reaction must be constanLly monitored.25 pain. especially when the patients can exer­ and TENS are helpful at this time. If during passive movement the home-especially a patient who thrives on warm patient perceives pain before the therapist showers and a heating pad-is often difficult. be helpful. Even with the pad on the lowest selting. it only for short intervals. Other guidelines to determine when and to CRYOTHERAPY what degree exercise should be used can be based on the end-feel and the pain and resistance Cryotherapy. A proportional amount of rub­ noted. but can prove beneficial in reducing any postexercise this can be done in subsequent visits as the pain soreness.25 In stage I . ice can combat the inflammation and reached and no pain is provoked. Convincing a patient to use ice at ing treatment. any portion of the cap­ EXERCISE sule can be treated specifically with proper posi­ tioning of the joint. helps in this decision making. ice for its analgesic effect is very exercises may be cautiously allempted. 75••• In the acute stage or stage 3 as the target capsule on stretch as ultrasound is ap­ defined by Cyriax. are useful as long as the patient does not Increased pain or pain lasting more than 2 hours apply a pad for long periods ·2 Patients fre­ after exercise is abnormal. but the pa­ ing pads.25 all active treatment is con­ plied. produces in­ sequence. Treatment in this stage should be A home program of heat before exercises can directed at pain relief. and vapocoolant sprays are all ef­ of the reduced ROM. In addition. safely and vigorously. they should be de­ such as a rotator cuff tendinitis or bicipital teno­ layed. Experience heating pad. ice. the joint is probably Ice. If exer­ useful. During passive motion testing. I f pain is experienced as the end of In the acute phase. As mentioned. The therapist may also put Exerci e is the most user-ul treatment in fTozen shoulder s•. when the extremity is range is reached. the therapist will obviously for more than 1 to 2 hours25 is abnormal. the patient is less acute and generally rested. the patient will be more willing to use the In summary. still capsular only in that it will occur at the end ice whirlpools. ture. usually them.25 An end-feel other than the capsular creased circulation and vasodilation to the area. however. the end-feel is with cold application. but each patient is different and must be individually evaluated.90 Ice packs. resistance is abnormal at the shoulder. active quently abuse heating pads by falling asleep with and passive exercises can be performed. thereby decreasing pain. traindicated.25 Combining these two factors will indi­ bing alcohol added 10 ice keeps it fyom refreezing cate the severity of the condition. before exercises will help the pa­ acute and acLive exercises are contraindicated. Ice not have a chance to evaluate the end-feel. and when the the mOllled skin of a patient who has abused the patient is aggravated by exercise. rest. thereby guid­ solidly. With lessened probably be tolerated without problems. reaches the end of range. cises exacerbate the pain. 270 PH Y S I C A L THERA PY OF THE SHOU L D E R 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 ulate a fTozen shoulder without some discomfort to the patient. "Shaking" the extremity and mo­ mental), pauses will help decrease pain and maintain patient relaxation s I Simple genLlc shaking of the extremity while in any position will stimulate the joint mechanoreceptors and decrease nociceptive input. 102 Both Maitland7S and Kahenbornsl offer guidelines to the amount of manipulation to per­ form in one session. Reassessment is important before and during each treatment session. Treat­ ment can continue as long as pain is decreased and motion is improved.sl Overtreating can cause increased pain and inflammatory reac­ tions,77 and may push the patient into an acute stage. The therapist should progress slowly until familiar with the patient's response to treatment. II is well documented that the course of fTozen shoulder is slow29•64; therefore, the therapist should not expect too much improvement too FIGURE 10.4 Righi upper Irapezius slrelch. quickly. A patient who is informed that improve­ Patient position: Supil1e wilh Ihe head off Ihe ment will be slow will be less frustrated. edge o( the table. Therapist position: Le(1 hand Lieboh 103 has recommended four passive under Ihe occipul wilh Ihe head 011 Ihe (orearm stretches that, performed over a period of time, slabilizil1g Ihe head and neck in Ihe desired will increase shoulder ROM in fTozen shoulder. amo",,1 o( /lexiDl1 al1d sidebe/1dil1g le(1 alld The four exercises are glenohumeral abduction, rolaliol1 righl. Righi palm over Ihe clavicle al1d external rotation, flexion with external rotation, scapula medial 10 Ihe acromioclavicular joil1l. and flexion performed at the end of the available Technique: Le(1 hmld mainlairzs head alld neck ROM. These exercises, however, do not deal with POSiliol1. Righi hal1d pushes Ihe clavicle and the loss of joint play. I have found that these exer­ scapllla il1(eriorly. cises in the cardinal planes often provoke pain and do little to increase ROM. Mechanical exercises with shoulder wheels, in mobilizing the soft tissue. Stretching of the pulleys, and wands are often standard exercises upper trapezius can be done in a number of in treating frozen shoulder. Unfortunately, like ways. Figure \ 0.4 illustrates a passive upper tra­ stretching in the cardinal plane, these do not ad­ pezius stretch. dress the loss of joint play. Murray77 outlines In a good home exercise for stretching the three disadvantages of the overhead pulley sys­ upper trapezius, the patient simply reaches be­ tem: ( \ ) there is no stabilization of the scapula hind the back and grasps the involved distal hu­ to avoid excessive abduction and upward rota­ merus. The patient should side-bend away from tion, (2) there is no force to depress the humeral and rotate toward the involved side, and flex the head, and (3) there is a tendency for the patient neck to a comfortable position. Once positioned, to extend the spine to decrease glenohumeral the stretch is imparted by pulling downward on motion. These same three points are applicable the involved humerus. to the shoulder wheel, finger ladder, and wand Frequently, pain may be provoked while the exercises. To improve the use of these appara­ shoulder is being manipulated. Although such tuses, stabilization of the scapula can be im­ pain is not desirable, it is often difficul t to manip- proved by placing a strap around the scapula and 272 P H Y S I C AL T H E R A P Y OF T H E S HO U L D ER 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 : 9. Cailliet R : Shoulder Pain. 2nd Ed. FA Davis, Phil­ 1 9 5 , 1 956 adelphia, 1 98 1 29. Reeves B: The natural history of the frozen shoulder syndrome. Scand J Rheumatol 4: 1 93 , 1 0 . Neviaser RJ : Painful conditions affecting the 1 975 shoulder. Clin Ol�hop 1 73:63, 1983 30. Simon WH: Soft tissue disorders of the shoulder. 1 1 . Thompson M: The fl'Ozen shoulder and shoul­ Frozen shoulder, calcific tendinitis, and bicipital der-hand syndromes. Practit ioner 1 89:380, 1 962 tend initis. Ol�hop Clin North Am 6:52 1 , 1 975 1 2. Simmonds FA: Shoulder pain wilh particular 3 1 . Bruckner FE, Nye CJS: A p.-ospective study of reference to the " frozen" shoulder. J Bone Joint adhesive capsu litis of the shoulder"frozen shoul­ Surg 3 1 B:426, 1 949 der" i n a high l'isk population. QJ Med 1 9 8: 1 9 1 , 1 3 . Macnab I: Rotator cuff tendinitis. Ann R CoIl 1 98 1 Surg Engl 53:27 1 , 1 973 32. Flicker PL: The painful shoulder. Prim Care 7 : 1 4 . Lippmann RK: Frozen shoulder; periarthritis; 27 1 , 1 980 bicipital tenosynovitis. Arch Surg 47:283, 1 943 33. Mulcahy KA, Baxter AD, Oni OOA el al: The 1 5 . Turek S: Orthopaedics. Principles and Theil' Ap­ value of shoulder distention al1hrography with plication: 18 LippincolI, Philadelphia, 1 977 in traal1icular injection of steroid and local an­ 1 6. DePalma AF: Surgery of the Shoulder. 18 Lippin­ aesthetic: a follow-up study. BR J Radiol 67:263, COli, Philadelphia, 1 983 1 994 1 7. Ozaki J, Nakagawa Y, Sakurai G et al: Recalci­ 34. Reeves B: AI1hrographic changes in frozen lrant chronic adhesive capsulitis of the shoulder. shoulder and post-tr1l Umatic stiff shoulders. J Bone Joint Surg 71 A: 1 5 1 1 , 1 989 Proc Soc Med 59:827, 1966 1 8. Neer CS, Salledee CC, Daisey RM et al: On the 35. Elvey RL: The investigation of aim pain. p. 530. value of coracohumeral ligament release. Orthop In GI;eve GP (cd): Modern Manual Therapy of Trans 1 3:235, 1 989 the Vertebral Column. Churchill Livingstone, 1 9. Kicras OM, Matsen FA: Open release in the man­ Edinburgh, 1 986 agement of refractory frozen shoulder. Orthop 36. Leach RE, Schepsis AA: Shoulder pain. Clin Trans 1 5:80 1 , 1 99 1 SPOlH Med 2 : 1 2 3, 1 983 20. Hsu SYC, Chan K M : AI1hroscopic distention in 37. Neviaser JS; Musculoskelelal disorders of the the management of frozen shoulder. Int Ol1hop shoulder I'egion causing ccrvicobrachial pain. 1 5 :79, 1 9 9 1 Differential diagnosis and treatment. Surg Clin 2 1 . Uitvlugt G, DeLIisac OA, Johnson LL e t a l : Ar­ NOI"lh Am 43: 1 703, 1963 throscopic observations before and after manip­ 38. Akeson WH, Arnie! D, LaViolette D: The connec­ ulation of frozen shoulder. AI'lhroscopy 9: 1 8 1 , tive tissue response to immobility: a study of the 1993 chondroitin 4- and 6-sulphate and demlatan sul­ 22. Pollock RG, Duralde XA, Flatow EL et al : The phate changes i n periarticular connective tissue use of a!1hroscopy in the treatment of resistant of control and immobil ized knees of dogs. Clin frozen shoulder. Clin Orlhop 304:30, 1 994 Orthop 5 1 : 1 83 , 1 967 23. Wiley AM: Arthroscopic appearance of frozen 39. Akeson WH, Amiel D, LaViolette D et al: The con­ shoulder. Arthroscopy 7: 1 38, 1 99 1 nective tissue response to immobility: an acceler­ 24. Rizk, TE, Gavant MS, Pinals RS: Treatment of ated aging response. Exp Gerontol 3:289, 1 968 adhesive capsulitis (frozen shoulder) with 40. Akeson WH, Arnie! D , Mechanic G L et al: Colla- 276 P H Y S I C A L T H ER A P Y OF T HE SHOUL D E R 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- Rehabil 58:406, 1 977 dcrsyndrome. A comparison of hydraulic distcn- 1 1 1 . Steinbocker 0 , Argyros TG: Frozen shoulder: tion and manipulation. lnt Orthop 1 7:275, 1993 treatment by local injections of depot corticoste- 1 1 8. Hulstyn MJ, Weiss APC: Adhesive capsulitis of roids. Arch Phys Med Rehabi! 55:209, 1 974 the shollIde,'. O,·thop Rev 22:425, 1 993 Etiology and Evaluation oj Rotator Cuff Pathology and Rehabilitation TODD s . ELLENBECKER 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 infraspinatus. The typical lying anterior thil·d of the acromion. tensile disease/injury.' disease generally consists of decompression of 8 . elevation. cromial ligament. coracoa­ age range for this stage of injury is 25 to 40 years.19 Bigliani et al 1 8 described three mion were measured between 85° and 1 36° of types of acromions: type I (flat). hori­ type I acromions were only associated with 3 per­ zontal adduction. coracoid. or biceps tendon . and sition of the shoulder in forward flexion.11 [n addition to Biomechanical analysis of the shoulder has bony alterations that are acquired with repetitive produced theoretical estimates of the compres­ stress to the shoulder. This is characteristically observed in younger patients who are more athletic. or acromial-clavicu­ Neer's stage I I I impingement lesion. other two stages and consist of a positive im­ and macrotraumatic failure. The po­ ders with a full-thickness rotator cuff tear. Full-thickness tears of the ro­ space. re­ Macrotrauma sults from the mechanical irritation of the ten­ Rotator cuff tear don from the impingement incurred with over­ Compressive disease head activity.280 PHY SICAL THERAPY OF THE SHO U L DER These data provide scientific rationale for the Etiologic {actors associated With concept of impingement or compressive disease rotator cuff pathology as an etiology of rotator cuff pathology. partial-thickness tears of the rotator ior radiographs and found to be 7 to 1 3 mm in cuff. Primary compressive disease or impingement is This occurs from repeated episodes of mechani­ a direct result of compression of the rotator cuff cal inflammation. and is the result inferior acromion and superior surface of the ro­ of continued mechanical compression of the ro­ tator cuff tendons is tenl1ed the subacromial tator cuff tendons. and varying degrees of muscular weakness. edema and hemolThage.I'-16 Poppen and Walker1 4 calcu­ The specific shape of the overlying acromion lated this force at 0. and internal rotation during centl8 I n a series of 200 clinically evaluated pa­ the acceleration and follow-through phases of tients.11 The physiologic space between the bOl. biceps tendon lesions. I I PRIMARY COMPRESSIVE DISEASE The second stage of compressive disease out­ lined by NeeI' is termed fibrosis and tendinitis. termed acromial archileclL/re." has outlined three stages of pri­ Tendonosis mary impingement as it relates to rotator cuff Instability pathology. Peak forces against the acro­ rotator cuff l8. is telTlled lar jointlO. type IT (cUl"Ved).1 7 as well as commonly in­ mion was found in 70 percent of cadaveric shoul­ curred i n ergonomic and daily activities. with process. The primary symp­ toms and physical signs of this stage of impinge­ discussed: primary compressive disease. and can include thickening or tendons between the humeral head and the over­ fibrosis of the subacromial bursae. I6 a position inherent in sport-specific and type III (hooked). second­ ment or compressive disease are similar to the ary compressive disease. and bony alteration size in patients with shoulder painl2 and 6 to 1 4 of the acromion and acromioclavicular joint may mm in normal shoulders.e spurs and le/1don nlplure.42 times body weight. pingement sign.IO. Microtrauma Neerlo. A type 1Il or hooked acro­ movement patterns'. 80 percent with a positive arthrogram had the throwing motion are likely to produce suba­ a type I I I acromion. and is described as a reversible condition with con­ servative physical therapy. Stage 1. the native shape of the sive forces against the acromion with elevation acromion is of relevance. of the shoulder. It has been measured using anteroposter­ tator cuff.2 times the studied in relation to full-thickness tears of the weight of the arm ." be associated with this stage. painful arc of movement. has been Lucas 15 estimating this force at 1 0. 1 9 cromial impingement due to abrasion of the su­ Surgical treatment for primary compressive praspinatus. 9 mately failed under the heavy load. 8.'.9 tive f"llnctional outcome 9. According to Co­ demands incurred in throwing or overhead ac­ field. povascularity in its deep surface 2 cm from its .9 Allenuation of the static stabi­ Full-thickness tears of the rotator cuff with bony lizers of the glenohumeral joint. The tensile stresses incUlTed by the I'Otator In his classic monograph on ruptures of the su­ cuff during the arm deceleration phase of the praspinatus tendon. other factors in­ fen'ed to as "angiofibroblastic hyperplasia" by herent in the rotator cuff have relevance with re­ Nirschl 2 0 occur in the early stages of tendon in­ spect to injury. 21 normal tendons do not tear.'·9 A progressive loss of gleno­ in the subjective exam.8. repetitive eccentric forces inculTed by the Additional EtiologicFactors in posterior rotator cuff musculature during the de­ Rotator Oujf Patlwlogy celeration and follow-through phases of over­ head sport activities can lead to overload failure In addition to the etiologic factors of rotator cuff of the tendon 9•2 0 The pathologic changes re­ pathology already mentioned. specifically the supraspinatus. humeral joint. can lead to anterior instability of the gle­ or more of the tendon must be damaged to pro­ nohumeral joint. The heavy. Unlike the previously mentioned rotator cuff classifications. 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. Due to the increased humeral duce a substantial reduction in strength . The vascularity of the rotator jury and can progress to rotator cuff tears [l'Om cuff. such as the cap­ avulsions of the greater tubel'Osity can occur sular l igaments and labrum fTom the excessive (Tom single traumatic episodes. has been ex­ the continued tensile overload9 tensively studied beginning in 1 934 by Codman. The biceps long head of either acquired or congenital capsular laxity. 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. tendon was found to have a similar region of hy­ as well as labral insufficiency. hori­ zone of hypovascularity located one-half inch zontal adduction. as 30 percent tivities. and internal I'Otation are re­ proximal to the insertion on the greater tuberos­ ported to be as high as 1 0 90 N with biomechani­ ity n This region appeared anemic with the ap­ cal study of highly skilled pitchers 7 The presence pearance of an infarction. cases involving macrotraumatic tendon failure usually entail a previous or Single SECONDARY COMPRESSIVE DISEASE traumatic event in the clinical history. can greatly in. Codman described a critical throwing motion to resist joint distraction. Al­ head translation.9 Open re­ MACROTRAUMATIC TENDON FAILURE pairs of associated full-thickness tears of the ro­ tator cuff are routinely performed. Further specifics of rotator cuff surgical treatment will be discussed later in this chapter. and beveling of cle tendon units. TENSILE OVERLOAD Another etiologic factor in rotator cuff pathology is repetitive intrinsic tension overload. 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 approximately 2 cm posteriorly to provide addi­ tional space for the inflamed tendons. ROTATOR CUFF PATHOLOGY ANO REHAB I LITAT I ON 281 mm of the anterior acromion with preservation crease the tensile stresses to the I'Otatorcuff mus­ of the insertion of the deltoid.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. tor cuff." 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. Blood flow was sociated intra-articular pathology by M iller and greatest in the critical zone in living patients with Savoie. tears on the superior or intertubercular groove. 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. and biceps tendon tears in 1 6. 30 have both em­ extend to include the infraspinatus. of the supraspinatus and infraspinatus tendons Additional research on full-thickness rotator with both being hypovascular with quantitative cuff tears has significant clinical ramifications. One hundred consecutive patients with Full­ Contradictory research published by Swion­ thickness tears of the rotator cuff were prospec­ towski et al. patients with full-thickness biceps.' 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 . teres minor. In the classification scheme listed ation of the biceps long head tendon from the earlier in this chapter. with anterior labral tears occu'Ting in 62.282 PHYS I CAL THERAPY OF THE SHOULDER insertion " Rathburn and MacNab" reported by Loehr et aI. ' 6 does not support this region of tively evaluated to determine the incidence of as­ hypovascularity or critical zone. or either partial or com­ bursal side of the rotator cuff are generally asso­ plete tears of the bi.-m in a position of terns of the glenohumeral joint. due to increased hu­ cant difference between the tendinous insertions meral head translation and ensuing instability. This consistent pattern spinatus did not influence the movement pat­ was not observed with the a. Partial-thick­ There are several primary types of rotator cuff ness tears can occuron the superior surface (bur­ tears commonly described in the literature. 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. whereas a two­ abduction. Full­ sal side) or undersurface (articular side) of the thickness tears in the rotator cuff consist of tear's rotator cuff. phasized that superior surface (bursal side) tears and subscapularis tendons. histologic analysis. 25 found no signifi­ function of the rotator cuff. '· Therefore. 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. 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. The progression of the mechanical and avascular margins to neovascularization irritation on the superior surface can produce a with cellular infillrate. 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. a constant area of hypo­ tendons. Brooks et al. 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. and Fukoda et al. ' 7 Often associated in the rotator cuff are the result of subacromial with a tear in the subscapularis tendon is sublux­ impingement. 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". '·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. that resulted in 8 partial-thickness rotator cuff One additional etiology for the undersur­ tears and 12 lesions in the posterosuperior la­ face tear of the rotator cuff in the young athletic bn.. and dy­ namic muscular imbalances are often reported. and labral lesionsJ> SCientifically based evaluation procedure is used Walch et al.1) .". capsular and labral insufficiency. and become pinched between cuff tear. The bursal side of the supraspinatus ten­ don was comprised of a group of longitudinal tendon bundles that could disperse a tensile load FIGURE 11.33 with permission. Although it is imperative to understand the rotator cuff is not functioning properly. 3 2 The presence of anterior don. ROTATOR CUFF PATHOLOGY AND REHAB I LITAT I ON 283 or articular side of the rotator cuff are generally associated with tensile loads and glenohumeral joint instability··31 Tears on the undersurface of the rotator cuff are commonly found in over­ head-throwing athletes. The the common causes and classifications of rotator posterior deltoid's angle of pull pushes the hu­ cuff pathology and types of rotator cuff tears. 3J arthroscopically evaluated 1 7 not only to identify rotator cuff pathology but to throwing athletes with shoulder pain during ultimately identify the cause. Impingement of the undersurface of the shoulder is termed "inside or under surface im­ rotator cuff on the posterosuperior glenoid la­ pingement. as evidenced by the classifi­ face of the rotator cuff tendons. 3I performed a histologic and biomechanical study of the ro­ tator cuff tendons. where anterior instabil­ ity.·3J Placement of the shoulder in a bnlm may be a cause of painf'ul structural dis­ position of 90' of abduction and 90' of external ease in the overhead athlete. Nakajima et al.3 I The results of this study further reinforce the proposed etiology of tensile stresses producing undersurface rotator cuff throwing and found undersurface impingement tears. . can produce me­ chanical nlbbing and fTaying on the undersur­ ing etiologic factors. has been confirmed al-throscopically during the Rotator cuff pathology has several underly­ subluxation-relocation test. which tear.lm. the skeletal. and joint cap­ tendollS. 34 Shear within the tendon appears to be re­ translation of the humeral head with maximal sponsible in the pathogenesis of this rotator cuff external rotation and 90· of abduction. Additional cation schemes and scientific research in the lit­ harm can be caused by the posterior deltoid if erature.. rotation causes the supraspinatus and infraspi­ One final type or classification of rotator cuff natus tendons to rotate posteriorly. To further understand the differing etiologies of rotator cuff tears. their re­ suits showed greater deformation and tensile strength of the bursal side of the supraspinatus tendon. it meral head against the glenoid. ligament. the posterior edge of the glenoid and the deep These authors found the anicular surface to be surface comprised of a tendon. This tear develops between the bursal the humeral head and the posterosuperior gle­ and articular side layers of the degenerated ten­ noid rim (Fig. tendinous.1 Schematic representation of and generate greater resistance to elongation posterosuperior glenoid impingement between than the articular or undersurface of the tendon. accentuating is of paramount imponance that a stnlctured. Biomechanically. to nib on tear is the intratendinous or interstitial rotator the glenoid lip.) sule complex that elongated poorly and tore more easily. (From Walch et al. 1 1. 39 was manifested by a hori­ joint kinetics inherent in each stage of these zontal adduction cross-body maneuver.36 pletely cover a comprehensive evaluation of the A detailed. A difference of Shoulder for Rotator Cuff more than I cm is considered abnormal. particularly for the overhead athlete. Merely es­ significant for two reasons. 35 Tests to identify scapular and abduction are performed during the evalua­ winging in multiple positions (waist level. can greatly assist in understanding the probable The loss of internal rotation range of motion is cause and type of rotator cuff injury. and training his­ of patients with glenohumeral joint impinge­ tory provide information that is imperative in ment. Identification of selective process that are of critica1 impOI·tance in identifi­ internaJ rotation range of motion loss on the cation and delineation of rotator cuff pathology.3 8 and professional baseball and specific types of rotator cuff pathology are pitchers. Specific muscular activity patterns and by Han-yman et al. ergonomic environment. but specific. A goniometric method using an anterior employed. Tightness of the presence of instability. A brief meral joint range of motion is a key ingredient to discussion of specific aspects of the evaluation a thorough evaluation. similar sport activities can assist in the identification of to that incurred during the follow-through of the compressive disease or tensile type injuries.2) to During the subjective exam. and tion of the patient with rotator cuff injury. is important. The multiple etiologies elite tennis players3 7. reflected in the types of clinical tests routinely 1 99 1). 1 1 . and Patlwwgy may indicate scapular muscular weakness and poor overall stabilization of the scapulothoracic It is beyond the scope of this chapter to com­ joint.284 PHYSICAL THERAPY OF THE SHOULDER Clinical. The throwing motion or tennis serve. 3 6 A tape measure is lIsed to measure the lated testing of glenohumeral joint motion is a . (Ellenbecker TS: unpublished data.32. however subtle. specific ques­ minimize the scapulothoracic contribution and tioning.·2 such as internal kinesia can be performed using the Kibler scapu­ rotation with extension. Evaluation of the distance from a thoracic spinous process to the infe. Measurement of active and passive internal Objective evaluation of the patient with rota­ and external rotation at 90' of abduction along tor cuff pathology must include postural testing with scapular plane elevation.33 whereas a feeling of instability or loss of the humeral head and superior migration are of control during the follow-through phase dur­ ing predominantly eccentric loading can indi­ two key factors indicated in rotator cuff pathol­ cate a tensile rotator cuff injury'" Additional ogy. during posterior capsule has also been linked to in­ the cocking phase of overhead activities can pro­ creased superior migration of the humeral head duce impingement or compressive symp­ during shoulder elevation 40 Anterior translation toms. is wan-anted. and abduction and ex­ lar slide test in both neutral and 90' elevated po­ ternal rotation.-ior angle of the scapula. The in­ what stage or phase of the overhead activity crease in anterior humeral shear force reported would. forward flexion. isolated assessment of glenohu­ shoulder. The relationship be­ tablishing that the patient has pain with over­ tween internal rotation range of motion loss head throwing or during the tennis serve does (lightness in the posterior capsule of the shoul­ not provide the optimal level of information that der) and increased anterior humeral head trans­ more speCific questioning aimed at identifying lation has been scientifically identified.9Internal rotation range of motion loss has questions regarding a change in sport equip­ also been consistently identified in a population ment. Testing for scapular dys­ patterns (Apley's scratch test). or substitution is recommended by this author. this is provided in Chapter 3. dominant extremity was consistently reported in however.4 1 understanding the stresses leading to injury. iso­ silions.9. and observation. 8. Docu­ 90' of flexion or greater) with an axial load via mentation of combined functional movement the arms are indicated. containment force by the examiner ( Fig. 2 Goniometric measurement of . Resisted internal rotation in the neutral ad­ ducted position is generally recommended for the subscapularis. 3 . deltoid.) 7 Detelmination of isolated and gross muscu­ lar strength during the evaluation of the patient with rotator cuff pathology not only has a major impact on the determination of the underlying cause. scap­ ular stabilizers.3 Supraspinatus MMT POSiTiol1. and distal upper extremity mus­ cle groups is highly recommended. and in normal controls. 44 Care must be taken when interpreting normal grade static manual muscle tests of the internal and external rotators. R OTATOR CUFF PATHOLOGY AND R EHAB I L I TAT I ON 285 FIGURE 11. . For the pa­ tient with subtle symptoms and apparently FIGURE 11. but assists in the formulation of a specific. 3 ) .44 Testing for the infraspinatus and teres minor is done with resisting external rotation in both the neutral adducted and 90° abducted posi­ tion. 30° anterior to the coronal plane (Fig. Iso­ lated testing in the "empty can" position for the supraspinatus is performed in the scapular plane. Nor­ mal grade % muscular strength has shown large variability when compared to isokinetic testing in patients with rotator cuff pathology. the consistent application of manual muscle testing for the rotator cuff. 4 J J .ntenw/ rota/ion range o( motio17. 4S Regardless of this repOl-ted variability. objectively based rehabilitation program. necessary requirement to identify important gle­ nohumeral joint motion restrictions. 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. grimace being indicative of a positive test. as well as the fulcrum. This test passes the rotator cuff under imparted. with cessation of the praspinatus under the coracoacromial arch.32 is performed with garding the relationship. 8. dy­ using one hand on the posterior aspect of the namic. the glenohumeral joint are a vital part of the The anterior band of the inferior glenohumeral comprehensive evaluation. ducting the humerus starting in 90° of elevation.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. as well as endfeel. 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. the patient's symptoms. The joint instability. reported by Hawkins and Kennedy. rior capsule· ( Further discription of these clinical tests can be The consistent use of these instability tests found in Chapter 3).11 places the shoulder in full forward translation in the position of 90° of abduction flexion with overpressure. more specific. 8. A second impingement Capsular mobility testing with the patient su­ test. and subluxation relocation tests. due to the sive or impingement etiology. with pain and a facial and 90° tests the integrity of the superior. 8 The reloca­ tion portion of the test consists of a posteriorly directed force produced by the examiner. This posterior force centralizes The classic tests for evaluation of a patient with the humeral head in the glenoid fossa. The subluxation relocation will provide the clinician with greater insight re­ test popularized by Jobe8. rior or multidirectional glenohumeral joint lax- . A positive rotator cuff pathology are the impingement subluxation/relocation sign consists of provoca­ tests. with the anterior Neerlo.48 Tests to de­ important hammock-like stabilizing function of termine the i ntegrity of the static stabilizers of the inferior glenohumeral ligament complex. 60°. 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. The identification of either ante­ examiner pushes the humeral head forward. The impingement test reported by tion of the patient's symptoms. 47 in­ pine at 30°. by Special Tests placing the heel of the hand over the humeral head anteriorly. Clinical tests for instability of the tion. the coracoacromial arch. 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. with 90° of glenohumeral tient's rotator cuff pathology and glenohumeral joint abduction and 90° of external rotation.286 PHYSICAL THER A P Y OF THE SHOULDER nOl-mal muscular strength. A and inferior glenohumeral ligaments. humeral joint and note the end point of the ante­ load and shift. 60°.10. This places the su­ and external rotation. if any. between the pa­ the patient supine. middle. respec­ final impingement test is the crossed arm ad­ tively·8 The degree of translation of the humeral duction test. isokinetic testing is indicated to better patient's shoulder. often repro­ ducing the patient's shoulder pain. 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. The anterior stress applied at 30°. symptoms with the relocation (posterior central­ and can compress the tendon and reproduce ization force). and 90° of abduction is also per­ volves 90° of forward flexion with full internal formed with both anterior and posterior stresses rotation. which involves horizontally ad­ head relative to the glenOid. to some extent. The presence of a force couple imbal. These small rotator cuff overlying acromion superiorly out of the path of cross-sectional areas paJe in comparison to the the elevating proximal humerus. 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 .!rther dem­ muscle has a compressive [unction when con­ onstrated in EMG analysis by Kronberg et al. 2 tracting. further perpetuates this force couple im­ vector of the deltoid. 5J The force cises.itati<m oj Rotator Cuff PaIlwliJgy FIGURE 11. with many other areas of significant emphasis. ' moving the the supraspinatus. as it produces up­ physiologic cross-sectional area is exhibited by ward rotation of the scapula. 3S . imbalanced pair in the overhead athlete. followed closely by the tus anterior-trapezius force couple is also impor­ infraspinatus-teres minor groupSO The smallest tant in rotator cuff pathology. The internal-ex­ larger force-generating capacities of the deltoid ternal rotator force couple is another commonly muscle. R OTATOR CUFF PATHOLOGY AND REHAB I LITAT I ON 287 ity should lead to the formulation of a treatment plan addressing the instability 9 The special tests listed above are by no means comprehensive. being of paramount importance. ! . balance. Biomechani. One factor of key impor­ tions of the humeral head to keep it stable within tance when clinically interpreting the force cou­ the glenoid. A force couple consists of a pair Weakness of the rotator cuff. if contracting unopposed. acting to assist in the caudal rorce that resists the superior migration movement and counterbalance the micromo­ of the humeral head. 1 1 . creatingan approximation of the hume­ This study illustrates that all of the rotator cuff rus into the glenoid (Fig.4). and subscapularis produce a shoulder movements. with basic natus. 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.50 are the serratus anterior-trapezius Research shows the subcapularis to have the and internal-external rotator couples. Interpretation of the results of a comprehensive evaluation will allow the clini­ cian to develop an objectively based rehabilita­ tion program for rotator cuff pathology. due to . 52 The supraspinatus tor cuff and deltoid musculature ic f. the force couple. The serra­ greatest force potential. The infraspi­ muscles are involved. which would create superior migra­ The coordinated interplay between the rota­ tion of the humeral head.4 Deltoid-rotator Cliff (orce callpie. is superior.cal Concepts Jor Rehalril. teres minor. Several biomechanical concepts have significant applications in the fOlmulation and application of rehabilitative exercise for the patient with ro­ ance is often identified on initial evaluation of tator cuff pathology. One important concept is the patient with rotator cuff pathology. coupled with hy­ of forces acting on an object that tends to pro­ pertrophy or training enhancement of the del­ duce rotation. such as tests to determine the integrity of the biceps and glenoid labrum. and the infra­ treatmenl . and wrist is indicated.54 often required. REDUCTION OF OVERLOAD AND TOTAL ARM specific emphasis on the caudal glide in varying REHABILITATION positions of abduction is applied assertively. Muscular force vectors have Thorough evaluation to determine the degree of been studied with the shoulder in the functional hyper or hypomobility of the glenohumeral joint.50.53. In postoperative rehabilitation of rotator Both nonoperative and postoperative rehabilita­ cuff repairs. pat1. and contraction stretching techniques that attenuate the anterior specificity incun·ed in ADL and overhead sport capsule. which overpowers the controlling and ties and modification of. tension.55 and scapular movement andior elbow kinematics. the use of joint mobilization tech­ tion of the rotatorcuff involve the following prin­ niques to both retard and address the effects of ciples. and the ability of RESTORATION OF NORMAL JOINT rotator curr muscular contraction to create ten­ ARTHROKINEMATICS sion and effect orientation of the capsuloliga­ mentous complex. Additional biomechanical stresses or loads to the injured tissues. Care should be taken to identify Further evidence of the rotator cuffs vital the presence of any compensatory actions in the function in glenohumeral joint arthrokinematics upper extremity kinetic chain. sport and ergonomic movement patterns is tors. but loss. The presence of increased anterior spinatllS as an adductor. .'8 Blaiser' in cadaveric studies.'6 identifies the int imate. predicates the progression of and in­ laris functions as a flexor and internal rotator.2o Application of modali­ strength. the subscapu­ surements. tak­ demonstrates the rotator cuff's critical contribu­ ing great care not to impart inappropriate tion to joint stability.icularly in strain on the anterior capsule (inferior glenohu­ postoperative cases where the degree and length meral ligament) with the shoulder in 90° of ab­ of immobilization is greater. This important scapulothoracic joint and submaximal strength­ stabilizing function to resist anterior translation ening of the scapular stabilizers is indicated.57 In this abducted position. research by Clark et al.288 PHY S I CAL THERAPY OF THE SHOULDER selective development of internal rotation not complete function. stretching techniques to improve internal rota­ tion range of motion are often indicated and ap­ plied. position of 90° of abduction and external rota­ coupled with isolated joint range of motion mea­ tion. adherent association of the rotator cuff to the capsuloligamentous structures. contraindicates the appli­ functional positions to most closely simulate the cation of joint accessory mobilization and actual muscular length. These studies have Early use of distal strengthening of the elbow. This study demon­ capsular laxity and underlying instability of the strates the importance of working the dynamic glenohumeral joint. In addition to the posterior capsular mobilization described. clusion of stretching and joint mobilization in the supraspinatus as an extensor. Posterior capsular mobilization and movement patterns. shown the rotator cuffs ability to reduce the forearm. Mobilization of the duction and external rotation. a finding conSistently found stabilizers of the shoulder in both neutral and in overhead athletes. such as excessive has been demonstrated by Cain et al. to The initial goal of any treatment program in­ stress the inferior capsule and prevent both ad­ cludes the reduction of pain and inflammation hesions and functional elevation range of motion by protection of the extremity from stress. immobilization is recommended. or complete cessation decelerative influence of the external rota­ of. The consequences of posterior capsular RehabilitaJ:Wn of Rotatnr Cuff tightness have been outlined earlier in the Patlwlogy chapter. boids 6J Use of closed-chain exercise. nor do they place excessive stress to the often attenuated anterior capsuloligamentous com­ plex. progressing rapidly to sub­ maximal isotonic exercises. These positions also do not place the shoulder in a potential position of impingement. and produce high levels of rotator cuff activation. Movement patterns re­ quiring high activation levels from the rotator cuff based on EMG confirmation via biomechan­ ical study are applied '9. Progression to advanced-level plyometric exercises for the . and rhom­ eieclromyographic research.and postoperative reha­ bilitation of the rotator cuff.5 have been biomechanically studied.61 The proper use of these patterns using a low-I·esistance ( never greater than 5 pounds and typically initiated with either no weight or as little as I pound) high-repetition format is recommended to en­ hance local muscular endurance62 of the rotator cuff musculature. The movement patterns recommended for strengthening the rotator cuff do not place the shoulder in elevation beyond 90° or posterior to the coronal plane. R O T A T OR CUFF PATHOLOGY AND R EHAB I L I T A T I ON 289 PROMOTION OF MUSCULAR STRENGTH BALANCE AND LOCAL MUSCULAR ENDURANCE The addition of resistive exercise is begun as in­ nammation and pain levels allow. Early submax­ imal resistive exercise in the rotator cuff and scapular muscles is initiated in the form of multi­ ple-angie isometrics. The movement patterns pic­ tured in Figure I 1 . trapezius. is also rec­ ommended in both non. Pallerns resisting scapular protraction and retraction. because of their in­ herent dynamic characteristics ·6 The pl·esence or lack of pain over the joint or affected ten­ don(s) determines the speed of progression and intensity of exercise. which ap­ proximates the glenohumeral joint and produces co-contraction of the proximal stabilizing mus­ culature of the scapulothoracic joint.5 ROlalor cuff exercises predicated 011 the serratus anterior. Similar positional limitations are applied in this stage of rehabilitation for strengthening the scapular stabilizers. Resistive exercises that em­ phasize concentric and eccentric muscular con­ tributions from the key dynamic stabilizers of the shoulder are used. elevation and depres­ sion produce considerable muscular activity in FIGURE 1 1. 7 the glenohumeral joint 6' and in the mainlenance of dynamic glenohu­ Resistive exercises with emphasis on the bi­ meral joint slability.'.46 Submaximal intensities at speeds shortening cycle of the scapulolhoracic muscu­ ranging from 2 1 0· 10 300·/sec are used.and postoperative re­ ercise. such as chest passes. they are considered for this progression. 3 5.6).6 (A & B) /sokillelic illlemaliexlenwl rolalion wilh 90·of abdtlClioll il1 l"e scaplllar plane. 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. tion using fasl conlraclile velocilies. 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 . using tissue tolerance as the Strengthening of the biceps in neutral and 90· of guide.67 activity is followed.' ·56 ceps muscle are recommended in rotator cuff re­ Progression from lhe modified position in habilitation. . lateral strength raoos. As patients lolerate medium-resis­ for the demands of overhead activily (Fig. 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. with concen­ in lhe scapular plane. to prepare lhe rolator cuff musculalure habililation. I 1 . lsokjnetic internal and external rotation shoulder flexion is recommended. due to the glenohumeral joint stabi­ palients who will reLUm to aggressive overhead lizing and humeral head depression actions.290 PHYSI CAL THERAPY OF THE SHOULDER upper exlremily is also indicated. wilh spe­ lature.65. with 80· to 90· of abduc­ tric and eccentric contractions implemented. 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. 46 Unilaterally dominant A B FIGURE 1 ( . Another commonly used surgical exposure the unilateral strength ratio may be o[ even for rotator cuff repair is the lateral "deltoid-split­ greater importance. with bilaterally provide both protection for the rotator cuff and symmetrical external rotation strength.46. 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. is also frequently used. along the line of the deltoid fi­ also altered « 66 percent) in the dominant atom bers. has been reported at 66% throughout the 6 cm in length.ilaticm oj Rotator Cuff tached from its origin). be accomplished using this surgical exposure. The procedures were performed such as anterior .53 . 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. in­ Progression of both range of motion and re­ cluding open rotator cuff tears.54 Isokinetic exercise and iso­ lateral corner of the acromion. 4 to de.41. 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. This surgical approach begins externaliinternal rotation ratio in healthy shoul­ with a transverse incision through the skin.46 The unilateral t i ng" approach.69 portant baseline comparison for the individual. restrictions regarding the Tears application of active OJ' resistive exercise are nor­ mally given.53. sistive exercise is much [aster following arthro­ In some cases. 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. using innuence on several aspects of the rehabilitative the lateral deltoid splitting approach. active-assistive. can nor­ process. anterior surgical exposure of scopic rotator cuff debridement (Case Study 2). Active-assistive movement following sur­ repairs of rotator cuff tears has a considerable gery with the m ini-arthrotomy technique. The deltoid's ori­ lated joint testing is an objectively quantifiable gin is protected and not detached. 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. Two surgical approaches commonly mally commence on the first postoperative seen in rehabilitation will be briefly discussed. This author's protocol for coid tip. the deltoid is due to the selective internal rotation strength de­ then split in line with its fibers near the antero­ velopment. J5 . 35 . 3 5. the shoulder requires detachment of the deltoid Active.5 4 prevention of further disease progression follow­ Although bilateral comparison does provide im­ ing its repair. 70 pathology. Regardless of the in overhead throwing and racquet sport athletes orientation of the skin incision. crosses the cora­ rehabilitation process. 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. 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. With the anterior deltopect­ Specijic Factors Influencing the oral approach ( where the deltoid can be de­ RehabiJ. 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. day.46. Open at initial evaluation. and hence often of rotator cuff disease. to retard atrophy and begin to a1�hroscopic debridement and subacromial de­ normalize muscular strength imbalances. on the clinical outcome of conservative treat- . 75 as well as postoperative management one to two postoperative days. low-resistance. 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. 72 compared the results of open surgical repair affect early rehabilitation emphasis. A up to 6 weeks following open rotator cuff repairs 2. 39.�hroscopic debridement in 87 consecutive immobilization in a sling or sling and swathe for patients with full-thickness rotator cuff tears. 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 .ctms IrIjl'l.(Jing tIw Results oj lar laxity in the overhead athlete with partial undersurface rotator cuff tears. laser capsulorrhaphy. Submaximal inten­ cussed.�ed repair of the tom rotator cuff tendon versus ar. with no deteriora­ The degree and length of immobilization of the tion of results over time. Traditional to a. 7 5 Itoi and Tabata74 repo.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 . or extensive compression are two options frequently dis­ subacromial decompression. 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. (2) SURGICAL PROCEDURE a history of pretreatment symptoms greater than Debate in the literature regarding the surgical 1 year. Extensive limitation contains an extensive an-ay of research demon­ in active and passive elevation.-tial rotator cuff tears. Clinical findings and prognostic mobilization and passive stretching techniques factors associated with unfavorable clinical out­ in this population. 7o compression of massive rotator cuff tears with an average 30 monlh follow-up. Finally. One tion. fol­ 93 patients who underwent open debridement lowing debridement of pa. 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. Montgomery et shoulder following rotator cuff repair can greatly al. as well as external strating the efficacy of various surgical proce­ rotation of the shoulder. often deemphasize the im­ portance of accessory joint mobilization.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. high-repetition format is recom­ Burkhart 73 studied 25 patients who undelwent mended early. require minimal accessory mobilization to re­ store normal joint arthrokinematics. repair of a Bankart lesion with throscopic debridement and subacromial de­ suture tacks. resistive exercise using a with an 8-year average follow-up evaluation. espe­ Several factors are consistently rep0l1ed in the cially to the anterior capsule. The com­ mon finding of associated instability and capsu­ Fa. and (3) Significant functional impairment management of rotator cuff tears exists. coupled with NO'Yl(J[Jerativ e RehahUitation oj minimal immobilization time following arthro­ Rotatm Cuff Tears scopic debridement. The literature tion and passive stretching. Eighty-eight per­ cent of the patients in this series were found to LENGTH OF IMMOBILIZATION have good or excellent results.292 PHY S I CA L THERAPY OF THE SHO U L D E R capsulorrhaphy. 7 ' .0 cm' . As stated earlier. and subacromial decompression for irreparable Because arthroscopic approaches to the shoul­ rotator cuff tears.lffl1.73 Rockwood and Burkhead7 ' followed sity resistive exercise is also initiated rapidly. Factors not associated with clinical out­ vious bouts of what he calls impingement dating come included patient age. Passive accessory mobility of the patient's left shoulder reveals a 2 + anterior CASE STUDY 1 translation at 60· and 90· of abduction. Anterior . loss of velocity were identified in their sample as limited abduc­ in his throwing performance. 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. joint arthrokinematics and normal muscular INITIAL FINDINGS strength. gender. unevent­ mary goal initially of restoring normal joint mo­ ful spring training. as com­ REHABILITATION FOILOWING pared to a 1 + on the right uninjured shoulder. he reported ini­ used to telminal ranges as tolerated. with a pri­ pain in early April following a normal. 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. and 20· of internal rotation. Although the patient denies tion. including nonsteroidal anti-inflammatory medication and physical therapy for rotator cuff and general upper extremity strengthening. dominance. objectively based evaluation and (articular side) tear in the supraspinatus tendon. 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. endurance. 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. associated with rotator cuff injury. His pertinent history includes pre­ patient. 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. Rehabilitation of rotator cuff pathology requires Diagnostic testing revealed an undersurface an extensive. active assistive and active ROM are any particular incident of i njury. and chronic­ years. A rehabil­ He is referred to physical therapy one day follow­ itation program aimed at restoring nOlmal ing arthroscopic surgel)'. Passive. he Summary was scheduled for further diagnostic testing. shoulder. 75· of external rota­ tremity kinetic chain approach to comprehen­ tion. abduction. Good distal sively address rotator cuff pathology. and internal rotation ROM. Accessory tially decreased recovery following pitching and mobilization is applied in the posterior and cau­ pain in the anterior aspect of his shoulder dUl. strength is present. and intact neurologic status is confirmed. the acceleration phase and continued pain dur. Posterior and caudal mobility are equal bilater­ ARTHROSCOPIC ROTATOR ally. Isolated treatment and evaluative in the infraspinous fossa on the left. He denies any dislocations of his left ity of onset. the mary factors relating to an unsatisfactory result patient complained of weakness. SUPRASPINATUS TREATMENT SUBJECTIVE INFORMATION WEEK I 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. 1 00· of abduction. After 2 months of nonoperative treat­ ment. The pri­ dition to localized anterior left shoulder pain. In ad­ tor cuff tear with a follow-up of 3 years.ng dal directions to facilitate the return of flexion. occupation. 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. back to his high school and collegiate baseball associated instability. Tol­ OPEN ROTATOR CUFF REPAIR erance of a minimum of 3-pound isolated rotator (DELTOID SPll1TING cuff exercises. tendonitis/impingement symptoms reported as . WEEKS 2 4 Continued use of ROM techniques at telminal WEEKS 8. medicine balls to simulate functional muscular contractions and facilitate scapulothoracic strength is initiated dUI-ing this stage. and equal external rotation ening program includes the use of closed-chain strength measured in the modiried position. negative impingement tests. 95° of external rotation. At Swiss ball exercise. At the end of the External/internal rotation ratios range between rirst postoperative week. Results of the pa­ assessed on initial evaluation. progressing over the next 3 to 4 weeks is of key importance. and ser­ this time the patient is progressed to an interval ratus anterior dominant activities including a Ihrowing program . with rior musculature to increase internal rotation. The isokinetic AROM of the left shoulder a t 1 75° of forward strengthening is progressed to a more functional Oexion and abduction. Continued titions. closed-chain . WEEKS 4-8 Addition of isokinetic exercise in the modified CASE STUDY 2 base position is warranted with this patient. continuation of a lotal arm strength program both in-clinic and at home is followed. revealing a relative weakness forward Oexion and abduction. A submaximal introduction to the isokinetic fOl-m of resistance The patient is a 5 1 -year-old male competitive is recommended. 90° abducted position in the scapular plane. 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. isotonic exercise using the pallerns with high and advancement of the scapular programs in levels of scientirically documented rotator cuff isotonic. he is progressed to throwing off the progress of this patient is documented with mound at 50 percent intensities. cent weaker external strength at 5 weeks postop. The and 40° of internal rotation. 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. and functional range of motion make him a candi­ APPROACH) SUBJECTIVE HISTORY date between 4 to 6 weeks postop.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. manual protraction/retraction). Isokinetic testing at 8 to 9 weeks with progression to 3 pounds by 3 weeks postop. and 35° of internal rotation measured dominant extremity. and plyometric venues activation. postop shows 25 percent greater internal rota­ Advancement of the patient's scapular strength­ tion strength. with posterior Continued mobilization and PROM to normalize glides and emphasis on stretching of the poste­ glenohumeral joint motion are performed. seated rows. and 1 20-foot stages. A plyomctric program with with 90° of abduction. the patient has 1 75° of 45 and 50 percent. 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. 90. Initially a I -pound weight is tolerated continues. and bicep/tricep and to 60. Isotonic rotalor cuff ex­ ening program includes concentric and eccentric ercise is progressed to not more than 5 pounds. Distal strengthening distance. with an isokinetic test to docu­ tennis player with a I year history of shoulder ment internal and external rotation strength ap. shrugs.1 2 ranges of motion are indicated. continued emphasis on the posterior capsule and Progression of the patient's rotator cufr strength­ posterior musculature. 90° of external or imbalance of external rotation strength on the rotation. 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. The patient . and 85° of external rotation tremity. and not performed on the postop shoulder at this eventually scaption are performed with no resis­ time. and terminal ranges of limitations of 100° of flexion and abduction. Concentric and eccentric crease local blood now. Submaximal multiple angle toid splitting approach. CLm-ent range of motion of radiation of symptoms and full light touch sensa­ the patient is 1 20° of flexion. He was unable The patients initial range of motion at 1 week to continue playing. and Continuous pain was reported. Sixty degrees of internal using the caudal and posterior directions along rotation is present with 90° of abduction. Evaluation of the patient's accessory cise patterns with isotonic resistance. During the third postop­ and sleeping. 50° of internal rotation. a match with minimal warm-up and felt a deep. scapular protractors/retractors. ROTATOR CUFF PATHOLOGY AND REHAB I L I TA T I ON 295 intelmittent based on his level of activity. and is refelTed for post­ isometrics are performed for shoulder IRIER. The scheduled. At 1 0 days movement reveals a decreased caudal glide and po top this patient has 1 55° of forward flexion. progressing the resistance level as toler­ ated. even with rest 30° of external rotation. is i ndicated. horizontal abduction. Initiation of resistive exercise denies any instability in either shoulder prior to in the form of isotonic internal and external rota­ this injury. The patient expressly arlhrokinematics. An M R l was gressed to active-assistive range of motion. The patient has no distal tation are included. Toler­ with passive stretching. 30° flexion. and internal and external ro­ to 40° external rotation. 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. Mobilization of the sca­ ance of 3-pound isolated rotator cuff exercises pulothoracicjoint is also used. The initial exam con­ 60° of external rotation. and 60° of internal rota­ sists primarily of a neurologic screening and pas­ tion. ion and abduction. prone extension. Instability or impingement tests are tion. 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. He subsequently gometer are added within the range of motion underwent an open surgical repair using a del­ restrictions listed. One of the elbow. Accessory mobilizations are applied with 90° of abduction. Continued mobilization of the glenohu­ sive range of motion measurement. passive range of motion is pro­ thopedic surgeon 2 days later. and distal forearm and wrist muscula­ INITIAL FINDINGS ture. and triceps. The patient presents with his right arm immobi­ PHASE II: TOTAL ARM STRENGTH (WEEKS 6-12) lized in a sling. just prior to impacting the ball. which revealed a full-thickness tear use of overhead pulleys and the upper body er­ of the supraspinatus tendon. tion and strong distal grip. posterior glide relative to the contralateral ex­ 1 45° of abduction. Passive stretching (ment ioned earlier) is demonstrated. particularly into extension because month ago the patient was hitting a serve early in of the continued use a sling for immobilization. tance. abduction. and following the match was status post open rotator cuff repair is 90° of flex­ unable abduct or flex his arm more than 90°. 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. and elevators. and he was evaluated by an or­ erative week. as operative rehabilitation 2 days following sur­ well as manual resistance exercise for the biceps gery. 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. 1 05° of abduction. Range of motion for throwing. 1 995 strength in preparalion for the interval return to 1 0. Andrews JR. Andrews JR. Am J Sports Mcd metric exercise with medicine balls intensifies. to begin to prepare the distal upper ex­ I . Vangheluwe B. Emphasis on con­ 1 978 tinued use a rotator cuff and scapular strength 1 5 . Walker PS: Forces at the glenohu­ tor cuff tear takes up to 6 to 8 weeks before pro­ meral joint in abduction. 1 980 this patient has continued to improve to 1 75° of 6. 1 Bone Joint Surg 54A:4 1 . The pa­ 5. Poppen NK. Scand 1 SPOlis Sci 2:52.296 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. Nemeth F. Achievement of greater external ro­ impingement syndrome in the shoulder. Golding FC: The shoulder: Theforgol lenjoinl. Rhll KN. well below the lar activities in the Lennis serve and overhead desired 66 percent balance. 1995 as does the entire scapular program. lobe FW. Fleisig GS. 23:233. Rideoul OF: Tears or the humeral ro­ ance to the forehand and backhand tator cuff: a radiological and pathological ne­ groundstrokes. 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. Br J Radio1 35: 1 49. including 8 . 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. McCormick J. 1989 strengthening. Sakurai S ct al: MusclI­ tient's ERlIR ratio is 54 percent. Typically the interval program cropsy survey. 1988 in the modified base position. COllon RE. The patient conlinues with reha­ 9. Jobe FW et al: An electro­ well as passive stretching in physiologic range of myographic analysis of shoulder fllnction in ten­ motion patterns. Neer CS: Impingement lesions. 1 964 following an open repajr of a full-thickness rota­ 1 4. Hebbelinck M : Muscle actions and ternal rotation strength bilaterally. Continued accessory mobilization to achieve full 1 990 ranges of elevation is applied to this patient. Brostrom LA: Muscle ac­ RETURN TO ACTIVITY PHASE (WEEKS /2-/6) tivity and coordination in the nannal shoulder: An electromyographic sJUdy. J stages of rehab. Lucas DB: Biomechanics of the shoulder jOint. 1 973 . 1 992 2. Arch Surg 1 07:425. Clin Olihop 257:76. 1983 will include groundstroke activity initially. A pre­ talion muscular strength and endurance is rec­ li monary repoli. Tsunoda T. Neer CS: Anterior acromioplasty for the chronic tennis play. Clin Orthop 1 73: val tennis program. Am J Sports tation. 95° of external ro­ analysis of the shoulder in pitching. An isokinetic test is performed nis players. lobe FW. Clin Olihop 1 35 : 1 65 . 1 984 of the patient's strengthening program includes 7. 1 986 cent external rotalion deficit identified. with a 35 per­ ground reaction forces in tennis. Escamilla the 90° abducted position for both isokinetic RF: Kinetics of baseball pitching with impl ica­ lRlER and surgical tubing strengthening. Blaiser RB. and 60° of internal rotation. 1972 ommended before this patient begins the inter­ I I . with emphasis on protraction for serratus Orthop Rev 28:963. Tibone lE et al: An EMG flexion and 1 60° of abduction. Am 1 SPOliS Med 1 6:48 1 . Kronberg M. lnt J Sports Bio­ mechan 2:88. 1 962 progression to volleys and serving based on toler­ 1 3 . maintenance program is followed upon dis. Shoulder Elbow SlIrg 1 : 1 40. Miyashita M . with 12. 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. Advancement Med 1 2 :2 1 8. Alexander EJ: Rotator cuff injury i n bilitative exercise and close adherence to a home throwing and racquet sports. 1 Bone Joint Surg 46B:314. The guided return to tennis 70. tected match play can resume. Plyo­ tions about injury mechanisms. as 3. revealing equal in­ 4. Dillman Cl. Maynes DR. of submaximal isokinetic exercise. Guldberg RE. Spor1s Med Ar1hros­ program to reinforce the concepts of total arm cop Rev 3:30. Daniels L. ElienbeckerTS. 1985 der intel-nal and eXlernal rotation range of motion 22. Blanksby B: A Ihree dimen­ Ther April-June 1994. p. Clin O'1hop 304:60.. Hawkins R J (eds): Surgery o f the 1990 Shoulder. Mosby Vear Book. 29. Washinglon. and strength in normal and Pathogenesis. Chandler n. Ellenbecker TS: Rehabililation of shoulder and (cd): Upper Extremity InjUlies in Athletes. Harryman DT. 1 990 isokinctic measurement of the shoulder intemal 3 1 . 1 988 36.. J Hand 1 7 . Brooks CH. Vamanaka K: Pathology ders. Marsh T. 1 59 niques of Manual Examination. Malsen FA I I I using laser doppler Oowmelry. Philadelphia. p. Noel E. J Bone Joint Surg cuff tendon. disease. Rokumma N. JungA: Shoulder 43. Nakajima T. 1 07 sional ci ncmatographic analysis of the tennis 33.-inled). Jobe FW. In Matsen FA. Wuelker N. Iannotti IP. Clin Sporls Med 1 0:823. Savoie FH: Glenohumeral abnormalilies 1983 associated with full-thickness tears of the rotator 44. Donell ST: Impinge­ se"'e. J Shoulder Elbow Surg 1 :238. Kummer FJ. 1 994 nohumeral joint (rep. 1 994 . Mosby. 1970 39. Prentice-Hall. 1 990 26. 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. Nirschl RP: Shoulder lendonilis.-. 208. DC. 5th Ed. O. Clark 1M. 1934 protocols.Elbow Surg 1 :4 . Flalow EL el al: The rcla­ don on the posterosuperior glenoid l"im: An ar­ tionship of acromial architecture to rOlalor cuff throscopic slUdy. Tomonaga A: nuence of coracoacromial arch analOmy on rota­ Pathology and pathogenesis of the intratendinous lor cuff Icars. Micheli LJ. lannolli JP: Lesions of the rotalor cuff: Pathology lems of nexibility. Hamada K. Thomas of elite junior tennis players: a comparison of two Todd. 1 99 1 diseasc of Ihc shoulde. Boslon. Piorkowski P : Shoul­ 974. Clin O'1hop 303:242. Am J Sports Med 1 8:366. Clin Orthop 1 73:3.Elbow Surg 3:79. Matscn FA Ill. Clin Sports Med can Academy of 011hopaedic Surgeons Sympo­ 14:87. 1 994 32. Ellenbecker TS: Muscular slrength relalionship viewed from en bloc h istologic sections. 1 993 and extremities. Kazuloshi H et at: His­ and extcmal rotators. Ameri­ elbow injudes in tennis players. Cuomo et al: The in­ 34. Louis. Roelert E P . Boulas HJ et al: In­ 40. Am J Sports Med 1 8 : 1 34 . Kibler WB. Elliol B. Rosemonl. Codman EA: The Shoulde. J Shou lde. 1 976 28. 1 990 540. 2nd Ed. Bigliani LU. Fukada H. 23. 1 994 drome. Philadelphia. 1 990 Siabilily. MacNab I : The microvascular pal­ comparisons of elite junior tennis players to other lem of Ihe rolalor cuff. U h l TL el al: Flexibilily 24. 1 995 sium. Sojbjerg JO. 1 994 20. American Academy of Orthopaedic Sur­ 42.-. 1992 teadng of the rotator cuff viewed from en bloc h istologic sections. 1990 4 1 . CT. Boileau P. Hamada K. Sidles lA. St. laxity. Kibler WB: Role of the scapula i n the overhead 2 1 . Miller C. Swiontowski MF. J Orthop Spo'1S Phys The. W B Saunders. Zuckerman JO. Plil' W. et al: Transla­ 25. Wort hingham C: Muscle Testing: Tech­ cuff. Clin Or­ between nOlmal grade manual muscle testing and thop 254:75. Fu Fl-!. Comemp O'1hop 22:525. Clin O'1hop 303:84. In Rockwood CA Jr. Loehr JF. Artnz CT: Subacromial impi nge­ traoperative assessment of rotator cuff vascularity ment. abstracled. Hawkins shoulders and shou lders with instability and im­ RJ (eds): The Shou lder: A Balance of Mobility and pingement. 1 986 and pathogenesis of bursal side rotator cuff tears 45. 1 992 72A:1 334. Hoppenfeld S: Physical examination of the spine geons. Warner JJP. Chansky HA. Ticker IB. J Bone Joinl Surg 74B: l S I . J Bone Joim Surg 67A: 37. Nakajima-T. IL. 1 986 ment of the deep surface of the supraspinatus tcn­ 1 8. In Pelll'onc FP 35. Helmig P. lannolli JP: The vascularilY of Ihe 1 7 :65.1hop Rev 23: February 1 994. 1 99 1 1 992 1 9. abstracted. In Post M . Walch G. R O T ATOR CUff PATHOLOGY AND R EHABI L I TAT I ON 297 1 6 . Fukuda H. Arslanian LE. Roelman B: Biomechanical supraspinatus tcndon: Reference to rotatOI' cuff data conccming thc shoulder impingement syn­ tearing. Cofield R: Current concepts review of rotator cuff Ihrowing mOlion. Norwalk. WB Saun­ 30. J Shoulde. J Ol-lhop Sports tologic and biomechanical characteristics of the Phys Ther 1 9:72. el al: Pal­ 27. Clin SPO'1S Med 1 0:807. 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. Revell WJ. Inl J SPO'1S Biomechan 2:260. 623. J Bone Joinl Surg 52B: ath leles. 1 993 rolalor cuff. Pink M: The alhlete's shoulder. Mon'ey BF.·. Ralhbull1 JB. (eds): T h e Shoulder. 1 99 1 38. A dynamic model. Ellenbecker TS. Glousman R. Arch Phys Med Rehabil 74:805. Weiner OS. In Andrews JR. Shwedyk E. Andreychik D. Cooper IE. New York. Paschall I L et al: Elec· compression for selected rotator cuff tears. p. Arnoczky SJ et al: The anat­ 63. J Biomecha­ thop Trans 1 2 : 1 90. Ath­ cuff tears. An KN : Gle· patients wilh massive rotator cuff defects by nohumeral muscle force and moment mechanics acromioplasty and rotator cuff debridement. Blackbum TA. J function of the biceps in stable and unstable Bone Joint Surg 26A: I . Bassell RW.1hop 275: 1 65 . Jobe FW Pink M et al: Electromyo· . nants of outcome in the treatment of rotator cuff graphic analysis of the glenohu meral muscles disease. Upper 54. 1990 7 1 . p. Saunders ill . Ellenbecker TS: Shoulder internal and external noid labium in antcl. 1994 ity of the glenohu meral joint. McLeod WO. Harryman DT: Common approaches to the shoul­ 2 : 1 . American Academy of Ol1hopaedic netic shoulder internal and external rotation Surgeons. Wilk KE. Kennedy JC: Impingement syn­ ing Programs. Clini­ lromyographic activity of selected shoulder mus­ cal results. Tabata 5: Conservative treatment of rotator analysis o f posterior rotator cuff exercises. Sidles JA. Rodosky MW. Browne AO. Burkhead WZ: Management of 57. Itoi E . 3. S & S Publishers. ew York. J Shoul­ motion dUI-ing performance of three feeding ac­ der Elbow Surg 3:70. de C M Abbot LC: Obser­ 66. Am J SP0l1S Med 8: 1 5 1 . 1 990 75. WI. Hawkins RJ: Open Repairofthc rotator thop SP0l1S Phys Ther (submilled) cuff. Kuechle OK. O'Hare SJ. 1 99 1 1 992 6 2 . Isokinci Exercise Sci 68. Kraemer W: Oesigning Resistance Train­ 47. Clin O. 1 994 shoulders. 1 995 Bone Joint Surg 70A:220. MOITCY BF. Matsen FA: The relationship Wilk KE (cds): The Athlete's Shoulder. Champaign. J Bone Joint Surg 52B:524. Fleck 5. 70. Fu FH: The role of the hu meral head. I n : Instructional Course Lectures. SPOl1S Med 1 9:264.stabil­ Shoulder. 1 992 Med 1 8 :449. Fu F et al: Anteriol. 1 994 tivities. 1 994 . Davies GJ: A compendium of isokjneLics in c1ini· during a baseball rehabilitation program. LaCrosse. Altchek OW. J Sports Med Arthroscop Rev 3:2.298 PHY S I CAL THERAPY OF THE SHOULDER 46. Burkhart 55: AI1hroscopic debridement and de­ 59. 1 993 73. J Or­ 69. 1 993 ican Academy of Orthopaedic Surgeons. 4th Ed. Ahmad 5: Determi­ 6 1 . J Bone Joint Surg 75B:546. 1 990 72. Obrien SJ. Tim merman LA. In: In· and clinical application. Cain PR. Ballantyne BT. Orthop Clin Phys Ther 73:668. Illinois strength in professional baseball pitchers. IL. 1 993 60. Rosemont. Yerger B. Hamer CO. 1 993 52. Neves MC. Moesley JB. Clin Orthop 308:90. 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. 1 987 open repair of the rotator cuff. Amer­ Ther 1 7:225. 1 87. J Ol1hop Sports Phys structional Course Lectures. Jobe FW. 1 990 64. Rosemont. based on biomechanical parameters. Am J cal usage. Bal1olozzi A. Inman VT. White B et al: E M G 74. Andrews JR. Clarke J. Savoie FH: Manage­ 58. Keirns MA et al: Stretch· 49. 1 980 1987 48. and patient selection cles in commonly used therapeutic exercises. Quanbury AO et al: Elbow ment of rotator cuff tears: a comparison of arthro­ joint restriction: effect on functional upper limb scopic debridement and surgical repair. Kunkel 55. I l l inois cJectromyographic analysis of the throwing 50. 65. I n Andrews JR. Churchill Livi ngstone. throscopy fOl' shoulder instability. Townsend H. Skyhar MJ. Clin Orlhop 254:29. Itoi E . rOlation stl-englh and range of molion of highly Am J SPOl1 Med 22: 1 2 1 . M u tschler TA. 1 992 letic Training 25:40. pathomechanics. Montgomery TJ. 56. 1 994 skilled junior tennis players. Newman SR et al: Stabilising vations on the function of the shoulder joint. Wilk KE: Mini­ Am J Sports Med 1 5 : 1 44 . drome in athletes. 1 994 cuff. Rockwood CA Jr. 1988 5 1 . MacNab I: Superior migration of the 67. Hawkins RJ. 1 988 nics 23:405. WalTen RF: Shoulder ar­ shortening drills for the upper extremities: theOl). Dillman CJ: Biomechanics of the rotator cuff. Churchill of the glenohumeral joint capsule to the rotator Livingstone. 01'­ in a position of shoulder instability. Human Kinetics. Jobe FW Tibone JE et al: Dynamic . The Shoulder. Am J SpOl·ts Med 20: 1 28. 1 992 der. Am J Sports tion program. shoulder with glenohumeral joint instability. 1 993 NOl1h Am 24: 1 1 1 .or stability of the shoulder. Wilk KE (eds): The Athlete's 55. 1 970 long head of the biceps muscle and superior gle­ 53. Maltalino AI: Concentric isoki­ Extremity. Voight ML. hepatitis. and less time given to plimary care phy­ dent. arms. dizziness. sports injury) or repeated micro­ sicians to make an accurate diagnosis of every trauma (overuse injury. bowel or ing diagnoses: high blood pressure. Was it a macrotrauma (motor vehicle acci­ testing. G RAY An important component of the inilial or­ problems. numbness. more acutely ill than the patients who presented neck. chest. fall. abdomen. 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. shortness of physical therapy have at least one of the follow­ breath. What was the mechanism of injury? tient orthopedic selling is evaluating and lreat­ 5. depression. disorder)? Consequently. Do you have any other symptoms through­ has found that approximately 50 percent of all out the rest of your body-headaches. rheumatoid arthri­ thopedic evaluation is to differentiate the etiol­ tis. Describe the first and last time you experi­ is a significant increase in the number of patients enced these same complaints . pins asthma. nau­ the patients refen'ed for outpatient orthopedic sea. vomiting. kidney problems. Are your symptoms the result of a trauma. and (3) there is an increase in the managed 2. fever. or legs? for therapy 1 0 or 1 5 years ago. cumulative trauma patient complaining of musculoskeletal pain. anemia. 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. fatigue. Recent research 6. chemical dependency. 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. fewer referrals for diagnostic 3. tingling. or heart attack . or are they of a gradual or insidious onset? care environment that encourages fewer refer­ rals to specialists. weakness. cancer. (2) there I . Visceral Pathology Referring Pain to the Shoulder J 0 H N c . the physical therapist in an outpa­ 4. diabetes. bladder changes. thyroid or needles? 299 . Do you have any other complaints of pain ing patients who have greater morbidity and are throughout the rest of your body-head. back. over the age of 60 seeking orthopedic medical care. dizziness. pulsating. night sweats. which should be left to the physician. 1 2. The idea is not to diagnose visceral I I. l iver. wall. and portions of the small and 4.'·5 Palpation i n the 3. axilla.3. tender. then you should sus­ does not stress the shoulder (walking or pect deep visceral pathology. " The appendix and skin. . menstrual cycle). 1 )· The kid­ 6. that may upper trapezius muscle). small and large intestines (Plate 12. 3. midline may indicate an aortic aneurysm · When 9. The onset of pain is not related to trauma ceral disease). tive of an aortic aneurysm). or rec­ are originating from the myofascial abdominal tal bleeding are present . ing affect your pain? but to assess whether or not the patient's symp­ toms are 0I1hopedic in origin. diarrhea. vomiting. Does bowel or bladder activity affect your late with a Pancoast tumor or a pulmonary in­ pain? farct . however. Constitutional symptoms are present: neys lie deep posteriorly in the left and right fever. dominal quadrant will reveal the stomach. Extraordinary relief of pain is obtained evaluating abdominal tenderness it is important with aspirin (bone cancer). tail of the pancreas. cough­ viscera . spleen. nausea. either aggravating or re­ ceral pathology or disease. gallbladder. Are there positions or activities that (Fig. Pain is described as throbbing. Does your shoulder pain get worse with ex­ The second important aspect of the evalua­ el1ional activities (climbing stairs) that tion is palpation. gath­ dial border of sternocleidomastoid. There is no relief of pain or symptoms large intestines (Plate 1 2. constipation. Does coughing. pale upper abdominal quadrants . The left upper ab­ with rest. which are normally up to I to 2 cm. the palpable tenderness disap­ 1 2 . with the abdominal wall contracted and the head and neck flexed off the table. right upper abdominal quadrant will reveal the deep aching. Shoulder pain increases with exel1ion that pears in the above situation. Is your pain worse at night? A self-administered patient questionnaire 8. rant. Palpation should include the don't directly involve your shoulder? lymph nodes (for infection or neoplasm). Pain is constant. " climbing stairs) . and other p0l1ions of the large intestine 7. supraclavicular. 1 ) is useful as a screen for possible vis­ change your pain. or deep breath­ pathology. or immovable lymph t. Pain is worse at night. or colicky. Indigestion. bowel or bladder activity. may be found in the left lower quadrant · A tender mass in the femoral triangle or groin area 8." In this way you can analyze the pa­ pain? tient's signs and symptoms to see if they con'e­ 1 0.4 and femoral triangle regions. if a pa­ lieving your symptoms? tient has a few checks under the "yes" column for pulmonary. anterior to ered during the history and interview." If.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 7. For example. or unexplained large intestine are found in the right lower quad­ weight loss . to differentiate the source as originating from 1 0. If palpable tenderness is again elicited ing or deep breathing. laughing. indicate possible visceral pathology or disease. Symptoms are bilateral. Pain changes in relation to organ function the superficial myofascial wall or from the deep (eating. 1 ) . 1 2 . or a large pulsatile mass (indica­ or overuse. Pain does not change with body position may indicate a hernia · A pulsating mass in the or activity. then refer to the section below 9. in the cervical (me­ The following are some warning signs. Does eating or digesting a meal affect your titled "lung. nodes'> Palpate the abdomen for muscle rigidity and significant local tenderness (possible vis­ 2. then the symptoms I I . knifelike. fatigue. The ability to palpate and interpret peri ph- . and portions of the 5. Abnormal find­ ings are swollen. recticular forma­ lar disease . and poorly localized. When pal­ chanical stimulation. In addition.121.14 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 . and an intense psychic stretching and distending or from the produc­ alarm reaction. dorsal root. These free nerve end­ of algesic chemicals in the vicinity of nocicep­ ings are found in the loose connective tissue tors ." Visceral pain results from pressure and heart rate. ' 2 Metastatic tumor infiltration of bone walls of the viscus. viscus. 12. tumors serous linings. or markedly re­ spinothalamic. at the base of the first and second metatar­ lapse of the microvascular network within the sal bones).' 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. I I .13 . 3 There is also a strong Somatic pain occurs as a result of activation of autonomic reflex phenomenon.7 Palpate the arterial encephalic tracts. then there is dorsal horn of the spinal cord (Plate 1 2 .. radial arteries at the wrist) and lower extremity such as bradykinins or proteolytic enzymes. 3. brachial artery in the cubital fossa. blood vessels in the viscus . and spondylosis in the elderly population.'·'2 plaints from cancer patients have several origins.ve fibers within sympathetic and parasympa­ tery with those in the cO'Tesponding vessel on thetic nerves . Be aware of the easy and common diagnoses can leak through a gastric or duodenal ulcer into of osteoarthritis. changes in arterial stant and localized.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. neural information is pating a pulse.) . including the epithelial and and gastrointestinal and genitourinal). response and the release nociceptors (Plate 1 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.2) . The arterial pulses may be palpated tion. 3.J .' Chemicals. degenerative joint or disc dis­ the peritoneal cavity.s Many asymptomatic elderly persons have posi­ Mechanical stimulation of visceral nocicep­ tive radiographs for these diseases. vasomotor (tumor metastasis to bone) and is usually con­ (blood vessel) responses.17 the opposite side. and into the tive touch. 3. 2)3" . s·7 • . Also. resulting in local abdomi­ ease. nociceptive impulses ascend in the (4). If the pressure is firm. respectively. spinoreticular. the el­ tors can occur secondary to torsion and traction derly in our society are at a greater risk for vis­ of the mesentery. popliteal ar­ ondary to ischemia of the viscus. posterior tibialis artery spasm or distension of the smooth muscle wall posterior to medial malleolus.). including sudo­ nociceptors in cutaneous and deep tissues motor (i ncreased sweating) changes. 3 After activation of common causes of pain in the cancer pa- .'. distention of a hollow viscus. or absent (0). as well as the walls of the local that invade abdominal and pelvic viscera are ve. slightly (3). 1 5. and emotional experience associated with nociceptors of the involved \�SCUS. nal pain ." in the upper extremity (axillary 3I1ery in the ax­ Chemical stimulation of nociceptors may re­ illa. ulnar and sult from a buildup of metabolic end products. the therapist needs to compare transmitted along small unmyelinated type C the amplitude and force of pulsations in one ar­ ne.3. '8 actual or potential tissue damage" . I 1 .3 Prolonged tery at popliteal fossa.' "'." The targets in the brain for pulses for cardiovascular and peripheral vascu­ these tracts are the thalamus. Pain com­ cuS. True visceral Visceral pain is not uncommon in patients pain can be experienced within the involved vis­ suffering from neoplastic disease. ceral pathology and disease. and spinomes­ duced ( 1 ). and dorsal pedis of viscera can cause ischemia secondary to a col­ arte. such as acidk gastric fluid. moderately (2). old or impaction.1 4 Viscera are innervated by tion of an innammatOl). and midbrain." Within the anterolat­ patient's 7 Pulsations may be recorded as normal eral system. sec­ (femoral artery at femoral triangle.). VI S C E R A L P A T H O L O G Y R E F E R R I N G P A I N TO T H E S H O UL D E R 301 eral pulses is another important diagnostic tool these nociceptors by sufficient chemical or me­ for the orthopedic manual therapist. . .... . • . . ...... WHEEZING OR PROLONGED COUGH .. . • . .. . . .. . .. .. . . HIGH BLOOD PRESSURE .. .. . . . . INCREASED AMOUNT OF VAGINAL DISCHARGE .. SANDY) . . ..... . ... . . . . .. . . . . ... SHORTNESS OF BREATH ....... .. SWEATING WITH PAIN . .. . . .. . .. .. ... ... • . .. . . ...... . . . .. ELEVATED CHOLESTEROL LEVEL . . HISTORY OF PNEUMONIA OR TUBERCULOSIS . 1 (A & B) A self-administered patiellt qLlestiol1lwire... . . . . . . . .... . . DRY EYES (RED.. SWELLING IN EXTREMITIES .... . DO YOU SELF INJECT MEDICINES/DRUGS . .. .. .... . .. . . .. .. .... .... . .. ... .. . . . ... .... . .. • INCREASED UTERINE CONTRACTIONS .. ..... ... .. .. .. FIGURE 1 2. . . . . .. . ... .. .. . . ... .. . ... HISTORY OF ILLNESS PRIOR TO ONSET OF PAIN HISTORY OF CANCER . . ..... . . . EMPHYSEMA OR COPD . . . .... .. .. . .. .. ... . • . . .. .. . ..... .... ... ....... . FAMILY HISTORY OF HEART DISEASE .. .. ... .. .. • .. .. .. CARDIOVASCULAR HEART MURMUR/HEART VALVE PROBLEM . . . PREGNANT WOMEN ONLY CONSTANT BACKACHE ... HISTORY OF HEART PROBLEMS . .. EPISODE OF FAINTING . . .... . . . .. . PAIN RELIEVED BY REST ... • FEVER AND/OR CHILLS . ... .. ... ... .. .... . . .. .. .... . . . . .... .. .. PULMONARY HISTORY OF SMOKING .. ..... . . . • .. . . . . .. . ....... .... . ... . ... .. . ... ... PAIN OF GRADUAL ONSET (NO TRAUMA) ..... .. ... . A INCREASED FREQUENCY OF URINATION . • UNEXPLAINED WEIGHT CHANGE . . . .. . PAIN WORSE AT NIGHT . ... .... . . • . .. . ... ... NIGHT PAIN/DISTURBED SLEEP ... . . . . .. .. . . .... . .. . . . . . .. . .. . . .. ...... . DRY MOUTH (DIFFICULTY SWALLOWING) ..... . . . . .... . . . . ... . . .. .... .. . . .... . .... .. ... • . . ... . .. ....... . .. . . . . .. . ... .. .. . .. . • ... . . . . . . . • . . . ..... .. ..... .. .... • ... .. . .. .... HISTORY OF ASTHMA. .. • ... ... . ... . ... .... . HEIGHT .. . .... ... ....... . . . . ..... .... . . .... .. HISTORY OF RHEUMATIC FEVER .. ... . CONSTANT PAIN . . .. . . .. . . . . PAIN/SYMPTOMS INCREASE WITH WALKING OR STAIR CLIMBING AND RELIEVED WITH REST . ..... . .. .... .. .. ... .. . . . DIABETIC .. DIZZINESS (SIT TO STAND) .. . .. . . • MENSTRUAL CRAMPS . FATIGUE .. . ..... .... FAMILY HISTORY OF CANCER . ITCHY. .. .. . . .... . .. . . .... .. .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 NAME DATE ______ AGE . .... . . . . .) . . . . ... . ... . . ..... . . . . . .. ... . ... . . ........ (Figllre cOlitilll/es. . ..... . . • . ..... .. .. ... . WEIGHT .... . • .. . .. . .. . .. . .. . • .. . INCREASED CONSISTENCY OF VAGINAL DISCHARGE COLOR CHANGE OF VAGINAL DISCHARGE . . . • . .. .. RAPID THROBBING OR FLUTTERING OF HEART . ... .. .. . • . . . • . .. . .. CONSTANT PELVIC PRESSURE . RECENT SURGERY (DENTAL ALSO) . . . ... . . .. .. .. • .... ... ... ... ... . .... . . .. .. . . • .. . . ... . . .. . .. .. .. .. . . .. . . . . ..... . ............ ... • . .. . . .... ... . . • .. . . . .. . . . .. .. .. .... . . . B HISTORY OF SWOLLEN TESTES . . .. .. ... . . PAIN CHANGE DUE TO BOWEL/BLADDER ACTIVITY PAIN CHANGE DURING OR AFTER MEALS . MALE UROGENITAL SYSTEM (MEN ONLY) PAINFUL URINATION . . .. HISTORY OF LIVER OR GALLBLADDER PROBLEMS HISTORY OF STOMACH OR GI PROBLEMS .. . . • .. • . • • . .. CHANGE IN COLOR OF STOOLS . . . .. . . (B).. . . .. . . ... ... . . . . .. . . . .... . . ... . . . . .. .. .... . .. .. . .. . . . . .... . . ... . . . • .. . . .. . VOMITING . ... . . PAINFUL MENSES . . . . . . . . . . .. . . ... . .. IMPOTENCE . . . .. .. • ... . . . . . . . . . . . . ... . .. ..... . . .. .... . . . . • . . . . ... . .. . . . . .... . ... ... . .... . . .. .... . ... CHANGE IN FREQUENCY OF URINATION .... . . . . ... . ... . • .. . . ... ..... .. .... . . .. . CHANGE IN THE FREQUENCY OF URINATION ... . .. . . . . . . ..... . .. .. . NAUSEA . . FIGURE 1 2 . . INCREASE IN URGENCY OF URINATION . . .. • . . .... HISTORY OF VENEREAL DISEASE . . . ... . . . . . . • . . . . .. . • . VAGINAL DISCHARGE . . . • . .... • .. .. • . ... . .... . . . . .. . .... ... ... . . . . .. • . .. . .. .. CONSTIPATION . . .. .. . .. . .. . .. ..... .. . .. ... . ... .. . . .. . .. .. . • . . .. .... . . . .. . .. . PAINFUL URINATION ...... . . . . . BLOOD IN URINE .. .. . .. .. . . .. .... . .. . HEARTBURN . . . .. ....... . . HISTORY OF VENEREAL DISEASE ... • .. .. ... . . .. . . . . . HISTORY OF URINARY INFECTION .. . . PAINFUL INTERCOURSE . ... • • . . .. BLOOD IN URINE .. DIFFICULTY CONTROLLING URINATION . .. . .... .. . . . .. INCREASE IN URINARY URGENCY . . . . . . .. . . . .. . DECREASED FORCE OF URINARY FLOW . . . ....... .... ... . .. • . • . . . .... . . . ... . . . . HISTORY OF ENDOMETRIOSIS . . ... ... .. . ... . ... . . ... . . • . . ... .. ... . . . . .. ... .. • . URETHRAL DISCHARGE ... . . .. . HISTORY OF INFERTILITY . . HISTORY OF URINARY INFECTION . POST-MENOPAUSAL VAGINAL BLEEDING . .. . .. .. .. .. . . ... .. PAIN WORSE WHEN LYING ON YOUR BACK .. .. . ...... . . .. . . .. .. . .... . FOOD INTOLERANCES . . . . . . • . . . . . ..... . RECTAL BLEEDING .. ARE YOU PREGNANT ... . . • . . . PAIN CHANGES IN RELATION TO MENSTRUAL CYCLE GASTROINTESTINAL DIFFICULTY IN SWALLOWING . . INDIGESTION . . . . .. . DIARRHEA . . • .. .. • ... 1 (Col1linuedj... .. . . .. • . .. .. LOSS OF APETITE . .. • . . .. . . .. . . . . .. .. . .... . • . .. . .. . .. . . .. .. . . PAIN WITH EJACULATION . .... . .. ... .. . . . . . . . • . . . .... . . . . . ... . . .. . . . • . . DIFFICULTY CONTROLLING URINATION . . ..... .... . . . . • . .... • • . . . ... .. . . . .. . . . . .... .. .. . . . . . . . . .. . . . V I S C E R A L P A T H OL O G Y R EF E R R I N G P A I N TO T H E S H O U L D E R 303 PATIENT QUESTIONNAIRE FEMALE UROGENITAL SYSTEM (WOMEN ONLY) � llQ DATE OF LAST MENSES ... in which efferent sympathetic activ­ ity promotes persistent pain. Referred pain is pain experienced in tissues tensity of response to injury. noci­ Referred Pain ceptors may be facilitated following injury.2o2 . or radiation t herapy for canceL" Ex­ guarding of the muscles supplied by T4. but as a result of tumor compression or infiltration true orthopedic dysfunction. visceral. 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. lead­ ing to lower threshold of activation." 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.304 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 tienl. and of spontaneous activity within the interneuron whose afferent or efferent neurones are not 9 pool of the dorsal horn . greater in­ I. hyperpathia. and the emergence that are not the site of tissue damage. 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." Cerebral Cortex Thalamus Spinothalamic Tract Cervical Segment of the Spinal Viscera fiGURE 12.2 Schematic drawing ora single afe f r nerve fiber receiving input {i'olll bOlh skin and viscera. I 1. Somatic. or hypomobility. movement around a nonphysiologic axis at that and postherpetic neuralgia. and deafferentation pain locking. I For example. I I Also. I I segment and subsequently lead to joint injury. may be complicated by sympathetically main­ tained pain. chemo­ diac t issue (angina) may cause renex muscle therapy. This may then produce spinal cord and/or cauda equina compression. and Theories on Visceral vasomotor and sudomotor changes .1 physically involved in any way. 2J stimulated these cOl-tical cells in the past. the years. 2 ). Visceral nociceptor activity converges with a speci fic area of the skin. V I S C E R A L P A T H OLOGY R EfE R R I N G P AI N TO T H E S H O U LD E R 305 2.2 4 and are rarely activated. 3. Referred pain fTom deep somatic structures The pain. these same sen­ do not really happen in hands or feet or sory cortex cells may become stimulated heads. I S In this way. is perceived to arise is often indistinguishable fTom visceral re­ fTom the area of skin that has repeatedly ferred pain. they happen in the images of heads with the cortex interpreting the origin of and feet and hands. one branch passing to a vis­ ceral organ as the other branch travels to a 5 . IS the spinal cord.3 Schematic drawing of a visceral afef r afferem l7erve converging Viscera onto the same spil70thalamic tract cell il7 the dorsal hom of the spil7ai cord. input from somatic nociceptors into com- Cerebral Cortex Thalamus Spinothalamic Afferent Tract Nerves FIGURE 1 2. tem. therefore. not in the damaged tissue itself. terpretation by the sensory cortex 24 Over 1 2. a vis­ ceral stimulus may be mistaken for the 6. Pain happens within the central nervous sys­ tors of a viscus are eventually stimulated. 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 5.2 . specific cortical cells are repeat­ edly stimulated by nociceptive activity fTom 7. Sensory fibers dichotomize as they "leave" more familiar somatic pain. .22 this sensory input based on past experience. The referred pain may lie within the der­ 4. When nocicep. Pains chemically or mechanically. Visceral referred pain may be due to misin­ site of reference in muscle or skin (Fig. C4) dorsal root ganglion input as coming from a peripheral cuta­ cells were seen that had collateral nerve fibers neous source. 3I NOImally there are no complaints of pain DIAPHRAGM in the region of the diaphragm. which is suffered trauma or a musculoskeletal strain to the surrounding tissues. Visceral pain to the shoulder through contact with the pain is then referred to remote cutaneous diaphragm (Plates 1 2.3). sive shoulder girdle elevation may cause pain.11 . stomach and pancreas) can refer th e dorsal horn of t he spinal cord. cervical (C3. in the suprascapu­ to the Shoulder lar region.3. . many viscera (liver.4 Schematic drawillg o( all a(e ( renl nen'e +--·PflTenic Nerve (rom Ihe diaphragm converging onto the same Spil1ol/llIlamic lracl cell as is a somatic afe f rent (rolll Ihe skill o( Ihe shol.2 3.2). which normally bombards that emanated fTom both the diagphragm and the central nervous system with sensory the skin of the shoulder (Fig. 1 2. 1 2. Local tenderness or shoulder pain during it is i nteresting in tel·ms of the distance it refers palpation of the diaphragm. segmentally innervated by cervical nerves C3 to CS via the phrenic nerve/ 30 can refer pain to Diagnosis the shoulder. Full active and pas­ its pain to the shoulder." stimuli (Fig.34 Although the diaphragm is a musculotendinous strllctUl'e and not a viscus.4)J [n sites because the brain "misinterprets" the the rat. unless the patient The central portion of the diaphragm. 1 . Also.1 5 .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.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.6. 1 2.29. 1 2. Cerebral Lortex ---t ThalaIIT US ----fj C4 Seg m en t the Sp ina l Cord ��=-C4 Affe rent Nerve FIGURE 1 2.25 .llder. and Fig. and in the upper trapezius mus­ c1e Jo. 1 6 ) were negative.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. 1 2. Six days prior to presentation the patient was CASE STUDY 1 involved in two competitive racquetball league HISTORY matches . Nine days prior to evaluation he participated in a 2-day walleyball (volleyball on a racquetball court) tournament. regardless of what he did. 4 . or paresthesias. laughing. Coughing. SHOULDER AROM AND PROM FIGURE t 2. The patient denied any fect on his symptoms. The pa­ or exacerbated by deep breathing. but denied any trauma. " of symptoms. and other complaints or symptoms throughout the deep inhalation did. The patient was young and appeared fit and healthy." Shoulder pain is reproduced either sport three to four times a week. produce a sudden sharp pain in the shoulder. to produce a sudden and was periodic. however. 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 UL D E R 307 because this motion changes the shape of the rest of his body. and severe. arm Eating and bowel or bladder activity had no af­ pain. Cervical axial compression (see Fig. to sleep on his left side without much difficulty. CERVICAL SCREEN Active and passive ROM was WNL and painless. however.32. localized left shoulder sharp pain with certain movements.6) did not pro­ duce any significant "red flags" to indicate vis­ ceral involvement. He denied neck pain. tation. 1 2. weakness. or tient reported pain for the 6 days prior to presen­ sneezing. sis of "left shoulder pain. 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. GENERAL HEALTH The patient questionnaire (Fig. He was able pain at the acromioclavicular joint (Fig. PAST MEDICAL HISTORY 1 99 1 : Muscle strain on left side of rib cage 1 990: Muscle strain on left side of rib cage 1 987: Low back i njury-sprain/strain J l PHYSICIAN-ORDERED TESTS No radiographs were ordered." His only complaint He was able. He played the diaphragm. . He reported he was a competi­ thoracic cage and subsequently puts tension on tive racquetball and volleyball player. coughing.5). 1 4) and Spurling's quadrant compression tests (see Fig. 4. headaches. . .. __ X DIABETIC . .. .. .. .. . . __X FAMILY HISTORY OF HEART DISEASE . . . . . ... . .... .... • --X- NIGHT PAIN/DISTURBED SLEEP . . .. . . . . ... . . .. .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 NAME Case S tudy 1!1 DATE 02/15/92 AGE .. . .. . ... . .... .. .. .... . . . . ... .. .. . . . . . ..... .. . .. --X­ RAPID THROBBING OR FLUTTERING OF HEART . • MENSTRUAL CRAMPS . .. .. . . . . . . .. . • . . . . ..... .. . --X- EPISODE OF FAINTING .. INCREASED AMOUNT OF VAGINAL DISCHARGE . . ... . . . ... . .. . ... . .. . .. x __ FATIGUE . . .. .. . . . . WEIGHT (Ibe) . . . . . .. . . .. . .. . .. . . .. . . __ x PREGNANT WOMEN ONLY CONSTANT BACKACHE . . . __ PAIN WORSE AT NIGHT .. . ....... .. ......... .. .. . ..... ... . . . .. ... ... . .. .. . . SANDY) .. INCREASED UTERINE CONTRACTIONS . .... . . .. . . ... . . . . .. . .. • .. .... ... .. ... . . . --X­ WHEEZING OR PROLONGED COUGH . • FEVER AND/OR CHILLS .... . . .. . .lI. .... • .. .. . .. . . ... . . . . . x __ PULMONARY HISTORY OF SMOKING ..•. .­ HISTORY OF CANCER .. . .. .. . .... . . .. . . . .. HEIGHT . . . FIGURE 12.. ... .. . • _x_ CARDIOVASCULAR HEART MURMUR/HEART VALVE PROBLEM . . --X- PAIN OF GRADUAL ONSET (NO TRAUMA) . . . ... . .. .. . . .. . . . .. .. .. . . . .. • � FAMILY HISTORY OF CANCER .. • .. .. . . ... . . . . .. ... . . ..... .. . .. ... ... .... . . .... . . . . .. . . . . . . .. . --X­ HISTORY OF RHEUMATIC FEVER .. • . . . ... .. ... ..... .... • .• __ X DRY MOUTH (DIFFICULTY SWALLOWING) .. . . .. . INCREASED FREQUENCY OF URINATION ... ... ..... ... .. .. .... . . . . . . . . .. . .. . . ... . . . .... .. . . • ... . __ X DO YOU SELF INJECT MEDICINES/DRUGS . .. . • .. • __X DIZZINESS (SIT TO STAND) . ... __X HISTORY OF HEART PROBLEMS .. • __ X DRY EYES (RED. .... .... . • __x HIGH BLOOD PRESSURE . . __ x PAIN/SYMPTOMS INCREASE WITH WALKING OR STAIR CLIMBING AND RELIEVED WITH REST ...... .. . . . . __X ELEVATED CHOLESTEROL LEVEL . . .... .. . CONSTANT PELVIC PRESSURE . . . .. .... . . . . . ... .... . ... .. .. . . • ... .. ... .. .. .... . ... .... x. .. . . . . .. .. CONSTANT PAIN .. . � SHORTNESS OF BREATH .. . ... . . ..... . ...... . . . . .. . .. ... . . .. ... . . ... ..... .­ HISTORY OF ILLNESS PRIOR TO ONSET OF PAIN . .. . • . . ... .. . ... . . .. ... __X SWEATING WITH PAIN ... .. .. ... ... ... .... ... ... ..... . INCREASED CONSISTENCY OF VAGINAL DISCHARGE COLOR CHANGE OF VAGINAL DISCHARGE ...... . .... . . . EMPHYSEMA OR COPD . � PAIN RELIEVED BY REST . .... . ..... ..lI... . .. . ...... .. . ..... .. . . . .. . .. . ... . • . . .. . . . __ x HISTORY OF PNEUMONIA OR TUBERCULOSIS . ... . ... . .. • __ x SWELLING IN EXTREMITIES .. . .. .. . . . ... .... .. . .. .... . . ... . . • __ X UNEXPLAINED WEIGHT CHANGE .. . ........ ..... .. . ..lI. . . . . . . .. ... . . . .. . . . ITCHY.. • _ _x RECENT SURGERY (DENTAL ALSO) .6 Patient questionnaire (or Case Swdy I. . . . . . . . . .. . . . . .. . . . . . • .. .. __ x HISTORY OF ASTHMA.. • .. . .. ... . ... . .. . There was no reproduction of symptom This extrinsic source appeared to be from an irri­ tation of the central left hemidiaphragm with PALPATION subsequent referred pain to the left shoulder. perfo­ rated appendix. Immediate and sharp left shoulder under "Diaphragm" earlier in the chapter. JOINT MOBILITY THORACIC SPINE AROM AND PROM Thoracic motion was minimally limited in flex­ Glenohumeral. and acromioclavicular joint mobility were all ever. . Palpation Perforation of an abdominal viscus can re­ of this peripheral portion of the diaphragm did lease air into the peritoneum.38 . range of flexion or extension. just under the rib cage. 12. however. sternoclavicu­ ion and extension. was reproduced with deep inhala­ There was no reproduction of symptoms. sternoclavicular.38A 2 Active deep inhalation and passive lower rib cage compression reproduced left shoulder pain. Air may become men revealed local pain and tenderness along the trapped within the peritoneal cavity in a number left anterolateral border of the diaphragm and of different ways. Pneumoperitoneum. Palpation of the lymph nodes and ity." There will be a variety NEUROLOGIC EXAMINATION of symptoms depending on which viscus is perfo­ rated. Sharp leFt shoulder pain. 32. with no symptom reproduction. how­ lar. testing of the upper extremities was WNL. See the associated symptoms under "Dia­ Sensation.42 Examples of not reproduce shoulder pain. this are a peptic ulcer. Symptoms The patient may complain of acute or spas­ RESISTED TESTING modic shoulder and/or abdominal pain .30 -32. Palpation of the abdo­ 1 2. the pain will be in the left shoulder. was noted with movement into the end WNL. An upright plain anterior­ nohumeral. upper limb nerve tension tests were aphragms 36 See the associated diagnostic clues negative. coughing. can refer pain to the shoulder due to pressure arterial pulses in the cervical spine and upper on the central por-tion of the diaphragm (Plate extremities was negative. or air in the peritoneal cav­ and shoulder. or laughing. scapulothoracic. V I S C E R A L P A T H O L O G Y 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 309 RESISTED TESTING pain. and a splenic infarct or rup­ RIB AROM AND PROM lure. tion. and acromioclavi­ posterior radiograph will demonstrate free intra­ cular joint compression and distraction were peritoneal air under one or both hemidi­ negative. ASSESSMENT The patient's signs and symptoms were consis­ RESISTED TESTING tent with an extrinsic source of shoulder pain. SPECIAL TESTS Diagl10sis 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. costal margin. acute pancreatitis. case of a splenic inFarct or rupture. deep tendon reflexes and strength phragm" earlier in the chapter. gTade 3. In the There was no reproduction of symptoms. There was no tenderness or reproduction of symptoms with palpation of musculoskeletal PNEUMOPERITONEUM structures throughout the celvical spine. chest.4).30.3 and Fig. Diaphragm Peritoneal Cavity '-----. which is innervated by thoracic nerves tercourse. 12. within 6 weeks postpartum. can lead to pneu­ LUNG moperitoneum. See the associated diagnostic clues rigidity is absent.7). The abdomen is not tender to palpation and phragm.Vagina air mllst travel in order /0 create a pneumoperitoneum. is another source of must first enter the vagina before it passes refen-ed pain to the shoulder.43. 3o . certain activities during preg­ itoneal air under the diaphragm.36. or follOWing ciated diagnostic clues under "Diaphragm.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. These include menstruation.4 1 To create pneumoperitoneum.Uterine Wall '------05 Cervix FIGURE 1 2.4.7 Schel1latic drawing of the pathway (hat �L-----." There will be a history of recent abdominal Diagnosis or vaginal surgery.3 is capable of referring pain from two chest stretching exercises.3. vigorous sexual in­ The lung.35." terior radiograph will demonstrate free intraper­ For females. 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. and knee to TS to T6.>··37.0 The last three . distinct diseases to the shoulder. See the associated symptoms under "Diaphragm. 3• See the asso­ nancy. air within the peritoneal cavity." abdominal or vaginal surgery.Body Cavity '----. Pain in the shoulder." SYl1lptOlltS Pain in the shoulder. ef­ fervescent vaginal douching.39.37. 32 . orogenital insufflation. The abdomen is not tender to palpation and rigidity is absent . 39 . 33 . An upright plain anterior-pos­ under "Diaphragm. . 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. See the associated Diagnosis symptoms under "Diaphragm. adrenal glands.-nal jugular phragm (Plate 1 2. secondary to contact between the cancerous endothelial (blood vessel) injury from surge. 5 1 Shoulder and arm pain may also occur tors for DVT include blood stasis due to bed rest." compression of the subclavian artery and vein. pulmo­ Symptoms nary angiography. and asso­ pain.50 Symptoms associated with pain when lying on the involved shoulder" cancer of the spine include a deep. and thoracic outlet syndrome or a C8 radiculopa­ prostate). 35. breast. dull ache that Symptoms related directly to the pulmona. 45.. 30-32 vein. low-grade fever. der and upper extremity symptoms similar to trauma.32 This is the medial aspect of the forearm and hand. Pain is exacerbated by percussion of the spinous pro­ cess. 43 .51 Lung cancer is the symptoms include Horner syndrome (contrac- .so I f a fracture is present. The most common clavicular fossa. in the supraclavic­ The lung itself is a common source of meta­ ular region. with walking.) . which may be tumor.4' Plain radiographs may not over 90 percent of patients with a Pancoast demonstrate the infarct. resulting in shoul­ ri k factors include congestive heart failure. Neurologic the associated symptoms under "Diaphragm" signs and symptoms will be present in some pa­ earlier in the chapter.46. thereby simulating a cough. colon. however.43. and ventilation-perfusion (V/O) scintigraphy are diagnostic tools available Shoulder pain is the presenting symptom in for the physician. acute dyspnea or tachypnea. and oral contracep­ lymphatiCS are often invaded by the tumor. chest then the pain may be sharp. arterial blood gas studies.43. 1 2.. surgery (especially of the hip. rales. See the thesias may be felt in the arm and hand due to associated diagnostic clues under "Diaphragm. persistent with mechanical stress. diffuse ciated with swelling S O Pain will be reproduced wheezing. tients due to compression of the spinal cord. of the involved verte­ Diagnos. pancreas. and acute anxiety. often involving hidden by the dome of the diaphragm.s brae so There is a history of recent surge.45. so Pain often precedes bolism may include swollen and painful legs a pathologic fracture.4). sympa­ thetic chain. and in the upper trapezius mus­ static cancer to bone.32.46 A.43." 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. 5 1 Cancer SYlllptOI11S can metastasize to the lungs fTom carcinomas in Pain in the shoulder is most often felt at the the kidney. with a reflex hammer. inte.32 . in­ a potentially fatal condition that needs rapid re­ cluding the fourth and fifth digits. restlessness. phrenic nerve. obesity. knee. c1e.)'.). 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. more than 50 years of age. infection. or lobes of the lung with the eighth cervical (C8) trauma.2 Associated (Pla te 1 2. common ca­ rotid artery. 45.46. and stellate ganglion.4 ) 30 .3 and Fig.30 . and a state of hypercoagulation 46 Other and first thoracic ( T I ) nerves. thy 35. or uterus 46 superior angle of the scapula. V I S C 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 D E R 311 The first is pulmonary infarction that is often most common fatal cancer in both men and secondary to a pulmonary embolism. decreased breath sounds. vagus nerve. The chest wall and subpleural diabetes. The womenso It commonly refers pain to the supra­ second is a Pancoast tumor.4S• fen'al for emergency medical attention.50 . localized.43.m pain is common. pregnancy. tachycardia. em­ may be unrel ieved by rest.48 See pure musculoskeletal dysfunction. Chest radiographs. the liver. 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.3I Patients will usually report the relief of and the brain' 6. recurrent laryngeal nerve. dyspnea.4S-47 Diagnosis Smoking is a risk factor. throat cancer. hoarseness. . bone lesion of the spine may be detected before lung lesion on plain radiograph.4).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 tion of the pupil. tell her physician about the numbness.6. o ver. TMJ (2 months ago) for a did. 32 . chronic cough.8 Pain diagrarn (1'01'11 a 66-year-old severe WIO) right shoulder pain that radiated right-/zGl. tient stated that her shoulder pain started gradu­ PHYSICIAN-ORDERED TESTS ally sometime in January 1 994. because lung cancer metastasizes to bone early. 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. 3 5 . Except for family history of cancer.S0 CASE STUDY 2 HtSTORY A 66-year-old right-handed female presented to physical therapy (May 1 994) with complaints of FtGURE 1 2. supraclavicular full­ ness. her father had prostate cancer. Relief of pain occurred were negative per physician.. along the ulnar border of her right hand. . u nexplained weight loss. and discoloration or edema of the arm. The patient presented with a diagnosis of "frozen shoulder. 1 2 . Plate 1 2 . re­ ther discussion she admitted that she forgot to solved in 4 months." She denied the patient denied any other complaints or symp­ neck pain. a The patient questionnaire (Fig. This symptom did not return. She 1 994: Surgery to R.8).9) revealed a greasy meal. report periodic mild numbness malignant melanoma.ded (elllale IVith a presel1tillg diagnosis down her arm and along the ulnar border of her o( "(rozell shoulder. bloody sputum. hand intrinsic atrophy. when she lay down on her right side. partial ptosis of the eyelid.. headaches. 5 . fe­ . and sometimes a loss of sweating over the affected side of the face. The pa­ 1 975: Lumbar disc surgery. some patients will complain of a sore throat.5 1 Also. however. On fur­ 1 99 1 : Fell on right shoulder.4). " forearm and hand to include the third through fifth digits (Fig. However.46. no fracture. weeks prior to her evaluation she reported an PAST MEDICAL HISTORY episode in which it felt like her whole right arm went numb. ancIJor wheezing. or a bowel movement.35"6 Peak incidence occurs in smokers around 60 years of age. or chest pain. About 6 toms throughout her body. 3. GENERAL HEALTH The patient denied that there was any change in her symptoms following stair climbing. 1 2 .3S Refer the patient for a chest radiograph (Plate 1 2 . Her grandmother had what she described on the patient questionnaire. . _x_ PAIN OF GRADUAL ONSET (NO TRAUMA) . . . . . . __X DIZZ INESS ( S IT TO STAND) . . . • • .9 Patient questiol1l1aire (or Case SlLIdy 2. . . . __ X (3) RECENT SURGERY ( DENTAL ALSO) . . . . . . . . . . . . . INCREASED AMOUNT OF VAGINAL DISCHARGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___x SWEATING WITH PAIN . WEIGHT (lbs) . . . . . . . . __ X CONSTANT PAIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __X E P I SODE OF FAINTING . . . . . . . . . . . . . . INCREASED UTERINE CONTRACT IONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __ X DO YOU SELF INJECT MEDICINES/DRUGS . . . . . FEVER AND/OR CHILLS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __ X UNEXPLAINED WEIGHT CHANGE . . . . . __ x H ISTORY OF ILLNESS PRIOR TO ONSET OF PAIN __ x H ISTORY OF CANCER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FIGURE 1 2. __ X RAPID THROBBING OR FLUTTERING OF HEART . . . INCREASED FREQUENCY OF URINATION . . . . . . . . INCREASED CONS ISTENCY OF VAGINAL D I SCHARGE COLOR CHANGE OF VAGINAL D ISCHARGE . . . . . . . . . . . . . . . . . . . . . . __ x DRY EYES (RED. . . . . . . . . . . . . . . SANDY) . . . . . . • . . . . . . __ X HISTORY OF HEART PROBLEMS . . . . . . . . . . . . . --'I- PAIN RELIEVED BY REST . . . • . . . . • . . . . . . HEIGHT . . . . . . . . . --'1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . --'I­ SWELL I NG IN EXTREMITIES . . • . . . . . . . ITCHY. . . . . . __ X FAMILY H I STORY OF CANCER . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . __ X HISTORY OF ASTHMA . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . __ X WHEEZING OR PROLONGED COUGH . . . . . . . . . . . . . . . . . . . . • • . . . . . . . . . . . . . . . __ X FATIGUE . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . • . . . . . . . . . . . . EMPHYSEMA OR COPD . . . . __ X PAIN WORSE AT NIGHT . . . . . . . . _X_ DIABETIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PULMONARY H I STORY OF SMOKING . . _x_ FAMILY H ISTORY OF HEART DISEASE . . . . . . . . --'I­ H I STORY OF PNEUMONIA OR TUBERCULOS I S . . . . . . . . . . . . . . . __ X SHORTNESS OF BREATH . . . . . . . . . . • . . . . • . . . . . . . . . . . . . . . . . . __ X NIGHT PAIN/DI STURBED SLEEP . . . . . . . . . • . . • . . PREGNANT WOMEN ONLY CONSTANT BACKACHE . . . . . . . . . . . . . . . . . . . . . . . . . . . . __x HISTORY OF RHEUMAT I C FEVER . . __ X HIGH BLOOD PRESSURE . . • . • . . . . . . . . . . • . . . . . . . . __x ELEVATED CHOLESTEROL LEVEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . CONSTANT PELVIC PRESSURE .( 1 ) PAIN/SYMPTOMS INCREASE WITH WALKING OR STAIR CLIMBING AND RELIEVED WITH REST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . --'I­ DRY MOUTH (DIFFICULTY SWALLOWING) . . . . 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 NAME Case S tudy lI2 DATE 5/31/95 AGE . . . . . . . . . . . . . . . . . . . . __x CARDIOVASCULAR HEART MURMUR/HEART VALVE PROBLEM . . . . . . . . . . . . . . . . . . . . • . . . . . . . . • • . MENSTRUAL CRAMPS . . . . . • . . . . . . . . . . . . . . grade cal axial compression testing was positive only in 3. 1 2. and to join the spinal nelve and enter the dorsal root the intrinsics of the hand were Ws ). stricted. is able to refer pain to the shoulder Lhrough contact with the central Sensation to light touch and pinprick was de­ portion of the diaphragm (Fig. 1 6). ganglia before entering the dorsal horn of the spinal cord (Plate 1 2. It also re­ both cases. The The pdmary afferent fibers. Minimal Suspicions were raised with respect to the shoulder pain and no arm pain was reproduced. Deep ageal pain is Lransmitted via afferents in the tendon reflexes were (2 + ) and equal at the bi­ splanchnic and thoracic sympaLheLic nelves. 1 S ceps. S. Following a chest radiograph the patient was diagnosed with Swelling and tenderness were noted in the supra­ a Pancoast tumor in her right lung. There was no edema or skin dis­ coloration noted in the extremities. This was Spurling's quadrant compression test was posi­ mostly due to muscle guarding.4) -'·6.3)I . and tdceps tendons. insidious onset of symptoms. 1 4). constant pain. both A-delta and C dght abductor digiti minimi tendon reflex was fiber neurons. patient history of cancer. arterial pulses. family history of can­ RESISTED TESTING cer. PalpaLion of the lymph nodes. and the abdo­ ESOPHAGUS men was negative. night pain. The glenohumeral joint was minimally re­ extension (see Fig. The The shoulder girdle muscles tested strong and patient was refen'ed back to her physician dur­ painless in the three muscle lengths tested. The shoulder and arm pain. brachial plexus tension pulmonary part of the questionnaire was signifi­ stretch also reproduced the symptoms. during PALPATION which minimal progress was made. The esophagus. minimal limitations in lR and flexion. 4 .2). Cervi­ scapuloLhoracic joint mobility was WNL. pulmonary symp­ toms. pass through the paravertebral ( I + ) . Strength was decreased as follows: right sympathetic chain and Lhe rami communicans triceps ('JIs ). The acromioclavicular.314 P H Y S I C A L T H E R A P Y OF T H E S H OUL D E R and her sister had pancreatic cancer. i n distraction only. clavicular fossa. sternoclaviculal'. 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). CERVICAL SCREEN JOINT MOBILITY Active and passive extension and. wrist flexion and extension ('Ys). and a 1 00 pack-year smoking history. Passive shoulder flexion with I R onto the same dorsal horn neurons (Fig. or E R was minimally painful a t the shoulder in . ing Lhe initial course of physical therapy. brachioradialis. which is segmentally innervated NEUROLOGIC EXAMINATION by thoracic nerves T4 to T6. age of the patient.I S RefelTed pain is SPECIAL TESTS thought to occur through convergence of visceral Glenohumeral joint compression and distraction (cardiac and esophageal ) and somatic afferents were negative. A Abduction and ER were moderately limited with brachial plexus lesion could not be ruled out . grade 2. Thoracic canl. tive on the right for reproduction of right arm pain (see Fig. outlet tests were negative. and right rotation reproduced shoulder pain. be consisted with a right C8 radiculopathy. Valsalva was negative. ASSESSMENT SHOULDER AROM AND PROM The patient's signs and symptoms appeared to Active and passive ROM were equally limited. separately.5 3 1 2. 5 2 Esoph­ creased in the right C8 and T I dermatome. 4. or by bending cardiac afferents. disease and cardiac disease are both able to refer Cerebral Cortex Thalamus -- Spinothalamic Tract Afferent Cervical Segn)ent Nerves of the Spinal Cord FIGURE 1 2 . weight loss. which is innervated by thoracic nerves and (in the late stages) drooling 47 Symptoms as­ T I to TS. V I S C 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 315 Symptol1ls novine slimulation.55 See the associated di­ agnostic clues u nder "Diaphragm. phrenic (dia­ Diagnosis phragm). hic­ shown evidence of convergence with esophageal cups. The heart. 54 In addition. and a dry nocturnal cough ·7 is known to mimic angina pectoris. neck. 1 0 Schematic drawing or a somatic afferent nerve (shoulder). The patient will complain of heartburn that is convergence has been demonstrated between aggravated by strenuous exercise. esophageal chest pain quent vomiting. and a (::::hr cardiopulmollGry afferent nerve converging onto the same agm spinothalamic tract neuron.3 is capable of referring pain to the sociated with cancer are bloody cough. fTe­ racic spinal cord B I n fact. hoarse­ shoulder. and bad breath 47 Symptoms associated afferents and somatic afferents in the upper tho­ with renux esophagitis are regurgitation. .3 ." Pain in the shoulder that may be exacerbated during or following meals J There may be subst­ ernal chest. 1 2 . vomiting.30-33 . vergence has also been noted with proximal somatic afferents (shoulder).52 .'9 This explains how diaphragmatic nium stimulation. abdominal viscera (gallblad­ over or lying down.56 Cardiac afferen t fibers have ness. 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. balloon distension. for example) afferents. a phrenic nerve (diaphragm).5 4 . acid perfusion. 1 0). fever. edropho­ (Fig. and cardiopulmonary spinal afferents Positive 24-hour intraesophageal p H and onto the cetvical spinothalamic tract neurons pressure recordings. or back pain 47 Other symp­ HEART toms include difficulty swallowing. nausea. and ergo. and is relieved by sitting up der. sore throat. J s 7 Diagnosis A history of shoulder or chest pain (angina) on effort or exercise." catching a football with his son." Blood pressure consistently higher "shoulder pain-bllrsitis.8 There may be a rest­ FIGURE 1 2. or aching in the above areas s. nausea. or deep inhalation. started 2 days after an afternoon of throwing and and sudden death.47. The patient denied a change in symptoms HISTORY after eating a greasy meal. and/or angiography. Other symptoms include exer­ tion and nocturnal dyspnea. ankle edema. The patient reponed that his symptoms as angina. syncope. A 48-year-old obese left-handed male presented coughing. or bradycardia . neck. he denied any other complaints or symp­ ing of moderate (0/10) pain in his left shoulder toms throughout his body. hean failure. blood test (increased CPK). bowel movement. Other to physical therapy ( December 1 994) with a diag­ than what he reported on the patient question­ nosis of "shoulder pain-bursitis. Symptoms The patient may complain of pain in the left shoulder that is often associated with reports of numbness and tingling in the left hand s . once Timely recognition of a cardiac problem cannot in a while. coronary anery d isease presents ago. pressure sensa­ tions."·5 7 did admit that his left hand "tingled" evel).• tachycardia. posterior thorax.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 pain to the shoulder and other cervically related derma tomes. high blood pres­ nied neck pain or upper extremity numbness. 1 1 Pain diagram (rolll a 48-year-old ing pulse greater than 1 00 or less than 50 beats le{l-handed male with a presenting diagllosis o( per minute. 8. . and physical inactivity. treadmill with echocardiogram. He re­ CASE STUDY 3 ported relief of symptoms with rest. weakness. 8 Re­ lief of symptoms with rest.47. 1 I ). or climbing stairs. myocardial infarction. He de­ ciated with smoking. easy fatigability. laughing. His shoulder pain started 2 months be overstated. 1 2..lse sweating. palpi­ tations. Heart dis­ (Fig.57 Pain may also be felt in the chest. " than 1 60/90 is a positive sign . His shoulder pain was aggravated by activities of waxing his car. . arm (usu­ ally the left and a C8 and TI distribution). Refer for ECG. obesity. s7 The pa­ tient may describe tightness. jaw. carrying groceries. anxiety. not associated with movements of the shoulder. " Nitroglycerin will provide immediate relief of symptoms. such as a brisk walk.3 I ." and complain­ naire. He sure. diabetes. prOrl.. He reponed the pain was not con­ ease is most common in men over 40 and is asso­ stant and did not radiate down his arm. throbbing. vomiling. cramping. or epigastrium 8•J5. is capable of refelTing pain to the shoul­ RESISTED TESTING der in cases of pericarditis . 47 SPECIAL TESTS Diag'lOsis Passive Oexion with humeral I R or E R was nega­ tive. Palpation chest or left shoulder. 1 6) were nega­ with nitroglycerin. heart.s. 3 . 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 . glenohumeral compression and distraction There will often be a pel-icardial friction rub. resolved any of the joints in the shoulder girdle. The patient's symptoms were not reproduced PHYSICIAN-ORDERED TESTS dudng a thorough neuromusculoskeletal exami­ No radiographs or special lab tests ordered. distended veins in the neck. .35 .. tachycardia. murmur. noted during auscultations of the . Subsequently the patient was referred back to the physician for follow-up to mle out cardio­ CERVICAL SCREEN pulmonary disease. serous fluid in the pedtoneal cav­ Sensation. in 3 months. upper limb nerve tension tests which has different characteristics than a heart were negative. tive . SHOULDER AROM AND PROM PERICARDITIS Active and passive ROM were WNL and painless. and therefore his complaints were not consistent with an orthopedic dysfunction or in­ GENERAL HEALTH jury. nation. and both his fa­ toms were reproduced when he climbed a hill ther and grandfather died prematurely of heart behind his house. The symp­ (palpitations and tachycardia). V I S C 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 OU L D E R 317 PAST MEDICAL HISTORY JOINT MOBILITY 1 993: Arthroscopic surgery to the right knee . No restrictions or hypermobilities were found in 1 993: Fell onto left shoulder. The heart. or lying Oat. nosed with myocardial ischemia with associated Cervical axial compression and Spurling's quad­ angina pectoralis. and strength ity. enlarged liver. sprained.5 7 Pericarditis is Shoulder girdle muscles were strong 'Ys and pain­ an inflammation of the sac sUITounding the less. Both symptoms rapidly went year smoker.3 s.. At the time of evaluation he was a 35 pack­ the shoulder pain. A return to the interview process revealed The patient questionnaire (Fig. live. 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 . 4 . ASSESSMENT 1 985: Lumbar disc surgery. His symptoms disappeared rant compression tests (see Fig. had a history of heart problems away when he sat down and relaxed. He was subsequently diag­ Active and passive ROM was WNL and painless. deep tendon reOexes. 5 7 PALPATION Symptoms No Significant musculoskeletal tenderness was There is usually a sharp burning pain in the found throughout the shoulder girdle.47• 57 Pain may be aggra­ of the lymph nodes and the abdomen was nega­ vated by deep breathing. coughing. Other symptoms include fever. allacks .35 . and a decrease in muscle mass . and dyspnea. were negative. 1 2. mal (grade 4) strength.47 Symptoms of NEUROLOGIC EXAMINATION chronic pericarditis include pitting edema of the arms and legs. which is innervated by thoracic nerves T 1 to T5. 35 . testing of the upper extremities was WNL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .. . . . . . . . . . . . � FAMILY HI STORY OF HEART D ISEASE . • . . . . . . . � HI STORY OF RHEUMAT I C FEVER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ilL FEVER AND/OR CHILLS . . . • . . . . . . . . . . . . . . . . . . . __X NIGHT PAIN/ D I STURBED SLEEP . . . . • . . . . . . . . . . . . . . . _X _ CONSTANT PAIN . • . . .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 NAME Case Study *3 DATE 12/11/94 AGE . . . . . . . . . .. . . . . . . . . . . . . . . • . . . . INCREASED AMOUNT OF VAGINAL DISCHARGE . . . . . . . . . _x_ DIABETIC . . . . . . . � DO YOU SELF INJECT MEDICINES/DRUGS . . . . . . � HI STORY OF ASTHMA . . . . . . . . . . . . . . • . . -1L­ UNEXPLAINED WEIGHT CHANGE . . . . . . . . . . FIGURE 1 2 . . . . . . . . . . . . . . . .. . . . . . . . . � DRY MOUTH ( D I FF I CULTY SWALLOWING) . . . . . . . • • . . . . .. . .. . . . . . . . . . . . . INCREASED UTERINE CONTRACTIONS . . . . . . . . . _x_ PAIN RELIEVED BY REST . . . . . . . . . � RAPID THROBBING OR FLUTTERING OF HEART . . .. . .. . . . • . . . . . . . . . . . . . � RECENT SURGERY (DENTAL ALSO) . . • . . _x_ PAIN WORSE AT NIGHT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _x_ HI STORY OF HEART PROBLEMS . . . . . . .. . . . _x_ FAMILY H I STORY OF CANCER . . . . . . . . . .. . _X_ PULMONARY H ISTORY OF SMOKING . . . . . . . . . . . . . . . . • . . � D I Z Z I NESS ( S IT TO STAND) .. • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .. . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . INCREASED FREQUENCY OF URINATION . . . . � HEIGHT . . . . • . . . INCREASED CONSI STENCY OF VAG INAL DISCHARGE COLOR CHANGE OF VAGINAL DISCHARGE . . . � WEIGHT ( lbs) . . . . . . . . . . . . . . . -1L- WHEEZING OR PROLONGED COUGH . . . . . . _x_ CARDIOVASCULAR HEART MURMUR/HEART VALVE PROBLEM . . . . . . . . . . . • . . . . . . . . . . .. � FATIGUE . . . . • . . . . . . . . . . . . . . 1 2 Patiel1l questiOn/wire {or Case Study 3. . _x_ ELEVATED CHOLESTEROL LEVEL . . . . . . . .. . . . . . . . _x_ HIGH BLOOD PRESSURE . . . . . . . . . . . . . . . . . _x_ EPISODE OF FAINTING . . . • . . . . . . .. . . . . . . . • . . . . . . . . . . . • . . . . . . . . . . .. . . . . . . . . . . . . __X SHORTNESS OF BREATH . . . . . . . . . . . . . . . . . . . . .. . . . . . .. . . • . . . . . . . . . EMPHYSEMA OR COPD . . . . . . . . . . � HI STORY OF ILLNESS PRIOR TO ONSET OF PAIN __x HI STORY OF CANCER . . . . . . _X_ PAIN/ SYMPTOMS INCREASE WITH WALKING OR STAIR CLIMBING AND RELIEVED WITH REST . . . . . . _x_ SWELLING I N EXTREMITIES . . . . -1L­ DRY EYES (RED. . . . � SWEATING WITH PAIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _x_ HI STORY OF PNEUMONIA OR TUBERCULOSIS . . . . .. . . . . . . . . . • . . . . . . . . . . . . . . . . . . SANDY) . CONSTANT PELVIC PRESSURE . . . . . . . _x_ PAIN OF GRADUAL ONSET (NO TRAUMA) . . . . . .. . . __ x PREGNANT WOMEN ONLY CONSTANT BACKACHE . . . . . . . . . . . . . . . . . . . . . . . . . . . . MENSTRUAL CRAMPS . . . . . . ITCHY. . . . . . . . . . . . . . . pain with cold and painful extremities.57-59 A 64-year-old right-handed female presented to physical therapy (September 1 993) with a diag­ SYlIlptoms nosis of "right shoulder pain. col­ palphalangeal. tachycardia . . She denied which may mimic a hemiated disc. positive blood test for anemia.57 Other Other than what she repor1ed on the patient symptoms include pale skin. increase in serum glob­ Bacterial endocarditis is another source of pain ulin concentration.59 Treatment is with antibiotics. or degenerative hemorrhage). headaches. decrease in serum albumin levels. elevated BACTERIAL ENDOCARDITIS erythrocyte sedimentation rate (ESR). bacterial en­ ripheral edema.58. The patient also stated that her low mately 25 to 27 percent of patients.57 In approxi­ and tingling.s . which is an exag­ Palpation of the i nvolved joint will reveal gerated decline in blood pressure during inspim­ warmth. fatigue. sternoclavicular.57 or symptoms throughout her body . Roth's spots (small white spots i1lnes include patients with abnormal cardiac in the retina. disease . and sacroil­ neck pain. 57-59 An acute tion.5 • .'7-59 Associated signs are dyspnea.57. or deep inhalation.57 The toms after eating a greasy meal. 3s . without trauma. congenital heart disease.47 Patients with chronic pericarditis will Diagnosis demonstrate pulsus paradoxus. 57-59 I t is an There is relief of symptoms with antibiotics.57-59 the hands or the soles of the feet. 1 3).'··59 There is a heart mur­ mur. sudden onset. especially the metacar­ viral and bacterial infection. 57-59 Low back pain. coughing.59 There may be an abrupt onset of The patient denied a change in her symp­ intermittent shaking chills with fevery. fingernail clubbing. musculoskel­ back had been stiff during the week prior to pre­ etal complaints are the first symptoms of this sentation. and upper trapezius pain approximately I month and is usually monarticular. or numbness iac joint pain are often reported. she denied any other complaints night sweats . weakness. Monarticular involvement is thought to be secondary to deposition of large particulate CASE STUDY 4 masses (emboli) that contain immune com­ HISTORY plexes. pe­ If left undiagnosed and untreated. and Janeway lesion drug abusers. usually surrounded by areas of valves. of right shoulder sternoclavicular. and weight IOSS 8.59 Risk groups for this spleen.47. questionnaire. bowel move­ patient may also complain of dyspnea and chest ment. postcardiac sur­ icular joints-which are not commonly involved gery.57 iIIness . prior to presentation (Fig.57-59 fen'ed pain. enlarged docarditis can be fataI. 1 2 . 57 . radiation therapy. or acromioclav­ lagen vascular disease. therefore the patient will have a posi­ tive musculoskeletal examination of the involved joint.59 in the region of the shoulder girdle.47 Diagnosis History will often reveal no trauma or previ­ may be difficult in elderly patients who have a ous occun'ence of these symptoms . anorexia. trauma. laughing. redness and tenderness. uremia.'··59 Symptoms are not due to re­ sponse to infection. myocardial infarction. or acromioclavicular joints. arm pain." She reported the Pain is most common in the glenohumeral. 57 bacterial endocarditis .47 There are a variety of etiologies including synovitis in a single joint. and those with a history of bacter­ (small red-blue macular lesions) on the palm of emia. inflammation of the cardiac endothelium overly­ Fever will be present at some time during the ing a heart valve due to a bacterial infection s . V I S C E R A L P A T H O LO G Y 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 319 thorax ·. parenteral rhagic spots on the skin). Plain radio­ higher frequency of non pathologic hear1 mur­ graph may show destructive changes indicative murs and are less likely to develop a fever in re­ of an infection . cancer. in other diseases-should raise suspicions of and aortic dissection. petechiae (small purplish hemor­ heart disease (calcific a0l1ic stenosis). and microhemaluria. neutral. " A palpable band of tender tissue was noted in the right upper trapezius muscle. 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. mid. SHOULDER AROM AND PROM Active and passive flexion. 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. protraction. RESISTED TESTING There was no muscle or group of muscles that reproduced pain in all three muscle lengths (shortened. 1 4) revealed SPECIAL TESTS recent surgery. Spurling's quad­ rant compression test was also negative (see Fig. 1 6). On further questioning Glenohumeral compression and distraction the patient admitted to an episode of chest pain were negative. 4. 1 2 . and strength GENERAL HEALTH were all WNL. extension. depres­ sion. fever. specific active and passive scapular motions of elevation. 4. There were no petechia or 1 975: Hysterectomy. 1 4). ative. There was no tenderness or enlargement noted with palpation PAST MEDICAL HISTORY of the lymph nodes. DTR. and ex­ tended postures (see Fig. The patient questionnaire (Fig. . Upper extremity sensation. PHYSICIAN-ORDERED TESTS NEUROLOGIC EXAMINATION No imaging studies were ordered. and relraction were also repro­ ductive of the patient's pain. the empty can sign was also neg­ ness from washing her windows. Palpation of the abdomen did not reveal rigidity or viscus enlargement. and horizontal abduction reproduced pain . passive flexion with IR or ER were 2 weeks ago. Cervical spine axial compres­ sion was negative in the flexed. and a prosthetic cardiac valve. but she related this to muscle sore­ equally painful. (grade 4) strength. with exquisite tenderness noted. 6 weeks ago . Pal­ 1 993: Root canal. Ankle edema was noted bilaterally. abduction. horizontal adduction. o( "right shoulder pain. shortness of breath. Janeway lesions on her skin.320 P HY S I C A L T H E R A PY OF T H E S H O U L D E R CERVICAL SCREEN Active and passive ROM into flexion or left side­ bending produced a "stretching ache" in the right upper trapezius. In addition. and lengthened). . . . . . . . . . . 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 321 PATIENT QUESTIONNAIRE NAME Case S tudy . . . . . _X_ ELEVATED CHOLESTEROL LEVEL . . . . . . . . . . . . . . . . . . . . . . _X _ HI STORY OF PNEUMONIA OR TUBERCULOSIS . . . . . . . . . . . . . . . . . . . . ITCHY. . . . . . ----lL- SHORTNESS OF BREATH . EMPHYSEMA OR COPD . . . . . . . . . . . . . . . . . . --1L- DIABETIC . . . . . . . . . . . . . . . . . . . . . MENSTRUAL CRAMPS . . . . . . . . . . . . . . . . . . . . . --1L- PAIN WORSE AT NIGHT . . . . . . . . . . . . . INCREASED UTERINE CONTRACTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 4 Patient qLlesti0l1l1aire (or Case Study 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .liL FEVER AND/OR CHILLS . . . . . __ x SWEATING WITH PAIN . . . . . . . • . . . . . . . . . . . . . . . . __ x HI STORY OF HEART PROBLEMS . . . . . . . . . . . . . . . . . . . . _x_ NIGHT PAIN/DI STURBED SLEEP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . __ x DRY MOUTH ( D I F FICULTY SWALLOWING) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 DATE 9/16/93 AGE . . . SANDY) . __ X PULMONARY H I STORY OF SMOKING . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . --1L- PAIN OF GRADUAL ONSET (NO TRAUMAl sudden onset . . . . . . . . . . . . -lI. . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . _X _ H I STORY OF ASTHMA. . . . . INCREASED AMOUNT OF VAGINAL DISCHARGE . . . . . . � HEIGHT . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . FIGURE 1 2. . . INCREASED CONS ISTENCY OF VAGINAL D I SCHARGE COLOR CHANGE OF VAGINAL D ISCHARGE . . . . . . . . . . . . . . . . . . . . . . . __ x DRY EYES (RED. . . . __ x CONSTANT PAIN . . . _X_ CARDIOVASCULAR HEART MURMUR/HEART VALVE PROBLEM . . . . . . . . . . . . . . . --1L- FAMILY H I STORY OF CANCER . . __ X RECENT SURGERY (DENTAL ALSO) . . . . . . . . . . . . . . . . . . . __ X FAM ILY H I STORY OF HEART D ISEASE . . . . . . -lI. . . . . . . . . . . . . . . . __ x DO YOU SELF INJECT MEDICINES /DRUGS . . . • • . . . . . . . . . . . . . . . . . . . . . . . . ----lL- H ISTORY OF RHEUMATIC FEVER . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . CONSTANT PELVIC PRESSURE . . • . . . . . . . _x _ WHEEZ I NG OR PROLONGED COUGH . . . . . . . . . --1L- EPI SODE O F FAINTING . . . . . . . . . . . . . . . . . . . • . __ X DIZZ INESS ( S I T TO STAND) . . . . . . . . . . . . --1L- PAIN RELI EVED BY REST . . • . . • . . . . . . . . __ X PAIN/SYMPTOMS INCREASE WITH WALKING OR STAIR CLIMBING AND RELI EVED WITH REST . . . . . . . . . . . . . . . . . . __ X H I STORY OF ILLNESS PRIOR TO ONSET OF PAIN __ x H I STORY OF CANCER . . . . . __ X UNEXPLAINED WEIGHT CHANGE . . . • . � WEIGHT ( lbs) . . • . . . . . . .- PREGNANT WOMEN ONLY CONSTANT BACKACHE . . . . . . . . . . . . . . . . --1L- SWELLING IN EXTREMITIES . . __ X FATIGUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . --1L- HIGH BLOOD PRESSURE . . .. INCREASED FREQUENCY OF URINATION . . . • . . . . . . . . . . • . . .. . . . . . . . . . . . . . . . .- RAPID THROBBING OR FLUTTERING OF HEART . . . . . . . . . . . . pallor.47 . The patient may also repo. or an the involved extremity . and/or chest pain. can result in pain at the shoulder -'D.47 . 47 Bilateral dilation of the tent with an irritable right sternoclavicular joint pupils will occur late.52 This is a poten­ Diagnosis tially dangerous arterial condition. The right sternoclavicular joint repetitive motions). refill and compress pain-sensitive stnlctures in the time ·7 Tachycardia and angina pectoris may upper mediastinum. " Rapid with the extremity elevated. leading to shoulder pain .47 A chest radiograph may with capsular and articular cartilage or meniscus or may not allow visualization of the aneu.60 order to rule out cardiac disease. JO.6• The extremity will be cool. acromioclavi­ be aggravated by an increase in activity level cular.32 was graded hypomobile. is a Se. costoclavicular.322 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 JOINT MOBILITY nausea. 3D also be present . involvement.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.63 Thrombophlebitis is an inflamma­ paresthesias. and relieved by rest . usually due to atheroscle­ valve surgery. dizziness. neck pain."iOllS situation. Pain was reproduced with both compres­ sion and distraction of the sternoclavicular joint. systemic hypotension. 47. fever. and sudden onset of in thoracic outlet syndrome. bing and cramping. pectoralis minor. as breath. grade 3.6 ' In the case of tho­ morbidity or mortality is expected if an aneu­ racic outlet syndrome. After a week on antibiotics her shoulder pain disappeared. in all direc­ tions. cyanotic.30. or upper extremity WNL. of the shoulder can pain without trauma were of concern." Aortic aneurysms can enlarge and demonstrate a prolonged capillar). fast walk. She was present as a deep constant pain or lead to is­ referred back to her primary care physician in chemic pain with exercise . The patient's history of prosthetic Arterial occlusion.sm.6 . This Other symptoms include night sweats. and a weak The patient's signs and symptoms were consis­ or absent distal pulse . 1 5). 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. one of the following tests rysm ruptures. Diagnosis ASSESSMENT There will be a prolonged capillar)' refill time for the fingers. quently widen it. The patient was subsequently diagnosed with bacterial endocar­ SYlllptoms ditis. coldness. grade 2. weakness. di­ plopia. 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.32 . aortic orifice of a subclavian vessel. recent surger)" shortness of rosis or compression of the subclavian artery.). and syncope ·7 Symptoms may The mobility of the glenohumeral.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. chest pain.47 tion of a vein in the presence of a blood clot. Raynaud's phenomenon. and fatigue in An aneurysm within a subclavian vessel. weight loss. and scapulothoracic joints was graded (climbing stairs. '2 . hyper­ abduction. 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 . because an emboli may .1 1 2 .35 will be positive: Adson's. and upper alm. or anterior chest diation. is another source of shoulder pain and dys- . in per­ Diagnosis sons with an abnonnal thoracic outlet ·3 Other Edema. healthy individuals with an athletic phy­ Symptoll1s sique.·3 . or hypercoagulability ·3 wall. The risk of pulmonary emboliza­ of breath. ra­ the hand. and cyanosis will be noted causes of venous thrombosis include the pres­ in the fingers. of the sudden onset of swelling and cyanosis in­ The shoulder-hand syndrome. shoulder. (From Rohrer:' with pem7ission. 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.) break free and travel to the lung. hand.·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.M Effort thrombosis is usually seen in young."··3 . pleuritic chest pain. upper arm. which is refen'ed to as effort thrombosis. 1 5Thrombosis or the subclavian vein at the level or the thoracic outlet. Fever and chills may be presenL47 The the pain and swelling. a potentially such as weightlifting ·3 Symptoms of shol'tness fatal condition. 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.•4 Dis­ ence of indwelling venous catheters (central tension of the superficial veins is usually seen in lines or pacemaker leads). 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. local compression.. coldness.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. and there is atrophy of the M R I of the abdomen. a history of pan­ thoracic nerves T7 to T9. pulse volume recording. fracture.. 30. herpes zoster. which is segmentally innervated Allen's test. cervical spon­ tastasis from primary cancers elsewhere in the dylosis. coldness. gallstones.32. and poorly localized to the upper abdomen or back 3 See the associated symptoms Diagnosis u nder " Diaphragm" earlier in the chapter. hand. 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.. 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. or smooth and glossy. cervical disc disease.60 This syn­ Fig.62 1 2. ·o PANCREAS Additional diagnostic tests that may be indi­ cated for a variety of vascular disorders include The pancreas. carpus. diagnostic ultrasound. hemiplegia. or the right shoulder through its contact with the inflammation of the pancreas. which is segmentally innervated by linked to diabetes.60 Symptoms Symptoms Right shoulder pain may be acute or spas­ Patients will complain of shoulder pain and modic in nature. vascular disease ·o These disorders are responsi­ lung. 1 2 . ·o After 6 months. swelling. gnawing. the left shoulder through contact with the central angiography. Doppler ultrasonic flow detector.7 .3 The patient may also complain tenderness in conjunction with aching. CT scan. and fatigue. or tenderness in the right upper strate stiffness. esophagus. wrist. and breast cancers) ·' Hepatitis.3 .52. ecchymo­ nails . muscular atrophy. stomach. and fingers will be noted Diagnosis in association with cyanosis.···7 . vomit­ and fingers ·o The symptoms are constant. palmar erythema.•. paresthe­ of headache.•. and sometimes the phalanges ·o th e peritoneal cavity. may be caused by central portion of the diaphragm (Plate 1 2 . quadrant of the abdomen. teries. an fingers ·o Eventually the fingers will demon­ enlarged liver. by thoracic nerves T6 to T I 0. flex­ nostic clues under "Diaphragm. 1 and Fig. spider angiomas. or inflam­ ble for a reflex stimulation of the sympathetic mation of the liver. and trophic changes of the signs are jaundice. the skin of the hand becomes radiograph. and the accumulation of serous fluid in merus.60 Pain fyom cancer of the liver may be described as deep.•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.•5 Refer the patient for After 9 months. and stiffness in the hand symptoms include indigestion. Limited mobility (active and passive) of the shoulder. laceration. coldness.7. myalgias.4).·5 See the associated diag­ subclItaneolls tissue and intrinsic muscles.·der.. pale skin." ion contractu res of the fingers. even ing. an­ show spoLly osteoporosis of the head of the hu­ orexia.3. can refer pain to systolic blood pressure. alcohol use. unexplained weight loss.•7. and osteoporosis of the entire extremity .•5 at resl. is able to refer pain to creatitis. and cardio­ body (colorectal.•. weakness. nausea. 1 and heavy alcohol use. and auscultation of the major ar­ portion of the diaphragm (Plate 1 2 . and a high-fat die! . 42 Pancreatitis. purpura.3. non pit­ ting edema. and hyperhidrosis in the hand and There may be an upper abdominal mass. plain radiographs will sis.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. pancreas. or rotator The liver is one of the mo t common ites of me­ cuff tear). and arthralgias " Other sias. or .•5 Associated flexion deformity.4) 3 . viral infection. " tive use.3 . anorexia. chest in order to relieve the pain . gnawing. and/or CT scan .47 .47. in the right phragm. 1 ).•s Cholelithiasis will produce There may be an abdominal mass. 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 .··7 In addition. is capable Dr rerer­ ring pain to the right shoulder. or tenderness in the epigastric area. ···2 Acute pancreatitis can be common in women).6·30-32 . jaundice. jaun­ Diagnosis dice. diabetes. CT scan. cancer.·47 These pa­ the passage of a stone through the bile or cystic tients will report an exacerbation of pain with duct. . 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. and often bend rorward or bring the knees to the rever ". See the associated diagnostic clues under "Dia­ and occasionally a palpable mass. vomiting. a high-cholesterol diet.•S Patients surfering with cholelithiasis. oral contracep­ rata1. andior back "··2 Patients with a pancreatic ab­ scess. ·s These disorders are more common in obese GALLBLADDER women over 40 years of age.3. dialThea. or greasy roods will exacerbate the symptoms or MRI may be necessary for an accurate diagnosis .47 ..• The gallbladder (Plate 1 2. and liver disease "S Gallbladder cancer is more commOn in men and women over the age Symptoms or 50 ] Pain in the left shoulder. and hypoten­ be the first symptoms ]··. and gastrointesti­ include chronic epigastric or right upper abdom­ nal bleeding.47 ing pain in the epigastric and left upper quadrant or the abdomen " Pain will be exacerbated byeat­ ing. weight loss. alcohol intake.· See the associ­ Diagnosis ated symptoms under "Diaphragm" earlier in the Gallbladder cancer is characterized by chapter. or pancreatitis may complain of Symptoms rever.. pregnancy. or vomiting. nausea.47 ." upper abdominal quadrant. diagnostic ultrasound.47 Diagnostic ultrasound. weakness. and ab­ dominal rigidity. sex (more generalized ache across the back of her right .• 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.•S Pain is usually re­ sion ·7 Patients with pancreatic cancer may also ferred to the right scapula.." In addition. mid epigastrium.3 . andior vomiting.6. tenderness over the gallbladder.•s Pa­ tients with cholecystitis will have a fever. patients with a Cramping pain or a deep. these lat­ ysmal pain in addition to chills and restless­ ter patients will complain of a waxing and wan­ ness. weight loss.47 A patient with pancreatitis will inal pain after meals.J . will complain of udden and severe parox­ walking or lying supine. andior jaundice.·7. gallbladder disease ]··s There will be tenderness.6··s Other symptoms complain or ratigue.· Rerer ror radio­ graph. deep.3 Risk factors ror the plained of a periodic severe. 52 . enlarged a low-grade fever in the patient "··7 Fatty or liver or spleen. and latter include age (increases with age). obesity. tachycardia. nausea. poorly pancreatic abscess may also report an abrupt localized pain in the back or right shoulder may rise in temperature." She com­ and cholelithiasis (stones). which is i nnervated by thoracic nerves T7 to T9. 1 7) was signif­ icant for gastrointestinal symptoms. Spurling's quadrant compression was neg­ intensity. shoulder did not reproduce pain. although mild and localized. . and left shoulder pain lefl shoulder pain. The left shoulder pain was sharp. She stated t ha t she had never had sig­ ative on the right. 1 6). Active and passive cervical extension. the patient denied any other com­ plaints or symptoms throughout her body. 1 6). 1 983: Diagnosis of diabetes. der blade over the past 2 months before presenta­ SHOULDER AROM AND PROM tion to physical therapy. whiplash. PHYSICIAN-ORDERED TESTS Cervical spine radiographs demonstrated mild to moderate spondylosis throughout the cervical spine. PAST MEDICAL HISTORY 1 994: Arthroscopic decompression of right shoulder (August). or left rotation reproduced neck and headaches. restrictions were noted with flexion. dght shoulder radiographs were negative. abduction. 1 990: MVA with diagnosis of cervical sprain/strain. Ac­ cording to the patient. " greasy meals. None of the cervical provoca­ there was an occasional ache in her right shoul­ tional tests reproduced dght shoulder pain. Other than the information she provided on the questionnaire. shooting. She did admit that (see Fig. 1 6 Pail1 diagram (rom a 51-year-old fever for the 3 weeks prior to the evaluation. 4. and extemal rotation. Further questioning revealed that she had a low-level FIGURE 1 2 . The pain in her left shoulder was not the same as the pain in the Active and passive ROM testing of the right right. The patient also stated that her right shoulder pain was worse following a large meal. coughing. neck pain. The symptoms in sion was negative in flexion and neutral. laughing. lefl side­ She admilled to a chronic history (5 years) of bending. The patient reported the CERVICAL SCREEN sudden onset of a severe ache in her t. She reported her pain was worse at night. GENERAL HEALTH The patient questionnaire (Fig. 1 2. and they remained mild in sion. shoulder (Fig. 1 2. 1 993: Diagnosis of hepatitis. there her neck and left shoulder did not change after was reproduction of left shoulder pain in exten­ cleaning her house. She right-hal1ded (emale with a presel11il1g diagnosis also admilled having upper abdominal pain after o( "righ t shoulder strain.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 The patient denied having more shoulder pain during prolonged walks or climbing stairs. Cervical spine axial compres­ with tingling in her left hand. or deep breathing did not increase her symptoms.ght shoul­ der after a day of housecleaning 2 weeks ago. left sided testing was positive nificant pain in the dght shoulder prior to the 2 for left shoulder pain and tingling in the left hand weeks before her evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . __ X CONSTI PAT ION . . . . . . . � FIGURE 1 2. . . . . . . . . . . . . . . was noted in the left upper Increased sensitivity to light touch and pin. . . . Hyperre· and the right infTaspinatus muscle belly. . . . . . . . . . . . . . . . _x _ DIABETIC . . . . . . . . . . . . . . . . . . . . . . . . V I S C E R A L P A T H O LO G Y 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 327 PATIENT QUESTIONNAIRE YES !!Q NAME Case S tudy '5 DATE 5/21/95 AGE 21 'J:11 . . . __ x PAIN OF GRADUAL ONSET (NO TRAUMA) . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . • . . . was noted in the left C6 dermatome. . . • . . . • . . . . . . . . . . . . . . 11l0di{ied to show signi{ical1l portions o( both pages. . . _X_ CONSTANT PAIN . . . . . . . . . . . . . . . . . . . . . . . . . .prick trapezius. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _X _ LOSS OF APETITE . . . . _x _ DRY EYES (RED. . . • . . 17:. . . . . . . . . . . . . . . _X _ PAIN WORSE AT NIGHT . . . . . . . . . . . . . . • • . . . . . . . . . . . . . . RESISTED TESTING nodes and arterial pulses in the neck and upper Resistive testing of the muscles throughout the extremity were WNL. . . . . . . . . . . . . . . . . . . _x _ DRY MOUTH ( D I F F I CULTY SWALLOWING) . . . . . . . . . . . • . . . . . . . . . . . 1 7 Patiel1t questionnaire (01' Case Study 5. . • . . . . . . . . . • . . . . • . . . . . . . . . . . . . . . . . . . . FEVER AND/OR CHILLS . . . . . . . . . . . . . . . . . _X _ HI STORY OF LIVER OR GALLBLADDER PROBLEMS _X _ HI STORY OF STOMACH OR GI PROBLEMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . _X _ PAIN CHANGE DUE TO BOWEL/BLADDER ACTIVITY _X _ PAIN CHANGE DURING OR AFTER MEALS . . . left middle trapezius and rhomboids. . . . . . . _x_ NAUSEA . . . _X _ RECTAL BLEEDING . . . . ---1L1 1 ) RECENT SURGERY ( DENTAL ALSO) . . . . • . . . . . . . . . . . _x _ HISTORY OF ILLNESS PRIOR TO ONSET OF PAIN _x_ HI STORY OF CANCER . . . . • . . . S WEIGHT ( lbs) . __ X HEARTBURN . . . . . . . . __ X CHANGE IN COLOR OF STOOLS . _X _ FOOD INTOLERANCES . . . . . . . . . . . . . _X _ INDIGESTION . . . . . . . . . . . . without reproduction of signifi­ cant shoulder pain. . . . . . . . . . . __ x PAIN RELI EVED BY REST . . . . . . . . • • . . . __X DIARRHEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . revealed rigidity and exquisite tenderness in the right upper abdominal quadrant. . . . ITCHY . . . . . . . . . . . . . . . • • . . . . . . . . . . . . . . . . . . . . . . PALPATION NEUROLOGIC EXAMINATION Mild tenderness. . . . . . . . . . . . . . . . . • . . . . . . . . . . . . __x GASTROINTESTINAL DIFFICULTY IN SWALLOWING . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . _X_ VOMITING . . . Palpation of the abdomen right shoulder girdJe did not reproduce pain. . SANDY ) . • • . . . . . . . . . . . . . . . . . . . . . Lymph flexia (3 + ) was noted for the left brachioradialis . . . . . __ x NIGHT PAIN/DI STURBED SLEEP . . . . • . . • . . . . . . . . . . . . _X _ PAIN WORSE WHEN LYING ON YOUR BACK . . . • . . . . . . . . . . . . __ X FAMILY HI STORY OF CANCER . . . . . __ x EPI SODE OF FAINTING . _X _ DO YOU SELF INJECT MEDICINES/DRUGS . . . . . . . • . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . HEIGHT . . . . . . . . . . . . . . . . . . . . . • . . __ x UNEXPLAINED WEIGHT CHANGE . . . . . . . . . . . . . . 67 JOINT MOBILITY Diagnosis The right acromioclavicular and scapulothoracic Tenderness will be noted at the costoverte­ joints were graded 3. low back.idney (Plate 1 2. renal artery oc­ 1 2. The patient was subse­ associated with poor calcium deposits in bone. The stomach. ureters. terior KUB (view of the kidney. hand symptoms were thought to be secondal). and renal in men and women over 50 years of age . will be a fever. frequent. ne­ portion of the diaphragm (Plate 1 2. grade 2. the empty can sign was also or painf"ul. grade 2.47 . quently diagnosed with cholecystitis.30 Cancer of the stomach is more common clusion. renal infarction. renal failure. passive flexion with I R plained weight loss. to white cell count. which is innelvated by thoracic nerves T I 0 to L 1 . hepatitis. maturia. CT scan. or MRJ . The right gle­ the primary complaint. and (3) curvature of shoulder pain associated with greasy meals. Right glenohumeral compression and distrac­ weakness. or nank pain. (2) ab­ patient's history of diabetes.' Chronic kidney disease may be trointestinal problems. nephritis. fatigue. fever. there tent with an active orthopedic injury of the right is no tenderness over the renal areas of the back. Some of the following complaints may be noted: acute or spasmodic ipsilateral shoulder. and blad­ The cervical spine did not appear to be a source der) radiograph will demonstrate the following: of right shoulder symptoms . and fever 67 A plain anteropos­ a mild and chronic left cervical radiculopathy. SPECIAL TESTS lower abdominal. or E R was negative. and other by thoracic nelves T6 to T I O. The k.3. probably due to muscle guarding .32. sence of the renal outline.1 Ie out any gas­ cramping pain . patients may benefit by refelTals for KIDNEY diagnostic ultrasound. The left shoulder and inal palpation . or urgent urination or he­ negative. or chills.1 ) . which is segmentally innelvated including cancer. brain.47 factors for an ulcer or gastritis include heavy al- . dominal quadrant.66 There are several pa­ thologies to consider with respect to the kidney. 67 There will be an elevated ESR. Cancer of the kidney is nohumeral joint was hypomobile. nausea. there sternoclavicular joint was hypomobile. It can metastasize to the lung.67 Refer the exquisite tenderness in the right upper ab­ for an intravenous pyelogram and/or CT scan.3. The right bral angle and. and the spine towards the side of the disease. vomiting. so The patient's signs and symptoms were i nconsis­ In patients with a pel-inephl-ic abscess.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 DTR.66 Musculoskeletal pain is rarely in distraction and inferior gliding. The patient was refen-ed back Kidney stones may produce a severe to her pl-imary care phYSician to 11. 1 . groin.3 may refer pain to the STOMACH shoulder girdle region. perinephriC abscess. Isometric manual muscle testing of the Symptoms upper extremities was WNL. phropathy. which will lead to a weak bone structure . Chronic joint dysfunction was noted and only mild distension is noted during abdom­ in the right shoulder girdle. in the case of innammation.' For all of the diseases of the kidney that have been discussed. WNL. in all most common between the ages of 55 and 60 s0 directions. shoulder.66.' Risk tuberculosis. Of concern was the ( 1 ) difficulty identifying the psoas stripe. can refer pain to disease processes such as kidney stones. nephrotic syndrome. Associ­ the shoulder through contact with the central ated disorders are pyelonephritis.4).2 and Fig.47. in mobility. or generalized myalgia. unex­ tion tests were negative. or liver so Metastasis to bone occurs late in the disease pro­ ASSESSMENT cess. irritable bowel syn.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. smoking.··42•47 Patients with stomach cancer may complain of a deep. anorexia. anti-inflammatory drugs (NSAIDs) 6. bloody bloody vomi!. a sense of fibers that join parasympathetic nerves. anorexia. nau­ report belching. and flatulence. which is inner­ intense cramping pain. unex­ from the GI is predominately mediated by affer­ plained weight loss. and lung are common 6. 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. 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 . fever. malaise. 1 ) 68 The gastrointestinal tract (GI) has tion commonly to the low back. alcohol. change in bowel habits. rectal bleeding. will produce is capable of refelTing pain to the right shoulder constant left lower abdominal pain with radia­ (Plate 1 2 .2). chronic dyspepsia-painful digestion.47 Diverticulitis. and L3 69 Disorders relevant to thi region in­ and abnOlTnal bowel sounds ·7 Diagnosis is con­ clude ulcerative colitis. or sea. 50 shoulder. foul breath. or a high fat content ·2 ness J . or alcohol. obstructive bowel disease. and the use of nonsteroidal drome. 3 The NSAIDs may also pain. and a loss of appetite.47 Abdominal CT scan or MRl may be nec­ I n addition to the above symptoms there may be essary for an accurate diagnosis.42 ." The patient may also complain of Smoking. diarrhea.3 flammation in the wall of the colon.42 Patients with cancer. or gastri­ mask the symptoms J Other dsk factors include tis may complain of weight loss. and short episodes of The colon and large intestine.47 Patients with gastritis may also bowel movements. painful tention.. rapid heart rate. and cancer. fatigue. roughage. bowel syndrome is the most common gastroin­ testinal disorder in Western society. fullness. heartburn. pelvis. exer­ ent activity in sympathetic nerves such as the tional dyspnea. liver.42 diverticulitis. indigestion. There are afferent leg 6 [n cases of cancer. fatigue. spastic colon. bloody stools. an in­ vated by thoracic and lumbar nerves T i l to L t .42 The ated diagnostic clues under "Diaphragm. or by eating a large There may be an abdominal mass or tender­ meal with fruit. which oc­ midabdominal region 6A2A7 There may also be curs with vomiting.7 Irritable under "Diaphragm" earlier in the chapter. and vertig0 6A7 .6. firmed by a positive colonscopy. night pain. NSAIDs.47 See the associated symptoms stools.42 Symptoms are aggravated or precipitated by emotional Diagl10sis stress.·9 Pain incomplete evacuation. or abdominal dis­ a fluctuation of pain with eating habits. 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. weakness. and weight loss J . and benign polyps fullness after eating. there may be a change fibers that join sympathetic nerves and afferent in the frequency of bowel movement. and caffeine may in­ epigastric or right upper abdominal quadrant crease the risk of disease. tions enter the spinal cord at levels between T2 abdominal tenderness. a sense of prior·cancer ofanother organ. jaundice. nausea." 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. See the associ­ constipation. 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. or a prior history of inflammatory bowel disease. vomit­ of the colon 6 ing. or left dual innervation (Plate 12. . an ulcer. vomiting. 30. thoracic. Epstein-Barr.70 regulation 7 1 . Persons with "leaky have been modified for instructional purposes. Damaging substances like unhealthy sion. It also appears to be a problem with muscle metabolism.7. especially glycolysis.75. or royal free tionship between PFS and fibromyalgia. toxins. chemicals. or if a patient does not respond to treat- .7 1 .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. or varicella) and up of lactic acid leading to early fatigue and com­ primarily affects skeletal muscle. such as ESR. It always follows a viral infection (cox­ ual anaerobic glycolysis. 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).78-8 1 Insidious onset of severe muscle fatigue and There appears to be an association between myalgia. are not able to filter out all of the damaging substances. This protective coating of microorga­ in fatty acid metabolism have been noted 7o.7 ' .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. in patients with chronic complaints.70-77 Recent research has suggested a rela­ syndrome.7 1 -73 bacteria. which results in a build­ sackie. criteria for a diagnosis of fibromyalgia syndrome includes neck and shoulder pain as well as a specific tender point in the supraspinatus Symptoms muscle. chronic fatigue dle. exacerbated by exercise.'2 A healthy intestinal wall is coated extremities is usually within normal limits. such as depres­ tection. sore throat. Mus­ with hundreds of different species of microorga­ cle biopsies are not diagnostic. andJor duction secondary to a problem with metabolic disturbed sleep ·7.7o There may be associated headaches. and Iceland. and wastes are fil­ Note: The case studies used in this chapter tered out and eliminated.72 . Range of motion in the spine or drome.7I·7•. with the in'itable bowel or "leaky gut" syn­ are not helpful.7•.7• The essential fatty acids are proposed to symptoms or have difficulty identifying a tissue have a strong antiviral effect.74 I n addition. and shoulder re­ lar acidosis during exercise.7o There may be associ­ provide the body with important filter-like pro­ ated psychological problems. in lesion.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 Most com­ PFS and the abnormal early onset of i ntracellu­ mon in cervical. gut" syndrome. Akureyri.9 neuromusculoskeletal tissues as a source of the Persons with PFS are more susceptible to vi­ symptoms. confidence.7o. but abnormalities nisms. however. toxins. and wastes leak through the intestinal wall and into Summary the bloodstream.7' The disease. cognitive dysfunction. If you cannot reproduce a patient's acids. chemicals. Epstein-Ba'T virus syndrome. . so that the patient is stuck in perpet­ women. diz­ thought to represent excessive lactic acid pro­ ziness. This requires skill. Subsequently. This is gions. 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. 75.' 1 .7• M itochondrial ally mild lymphadenopathy and fever.47 Plain ra­ damage and fibromyalgia have been associated diographs and laboratory studies.75-7. 83-.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. There is usu­ plaints of muscle soreness.7. rubella. unhealthy bacteria. In Boissonnault WG therapy. Bridenbaugh P (cds): Neural Blockade in Clini­ 2. J Orthop Spor�s Phys Ther 1 2: 192. Philadelphia. HarTington G. I . 1 949 4. In Cousins M. 522. 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. Am J References Med 9 2 : 1 I S. J Am Osteop Assoc 76:62. J Orthop Sports Phys Ther 20:2. 22. Michel TH.- Limbs. 2nd Ed. 3 . p. An orthopedic patient who Screening for Medical Disease.. p. In: Vascular ciated phenomena. 1978 I I . Snyder TEK: Systemic origins of cal Anesthesia and Management of Pain. 1 978 LivingsLOne. Screening for Medical Disease. 2nd Ed. WB Saun­ 1 990 der'S. Oral Surg death by early referral to the appropriate physi­ 40:678. SnyderTEK: Introduction to differ­ 1 9 . Screening for Medical Disease. Fulton J (ed): Textbook of Physiology. 1 995 9. visceromotor reOexes and other asso­ tests of al1crial circulation. physiology. Can J Physiol PharmacoI 69:627. Cancel' 63:2266. block. 1 0 1 . In: Textbook of 0. In: Dif­ in disease. 1 0. New York. Cousins M : Lntroduction to acute and chronic tOly pronle: orthopaedic physical therapy outpa­ pain: implications for neural blockade. In Boissonnault WG 1982 . 1 975 cian. biologic Mechanisms in Man ipulative Therapy. I . Lewit K: The contribution of clinical observation cal disease: physical therapy assessment and to neurobiological mechanisms in manipulative treatment principles. 2nd Ed. 1988 toms. Downing J : Screening for cardiovas­ sue Lesions. p. 1995 Plenum. In: Common Examination in Physical Therapy Practice: Vertebral Joint Problems. Henry J. p. Philadelphia. I . Raj P: PI"ognostic and therapeutic local anesthetic Therapy. WB Saunders. 1 978 5. Plenum. 1 59. In Cousins lients. 1 994 M. Procacci P. and Acknowledgernent. Goodman CC. Bailliere Tindall. Bass C: Pathological origins of of Pain. 1 98 1 thopaedic Medicine. Diagnosis of Soft Tis­ 8 . 1 939 Problems in Musculoskeletal Disorders of the 24. 1 995 2 1 . p. Boissonnauh WG. Philadelphia. 1 989 1 2 . Philadelphia. Funct NeuroI 4 : 1 9 . Payne R: Cancer pain: anatomy. Churchill demonstrates signs and symptoms of visceral pa­ Livi ngstone. 1 9 9 1 1 4 . 5 1 . 229. Kellgren J: Observations relating to rc­ 7. New York. Ness T : Central mechanisms o f vis­ ceral pain. Med Bull 47:549. 1992 I . In Korl' 1 M (ed): The Neurobiologic (cd): Examination in Physical Therapy Practice: Mechanisms in Manipulative Therapy. I n ceral disorders. In: Di fferential Diagnosis in Physical 1 7. Pelvic and abdominal vis­ 1 8. In Korl' 1M (cd): The NeUl'O­ ferential Diagnosis in Physical Therapy. 2nd Ed. Mandel M : Anginal pain thology can be saved from severe morbidity or referred to the teeth: report of a case. cular system disease. Maresca M: Clinical aspects of visceral I wish to thank Ola Grimsby and Jim Rivard for pain. Vol. 1 988 trunk and neck pain. 1 . Goodman CC. Br trations for this chapter. then ruling out visceral pathology be­ (cd): Examination in Physical Therapy Practice: comes imperative. Miller OS: Clinical and laboratory fen'ed pain. Cervero F: Mechanisms of acute visceral pain. JB lip­ musculoskeletal pain: associated signs and symp­ pincott. Bridenbaugh P (cds): Nellral 1 995 Blockade in Clinical Anesthesia and Management 3. Janos SC: Screening for medi­ 20. Gebhart G. Cyriax J: Refen'ed pain. Koopmeiners MB: Screening fOI" gastrointestinal mental facilitation. 2nd Ed. London. Springer-Verlag. p. 3 1 . New York. Koopmeiners MB: Medical his­ 1 6. Boissonnauit WG. Churchill New York. 1 989 their contribulions and hard work on Ihe illus­ 1 3 . Korr 1M: Sustained sympatheticotonia as a factor ential screening in physical therapy. Boissonnault WG. 1 976 system disease. Abramson 0 1 . New York. Gdeve G: Clinical features. Natkin E. p. Ruch T: Viscera] sensation and refen'ed pain. Lynn R: Mechanisms o f esophageal pain. Montuschi E: Cardiac pain refen'ed to site of previously experienced somatic pain. p. 8th Ed. Churchill New York. Lewis T. Patterson M: A model mechanism for spinal scg· 6. BI' Med J 9: 1 605. p. 1 98 1 Livi ngstone. p. Churchill Livingstone. In Boissonnault WG (ed): 22. Philadelphia. 1 995 23. Clin Sci 4:47.s pharmacology. 1 99 1 1 5. WB Saunders. New York. 18 Lippincott. Kovach SG. 2. 7. FA Davis. Sims C. 1 936 the problem of refclTcd pain. Neurosci Leu 24:25. Churchill Pain in the Pleura. Am J Obstet Gynecol glion cells with collaterals to both shoulder skin 72:903. 2nd Ed. Chandler M el al: Convergence coast tumor: a diagnostic dilemma. Nelson P: Fatal air cmbolism i n prcg­ study in the ral. 1 995 30. cular and pulmonary system. 1 990 33: 1 88. 1 980 toneum following vaginal insufflation and coitus. Rucker C. Spi-inghousc Corp. 2nd Ed. Blum berg H. Nov H: Pneumoperitoneum 5 3 . Coventry MB: Problem of painful shoulder. Philadelphia. Pericardium. Bass C: Pathological origins of 35. J Onhop Spons 1 990 Phys Ther 1 2 :208. Am J Obstct Gynccol as well as somatic structures? A contribution to 3 2 : I 054. Netter FI-I: Diseases and pathology. Livingstone. Philadelphia. Newman A: Spontaneous pneumoper­ study on prevalence of esophageal chest pain in itoneum occun'ing during postpanum exercises patients referred on an elective basis to a cardiac . McGee 1-1: Pneumoperi­ tion. NJ. C3-T6 spinothalamic tract cells of the monkey. 1 992 45. 1 9 8 1 48. 1 988 tory System. A nuorescent double labelling 40. Bolser D. 43. 1 967 26. Welch WC. J Neurophysiol 65: I 042. Am J Surg Res 529: 1 49. 147. J Orthop SPOl�s PhysTher 1 2 :2 1 6. Hubner KF. p. Springhouse. In Boissonnault WG (cd): Ex­ Hosp J t Dis 1 4:7 1 . Bass C: Pathological origins of trunk and neck pain. Vol. A model [or referred pain? Brain nancy resu lting from an unusual sex acl. Postgrad Med 87:263. 1 994 Neurophysiol 68: 1 575. Bahr R. 262. Calliet R: Visceral refelTed pain. 1 995 for the theory of refelTed pain. Sorensen K: Cervical danml root gan­ in the knee chest position. Bull tem disease. Goodman CC. Pennsyl­ 3 1 . Buonocore E: Pul­ 3 4 . Ryan M: Screening for pulmonary sys­ 3 2 . Snyder TEK: Overview of pul mo­ lamic tract neurons in the monkey: implications nary signs and symptoms. 3. Miller R. Erhard R. p. 1 93 2 49. 1 990 5 1 . Janssens J. Leland J : Visceral aspects o f shoulder pain. JAMA Ann Emerg Med 9:480. Clyde B et al: Systemic ma­ OI-ganization of visceral and somalic input onto lignancy presenting as neck and shoulder pain. Chandler M. Boissonnau l t W. 1 985 Gyneco1 30: 1 27. Obstci Res 33 1 : 1 60.332 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. Arch Phys Med Rehabil 7 1 :606. 2nd Ed. and Peritoneum. O'Brien W et aJ: Postcoital pneu­ Ciba Colleclion of Medical l I lustrations: Respira­ moperitoneu m. Niethammer JG. Arnall D. 1 983 toms. 1 984 information on cervical and thoracic spinotha­ 46. Huslig EL: Shoulder pain and Pan­ 29. Nevcns F. WE the common bile-ducl in man and its implication Saunders. 69. 2nd Ed. In: The 36. Capps J : A n Exper-i mentaJ a n d Clinical Study of ing for Medical Disease. 1 95 3 amination in Physical Therapy Practice: Screen­ 33. 2 1 5 . 1 978 50. Philadelphia. p. New York. J Arch Phys Med Rehabil 75:9 1 8 . Angel J. Doran F: The sites to which pain is rcfclTcd from tial Diagnosis in Physical Therapy. Br J Surg 54:599. Lozman H. New York. 1 980 1 5 1 : 1 77. Bolser D et a l : Segmental 44. 1 05. In: The Shoulder and Neck. Bateman J : Applied physiology o f t h e shoulder monary embolism: how V/Q scanning helps in di­ and neck. Disorders of the cardiovas­ skeletal system. Obstet Gynecol 7 1 : 1039. 1 995 Macmillan. WB agnosis. Ciba-Geigy COI'pora­ 37. p. Philadelphia. WB Saun­ heart. 1956 and the diaphragm. 1 99 1 ders. Danzl D . J Manipula­ of phrenic and cardiopulmonary spinal afferent tive Physiol Ther 7:25. Flood K: Pancoast tumor presen ting as 1 967 cervical r-adicu lopathy. 52. 1 967 54. Hobbs S. Christiansen W. p. Piessens J el a l : Prospective 39. Campbell S: RefelTed shoulder pain: an elusive 47. 1 990 Saunders. Arons�n M . 1 993 der Pain. West Caldwel l . Gaspar 1 : Fatal air embolism on the afferent fi bers exist which supply visceral organs eighth day of pucrpel'ium. Qu igley J. 1 95 3 38. Laurberg S. 67. 1 990 28. Goodman CC. Postgrad Med 73: 1 93 . Vargo M. Loeb S: Professional Guide to Signs and Symp­ diagnosis. p. Janig W: Do dichotomizing 4 1 . 42. Brain two cases and a review of the litcrature. Hobbs S. Discases of the musculo­ trunk and neck pain. Snyder TEK: Overview of gastroin­ 1 98 1 testinal signs and symptoms. In: Shoul­ vania. Boissonnault W. I n : Di fferen­ 27. 3rd Ed. I n : Differential for rcfen'cd pain from the diaphragm and the Diagnosis in Physical Therapy. Ammons W: Cardiopulmonary sympathetic affer­ secondary to pel-forated appcndicitis: a repor't of ent input 10 lower thoracic spinal neu rons. Wilgis EFS: Diagnosis. Agents Actions 39:C24. Geraci J. J to usc of nonsteroidal anti-inflammatory drugs: a Fam Pracl 1 5 : I 059. V I S C E R A L P A T H O L O G Y 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 333 unit for suspected myocard ial ischemia. Jaakkimainen L. 2nd Ed. Rohrer MJ: Vascular problems. Miller OS: Vascular complications 80. 1 988 55. Lancel 1 980:443. Thompson T: Fibromyalgia and myo­ 62. p. Behan W: Post viral fatiguc syndrome. Blanton ME: Clinical features and diag­ AM (cd): Upper Extremity Injuries in the Athlete. 77. p. Dig Dis 69. Essentials in Nutritional Medicine. Philadelphia. Boston. Epslein­ clusion. 1994 skeletal Disorders of the Limbs. Snyder TEK: Overview of hepatic 82. Behan W. 1 983 Gig Harbor. Hundcr G: When musculoskelclal symptoms acids. SI. lillie. ChUl'chill M.D : LeukotJiencs i n the pathogenesis urologic signs and symptoms. New York. New York. 8 1 . 1 983 78. In: Applying New and Diseases of the Upper Limb. 75. p. Ann 58. J Neurol Neuro­ and Diseases of the Upper Limb. 56. Abramson 01. 1 980 of chronic NSAlDs on gastdc mucosal injury rc- . Gabr'iel SE. 1 982 mela-analysis. Arnold D. 1 . Ramsay A. Wolfe F: Fibromyalgia. nary adenosine causes angina pectoris like Cril Rev Neurobiol 4: 1 57 . 77. and essential fatty 59. Brown. 1 990 both vascular and orthopedic components. 1 5 . Philadelphia. Hegarty J. Hansen S: Electrophysiological sludies der girdle and arm. 1 990 point to endocarditis. p. Gantz N el al: Chronic fa­ Saunders. 1n: Vascular Injul'ies fascial pain syndromes. p. J Musculoskel Med 9:33. Springer-Verlag. Hunder G : Musculoskeletal lnlem Med 108:387. Springer-Verlag. 1 993 Saunders. 1984 6 1 . Goodman CC. Behan P. 1 995 63. Ann Inlern Med 1 1 5:787.. Salil I . In Pappas 79. Behan p. Litlle. 1 992 tial Diagnosis in Physical Therapy. 254. Brown. Snyder TEK: Overview of renal and 83. p. Bland JS. 1985 the shoulder and hand complicating coronary oc­ 72. Bat L et al: Site of pain 85. Ncw York. Whelton C. Rainsford KD. 2nd Ed. Br J Rheumalol 30:220. Lewis E. Claire SM: Diagnosis and trealment of fibro­ of musculoskeletal disorders produced by myalgia syndrome. HealthComm. In: Vascular InjUlies in the postviral fatigue syndrome.py. Kaplan J. Beer'mann B: Lntracoro­ 70. Miller OS: Clinical entit ies with fection? Poslgrad Med J 66:526. 284. McCal1ney R et al: Myalgic 1 992 encephalomyelitis-a persistent enteroviral in· 60. WB damage. 1995 84. Kavanagh G. Moldofsky H: Sleep. James C. WB 73. WB different expressions of a common pathogenetic Saunders. 1 988 pain-an inquit)' into the nature of visceraJ pain. p. Churchill Livingstone. Bell E: The poslviral fatigue Cardiovasc Res 24:609. J Musculoskel Med 9:24. 1 99 1 pain. Abramson OJ. Fielding JF el al: Pr'imary and bil iary signs and symptoms. Baillieres Clin Gastroenterol 2: 1 83 . Fan PT. 1995 process. In: Di ffer­ fibromyalgia and the initable bowel syndrome: enlial Diagnosis i n Physical Therapy. musculoskeletal pain. surg Psychialry 48:69 1 . 1 9 4 1 BarT virus infection. Radda G et al: Excessive intra­ [n: Vascular Problems in Musculoskeletal Disor­ cellular acidosis of skeletal muscle on exercise i n ders of the Limbs. p. 1 995 1 992 64. [n: Differen­ drome. J Neuromusculoskel SYSt 2: trauma. l n : Vascular Problems in Musculo­ 1 0 1 . p. Veale D. 1 995 tigue syndrome: a working case definition. Han-ubin D: Post-viral fatigue syndrome. 1 99 1 66. Lancel 1 984: 1 367. Philadelphia. 1 98 1 1 995 65. Lagerqvist B. Med Hypolheses 3 2 :2 1 1 . 1 990 syndrome-an analysis of the findings in 50 cases. 2nd Ed. Daehler 0 et al: Perin­ for selious gastrointestinal complications related ephrcn ic abscess and chronic low back pain . Cervero F: Neurophysiology of gastrointestinal Sci 36:229. a patient with a post-viral exhaust ion/fatigue syn­ 1 98 1 drome. Wilgis EFS: Compression syndromes of the shoul­ 77. Davidson R. Am Heal' J 22: I . Washington. Synder TEK: Overview of cal'dio­ depressive symptoms in chronic fatigue syn­ vascu lar signs and symptoms. Sylven C. 263. Goodman CC. vil'3l in­ tern Med 87:754. Jamal G . Goodman CC. J Rheumalol 1 9:939. Askey JM: The syndrome of painful disability of J Infect 1 0:2 1 1 . 7 1 . and 57. Holmes G. Semin Spine Surg 7:200.lable bowel. 1 99 1 68. Ann tn­ 74. 76. Rainsford K. Swarbrick E. 1 988 manifestations of bacterial endocarditis. Dowsell E. 1 977 fections i n atopic eczema. In: Di fferen­ of NSAfD-induced gastric and intestinal mucosal lial Diagnosis in Physical Ther. 1985 Boston. nosis of fibromyalgia. Bombardier C: Risk 67. 69. 1 8 1 . Johnson D M et al: Effects from Ihe in. Bore P. Bateman ON. Bennett JR: Case !'ep0l1: radiolog­ Actions 35(sllppl):93. 1 995 tancy: comparative I month repeat oral dosestucl­ 90.334 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 latcd to mucosal prostanoids. 1 99 1 . Lanas A: NSAID association with 8 1 7 . Am J Clin diclofenac. 1 99 1 ical appearance or colonic stricture associated 87. Agents 89. and plasma drug 88. AAS 32:33. Gentry C. Clin Radiol 50:268. 1 99 1 Nutr 54:438. O'Connell C et al: Anti­ with the usc or nonsteroidal anti-i nflammatory inflammatory efficacy and gastrointestinal irri­ drugs. 1993 cine may be worse than the disease. Br Med J 3 1 0: 86. Nicholson AA. Agents Ac­ flammatory drugs and elderly patients: the medi­ tions 39:C2 1 . Kennedy JG: Non-steroidal anti-in­ concentrations in human volunteers. ibuprofen and disease and in growth and developmenl. 1995 gastrointestinal bleeding and peptic ulcer. Melarange R . Simopoulos AP: Omega-3 fatty acids in health and ies in the rat with nabumetone. H irschowitz 61. Mathews. dis­ healing constraints we can establish criteria for tractions.Manual Therapy Techniques ROBERT A DONATELLI TIMOTHY J M cMAHON The p. The force used during articular techniques is 835 . muscle function. Manual therapy has been demonstrated movement of bones). manipulation and mobilization all de­ phases of manual therapy techniques. and provide foun­ DEFINITIONS dations of neuromuscular mechanisms to re­ store homeostasis. decrease pain. and shoulder evaluation procedures. 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. Manual therapy sive movement applied in a smooth rhythmic will be discussed in relation to soft tissue and fashion to stretch contracted muscles. Amie!. I Through an understanding Several terms must be defined when mobiliza­ of the effects of immobilization and sort tissue tion is discussed. and capsules gradually. scribe a specialized type of passive movement. osteokinematics (the tissues. Woo. and neurobiomechanics (addressed tion and assessmenl of restricted joint move­ in Chap. Clinical application of manual techniques can result from altered function of any or all of is based on an understanding of joint mechanics. extensibility of scar lissue. and muscle function.' nonprotective injuries. oscillation. joint mobilization and muscle reeducation. Please refer to Chapter 3 for searchers as Akeson." 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. reduce the develop­ ment of restrictive adhesions.. and assist regeneration of chanics of joint surfaces). This chapter will focus on manual therapy Articulatory techniques are derived [rom the for the shoulder complex from a basic science osteopathic l iterature. A detailed sequential evaluation tissue histology. fascial ex­ clinically to be an important part of rehabilita­ tensibility. ligaments. 6). Dysfunction and pain of the shoulder ment. Articulation. Manual techniques ing critical stages of wound healing to influence discussed wiu focus on the shoulder complex. Clearing the Peacock. They are defined as pas­ and problem-solving approach.mary goal of the clinician is to optimize Normal joint function includes a dynamic function. restore proper mechan­ combination of arthrokinematics (intimate me­ ics. 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. these systems. facilitate healing. Protective injuries are £i'om surgery and/or Mobilization. tion of scar tissue. In phYSical therapy. and thrust for patients with protective injuries is divided . 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. 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. which can be a small or tion. carefully analyzed. fixed or ankylosed part movable. A esthesia is a medical procedure used to restore case study EOImat will be used for each categol). who describes oscillations as passive stricted secondary to trauma and immobiliza­ movements to the joint. and shoulder dislocation. Bankart repair. I Ad­ are designed to separate the joint surface at­ ditionally. prominence.There are four grades of oscillations. 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. the What djrection should stress be applied? These forceful passive movement of a joint beyond its active limit of motion. Examples of protective injuries include an­ restore the arthrokinematics and osteokinema­ terior capsular shift. These same techniques can be effective large amplitude and applied anywhere in a range tools i n assessment of specific joint impair­ of movement. tendon. distractions. and ligament. articulations. attempting to pair. Restoration of motion to ajoint.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 joint surfaces are held distracted or com­ Soft tissue mobilization (STM) for purposes pressed'. 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. mobilization after trauma must be tempting to stress the capsule. The techniques are built on active or lissue limitation. and thrust techniques. oscillations. normal joint movement by breaking adhesions. Manipulation is a sud­ we can determine the indications for mobiliza­ den movement or thrust."6 To the clinician. Rehabilitation ticulations. mobilization is passive movement that is designed to improve CASE STUDY 1 soft tissue and joint mobility. distractions. I t can include oscil­ PROTECTIVE INJURY lations. is defined as trauma with significant soft tissue damage or re­ a specialized passive movement. but not reaching the limit ohhe range. 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. 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. Grades 3 and 4 are designed to initiate Contraindications Jor mechanical changes i n the tissue and do engage tissue resistance. and passive joint mechanics and are directed at Oscillatory techniques are best defined by the periarticular structures that have become re­ Maitland. muscle. in this chapter. of small amplitude. Mobilization includes ar­ repair.'" Grade 3 is a large-amplitude movement up to the limit of range. and which can be performed while ments. rotator cuff tics of joint movement."7 Maitland describes two important questions must be answered before manipulative procedures. to illustrate changes in treatment and discuss the Mobilization is defined as "the making of a rationale of each phase. " 6 Distraction techniques connective tissue following immobilization. 90· of abduction. 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. selTatus anterior. 45° of internal rotation. A 16-year-old female basketball player was re­ Hypermobility of wrist. pectoralis minor. and return pula. The patient presented 2 weeks postopera­ tively with stiffness. 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 Abbreviatioll: NT. and neutral external rotation to be started 1 to TABLE t3. and tightness and middle trapezious stretch weak­ difficulty sleeping on the effected side. knee bilaterally. anterior capsulolabral reconstruction. protected Palpable tenderness and trigger points on mobilization. and lower portions to function. along fascia of inferior clavicle. position -10 18 30 53 75 External rototion. nOI rested. fen'ed for postoperative rehabilitation of a right and left shoulder joints. Func­ tional limitations included weakness and insta­ phase. 1 Protective injury case study I: Summarizariol1 o( ROM measuremel1ls WEEKS P OSTO PER A T IVELY 2 4 • • I. Additional ness. concepts of phased rehabilitation in a patient Scapular gliding revealed pectoralis major with a protective shoulder injury. and minor tightness. weakness. scopic surgery to repair torn cartilage to the same shoulder 2 years prior with little change in symp­ PHASE I : MAXIMUM PROTECTION PHASE (I 1010 Days Postwoulld) toms. Inherent ligament laxity throughout other past medical history includes previous arthro­ joints. TREATMENT SUMMARY OF I N ITIAL FINDtNGS See Table 1 3 . especially with basketball activities. minimum protection. and flexion. This case study will illustrate the of longus colli muscles. 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. �5° abd. levator sca­ ate protection. Patient appears to have anterior pectoral bility. 450 obd. Pa­ pair. and some mild pain. position NT NT 38 56 80 Internal rototion. Patient was immobilized in a sling postopera­ tively for the first 5 to 7 days. and excessive mobility H ISTORY of the scapula in an anterior direction. AAROM and PROM Slightly elevated and protracted scapula R in the following protected ranges: Up to 90° of Decreased fascial mobility of suture. Prior to surgery the patient had recurrent tient is cUITently in the protective mobilization anterior dislocations for the past 3 years. The pro­ cedure performed was a mini-open procedure ASSESSMENT that include a rotator cuff interval reduction and Adolescent female athlete with a protective anterior capsular shift with labra! cartilage re­ shoulder injury and reconstructive surgery. 1 for ROM measurements. 90" abd. . moderate protection. late moder­ subscapularis. 9. bers must glide on each other. with already begun. and the labrum were primar­ scar. nique" to spinal and rib dysfunctions. edema. it is helpful to have an operative Peacock hypothesizes that the mechanism by report to inform the therapist of the specific tis­ which the length of the scar is i ncreased becomes sues involved in the procedure. Ice can be used to control swelling and intermolecular cross-linking of collagen de­ pain.'·12 Pea­ macrophages.' Stretching. Little cock has substantiated this peak production of to no motion should occur dUling the first 3 to scar by the increased quantities of hydrxypro­ 5 days in order to protect the newly forming net­ line. designed to resist tensile forces. IO gins on the fourth day of wound healing and in­ The scar is still quite cellular with presence of creases rapidly during the first 3 weeks. the anterior capsule.' Excessive motion too early synthesis. and prevent adhe­ I n contrast. and fibroblasts. of the collagen fibers. The fibroblastic 2 1 st day postwound. mast cells. The inflammatory stage be­ The goal of this phase is to promote a functional gins I hour postwound and continues for 72 scar and attempt to decrease other compensa­ hours. PROM and AAROM in protected positions described in RATIONALE the previous phase.9. Scap­ molion starting around the I Dth day and pro­ ular gliding passive and active assistive.'·13 Collagen production begins and can result in a prolonged inflammatory stage and continues to increase For up to 6 weeks.' For this to occur. and tDly or contributing dysfunctions. helps to demonstrated that after 1 4 weeks of scar matura­ faci litate aligning of newly forming collagen fi­ tion. or an increase in length of the the subscapularis. " Early gentle passive gressing toward grades 3 and 4 by 3 weeks.'·13 The By the 7th to IDth day postwound gentle first peak in tensile strength occurs around the stress to the tissues is initiated.9 The matrix and cellular prolifera­ glide. the collagen fi­ Weeks) See Table 13. the 3-week-old scar was significantly sion formation. The gliding mech­ anism is hampered in unstressed scar tissue by the development of abnormally placed cross­ TREATMENT links and a random orientation of the newly syn­ Continued grades I and 2 joint mobilization pro­ thesized collagen fibrils. Ice and rest with al-m counterstrain an indirect positional release tech­ supported for pain reduction. 2 .338 PH Y S I C A L T H E R A PY OF T H E S H OULDE R 2 weeks postoperatively. such as with grades I and 2 joint mobiliza­ I-ity of the collagen tissue. elongation of scar was no longer possible. the fibroplasia stage of healing has characterized by endothelial capillary buds.' Hydryxyproline is a byproduct of collagen work of capillaries.IO excessive scarring. As the infiammatolY tive stage begins 24 hours postwound and is phase ends. Immobilization during the first 3 to 5 days is crit­ ical to allow the inflammatory and proliferation RATIONALE stages to proceed." . Strain gressing to the 2 1 st day facilitates the develop- . bers. In protected injuries with surgi­ . during which vasodilation. Heat should also be avoided The newly syntheSized collagen fibrils are secondary to vascular stress on capillary bud­ weak against tensile force. velopS. aid muscle relaxation. a small portion of nism. Early mobili­ phagocytosis of debris in and around the wound zation is critical in effecting scar tissue length. Intramolecular and ding.' stage of healing has already begun with presence Gentle mobilization techniques can be effec­ of fibroblasts in the wound.1 {or current ROM measures. Arem and Madden tion and PROM in protected positions. " cal involvement. For this case critical for the restoration of the gliding mecha­ study. lengthened when subject to the same tenSIOn. lo Gentle early mo­ tive during early fibroplasia due to the immatu­ tion. I. are occurring. The production of scar tissue be­ fibroblasts synthesizing extracellular matrix. and tensile strength. is a result of straightening or reorientation ily involved. without a change in their PHASE 2: PROTECTED MOBILIZATION (10 Days 10 3 dimensions. AROM PNF pallerns for upper extremity to 45' a'1erior to frontal plane) for internal and initiated with some resistance in weak aspects external rotation. inferior cia. Collagen production continues to be high (PREs) in protected ROM with emphasis on rota­ until the 6th week.2 [or PROM measures. stimulate inhibited muscle and provide dynamic tension to healing soft tissue. Sutures dynamic proximal stability. ternal rotation to 45').z.o. providing ing soreness and pain of GH joint at rest. before elevation especially in contractile compo­ nent i njuries). Progressive isomet­ have been removed and superficial closure com­ ric exercises in protected posi tions can be used plete. At 5 weeks iso­ scapular pallerns working on any areas of weak­ metrics begun in the Plane of the Scapula (30' ness. realign randomly rotation in the plane of the scapula (limited ex­ oriented collagen.\ for ROM measures. See Table \3. RATIONALE At 8 to \ 2 weeks. allowing gentle AROM as proved tensile strength allows for early AROM early as 3 weeksz i n protected positions (rotation in the next phase. Gentle AAROM and AROM sis on external ROM in the plane of the scapular initiated but continuing to avoid combination of and 45' abducted position. 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 concentric pallerns (primarily posterior eleva­ Six to eight weeks PROM stretching with empha­ tion and depression). first rib. Continued and effects of immobilization. Continuing PNF external rotation and abduction. TREATMENT PHASE 4: LATE MODERATE PROTECTION (61012 Weeks) PROM stretching and physiologic oscillations to 30' of external rotation in neutral and 45' ab­ REASSESSMENT ducted positions. . Patient continues with anterior chest mus­ around 5 weeks by the patient at home or work to cle tightness and decreased scapular excursion. Submax isokinetic internallexternal of newly synthesized collagen. extension. STM to superficial scar (suture). Additionally. clavicle.-ther facilitate extensibility exercises. joint mobilization G H joint with grades 3 and 4 in a posteroanterior (PA) Decreased tenderness and improved fascial glide direction and gentle posterior capsule stretch­ of suture scar and sU'Tounding superficial fas­ ing. PNF scapular pat­ muscle guarding of subscapularis. and scalenes with lillie terns during this phase foster activation and res­ to no tenderness. REEVALUATION An additional goal of rehabilitation for this phase is to prevent muscle atrophy. and decreases pain. and abduction. inhibition. and enhance fiber glide be. eccentric. AROM exercises begun in The moderate protection phase allows for more unrestricted ROM (no loadjngofjoint in external AAROM progressing toward AROM by the 4th and abduction). Muscle reeducation initiated with proprioceptive neuromuscular facilitation PNF TREATMENT scapular techniques with active. Active scapular stabilization and movement pallerns incorporating closed kinetic chain exercises. Serratus ante­ terns with a progression towards resisted pat­ rior. longus colli. progressing to overhead at this stage is to fu. M AN U AL T H E R AP Y T E C HN I Q UE S 339 ment of tissue tensile strength by helping align tween collagen fibers. ( Progressive resistive exercises) week. im­ reached its first peak. of the pallern.lo The goal of rehabilitation tor cuff strengthening. major and minor and between rib cage and pec­ toralis minor. Scapular mobility within normal limits. fascial restricitons between pectoralis Refer to Table 1 3. Subjective reports of decreas­ toration of scapular muscle activity. Tensile strength has newly synthesized collagen. because by 1 4 weeks scar deformabil­ to restore force couples around the scapula and ity may be greatly decreased.4. Scopular release PNF UE patterns A.. mob. to 3 3-6 week. Eorly nbroplo. The of function of the parascapular muscles in the maturation or remodeling phase of healing be­ previous phase. protected T-bar. PNF streich prolonged tissue. inAommotory ranges Swiss boll. Maturation Maturation AIIoturotion proliferative maturation early fibroplasia GooI. emphasis shifts toward . Joint mobs. dear muscles $pinal and rib dysfunction Monual therapy 7-10 day. protected previous. needed for techniques postwound. scopular plyoboll AAROM stabilization throwing and exercises. of PROM in exercises. PNF scapular stretch if scapular pottems needed pottems. seer force increase aligning couples. PNF with any deficits grades 1 end 2 suture. ROM. progressively $Cor. 3. signi�cant and 2 joint progress ta scapular Iow-lood resistance.2 Summarization of phases of rehabilitation for protective shoulder il1juries 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. grades 1 STM to tech. collogen di. protected PROM Other Position Home program (odmon lsokinetics in Some os Progressive retum theropeutic education.io Fibroplasia. to sport interventions onti. These exercises help essential. As previous. Some as previous Retum to function formed scor functional strength of restore phose. Protect newly Facilitate Enhonce tensile Stress scar. effort and recreational modolities.340 P H Y S I C AL T H E R AP Y OF T H E S H O U L DE R TABLE 13. rototor cuff. exercises RATIONALE PNF scapular pallerning to reestablish balance At 6 weeks collagen production tapers off. 13 Strengthening is usually involve some co-contraction or synergy emphasized more during this phase_ pallerns of the rotator cuff. increasing drill" ligh." Maximizing scar extensibility is tion activities are initiated. 10 day. STM release prolonged low-food surrounding tech. foam octive ROM. strength new proximol.tol poroscopulor fibers.. AROM PRE. submax. 6-12 weeks 12-16 weeks + 16 weeks weeks Stage of heeling InAommotory. During the last 3 to Some strengthening has already begun using 4 weeks of this pha e . During the firsl 2 to 3 weeks of gins around 3 weeks and continues for up to 12 this phase. active and reactive scapular stabiliza­ to 1 8 months. UE pottems. activities ice roller. Activities of daily liv­ happens sooner based on patient response.ly shoulder dysfunctions that have no significant PHASE 6: RETURN TO FUNCTION (16 Weeks +) soft tissue healing constraints. Often these pa­ tors ratio at 8 1 percent and 20 percent stronger tients present with pain. 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. This phase increased with resistance. and restore functional movement patterns. Nonprotective shoulder IIlJuries are primaJ. PHASE 5: M I N I MAL PROTECTION (12/016 Weeks) REEVALUATION RATIONALE See Table 1 3 . Patient was discharged at 1 8 for this case study for internal and external rota­ weeks with an extensive program of rotator cuff tion effected healing subscapularis tendon and strengthening and scapular stabilization exer­ enhanced dynamic GH joint stability. Isokinetic testing reveals externaVinternal rota­ and impingement syndromes. ball. previous phase of exercises. 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. Ex­ tivities and exercises. adhesive capsulitis. healing. 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. Low-level weights or theraband resistance postoperatively. lsokinetic testing of rotator cuff TREATMENT muscles infOlm the therapist of any deficits in particular internal External ratio's. Patient was in­ couples are established before distal force cou­ structed not to begin team play until 22 weeks ples. excessive scapula elevation free of abnormal patterns and pain. function. that may in­ Continued progression of weights and reps of dicate increased hazard for return to function.5-1 b. M A N U A L T H E R A P Y T E C H N I Q U E S 341 strengthening the rotator cuff throughout the TREATMENT full range of movement. tinue to provide sLress to the maturing scar. ual and PRE strengthening of lower trapezious In summary. REEVALUATION prolonged immobilization. stiffness. reestablish force cou­ Multiple repetitions in unresLricted ROM con­ ples. and level of function requ ired. Table 1 3. proximal stability and force and drill activities at 1 8 weeks. spe­ ing within normal limits. Chest pass throwing Currently reimbursement issues and managed against plyoLrampoline with 2. Through the progres­ Patient began progressive basketball shooting sions described.2 summarizes the various stages. Examples of non­ protective injuries include postacromioplasty. 1 for ROM measurements. 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. Manual therapy techniques used at spe­ cific stages of healing can enhance the strength RATIONALE and extensibility of scar. Man­ ual techniques during this phase are used to fur­ ther fine-tune function and clear any remaining restrictions. No pain with most ac­ cific trauma. protected shoulder injuries can and sen-atus anterior. ercises are more functionally based and maximal efforts are used. and limited than uninvolved side. cises. This case study will illustrate the con- . . SUMMARY OF I N I T I A L FINOINGS I N ITIAL PHASE See Table \ 3.y case slLldy 2: Summarizatiol1 or ROM measurements T IME INITI A L 2 WEE KS 4 WEEKS 6 WEEKS 10 WEEKS PROM Idegree. Lert L shoulder be­ Patient with nonprotective shoulder injury. 900 abel position NT NT 40 46 75 Internol rolotion. L scapula protracted. placing hand behind back. Patient began having pain ASSESSMENT and stirfness several months prior possibly due to overworking in her yard. PROM stretching to tolerance in dressing.or cervical spine matory modalities.-.(lIio.s.1 flexion 102 112 140 150 174 Abduction 70 80 120 150 170 External rotation. . grades I and 2 joint mobiliza- TABLE 13.-. secondary to muscle guarding or rotator curr and subscapularis muscles. TREATMENT Indirect techniques such as strain and Functionally. 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. Patient instructed in posi­ debending L or cervical spine were limited tioning comrort ror L shoulder and cervical by 50 percent and painrul actively and pas­ spine. I/ot tested.3 ror initial ROM measurements. ante. rib. infraspinatlls. downwardly rotated. L subscapula. and external and internal rotation. Poste­ protective injury.. RATIONALE and winging The initial phase or rehabilitation ror nonpro­ Tenderness and muscle spasm: Posterior lected injuries primarily rocuses on anti-inflam­ cervical spine C 1-2. Unable to fully assess capsular restrictions neck" 2 to 3 years ago. Joint mobiliza­ Upper quarter screening: Extension and si­ tion or grades I and 2. supraspinatus. Moderate difficulty with musculature. teres minor. patient is unable to reach over­ counterstrain used on cervical. and shoulder head. NT. 450 abd. 450 abet position 10 20 45 56 70 External rototion. sively with over pressure. neutral position -20 5 30 36 62 External rotation.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. fasten bra. position 52 54 52 53 71 Hyperextension 48 50 53 53 71 AROM (degree'l Scoption 70 90 112 132 155 Abbre". rior aspects or ribs 2-4 L. Past medical history: "stirr laris.ve inju. HISTORY and levator scapula A 46-year-old remale homemaker presents with Capsular testing revealed restricted motion lert shoulder pain and stirfness. flexion and ab­ washing opposite axilla duction with scapula stabilized.3 NO'lprOleCl. Patient was re­ in all dil'ections rerred 5 days postarthroscopic surgery and closed manipulation. 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. Patients often will perform pula using theraband and a I -lb weight ini tially habitual patterns of movement. 1 . patterns progressing from passive to resistive movements with emphasis on posterior depres­ INTERMEDIATE PHASE sion. maintaining cur­ for 1 0 minutes progressing to 20 minutes over a rent state of dysfunction. or cessation of predisposing activities is es­ (2000/s) isokinetics were initiated for internal sential. Clearing spinal and within subscapularis. Goals of rehabilitation during this phase and external rotation in the plane of the scapula are to reduce inOammation and pain. M A N UA L T H E R A P Y T E C H N I Q U E S 343 tion. Correction. niques used to mobilize fascial restrictions and avoid painful positions. modifica­ series of 4 to 5 treatment sessions. Still experienc­ The intermediate phase of rehabilitation begins ing pain with reaching and overhead activities. De­ sive progression of techniques.3 for ROM measurements. arthokinemalic movements of joint surfaces oc- FIGURE 1 3. REEVALUATION By the third treatment. patient repons decreased RATIONALE soreness of the L shoulder at rest. restore in the available ROM.1 . scapula muscle activity. High-speed tion. and education. Continued abnormal posi­ of shoulder movement and normalize force cou­ tion of L scapula. when patient reactivity allows for more aggres­ See Table 13. Continued PROM stretching. PNF scapular tional outcome. Patient staned on low-load pro­ to treat limited shoulder ROM have followed the longed stretch with heat in the plane of the sca. Emphasi is placed on restoring rotation at the GH joint and then TREATMENT on elevat ion. and leva­ rib dysfunctions that contribute or are source tor scapula. joint mobilization Traditional manual therapy techniques used as previous. Joint mobilization. se'Tatus anterior. Scapular release tech­ proximal stability spine. ples of scapula and GH joint. Goals of this creased pain and stiffness of cervical spine but phase are to maximize ROM of all components ROM still restricted. as illustrated in Figure 1 3 . If loading is continued storing rotation to the glenohumeral joint in into the plastic range. subscapularis. 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. then manual therapy should be aimed and rotational exercises in the plane of the sca­ at producing plastic defOl·mation. Mus­ lize depends on the implicated tissue. Only patients with of abduction. Howell monly restricted in shoulder dysfunction. brittle fashion. Therefore. limited subscapularis extensi­ mation does not exceed the elastic range. and and configuration. force However. the humeral is mation. tions such as adhesive capsulitis. 23 pula in our case study are an atlempt to reverse . the implicated tissue of restriction is the of myofilaments. If the amount of defor­ Functionally. capsular and ligamentous stmctures. passing the yield point.17 Soft ducting and intemally rotating the GH joint. The cent more sacromeres and demonstrated no rate of deformation is not dependent on speed of change in resislance to passive motion.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. 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. subscapularis The type and fTequency of force used to mobi­ may accommodate to a shorten position. It was demonstrated ure of the tissue will occur. 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. the bility may effect functional elevation. joint surface geometry may be a greater determi­ In prolonged immobilization and dysfunc­ nant of the arthrokinematics of the GH joint. Connective tissue structures such as found that muscles immobilized in a shortened ligaments. 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. report a movement of tensibility must also be addressed. 15 Forexample. decrease in mitochondria. ing i n a more yielding manner with plastic defor­ during elevation of the shoulder. Tabary et al. 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. 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. causing tissue tearing. ' 8-21 Viscoelasticity is a mechanical resistance to passive movement. ligament rather than thus shortening subscapulmis. the external force applied. The authors advocate the use of and decreased ability to generate tension. GH ligaments. ternal load and at a constant length. data are now available that challenge relaxation occurs. 28 structure can return to the original resting length have recently documented the importance of re­ after the load is removed. muscle ex­ Poppen and Walkeri. change in sacromere alignment anterior and inferior capsule. If the tissue is held under a constant ex­ sliding inferiorly as the bone moves superiorly. Sub­ et al. Clinically the the humeral head in a superior and inferior di­ authors have found subscapularis to be com­ rection during elevation of the shoulder. Taylor et al. strictions. 24 the concave-convex mle of arthrokinematic mo­ In addition to increasing extensibility of GH tion. 22 tion while that of subscapulmis is enhanced with If pel-manent increase in ROM is a goal of external rotation. In this case cles respond to immobilization by degeneration study. head an a concave glenoid surface occurs in the Gradually applied loads result in tissue respond­ opposite direction of the humems. tissue tension capsular. fail­ order to facilitate elevation. slidingofthe convex humeral i n a stiff. Rap­ ing mobilization technique by the convex concave idly applied forces will cause material to react mle. " Additionally. Otis et al. 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. 28 Low-load prolonged stretch treatment. tems in dysfunction or restriction. Continual TABLE t 3. a home tus anterior and levator by their fascial connec­ program is finalized to further facilitate physio­ tion. Patient of tissue or system response desired. creasing the extensibility of the fascia of these In summary. PNF scapular and UE pottems with PNF patterns. traction and downward rotation of the scapula with trigger points in the levator scapula. and pectoralis minor.n' ond scopulor education toping techniques . AAROM with T bars. scopular Fine-tuning of functional techniques joint mobs release techniques.4 RETURN TO FUNCTION PHASE summarizes the phases of rehabilitation. working ratation before elevation in POS. the se'Tatus anterior and levator scapula and training error cOITecUon is essential to pre­ work as a force couple to rotate the scapula.4 Summary o( phased rehabilitation (or nonprotective shoLilder injuries PHASES IN T I A I L INTERMEDIATE RETURN TO FUNCTION Signs and Pain at rest. loom rollers. 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. Further­ petitive and industdal athlete. In­ vent recurrence of dysfunction. Restrictions of subscapularis tend to also affect parascapular muscles secondary to the altered TREATMENT scapulohumeral rhythm. Iow·1oad prolonged stretch Other therapeutic Anti-inRammatory Heat with stretch. serra­ tus antedor. rehabilitation of nonprotective three muscles would allow proper functioning of injUlies depends on the implicated tissues or sys­ parascapular force couples during elevation. GH io. functional symptoms sleeping. 3/4 normal SB L and R. Swiss errors activity bolls.3 for I O-week ROM measurements.vical spine bility and strength of the subscapularis muscle.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. 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. In this to progress back to swimming and gardening ac­ particular case. STM. G H joint arthrokinematics may be strongly inOu­ REEVALUAT t O N enced by periarticular tissue extensibility and See Table 1 3.4 ioint mobs. isokinetic and isotonics Home program. limited rot. movement poin free. Excessive tone of pectoralis minor effectly logic changes such as increased sacromeres and depresses the scapula and restricts the scapular remodeling of periarticular tissues. difficulty No poin at rest. more. Table 1 3. fonn. technique. In the com­ rotation necessary for proper elevation. poin reactivity. Patient allowed a result of abnormal movement paLlerns. and elevation. (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 . Scapular release techniques and STM (de­ Patient instructed in exercise progressions for sc. poin with resistance. moderate ROM maximized. increasing the extensi­ without cervical pain but ROM ce. technique and training positioning and isometrics. the patient had excessive pro­ tivities to tolerance. Warwick and RAT t O N A L E Williams29 report a possible fusion of the sen·a­ Once ROM and strength are optimized. correct interventions modalities. neurologic dysfunc­ The biomechanical effect of joint mobiliza­ tion. ' ·3 Passive movement or the movement of the mobilizing hand by apply­ stress to the tissues can help to prevent theses ing an equal but opposite force or by supporting changes by maintaining tissue homeostasis. selection of a specific technique ceptors are unmylelinated nerve fibers that have will determine contraindications. mobilization to joints that are moving nor­ The neurophysiologic effect is based on the mally or that are hypermobile can create or in­ stimulation of peripheral mechanoreceptors and crease joint instabilities. bone weakness and destructive disease. lion. rarely have contraindications. The periarticular tissue and muscles sur­ The mobilization techniques are designed to re­ rounding the joint demonstrate significant store intimate joint mechanics. ' joint mobility and facilitate proper biomechanics I mproper techniques. disloca­ one method of enhancing the fTequency of dis­ tion. an increase in abnormally placed collagen The mobilization hand should be placed as cross-links (which may contribute to the inhibi­ close as possible to the joint surface. exact mechanisms of prevention are uncertain.3o Wyke postulates They are of small amplitude and controlled ve­ that this phenomenon is due to a direct release of locity. such as extreme force. Joint mobilization is tions for thrust techniques: arthrides. and ob­ CONTRAINOICATIONS jective measures assists the therapist in evaluat­ We can understand contraindications to Jomt ing treatment effectiveness. have substantiated a decrease in water and cation of the techniques. of involved structures. Several general changes after periods of immobilization. of peripheral mechanoreceptors blocks the trans­ These techniques are mainly used to block pain. The abuses of pas­ sive movement can be broken down into two Role of Mobil:ization categories: creation of excessive trauma to the tissues and causing undesired or abnormal mo­ The primary role ofjoint mobilization is to restore bility. 2 The or preventing movement at sUITounding joints. and excessive velocity. Excessive tension in the therapist's hands during . trauma of recent occur­ charge fTom the mechanoreceptors. and infectious disease. proposed rationales-neurophysiologic and bio­ may result in serious secondary i njury. In addi­ mechanical. mi nishing the intensity of many types of pain. In contrast.32 tion is focused on the direct tension of periarticu­ lar tissues to prevent complications resulting from immobilization and trauma. Akeson principles should be remembered during appli­ et al. inhibiting the onward flow of incoming the following conditions as major contraindica­ nociceptive afferent activity.346 P H Y S ICAL T H E R A P Y OF T H E S H O U L DE R reassessment of subjective. and the lion of collagen fiber gliding). manipulative techniques have inhibitory transmitters within the basal spinal many contraindications. mission of pain to the eNS. circulatOlY disturbances. Haldeman describes nucleus. the fibrous tissue lu­ bricant). the inhibition of nociceptors (pain fibers). and the loss of fiber forces applied should be directed at the periarti­ orientation within ligaments (which significantly cular tissues. as described receptors ]o. an increase in fatty fibrous infiltrates Hand Position (which may form adhesions as they mature into scar). thereby di­ rence. For example.3 I There is evidence that stimulation by Maitland. hypelmobility. Noci­ Ultimately. functional. The stabilization hand counteracts reduces their strength). glycosaminoglycans (GAG. The lack of PRINCIPLES OF JOINT MOBI LIZATION stress to connective tissue results in changes in TECHNIQUES normal joint mobility. a higher threshold of stimulation than mechano­ the very gentle gradc I oscillations. Joint mobilization has two poor direction of stress. mobilization by becoming aware of the common abuses of passive movement. of mobilization. or increasing fiber glide. 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. M A N U A L T H E R A P Y T E C H N I Q U E S 347 JOint mobilization can result in the patient demonstrate the elongation of tissue under var­ guarding against the mobilization.35 The results indicated that The direction of movement of mobilization low-load. with the involved extremity close to nique for obtaining permanent elongation of col­ the edge of the table. A high-load.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. Biomechanical effects will be appre­ ance by the patients. Certain move­ with the stretch has been found to be more effec­ ments stress specific parts of the capsule. long-duration stretch was more effec­ should take in account the mechanics of the joint tive in obtaining a permanent elongation of the mobilized. For example. The resistance represents the stretch with heat to facilitate plastic deformation direction of capsular or joint limitation. . The patient needs to be in surTounding tissue. 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 mechanical changes may a subacute stage of reactivity and the stretch is include breaking up of adhesions. The stretch is per­ the anterior recess of the capsule. 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. Figure 1 3. The extremity is abducted loading time. and the cur­ that the optimal method to obtain plastic defor­ rent reactivity of the tissues involved. Heat used in conjunction collagen. mation and reestablish ROM is static progressive The direction of forces to the joint is also de­ stretch (SPS).37•3• The patient's shoul­ ample.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 au­ ciated if forces are directed towards resist but to thors advocate the use of low-load prolonged patient tolerance.36 determined atic impairments of the dysfunction. the aI1hrokinematic and osteokinem­ tissue. The therapists hands and arms should be positioned to act as fulcrums and le­ vers to fine-tune mobilization. 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. Often the duration is deter­ pist is able to impart desire direction and force of mined by the change desired by the therapist. One to two 3D-minute sessions per termined based on the response desired. shon-duration treatment ( l OS g to 1 65 g for 5 minutes) and a low-load. realignment of to patient tolerance. with exceUent compli­ posite pain. Body Mechal1ics Duration of stretch can be from 20 to 30 minutes. For ex­ tive than stretch alone.34. Gherwhurneral Joint Techniqu£s FIGURE 1 3. The thera­ tion of oscillation. As previously noted.3: I N FERIOR GLIDE OF THE Duratiol1 (Illd Al1IplilLlde HUMERUS Several animal model studies have been per­ Patiem Positiol1 formed to determine the most effective tech­ Supine. long-duration treatment (5 g for 1 5 minutes) Direction of Movement were compared. A strap may be used to lagenous tissue. Move­ of shoulder capsular restrictions. Bonutti et al. movement if working from a position of stability. using different loads and stabilize the scapula. In humans. The studies used rat tendons to to the desired range. ied loads. allempting to stress the axillary FIGURE 1 3. sisting hand/arm can also impart distractive Cephalad hand web space is placed on superior force and change amount of rotation. Assisting lizing hand glides the head of the humerus hand supports the weight of the arm by holding inferiorly.348 P H Y S I C A L T HERAP Y O F T H E S H O U LDE R FIGURE 1 3.t. As­ Facing the lateral aspect of the upper arm. The mobi­ ghenohumeral i nferior to acromion.OI1 the distal upper arm superior to epicondyles and bracing patient's arm against therapist.3 .2 Therapist Pos. fiGURE 1 3. with arm slightly abducted and flexed into plane of the scapula and resting on fiGURE 1 3.5 the therapist's thigh.5: POSTERIOR GLIDE Of THE HUMERUS Patient Position Supine.4: LONGITUDINAL DISTRACTION-I NfERIOR GLIDE Of THE / HUMERUS Patielll Position I / Supine. . with the involved extremity as close as possible to the edge of the table. FIGURE 1 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. To increase the ef­ ficiency of the pull. A prolonged stretch is often eFFective with this technique. The outer mobilizing hand grips the epicondyles of the humerus and imparts a distractive force stressing the inferior capsule. Therapist Position Facing the joint. the therapist can weight shift and rotate the body slightly away from the pa­ tient. with inner hand up into the axilla pressing against scapulaghenoid.4 pouch or inferior portion of the glenohumeral capsule. with a wedge or rolled towel Paliel1l Position under lateral scapula. The level of flexion can be changed to work the most restl. The mo­ Prone. Assist­ ing hand stabilizes the scapula under patient. therapist should align his or her trunk along vector of mobilization. Therapisl Posil iOI1 Sitting on treatment table at 45° tum from FIGURE 1 3. force while the i n ner mobilizing hand glides . Therapist Posiliol1 Facing laterally. close to edge of table. The therapist should assess which vector of movement is most restricted by staJiing laterally with mobilization FIGURE 1 3.350 P H Y S I CA L T H E R A P Y OF T H E SHOULDER Therapisl POSilioll Opposite side of patient's shoulder. Mobiliz­ ing hand is same is i nvolved shoulder. FIGURE 1 3. A strap and the table stabilize the scapula. The outer hand applies slight distraction horizontal adducted to first tissue resistance. Mobilization movement is along 35° of glenOid tilt.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. with the in­ volved extremity flexed at the elbow and gleno­ humeral joint.cted part of the capsule. The extremity is abducted and flexed into the plane of the scapula. The head of the glenoid. To improve delivery of oscillation or stretch. The extremity rests on the thera­ pist's shoulder. Assisting hand supports distal extremity to facilitate relaxation. This tech­ nique is useful with subacute and chronic poste­ rior capsule tightness. towel roll is placed just medial to joint line under the coracoid process. Therapist cups patient's elbow in mobilizing hand and as­ sists mobilization with therapist sternum. both hands grasp the hume­ rus as close as pO sible to the joint.7: LATERAL DI STRACTION OF THE HUMERUS Paliel1l Posilion Supine. A wedge or shoulders with posterior capsule tightness. Mobilizing hand is placed on ante­ OF THE HUMERUS rior humeral head. with the involved extremity as close bilization is directed posterior along the plane of as possible to the edge of the table. This technique is useful for reactive the humerus must be off the table. FIGURE 1 3.6 and proceeding caudally.8: ANTERIOR GLIDE OF THE HEAD sagittal plane. The the therapist's knees. stressing Facing laterally in a silting position.7 Therapist Position the head of the humerus anteriorly. Grades I and 2 are mainly used with this tech­ nique to stimulate mechanoreceptor activity. 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.9: ANTERIOR/POSTERIOR GLIDE FIGURE 1 3. by the table. FIGURE 1 3. pillow. restricted. A towel roll. FIGURE 1 3. 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. with the the anterior capsule. The tendon of the subscap­ forearm of the involved extremity held between ularis is also stressed with this technique. with the involved extremity over the Supine with the involved extremity supported edge of the table abducted to the desired range. 1 0: ANTERIOR/POSTERIOR GLIDE OF THE HEAD OF THE HUMERUS OF THE HEAD OF THE H U M ERUS Patient Position Patient Position Prone. or wedge is placed A strap may be used to stabilize the scapula.8 . under the elbow to hold the arm in the POS. 10 . the heel ohhe ceph­ gentle up-and-down movement is applied. The arm is held in the plane of the scapula. through both hands. Force is applied lions. This alad mobilizing hand over the lateral aspect of technique is used with grades 1 and 2 oscilla­ the head of the humerus. The Facing laterally with caudal mobilizing hand fingertips hold the head of the humerus while a grasping the distal humerus.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 Therapist Position Therapist Positiol1 Facing laterally in a sitting posItion. FIGURE 13. Patient Position Supine with the involved extremity sup­ ported by the table. 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. The ported by the table. 1 2: EXTERNAL ROTATION! Therapist Position ABDUCTION/INFERIOR GLIDE OF THE Facing laterally with the caudal hand hold­ HUMERUS ing the distal humerus and the heel of the cepha­ Patient Position lad hand over the head of the humerus. 1 2 . The arm is abducted in the cephalad hand simultaneously pushes the head plane of the scapula. 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 . of the humerus into extemal rotation and slight FIGURE 1 3 . 1 1 FIGURE 1 3 . The cau­ dal hand abducts the arm and externally rotates Supine with the involved extremity sup­ the humerus while maintaining the POS. The right Supine at a diagonal to allow the involved thumb reinforces the dorsal aspect of the left acromioclavicular joint to be over the edge of the thumb. The patient's cel-vical spine sidebent to­ the most lateral edge of the clavicle. 1 4: INFERIOR/POSTERIOR GLIDE Therapisl Position OF THE STERNOCLAVICULAR JOINT Mobilizing force is perfol'med with both Pat.tioll the most medial aspect of the clavicle.st POS. Elevating the involved shoulder to a STERNOCLAVICULAR JOINT position of restriction and then performing mo­ bilization the SC joint may assist the rotational Palienl Position component of clavicle motion joint./. Mobilization is performed in a Acromiocla'lli. using thumb pad or pisiform contact on the most medial pOl1ion Sternocla:vwular and of the clavicle. Both thumbs mobilize the clavicle supe­ riorly. Graded oscillations are most successful table. 1 5: ANTERIOR GLIDE OF THE Therapist Position ACROMIOCLAVICULAR JOINT Facing cranially. Graded oscillations 30'. The volar sUiface left thumb pad is placed over the infelior surface of Patient Pos. FIGURE 1 3.el1l Position thumbs (dorsal surfaces together). 1 3 infelior glide. are mainly used with this technique. Therap. with this technique. . or a prolonged stretch.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 . Both thumbs ward and rotated away from involved side 20' to push the clavicle anteriorly. FIGURE 1 3. The force can be oscillated.cular Techniques inferior/posteriorflateral direction parallel to the FIGURE 1 3. 1 3: SUPERIOR GLIDE OF THE joint line. Supine with the involved extremity close to the edge of the table. The therapist Supine with the patient's head supported on places the distal tips of the thumbs posteriorly to a pillow.o/l thrusted. At the head of the patient. tendon. M A N U A L T H E R A P Y T E C H N I Q U E S 355 FIGURE 1 3 .oll the shoulder. ACROMIOCLAVICULAR JOINT elongation of collagen tissue. obtainjng a general stretch to the capsular structures of the acromioclavicular joint. 1 4 The force is applied simultaneously. over the spine of the scapula and the thenar em­ Adhesions within the fascia may reduce the mus­ inence to the right hand over the distal clavicle. muscle. Oscillations or a pro­ longed stretch are used with this technique. areas of tenderness and restricted Facing laterally with the heel of the left hand extensibility of connective tissue may develop. increase in GAGs.ws Soft tissue mobilization for purposes of this chapter will be as defined by Johnson: "STM is the treatment of soft tissue with consideration of layers and depth by initially evaluating and FIGURE 1 3 . trauma. cles' ability to broaden during contraction and ." · The goals of STM in the patient are similar to those of joint FIGURE 1 3. postsurgical conditions. 1 5 treating superficially proceeding to bony promi­ nence. Patient Positiol1 and facilitatation of lymphatic drainage . Soft Tissue MolJi1izatWn and Scapulotlwradc Release Techniql. 1 6: GAPPING OF THE mobilization: development of functional scar. ligament etc. Both hands push the bones in opposite directions. and abnormal movement patterns of Therapist Posit.'9 Silling close to the edge of the table In overuse syndromes. 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. and distracts the involved the shoulder as in Figure 1 3 . while the caudal hand (thenar side) . F I G U R E 1 3 .5 Treatment hand tecimiq"es compensations may occur. Assistive techniques are sus­ Cephalad hand simultaneously elevates. J9 wi/It penniss.oll. possibly leading to breakdown of compensating tissues. shoulder. 1 7B. along Ihe edge of Ihe muscle belly '" along bony conlou" Table 1 3. 1 7 SUBSCAPULARIS (Adapted (rom 1011"S0I1.356 P HY SI CAL T H ERAPY O F T H E SHOULDER FIGURE 1 3 . Parallel mobiliza­ Therapist Position tion or perpendicular strumming or direct oscil­ lation may be used.'9 Abnormal TABLE 1 3. mations of a muscle belly to improve muscle play and reduce tone FIGURE 1 3 .) Patiel1l Position Supine with the shoulder abducted to toler. I B: SUBSCAPULARIS ARC ance STRETCH Patient Position Therapist Position Supine Facing axilla with mobilizing fingers on muscle belly of subscapularis. 1 6 lengthen during passive elongation . 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. 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. ex­ taining pressure while elevating and adducting ternally rotates.5 defines the types of techniques re­ Perpendiculor (transverse) strumming: Repealed mylhmicol defor­ ferred to in the figure legends. Often pectoralis minor is bound down and tender in shoulder dys­ FIGURE 1 3.29 STM tech­ Therapist Position niques: sustained pressure. The thera­ pist can use the fingers of top hand to roll over Patient Positio/1 and palpate the superior fibers of the serratus Supine or sidclying with aim slightly ab­ anterior that attach to the 1 st and 2nd ribs as ducted and Oexed. direct oscillation. M A N U A L TH E R A P Y T E C H N IQ U E S 357 A FIGURE 1 3. STM techniques used: direct oscilla­ ANTERIOR -LOWER PORTION tion. 1 7 B stabilizes the lateral border o f the scapula. STM techniques used: parallel techniques . sustained pressure . Assistive techniques are Patient Position inhalation. well as the fascial attachments between levator scapularis and serratus anterior. contract relax with shoulder protrac­ Sidelying. FIGURE 1 3. arcing fashion. derneath pectoralis major. Caudal hand elevates the scapula in an cephalad FIGURE 1 3. tion. deep breath. As­ Mobilizing fingers glide along in a superfi­ sistive techniques: resistive PNF djagonal con­ cial vector along ribs 3 to 5 lateral to medial un­ tract relax. 1 9: PECTORALIS MINOR and anterior direction off the rib cage. 2 1 : SERRATUS function. rior. perpendicular and par­ allel deformations. Both Therapist Positiol1 movements occur simultaneously in a slight Standing posterior to patient's shoulder.20: SERRATUS Therapist Position ANTERIOR-UPPER PORTION Place mobilizing fingers along an interspace Patient Position of ribs 2 to 8 on interdjgitations of serratus ante­ Side\ying with involved side up. 358 PHYSICAL T H E R A P Y O F T H E S H O U L D E R FIGURE 1 3. 1 9 . I 8 FIGURE 1 3 . 22: INFERIOR CLAVICLE medial. 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. . ture or abdominal surge.20 FIGURE 1 3.).2 1 along rib contours medial to lateral or lateral to FIGURE 1 3. rotation of the thoracic pine to the same side. con­ Patient Position tract relax with scapular depression.. Restrictions Supine with involved extremity supported by may be evident with previous history of rib frac­ a pillow. Assistive techniques: deep breath. A pillow may be placed against the patient's achieved. Posterior to patient with therapist's hips in perpendicular orientation to patient's trunk. sible to the therapist. .23: SCAPULAR DISTRACTION Therapist's adjacent leg on the treatment table with knee bent and placed along midthoracic Patient Positim.22 Therapist Position FIGURE 1 3. Palpating medial to lateral or vice versa along inferior clav­ Patient Position icle.24: SCAPULAR DISTRACTION. the therapist leans back. 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. 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. distracting chest to provide anterior support. sub­ Sidelying as previous bUI closer to posterior clavius muscle. 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.360 P H Y S I C A L THERAPY OF THE S H O U L D E R FIGURE 1 3. look for fascial restrictions and tenderness especially at the costoclavicular ligament. POSTER I O R APPROACH Same side as involved shoulder. and the conoid and trapezoid lig­ edge of table. Sus­ tained stretch most effective with this technique. the scapula away from the thoracic wall. Therapist Positiol1 FIGURE 1 3. 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. Once hand placement is pist. spine. aments. 23 FIGURE 1 3.24 Therapist Positiol1 pula. . and inferior angle. points. The force is applied simultane­ spray and stretch to upper trapezious trigger ously. 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. Assistive tech­ The cephalad hand grasps the superior aspect niques include patient actively rotating cervical of the scapula while the caudal hand grasps the spine toward and away from involved side. producing an external rotation of the sca.26 demonstrates external rota­ tion of the scapula with soft tissue technique Facing the patient with the caudal hand using the therapist's elbow to mobilize upper under the extremity through the axillary area. Figure \ 3 . trapezious and levator scapula. 25 FIGURE 1 3.362 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 FIGURE 1 3. Prone with the involved extremity supported by the table. The forces are applied simultaneously. hand web space under the inferior angle of the PRONE scapula. 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 .26 FIGURE 1 3.27: SCAPULA DISTRACTION. Patient Position The outer hand lifts the G H joint while the adja­ cent hand lifts the inferior angle of the scapula. Woo SLY: Immobility ef­ the shoulder complex. FA Davis. J 980 The application of manual techniques for the 4. Ann Plast Surg 3:264. Frank C. and wound healing. Colorado Spl'ings. LillIe. The pathomechanics of stress on various tissues. Andriacchi T e t al: Ligament: InjlllY and repair.P. 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. American and John Zubal. 3rd Ed. J 1 . Boston. Arem Al. Peacock EE II': Wound Repair. 1 99 1 Ackrwwledgements t o. Friel I (cd): Dorland's Ill ustrated Medical Diction­ cussed from a perspective of protective versus al)'. Clinical lional). In Wolf011 FG (ed): Acute Hand References Injuries: A MulLispeciaJty Approach. Madden JW: Effects of stress on healing . pair of the Musculoskeletal Soft Tissues. Clin Or­ on wound healing. 1959 evaluation and continual reassessment. 49. 1 977 management o[ shoulder i njuries has been dis­ 7. Functional Or· rehabilitation have been presented. Akeson WH. effects of biomechanical fects on synovial joints. Butter· tions and contraindictions for mobilization are worth Publishers. Buckwalter J (eds): InjUJ)' and Re­ comply with current and future discoveries. Woo S el al: Physiology and 1 3 . Kellet J : Acute ST injuries. Madden JW: Hand surgel). McCoy BJ. Philadelphia. normal and abnor­ 2. and muscle function. Brown.T. Stoddard A: Manual of Osteopathic Technique. Med Sci SPOI'ts Exel'c 1 8 :5. Maitland GD: Pedpheral Manipulation. Cohen KI. Indica­ 5. Jones LH: Strain and Counterstrain. Philadelphia. 1 980 I . and traditional concepts and techniques should In Woo SLY. Johnson GS: Course notes. 1 974 nonprotective injuries. San Fran­ cisco. p. joint contracture. Kelly M . London.C. A. and phased programs of 8.27 stages of sort tissue healing. 1 9 8 1 the manual technique piclures. Mal'eh 1 99 1 the efficacy of manual therapy must be advanced 9 . J 970 based on an understanding of the histology of 6. Dicgclmann RF: An update therapeutic value of passive joint motion. Biorheology 1 7:95. WB Saun­ mal arthrokinematics and osteokinematics of ders. 25th Ed. 1 979 Ihop 1 85: 1 1 3 . R. Akeson WH.T. institute for Physical Art. 1 986 We would like to Ihank Jill Heinzmann. 1984 3. London.. Research on thopedic 1 . shoulder is dependent on a thorough sequential HUlchinson. Ameri· can Academy of Orthopaedic Surgeons. 1 2 . Amici D. Clayton L (cd): Taber's Cyclopedic Medical Dic­ immobilized and traumatized tissues. WB Saundel'S. 1984 1 4 . Philadelphia. a review o f the litera· ture. for their assistance with Academy of Osteopathy. 33. England. Louis. CT. Tardieu C et al: Physiologi. suppJ. CV Mosby. Walter PS: Normal and abnormal muscles with abduction and rotation. 1 98 8 Surg Engl 4 1 :25. WalTen CG. Philadelphia. Masock AJ . Wyke BD: The neurology of joints. Bauer E: Structure and mechanical tury-Crofts. Am J Sports 2 1 . p. Koblanski NJ: Elonga­ 6 : 1 26. Olaf Norris Bokhandel. Bone Joint Surg 58: 1 95 . MTP Press. Girgis FG: Sta­ extensibility. Taylor DC. Lehman IF. Appleton-Cen­ 20. J Bone Joint motion of the shoulder. 1 969 a review of some cun-cnt concepts. 1 976 cle due to immobili7. 1 9. 1 994 . I n Lancaster.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. Kummel BM: Spectrum of lesion of the antedor 1 980 capsulc mechanism of the shoulder. Betsch OF. Seaber AV et al: Viscoelas­ stretch tech-procedure: an evaluation using rat tic properties of musculotendon units: The biome­ tail tendon. Vidik A : O n t h e rheology and morphology of soft 3 1 . 1 994 1 976 29. Bonutti PM. 1 990 stretch to . 1 992 and regeneration of skeletal muscle i n cats. 1 972 R. Noyes FR et al: Biomecha­ Med 7: 1 1 1 . Wickicwicz TL et al: Changes in 1980 the movement alms of the rotator cuff and deltoid 1 6. Churchill Livi ngstone. Oslo. 1 985 pies and Practice of Chiropractic. J Bone Joint Surg 63: use of thermal agents to innuence the effective­ 1 208. Haldeman S: Modern Developments in the Pdnci­ Physical Therapy. Johnson GS: Soft tissue mobilization. Butler DL. 1 974 3 5 . COOpel' RR: Alterations during immobilization Sports Phys Ther 1 7:200. Reigger LL: Mechanical properties of bone. WB Saunders. Eag n J . J Surg cal and structural changes on the cat soleus mus­ Res 20:93. 28. I . Otis JC.ation at di fferent Icngths by 1 5. apy. Windau BS et al: Stalic progressive 1 8:300. 1973 mal mechanics of the glenohumeral joint in the 30. East Norwalk. Tabary JC. WalTen CG. Dalton 10. Hirsh G: Tensile properties during tendon heal­ ture. 1 98 1 Davis GJ. Hetherington T. 1 979 nics of ligament and tendons. 1 979 tion of rat tail tendon: effects of load and tempera­ 22. Warren C G . In Swer­ dlow M (ed): The Therapy of Pain. 1 994 chanical behavior of loe extenSOl' tendons uncleI' 37. Follis DG: A study of the me­ Ol�hop 303: 1 28. Arch Phys Med 46:369. Clin 24. Surg 76:667. Exer SPOl1 Sci Rev 34. Ol�hop 26. Koblanski applied stress. Biorheology 1 7:84. 1965 IN: Effects of therapeutic temperatures on tendon 25. Lentell G. J. Arch Phys Med Rehabil 52:465. Gould JA (eds): Orthopaedic a n d SPOI�S 32. 1 9 7 1 ing. Galinat BJ et al: NOImal and abnor­ 35th Blitish Ed. Lehman IF. 1 980 propel�ies of rat tail tendon. 1 53: I . Arch Phys Med Rehabil 5 1 :48 1 . Marshall n. Poppen NK. Howell SM. Lehman JF. 1 970 bilizing mechanisms preventing anledor d isloca­ 38. J Anat 1 05 : 1 84. Wooden MJ (cds): Ol�hopaedic Physical Ther­ 27. Wanvick R. J Bone 39. 1 972 Joints. Kaltenbom FM: Mobilization of the Extremity plaster casts. 1 7 . Turkel SJ. Tabary C. 1 966 1 8. Panio MW. Jiang CC. Arch Phys Med Rehabil 57: 1 22. 1 98 1 ness or a low load prolonged stretch. Am J Sports Med 36. Wyke BD: Neurological aspects of pain therapy: collagenous tissue. Grood ES. Ann R Coli hOlizontal plane.-eestablish elbow range of motion. Williams P (eds): Gray's Anatomy. Van Brockl in JD. J Bone Joint Surg 70:227. Koblanski N J : Heat and 23. J Physiol 224:23 1 . Morgan M: The tion of glenohumeral joint. 1 976 chanical effects of stretching. Sl. In Donatelli Joint Surg 54:9 1 9. Norway. New York. Acta Orthop Scand. (2) maximal strengthening regime." Muscle endurance has been described as performing work using mod­ erate to heavy loads over a period of time. and metabolic early mobilization and strengthening are gaining capacity.' Strength training can positively effect phosphokinase (CP). strengthening often becomes the main placed upon joints throughout the body. and maximum strength largely com­ cle. ducing the potential for injury both with work­ strength training principles. creatinine mance. mass.' 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.' tdbute to muscle endurance. and exercise pre­ related and athletic activities. strength level .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."" Factors that of treatment. mus­ activity.' Concentrations of 365 . (3) neural adaptations. This chapter will provide some conu. possibly increasing performance and re­ The present chapter defines strength.. prise anaerobic capacity. however. increases Strength is important in both health and perfor­ in adenosine triphosphate (ATP). As the effects of prolonged Strength training i ncreases skeletal muscle immobilization are becoming more apparent.ly on anaero­ patient is as important as any other component bic metabolism until exhaustion. Cardiovascular factors may con­ and is often used as a measure of ability.3 scription. myokinase the entire musculoskeletal system as bone. Incorporating strengthening exercises ity to maintain a given fixed submaximal force and exercise prescription appropriately to each output during work relying prima. glycogen stores. and (4) muscle hypertrophy. 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. Muscles essential to shoulder mobility and stability are discussed along with specific strengthening exercises for the shoulder. These cases apply strengthening principles to the rehabilitation "Absolute muscular endurance (AME) i the abil­ plans. force-generating capability.bute to AM E or anaerobic capacity include guidelines to follow when designing your own (1) biochemical adaptations.' focus of treatment. Strength training also increases nexi­ in popularity. The case studies present treatment programs Muscular Endurance for two shoulder patients. bility. and associated connective tissue adapt ac. 366 PHYSI C AL THER APY OF THE SH OULDER ATP-CP and glycogen in skeletal muscle are im­ Strm1{/th Training portant in maintaining high-intensity work loads and work rates.• Neural factors include motor unit activity. neural. 6 Cre­ blunted possibly secondaty to the transforma­ atinine phosphokinase and myosin kinase are re­ tion of fast twitch to slow twitch muscle fi­ quired for anaerobic metabolism. and modulation of the fTequency of motor unit firing.­ cruitment of motor units. mak­ ral adaptations are thought to mediate the initial ing movements raster.1 2 . 10 Muscle Piher Types Strength training improves the strength of each motor unit. more motor unit reserves muscle fibers. the ability to rapidly change the di­ nisms contributing to this initial increase in rection of the body. (2) better co-contrac­ increases in the strength of the legs accompanies tion of synergists. training. When fTom nonoxidative metabolism. I contraction7 The moment arm identified and An i ncrease in power allows the athlete to per­ the force generated by the muscle comprise the form at higher work rates. "force equals training is an increase in the cross-sectional area mass times acceleration. anaerobically.s Type 1 fibers are able to maintain are available for continuation of work. I I lism. a major contributor to muscle strength. how­ Strength-speed training and speed training in­ ever. deriving their energy by oxidative metabo­ ability of strength-power athletes to perform. Type II fibers produce more Andersen and Kearney" demonstrate that a so­ force than type I fibers. which a skill is performed can be expressed in The most consistent finding after resistance terms of Newton's second law." The velocity of a move­ of the muscle. and mechanical factors7 . neu­ strengthening of the appropriate muscles. aerobically.. During the first few weeks. Muscular factors Power and A[!ility include the cross-sectional area of a muscle and the length-tension relationship at the time of Power is the rate at which work is performed. At very short and very long power would enable an athlete or patient to work lengths. deriving their energy called repetItion continuum exists. The actual muscle fiber size increase is secondary to the addition of myofiblil proteins to the muscle fibers. Studies have shown that significant motor neuron excitability.· Observations of increased ATP­ CP and glycogen stores have been found after Strength training results in the interaction of strength training. Increasing maximum mechanical factors. muscle contractions for extended periods of Pure aerobic training will likely reduce the time. Several of the mecha­ Agility. and (4) an increase inhibition General performance may be increased by in­ of antagonists'O Muscle fiber size does not creasing maximal strength through resistive change until approximately 8 to 1 2 weeks of training. muscle generates low tension'" There is at a smaller percentage of maximum and there­ an optimal length at which a muscle is able to fore endure longer work periods.! tive mechanisms. 1.' strength improvements. strength and endurance training al'" performed Adenosine l1-iphosphate is required for energy to in excess.lo Lncreased cross-sectional area is ment may be enhanced by increasing the force. (3) inhibition of neural protec­ increases in power and velocity or movemenl. maximal strength performance can be create and maintain muscle contraclions. muscular. 10 are slow or type I muscle fibers and fast or type Il After strength training. initial gains in muscle strength are not due crease the speed of movement by general to this increase. The speed at generate the most tension.ll. is strongly related to strength force production include (I) an increase in and power. bers. and thus fewer motor units are The two basic fiber types found in human muscle required at a given submaximal workload.. are appropriate to training. Recommendations for frequency juries were wound healing is present.. Plyometrics INT Plyometrics are high-intensity training bridging Intensity or volume is den pendent on the num­ the gap between speed and strength. periodization and maintenance Chapter 16. allowing pain-free is recommended that a training schedule with strengthening with possible strength improve­ alternating days of heavy lifti ng and plyometric ments in the affected range. however.'7 Adequate recovery time must be allowed isometrics and dynamic training. power. there­ type of training.'4 Isometric training is not effective ity. prior to the produce strength gains specific to the joint angle active concentric or push-off phase of the activ­ performed. Maximal eccentric contractions tion. intensity. amortization. Eccentric training requires longer recovery periods and alone has not been shown Exercise Presr:riptiun to be superior to concentric training. ration of workout. It overflow with isometrics. and specificity. would provide because plyomet. be­ and overall function. isometric and multiangle covery is suggested depending on the SPOil and isometrics are advantageous with protective in­ time of year. contraction is a muscular ing in a grealer concentric contraction. velocity.'7 Plyome­ ber of sets and repetitions. frequency. 1 7 The ec­ contraction where there is no change in the angle centric. and the amount of weight or . and concentric phases of the involved joint(s) and little or no change in comprise a plyometric exercise. The shorter and quicker the amortization throughout the range of motion unless many joint phase. result­ isomeldc. 17 angles are trained.' WaI-m-up. Drills should progress from basic to ad­ ties that require dynamic strength is not vanced with intensity progressing from low to recommended. or static. and isokinetics. and use when a predetermined amount of work is specificity will be discussed in the following sec­ to be performed. Two to four days of re­ In rehabi litation." Isokinetics are discussed in detail in rest periods. adequate strength is a prerequi­ fore. multijoint movements. rest between sets. or stretch-shortening cycle. concentric contraction." Iso­ training may vary. training with isometrics ror sports or activi­ site. is clude isometrics. Amortization the length of the contracting muscle. duration. traction where a constant load is moved through The types of contractions used in strength a range of motion of the involved joint(s). must also be incorporated into a complete exer­ cise prescription. the principles of tonics include conccntric (shortening) and ec­ strength training must be considered for all pro­ centric (lengthening) muscle contractions. duration.cs incorporate maximal-erfort the benefits of both types of strengthening. isotonics. S T R ENGTHENING EXER CI SES 367 eccentric contraction. Iso­ grams to improve strength. tonics mimic many functional activities and. The The three basic methods used in strengthening in­ stretch reflex. 15 training be constructed to provide sufficient re­ An isotonic contraction is a muscular con­ covery periods. An evoked by the rapid eccentric contraction. traction through a range of motion at a constant frequency. endurance. the more power will be developed. including high. Combination training. with 1 5 to an approximate 20' physiologic strengthening 20 minutes per session depending on the sport. There is range from one to three days per week. Isometric and dynamic mea­ Because plyometrics are a high-intensity sures of strength are not strongly related. of a mass is followed by a Exercise Types rapid acceleration. " Isometrics occurs following the eccentric phase. 1 6 An isokinetic contraction i s a muscular con­ The basic principles of training include intcnsity. produce higher tension levels than concentric conlraclions. The principles of strength cause the resistance is preset. du­ trics are exercises in which a rapid deceleration. 368 PHYSICAL THERAPY OF THE SH O U LDER load used.'o Athletes recover faster of 1 0 repetitions are performed until a weight . This over a given number of repetitions before fatigu­ will vary according to the muscle groups trained ing is a repetition maximum. 20 joint exercises.' . '9 The spe­ less energy. from Single-joint exercises than from multiple­ only al Iowing 1 0 repeltltons IS performed . demands imposed upon it. however. usually 80 percent.20 Weight based on and dictate the intensity. '4 Thus. prepubescent athletes. more weight is added and additional sets 1 0 percent per week. ery. Specificity of trammg is the most important Six or fewer repetitions. 19 Novice trainees can in­ terns for the shoulder prior to perfOimance of crease strength with a load of 35 percent of iso­ single-plane internal-external rotation exercises metric J RM and 45 percent of J RM in circuit of the shoulder. and the desired outcome. that the body will gradually adapt to the specific The intensity of training is categorized as high. eccentric loading causes dard chart to derive 1 RM. one exercise performed consecutively without and frequency or days per week. the demands moderate or low with corresponding RMs of 90 • must be specific to the desired goals and con­ percent. whereas upper body training may be per­ using a predicted RM to determine a load to be formed more often withoul overtraining. Also. After a 2. 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. . training. 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.to 4-minute rest 50 to 60 percent of preinjury status and increase period. The maximal load lifted training 3 days per week is recommended. rest is known as a set. the desired ing should be less to avoid injury and over­ percentage. with weight based principle in strength training. repetitions. and dura­ 6 RM to 1 2 RM provides moderate gains. monly used with athletes. . Determining the first few weeks of training. provide the most goals will determine the specificity of training strength and power benefits. It is recommended that athletes re­ To determine 1 0 RM the patient performs 1 0 rep­ covering from injury should resume training at etitions with a weight. the frequency a 1 0 RM. and the frequency of train­ method.' Generally." The completion of periments varying sels. Dudng used is more appropriate and safe. when both exercises are to be training.U P populations. frequency. may be obtained." Paulello describes repetitions (reps) FREQUENCY AND DURATI O N as "the number of times an exercise is done with­ Recommendations on training are based on ex­ out resting during one set.2o I n rehabilitation. 70 to 90 percent and below 70 percent. and during the other training days work­ outs are performed at 50 to 90 percent of 1 RM. multiple-joint I t is known that high-intensity load training exercises requiring more energy should be per­ or high volume (sets and reps) will result in mus­ formed plior to single-joint exercises requiring cular adaptations and strength gains. Lower body and larger Determining 1 RM may be feasible when the muscle groups will require more time for recov­ athlete is healthy. well as reduce the . Once 1 RM is established. exercises. The rehabilitation on a low RM (I to 5 RM). An example of this principle includes cific amount of resistance required for these performance of multiplane PNF diagonal pat­ strength gains varies. 20 stantly change for continual adaptations and re­ Moderate workloads and moderate volumes of sultant increases in strength. is a more feasible more muscle damage. SP depending upon the goals of training. and then calculating or using a stan­ should be less. The I RM is tested weekly. work are suggested for athletes retraining after injury. Eighty percent of I RM is more com­ performed during the same workout. I n a clinical selling. abbreviated RM. and hypertensive WARM.-isk of injury from training. periodization is geared for peaking on a given day. longer rest periods ( 3 to 5 min­ Stone and O'Bryant I recommend using three utes) are used between heavy. Mesocycles begin with high-volume. and progress to low-volume. low-inten­ sity training. and endurance levels to prevent reinjury. nance programs that comprise three sets of 8 to PERIOOIZA ION T The periodization system is used to prevent over­ training while optimizing peak performance.1 Elevation in the plane of the scapula riodization principles.2 i Two or more meso­ cycles can occur in a macrocycie.'9 Brief rest periods of 30 to 60 seconds for major exercises. They should be designed with the endurance levels but not producing an overload strengthening goals in mind. We believe rehabilitation goals and discharge main­ tenance plans can also be designed using the pe­ FIGURE 14. A macrocycie in peliodization refers to the overall training period. warm-up also allows for the observation of the power. power. It is our experience that specific developed to maintain reasonable strength. Periodization in­ volves not only in-season but also off-season and preseason. and or and loads. or football where all the games are important. The 13 type of transition period. periodization is geared for peaking for an entire season. Rehabilitation maintenance programs are simi­ lar to in-season programs used in atheletics where competitive seasons are of considerable REST PERIO DS length. near-maximal rep­ sets of 2 to 3 reps with moderate to heavy weight etitions. These mesocycles comprise the distinct periods of preseason. proper technique for the exercise performed. consisting of weeks to months in length. We have found success in mainte­ exercises. more exercises. with internal rotation. length. high­ intensity training just prior to competition. such as basketball. and off-season or transition peliods. and moderate loads (8 RM to 12 RM).2i Peliodization is a systematized and organized method of [raining to "peak" at the right time. absolute strength. The volume and intensity must be suffi­ Rest periods are dependent upon the volumes cient enough to maintain strength. in­ season. . Specific warm-up includes light to moderate sets performed for Maintenance programs i n rehabilitation must be each exercise. and number of mesocycles are sport or activity dependent. With event sports. Variation in training is important in break­ ing up the monotony that occurs when the body adapts to imposed demands. and 3 to 5 reps with resistive are used with higher volumes of exercise. When training for when combined with work or sport activities. With team sports. S T R E N G T H E N ING EX ER C I S ES 369 General warm-up should include stretching of M AIN TEN ANCE all muscles crossing all joints. baseball. Overload and change in stimulus are required to optimize training. These exercises were Saha. and full in­ fossa. reporting the . 1 4.117 extenw! rOlatio1l. 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.2. (3) prone major. Jobe and Moynes2• also support Dynamic glenohumeral stability is provided that the rotator cuff muscles should be evaluated by the rotaLOr cuff. 1 4. The fraspinatus. I. and sternal head of the The supraspinatus has been identified as the pectoralis major are collectively the third group. 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. 1 4 . in­ horizontal abduction with the arm externally ro­ clude the supraspinatus. 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.24 The sheer forces across scribed by Jobe and Moynes2• and analyzed the joint from the deltoids' upward pull are bal. and in­ tated ( Fig. The rotator cuff muscles are and strengthened individually.27 duplicated this test position de­ scribed by Inman et al. 1 ) (2) Oexion.2 Prolle horizontal abdLlctiol1 at 100°\\1. teres major and minor. subscapularis." The first group. cuff group. 30' of ho. Townsend et al. This group majntains the humeral plane of the scapula is fun her defined in Chapter head in the glenoid.ng ele­ with moderate weights. and (4) press-up (Fig. 10 repetitions pel-formed 2 or 3 days per week anced by the [iring of the rotator cuff dUl.>' The importance of force coupling be­ ternal rotation in the upright position. include ( I ) elevation in the plane of the scapula with in­ the deltoid and clavicular head of the pectoralis ternal rotation (Fig. vation. most frequently injured muscle of the rotator the depressors.2).3). Finally. Black­ tween the rotator cuff and the deltoid is best de­ burn et al. The second group. vm·iolls other exercise positions.-izontal Oexion. steering muscles. prime movers.25 performed an electromyo­ graphic (EMG) analysis of the glenohumeral muscles.370 PHYSIC A L T H E R APY OF THE SH O U L D E R FIGURE 14. the latissimus dorsi. increased stability is greatest during the middle Won-ell et al. 1 ). The roles of these muscles and exercises are further dis­ cussed in detail in Chapter 2. inrTaspinallis and teres minor were maximized Tension in the long head of the biceps increased wit h (prone) external rotation with 90· of abduc­ torsional rigidity to external rotation.3 Press-lip.6). as a compressor of the humeral head. The EMG activities of the . we suggest that the patient remain pain fTee cific to the shoulder and consequent improve­ while perfolming this or any exercise in the ments in f"lll1ction. Many force couples exist around the shoulder complex. 14.rer serratus anterior.32 Rodosky et al...7). lower tra­ pezius. assisting the rotator cuff. rhomboids.29 These muscles include the upper trapezius.o. the rotator cuff and biceps brachii depress greatest supraspinatus EMG activity in the prone the humeral head. EMG activity during the two previously de­ scribed test positions for the supraspinatus. strated strength gains and improvement in . Dy­ namic balance and coordination are provided at the scapulothoracic joint. 1 4. redUCing shear forces from position with the humerus horizontally ab­ the deltoidJI.33 demon­ prone position. These ex­ ercises include (I) elevation in the plane of the scapula with internal rotation (Fig. upper trapezius.'9 examined and identified four exercises that best strengthen the scapular rotators. 1 4. re­ vealing the prone position superior to standing for EMG activity. This at the elbow joint (Fig.3o Moseley et al. These muscle act synchronously on the scapula to upwardly rotate and position the glenoid dur­ ing full elevation of the humerus. 1 4. and pectoralis minor. S T RENG THENING E X ERCIS E S 371 The scapular rotator muscles are essential to glenohumeral mobility and stability. How­ Few studies exist involving strength training spe­ ever. The prone position is advo­ Does Strength Equal FUnction? cated in strengthening the supraspinatus to pro­ mote more supraspinatus muscle activity.33-35 Wooden et al. and lower trapezius at the scapulothoracic joint. 1 4.2)." As the scapula upwardly ro­ tates. middle and lov.4).5) (3) push-up with a plus (Fig.'2 investigated the ducted I DO· and externally rotated to thumb-up effects of tension on the long head of the biceps position (Fig. The anatomic align­ ment of the biceps brachii allows it to function. Strengthening o f th e biceps brachii i s an im­ portant component of the shoulder rehabilita­ tion program (Fig.'· compared the supraspinatus ranges of elevation. increasing tion at the glenohumeral joint and 90· of Ilexion anterior stability of the glenohumeral joint. 1 4.3).�th the arm abducted and externally rotated. 1 4. levator scapulae. FIGURE 14. and (4) press-up (Fig. most impor­ tantly the serratus anterior. (2) rowing (Fig. The scapular rotator muscles stabilize the gle­ noid fossa as the humeral head al"liculates. " compared the effects of resislance and endurance training illustrate the concentric isokinetic versus eccentric isokinetic effects on performance. compared isokinetic in muscular strength during the first few weeks training of the shoulder internal and external ro­ are secondary to neural adaptations. Mont et al. Improvements in eccentric strength and serve velocity were only found with the concentric training group. not using a controlled group weakened the results of Summary this study. Increases tators using concentrically trained. strength and power and must be recruited dur­ All three studies illustrate sport-specific ing training to be hypertrophied. Initial gains serve velocity. Isotonic con­ funcUonal improvements through strength centdc exercises were used on an isokinetic de­ training.372 PHYSIC A L THERAPY OF THE SH O U LD E R FIGURE 14. verticle jump. eccentrically in cross-sectional area of muscle contdbute to trained. Training with .4 Prolle extemal rotatiol1 with 90·of abductiol1 at the shoulder and 90·offlexiol1 at the elbow.mction training baseball pitchers. Several other studies have shown in­ vice. Slatistically signifi­ strength gains after the first few weeks of train­ cant concentric and eccentric gains were ob­ ing. Extensive reviews of the physiologic effects of Ellenbecker et al. weeks of training. Concentric strength was just a few of the va.ables increased with resis­ significantly improved in both groups after 6 tance and endurance training. 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. The plimary cellular effects of strength tained with both training groups when com­ training occur in the fast. netically and functional outcomes using tennis muscular. however. Ellenbecker's examining strength training isold­ Strength is a result of the interaction of neural.. type II. f. pared to the control. exercise on rotator cuff strength and power and endurance.36-39 Muscle strength. The increase in serve The type II fibers are responsible for muscle velocity was greater than I I percent. muscle fibers. and sprint speed are on tennis serve velocity. I increase in external rotator torque. and control groups. Mont et al.37 performed a study similar to Strength is a measure of human performance. and mechanical factors. eral rhythm.5 (A) Sealed rowing." work together to provide adequate stability and Proprioceptive exercises and eventually plyo- . and tion of the humeral head. rotators of the scapula. (B) One-anu ro\. Ade­ tator muscle weakness allows excessive scapular quate muscle strength and endurance at the movement. Abnormal humeral head transla­ quate physiologic and accessory motion. STREN GTH E NI N G EXERCISES 373 A FIGURE 14. 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. and the deltoid. or altered scapulohum­ thus normal scapulohumeral rhythm. This is achieved by synchronous activ­ stimulus.vil'1g. long head of the biceps. B low or moderate weight will not provide this mobility. can contribute to initation of The muscles at the shoulder complex must adjacent tissues and shoulder pathology. cally designed to meet the rehabilitation goals. contdbuting to poor scapulohum­ shoulder complex is necessary to maintain ade­ eral rhythm. Strength training must also be specifi­ ity of the rotator cuff.'9 Scapular ro­ an overall increase in muscular endurance." 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. lar control. Criteria for reduction in IMPINGEMENT SYNDROME pain and improvement in ROM and strength must be met before the patient is progressed. some mobility and muscular strength and endurance form of f�mctional training must be incorporated to the shoulder complex and educate the patient prior to the return to work or sport. This patient repOJ1s his job tasks require overhead athlete.374 PHYSICAL THERAPY OF THE SHO U L D ER FIGURE 14. demonstrates the need for working on airplanes from supine. to complete a rehabilitation program. and . involving an chanic. FIGURE 14. The first case illustrates a work injury HISTORY that demonstrates the importance of strength at the shoulder joint in providing stability to avoid This case presents a 45-year-old airplane me­ impingement.7 Biceps curls. strengthening to provide dynamic stability to metrics must be applied to enhance neuromuscu­ avoid instability and overuse. The second case. Progression of the strengthening program must be sequential while working to CASE STUDY 1: meet the patient's goals. in a maintenance program specific to his job­ related tasks. All types of strengthening must coin­ cide with the stage of rehabilitation appropriate for that patient. The next two cases discuss two common pa­ tient types. Fi­ The focus of this case was to restore soft tissue nally. kneeling.6 Push-up with a plus. Gross pos­ respond to overactivity of these muscles com­ tural changes including an increased thoracic pensating for the reduced scapular motion. levator scapulae. 20. however. Overall passive scapular mobility was limited per week during the first 1 2 weeks of physical in rotation and distraction from the lib cage. because INITIAL EVALUATION maximum shearing forces of the deltoid occur Radiographic findings did not reveal an abnor­ at this phase. rhom­ longed stretch are thought to cause plastic defor­ boids. and extel11al glenohumeral rotators. Im­ mation in connective tissues. mild bone spur­ in which this patient performs the majority of ring was present on the underlying surface of the his work-related tasks. niques to reduce trigger points followed by Neurologic testing was normal. 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. therapy." acic movement. and rotated humerus All of this patient's findings are contributors were apparent. weakness. This middle range is also the range mal shaped acromion. 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. upper trapezius.to 3-pound weights were progres­ the prone test position for the supraspinatus. 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. there is an i ncrease in scapulothor­ ment syndrome. Active elevation of the humerus to a reduced suprahumeral space leading to im­ in the plane of the scapula was approximately pingement. Visual inspection revealed gross atro­ points i n the muscle and shoulder complex cor­ phy of the right shoulder complex.43 kyphosis.42 Adequate glenohumeral and scapular rotator strength is critical. The patient was not able to assume plane and 1. Palpation re­ glenohumeral and scapular mobilizations were vealed trigger points within the subscapularis. This patient was seen three times ity. 80· and limited by pain. pectoralis major. During this middle phase of elevation to physical therapy with a diagnosis of "impinge­ (60· to 1 40·). He has strate limits in mobility of the subscapularis and been performing these job duties for 1 5 years. 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. Active stretching of the antagonistic mus­ cles. STRENGTHENING EXERCISES 375 standing positions. forward head. serratus moist heat in conjunction with a low load pro­ anterior. Janda45 . and praspinatus testing standing revealed pain and 30 minutes in consecutive treatment sessions. Initial treatments focused on restoring Isokinetic assessment of the rotator cuff was soft tissue mobility. The hu­ vealed 4/5 intel11al rotator and 3/5 extel11al rota­ merus was positioned 30· anterior to the frontal tor strength. middle and lower trapezius. however. and pectoralis major muscles. He has been referred findings.8). 1 4. then performed.44 Soft tissue tech­ pingement testing was positive (see Chapter 3). Strength assessments revealed 3 + 15 Elevating tissue temperatures with superficial muscle grades for the scapular rotators. 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.4I Limits in the scapuloth­ He reports intermillent shoulder pain during the oracic articulations were also identified. gross manual muscle tests re­ was applied to the shoulder (Fig. Heat in conjunction with a deferred at this point due to limited ROM for low load prolonged stretch into external rotation rotation. with most activities requir­ joint. Su­ sively added to patient tolerance for 1 0. The presence of trigger AC joint. The lateral border of the scapula protracted excessively during active TREATMENT PLAN AND RATIONALE elevation. Limits in passive range of motion demon­ ing reaching in front and/or overhead.40. capsular structures. 9). 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. 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. and to reduce delayed-onset muscle the arm internally rotated (Fig.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. session concluded with ice to the shoulder for 1 0 Isotonic strengthening exercises included minutes. 1 4.inetic testing of the glenohumeral rota­ daily tasks were limited to 90· of elevation during tors was performed in the plane of the scapula. Biceps curls (Fig. this patient was seen three times per week.46 2.3) During the following 3 weeks of physical ther­ 4. inOammatory responses secondary to stretching. 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. this phase. Prone extension with internal rotation (Fig. Press-up (Fig. implicating impingement of subacro­ assessed. mial tissues. stresses the importance of stretching the antago­ 6. 1 0) After two visits. Elevation in the plane of the scapula with treatment.8 Moisl heal wilh a low load prolollged wilh 2 Ib weighI slreleh into extenwl rotQtim1. 5. 1 4. Scapulothoracic rhythm was cises. Active weight. During the next visit. Three sets of 1 0 repetitions was preceded improved.5a) apy. 1 0 repetitions (Fig. nists prior to strengthening the agonists.1 I) Each physical therapy repeated five times. All strengthening movements and Isok.376 PHYSICAL T HERA P Y OF THE SHOULDER FtGURE t4. Seated rowing (Fig. a painful arc was form the exercise through pain-free ROM was present. 1 4. and excessive protrusion of the sca­ by a specific warm-up of the exercise without pula with active movements was reduced. Test results indicated a 45 percent deficit of the A 5. lee was applied t o prevent any adverse the following. isokinelic ing and strengthening exercises (Fig. 1 4. 1 4. 1 ) soreness. At this time the patient's ability to per­ elevation was full. 1 4. 1 4. however. to maintain the plastic deformation gained with I.7) Heat with stretch and soft tissue manipulation . FIGURE 14. manual muscle testing re­ 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). S T RENG THENING EXERCI S E S 377 FIGURE 14.10 Prone extension with inlernal vealed 4/5 strength of the scapular rotators. continued prior to strengthening until active and passive mobility testing was within normal lim­ its (at the end of week 3). Isotonic and isokinetic strengthening were continued.9 Upper body ergometer. Iso­ rotation. progressing to six sets of 1 0 repetitions by the fourth week of treatment. A set of 1 0 repe­ titions was added to the isokinetic strengthening weekly. kinetic reassessment demonstrated a 1 5 percent . FINAL PHASE ( W E E K 6) Prior to discharge. A new I RM was established at the beginning of each week with the load increasing accordingly. 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. Apprehension and in internal rotator strength. 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. independently perform lower body pared to the uninvolved side. evident by the tendonitis.2) The treatment. upper. The peak torque of the external rotators was 50 percent of the internal rotators." lar tightness are also predisposing andlor precip­ itating factors. head. 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. The patient scapular rotators (serratus anterior. to constant. She presented with and conditioning workouts. 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. when com­ however. Isokinetic testing of the glenohumeral rota­ CASE STUDY 2: ROTATOR CUFF tors was performed in the plane of the scapula. Manual the isotonic strengthening exercises performed muscle testing demonstrated pain and weakness during therapy. A continued program of three sets of strength. uninvolved side. AND BICIPITAL TENDONITIS Test results i ndicated peak torque. and infra­ ternal rotation exercises replacing the isokinet­ spinatus/teres minor (315 muscle grades). tennis player with a complaint of chronic right shoulder pain. for the internal rotators when compared to the and return this athlete to competitive sports. The ics for the glenohumeral rotators. Visual in­ I NITIAL PHASE (WEEK I ) spection revealed moderate right scapular eleva­ tion. 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. ited by 30' in the adducted position. protraction. Her prior history for this shoulder INTERPRETATION OF FINDINGS includes similar painful episodes. She did. INITIAL EVALUATION TREATMENT PLAN AND RATIONALE Radiographic Findings were normal. subscapularis. and was significantly aggravated by most activities using the right arm over 90' of elevation. to discharge. and lower trapezius. Her CUITent medical diagnosis is "ro­ scapular rotator weakness and posterior capsu­ tator cuff and bicipital tendonitis. Posteriorly. during the past 3 years. usually occur­ ring mid to late season. She was seen for ^1 . mid­ was instructed to perform three sets of 1 0 repe­ dle. External rotation was lim­ during the initial phase of treatment.378 PHY SICA L THERAPY OF THE SH O U LD ER external rotator deficit and a 1 0 percent increase pos i tive impingement sign. but fatigued quickly with repetitive 1 0 repetitions for each exercise was recom­ testing. and atrophy of the posterior This athlete was restricted from tennis activities rotator cuff muscles. the external rotators and greater than 20 percent initiate the appropriate strengthening program. power. This program incorporated all of li mited capsular mobility was detected. and rhomboids) dem­ titions for each exercise 3 days a week for 6 onstrated fair plus (3 + 15 muscle grades) weeks. Biceps brachialis A majntenance program was reviewed prior testing was positive for Speed's test. relocation tests were positive. with sidelying internal and ex­ of the supraspinatus. All treatments dur­ 1 4. 1 0) A FIGURE 14. manually stimulation to the subscapularis trigger points performed by the therapist. 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. S TR E N G TH E N I N G EXERCI SE S 379 5 consecutive days during this initial phase. 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. on the UBE prior to active stretching and iso­ Low-voltage medium-frequency electrical tonic strengthening exercises as in Case I. to begin treatment. Prone horizontal abduction at 1 00° with ex- with an iontophoresis treatment at the rotator temal rotation (Fig. Sen'atus press (Fig. 1 4 . 5. the scapula for 1 5 minutes. Biceps curls (Fig. 1 2 ) Overall tissue reactivity and subjective re­ 6 . port of pain were reduced by the fourth day 1 4. B . and posterior rotator cuff while isometric were performed for external rotation in the plane of I.5a) phosphate followed by a l a-minute application 4. Prone extension with internal rotation (Fig. Elevation in the plane of the scapula (Fig.2) cuff insertion site using dexamethasone sodium 3. 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. 1 4. 1 4. of treatment. 14. Seated rowing (Fig. Iso­ simulation was applied to the supraspinatus tonic exercises included the following.1 z (A & B) SerratLls press. 1 ) ing this initial phase of treatment commenced 2 . tissue mobility within the shoulder complex.7) of ice. Isokinetic training began with 8 2. functional drills were safely incorporated. isokinetics were progressed to a maximal effort . Balancing on hands and knees on an exer­ cise ball FI N A L P H A S E ( W E E K S 7 A N D 8 ) A reassessment of the glenohumeral rotators re­ vealed a 5 percent deficit of external rotator strength. Thirty-sec­ tion in the plane of the scapula ond rest periods between sets and 60-second rests periods between exercises were incorpo­ Modification of these exercises included adding rated. Proprioceptive training progressed to in­ clude the following closed kinetic chain activi­ ties. by Drills with surgical tubing the calculated 1 0-RM method. Scapular rotator strength assessed by manual muscle tests were 515. began each treatment session during the final phase. allowing I S-second (forehand and backhand) . totaling 3 days per week. 1 4. A I O-minute applica­ tion of ice terminated each session. Based on the FIGURE 14. strength improvements. 1 I). using a weight equal to 80 percent of I RM. a brief hold and vaL)'ing the speed of arm move­ Submaximal concentric training of the gle­ ment. I. and Three sets of 1 0 repet i tions were perfornled included the following activities. and to 1 2 4.I . BalanCing on hands and knees on the bal­ ance board 3. The upper body ergometer warm-up. 1 3) 1 0 repetitions during weeks 4 and 5. three sets of 1 0 repetitions of isotonic exercises and the isokinetic velOCity spectrum. As the athelete tolerated. nohumeral rotators was initiated during week 2 Orilla with PlyobalVminitramp (beginning using a velocity spectrum from 1 200 to 3000 per with 1 0 throws. An additional set I . Chest pass repetitions during weeks 2 and 3.ll1 k rotations mirroring ground strokes repet itions during week 6. Single-arm baseball throw (Fig.13 Plyoball sil1gle-arl7l baseball {hrolV. increasing to 3. Internal and external rotation at 900 of eleva­ progressing to seven sets by week 6. Tn. other day. J 4. These drills were perfornled evel). increasing by 1 0 each session): second (Fig. and a 75 percent external to internal rotalDr value. Balancing on hands and knees 2 . 2. PNF diagonals for 0 I and 02 for each isotonic exercise was added each week. one set of 1 0 repetitions at each speed. Overhead soccer pass with two hands level by week 3 . a t 5 percent increase in internal rotator strength. Balancing on hands and knees on the mini­ tramp 4. detel-mined dur­ ing the first session each week.380 P H Y SI C A L TH ERA P Y OF THE SH OU LDER rest periods between sets. Enoka RM: Muscle strength and its development: 23. 1 982 tance training programs on muscular slrength 27. Flcck 5J. Kraemer WJ: Exercise physiology comer: the dy­ overhead namics of muscular stnlcturc and function. D: Load assignmenl. Rowinski MJ: Concen­ lIic versus eccen tric isokinetic strengthening of the rotator cuff. lL. Allcrheilgn WB: Speed development and plyomc­ References tric training. Human Kinetics. Bodine-Fowler SC: Skeletal mllscle on the function of the shoulder joint. Am J Sports Med tials of Strength Training and Conditioning/Na­ 20:264. Exel' SP0l1S Sci Rev round training with in-season. Saha AK: Theory of Shoulder Mechanism. Abbot LC: Observations 9. Champaign. Lamb DR: Physiology of Exercise: Response and Two-minute rest periods were allowed between Adaptations. Kleinman P : Symptomatic new perpectives. Moynes DR: Delineation o f diagnostic Human Kinetics. Burgess International. 1 987 Kinetics. Mosby Year Book. the gap: anaerobic capacity physiological basis. Amheim Dd. 1 4. and 9: 1 . 2 2 . Atha J: Strengthening muscle. Human tine Approach. 1 984 each exercise. l L. Kraemer WJ: Designing Resistance tions. 8th Ed. Pen. McLeod WD. 26. 1 982 6. 1 984 2 1 . IL. 1 983 1 3 . J: EMG 1 0. J Bone Joint mcchanics: implications for rehabilitation. Goss T. 1 9 8 1 Physiol 55: 1 00. Rozenek R et al: BJ"idging National Strength and Conditioning Association. 1 994 crileria and rehabilitation program for rotator 20. Champaign. Inman VT . Saunders M . 1 96 1 7. IL. Pink M. Training and Conditioning/National Strength and lL. this program encompassed year­ t S. S T REN G THENI N G EXERCI SE S 381 S. Moyers DR: Delineation of diagnostic I-Iuman Kinetics. TR (cd): Essen­ baseball rehabilitation program. White B Wofford L: . Jobe FW. Champaign. Stone MH. Using periodiza­ 1 993 tion principles. Wilson D. Prentice WE: Principles of Athletic Prior to discharge a program was developed Training. 1 986 (cd): Essentials of Strength Training and Condi­ 1 9. Eur J Appl labrlllll. In Baechle (ed): Es­ cuff injuries. Stone MH. 1 993 "25. Macmillan. Champaign. In Baechle (cd): Essentials of Strength Training Programs. 1 988 shoulder instability due to lesions of the glenoid 8. Wathen D: Training volume. In Baechle. 1988 1 7. LOllis. Andersen T. O'Bryant H : Weight Training: A Scien­ Strength and Conditioning Association. In Baechle TR J 8:33. Davies GJ. Am J SPOl-tS Med 9: I I . 1 994 National Strength and Conditioning Association. Sit-ups with a ball toss/catch using a and absolute and relative cndurance. Am J Spotts Med 1 0:336. Colliander EB. 1 994 NSCA J 5:40. 1 982 sentials of Strength Training and Conditioni ng! 4. 3. Pauletto B: Let's talk training #2: intensity. 1 6. Blackbul11 TA. Human Kinetics. Am J SP0l1S Mcd 1 0:336. hcaVY-I'csistance exercise. In Baechle TR (cd): Essentials of Strength Training and Conditioni ng/National I. Townsend H. Wathen. Tesch PA. Kraemer WJ: General adaptations La resistance 1 8. 1 986 Charles C Thomas. 1 99 1 tional Strength and Conditioning Association. 1 994 Thel' 73:844. Am J SP0l1S Med 1 6 :64. SI. Dudley GA. 1 986 24. lL. In Baechle (cd): Es­ tioning/National Strength and Conditioning Asso­ sentials of Strength Training and Conditioni ng/ ciation. Jobe FW. Human Kinetics. Champaign. Pappas A . Wathen 0: Periodizalion: Concepts and Applica­ 5. Springfield. off-season. 1 994 criteria and a rehabilitation program for rotator I I . 1 994 olism during intcnsc. El lcnbeckerTS. NSCA J 4:46. Champaign.). ElIr J Appl Physiol 55:362. 6. 1 994 2. Jones DA: The role of learning and coordination in strength training. Rut herford OM. I L . Phys Surg 26: I . Kaiser P: Muscle metab­ Champaign. lobe FW. Harris RT: Neummuscular adapta­ analysis of the glenohumeral muscles during a tions to conditioning. 2nd Ed. with the athlete and her coach. 1 987 Conditioning Association. Spotts Med 6: 1 46. NSCA and endurance training programs. Human Kinetics. Res Q Exer slanted minitramp Sport 53: I . 1 9 8 1 preseason guidelines. New York. lL. Prone trunk extension with the plyoball 1 2 . Lieber RL. Kearney JT: Effects of three resis­ cuff injuries. Phys Ther 66: 1 855.382 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. Harris Sl. Balt imore. 1 994 back problems. Deschenes MR. 28. Bagg SD. Panio MW. In Leadbetter WB. 1 992 tions for athletic conditioning. Amedcan Academy of Orthopedic Sur­ and superficial heat agents. Kraemer W1. 1 984. Matsen FA: noid labrum in anterior stability of the shoulder. Fleck S1: Physiolog­ shoulder isometric force developmenl. Worrell TW. Fu FH: The role of the 63A: 1 208. 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. 29. 1 986 34. Park Ridge. 1 990 Thermal Agents in Rehabilitation. Travell IG. 35. FA Davis. Sidles lA. Davies GJ. 1 986 Lion of the glenohumeral joint. Spor1s Med 1 1 :2 1 0. 1 992 Health-and pelformance-related potential of re­ 30. exercise training. Han-yman DT. p. Triplett NT. 1 l. J Orthop SpoJiS Phys Ther 1 5:223. 1 98 1 long head of the biceps muscle and superior gle­ 4 1 . Marshall Jl. In Bernhardt DB cd: Sports Physi­ Athletic Training 25:40. Corey BJ. Carmichael SW: Biomechanics of the sistancetraining. Buck­ Plenum. Rowinski MJ: Concen­ 43. Greenfield B. Pinks M: EMG analysis of 1 988 the scapular muscles during a shoulder rehabilita­ 39. Gordon Sl cds: Sp0l1s-Induced Innam­ 4 6 . Moseley JB. J Bone 33. Rodosky MW. Am J Sports Med 20: 1 28. Santiestaban J: 1 986 An analysis of supraspinatus E M G activity and 38. Cohen DB. Wooden MJ. 1 97 8 walter lA. Am J Phys Med 65: 1 1 1 . Williams the rotator cuff. lehman JF. Janda V: Central nelvous motor regulation and Am J Sports Med 22:5 1 3 . 1 988 Wilkins. Stone MH.1 D. Churchill Livingston. J OJ1hop Sports Phys Ther 6:229. Forest WI: Eleclromyographic study of shoulder muscle perfonnance on teenage baseball the scapular rotators during ann abduction in the players. In Michlovitz Sl (ed): geons. New York. training. Ha. 1 986 . Jobe FW. p. J Bone Joint Surg 32. Daniels Wl: Physiological effecls of adelphia. WatTen G. Am 1 Sports Med 1 6:64. The Trigger Point Manual. New York. 1991 shoulder. 659. The role of the rotalol' cuff intelval capsule in pas­ Am J Sports Med 2 2 : 1 2 1 . ElienbeckerTS. Simons DG: Myofascial Pain and Dys­ tric VCI"SliS eccentric isokinetic strengthening of function. Peat M: Functional anatomy of the shoulder com­ bilizing mechanisms preven ting anterior disloca­ plex. Grigis FG: Sta­ 3 1 . 1 985 40. In Korr 1 M (ed): The Neurobiolo­ 36. Michlovitz S L : Biophysical pdnciples o f heating malion. Med Sci ical adaptations to resistance exercise: Implica­ Sports Exer 24:744. York Sl. Kraemer WJ: tion program. Fleck SJ. 1 994 sive motion and stability of the shoulder. Campbell KR et al: Isoki­ 44. Hamer CD. 1 990 cal Therapy. Ach Phys Med Rehab 57: 1 22 . 29. 1 992 fects of su-englh training on throwing velocity and 42. Kraemer WJ. Mont MA. Sports Mcd 6:246. 1 976 performance enhancement in elite tennis players. Johanson M et al: Ef­ Joint Surg 74A:53. 45. Turkel SJ. Phil­ 37. Kraemer WI: Physiological and cellular effects of gic Mechanisms in Manipulative Therapy. 1 992 scapular plane. on the other hand. relying on palpa­ total water content! Skin. A strong interrelationship exists between sues. sUITounding fascia are categorized as soh tis­ 3. liga­ tion rather than arthrokinematics. 15.1). skilled passive movement of a joint. and tion.'" This move­ ment is gained pIimarily by following the rules of arthrokinematics. myofascial manipulation? What is the difference between the two? Both joint mobilization and myofascial manipulation have their effects upon The pIimary focus of this chapter is the treat­ connective tissue. Evalua­ tion and treatment of the shoulder must there­ I. (Find the lesion Two highly inten'elated approaches to treat­ and treat in the direction of the restriction.ss'tw zation. Many myofascial lesions do not follow any Connective tissue comprises 16 percent of a per­ arthrokinematic rules. ments. By definition. joint capsule. and adipose tissue can also 383 . beginning with its most superficial The complexity of the shoulder joint ohen makes layer and progressing into depth. chapter is direct technique. myofascial manipulation is and blood vessel walls all contain connective tis­ defined as "the forceful. aponeuroses. is not as clear-cut. while taking it a difficult joint for a physical therapist to evalu­ into account its relationship to the joints con­ ate and treat. muscle. The basis for myofascial son's body and stores 23 percent of the body's mobilization is more intuitive.) ing the shoulder are joint manipulation and my­ 2. ment of the myofascial tissues significant to the Joint manipulation has been defined as "the shoulder joint.Myojascial Treatment DEB 0 RA H SEIDEL COB B ROB E R T CAN T U Introduct:ion musculofascial elements through its restrictive directions. passive movement of sue. periosteum. All of the myo­ fascia is key to its successful implementa­ fascial tissues including capsule.'" This definition contains several key the shoulder is a function of an interrelationship elements: between bony structures and myofascia. This makes joint mobilization easier to understand and use. The biomechanical complexity of cerned. The question is. Bone. Awareness of the 3-dimensionality of myo­ ofascia I manipulation (Fig. Myofascial manipulation as defined [or this fore address both of these components. ligament. Myofascial mobili­ HistoliJrJy of Connective 'fli. when is one performing joint mobilization and myofascial manipula­ joint mobilization and when is one performing tion. cartilage. tendon. and retinaculin (Table 15. 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. lining of arteries and ligamen­ its compactness.384 PHYSICAL THERAPY OF THE SHOULDER Connective Tissue Mobilization J oint Myofascial Mobil ization Manipulation · FIGURE 15. Reticulin: Most elastic fiber. Ten­ dons and ligaments are comprised primarily of dense regular connective tissue.1. which is charac­ TABLE 15. and a parallel arrangement of Type I collagen: Ordinary connective tissue (loose and dense) fibers. elastin.1 Int to treatil1g the shoulder. Healing time is therefore signif­ tum flovum icantly increased after any trauma (see Fig. Framework of lymph nodes and glands Dense irregular connective tissue is found in Ground substance: Viscous medium in which cells and connective joint capsule. 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. and loose regular.4). ligaments.1 ) 5. and tendons. and aponeuroses. cia.6 As therapists. and three fiber types: Colla­ CLASSIFICATION OF CONNECTIVE TISSUE gen.'5 Connective tissue is comprised of cells. fascial tissue lie sheaths. These characteristics allow for high ten­ Type II collagen: Hyaline cartli oge sile strength with low extensibility. 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. Components of connective (issue terized by a high proportion of collagen fibers to Collagen: Mo�1 tensile of connective tissue fibers ground substance. periosteum. dense irregular. As compared to dense regular connec- . 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. dermis of skin. 15. 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. ground substance. Massage causes capillaries to knee then analyzing the histologic effects on con­ dilate in the region of the stroking. IS-17 Under histologic examination. pal·tial joint sue is the most easily mobilized with myofascial mobility could be restored. Manipulation zation. 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. With the loss of ground substance came a de­ connective tissue massage stimulates circulation creased fiber distance. The authors found fibrofatty infil­ increased blood volume and now. the basal metabolism. 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. it was found that if and muscle sheath. . 14 the superficial and deep fascia as well as nerve In a study by Evans et ai. Three secondary effects fundamentally different from patients typically are on blood now. the rate of around the body.3-5. This is essential so that realistic goals can be set in the clinic. Histamine causes creased tissue extensibility·-13 When immobili­ vasodilation. endomysium. resulting in increased blood now " zation occurs for less than 12 weeks. radation exceeds collagen synthesis. cance is the fact that milder massage does not With longer periods of immobilization greater produce the same effect. Longer pe­ Effects oj immofliJ:ization and riods of immobilization result in less optimal re­ turn of mobility. Ebner reported that substance (glycosaminoglycans and water). This held true for immobilization of less than 30 days. MYOFASCIAL TREATMENT 385 tive tissue. then portive structure of the lymph system. The mechanical friction created by mas­ collagen fibers. I autonomic system. Deep massage strokes in­ sue dut. Of signifi­ trates. IS. produced on the body. leading to cross-link de­ in a region of the body.13 MolJilization on Connective Tissue With an understanding of the normal biomecha­ nics and histology of the myofascial tissue.19. and remobili­ MyojasciaJ. Immobiliza­ increased circulatory pathways to other body re­ tion leads to a lack of stress being applied to the gions. ground substance as well as increased vascu­ After 12 weeks of immobilization. collagen deg­ larity. and the seen in a orthopedic clinic. This tis­ manipulated under high velocity. primarily in the areas of capsular folds. [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. it possesses a higher proportion of collagen synthesis and degradation are the same. Amiel et al.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. it is now important to see how these tissues are af­ Other Physiologic Resprmses To fected by immobilization. If these joints were techniques . trauma. resulting in Loose regular connective tissue is found in a net collagen 10ss. Additional effects come from research done on animals. This is mented in the literature. and the sup­ rat knees were experimentally immobilized. resulting in nective tissue. no significant The autonomic system has also been shown loss of collagen was found-only loss of ground to be effected by massage. full mo­ bility could then be restored. which in turn opens up velopment between collagen fibers.7 allowed to move prior to manipulation. most of of massage on the body have been well docu­ which were normal and nontraumatized. performed extensive animal Massage has been shown to increase blood studies on the immobilzation of connective tis­ now to the extremities. If a leg length discrepancy exists. In the case of a fTozen shoulder pa­ duced. movement. The individual findings of pos­ typical patlem of tightening of the upper trape­ ture or tightness were not significant until they zius. levator scapulae. . The evaluator should be looking for When evaluating the shoulder. kyphotic. Because fas­ might be indicative or a dysfunction. Exter­ balances. (Table 15. the strength of the in­ mechanical origin is more specific. it would make sense to first stretch out the By knowing the behavior of the patient's pain. latissimus dorsi. protracted posture often seen in the clinic.386 PHYSICAL THERAPY OF THE SHOULDER MyoJascial EJuai:uation oj the For the shoulder. Postur­ tions. It does not History gives valuable insight into patient condi­ seem reasonable to start a strengthening pro­ tions before a hand ever touches them. are not necessarily dysr"lmctional. this patient assumes a protracted position. and teres major. Janda observed that Physical evaluation reveals tightness of the inter­ changes in muscle function play an important nal rotators and adductors. in the absence or other objective find­ longed shortening or lengthening or a muscle or ings. II is im­ needed. All or these contribute to the typical ponents contributing to the dysfunction. should be considered. phasic muscles of with objective findings. the physical ther­ areas of muscle or connective tissue asymmetry apist is looking for acorrelatiol1 of (indil1gs that as well as increased muscle activity. we can begin to isolate the nature of the problem. and pectoralis with weak­ con'elated with pain and loss or motion. History. 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. consistent findings are a beller indicator of a Vladamir Janda helped demonstrate the er­ problem. After stretching usually dull and nonspecific. Postural vers J. If a patient hibited muscles may retum without any rurther reports specific sharp pain that is easily repro­ treatment. a head to foot evaluation may be palpatory exams.20. a pa­ portant to remember that connective tissue tient may develop muscle asymmetry due to pro­ changes. consider a patient who fects of myofascial imbalances on postural im­ presents with a stiff and painrul shoulder. especially pectoralis role on the pathogenesis of many painful condi­ major. 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. He looked extenSively at how muscles nal rotation and abduction are most limited. Treat­ ening of the deep neck flexors and lower scapular ment must then address all the significant com­ stabilizers. We then move on to try to correlate the history TABLE 15. a more specific pathology may be present. In the upper extremity we see a abnormalities. Myorascial pain or of the tightened muscles. respond to dysfunction. and the body. For exam­ gram for the weakened antagonist as the first ple. myorascial pain of nonmechanical origin is step in a rehabilitation program. 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. as cial planes can be restricted over large areas of well as the results from visual.21 HISTORY Tight muscles tend to act in an inhibitory way on their antagonist muscles. tient. Janda defined a poslLlral muscle as one that ally. For example.2.2). The impor­ Pectoralis major (upper portion) Rhomboids Cervicol erector spinae Anterior cervical musculature tance of posture is in how it relates to runction. Several group of muscles. MYOFASCIAL TREAT MENT 387 shortened internal rotators and adductors like the layers of tissue perpendicular to the tissues the subscapulal. It involves the lifting away of the su­ perficial connective tissue and skin fTom the un­ J. POSITIONING OF THE PATIENT AND PALPATORY EXAM THERAPIST Now that posture and movement have been as­ Maximum effectiveness cannot be achieved if sessed. or the therapist may with postural and movement findings to be of be pUlling undue stress on the patient's body. palpatOlY findings must also correlate may not be able to relax. so it is im­ shoulder motion.3 and 15. joints. Palpatory ing to the entire body when looking at active findings will change with treatment. This involves bending of th� muscle to assess its transverse ings. See Chapter 3 for a detailed eval­ any technique can be modified to suit the patient uation sequence.s before allempting to as well as moving the perpendicular tissues. The ex­ aminer should be assessing for temperature. These techniques have been chosen because limitation by soft tissue? Proper stabilization is of their effectiveness in the clinic as witnessed necessary to achieve true range of motion and by the authors. The strengthen the weakened external rotators and examiner should be able to palpate the tendons. This will decrease the problems of Deep palpation involves palpation through hyperrnobility and early arthritis. Because the hands are the primary tool of the moisture. It is important to onsider what is happen­ flexibility.der see limited forward elevation of the shoulder. needed. the patient tioned. if on postural evaluation the patient was found to Myof(J$ciaJ. and deep periosteal layers of tissue. abductors. it is essential to protect them. A pillow between the patient and of the joint structures. As previously men­ therapist is not properly positioned. (see Figs. Palpation of the shoulder therapist can provide a mechanical baiTier as must include the scapular. the examiner can begin to palpate for the the technique is not efficiently executed. muscle sheath. 15. It is important to remember that proper endfeel. Techniqu£s for the have a forward head position with pectoralis major and minor shortening. sibility of the connective tissues. To as­ MOVEMENT ANALYSIS Active movement testi formation with which l may provide further in­ correlate postural find­ sess mobility of muscle. we may expect to Shoul. Quality as well as quantity portant to be constantly reassessing. thoracic.and light touch to determine the exten­ manual therapist.or is there der. joint capsule. Superficial palpation is performed on the JOINT PROTECTION skin and superfiCial connective tissues. cervical. problem or needs of the clinician. If a location of the dysfunction. . Avoid hyperflexion or hyperextension of the derlying structures. Do limitations in range con·e1ate to postural findings? For example. myotendinous junctions. muscle bellies. any significance. The palpatory exam includes Remember to avoid needless body contact with the myofascial structures by layer and palpation the patient. a technique called trans­ verse muscle play may be used. 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. tenoperiosteal junc­ tions. and anterior chest wall regions. Is the endfeel capsular. should be considered.4). Passive range of motion should also be for The following therapeutic techniques are just a both quality and quantity of movement as well few of many available treatments for the shoul­ as for endfeel. Use elbows. vigorous treatment of a patient. The strokes may be­ come progressively deeper. I n order to who are too large to safely use your fingers achieve full shoulder range of motion and pos­ on. This technique is Gently lift and bend the pectoral muscle of great value to patients who have protracted away [Tom the anterior chest wall. The patient may rest the arm on the therapist's knee to � hieve beller relaxation. Small oscilla­ shoulder girdles.388 PHYSICAL THERA PY OF THE SHOULDER Palient Position Supine with the head in a neutral position on the treatment table. THE UPPER THORACIC REGION (FIG. try to rest your hands and protect them h'om excessive strain. tural correction. Patienl Position 4. During off hours from work. Therapist Position Alongside the patient at a 45° angle to the ANTEROPOSTERIOR LATERAL ELONGATION Of shoulder girdle. 15. pisiforms. Therapist Position Seated near the patients' head at a 45° angle to the shoulder girdle. replace the hands in the original posi­ tion and repeat the stroke. 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). 15. 15. Procedure Begin stroking with the fingertips in a medial to lateral position.3. I t should be used before trying tions can be performed as well as a static hold. Be creative. to teach postural correction or strengthening. Rationale This technique is used for relaxing and Procedure lengthening the myofascia in the upper thoracic region and the shoulder girdle. TRANSVERSE MUSCLE PLAY OF THE PECTORALS (FIGS. or fists on patients those with the forward head posture.2) The thumbs are place Funderneath the muscle ?! and the fingers grasp f": above. . Be careful to not contact breast tissue. Once the glenohumeral joint is reached.4) Ratior/ale FIGURE 15. especially 2. 3.2 Tightening of the pectorals is a common problem found in shoulder patients. the extensibility of these mus­ cles must be restored. 4 .3 FIGURE 15. MYOFASCIAL TREATMENT 389 FIGURE 15. 5 FIGURE 15.6 .390 PHYSICAL THERAPY OF THE SHOULDER FIGURE 15. The Procedure arm may rest against the therapist for relaxation.7) Rationale Procedure This technique elongates the superficial an­ The fingers of the lower hand apply a deep terior fascia. ROTATIONAL THORACIC LAMINAR RELEASE (FIG. motion cannot be achieved. The upper ANTEROLATERAL FASCIAL ELONGATION (FIG. This is a deeper tech­ grasp from beneath to per[olm a muscle play nique than those already described.8) Proced"re I RatiO/wle Small oscillations or sustained pressure can be used as a therapist applies moderate pressure To mobilize the paravertebral and perisca­ into the subscapularis. When [·ull shoulder arm and providing a gentle upward distraction. Lubricants should not laris. the fingertips may be used to snugly between therapist and patient. The other hand may be used to stabilize be used to prevent shear force. One hand is tion of force may be changed to accommodate placed from above into the belly of the subscapu­ the existing restrictions. hand rests on the glenohumeral joint. grasping the patient's posture or immobilization.6) Supine with the shoulder elevated 120' to Rationale 160' depending on the area of restriction. The bottom hand may pular muscles into rotation. The direc­ Standing alongside the patient. which is often restricted in patients pressure in a sweeping downward motion. 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. The therapist places the palm of the hand along the lateral border of the sca­ Therapist PositiOI1 pula. the therapist should The palm of the upper arm is placed just below recheck the subscapularis and the surrounding the breast line. the upper hand retracts the shoulder girdle and . 15. 15. If more specific fascial re­ Directly facing the patient with a pillow fit strictions exist. gently distracted. Patient Position Supine with the arm abducted 30' to 60'. Gentle stroking in a caudal direction is ap­ plied with the palm. The therapist applies a stronger tractioning force on the flexed arm while the lower arm trac­ Therapist Positiol7 tions in the direction of the umbilicus. Be sure of proper draping and myofascia for trigger points or restrictions. 15. technique. appropriate hand placement when performing this technique. or it may be used to assist the upper hand in doing the mobilization. Patient Position Procedure 2 Sidelying with the head suppolied and the The patient's arm is elevated into flexion and upper arm resting on the side of the body. the patient's arm. Patient Position 15. The lower provide a static or oscillatory pressure. while with a protracted shoulder girdle position.5. hand is placed along the paravertebral muscles near the medial border of the scapula. MVOFASCIAl TREATMENT 391 SUBSCAPULARIS TECHNIQUES (FIGS. 8 .7 FIGURE 15.392 PHYSICAL THERAPY OF THE SHOULDER FIGURE 15. 15. The palm of the A commonly performed technique that de­ upper hand is placed over the lateral border of creases tone in the periscapular muscles and pre­ the scapula. Procedure for Superior Border Parienr Posiriol1 Place the fingertips of both hands medial to Lying on the side faCing the therapist. and then strokes caudally with a pares the scapulothOiacic tissues for aggressive Firm pressure down the length of the border. . a gentle stretch performed with the palm of the hand can be Therapisr Posiriol1 given at the end of the stroke. This along the medial border of the scapula. stretching. Standing Facing the patient with the upper hand placed on the anterior acromion. Stroke outward toward the acromion should be resting comfortably on the pillow. and preparation of the tissues by scapular flaming. SCAPULAR MOBILIZATION (FIG. Gently technique should be done after there has been retract the shoulder with the upper hand. If needed. 11) Procedure for Lareral Border Rariol1ale Place the palm of the lower hand over the acromion to stabilize the joint.12) 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. border of the scapula with the lower hand. 15. with a film pressure.9 applies a rotational force through the thoracic then stroke in a downward direction along the spine. SCAPULAR FRAMING (FIGS. with the cervicothoracic junction over the upper tra­ a pillow separating the two.9 TO 15. MYOFASCIAL TREATMENT 393 FIGURE 15. The patient's arm pezius. 394 PHYSICAL THERAPY OF THE SHOULDER FIGURE 15. 1 I . I 0 FIGURE 15. Procedure 1 SEATED PECTORAL AND ANTERIOR fASCIAL A posterior force towards the patient's head STRETCHES (FIGS.13 TO 15. The patient's arms may also be used to elongate the anterior fascia and pectoral fully extended for this technique. If the patient is larger. 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. two hands may be needed. The fingers of the bottom hand lightly grasp the medial border of the scapula. The patient is lying on the side facing the therapist. off of the thoracic rib cage. The therapist grasps the patient just below the el­ Lift the scapula and shoulder girdle complex bows. . MYOFASCIAL TREATMENT 395 fiGURE 15. As previously mentioned. Patient Position Therapist Position Seated with the hands behjnd the head. Standing directly in front of the patient with the top hand placed on the anterior shoulder Therapist Position joint. 12 Patie'1t Position muscles to allow for better posture and improved shoulder range of motion. These stretches can be force is applied. To incorporate the lateral fascia and muscles. with a pillow separating the two.15) is applied while the patient takes deep breaths Rationale to improve anterior elongation. 15. Standing directly behind the patient with either the knee or rup stabilizing the thoracic re­ gion. a pillow should Procedure be placed between therapist and patient. 15 Proced"re 2 The patient may have only one arm extended upwards. Patiel1t Positiol1 Supine with the arm abducted 30· and the elbow bent.14 Tilerapisl POSiliol1 At the patient's side supporting the arm with the bottom hand.16) RatiO/wle Cross-friction is used to increase local blood now to enhance the rate or healing. while the therapist places one hand along the lateral I-ib cage and the olher just below the elbow.396 PHYSICAL THERAPY OF THE SHOULDER FIGURE 15. A rotary component can also be added using the technique stated above. CROSS-FRICTION OF SUPRASPINATUS AND BICEPS TENDON (FIG. It is vel)' effective in treating tendonitis or the biceps or supraspinatus.13 FIGURE 15. The thumb or the top hand is in the bicipital groove. A traction rorce is then applied in op­ posite directions. . 15. FIGURE 15. Trigger points in the UIT and scapulothora­ trapezius. 90° of abduction. Increased tone in the levator scapulae pain following a fall. the therapist abducts the shoulder 80° to pulothoracic.levator scapulae. and pec­ toral muscles. PATIENT PROBLEMS I. She has a history of a Bank­ 4. Increased tone in the upper trapezius CASE STUDY 2. AC joint pain sents with atrophy of the rhomboids and lower 7. and 45° of groove is applied with the thumb. Left shoulder active range of motion gentle friction. MYOFASCIAL TREA TMENT 397 FIGURE 15. The second external rotation. 90° of abduction. The musculotendi­ tion and to internal rotation and adduction nous junction lies here. Decreased range of motion of the left injury sustained in a motor vehicle accident. and 55° of external interphalangeal joints may also be used if the rotation with pain before end-range. Significant increase in tone is present dc regions .16 Procedure in the upper trapezius. There are patient is less acute. as described earlier. On evaluation she pre­ 6. Passive range of motion is 100° and third fingers with slight flexion at the distal of flexion. To friction the supraspi­ multiple tender spots in the upper thoracic. Use the same technique movements. and anterior chest wall regions. sca­ natus. Direct fl-iction over the bicipital is 100° of flexion. Increased tone in the pectorals art repair to the same shoulder in 1990 after an 5.Iled out injury to the prior re­ pair as cause for her pain. The shoulder 0I1hopedist has I1. 90° and palpates the notch fOI-med by the acro­ The acromioclavicular joint is painful to palpa­ mion spine and the clavicle. Increased tone in the rhomboids A 34-year-old female patient presents at our clinic with an 8-week history of left shoulder 3. Cervical range of motion is limited The therapist may alternately laterally and by 25 percent into rotation and sidebending to medially rotate the shoulder to create some the right. (A & B) PreseJ1lalion o( Ihe palieJ1l after Ihe (irsl (our IrealllleJ1l sessions. consider cial elongation with or without a rotary a change in technique. Once the myo­ tion or strength. 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. Restricted anterior chest wall: anterior fas­ proach. Consider each pa­ tient's problems individually. Remember that the afore­ componenl mentioned techniques are only a small sample of available treatments.398 PHYSICAL THERAPY OF THE SHOULDER 8. Restrictions in the anterior chest wall myo­ After performing each myofascial technique. If one approach is not working. Increased pectoral tone: pectoral muscle sessing the causes of limitation. subscapularis release ment assisted in the ability to isolate the primary 4. 3. cises if they are still required. Use these play findings to guide your choice of treatment ap­ 2.17 A 34-year-old palienl who preseJ1led wilh al1 8-week hislory o( le(1 shoulder pain (allowing a (all. In the case of this patient. fascia reassess the patient's range of motion to see what 9. this patients pain centralized to the A FIGURE 15. Increased tone in paravertebral muscles: ro­ After 4 treatment sessions using the discussed tational thoracic laminar release techniques. 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. The previously discussed tech­ fascial restrictions are eliminated and the range niques might be incorporated into treatment of of motion is improved. myofascial treat­ scapular mobilization. continually reas­ I. Peliscapular restlictions: scapular framing. begin strengthening exer­ this patient in the following way. B . 5. Large increa es in range can be achieved through the perfor­ From a myofascial standpoint. Increased tone in upper thoracic problem. Decreased cervical range of motion effect the treatment has made. Akeson WH. Williams PL: Gray's Anatomy. the positions of the tracture. 1962 References 16. At this point. 1985 tive Tissue Response to Immobility. 1968 protective muscular responses of the body. MYOFASCIAL TREATMENT 399 acromioclavicular joint. Connective Tissue Res 5:15. Akeson WH. 28. skin and tendon in nOlmal l"31s. p. AI1hdtis 23. 1989 22. Schliack H. Basic Biomechanics of the 2. p. 1989 . Cummings G: Soft Tissue Changes in Con­ subjects and paticnts with rhcumatoid arthritis. KlUsen F: Cuta· 3rd Bdtish Ed. Cormack DH: Histology. lion effect on metabolic turnover of medial collat· eral ligament collagen. The patient joints. 10. 1979 Phys Med Rehabil 30:135. Martin GM. Arch Philadelphia. Exp Gerontol 3:289. Butler JK et al: Experimental mal and the prominence of the acromioclavicu­ immobilization and mobilization of rat knee lar joint has become more obvious. Ebner M: Connective Tissue Manipulation. UD. WE Saunders. Phila· ive Therapy. delphia. 1973 neous temperature of the extremities of nOlmal 6. Copenhaver WM. Cantu R: MyofasciaJ Manipulation: 21. Stokesville Publishing. 151. FL. Akeson WH. 1975 back problems. LaViolette 0 et al: The con. Neuberger A. 1977 problem became obvious. Grodin A. Akeson WH. Cuthbenson DP: Effects of massage on metabo· Theory and Clinical Management. 1980 scapula and clavicle have moved closer to nor­ 13. 1946 7. Wolfson H: Studies on the effect of physical thera­ ley's Textbook of Histology. Scarsdale. the cross-linking alterations in joint contr-acturcs.17 show. Akason WH et al: Connec­ Kreiger Publishing. Amial 0 et al: The connec­ biologic Mechanisms in Manipulative Therapy. J Bone Joint Surg 42A:737. Amial 0: Immobility effects of syno· presentation of the patient afler the first 4 treat­ vial joints: the pathomechanics of joint con· ment sessions. Amial 0. Baltimore. Woo SL. 1953 Aspen Publishing. Matthews N. Roth GM. 1949 4. Forum Med­ lism. Glasgow Med J 2:200. Clin O. J. 8. Clin Orthop 93:356. 1975 JAMA 96:2020. Biorheology 17:95. 1992 17. 1933 icum. New York. Donatelli R. Cantu R. tracture. Atlanta. Gaithersburg. Nordin M. wolrr A: A Manual or ReOex· Skeletal System. lion of nonnal and paralyzed extremities. NY. 1960 was refen'ed back to the orthopedist for closer 14. p. bones. Eggers G. Once II. the 12. Janda B: Central nervous motor regulation and Rheum 18:257. Williams & Wilkins. p. Bunge RP. 1973 Therapy. 20. This problem could not nective tissue response to immobilitiy: an acceler­ have been easily identified early on due to the ated aging response. Wooden M: Orthopaedic Physical sue of the rabbit knee. Slack H: The metabolism of collagen fTom liver. Warwick R. Biochem J 53:47. Woo S et al: Stress dep. Amial 0. Malabar. VA. Laban MM: Collagen tissue: implications of its re· sponse to stress in vitro. Evans E. Frankel VH. Arch Phys Med Rehabil 43:461.·iva. JB Lippincott. Woo S.1hop 172:265. S Simon Publishing. 1983 J 5. MechanicGL et al: Collagen those protective mechanisms were removed. Amial 0. Dicke E. In 1M Korr (cd): The Neuro· 9. examination of the AC joint. Philadelphia. New York. Grodin A: Myofascial Manipulation. Runge R et al: Bai· 19. 32. Berryville. Elkins C. 90. peutic procedures on function and structure. Lea and Febinger. Figure 15. Akeson WH. 1931 5. 1978 chanical changes in pedarticular connective tis­ 24. tive tissue response to immobilization: biomc­ Plenum Press. Wakim KG: The effects of massage on the circula· 3. Churchill Livingstone. 1980 1978 18. 1985 Arch Phys Med Rehabil 27:665. Ham AW. 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). Therefore. including the shoul­ it is possible that the muscle is being strength­ der complex. both for testing muscle function and tions of test data interpretation. because of these factors. positioning. or high speeds Practical Advantages oj Isokinetics ("power" and "endurance" deficits). be­ resislive exercise in the physical therapy clinic. lever aI-m lengths (in the tion relaling to the knee. recenl ad­ equipment and in the patient's limbs). Consequently. However. the muscle is cially sports activities. Cedar Rapids.. Ihrowing. WOODEN Isokinelic exercise has become a popular form of With isotonic equipment or free weights. in a maxirnum­ not fast enough to ·match many activities. and cular contraction. resistance to the movement speeds. exercising at loaded maximally at each point in the range of different speeds may cause quantitative and motion (ROM). effective resis­ positioning to apply isokinetics effectively to tance occurs only at a certain point in the range. at 500"/s. ALBERT MICHAEL J . cause the speed of movement is not preset. to describe the adapt­ effectively throughout its ROM by fixing the ability of several dynamometers to shoulder di­ speed of movement. resis­ Since the late I960s. agonal patterns. LA). and cam vances in equipment have made it possible to use sizes. and to describe considera­ of speeds.3 If. The purposes of this chapter are to ened only at that point. of­ normal activities in which angular velocities (as fers totally accommodating resistance to a mus­ in walking. to discuss principles of isoki­ [sokinetics offers several other clinical ad­ netic testing and training with emphasis on vantages.'-3 qualitative recruitment of different muscle fiber 401 . espe­ effort isokinetic contraction. most other extremity joints. such as the capacity for a wide range shoulder positioning.3 Even the highest speeds of the MERAC varies according to the amount of force applied (Universal Corp. the literature has consisted tance to muscle contraction will vary according primarily of research data and clinical infonna­ to gravity. isokinetic list some advantages of isokinetics in shoulder exercise offers the advantage of loading a muscle evaluation and treatment. Isokinetic Evaluation and Treatment MAR K 5 . unlike isotonic exercise. swimming. are to the resistance arm.'-3 Because the speed of move­ other activities) are far in excess of most isotonic ment is constant. nmning.2 Testing and training at higher speed attempts to simulate lsokinelic exercise. However. Extremity joints. isokinetics the time required for multiple dynamometer po­ possesses several disadvantages or precautions. however4. Controversy exists as to the safety of ro­ theless. be­ ies3 cites many other physiologic and clinical ad­ cause so many positions and motions are recom­ vantages of isokinetics. NY). diately. With the advent of action forces at the joint should also decrease. axis of the patient's shoulder. 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 Never­ dation. further are produced by robotics. at sistance will accommodate to pain levels. Shirley. of course. Biodex (Biodex. are multiaxial. 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. isokinetic re­ the alterations in the force-velocity curve th . the resistance will decrease imme­ axial. In ad­ test the different movements. for reasons previously stated. sition changes. A key concept to robotic testing used. is uni­ cause of pain. several important biomechanical princi­ rehabilitation and testing of the glenohumeral ples warrant consideration. and temporarily "spare the joint" by redUCing joint Lido (Loredan Biomedical. increasing the speed may nooga. As with all types (or mended. 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. CAl have the reaction forces.402 P H Y SIC A L THERA P Y OF T H E S HO U LD E R types: therefore. Davi . in turn. Increases in speed of isokinetic concentric however. and training involves thorough understanding of Whether at fast or slow speeds. and improved joint lubrication. because if the patient needs to Another consideration is that the resistance decrease or stop the contraction suddenly be­ mechanism. training may also produce pain reduction selec­ the amount of floor space required. Dav­ ticular problem with shoulder evaluation. niques. TN). example. To protect injured tissues tension eccentrically9 and because much of func­ while maintaining effective strengthening tech­ tional movement requires eccentric contraction. while assessing multiple muscle which will be discussed in the next section. The latter is a par­ dition to the advantages already discussed. recent technology in dynamometry. because resistance will never exceed the as their instantaneous centers of rotation change amount of force applied] Unlike isotonic exer­ constantly through movement. 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.'O-'4 The exten­ cise. and the time tive recruitment of muscle fiber type (slow twitch required to change positions and attachments to or type I). 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. 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 . Submaximal effort in the clinic include the high cost of equipment. compromised force used in isokinetic resistance exercise will. 10-1J Isotonic loadeds-s exercise inco'lJorates eccentric muscle loading. decrease joint reaction forces as pro­ Other practical disadvantages of isokinetics duced in submaximal eff0l1.. For groups. Testing of diagonal pallerns reduces modes) of clinical muscle training. require decisions about the positioning of the Because muscle generates the most amount of glenohumeral joint. ensuring safety. Decreasing the machine axis with the changing. Chatta­ sponse to exercise. most or all of the muscle can be from clinicians and investigators. compressive re­ llIm or force vector problems.'·s-s Therefore. miminal momentum is produced with isok­ sive mobility of the shoulder and the multiple inetics. inSlluments In joints that exhibit an inflamed or painful re­ such as the Kincom (Chattanooga CO'lJ. at least on Cybex equipment. /$ of the position may risk glenohumeral joint im­ pingemenl. adduction. applied to all dynamometer setup capacities. 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). These di­ found to exist. or 45'. ments. Finally. appro­ in proprioceptive neuromuscular facilitation priate protection for both the anterior and poste­ (PNF). with minor patient position or machine adjust­ ment . cular. diagonal Blaschak lS suggest the need for multiple posi­ movement testing may also be more functional tions for testing and training and. Excessively high charges and ques­ vascular wringing out effect. that no Single patient or glenohumeral po­ isolate and measure motion of the acromioclavi­ sition is optimal for all clinical purposes. however. the neutral position (elbow ad­ indicated for certain pathologies. Two nega­ consuming. KnOll and V oss. torsion forces are transmilled from the scapula extension. and internal and external rotation. first described "mass movement patterns" rior capsular and labral mechanisms also was as being inherently diagonal in nature. and consequently pro­ vide a comfortable training position for most pa­ The first diagonal movement described is the tients with pain. Although Hageman et al. and can be clinically un­ tive considerations of this position are the micro­ manageable.2.uatiJm oj SlurukJer IMg()'l'l(). and/or rotator cuff combination of extension. Resisted diagonal movement will load tion. the 45' AP positions conform closely to the natural.· Photographs and descriptions weakness. internal suppression. 1S In addition. sternoclavicular. restl. which fail to ingly. adduction. rotation (ExlfAbdJIR) and flexion.c muscles or muscle groups and are In contrast. The 45' AP is also simply to the classic upper extremity PNF pallerns. the proximity EvaJ. abduction. thus eliminating several lengthy steps.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. 25 pioneers ' external and internal rotation at 45' AP.3.ctions. a compromise position that is safe joints ' Of course. Interestingly.'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. functional plane of motion Testing Procedure (the plane of the scapula). lines of muscle pull. 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. on speci(. ex- . and scapulothoracic However. flexion. 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. which creates most used in everyday activities. 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. abducted posi­ tion. Both Hinton 12 and Soderberg and In addition to its practical benefits.'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.25 The move­ low capsular stress and produces peak isokinetic ments to be described in this chapter are similar rotator cuff torque?3. through the coracoclavicular ligaments into the These procedures provide excellent information acromioclavicular joint. not surpris­ than cardinal plane movements.'2. the 45' AP closely agonals are dictated by anatomy-shapes of simulates the modified base position advocated joints. movement of these joints oc­ frOI'll both vascular and biomechanical perspec­ curs throughout the range of glenohumeral mo­ tives is the intermediate.22 found high con­ muscles that effect movement at all joints in centric and eccentric torque values for both the shoulder girdle. To same diagonal. (C) El1d of diagolwl 1Il0Velllel1t FlexlAddJER. (B) End of diagonal move/1/em ExtlAbdJIR. 1 B shows the end of that ing on which movement is being performed. Figure 16. ratus. that the rota­ sitions for the FlexlAddlER movement. tional component cannot be resisted by the appa­ For both movements.1 C illustrates the end po­ should be pointed out. 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.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 FIGURE 16. and Figure 16. a swivel handle is used. blocked manually to prevent hy­ allow for rotation. Figure 16. as would be the case if manual J'esistance . the patient is in. It perextension. however.1 (A) Initiation of the diagonallllovel1lellt ExtlAbdJIR. temal rotation (FlexlAddlER). 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· ' . '" A B 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- FIGURE 16.3 (A) fnilialion o( diagonal movel1lel1f ExIIAdd/fR. (B) End o( diagol7all1lovel1lenl ExtIAdd/fR. (C) h,ilialion o( diagol7all1lovel11el1f Flex/AbdIER. I S OK I N E T IC E V A L U A T I O N A NO TR E A T M E N T 407 A FIGURE 16.4 MERAC iso kil1etic diago.-wl pallems. (A) fl1itiatiol1 o f diagol1al movement £ttlAeldifR. (B) E .-,eI of diagOlwl movel11el1f ExtlAddlfR. B 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 /nterpretat:inn of /sokinetic Test Because the upper extremity muscles are smaller in cross-sectional area than most lower Parameters extremity muscles, they tend to demonstrate smaller normative peak torque to body weight Traditional clinical practice with isokinetics has (PTIBW) relationships. The strongest muscle focused on the knee, with consideration of a spe­ groups of the upper extremity also produce the cific agonjst to antagonist torque ratio (ham­ highest PTIBW ratios: 45 percent to 56 percent string to quadriceps) as a key clinical parameter. for adductors and 25 to 26 percent for abductors, Similarly, the glenohumeral joint presents a key as consistently reponed by Davies3 and Alderink clinical parameter with external rotation to in­ and Kuck. 13 No consensus regarding external ro­ ternal rotation (ERIIR) torque ratios expressed tation and internal rotation PTIBW ratios has as a percentage. Two studies,,·2. have reported been reported, with external rotation values ERIIR ratios of 80 percent or greater; however, ranging from 8 percent to 16 percent and inter­ most studies3 , J 2, 13, J 5, J 8,29,33 have consistently nal rotation values ranging fTom 13 to 22 per­ demonstrated normative ratios of 60 percent to cent. 3,13,18 70 percent Table 16.2. Consequently, the ERIIR The limited number of studies regarding ratio of 60 percent to 70 percent provides a basis shoulder isokinetic parameters and normative for clinical description of normal force couple data have been performed with a variety of pa­ synergy and muscular tension capacity. The pa­ tient populations (mostly small numbers), differ­ rameters of total work and endurance should ing test speeds and dynamometers, inconsistent also be examined, as they provide an additional methodology, and varied patient positions. Con­ perspective for clinical decision maIUng and dis­ sequently, applying the normative data to a given charge status, and perhaps have greater func­ population or to predicting functional progress tional significance than peak torque values.'9 or discharge status must be done \vith caution, TABLE 16.2 Comparisons of upper-extremity 11lUsc!e torque STUDY SUBJECTS SPEEDS FLEXION! ABDUCTORSf EXTERNAL ROTATI ONI E XTENSION ADDUCTORS INTERNAL ROTATION Cook et 01.27 Mole pitchers 1 800/, 70-8 1 % 70-8 1 % and 76-99% NA 8 1 %° nonpitchers Soderberg and Moles, 600, 1 800, NA NA 57-69% Blaschak" nonothletes 300"/, Dovie,'(Ch. 1 2) 20 Mole, and 600 and 300°/, 60% Mole" 48% 66% Mole" 52% 64%° femole, females females Ivey et 01.29 31 Normals, 600 and 1 80°/, 66% Mole" 73% 61 % Mole" 57% 67%° mixed females females activity Alderink and 24 Mole" high 90°, 1 20°, 1 80°, 48-55% 50-57% 66-76%° Kuck'J school and and 300"/, college pitchers Hinton12 26 Pitchers, 90" and 240°/, NA NA 56-62%° high school Connelly·Moddux 21 Male,, 20 600/, NA NA 63% Mole" 7 1 % et 01.18 females females NA, /tOI available, " Data (rom 90" shoulder abducted posirioll. I S O K I N E TIC E VA L UA T I O N AN D TRE A T M E N T 409 However, userul and consistent concepts have TABLE 16.3 Exercise progress iol1 bas e d on the emerged from available isokinetic normative time/healil1g stages (earliest to latest) shoulder studies that provide general guidelines for clinical decision making. Multiple-angle isometrics (submoximal effort) Bilateral compa,;son testing, in which peak MultipJe·ongle isometrics (maximol). inertial torque at the injured joint is expressed as a per­ Short·orc concentric isokinetics Isubmoximal), inertial Short-arc isotonics centage of deficit compared with the uninvolved Short·arc concentric isokinetics (maximal) ("normal") side, is one method of interpretation Full ROM concentric isokinetics {submaximal) of isokinetic test data commonly used in the clin­ Full ROM isotonics ical setting. Unfortunately, this method fails to Full ROM concentric isokinetics (maximal) account for differences in strength that may arise (Adapted (rom Davies, j with permiss;oll.) from hand dominance, sports activity, occupa­ tional demands, and preexisting injury. Com­ mon disagreements on whether strenglh differ­ ences occur between the dominant and stage. Although full active ROM is not required, nondominant sides provide a dilemma for clini­ it should be painless at its extremes. [n postsurgi­ cal consideration. lvey et al.,29 Connelly-maddux cal cases, knowledge of the surgical procedure et al.,'8 and Reid et al.28 found no statislical dif­ (review of the dictated surgical report is ex­ ference between dominant and nondominant tremely helpful) is essential in determining di­ sides, ,while Alderinck and Kuck 13 concun'ed rection of resisted movement. Table 16.3 reviews with the exception of shoulder adductors and ex­ resistive exercise progressions that are effective tensors. In contrast, Cook et al.27 and Coleman3o preparatory stages for isokinetics and indicates described strength differences between sides in the appropriate timing of isokinetic resistance baseball throwers, and Davies3 determined 10 to modes. 25 percent differences between nondominant Isokinetic training should be applied after and dominant extremities. Perhaps, then, a small consideration of patient position, dynamometer strength difference should be expected in a pa­ position, and attachments. In addition, the pa­ tient with vigorous and repetitive occupational tient's scapular control, parameters of repeti­ or sports use of the dominant arm, but normal tion, rest periods, speeds, allowable ROM for the use in activities of daily living (ADLs) does not particular pathology, and stage of healing should produce an expectation for greater peak torque be considered. of the dominant side. Despite careful clinical planning with isoki­ When possible, industrial or sports pre­ netics, some patients will respond negatively screening with isokinetic testing provides an with val"ied inOammatory responses of the ten­ ideal situation to establish "normal" values for a don, capsule, and synovium, requiring immedi­ given individual that are useful if injury or dys­ ate treatment. The use of cryotherapy postisoki­ function occurs. netics is useful to prevent such symptomatic responses. Our clinical expel"ience, in agreement with Engle and Canner.'9 indicates that each isokinetic training session should be followed by Treatment Protocol$ continual reassessment of program tolerance and results, and progression to more challenging In general, isokinetic rehabilitation of the shoul­ training should be preceded by two or three trial der can be initiated when the joint complex has sessions of fixed intensity. progressed to tolerance of resisted exercise [n all cases of painful arc, joint restriction, through a given ROM. Fractures, dislocations, and instability, approptiate use of SlOps to block muscle tears, and other soft tissue injuries movement is necessary, especially when using should be well healed, stable, and past the acute faster speeds in excess of 1800/s. Blocking may 410 PHY S I C AL T H E R A PY OF T H E S H O UL D E R 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 meral instability problems require restriction of 60"/s t . Strength de�cit > 25% external rotation with abduction, while posterior 2. Potient too weak to generate torque instability requires restriction of internal rota­ at higher speeds tion with Oexion. J. High-speed mevement toe painfvll In choosing which speed to use in isokinetic 180"/s t. Strength de�cit < 25 rehabilitation, several criteria are used. The 2. low-speed controction too painfvl most simple determination is based on the evalu­ 3. Decrease joint reaction forces ation. For the most part, low-speed torque defi­ Velocity Trein at several speeds; simulate speeds cits require low-speed training, whereas faster spectrum used in normal activities speeds are used for high-speed deficits. Often, protocol Short-orc To ovoid painful ranges; possible however, deficits occur at both testing speeds, as contraction instability at end range the curves in Figure 16.2 indicate. In this case, Submoximum 1. Not ready for maximum effort at a helpful guideline is the "25 percent rule." That effort ony speed due 10 poin, is, if the strength deficit at the 60'/s testing speed contraction inAammation, incomplete healing, is greater than 25 percent, rehabilitation at that etc. speed is indicated. If the deficit is less than 25 2. Poor tolerance to initiol test done ot percent at the lower testing speed, training maximum effort should be at 180'/s or faster. There are several exceptions to this rule. As mentioned previously, the need to reduce joint siderations is 30'/s to 180'/s with common reaction forces may necessitate high-speed train­ starting speeds of 60'/s to 120'/s. ing even though major deficits at the low testing speed are found. The same is true for a painful joint when the patient will not tolerate move­ ment at the indicated speed. Contractile pain is General. Test and Warm-Up usually less at faster speeds, although occasion­ CO'fISiileratWns ally slow-speed exercise is tolerated belter. Other ways of lessening pain include submaximum ef­ Before maximal-effort isokinetic tesiing, it is im­ fort and short-arc contraction, which avoids portant to provide a warm-up stimulus to in­ pain localized to a portion of the ROM. Some crease intra-articular temperature and influence general guidelines for selecting speeds and pain­ the viscoelastic properties of collagenous tissues reducing protocols are listed in Table 16.4. Sub­ to reduce strain potential. Warm-up sessions can maximum effort training is sometimes done for consist of upper extremity repetitive, low-load a few treatment sessions prior to actual testing isolonics, and/or submaximal aerobics for up to of a patient who is not yet ready for the maxi­ 5 minutes' duration, avoiding muscular fatique. mum effort contractions that are necessary for Apparatuses such as the Schwinn AirDyne bilateral strength comparisons. Eccentric isoki­ (Schwinn Bicycle Co., Chicago, IL), UBE (Cybex, netics also present a major contrast to concentric Ronkonkoma, NY), or the pulley mechanism of speed selection. Because of inherent force-ve­ the Nordic Trak (Chaska, MN) can all provide lOCity curve differences between eccentric and the aerobic component. Warm-up repetitions are concentrics, eccentrics speeds for the shoulder then provided on the dynamometer with 5 to 10 must be much slower for both early and ad­ graduated efforts at 120'/s and five warm-ups at vanced applications. A useful clinical speed spec­ each test speed. trum for a variety of diagnostic and patient con- As a general rule, test speeds will vary fTom I S O KI N E T I C EV A L U A T I ON AND T R E A T M EN T 411 600/s to 3000/S.27 Based on clinical expe.-ience, TABLE 16.5 Velocity spectnllll re habilitatiol1 600/s is excessively slow for initial training and protocol test speeds because of the production of large REPETITIONS shear forces that are contraindicated in cases of PER SPEED acute injury, capsular sprains, and joint instabil­ S 10 60-90-120-150-180-210-180-150-120-90-60 ity. Davies3 and Soderberg and BlaschakI sup­ port early clinical training with intermediate (Adapled (rom Davies,J wil" penllissioll.) speeds (1200/s to 1800/s) and gradual change to velocity spectrum rehabilitation protocol (VSRP) with increased velocities up to 3000/s home exercises at this stage to promote full re­ and, finally, incorporating slow speeds 600/s to covery. 900/s) du.-ing late-stage rehabilitation. As de­ scribed by Wallace et al.,31 1200/s is easily con­ trolled and tolerated by most individuals and provides the basis for our preferred initial wal-m­ Updn.ted NorrJULtive and up speed. Punctinnal CO'I1Si.derations Maximal effort testing of the glenohumeral joint after most traumatic injuries, arthroscopy, Updated literature provides a clear consensus on rotator cuff pathology, or arthrotomy should not isokinetic torque normative data trends, but, it be instituted until good tolerance of submaximal remains difficult to make precise comparisons work has been demonstrated, at least 1 month of isokinetic norms due to large methodologic after the procedure. Retest sessions should be variations in test devices, patient populations, scheduled at I-month intervals to avoid negative patient test positions, and test speeds used. This reinforcement to the patient, owing to the pre­ section will review several areas of data impor­ dicted gradual changes in muscle physiology and tant in clinical judgement and patient program force development that may manifest only 5 per­ management with respect to normative data for cent increases per week.32 speCific sports, sport-specific torque shifts ex­ Questions regarding numbers of repetitions pected as a result of training, limited perspec­ and frequency of training sessions are difficult to tives on functional inferences (validity), and ec­ answer because there is great variability among centric Lo concentlic ratios for individual patients and the conditions requiring rehabilita­ muscles. tion. A recommended starting protocol for low speed diagonal training is 60 repetitions (e.g., six SPORT-SPECIFIC NORMATIVE DATA sets of 10 repetitions) at 1200/s. To avoid overuse, patients work out no more than three times a Although exact etiology is not yet proven, many week at regular intervals, with repetitions added studies concur that the propulsive phase (power depending on tolerance, until 90 repetitions are or accelerative phase) of overhead upper extrem­ pelformed. ity and shoulder motions produce a clear torque High-speed training can be progressed in a ratio shifts in many athletes, specifically in base­ similar way at 1800/s, although Davies3 recom­ ball, tennis, and swimming.34-37 Athletic torque mends the use of several speeds at each session, ratio shifts are most apparent for the external to using the VSRP-' Patients may build up to three interna1 rotation ratios and fOl- the abduction to sets of 10 at three different training speeds. Table adduction ratios. Possible training induced 16.5 is an example of VSRP. changes create disproportionate increases in the in general, when retesting shows strength torque levels of the propulsive muscles, the ad­ deficits to be reduced to 10 percent or less, isoki­ ductors, and internal rotators, without concomi­ netic training is discontinued. It is important to tant increases of external rotation or abduc­ emphasize functional activities and ongoing tion.13.34-36 McMaster et aP4 found 52 percent 412 P H Y S I C AL T H ERA P Y O F T HE S H O ULDER TABLE 16.6 Sport-specific 170mwlive torque ratios STU OY POPULATION POSITION ABO/ADD ERlIR Beach et 01. 37 28 OJ,,. 1 swimmers Prone 900 oW. 56% 70% (hondler el 01." 24 College tennis players Supine 90" abel. NA 60-70% McMoster et 01.3'4 27 College swimmers 45" obd Men 48% 45-57% Women 48% 57-74% McMaster el 01.38 15 Olympic-level water polo players NA 65-68% 67-75% Ng and Kromer39 20 Female college tennis players Scapular plane NA 78% Wilk et ol."'o 83 Pro baseball players Sitting, frontal plane 78-84% 65-75% wilk el 01:" 150 Pro baseball p;lchers Sitting, 90° abd. NA 61-65% wilk et ol."2 50 Pro baseball pitchers Sitting, frontal plane NW 93-72% W 77-89% NA Abbrev;aliotts: NW. llOl1willdowed data; W, windowed data. 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 The patient reported decreases in pain and in'ita­ There was widespread ecchymosis of the upperal'm to theelbow joint. Mild tenderness and bility, as well as a considerable improvement in hypomobility of the surgical scar were noted. case of ADL The following objective improve­ ments were noted: There was also tenderness of the supraspinatus, infTaspinatus, teres minor, and subscapularis muscles. Although these muscles were weak there was no significant atrophy. Right scapular mobil­ PASSIVE JOINT MUSCLE ROM REACTIVITY STRENGTH ity was normal. The cervical spine, elbow, and wl-ist regions were clear. Flexion 1 550 Moderate 35+ Treatments goals included full decrease in Abduction 1 460 Moderate 3/5+ pain and reactivity, shoulder joint ROM to 90 External rol. 450 Moderate 3/5 Internal rot. SO" low 3/5 + percent of the left side and muscle strength in­ crease to 80 percent of the left side. The main functional goal was pain-fTee resumption of all Based on these findings, treatment was al­ ADLs, and the ability to lie on the affected side. tered as follows: 84° low 4/5 + 4. and pine with the shoulder in 30° abduction in to return if any further problems arose. the plane of the scapula (POS). 2/s Extension RIL 3 + /4 . but the patient was within these parameters: 900/s. with minimal ADL restrictions. Difficulties with all ADLs. No deficit No deficit and return to work tasks including lifting of External rot. following deficit in mean torque. L-3fT-6 Extension No deficit No deNcil External rotation (60° elevated. size. respecting reactivity. Pain level to 5 to 7 with movements. employed as of the "super seven" rotator cuff exercises a fTeight and box handler in an industrial setting. The patient had surgery on September 7th and ROM and muscle strength were as follows. Internal rot. External rotation RlL. Physical therapy was ternal and ext�rnal rotation was begun discontinued at this time. ( . especially to increase ex­ The patient denied any previous injury to the ternal rotation. R arm supported in sling ROM REACTIVITY STRENGTH 2. but had minimal pain. with low resistance. 78°1 175° Flexion 1 4° 1 2% Internal rOlalion RlL. Submaxi­ mum effort contractions were increased gradually to maximum effort over three treatment sessions CASE STUDY 2 Progressive resistive exercises (PREs) in­ HISTORY cluded weighted wand exercises and most Patient A. Pain level at rest 3 External rot. The patient was able to lie and sleep on the injured side. Strength as follows Elevation (self-selected plane) RIL 2 + /5 . Functional goals-pain-free. 24% 26% boxes above head up to 35 pounds . especially dress- Flexion 1 72" Normal 5/5 ing and personal hygiene Abduction 1 66° low 4/5 + 3. Overhead ac­ INITIAL EVALUATION tivities were still somewhat difficult. was seen in the clinic on September 14th with the following phYSical status: PASSIVE JOINT MUSCLE I. patient su­ instructed to continue her HEP indefinitely. Mobility 90° PER SECOND 180" PER SECOND Elevation (supine. was continued along with maxi­ right shoulder or to the neck and presented to mum effort IKN exercise and PREs. the orthopedi t with complaints of inability to By the end of week 5 the patient reported lift his arm.1 5°)/88° Adduction No deficit No deficit 7. significant improvement in strength and mobil­ ity. I S O KI N E T I C E V A L U AT I O N A N D T R E A T M E N T 41 5 Pain modalities were discontinued. Concentric isokinetice testing revealed the Internal rOLation RIL 3 + /5 . is a 47-year-old male. normal ADLs Internal rot. 92° Normal 5/5 s. DISCHARGE Mobilizations were increased to grades 4 to External rotation and abduction were still mod­ 4 + . 6. erately weak. supine) Abduction 22% 1 9% RlL. assisted) RlL. Vigorous mobilization. and sustained a full­ WEEKS 4 A N D 5 thickness rotator cuff tear of 4 cm by 4 cm. but the patient's function was ap­ Concentric isokinetic strengthening for in­ proaching normal limits. 1994 when he porated in the patient's HEP slipped and fell backward onlO his dominant right shoulder at work. These were also incor­ He was injured on August 15.P. IS/50 contract/rest time Assisted concentric elevation from 1 10° to 150°. All exercises Ability to do dressing and ADLs slowly given for the home program will be designated Active assisted elevation: 98°. 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. 3 sets of 10 at 180° pine): 5° Electrical stimulation 12 minutes with med. fol­ MONTH 2 lowed by unassisted negative elevation fTOm PROGRAM 125° to 0° D/e pendular exercises STATUS St3l-t actual external rotation (in supine to 45° Minimal pain or stiffness with ADLs (HEP) Active elevation to 130° with controlled scapular Upper body ergometer (UBE): 6 minutes position Eagle row: 2 plates. rota­ tion (in supine) PROGRAM Passive concentric phase elevation to terminal. continue electrical stimula­ Active external rotation to 56° in supine (90° of tion abduction) Scapular mobilization in multiple planes ShoulderEase brace applied in place of sling for daywear only MONTH 4 Hold-relax stretches for elevation and ext. 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). HEP) Lido continued as above Grades 2 and 3 inferior glides to humeral head Ann lifts into flexion added with 2 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 TREATMENT PROGRAM STATUS Mild. active elevation to as H EP for home exercise program. su­ 1200/s. 80° Active external rotation: 33° External rotation strength: Grade 4 - M O N T I·I I PROGRAM MONTH 3 Active assistive ROM: Elevation and external ro- tation (HEP) PROGRAM Electrical stimulation: High voltage. 6 sets of 10 repetitions at Active external rotation (60° of abduction. negative unassisted in reverse range. fre­ Active assisted elevation: 98° quency. episodic pain and stiffness of shoulder Grouped in monthly progressions. 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. gram and protection of his arm/shoulder relative Although clinically useful normative data to safe biomechanics. 6 % better in L R Peak torque such as baseball pitching. safety. Phys Ther 49:735. with the goal of improved tient had achieved nearly normal ROM and con­ patient care and potentially new uses for isoki­ trol. the STATUS patient and glenohumeral positioning used. 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. it appears that the 45° position offers Isokinetic testing results: Plane of scapula supine the optimal compromise of physiologic. no apprehension with lifting netic technology as applied to the dynamic stabi­ or exertional activities. Whipple R. amount of patient effort. resolved pain. Similarly. lizer system that is so critical to functional ca­ pacity of the human upper extremity. certain injlll. exist. 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°. Laird C. Diagonal movements relate 2. 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. are involved. Moffroid M. internal/external rotation and strengthening goals [or clinical training. respectively. Simi­ striction of no more than 5-pound lifts larly. and impo. Summary References A method of evaluating and treating shoulder t . Toward underslanding the ler- . Holkosh J el al: A study girdle muscle weakness and joint dysfunction of isokinetic exercise. the isolated movements described in the to light duty work status with physician re­ isokinetic manual may be more helpful. external rotation-R/L to the shoulder.. 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. MONTH 5 Both isokinetic testing and training sessions PROGRAM should be preceded by warm-up techniques. 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. Al­ Elevation to 165° though both the neutral and 90° AP have specific Supraspinatus strength: Grade 5 .g. and was discharged. 1 969 has been described. the internal and external rotators. 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.es or surgical " epairs may ne­ cessitate isolation of movement to a cardinal plane with blocked motion as appropriate. the pa­ search investigation. in rotator cuff No pain with light lifting and all ADL'sReturned tears). this new area of isokinetic practice needs continued research. Rozier C. number of repetitions. existing clinical Despite the external/internal rotation torque protocols and positions require additional re­ imbalances and external rotation deficits. For specific weakness of a mus­ = 75°/88° cle or small muscle group (e. Same program with increased effort on Lido Clinical decisions with isokinetics include tim­ isokinetics and on inertial patterns as listed ing of application. advantages.·tantly. 1 98 1 strength in plane of scapula vs. Williams P. O'Rahilly R: Anatomy: A Re­ I I . Phys Ther 60: 1 t 52. J Bone Joint Surg 52:540. 2nd Ed. 1 989 7. 1 987 1 0: 5 1 . Salboe L. Coleman AE: Physiological characteristics of t h rough a velocity speclrum in di ffe!ing positions. J 011hop SPOl1S Phys 4:229. 1 03. Moynes 0: EMG Faci litation: Patlel1lS and Techniques. NY. 1 982 1 6. 1 988 1 987 1 3. A prel imi nary Harper & Row. Arch 1 5. 3rd Ed. Voss D: Proprioceptive Neuro-muscular 10. Am J Sports Med I I :3. Philadelphia. laCrosse. et al: Isokinetic WB Saunders.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. Am 9. Elsner RC. Davies G: A Compendium of Isokinetics in Clini­ J 9. Connelly-Maddux RE. 6. stability in throwing athletes. Gray 0. Calhoun J H . 2nd Ed. Rusche K. Gray VL. 1 980 testing of shoulder strength: normal valucs. 1 989 Shoulder antagonist strength ratios: a compali· 1 2 . Rylund KW. Welsh (cds): Surgery of the Shoulde!'. 1 983 Lexington. Lea & Febiger. Karlsson J: Force ve­ 23. Churchill 1 986 Livingstone. Lang J: Protocol fOI' 3 1 . In Donatelli R pitchers. Reid DC. locity relations and fiber' composition in human A plea for the plane of the scapula as the plane of knee extension muscles. EllenbeckerTS. 1 983 Bateman. Greenfield B. Davies GJ. 1 979 de!'. 1 985 and extemal rotation peak torque production 30. Gardner E. fects of position and speed on eccentric and con­ centric isokinctic testing of the shoulder rotators. J 011hop SPOl1S Phys Ther 7 : 1 63 . analysis of the shoulder i n pitching. 1 989 3. Mason OK. Perry J . 1 984 Phys Ther 1 0:488. Mun'lly WA: The power strength testing and rehabi l i tation of the upper available dul"ing movcment of the shoulder. 1 963 the rOlatol. reference for movement occurring at the humel'O­ 1 976 scapular joint. major league basebal l players. 1 984 shoulder. 1 989 4. New York. p. 1 988 5 . Einhom AR. Philadelphia. Cote C. Canner GC: Posterior shoulder instabil· cal Usage: Workshop and Clinical Notes. 1 967 25. Rasch P. J Appl Physiol 40: 1 2 . et al: Ef­ ent cOnlractile velocities. (ed): Physical Therapy of the Shoulder. Kibler WB. Ivey FM. Burke R: Kinesiology and Applied Anat­ J SPOl1S Med 1 8: 1 24 . frontal plane. 1 970 tem of the rotator cuff. 1 990 omy. I n Jackson OW (ed): Shoulder 32. Hageman PA. Kuck OJ: Isokinetic shoulder 28. Cybex: Isolated Joint Test ing and Exercise: A 20. Rathbun JB. In extremity. 1 987 1 4. Br J Surg 2:252. 1 985 lal muscle fiber hypel1rophy? Arch Phys Med Re­ 1 8. Rockville. Phys SPOl1S Med J Orthop Sports Phys Ther 8:5 1 8. 1 983 26. habil 69:28 1 . Wallace WA. 17. Phys Ther 59: netic peak torquc and work valucs for the shoul· 287. Si moneau JA. New York. Melton P: lsokinctic versus isotonic 24. J Orthop Sports Phys Ther 1 :264. Unpublished study. 3rd Ed. WB tric versus ecccnu-ic isokinetic strengthening of Saunders. Donatelli R. BUl11ham R: CUlTent Research strength of high school and college age baseball of Selected Shoulder Problems. Cook EE. 1 968 1'0 1'011. Cybex. Am J SPOl1S Med 1 6:274. 1 980 J 011hop SPOl1S Phys Ther 1 1 :64. Blaschak MJ: Shoulder intemal Phys Med Rehabil 66:384. Grimby G. Barnes WS: The relationship of motor unit activa­ 1 970 tion (0 isokinctic muscular contraction at differ­ 22. Whipple R: Specificity of speed of 2 1 . 1 988 . Philadelphia. New York. Uhl T: Isoki. J 011hop Sports Phys Ther 8:45 1 . Knott M . Tibone IE. Phys Ther 50: 1 693.cuff: objective data versus functional 27. W I . S & S ity: approach to rehabi litation. Hinton RY: lsoki netic evaluation of shoulder rota· son between college-level baseball pitchers and tional strength in high school baseball pitchers. Smith M. KY. AIdel'ink GJ. McNab I: The micro·vasculature pat­ exercise. Kibler WB. Engle RP. Wooden M . Warwick R: Gray's Anatomy. J Orthop Sports Publishers. Techniques in Ot1hoped· sU'cngth training protocols: do t hcy induce skele­ ics. Chandler TJ: Functional scapular in­ Handbook for Using Cybex IT and the UBXT. Jackson OW: Rehabilitation or the BC Decker. Johnston T: The movements of the shoulderjoint. 1 952 8 . Am J SP0l1S Med 1 6:64. Aspen Publications. Am J Sports Med 9: Comparison of isokinetic shoulder rotation 275. Wilkes J: variable resistance training. Rowinski MJ: Concen­ gional Study of Human Structure. MD. Barton MJ. Ronkokoma. Thorslensson A. Soderberg GJ. 29. Jobe FW. Savinar. Moffl"Oid M . Pedegrana LR.Nogue E. nonpitchers. LaGasse P. el al: Isokinetic Surgery in the Athlete. Medeiros J: test. . Fagerlund M el al: torque i m balances in the rOlator cuff of the elite Spl"imers and marathon runners. 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. 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. Greenfield B. 34. 1 989 . 1 994 tive athlete. lege tennis players. 1 992 42. Wilk KE. 1 9 9 1 knee exte nso. Storey MD. Krebs DE: Isokinetic." pe rfom1 ance renecl muscle size 39. Am J 44. Churchill-Livingstone. Caiozzo VJ: 1sokinetic 48. Kromer JS: Shoulder rotator torques i n and structure. Am J SPOltS Med 20:455. 1 987 females tennis and non-tennis players. AlbeIt MS (cd): Eccentric Muscle Training I n of the internal and external shoulder rotators in Sports and Orthopedics. Weir JP. 1 988 and adductor strength characteristics of profes­ 50. Tata GE. electrophysiologic and clin­ sional baseball pitchers. Arrigo CA.go CA: The Abductor ligament injUly.go CA et al: The 5 1 . and endurance in col­ 1 993. Wooden MJ. ical function relationships following tourniquet­ 1 995 aided knee alt h rotomy. Ar". 1 992 strength during concentric and eccentric muscle 35. Ng LR. Lorentzon R. Kibler WB. Beach ML. Caiozzo VJ: Shoulder 1 992 torque changes in the swimming athlete. Long SC. 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. JOSPT 1 5 :223. Chandler TJ. JOSPT 1 0:97. Wilk KE.stlcrs ac!"Oss age. Andrews JR: 1sokinetic test­ 52. Whitney SL. 1 995 trem ity range of motion and isokinetic strength 46. Phys Ther 69: 1 989 4 1 . 1 994 38. Wilk KE. 1 99 1 1 6:577. Andrews JR. Unpublished clinical study. Kramer IF: Shouldel' antagonist SP0l1S Med 20:323. Joha nsson C.? Acta Phys iol Scand 1 30:663. Dickoff-Hoffman SA: Re­ netic concentdc versus eccentric training o f lationship of shoulder flexibility. Han-ah A et al: Uppel" ex­ 30:S37. 1 993 players. Am J SPOl1S Med 23:307. 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 5 : 1 83. Loredan Co: Lido isokinetic normative values for 43. major league baseball players. JOSPT its relationship to throwing speed in the compeli� 1 5: 1 07. Doers isokinctic water po lo player. A m J SP0l1S Med 19:72. shoulder muscle perfonnance in teenage baseball Am J Spo rt s Med 2 1 :6 1 . Davis. JAT 36. N iehues SL. CA. Wagner LL. 45. 1 992 Am J Sports Med 22:5 1 3 . Ng L R . Am J SP0l1S Mcd 1 7:89. Campbell KR e t al: Isoki­ 37. 1988 47. Stracener EC et al: actions in the scapular plane. JOSPT 1 3: 49. abducti on and adduction strength at the shoulder 1 987 of high school wl. JOSPT 1 8:654. Am J SP0l1S Med New York.. Toy BJ: Concenu'ic and eccentric shoulder 1 992 strength evaluation of college aged females. Shoulder strength. HOllsh TJ el al: Horizontal shoulders. Ar". Cohen DB. Andrews JR. 1 9 9 1 ship in the thigh muscles after an lelior cruciate 40. power. Long SC. Kannus P: Peak Torque and total work relation­ 40. McMaster WC. Mont MA . Brown LP. Bartlett LR. JOSPT 1 6:262. McMaster WC. 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. primarily by the rotator cuff The understanding of these pathomechanics is musculature. dy­ anatomy can help restore stability. diagno is.ity. Negative intra-articular pres­ of abduction. crucial in making clinical rehabilitative and sur­ It has been estimated that 40 percent of the dy­ gical decisions.2 Since this initial report.es of stability factors repair and/or reconstruction of capsulolabral about the glenohumeral joint: anatomic.. Rehabilitation ad­ Pathorn£chanics dressing neuromuscular conditioning can strongly influence shoulder stability. and years. Gleno­ ligament in the adducted position. contributing to instability. MATTALINO Evaluation. tion· Inferior translation of the glenohumeral The shoulder joint has great mobility. Better diagnostic tools have led to better weakness of the rotator cuff musculature can presurgical visualization of shoulder pathology. and the rotator cuff interval por­ sure and dynamic compression forces by tion of the anterior-superior shoulder capsule. namic forces are contributed by the rotator cuff musculature and that removal of the labrum re­ duces these forces by half. InjUl)' to the labrum is the inferior glenohumeral ligament complex as thought to disrupt this atmospheric seal. ' Surgical There are three categOl. thus the primary stabilizer resisting ante"." The ament complex from the anterior aspect of the negative atmospheric pressure within the gleno­ glenoid.6 muscular forces. 3 of shoulder instability. are examples of these influences.or transla. The anatomic category in­ Bankhart initially described the detachment cludes the labrum. ' the inferior humeral stability is maintained via static and dy­ glenohumeral ligament complex at 45' and 90' namic influences. with joint is affected by the superior glenohumeral stability throughout its range of motion. 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. Capsular mechanics have greatly improved in recent lax. insufficiency of the glenoid labrum. and treatment of shoulder tion when the shoulder is at 90' of abduction. "changing a saucer to a bowl. and static. Arthroscopic surgery and The inferior glenohumeral ligament (poste­ open surgical techniques to correct shoulder in­ rior band) is the primary contdbutor to poste. Instabilities ANGELO J . namic. which adds depth to the gle­ of the labrum and the inferior glenohumeral lig­ noid surface. instability is a complex and constantly evolving Plastic deformation of the glenohumeral liga­ process.or stability patterns are evolving and still im­ stability of the shoulder when in 90' of abduc­ proving. scientific ex­ humeral joint is another important anatomic perimentation has further delineated the role of contributor to stability. 421 . The rotator cuff mechanism cont.ion the glenohumeral joint. this dynamic dericit of the subscapularis. [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. Physi­ structural weakness. and its dynamic support is negated with the shoulder bony landmarks of the AC. an encapsulating network throughout glenohu­ meral joint range of motion. begin­ helping to decrease anterior translation of the ning with forward flexion. InstaiJility Testing Patient History When testing for instability. should be obtained. in partic­ structures work in conjunction. 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. The magnitude and this book. SC. discem any motor and/or sensory deficits is per­ The infraspinatus muscle helps supplement fOlmed. Certain infor­ compare bilateral shoulders and check for natu­ mation should be obtained if not volunteered by ral laxity in other joints. Internal and external rotation should be rotation. but head biceps tendon. The static stabilizing traumatic event should be determined. the patient.un Strength levels need to be determined and compared to the unaffected shoulder. and what activities worsen and re­ lation. The dominant hand should be deter. rotator cuff insertions. Decreased extemal humeral joint. Remember that the long head of biceps measured at O· and 90· of abduction. abduction. scapulothoracic. The middle glenohumeral ligament con­ lieve the symptoms. direction of instability paltems can be deter­ mined by an astute examiner. in abduction and external rOlation.-ibutes "dy­ namic" support by compressing the surfaces of Objective Examinal.-ibute to anterior stability dur­ and supine. The subscapularis is considered the ness is recommended. Weakness Decision making is very dependent upon the secondary to pain should be discemed from true clinical subjective and objective findings. by Range of motion should be compared. Palpation for areas of tender­ duction. anteriorly over the long most important in decreasing displacement.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. Clinical. 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. 7 rotation is often encountered in shoulder insta­ bility patients. it is essential to Listening to the patient is crucial. portant in preventing anterior and inferior trans­ frequency. tional demands required of the affected shoul­ The inferior glenohumeral ligament is most im­ der. A neurologic exam to herent in the "cocking" phase of throwing. which are in­ and glenohumeral joints.d shift test can determine both . 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. both silting is also felt to cont. using local anesthesia if cal examination in the clinic and operating room necessary. Examinati. and together providing tions. and exten­ glenohumeral joint during extremes of extemal sion. Description and location of symptoms. The load UI. Onset tributes static stability by resisting extemal of the problem and specific description of any rotation and abduction. " Variation in the degree of horizon­ ferred symptoms. (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. 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. 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. but it . Hill-Sachs might report pain or apprehension with the defects. defined as the humeral head glid­ notch view. Grade l. Feel for a "clunk" as the humeral head A thorough and complete musculoskeletal potentiaJly translates anteriorly and/or poste­ examination of the neck. the examiner should feel dislocation force to the humerus. INSTABILITIES 423 anterior and posterior glenohumeral joint insta­ and/or pain dissipates with a subsequent force bility.9 With the patient elbow (flexed at 90") and the other hand placed in the sitting position. s usually considered to indicate evidence of p. The patient is placed in the supine posi­ directed posteriorly. defined as the humeral head riding the clinic to evaluate shoulder instability. and riorly. and (4) Stryker 4. cervical spine. This apprehension cial in identifying rotator cuff pathology. Bankhart lesions. Standard radiographic studies can be taken in 2. 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. 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. The examiner applies posterior due to shoulder instability. defined as a small amount of hu­ Instability meral head translation. tion. The use shoulder in external rotation and abduction with of magnetic resonance imaging has been benefi­ the anteriorly directed force. defined as the humeral head glid­ with the humerus in internal rotation. This up the glenoid but not over the rim. a positive "clunk" test can be indicative of elbow should also be performed to rule out re­ a labral tear. Arthrography translation has been performed. palpate the glenohumeral just distal to the humeral head. moved. The axillary view can reveal the tion. more invasive diag­ force to the glenohumeral joint after anterior nostic imaging can be performed. Next. A positive test for "play" posteriorly and/or anteriorly in the gle­ will produce a palpable and/or visible divot in nohumeral joint. both anteriorly joint laterally and apply an inferiorly directed and posteriorly. and intra-articular loose bodies. This test has a grading system: Irrwging Studies jor Shoulder l. Patients with anterior instability sular redundancy. Grade III. This finding can indicate prior capsular in­ to the shoulder applies force in an anterior direc­ jury at this area. 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. tal adduction and abduction may allow the ex­ aminer to reproduce familiar symptoms for the patient. Trace. 'o Studies have found the Stryker symptoms of instability. (3) prone axillary 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. then the examiner's hand placed posterior noid. the knee.-ior episodes of glenohumeral instability and/or frank dislocation. author prefers these views: (1) scapular AP view 3. much like the Lachman test for the lateral aspect of the shoulder. cap­ nal rotation. Grade II. tion. with good pre­ the sensitivity to identification of labral and cap­ liminary results. thus improving tion both done arthroscopically. Suretac transglenoid utures. baseball pitching. Open reconstructive procedures such dancy and injury without concurrent effusion. been described in the orthopedic literature. ating soft tissue pathology in patients with shoul­ For the overhand athlete. limited range of motion. but on the return to preinjury level of activi­ The role of surgical intervention in the case of ties. The anterior capsule is en­ throscopic repair. proaches and thus employ them as individually MRl can underestimate capsulolabral redun­ indicated. 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. occasionally patients are anterior capsulolabral reconstruction. or . when an early. for example. The throwing athlete. as capsular shift and open Bankhart repair are In this author's experience. Thus arises the most recent ferred to as the open Bankhart repair. when deciding which surgical tech­ niques to employ.OIl tions. in par­ classically achieved through drill holes and more ticular the external rotation needed. it is crucial to be mindful of a patient's expectations. Presently. bone block transfer. the two most consistently employed Though some of these procedures provide con­ are the open Bankhart reconstruction and the sistent "stable" results. 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. Thus. recently with other bony fixation devices-bio­ I recognize the pros and cons of both ap. muscle shoulder "instability" without some associated transfer. 17. 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. intra-articular gado­ recommended to individuals who have a history linium-enhanced MRl has been reliable in evalu­ of multiple frank dislocations. morbidity. for example.1).424 PHYSICAL THERAPY OF THE SHOULDER is not as reliable in diagnosing labral pathology. that is. cal bone. absorbable tacs. As exemplified by the many different surgi­ More than 100 open surgical procedures have cal procedures that have evolved over the years. The an­ athletes involved in contact sports such as foot­ terior glenoid neck is debrided to exposed corti­ ball and rugby. Open reconstructive proce­ tered anteriorly in a vertical fashion where the dures have been traditionally recommended for capsule attaches 10 the glenoid medially. They no one procedure has consistently con'ected basically involved capsular tightening. unable to return to their preinjury level of activ­ ity due to certain postoperative physical limita­ Open Bmlkharl ReCOrISIl1/ct. shoulder instability is to repair or reconstruct the pathology and stabilize the glenohumeral OPEN RECONSTRUCTION TECHNIQUES joint with minimal surgical morbidity. aggressive reha­ sular pathology. I emphasize that a suc­ Sur[Jical /nterventiJm for cessful surgical reconstruction is based not only ShouIiJer /nc. bilitation protocol is followed (see case study I). The attachment is without compromising range of mOlion.tabil:ity on obtaining stability and a low reOCCUITence rate. J favor arthroscopic stabiliza­ articularly via fluoroscopy to produce capsular tion. and/or osteotomy.2 •12 The controversy of open versus arthroscopic surgical Bankhart reconstruction attempts to anatomi­ reconstruction for shoulder instability. Gadolinium is injected intra­ throwing athlete. particularly the der instability. Most recently I have combined the laser distention and improved labral-capsular con­ capsulon'aphy technique with anterior stabiliza­ trast depicted on MRl images. 25 with perl11issiol1. A B Rop c o I .1 (A-E) Ba/wkhart reconstruction to correct the primary stabilizer of the shOtdder and the il1ferior glenohumeral ligal11el1lolls coll/plex. FIGURE 17. INSTABILITIES 425 I .j E .. (Frolll Hawkins et al. T-shaped incision. 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. flap. 17-2).}6 with permissioll. in particular multidirec­ added to these redirected leafs ror rurther tight­ tional instability. The capsule is rior surgical approach. according to prererence or the then incised rTom the glenoid margin rOlming a surgeon.. because the subscapularis is not de­ soft tissues to heal and promote normal joint tached. bilitation consists of progressive increases in less deficiency of external rotation with abduc­ range or motion and stretching. 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. (From Jobe et al. The capsule is then reflected from the sub­ Opel/ Repair of Posterior Illstability scapularis in a medial to lateral direction. It is also thought to cause less ening ancIJor reinforcement of the repair. (B) Superior shift of the inferior capsular flap and il/ferior shift of the superior capsul". Labrum A B FIGURE 17. its upper two thirds and lower one third junc­ tions. This involves more ag- 2. 13 Rather than detaching the subscapu­ arthrokinematics and upper extremity strength laris tendon. Shifting or the inrerior lear or the capsule obliterates any redundancy or the capsule.426 PHYSICAL THERAPY OF THE SHOULDER suture anchors. Reha­ resultant range of motion deficits. which allow the tion. More sutures may be shoulder instability. The superior lear is then shirted inferi­ Ope/1 Capsular Shift Procedures orly.2 (A) T-shaped incision ill the glenohumeral joil7l capsule alld sYllovial lilling.) . in particular. it is split in line within its fibers at (see case study 2). A similar T-shaped capsular del' should be examined first. >o laser capsulorrhaphy. arthroscopic or open stabilization procedure. At stages of the rehab process. shifted superiorly and to the glenoid's anterior . 17. posterior. pillow/brace at about 20· of abduction for 4 to 6 Next the anesthetized patient is positioned weeks.3). the surgeon must decide that the clini­ ion. Strengthening exercises that develop the ante­ Many different arthroscopic stabilization rior musculature. The and then both are allached to roughened bone clinical examinations addressed earlier in this on the humerus. such as the subscapularis. and external rotation range of cal diagnosis of any instability pattern has been motion is followed prior to the progression of confirmed. The obvious reason is that from its humeral insertion. " Regardless of the specific stabilization tech­ Arthroscopic Techniques for nique employed by the surgeon. are techniques have evolved over the years.-tion at the tent of instability patterns. partial rotator cuff tears. and inferior insta­ lar shift. '9 and glenoid abrasion without internal fixation. 17. CT scan. Progression of flex­ this point. the or MRl studies. If the capsule best diagnostic tool for shoulder instability.ion are not indicated due to the stress im­ surgeon vary from resorbable tacks. La­ is redundant and/or reattached inferior to the an­ bral pathology. Second. to protect the posterior of labral tears. Diagnostic arthroscopy is then begun in rotation and horizontal adduction ranges of mo­ the usual fashion. gical decisions on the affected shoulder. and/or intra-articular loose bod­ from its allachments ( Fig. With and/or bony block of the posterior glenoid. INSTABILITIES 427 gressive inferior capsule detachment and Examination under anesthesia is the first superior advancement. removal of loose bodies. two steps should Shoulder Instahilil:ies be followed prior to fixation. patients often have inherent laxity.19 metal sta­ pling. partial rotator cuff tears. The unaffected shold­ greater tuberosity. Arthroscopy can be employed capsuloligamentous complex is grasped and preceding open stabilization procedures. documenting any bilateral discrepan­ and external rotation during the posterior capsu­ cies in anterior. infraspinatus is dissected from the posterior cap­ the surgeon can more accurately discern the ex­ sule and cut diagonally fyom its inse.18 suture anchors. followed by the incision is employed approximately 4 to 6 mm pathologic shoulder. 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. with the metal staple introduced by Johnson in Closed-chain exercise with the shoulder in 90· of the I 980s.-thro­ proach can employ a posterior capsular shift scopic procedures of shoulder instability. pending on the fixation technique selected. transgle­ parted onto the posterior capsule. starting emphasized. and if so then proceed with either an internal rotation and horizontal adduction. depend­ Arthroscopic evaluation of the shoulder is the ing on the pathology encountered. The first is prepara­ tion the capsuloligamentous complex. abduction. The direct posterior ap­ stage of surgical treatment both open and a. it should be dissected free lar redundancy. The patient is placed in an abduction bility. 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. Internal geons. as well as the scapular stabilizers. The muscular relaxation induced during anesthesia. and/or any zation is strictly contraindicated in the early other pathology encountered is performed. 16 Present options for the arthroscopic flex. chon­ capsule."·'5 Arthroscopic debridement tion are limited initially. capsu­ terior glenoid margin. 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. Rehabilitation following a posterior cap­ either in the lateral decubitus or "beach-chair" sular shift to stabilize the patient with posterior silling position. noid suturing. de­ ies are often not seen on arthrography. and the use of a posterior glide mobili­ dral defects. " I have used the Holmium YAG laser effectively in the shoulder for debridement and FIGURE 17.11 with perm. suraf ce. 1 7. laser system and pres­ ently with the Holmium YAG laser. moved wilh a grasper while usil7g a banana and its strength diminishes over the next 4 to 1 6 kni{e or shoulder elevalor.6). The polyglyconate tac biodegrades. r have had short-term success with successful stabilization.) membrane (Fig.428 PHYSICAL THERAPY OF THE SHOULDER My prefen'ed technique for arthroscopic sta­ bilization is the Suretac biodegradable tac. if the surgeon feels optimal ment of the capsular ligamentous tissue (Fig. (From Esch and weeks. a successful stabilization arthroscopicaliy is good visualization during the arthroscopy. The biodegradable tac has a pullout strength of 1 00 N and a broad flat head with spikes on its FIGURE 17.) sulaligamentous structure commonly found in . Visu­ alization is dependent on proper portal place­ ment and employing appropriately angled ar­ Laser throscopy. beginning with the CO. tightening of redundant tissue has not been ac­ 1 7. essential to YAG Laser capsulorraphy techniques. which emits a wavelength of 2. The plastic defonnation and redundant cap­ permissiol7..ission. it should avoid the potential posterior complications associated with transglenoid drilling and/or posterior sutur­ ing.5).4 The anlerior labrum is decorticared resection of labral tears during shoulder arthros­ wilh a burr or rasp 10 provide a bleedil7g bony copy. and ablate cartilaginous tis­ sues. The surgical repair technique is similar to the transglenoid suture technique. resect. The lissue is and control.22 Though technically demanding.4). it is eventually reabsorbed by the synovial Baker. The Holmium YAG laser has been shown to produce a minimal amount of thermal necrosis and can precisely cut. was observed in a clinical study comparing laser versus conventional meniscetomies in knee ar­ throscopy.1 mm and is transmitted through optical fibers in a saline medium. 1 7. and accelerated reattainment of full range of motion. The glenoid neck is debrided and decorti­ by employing the Holmium YAG laser capsulor­ cated to exposed bleeding bone prior to reattach­ raphy technique.3 The capsule-labrum complex is underside to enhance capsular tissue purchase mobili<." Less postoperative pain and sweUing. Also. '9 The capsuloligamen­ tous tightening can be enhanced with the trans­ glenoid suture technique used in conjunction or ridge. These two steps are the most crucial to a complished. with potential to repair Bankhart lesions and fixate the shifted and tightened inferior glenohumeral ligament complex (Fig. These types of procedures are not for the novice or "occasional" arthroscopist! I have used lasers in arthroscopic procedures.ed ul7li1lhe lissue is {ree. no matter which of the the combination of the Suretac and Holmium fixation techniques is selected. Fur­ capsular shrinkage can be achjeved with the ap­ ther laboratory and clinical outcome studies are plication of nonablative laser energy without det..Ising the Suretac biodegradable taco After removing the drill. When tapping the SUI'etac into the glenoid. (Courtesy of Dyol1ics Corp. which can be cases. �. Al1dover. " 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. 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. needed to confirm the potential. particularly in the overhand athlete. A second Suretac is placed more proximally in a similar manl?er (C). the Suretac is placed over the guidewire and the Suretac driver is used to seat the Suretac (A). INSTABILITIES 429 B A FIGURE 17. Reports on studies in­ cent of 41 patients. controlled by the amount of energy delivered via Fanton had excellent clinical results in 93 per­ the Holmium YAG 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. 18 laser. which are cUITently under clinical study.) 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. avoid overpenetratil?g the ligament (B). The procedure . The guidewire is thel? removed through the driver to el?dure easy removal of the guidewire. Early success has been observed in these capsuloligamentous structures. 14 A study demonstrated that signjficant terns.5 Surgical repair /. " Postoperative treatment is described der shows only I° of anterior translation. Capsular mobility of the pair with or without capsular shifting as indi­ uninjured shoulder shows 2 + antedor transla­ cated. The left postoperative sholll­ observed.6 Mufliple SLllures are passed through the sil1gle drill hold. The pa­ loligamentous structures. and there is marked hyperexten­ medium to perform capsulOlTaphy of the capsu­ sion of the MCP joints on both hands. and 55° of internal ARTHROSCOPIC ANTERIOR rotation with arm abducted 45°. with in case study I. \Y INITIAL POSTOPERATIVE MANAGEMENT The patient is immobilized for the first 1 0 to 1 4 days in a sling. She underwent an arthroscopic antedor sta­ bilization using Suretac bioabsorbable tacks and a laser capsulorraphy using the Holmium: Vag laser. Ice is used to control postoperative pain. Nonoperative physical therapy and continued exercises performed with the left shoulder did not reduce her feelings of instabil­ ity. The patient is given grip pully and instruction for distal range of motion for the elbow forearm and wrist. with 3 to 4 continued incidences of subluxation and feelings of insta­ bility with aggressive overhead movements dur­ ing volleyball. with scapular winging and atrophy in the infTaspi­ anterior stabilization andior Bankhart lesion re­ nous fossa on the left. 0° REHABILITATION FOILOWING to 1 5° of external rotation. (From Esch al1d Baker. gentle manual resistance. The patient is STABlllZATION WITH LASER able to volitionally contract the internal and ex­ ternal rotators on initial exam. CAPSULORRAPHY SUBJECTIVE INFORMATION INITIAL TREATMENT (WEEKS 3-4) 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. Pas­ CASE STUDY 1 sive range of motion of the left shoulder is ini­ tially 0° to 95° of nexion. . and history of anterior instability in her left shoulder.) (3 WEEKS POSTOP) Examination of the patient shows moderate is performed during shoulder arthroscopy. using the Acufex Suretac system for fixa­ tion with a load and shift and supine capsular tion. with removal o f the sling only for range of motion of the elbow to prevent nexion contracture. multiple angle isometrics for shoulder lRlER. The tissue shrinking tient shows increased physiologic laxity of her described by other authors has been consistently upper extremities.430 PHY SICAL THERAPY OF THE SHOULDER She initially incurred an antedor dislocation that required reduction. FIGURE 17. further clinical testing deferred at this time due to the patient's acute postoperative nature. The elbows passively hyperextend under direct arthroscopic evaluation in a saline 1 5° bilaterally. The Holmium YAG laser is then employed mobility test. 22 INITIAL POSTOPERATIVE EVALUATION AND TREATMENT with permission. 0° to 60° abduction. Plyometric exercises consisting of chest activities such as skiing. He is involved in precarious sporting postop. . Isokinetic exer­ over time.to 4-week period without range of motion and joint mobilizations such as overhead hilling or selving. anterior glides are not per­ arm. The injury and sur­ eccentric loads inherent in sport activity. For functional reasons. the patient's range of motion is D· right handed. 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. Specific closed-chain exercises. however. The pa­ used to facilitate ROM and control discomfort. Internal rotation of external rotation. Modali­ percent. 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. Closed-chain exercises are em­ OPEN CAPSULAR SIllFT ployed to enhance scapular co-contraction using SUBJECTIVE INFORMATION therapeutic balls and wall push-ups. as well as achieving a full functional range of mOl ion. He was immobilized for 2 weeks to 1 75· of flexion. and 45· speeds 90·. The patient is a 30-year-old male who initially dislocated his shoulder 2 years ago while snow­ WEEKS 10-16 boarding. tient's current range of motion at 6 weeks postop is D· to 1 60· of flexion. and are approximately 1 0 to 1 5 percent ties such as electric stimulation and heaUice are below the desired 66 percent standal·d. with ex­ exercises. and a general scapular program with ternal rotation slowly progressed to 90·. and D· to 60· of internal therapy. Range of motion limi­ vealed 1 5 percent deficits in external rotation at tations of IDO· of flexion and abduction. At 1 4 gery occurred to his right arm and the patient is weeks postop. Over the course of a 2-year period. snowboarding. D· to following surgelY without any movement or 85· of external rotation. 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. tient continues with rehabilitation on a three times weekJy basis with continued emphasis on TREATMENT rotator cuff strengthening. 21 D·. D· to 55· of external rotation. 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. and passes and medicine ball catches are used to pre­ mountain biking. and 300·/s. D· to ISO· of abduction. INSTABILITIES 43 1 bicep and tricep. An isokinetic test shoulder in a sling. D· to 125· of abduction. and scapular protraction/re­ performed in the modified base position re­ traction arc emphasized. 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. and hopes to return to these pare the shoulder for the rapid concentric and activities following surgery. and D· to 45· of internal rotation. with a gradual pro­ the posterior glide. 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. He presents to physical therapy with his rotation with 90· of abduction. Strengthening exercises are CASE STUDY 2 progressed to isotonic PREs. Her intelval return to vol­ emphasis is placed on regaining intemal rotation leyball includes a 2. ERlIR unilateral strength ratios are 55 to 60 formed to protect the anterior capsule. emphasizing rota­ tor cuff-dominant movement pallems and scap­ REHABILITATION FOLLOWING ular stabilization. and a J . with progression patient is using a 5-pound weight for his isolated into manual resistance by the fourth postopera­ rotator cuff exercises. PROM is initiated within the ticular emphasis on posterior glides to enhance ranges of J 00° of flexion and abduction as toler­ both flexion and internal rotation range of mo­ ated.5-pound shoulder is 90° of flexion. this level rubber tubing. Low resistance and high repetition and is fully intact to light touch sensation imme­ formats are followed. tricep. 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. flexion. 20° of external rotation at 45° of abduction. tolerance of a minimum of 3-pound isotonic ro- . forearm. 80° of external rota­ tion with 90° of abduction. Rotator cuff strengthening begins with no weight in patterns within the allowed ranges The patient has a well-healed anterior incision. At 6 weeks postop. as well as caudal glides. and gentle manual resistance for the plyometric exercises initially with the therapeu­ bicep. and 60° of internal rotation. rows. Continued passive stretching and gleno­ Sling immobilization continues until the fourth humeral joint mobilization are applied with par­ postoperative week. At this time the goals for the patient are for the gradual reattainment of full terminal ranges of INITIAL TREATMENT (WEEKS 2-4) motion. diately sUITounding the incision. is used modified base position is recommended. 1 55° of abduction. scapu­ tic balls. The initia­ the healing anterior capsule. and progressing to medicine balls. Gripping exercises with putty strengthening program is advanced to include are used. wrist musculature. The patient's left shoulder has J 45° of flexion. lothoracic protractors. and no hypermobility is noted at the ating rotator cuff strengthening exerci es with elbows or MCP joints. The cri­ to improve kinesthetic awareness and promote terion for isokineLic exercise progression is the strength via the co-contraction of scapular mus. and full internal ro­ tion. with moderate ular musculature. with the patient in a supine position. Range of motion at J 2 weeks postop is J 70° of and 50° of internal rotation.·otation. J J 0° of abduction. tion.432 PHYS ICAL THERAPY OF THE SHOULDER INITIAL FINDINGS culature. and 50° of internal rotation. At J 2 weeks the and performed as tolerated. and is also using medium­ tive week. 0° of weight. By the fourth postoperative week. of motion. Initial PROM of the right light-resistance rubber tubing. Shoulder shrugs. 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. 45° of ab­ shows I° of anterior translation with a load and duction. and 65° of internal TREATMENT rotation with 90° of abduction. WEEKS 4-6 WEEKS 12-20 Continued use of passive and now active assistive and active range of motion is followed. Submaximal isometrics for cuff strengthening are advanced up to as-pound the internal and external rotators are initiated maximum level on this patient. Mild atrophy and closed-chain pendulum exercises over a of the deltoid and pectoralis major muscles is therapeutic ball are used to strengthen the scap· noted when compared bilaterally. The patient's tation as tolerated. A 6-pound medicine ball is patient has J 20° of passive flexion. the patient infraspinatus atrophy. PREs for rotator glenohumeral joint. 50° of abduction. and retractors is per­ Weight-bearing protraction step-ups are used to formed with both support and protection of the enhance scapular sLabilization. 90° of abduc­ controlled during the plyometric exercises. 0° of external rotation. No further special testing of the shoulder is per­ formed at this time due to the patient's acute WEEKS 6 -12 postoperative nature. external . He is toler­ shift test. . JOSP 1 8:365. AlTigo C: Current concepts i n the "eha­ bilitation of the athletic shoulde. a satisfactory clinical patient shows external rotation strength to be 5 exam with respect to impingement. and 4. Bankhal1 A: The pathology and treatment of re­ greater internal rotation strength at the three cun"cnl dislocation orlhe shouldcrjoinl. J Bone Joint Surg 62:897. 1 948 to perfOlTn the sport-related movement patterns 1 3 . I n Rockwood CA. Clin Orthop 1 94 : 1 53. Fue FH: The role of a plus. No der problems. Fegain J . 85° of external rotation. Jobe FW. In­ 3 . 1 980 standard open-chain rotator cuff and scapular 1 0. Hanyman D. 1 990 tivities. lobe F. Criteria for progression 1 2 . Weiss C el al: The roentgeno­ Traditional interval return programs. NeeI' C. Bankhart A: Discussion on reCUlTcnt dislocation of the interval programs are adequate strength the shoulder.. 1 938 training is cutTently tolerated by the patient. Am J Sports Med overhead stretching for interior capsule) to 20:675. Abbot H: Modified axially roentgenogram. References WEEKS 2 0 . 1 49. Addi­ rotator i ntelval capsule in passive motion and sta­ tional home exercise is given to this patient in bility of the shoulder. 1 972 exercises. Active range of motion is 1 75° of flexion. are discussed ity. Interval sport pro­ 6. DengX. 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. Rodosky MW. and wall push-ups with the long head or the biceps muscle and superior partner overpressure. 1 988 The patient is discharged to a home exercise 5 . 1 992 . Wan'cn R. Wilk 1(£. 1 994 pact often incurred in his precarious sport activi­ 8. Br J Surg testing speeds. However. seated press-ups. and tion or the glenohumeral joint. Pain-free isotonic and isokinetic 26:22. to attempt to prepare the glenoid labral in anterior stability of the shoulder. such graphic evaluation of anterior shoulder instabil­ as those for throwing and tennis. 01-· thop Rev 1 8:963. inclusion of plyometric and 9. WB Saunders. I I . Boker D: Clinical evaluation of shoul­ ties such as skiing and snowboarding. O'Brien S: Capsular restraints lO the 65° of internal rotation measured with 90° of in­ abducted shoulder: A biomechanical study. Or­ ternal rotation. An isoki­ of glenohumeral joint ER. 1 985 elsewhere in this book. thop Trans 1 2 :727. Ph ila­ lent trauma often incurred in these sporting ac­ delphia. Kivitne RS: Shoulder pain in the over­ dependence is gained in the strengthening pro­ hand or throwing athlete: the relationship of ante­ gram. Hawkins R. and instabil­ percent weaker on the postop extremity. Harner CD. Rubenstein D. p. WalTen R el al: Static capsuloli­ program. Matsen amount of preparation will be sufficient for vio­ FA IU (eds): The Shoulder. athletes. push-ups with 1992 7. Roukous J. 1 992 maintain range of motion. Sidles J. Warner J. Pavlov H. Matsen F: The role of lhe grams are normally initiated at this time. An isokinetic evaluation at week 20 postop shows 1 993 equal external rotation strength and 5 percent 2. the closed chain such as push-ups. adequate range of mo. J Bone Joint Surg 74:53. 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. thus placing increased netic test performed at 1 4 weeks postop on this valgus stress on the elbow). dor instability and rotator cuff impingement. and cor­ ity testing (TSE). J Bone Joint Surg 30B:46. responding internal rotation strength to be 20 to 25 percent weaker across the three velocities tested. J Shoulder Elbow 1 :229. patient's extremity for weight bearing and im­ Am J SPOl1S Med 22: 1 2 1 . 1 989 1 65° of abduction.2 8 1 . and full range of motion tion to prevent injury to adjoining segments (lack within the isokinetic training ranges. Sc!nvaT1Z R. and will lise pulleys and capsular gamentous restraints to supeIior-inferior transla­ stretches (cross body for posterior capsule. Clinic On hop 82:84. INSTABILITIES 433 tator cuff exercises. Lippitt SB: Atlas of Shoul­ 1 9 . Skyhar M . Baker C : Ante. Am J Sports Mod 23:482. Al-t hroscopy 7:3 1 5 . St Louis. Markel M .or Inslability. 1 995 nique.. Wan·en R: Shoulder ar­ 22. 1 988 propert ies: art in vitro mechanical study using a 1 8. 1 05 . Bramhall J. New York. Church­ tion shoulder without the use or intemal rixation. Hawkins RJ. 1 99 1 1 5. Bell RH. Caspari R: A11hroscopic reconstruction for ante· 24. Philadelphia. 1 994 1 7 . Johnson LL: Symposium on Arthroscopy.. Techn Olthop I : 1 84. p . Techn Orthoped 3: or nonablative Laser energy on joint capsular 59. Olthopaedic Knowledge meeting. p. Oper Techn Orthop I : 1 80. Thabit G: orthopaedic uses or a11hros­ throscopy Associalion of North America annllal copy and lasers. SC31-pinlo D. Warren R : Arthroscopic Bankhm'L rc­ capsulolabral reconstruction or the shoulder in pair lIsing a cannulated absorbable fixation de­ athlet. Wolf E : Arthroscopic Bankhart repair using su­ der Surgery. Maki N: Arthroscopic stabilization: suture tech­ rabbit model. Redler M . sition.434 PHYSICAL THERAPY OF THE SHO ULDER 1 4. 1 99 1 26.or 20. AI"lhroscopy 4:256. Ar­ 23. MOS. Eisenberg J . 1 988 JB Lippincott. 1 993 1 6. 1 99 1 . p. 1 996 ture anchors. Oper Techn On hop I : 1 92. Giangan-a CE. 47. In Andrews bilization or the chronic subluxaLing or d isloca­ JR. Hecht P: Arthroscopic sta­ arthroscopy of the shoulder. Am J Sports Med 1 9: vice. ill Livingstone. Hayashi K. Andrews JR: Operative 2 1 . March 1 986 Update SPOltS Medicine. San Francisco. In: lhr"Oscopy with the patient in the beach-chair po­ Surgical Arthroscopy: The Shoulder and Elbow. Fanton G. Jobe FW. 1 99 1 428. Altchek D. Mosby-Year Book.es in overhand Sp011S. Wilke K (cds): The Ath lete's Shoulder. 1 994 abstracted. 99. Kvilne RS et al: Ante. Esch J . 1 99 1 25. Thabit G et al: The effect dol' shoulder capsulorrhaphy. Warner J . Rotator Cuff Repairs JOSEPH S . and infraspinatus sec­ load-type forces are placed on the rotator cuff. These mechanisms can injure the the primary cause of rotator cuff disorders. secondarily.6. 18. thus placing a large distraction force Previously it was believed that impingement was on the arm. 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.5. ath­ and tendon ruptures Fig. 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. Eccentric overload of the rotator cuff rotator cuff. in­ capsule and other muscles of the shoulder. such as when a great force is applied to the abducted arm while the rotator cuff is active.2. 18. which causes rotator cuff tears ment causes the same type of wear pattern. Secondary impinge­ ment syndrome. 18. An cluding tears. resulting in overuse and fatigue. Instability can cause fraying precipitating activity. and its integrity should be evaluated. Other causes of rotator cuff tears are calcific tendinitis Fig. 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.3 Tears in older patients are primar­ can also be involved in the impingement syn­ ily the result of coracoacromial arch abrasion4 drome.3. 1 . They may be traumatic or of either the upper or lower surface of the cuff degenerative.5 tumors: and degenerative changes of the coracoacromial joint that produce inferior spurs Fig. 18. The subscapularis letic patienl. 18.4. The Instability patterns can also produce impinge­ subscapularis should be used cautiously in a re­ construction procedure.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. extrinsic overload. The c1ini- 435 .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. and is probably the cuff that subsequently leads to rotator cuff tears most common cause of tears in the young. ondarily-they are the most fTequently torn Acute tears of the rotator cuff can occur fTom muscles of the rotator cuff Fig. Fiber failure can also occur from chronic tendinitis. Patients with primary impingement muscles. 18. largement of the tendon Fig. including those space from either bony encroachment or en­ of the rotator cuff. Because of their locations-the su­ depending on whether impingement or over­ praspinatus primarily. causes have fraying of the upper surface of the rotator fiberfailureofthe rotator cuff. Infraspinatus m.3 Calcific deposit lVithil1 the and flexed positiol1.436 PHYSICAL THERAPY OF THE SHOULDE R Clavicle Coracoid process Acromion Coracoacromial ligament ��:i-:1� Coracohumeral ligament Supraspinatus m. FIGURE 18. r':::����--':��]J-.Subscapularis m.2 The pain of impingelnenl is reproduced with Ihe anl1 ill Ihe fully abducted FIGURE 18. supraspinatus tendon. Biceps tendon FIGURE 18. .!i 14�. \o-'�"--.1 Anterior-superior view of the shoulder sliolVs Ihe relatiOl1Ship of the osseous structures 10the rotator cuff and the coracoacromial arch. . IF DIAGNOSTIC IMAGING TECHNIQUES symptoms persist after a trial of conservative Currently.5 Arthroscopic view o{ the in{erior FIGURE IS. for many years. indicating a lear of the rotator CLiff. and size of a defect in the rotator cuff. routine radio­ should be undertaken to determine the status of graphs frequently show sclerotic or cystic the rotator cuff.4 Osteoarthritis of the AC joint. most important components in making the diag­ nosis. was the standard for documenting a rotator cuff tear Fig. location.8 As part of the initial examination of a pa­ tient with a shoulder problem. An in{erior spLlr is impinging on the rotator cLI{f FIGURE1 8.79 The arthrogram is 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. 18. The arthrogram.6 Arthroscopic subacromial view cal history and physical examination are the shows {rayil1g of the rotator cLIff (grade II). changes in the area of the greater tuberosity that may indicate advanced rotator cuff disease. further noninvasive evaluation confirming the presence. . there are several imaging method for treatment. ROTATOR CUFF REPAIRS 437 FIGURE IS. 18. cal treatment is a documented partial. With newer technology.praspinatus tendon indicating a tellr.8.9 and to differentiate partial. acute. and their location with a high degree treated nonoperatively. During don disease.13 Magnetic resonance im­ Surgical. it usually cannot provide in­ thickness tears from chronic tendinitis. the integrity of a needle and dye into the glenohumeral joint. However. Ultrasonography is non­ ioint examined £Or instabi\it)'.12. with greater than 90 percent sensitivity scopically. The rotator cuff can be palpated with and specificity. tears on the copy can also help detect instabilities that may superior surface. Initially. but the presence of partial tears. AI1hrography requires insertion of the arthroscopic examination.and full­ results. the supraspil1afLIs portiol1 of the rotator Cliff extremely sensitive for full-thickness rotator cuff along with the biceps tendon can be seen arthro­ tears. symptomatic tears in rela­ evaluating the rotator cuff for tears.'2 However. Both the in­ tively young individuals should probably be re­ ferior and superior surfaces of the rotator cuff paired early. Arthros­ formation about incomplete tears.or) racy as the arthrogram.13 lesions of the labrum can indicate glenohumeral Recently.9 Arthroscopic view of the area and al1 abl10rmal signal in the glel10htlmeral joil1t shows the undersura f ce su.8 M Rl of the supraspinatus showing the compact space under the coracoacromial FIGURE 18. or advanced rotator cuff ten­ be associated with rotator cuff disorders. 18.11 arthroscopic instruments to determine its integ­ cent and an 8 percent incidence of false-negative rity Fig. SLP-P (se'Paralion invasive and has approximately the same acclI­ of the superior labrum anterior and poste'. has become well established in the evaluation of the rotator cuff tear.'O. the sensitivity and specificity are greater than 90 per­ cent in most studies.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. most rotator cuff tears should be their size.or glenohumeral Extravasation of dye into the subacromial bursal ligament should be assessed and the shoulder area suggests a rupture. Treatment aging can detect not only the presence of full­ thickness tears. magnetic resonance imaging MRI dysfunction. The indication for surgi­ of accuracy as well Fig.438 PHYSICAL THERAPY OF THE S H OULDER FIGURE 18.15 . the anterior labrum and infel. sutures are passed through suture anchors in the greater tuberosity. using an intra­ articular suturing technique. 1 1. 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. Medium and large be combined with the surgical treatment of some tears frequently need moderate mobilization of tears. Certainly. Small tears can generally be de­ brided and advanced to the bony bed without Arthroscopic evaluation of the rotator cuff can problems Fig. 13. The same principles of repair are used as for an open repair. 18. large. to allow remaining fibers hold the cuff in position to heal. Instability and tients over the age of 65 years have a less favora- . 14. 18. age and the severity of the tear. Exposure of the rota­ ends. tor cuff tear is facilitated by a coracoacromial decompression. Pa­ when there is a rotator cuff tear. 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. 19 Although it has During the arthroscopic evaluation. a coracoacromial decompression proce­ dure should also be performed. the greater tuberosity in the area of the involved tendon is burred down to a bleeding bony trough. ROTATOR CUFF RE PAIRS 439 labral abnormalities can also be evaluated at this time. and the rotator cuff is attached to the bone by tightening the suture Fig.10Arthroscopic view o(the tears. In these patients. Massive rotator cuff repairs require of the tendon Fig. thus stimulating a healing response. 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. For a superior lesion. Small full-thickness rotator cuff tears « I cm) can frequently be repaired by an arthroscop­ ically assisted method. particularly tor cuff. Lesions larger than I cm should be repaired by an open technique. 12B and C. and the age of the patient. the degree of patient satisfaction with cuff lesions.7. 18. 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.12A. The debridement allows extensive mobilization of the muscle bellies and for freshening of the injured portion of the rota­ perhaps of the sUITounding muscles. These lesions can be sub­ divided into small. but the program is slightly accel­ erated. Frequently.10. and massive FIGURE1 8. Next. associ­ sis of the long head of the biceps is indicated ated pathology. medium.16-18 period with regard to activities. debridement or tenode­ the repair depends on the size of the tear. Under ar­ throscopic visualization. 18. The rehabilita­ tion is similar to that following open repair of the rotator cuff. or a V-Y repair can be done treated with debridement of the involved portion Fig. 18. coverage of the humeral head. The of the subscapularis or infraspinatus. 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. .:. of humeral (E) Sutures are passed through suture anchors in the greater tuberosity.1= . (D) Arthroscopic view of the greater tuberosity after 0. The arthroscopic porIaI is in the subacrolllial bursa....-'-....ll (A) Arlhroscopically Suture anchor ��[J��. (B) ubacromial --'y!ti�----"� Humeral head bursal arthroscopic view of a tear of E the rotator cuff (C) Ruplllre of the Supraspinatus tendon tendinous insertion of the supraspinatlls at its attachment to the humeral head.Suture assisted repair of a rOlalor cuff tear...J. B A Supraspinatus m. (F) Arlhoroscopic view of the repaired rotator cuff.. FIGURE IB..-. . D . Acromi Supraspionnatus m. Greater tuberclheade preparation for rotator cuff repair.-+..Exposed bone of humeral head c c?4=.. (G) Supraspinatus tendm1 is sutured to G the humeral head. 440 . the patient had full range symptomatic patients of any age with complete of shoulder motion. She was scheduled for arthroscopic examination A 46-year-old woman is a volleyball coach for a of the shoulder. early 1994. the diagnostic al. When its inferior surface tions and physical therapy without relief. When she first presented to thought that open repair was necessary. butthe inferior labrum was intact with no with nonsteroidal anti-inflammatory medica­ evidence of instability. (C) Small teM repaired by open c technique.20 vascular examination was intact. and it was ble rotator cuff tear. An was viewed. which showed to be abnormal and to have a tear Fig. In an intact biceps tendon and articular surfaces. although our office in Apl-il 1995. she noted increasing pain and dis­ She had a separation of the anterior superior la­ comfort in her right shoulder.12 (A) The acromiol1 al1d clavicle are owlil1ed (or the il1tended superior lateral il1cisiol1. local college. (B) Small tear exposed with the open techl1ique. R O T A T OR CUFF REPAIRS 441 A B FIGURE 18. 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°. 18.hroscopy showed as an athlete and a coach for over 20 years. Radiographic examination showed nOl-rnal bony structures and joint spaces. She was treated brum. She has participated in volleyball At surgery. ble outcome than those under 65. 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. It an abnormal supraspinatus tendon with proba­ was abnormal over a fairly large area. There- . She had no instability and her neuro­ pair. the rotator cuff tendon was found MRJ was done in the fall of 1994.15. 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. . (B) Tear is trimmed and CUI i"to a V shape. The edges of the V cut are reopposed along the directiOl/ of the muscle {tbers.442 PHYSICAL THERAPY OF THE SHOULDER :w. The edges of the sup raspillatus are c buried in a bony trough i" the humeral head.13 (A) Medium to large tear with supraspinalLls muscle retractio". (C) V-Y Closure of lear.:�\. she was progressed satisfactorily over the next 6 to 8 weeks to full range of motion and full strength.16 . she was allowed to resume her normal activities. Trough A B FIGURE' 8. which she continued for the first cuff. He had no instability and had full range of mo­ tion. 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. 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. He re­ sLlra f ce tumed in the late spring of 1995 with recurrent . Subscapul mobilizedaris ������!����subscapularis m. The area was ion to 90° and abduction to 60° but minimal ex­ freshened. FIGURE ' 8.. He had pain in the 60° LO 120" arc of motion and some pain on forced abduction at90" but he had good strength. fore. Humeral head � Infraspinatus m. 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.'4 (A) Massive tear of the rotator wf( with the "bald head" appearance of the humeral head.Inmobi fraspiliznedatus Supraspinatus m.y medications.�oi=����--::::. At Lhat point. 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. where a 2-cm superior tear was identified 4 weeks after surgery. After surgery.y. He began a trial of physical therapy and nonsteroidal anti-inOammato. At that time she had Oex­ with some retraction of the tendon. ROTATOR CUFF RE PAIRS 443 . 3 months after surge. 18.'5 Arthroscopic view of the inferior which allowed him to improve somewhat. and the rotator cuff was repaired to ternal rotation. which was slightly pulled away fTOm at that time was essentially unchanged. the scan showed a probable rotator cuff tear. With the shoulder in with the arthroscope in the subacromial bursa the abducted position. 1B. {B} Repaired rOlalor cuff in Case Study I. However. The tear extended through approxi­ to the bony bed Fig. Examination with plastic suture anchors.ll{ace of Ihe rOlalor cuff sholVing all illcomplele lear of Ihe rOlalor ClifT ill Case SlLIdy 2.1B. An MRI the bone. Postoperatively. 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.16 {A} Appearance of lite rotalor cLIff lear il1 Case Study / afler exposure by opell lechl1iqtle. 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. .17 {A} Arlhroscopic view of Ihe L111lIersur{ace of Ihe rolalor cufT ill Case Sludy 2.178.17A. he had fraying of the were placed through the supraspinatus tendon. the mately 80 percent of the supraspinatus tendon patient was started on f"ull passive range-of-mo- A 8 FIGURE 18. the sutures were digitally showed a I-cm tear of the rotalOr cuff without tied.444 PHYSICAL THERAPY OF THE SHOULDER A 8 FIGURE 18. the sutll1"es were anchored into the bone the supel-ior aspect Fig. After subacromial decompression. IB. pulling the rotator cuff tendon back down retraction. {B} Arlhroscopic subacromial view of Ihe sLlperior s/. Two sutures an intact labrum. pain in the shoulder. 18. His physical examination Fig. He was started on an in­ 14. Surg 2:57. NccrCS II: Anlcrior acromioplasty for the chronic tor cuff.1S Med 10:595. Bayley JI. Neviaser TJ: The repair 2. 640. Burk DL Jr. 1994 16. 1988 J Bone Joint Surg 60A:68 I. Neviaser RJ. p. Tibone JE: Ten-year assessment of 6. 1972 t 7. Karasick D. 1994 8. Hawkins RJ. Rodosky MW: Techniques in repair of large rotator cuff tears. J Bone Joint Surg 54A:4 I. Adamson GJ. Baye. In Delee JC. p. Am J Spor'ls cuff of the shoulder. Hsu He. IL.-actice. Tech Orthop 9: I 33.1979 1983 5.M: Repair of the rota­ 1. Philadelphia. Packer NP. p. KUl1Z AS et al: Rotator exercises. 1988 tive treatment of chronic ruptures of the rOlalor 4. 1985 range or motion and had started strengthening 13. Hollinshead RM: Solitary osteochon­ primal)' rotator Cliff repairs. 1988 10. Philadelphia. Phys Spol1smed 16: t 29. American Academy of O. t 986 inary reporl. Clin Spo. he had excellent range or cuff tears: prospective comparison of MR imaging wilh arthrography.18 Arthroscopic subacromial view or tears: evaluation using double-contrast shoulder the repaired rotator cuff arthrography. O.1S Med Fitness I :225. Hobeika PE: Surgery for full-thickness rotator-cuff tcars.." PT. By 6 weeks. J Shoulder Elbow Surg 4:95. J Bone Joint Surg 68A: 1 t 36. Neviascr JS. Wu JJ. J Shoulder Elbow droma of the distal clavicle causing a full-thick. 1989 postoperative pain. ROTATOR CUFF REPAIRS 445 ness rotator cuff tear. 1991 15. Brems J: Rotalor cuff tear: evaluation and lI--eal­ ment. 1985 12. Med 7:102. WB Saunders. Drez DD Jr. Rappaport M: Rotator cuff FIGURE18. Brewer 6J: Aging of the rotator cuff. Am motion and was gaining strength with relier or J Roetgenol 153:87.·actice. J Shouldcl' Elbow Surg 3: 266. Hawkins RJ. In Delee JC. 1994 20. Fallon PJ. Hawkins RJ. End-result study of faCial'S innuencing impingement syndrome in the shoulder: a prelim­ reconstruction. HatTis E. HankerC. Mohtadi N: Rotalor cuff problems in athletes. Iannotti JP (ed): Rotator Cuff Disorders: Evalua­ tion and Treatment. 1994 9. Park Ridge. Haltnlp SJ: ROlator cuff I'epaic relevance of pa­ and rotator cuff tearing: a clinical and radio­ tient age. Kessel L: Opera­ lete. Calve.1hopaedic Surgeons. J Shoulder Elbow Surg 3: I 59. Jim YF cl al: Calcific tendinitis 19. 645. 1978 3. 199 I I I. J Bone Joint SU'1l 65B: 17 I. sonography and surgery. J Bone Joint tion exercises. Drez DD (cds): Ol·thopaedic Spons Medicine: Principles and References P. the shoulder by use of a freeze-dried rotator cuff. MisamoreCW. chronic. (eds): Orthopaedic Sports Medicine: Principles and P.1hopedics I I :69. WB Saunders. 1993 . 1995 graphic study. 14. Snyder SJ: Rotator cuff lesions: acute and creased exercise program. Bigliani LU. Adv Spo. Mohtadi N: Rotator Cliff problems in athletes. Nash HL: Rotator cuff damage: re-examining the of chronic massive ruptures of the rOlatOl" cuff of causes and treatments. Fowler PJ: Shoulder injuI'ies in the mature ath­ 18. Mink JH. 1994 7. Radiology 157:62 I. Ellman 1-1. By 10 weeks. he had achieved rull Surg 67A:1349. ion and new bone formation continue as tion well after the fTacture has healed. which differentiate logic. and the patient's age. WOODE N DA V I D J CONAWAY Shoulder pain.2 Some of are offered. inflammatory sIage2 of hematoma formation. thopedic physical therapist.jfects oj Immobilization on Soft allow the fracture to progress through the stages Tissues of healing. Shoulder Girdle Fractures MICHAEL J . general health. These cells. Immediately following the fracture is the acute. and level of activity. how zation are also summarized. Fractures are always osteoclast cells resorb necrotic bone from the accompanied to some degree by soft tissue in­ ends of the fTagments. In this stage of vasodilation and ser­ The combination of trauma to soft tissues and ous exudation. displaced fTactures of the shoulder girdle must be immobilized to F. Stages ojFracture Healing As in any other body region. and weakness after frac­ the hematoma through capillary formation to ture are common problems presented to the or­ form a callous of immature bone. invade iting effects are as follows: 447 . cartilage. period should be ending so that come of function. the recovery that will determine the ultimate out­ immobilization. inflammatory cells are brought subsequent immobilization needed for bone to the area to remove necrotic soft tissue and healing contributes to stiffness of periarticular bone from the ends of the fragments. leaving serious implications for rehabilita­ resorpt. Meanwhile. much bone is lost. biochemical. and begin to produce collagen. which bone is fTactured. 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 effects of trauma and immobili­ these include the severity of the trauma. how effective the immo­ bilization is.3 Much has been re­ the reparalive sIage. In the remodeling sIage. general rehabilitation guidelines stage is influenced by many factors. primarily osteoblasts. As the he­ connective tissue slructures and weakness of the matoma becomes more organized at the start of sUITounding musculature. the most signjfjcant motion-lim­ bone. the presence of infection.2 jury. some of the more common shoulder girdle frac­ The length of time required for each healing tures. and To summarize. stiffness. For each. I the necessary "stress" is provided by remobiliza­ This chapter presents a brief overview of tion of the limb.2 a "fibrin scaffold" is pro­ searched and wrillen about changes in histo­ vided for the reparative cells. and mechanical properties. ' Active range of motion (ROM) exercises should 4. but may be particularly important mining the readiness of movement.9.'actures (Fig. Deposition of fibrofatty infiltrates between joint structures acting as intra-articular "glue. 2. The laller is often striction. Fractures Scapula fractures arc usually the result of a di­ rect blow. In most tends to prevent or reduce these changes in con­ cases. is knowing when to begin active stiffness. either in a clavicle (or figure eight) brace in abelTant cross-linking and a loss of move­ or a sling. Clavicle r.13 Most are nondisplaced. as clinicians. 19. glenohumeral. acromioclavicular. Loss of extensibility of capsule. Evaluation of the direction of re­ and scapulothoracic joints. Breakdown of hyaline anicular canilage.2) and often in the middle one­ tendons. This contributes to an increase days.4. Immobilization results third (Fig. Exercises should in­ muscle. ligaments. a home program is sufficient."7 REHABILITATION 3. and retraction) and the shoulder Conversely. depression.1) most commonly occur fTom a fall on the lateral aspect of the shoulder or. Re­ Clavicle Fractures sistive exercises can begin when the Fracture ap­ pears solidly healed and when pain with move­ ment is reduced. and fascia. Badly comminuted.448 PHYSICAL THE RAPY OF THE SHOULDE R I. less commonly. one-third (Fig. 19. no. motion and when to progress to passive exercise.10 volve the shoulder girdle (elevation. lillie or no immobilization is required. delayed union. 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. in a decrease in water and glycosaminogly­ The shoulder is immobilized for 14 to 21 can content. protraction. pain. 13 The clavicle typically fractures at the juncture of the middle one-third and distal Scapu/fJ. or ment between fibers4-6 surgically repaired fractures will require more immobilization. Prolonged immobilization can also result in muscle weakness and even in visible atrophy. . 19. and reactivity is essential in deter­ overlooked. ment is not usually severe.1 Clavicle (raclUres at the (I) itlllclUre notch to the lateral border (Fig. it has been shown that movement joint (pendulum and wand exercises).3). NECK OF THE SCAPULA The fracture line extends from the suprascapular FIGURE 19. of the middle lIlld distal thirds alld the (2) Downward displacement of the glenoid frag­ middle one-third. therefore. In unusual nective tissue··11 and muscle9•loThe problem for cases of prolonged immobilization and excessive us. passive mobilization may be necessary. I). onto the out­ stretched arm. 19. Atrophy and adaptive length changes in begin within 14 to 21 days. tissue healing.12 because of immobilization in a retracted posi­ tion. The effects of will suffice. All joints in cle. 2). spine and rib mechanks should also be evalu­ aledo ACROMION PROCESS Again. Fractures o[ the upper humelUs can involve the REHABILITATION greater tuberosity. neck. trauma and immobilization on glenohumeral . SHOULDE R GIROLE FRACTURES 449 A FIGURE 19. 19. this is not often displaced.5). 19. 3). active ROM exercises can begin Mechanisms of injury are varied. thoracic sionally is displaced downward (Fig. as are the needs within the first few days. If a direct blow to The fracture is usually not displaced.ctllre o( the lIIiddle and distal thirds (A) be(ore redLiction and (B) after reduction. even if comminuted (Fig. occasional prolonged im. However. no. B BODY OF THE SCAPULA mobilization because o[ severe displacement or surgical treatment may necessitate passive mo­ Fragments are well protected by layers of mus­ bilization and muscle strengthening. with particular emphasis on the scapulothoracic CORACOIO PROCESS and its related musculature. In most cases. the shoulder girdle complex should be evaluated.2 Radiograph o( clavicle (ractLire at the jtll. but occa­ the scapula was the cause of injury. or shaft (Fig. 4). no.4. If the fTacture is communiled or badly displaced. 19.4. no. and a home program [or immobilization and surgery. 19.4. [Tagments Jilract:ures of the Humerus can be removed surgically (Fig. which will result in pain. Fractures of the greater tuberosity are usually the result of a fall on the shoulder. joint soft tissues have especially significant im­ ful. often in el­ so that active exercise can begin soon. early coacromial ligament. The immobilization re- .3 Radiograph of clavicle fracture ill the middle ol1e-third (A) before reductiol1 al1d (8) B after reduction. treated surgically with a fixation screw. An avulsed derly. 13. 19. osteoporotic women.13 In nondisplaced Humeral neck fractures are caused by a fall on fractures (Fig. movement is desirable. limited abduction.450 P H Y 5 ICAL THE RAPY 0 F THE 5 H 0 UL 0 E R A FIGURE 19. Postoperative im­ GREATER TUBEROSITY mobilization is from 14 to 21 days.6) splinting should be avoided the outslretched arm or the elbow.14 These are often plications for rehabilitation. Addi­ tional clearance acromiopla ty or removal of the acromion may be necessary. 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. most com­ NECK OF THE HUMERUS monly in elderly individuals. the exercises should be increased gradually in range and vigor. a/1d (3) dle one-third. careful passive when safe. 19. inter­ nal rixation with plates or intramedullary rods. is essential. However. Even while the arm is in mobilization can begin. REHABILITATION Once the fracture is stable and reactivity is Because the glenohumeral joint is particularly reduced at least to moderate (pain and end-range susceptible to stiffness. resistance are simultaneousI2. As in other upper humerus fractures. mobilization period ends. 19. depending on the stability active assistance-providing exercises.7). If the fragments are dis­ placed (Fig. twisting force that causes a spiral fracture (Fig. (2) /1eck.4 Scapular (ractures o( the (I) neck. early remobilization. Each movement should a sling or cast. (3) coracoid process. (2) body. the patient should be taught be tested ror reactivity prior to mobilizing. Occasionally.8). the arm may need to be immo­ bilized in a sling held tightly to the chest for 14 to 2 1 days. resulting from a direct blow or a sha(t. early joint motion is desirable. As the im­ and whether casting or surgical fixation is used. the arm can come out of the slinJ( frequently ror exercise.1S).5 Fractures o(the upper humerus in Humeral shaft rractures usually involve the mid­ the (I) greater tuberosity.9). be- . 19. and (4) acromio/1 process. immobiliza­ careful active exercises or be seen frequently for tion is greatly variable. an abduction splint is needed for as much as 4 weeks. ·quired depends on the severity or the displace­ ment. SHAFT OF THE HUMERUS FIGURE 19. Immobilization will be variable in cases of open reduction. [n impacted and nondisplaced fractures (Fig. SHOULDE R GIRDLE FRACTURE S 451 3 FIGURE 19. For example.'6 In this capsular pattern. 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. immobi­ pain should always be respected.lctures may be more inflamed portions of the capsule. When reactivity is low to mod­ all movements at the glenohumeral joint.6 Radiograph o( nOI1- displaced greater ILIberosily (raclLlre.7 Radiograph o( impacted humeral neck (raetLlre. . When reactiv­ lizing the arm in a sling or in a position of adduc­ ity is moderate to high. espe­ erate. mote relaxation.'7 Therefore. grades III and rv accessory and physio­ cially external rotation and abduction. mobilization should em­ Allhough most effort will be concentrated at the phasize stretching the anterior and inferior glenohumeral joint. and painful than others. other joints in the shoulder FIGURE 19.452 P HYSICAL THE RAPY OF THE SHOULDE R FIGURE 19. During mobilization. cause some trl. will be re­ logic mobilizations are used to increase ROM's stricted. that she needed her husband's assistance with After immobilization. and ROM is at least 50 per­ ing dressing. The patient did tolerate netics. but the fracture was bilization. When possible. with progression to maximal ef­ unable to move the upper extremity because of fort a tolerated. Muscle strength nals Chapter 16 outlines the use of shoulder isoki­ was grossly 2/5. 19. To facilitate shoulder joint range of mo­ tion as the patient began physical therapy. especially at the glenohumeral joint. indicating isometric exercises should be instructed early. regardless of the location of the frac­ ture.1OA). This kept the rod from impinging in the area of the supraspinatus. l1eek (mewre. if the fracture is stable. and all muscles of the rotator with complaints of severe shoulder pain (7 on a cuff.8 Radiograph o( displaced humeral rod was removed I month later on July II.1OB). the pectorals. and get­ cent. going to the toilet. is a 58-year-old woman who slipped and fell onto her right shoulder on June II. CASE STUDY HISTORY Patient O. includ­ reactivity is not high. She reported having been ercisescan begin. 1994. The reader is referred to Chapter 13 stable enough for the patient to begin physical for a detailed summary of shoulder joint and gir­ therapy. the FIGURE 19. bathing.lsokinetic devices are preferred. early move­ ment is essential. the pain.C. 1994. submaximal effort progressive resistive ex­ ting in and out of bed. specific scale of 10). range of and because resistance can be applied to all motion (ROM) and accessory motions could not planes of movement. moist heat and grades 1 and 2 oscillations to re- . because of soft tissue U'auma and immobili­ zation. INITIAL EVALUATION Immobilizing the shoulder girdle can result in significant muscle weakness. and disability. often result in stiffness. SHOULDE R GIRDLE FRACTURE S 453 Summary Fractures of the shoulder girdle are common and. dle mobilization techniques. After a period of immobiliza­ tion. with anterior dislocation of the glenohumeral joint (Fig. 19. She presented zius. There was radiographic evi­ girdle should be assessed after prolonged immo­ dence of delayed healing. Muscles com­ The patient was refelTed for physical therapy 6 monly involved are the upper and middle trape­ weeks postinjury on July 25. including functional diago­ be assessed on the initial visit. as well as internal fixation of the fracture with an intramedullary rod (Fig. all joints of the shoulder complex should be assessed. sustaining a comminuted fracture of the proxi­ mal humerus. This combined injury required open reduction to relocate the shoulder joint. nearly all activities of daily living (ADL). at best. 1994. stiffness. To minimize weakness and atrophy. because "stops" can be used to protect the joint Because of pain and high reactivity. The patienl's home exer­ AAROM exercise. and the patient lum exercises to be done at home.9 Radiographs o{ spiral/oblique humeral shaft {racture (A) be{ore surgical reduction al1d (B) after open reducliol1. abduction. findings were as follows. and oscillations were used to functional muscle strength. and internal Abduction 42" High 2/5 and external rotation. il1lemal {lXaliol1. and was able External rot. During this Lime the patient tolerated tion (PNF) was begun. nan'ow-pulse elec­ traction/retraction were begun. was more tolerant to passive glenohumeral ROM and mobilization techniques. wand exercises in all planes. duce pain. and low-resistance PROM REACTIYITY STRENGTH theraband strengthening exercises for shoulder flexion 6Cf' Moderate 2/5+ elevation. To increase trical stimulation. adduction. By the end of the second week. 10" High 2/5 week. Abduction 98' Moderote 3/5 She was better able to dress herself. and pro­ Combinations of moist heat. cise program (HEP) included pendulum and PROM and muscle trength were as follows. and was instructed in gentle pendu­ reactivity continued to lessen.454 P HYSICAL THE RAPY O F THE SHOULDE R A 8 FIGURE 19. Internal rot. 30" Moderate 3/5 PROM REACTIYITY STRENGTH WEEKS3T06 flexion 120" low 3/5+ The patient reported gradually decreased pain. passive scapu­ WEEKS I AND 2 lar distraction. At the end of the sixth External rol. To improve de­ TREATMENT creased scapulothoracic mobility. 64' low 3/5+ . and to promote relax­ scapular proprioceptive neuromuscular facilita­ ation. 42" Moderate 3/5+ to get comfortable at night. During this time joint Internal rol. elevation/depression. glenohumeral and reduce pain and reactivity. c. and to return for reevaluation if any prob­ lems arose. nitely. commil1tlled FIGURE t 9. To promote further Abduction 155· No poin 4/5+ scapular strength and mobility. occasional pain. 19. 1995. The patient was seen for a follow-up DISCHARGE AND FOLLOW-UP visit by the surgeon on January 24. and elbow curls. lsokinetic internal and external rotation in the plane of the scapula at maximum effort She was advised to continue her HEP indefi­ was employed dudng the last 3 weeks of therapy. 90" low 4/5+ chain exercises included wall pushups. closed kinetic External rot. with the imramedullary rod il1 place. WEEKS 7 TO 10 independent in her ADL. although overhead ac­ By this time physical therapy fTequency had tivities were still somewhat difficult. She was fully factory (Fig. with anterior dislocatiol1 o{ the glel10humeral joint. (8) After A reductiol1.The passive mobiliza­ tion program now included grades 4 to 6 physio­ logic and accessory movements with excellent PROM REACTIVITY STRENGTH tolerance. Radio­ On October 31. . ROM and been reduced to twice weekly. and 14 weeks after surgery. military Flexion 175· No pain 4/5+ presses. after 10 weeks of therapy graphs revealed that some alignment was lost. tion continued to improve. modified Internal rot. the patient reported but that overall position and healing were satis­ only minimal.. 1994. PREs included pull downs. SHOULDE R GIRDLE F RACTURE S 455 B (A) Patient O. t 0 fracture o{ the right huments. 85· No poin 5/5 prone push-ups on 4-inch foam rolls. and the upper extremity ergometer with resistance to tol­ erance.11). as ROM and func­ strength findings were as follows. 3. J 973 7. La Vignc A.'ac­ 18. Amici D. J Physiol (Lond) 224:221. Horowitz M: The intra·al1icular er· fecls of immobilization on the human knee.'apy of the Shoulder. 147. Wooden MJ (eds): Ol1ho­ paedic Physial Therapy 2nd Ed. Mallhews N. 1983 . 9lh Ed. Saunders SR: Evaluation of the shoul· der: a sequential approach. New York. Atlanta. Engles M: Tissue response. 1968 Connolly JF (ed): DePalma's The Management of Frac­ 6. 1972 8.. 1980. Philadelphia. 1980 5.-ipheral Manipulation. New York. Gradisar IA: Fracture stabilization and healing. Ballien'c Tin· 2. Mechanic GL et al: Collagen crosslin king alteration in joint contractures: changes in reducible crosslinks in perial1icular connective tissue collagen after 9 weeks of immo­ bilization. TardieuS et al: Physiological and sll1Jclural changes in cat soleus muscle due to immobilization at different lengths in plaster casts. University ofSlrathclydc. p. J Bone Joint Surg 54A:919. Cormack D: Histology. Cruess RL: Healing of bone. SI. WB mobilization: induced stiffness of monkey knee Saunders.Scotland University Park Press. 1988 aging response. Akeson WH et al: Connec­ Chapman MW (cd): Operative Orthopaedics. 14. Including Joint Inju. JB Lippincoll. In Donatelli R. Louis. 1972 10. 118. Akeson WH. 23. In Donatelli R. Institute Press. Paris SV: Extremity Dysfunction and Mobiliza· References tion. 8th Ed. 1984 Butlcrwol1h Publishers. Philadelphia. Moran CA. Philadelphia. CV Mosby. WOO S. Tabary JC. Connect Tissue Res 5:5. JB Lip­ tive tissue response to immobility: an accelerated pincoll.11 Patiel1l a. 1978 3. Churchill Livingstone. J Bone Joint Surg 54A:973. Baltimore. Cooper R: Alterations during immobilization and regeneration of skeletal muscle in cats. New York. tendon and ligament. 7 11I0l1lhs poslinitlry. In Davies G. Adams JC: Outline of Fractures. 16 Lippincoll. Turek SL:Orthopaedics: Principles and Their Ap­ plications. 2nd Ed. p. 4th Ed. Cyriax J: Textbook ofOl1hopaedic Medicine. 1991 4. p. G''een DP (cds): F. Diagnosis of Soft Tissue Lesions. London. Amici D. 1978 p. 1994 fiGURE 19. 6iorheology 17:95. 1977 12 Wooden MJ: Mobilization of the upper extremity. Vol.456 PHYSICAL THE RAPY O F THE SHOULDE R joints and posterior capsules. In Rockwood CA.ies. 1985 t. 2nd Ed. Proceedings of a Symposium of the Biological Engineering Soci­ ety. 1991 Sports Physical Therapy. 297. Woo S: Immobility dfects on synovial joints: the pathomechanics of joint Suggested Readings contractures. Vol. Akcson WH. dall. lures in Adulls. 1980 16. 3rd Ed. 1979 9. p. 16 Lippin­ COli. Enneking W. (ed): Physical The. Ham A. Exp Gerontol 3:289. 1972 II.c. Watkins R: Preliminary results on im· lures and Dislocations: An Atlas. 1989 13. London. In Donatelli R 1. Maitland GD: Pe. p. Tabary C. 17. 2. Churchill Livingslone. Wooden MJ (eds): Orthopaedic Physical Therapy 2nd Ed. Philadelphia. London. Gould J (eds): Orthopaedic and Churchill Livingstone. 938 15. Chunchill Living­ stone. Philadel­ phia. 1983 ders. JB Lippincott. Green DP. Phila­ Livingstone. Churchill Livingstone. 3rd Ed. 1982 delphia. 1986 Rowe CR: The Shoulder. York. New Park WH. tures in Adults. Vol. Bucholz RW (cds): Frac­ Cruess R: AdultOrthopaedics. Philadelphia. Philadel­ New York. WB Saunders. 3. 1991 DePalma AF: Surgery of the Shoulder. New York. New York. 1988 . WB Saun­ Philadelphia. IS Lippincott. In Pet­ Blackwell Scientific Publications. SHOULDE R GIRDLE FRACTURE S 457 Craig EV: Shoulder rractures in the athlete. London. 1970 Rockwood CA. JB LippincolI. !-Iughes SPF (cds): 011hopaedic Radiology. Philadel­ Crenshaw AH (cd): Campbell's Operative 011hopae­ phia. Matsen FA: The Shoulder. 1974 dies. trone FA (cd): Athletic Injuries of the Shoulder. Churchill Livingstone. Rockwood CA. Philadelphia. Churchill medullary Osteosyntheses. 1984 phia. 1987 McGraw-Hili. 1991 Mueller KH: Intramedullary Nailing andOther Intra­ Rodgers LF: Radiology of Skeletal Trauma. WB Saunders. 1995 Rang M: Children's Fractures. family history. immune system. redesigned in 1973. Before patients can be considered for shoulder Pean.derations been of intereSI to the orthopedic surgeon and physical therapist for a long time. is the standard joints. Principles of the postoperative rehabili­ and recrealional requiremenls. Unconstrained total shoulder replace­ vital structures. such as This chapter will discuss various clinical asthma. and organ against which all new modjfjcations must be systems of the patient. shoulder prosthetic replacement from the early Medically. Total Shoulder Replacement G E0 R G E M .E. conditions that often result in prosthetic replace­ Other factors in the history that are impor­ ment and some o[ their distingujshing clinjcal tant considerations are the patient's age. have led to a dramatic increase in the ments as well. MeeL U 5 KEY II I TIMOTHY U HL The painful arthritic glenohumeral joint has Clinical. adjacent soft tissue structures. which not only causes de­ thetic design. tendons. but af­ pathologic anatomy and kinematics of shoulder fects sUITounding muscles. work features. because some medical conditions have a direct effect on the other thesis. Recent advances in technique and pros­ rheumatoid arthritis. Consi. Rheumatoid arthritis can also number of total shoulder replacements in this involve the lungs. Neer's total shoulder pros­ anesthesia and surgery. socioeconomic tation required for patients undergoing replace­ and educational background. handedness. and ment surgery will also be reviewed. and the details of the spe­ Charles Neer pioneered the development of cific disease process involving the shoulder. One example would be judged. and other country. and liga­ diseases. roids to treat medical conditions. which can occur from the use of ste­ gard to pain relief and improved [unction. J. Dr. they must undergo a thorough rubber implant for the glenohumeral joint of a evaluation of their overall medical history. their young man afflicted with tuberculosis. physical examination. they should be good candidates for 1950s to the present. in 18921 He substituted a platinum and replacement. and a clearer understanding of the struction of the shoulder joint surfaces. Another example is osteo­ ment has consistently given good results with re­ necrosis. The earHest HISTORY reported arthroplasty for the painful shoulder joint was performed by a French surgeon. A preoperative assessment of the 459 . 1(A) Al1Ieroposterior al1d (B) lateral radiographic views show osteoarthritis .17 this patient.2 (A) Anteroposterior al1d (B) lateral radiographic views of rheumatoid artltrjris ill this patiel1t's shoulder. Hypertrophic spurring is seen a/Dug the hUlI/eral neck 'nld glenoid alol1g lVitit posterior glenoid wear and c017comiw111 posterior subluxati0l1 A o( the humeral head. Osteopenia o( the bOl1e with degenerative cysts and central glenoid \Veal' are A visible along \\lith erosion o( bone al1d cartilage.460 PHYSI CAL THE RAPY OF THE SHOULDER B FIGURE 20. B FIGURE20. The glel1ohul1Ieral joil1l space is diminished (rom canilage erosiol1. . cervical. A general physical examination must include a duration. In some cases. detailed examination of both shoulders. A sys­ Additional causes of shoulder pain. B patient's motivation and ability to understand bone loss.3 (A) Ameroposlerior radiographic view il1 a patiel11 wilh stage 3 oSleol1ecrosis o( Ihe humeral head showhlg avascular bone with st/bchol1dral col/apse {Illd crescenl sign indicalive o( st/bch011dral (raclt/re. Commonly.2 Pain characteristics-location. These patients are placed in a "limited goals" plain of night pain. 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. character. strength are limited. including tematic method of recording joint motion should neurologic. pain at rest. voked by activities of daily living. and pain pro­ rehabilitation program postoperatively. and thoracic causes. cant functional improvement. patients with glenohumeral be investigated. In general. For full passive motion while active motion and most patients who have degenerative lesions. and the goals of The primary indication for a prosthetic re­ surgery become pain relief and prosthetic stabil­ placement is pain. and and participate in a postoperative rehabilitation nerve injuries preclude the possibility of signifi­ program is crucial. TOTAL SHOUL DE R R E PLAC E ME N T 461 A FIGURE 20. Limited external ro­ but they should only be considered secondary tation is more sensitive than forward elevation indications. should be used. Shoulder pain at rest is generally tol­ PHYSICAL EXAMINATION erated less well than that of the hip or knee. and recreation. (B) Ht/l1Ieral head replacemellt was needed. fTequency.2 Patients with rotator the clinical diagnosis and decision. of scapulothoracic motion. soft tissue retraction. Evidence of advanced destructive in detelmining the degree of restricted joint mo­ joint disease on radiographs should only support tion in arthritic shoulders. 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. restoration of shoulder motion and f-unction to Posterior joint line tendel�ness is a character­ "near normal" is realistic. scan·ing. work. severe istic finding in patients with glenohumeral arthr- . and radiation-are important to note. patients com­ ity. Muscle atrophy and nerve injury that cause muscle weakness must be considered. If the rotator cuff is severely compromised or irrepara­ bly tom.ssive e. are neces­ sary for a stable shoulder replacement.ol1 o( Ihe tional improvement. Impingement syndrome shoulder Llsing a Slick IVilh anl1 supporled 011 a and acromioclavicular joint arthritis must be pillow. exercises to regain FIGURE 20. The strength and overall r�mction of the rotator cuff and deltoid are especially important in the pre­ operative assessment.462 PHYSICAL THE RAPY OF THE SHOULDER recognized preoperatively and addressed at the time of surgery. Crepitation and tenderness at the an­ terolateral aspect of the acromion and sub­ acromial space is more common in rotator cuff and impingement lesions. It is often associated with crepitation in the glenohumeral joint with gentle rotation of the shoulder. A standardized muscle grading system al­ lows the surgeon to record and compare preop­ erative and postoperative changes in strength ef­ fectively. . shoulder replacement results are less predictable with regard to pain relief and func­ F I GURE20. modalities.x. Soft tissue balancing of the rotator cuff. and glenohumeral liga­ ments. medications. capsule. itis.tenw! rotat. particularly when the plan is to use a nonconstrained-type prosthesis.5 Pa. The glenoid cOll1ponenl is made of polyelhylene and Ihe humeral compon""1 is modular. shoulder replacemenl. Options include modification or activities. arthritis. especially when a defective rota­ tor cuff is repaired concomitantly with pros­ thetic replacement. allowing Ihe surgeon 10 mix and malch slem and head sizes. or congenital abnormalities. and proper alignment of prosthetic com­ ponents regarding height and version. Previous operations performed for instability can cause subluxation or dislocation of the oppo­ site side of the shoulder joint from overtighten­ ing or soft tissue contracture on the operated side (as with posterior subluxation fTom an ante­ rior contracture following surgery for anterior instability).4Stage 4 osteonecrosis requires a 1010/ motion and strength. deltoid. Patients with glenohumeral arthritis should exhaust all nonoperative treatment options be­ fore shoulder replacement. Glenohumeral instability can be secondary to trauma. . cuff tear arthropathy. v - . .6 Passive (onvard eLevation in the the humerus or glenoid can be problematic..7-9 Absolute contraindications to shoulder pros­ thetic replacement include active infection. replacement. . I . and therapist. . TOTAL SHOUL D E R R E PLACEMENT 463 and injections. and . pa­ ralysis. I . post-traumatic arthropa­ thy. . . neurotrophic shoulder. extensive injury to both the rotator cuff . arthritis of dislocation." Arthroplasty is also indicated for acute and chronic trauma and revision surgery. '- . Therapy programs should be in­ dividualized for each patient and should empha­ size good communication between the patient. . 110 \ .S and tumors.3 rheumatoid arthritis" osteonecrosis.-_ . The patient should be in­ formed about the diagnosis and goals of rehabili­ \ tation. \ \ \ \ Indicalifms \ \ The disease processes that are considered indica­ tions for shoulder replacement include osteo­ arthritis.. . . ' r 't FIGURE 20. inappropriate patient motivation. they plm. surgeon.2. . .. and deltoid muscles.2 Although tearing of the rotator cuff and bone loss involving FIGURE 20. Preoperative exercises to maximize pas­ \ sive range of motion and to condition shoulder \ muscles prepare the patient for postoperative re­ \ \ habilitation.7 Elevation of the an11 with assistance ) -­ -. of the scapula with the assistance of are not considered contraindications to shoulder another perSOf1. of a rope and pulley system in the plane of the scapula. In the osteoarthritic shoulder. Restoration of the deltoid myo[as­ cial sleeve tension is critical for function of the OSTEOARTHRITIS cuff and deltoid muscles. osteoarthritis in shoulders subjected to everyday activities require an intact rotator cuff. loose osteochondral bodies are candidates for nonconstrained prosthetic re­ often found. there is usually complete loss of the normal glenohumeral joint space. This posterior glenoid wear is charactel·istic. Patients with primary osteoarthritis are ideal At surgery. bur­ cences along the bicipital groove entrance. and when bone loss is ex­ treme." 10 NeeI' has . and tendons as well.464 PHYSICAL THE RAPY OF THE SHOUL DE R cartilage and underlying subchondral sclerosis and cyst formation in the metaphy eal portion of the humems. e pecially in the subscapularis placement.8 Scapular stabilizing exercises or release of contractures anteriorly.1). 20. The glenOid articular cartilage is charac­ teristically worn eccentrically with minimal car­ tilage loss anteriorly and complete eburnation of articular cartilage posteriorly leading to progres­ sive wear and bone loss. Special techniques can be used during prosthetic replacement to balance soft tis­ sues and to regain near-normal glenohumeral version. making them appear larger at surgery when compared with their preoperative radiographic appearance. The osteophytes limit gleno­ humeral rotation and are covered with cartilage. they are usuaJly unrelated to rotator cuff disea e with its im­ Rheumatoid arthritis not only affects the joint pingement but rather are due to bony excres­ surfaces in the shoulder. rotator cufr tears are repaired and compression forces required to produce primary bicipital lesions are treated appropriately. and proper orientation of prosthetic components. The large rimming osteophytes are characteristic radiographic findings in osteo­ arthritic shoulders. should be rotator cuff and biceps tendon are intact in 90 smoothed without detaching the deltoid muscle. Also. the and if clinically symptomatic. ligaments. sae. Acromial spurs hypertrophic osteophytes around the margin of and acromioclavicular arthritis with spurring the articular cartilage that give good supporting should be assessed preoperatively by radiograph. The humeral head is enlarged with bursa. They include subscapularis lengthening. percent of these shoulders! because the When present. may preclude use of the glenOid prosthesis or require bone grafting for prosthetic stability. grafting. but the muscles. glenoid bone retraction and elevation. Posterior subluxation of the humeral head occurs with progressive posterior glenoid wear and con­ comitant contracture of the anterior capsule and subscapularis. FIGURE 20. Rotator cuff Pathologic findings involving the proximal tears are found in 30 percent to 40 percent of humems include loss or thinning of the articular patients with rheumatoid arthritis. stmcture for the prosthesis (Fig. When bi­ RHEUMATOID ARTHRITIS ceps tendon mptures do occur. and should be removed. 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. . A B /� u � )( E -� ! \ . . 465 .-_.. � C 0 FIGURE 20."'- :-(' . which will be dis­ cussed later. Occasionally. Synovial prolifera­ tion and hypertrophy can be marked. and loss of joint space occur.466 PHYSI CAL THE RAPY OF THE SHOULDE R described three clinical varieties of rheumatoid arthritis that involve the shoulder-the dry. In most shoulders. and acromioplasty is seldom indicated. severe bone 10 s. and resorptive forms'> The dry form resembles osteoarthritis in that sclerosis. In others. 1l is some­ times referred to as "mixed arthritis. the head subluxates posterioriy following an an­ terior approach for a procedure to correct recur­ FIGURE 20. shortening of ante. bone erosion secondary to pannus. tional surgical approach was used for a . 20." The wet and resorptive forms are characterized by severe bone loss. Rotator cuff defects are usually repairable.-ior soft tissues is rare. In rheumatoid shoulders. requiring aggressive synovectomy as part of the operative procedure. and external rotation is easily achieved without sub­ scapularis lengthening. ero­ sion. contracture and FIGURE 20.10 Active assisted elevation with a rent anterior dislocations. These patients are placed in a "limited goals" rehabilitation program. A hardside suitcase with a towel draped over it works well to sLipport the ann. wet.11 Gravity-elilllil1ated f/exiol1 i/1 the sidelyi/1g positio/1. and central glenoid wear with "centralization" of the humeral head (Fig. a unidirec­ stick in the plane of the scapLila. rimming osteo­ phytes.2). 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. and centralization of the humeral head make glenoid replacement and cuff repair inad­ visable. TOTAL SHOULDER R EPLACEMENT 467 \ \ \ \ \ \ I I I I I I I (�:C�-_-�:-::"-_I FIGURE20.12 Beginning inlenw/ rOlalioll and P, , ' extension exercise using a , I , , stick. L.I 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 ternal rotalion. Osteonecrosis or avascular necrosis can be the Glenoid wear is usually pronounced when result of trauma, steroid use for systemic disease, the humeral head is located eccentrically in the alcohol abuse, or other causes. Only the femoral glenoid. Altering the version of the glenoid com­ head has a higher incidence of nontraumatic os­ ponent is preferable to glenoid bone grafting in teonecrosis than the humeral head. Neer2 and most shoulders. Stretching of soft tissues to ac­ others"·l2 have divided osteonecrosis into four commodate a chronically subluxating or dislo­ stages. Stages 3 and 4 of osteonecrosis usually cating humeral head must be addressed with a require prosthetic replacement. In stage 3, the capsulon'haphy to balance soft tissues and to sta­ humeral head displays collapse of subchondral bilize the prosthesis along with cOlTesponding bone with a normal glenoid articular surface 468 PHYSICAL THERAPY OF THE SHOULDER � --....\ ) --,' ( � " / ../ 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 ,, " , /' FIGURE 20.14 Elastic resistive exercises {or 'he glenohumeral joil1f. ElbolV is flexed 10 900'° decrease lever arm slress. 469 470 PHYSICAL THE RAPY OF THE SHOULDE R Postoperative rehabilitation must be individ­ ualized for these patients, with close communi­ cation between the surgeon and therapist. Early restoration of passive motion prevents reforma­ tion of unwanted scar tissue that blocks motion. Patients with preoperative instability and dislo­ cation must restrict motion in provocative posi­ tions to avoid prosthetic dislocation . One year of exercise is required to regain full motion and strength in these patients. RelwhiJ:itatUm The rehabiliation of a patient who has had a total shoulder replacement should be like that of any other total joint replacement rehabilitation pro­ gram. The primary reason for undergOing the surgery is pain relief, and the secondary goal is improvement of function. In our attempts to as­ sist these patients in recovery, we must keep these goals in the con'ect order. It is velY easy for the therapist to focus on the functional as· pects too intently and sacrifice the primalY goal of decreasing pain. This is not to say patients will not have any discomfort as they rehabilitate their FIGURE 20.15 Assisled elevation wilh slick shoulders; however, it should be monitored and (allowed by isomelric hold al end rQl'ge minimized. Along with these goals, the immedi­ independelllly, (allowed by aClive eccenlric ate postoperative goals for rehabilitation are to lowering as loleraled {shown above}. II is prevent glenohumeral contracture while simul­ usually reconlllle"ded 10 Ihe palielll 10 keep Ihe taneously protecting the prosthesis, rotator cuff, slick close 10 Ihe ann 10 aid ill support in and deltoid. It is critical for the therapist, doctor, lowering, especially i( Ihe palielll has a pai"(1I1 and patient to have reasonable and clear goals or iveak arc. going into surgery. some patients. The procedure can be compli­ CATEGORIES OF REHABILITATION cated by soft tissue scatTing, bone loss, retracted tuberosities, malunion, nonunion, and nerve in­ Rehabilitation after shoulder replacement julies. Retained hardware and deltoid deficiency should be individualized to the needs of the pa­ from previous failed surgeries often complicate tient and related to the goals of the procedure. the situation further and elevate the risk for in­ J n general, however, there are three categories fection with subsequent procedures. of rehabilitation programs: (A) programs for pa­ Special attention should be given to the re­ tients with a good rotator cuff and deltoid, (B) pair of a torn, retracted, and scarred rotator cuff programs for patients with a poor rotator cuff to maintain proper deltoid tension and restore and deltoid, and (e) limited goals programs. normal humeral length and glenohumeral ver­ The first two categories are designed to acco­ sion. modate the patient's rotator cuff status and del- TOTAL SHOULDE R R E PLACE ME NT 471 FIGURE 20.16 Scapliol1 is elevaliol1 of Ihe ami il1 lite scapular plal1e 10 slrenglhel1 Ihe deltoid, supraspinarLls, and lrapel.ius. toid integrity. The third category is included for those patients who have one or a combination of the following pathologies that leads to total shoulder arthroplasty: rheumatoid arthdtis, pre­ viously failed rotator cuff repair, rotator cuff arthropathy, Erb's palsy, or previously failed total shoulder arthroplasty. The following guidelines can be used by the clinician to develop an individualized rehabilita­ tion program based on the status of the rotator cuff and deltoid musculature. It is important to listen to the patient's comments, as this will guide the rehabilitation progress. The time lines in Appendix 20. 1 A-C are merely sugges­ tions for rehabilitation progress. It is more im­ portant to listen to patients regarding their progress. Patients in the limited goals program are FIGURE 20.17 Sidelyil1g exlerrlal rolalion 10 placed in this category based on the recommen­ slrel1glhel1 Ihe infraspil1alus is usually dation of their surgeon. Pain relief is the primary per{onued wilh a small pillow under Ihe elbow. goal of surgery for these patients. Full return of 472 PHYSICAL THERAPY OF THE SHOULDER Lifting the Arm The initial treatment session is by far the most impOliant step in any shoulder rehabilita­ tion program, because it sets the stage for the rest of the process. If this session is good, the patient develops trust and confidence in the ther­ apist. However, if the session is bad because the " I patient resists the passive motion or has pain, I I , I the patient will associate pain with rehabilitation , I , I throughout the healing process. } I I Within the first minute or two, the therapist \ 1 � , must dete,-mine the best way to approach each in­ \ ' \ \ dividual patient. Here is where the therapist's \ \, 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. Communication between surgeon and thera­ Exercise Prescription pist, whether wrillen or oral, is c,itical. The sur­ geon's opinion regarding the status of the re­ Most patients who have a total shoulder re­ paired tissues and the prosthetic components placement are elderly and may have other medi­ guides the therapist in choosing a protocol and cal problems; therefore, the volume of exercises selling realistic goals for the patient. For exam­ should be kept at a reasonable level. Patients are ple, if the surgeon had to antevert the glenoid generally very compliant in the early stages of component more than normal, the amount of ex­ rehabilitation because they do not want to jeop­ ternal rotation the patient could expect to re­ ardize the results of their surgery and they want cover would be lessened. If full external rotation to get the arm moving again. Keep the number is forced in such a patient, the 'isk of shoulder of repetitions low-in the 5 to 10 range-and the dislocation would be high. frequency at 2 to 4times each day. Some patients TOTAL SHOULDER R EPL ACEMENT 473 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 Summary II. Ficat P, Arlet J: Necrosis or the remonll head. p. 53. In: Ischemia and Bone Necrosis. Williams & Wilkins, Baltimore, 1980 The purpose of this chapter is to provide sugges­ 12. Springfield OS, Enneking WJ: SurgelY of aseptic tions and guidelines for clinicians who are estab­ necrosis ofLhe femoral head. Clin Ol�hop 130:175, lishing individual rehabilitation programs for 1978 APPENDIX 20. 1 Rehabilitation Programs Following Total Shoulder Replacement CATEGORY A Postoperative Rehabilitatiol1 Program (or Total Shoulder Arthroplasty-Good RotGtor Cuff and Deltoid 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 CATEGORY B Postoperative Rehabilitation CATEGORY C Lill1ited Goals Program Program (or Total Shoulder Arthroplasty-Poor Rotator Cuff and Deltoid In Hospital In sling with obduction pillow. Elbow, wrist, and hond active range of Day I In a sling with obduction pillow of varying size, molion. or airplane splint. Weeks 2-3 Sutures removed. Out of bed into choir and ambulating. f.Aay or may nol begin passive forward Elbow, wrist, and hand active range of motion. elevation in the plane of scopula with Day. 2-3 Passive pendulum with therapist to tolerance. ossistonce of family member. Family member is instructed in technique Week 6 Begin passive forward elevation iF nol started of passive forward elevation for previously. rehabilitation at home. Remain in sling for another 3 to 6 weeks for May or may not begin passive external rotation activities of doily living. with stick, to pain tolerance. Begin passive external rotation in limited Discharge from hospital. range 10" to 20", Home Passive pendulum. Begin scopular stabilizing exercises in poin Program Elbow, wrist, and hand active range of motion. tolerance. Passive external rotation with stick. Weeks 12-14 Begin isometrics. Precautions No active range of motion activities for the Begin gravity eliminated activities within pain shoulder. tolerance. If in obduction pillow sling, do not let arm Months 4-5 Begin light elastic resistance exercises. come into adduction, extension, or internal Progress to active elevation activities as poin rolation. allow•. Week. 1 -2 Passive forword elevation in the plane of the Reasonable Active elevation to 1200. Active external scapula. Instruct family member to 120"; Outcomes rotation to 30". Goal of pain-free use of progress to rope and pulley. arm belaw shoulder level. Passive external rotation with stick to 30°. Months 5-6 When 85 percent of available active range of Week. 4-6 Begin scapular stabilizing exercises within pain motion is possible and anterior deltoid tolerance. and internal and external rolator cuff Begin glenohumeral joint isometrics with elbow strength reach four (out of a possible five) Rexecl within pain tolerance. on manual muscle testing, modified sport Week. 6-8 Begin active assisted range of motion exercises and weightlifting activities are allowed as or gravity eliminated exercises for tolerated. elevation and external rotation exercises Continue terminal stretching in elevation and with appropriate scapulohumeral rhythm in external and internal rotation. as available. Begin terminal stretching for elevation and external rotation. Begin gen�e internal rotation stretches. Week. 8-10 Replace isometric exercises with light elastic bond exercises below shoulder level. Assisted elevation of arm with stick, wall, or rope and pulley with isometric hold at end range and active eccentric lowering. Week. Replace light elastic bond exercises with light 1 2-14 dumbbell exercises. Focus on correct scapulahumeral rhythm with active range of motion of shoulder. 9-10 Acromidchoid mu�clc. gia.12f. 449. 355.6f Acromioclavicular joint. 339 slcl11oclavicuial.9.179-184 humeral �tability.473 with extcnsionJintcmaJ rotation in active range of 11101 ion assess­ Acromioclavicular ligament.reasons for. 5-6. 249f. 449 Anaerobic capacity. 36-37.63-65.myofascial mobili7 . 3f position of. 258 II 14 in impingement syndrome arthrography in. 258.2[.S.68.v on. those followed by t indicate tables.40M. 1-3. 691.rcfen-ed pain from.330 477 . 69t.3tion techniques involving Acupuncture in frozen shoulder. 169.235f. See {lisa Eleva­ in total shouldcn-epiacement.formation of.45 I 330 365-366. in fTozen shoulder. shape of. 2f.432 relationship to spine.370f. 32. 262 movement!. See Daily living activities in isokinctic exercise e.273.10 analomy of. 207.236 in range of motion a�scssmcnl. 30.207f Adhesions. 136-137. Absolute muscular endurance.29(. injuries of shoulder. 3 175-176 under. 1-2. 268 Angiofibroblastic hyperplasia. 387 Agility..aclures of.262f ostcokinematics in. 448 Akureyn disease. 398f in exercise program for throwing teroidal gapping in.232f in immobilization. I tr-13f. I.capsula. 62 brachial plexus in.glide in. 319 ing. 281 antedOI.'r.10 movement. in elevation of �houidcr. 451 f testing of.281-282 and.xacerbation of instability in.99 tuberosity undel� in hemiple­ 365-366 muscles in.259 in exercise program for throwing role of. nons- case �tud. 239 Aerobic training. 243 Adson's test in thoracic outlet svn­ with cxtensionlinternal rotation in impingement syndrome.269-270.265 in total shoulder replacement.8 in postoperative management of glenohumeral joint in. I. in impingement syndrome. 354-355. in isokinetic excl-cbe tion of !>houldc.37f. Anesthesia.95-96 in abduction of shoulder.464.!.230f.272 acromioclavicular joint in.406[.59 473 Aneurysms.Index Page numbers rollowed by r indicate figures. 238. 252f. 407 evaluation of.. 196.41 .9-10 in protective injuries.6.63 hypov3scuial-ily of rotator cuff dur­ postviral fatigue syndrome (PFS) refcn-cd pain to.12.235.64f.198 in frozen shouldcl-. 234f. 5-10 72 in exercise program. 466f. 235. 280 manipulation techniques in.270. 273 innervation of.430.231-232. posture in.373 of scapula. 448 strength. forces in. of.7.".'(crciscs. drome. 407. I. 373 AccessorV' motion in joint mobility.171 of clavicle. referred pain from. of humerus. 356f injuries of shoulder.64[. 2r instability..403-407. 2361 in scnpulm" plane.3-5. 280 movement. Abduction of !>houldcr..270 49f. 406f 100f f..406f Aclive motion Age with nexionlcxtcrnal rotation in brachial plexus inju1'ies.170 movements. 13 predictive value of.51 Acromioplasly ADL. 462. 450. in gleno­ limitations in. 397-398. 232.joint in. 473f in fractures of shoulder girdle.404f.366 405f. 63 scapulothoracic jOint in.346 30r. 365-366.3-5.473 in thoracic outlet syndrome.23lf and frozen shouldel� 258.38r. 72. 136-137 Acromion with flexionlextel11al rotation biol11cchanic. 322 mobili/.62-65. 431. 412 in Mrcnglhening c. in frozen shoulder.99-100.265-266 Anatomy of shoulder complex.336 in frozen shoulder.32f.ation in nexion of �hould(.29. 464.355f Adduction of shoulder Anti-inflammatory agents.9f arthritis of. 40?r ment. 4f impingement of humeral grealer Adenosine triphosphate (ATP).72 arthrokinemmics in. 13r.41f in impingement syndrome. 4f.372f. 260. 3f 387 torque and.11-14. 366 lesling or.relationship to power and 251r. 82. 427-428. 427 Axillary pouch or n. 76-77. case study on. 9. 468. and vein strengthening c'\:cl'-cises ror. 5 1 . 86 428-430 c1cs.'Ccss. 438. 245 glenohumeral. 272-273 1 17 hypovascularilv or. 309 AI1icuiation techniques. tOlal injury or. Biorccdback techniques in hemiplegia. 50r. 20. 7 3 in injured athletes. 286. 474 joint. 22-23 as surgical treatment. nonopcralivc treatment options for. 397r �UrgCI)'. 259-260. 7. 462r. isokinetic torque ratios for. 443r Iypes or motion. 75 lests in evaluation or. 2 8 1 -282 in instabilities of shoulder. 86 in instabilities or shoulder palsy or. 85r. Bankhal1 l"Cconstru cl ion. J3 on. 300-301 Atherosclerosis. 3 1 9-322. predictive value or. 428r B 21 as stabilization technique. 424 Axillary region. 464. posHraumatic. 423 rotator curr pathology in. 42r oSlcoarthdlis. 4081.'\:iohumeral and axioscapular mus. l'Cren'cd pain rmm. pillpation or. 82. 438r. 460f. 8 tenosynovitis or. 4 1 3 after dblocalion. Baseball players 423 tion procedures impingement and instability in. 412t inappropriate u�e or. 240-253 in frozen shoulder.ation in. 437r. 4f. 2 3 . I instabilities in. 250 loneum from. 81 [-83r.478 IN 0 E X Aplcy'� :. 47 1 . 262. 3 Avascular necrosis in scaption-abduction or shoulder. 232. in musculocutaneous ncn'c palsy.ation or.cratch test. in stabilization or glenohumeral mobili7.. laser capsulolT'Uphy in. See a/so Overhand athletes. 4081. 463. 27 1 A:dll3ry artcf). 437-438 strength training improvements in. 270. in abduction of shoulder. 1 88 myorascial mobili7. throwing injuries or shoul­ Apprehension lest in instability of AI1ificial shouldcl' joints. 258-259 Arthrography isokinetic IOrque ratios ror. in rotator cuff tcal'S. 440r. 320r. 1 9 1 te�ts in evaluation or. BOr concave--convex mlc of. 464 in I'olator cuff tears. Basal ganglia. 439. 266 total shoulder replacement in. 444r Bankhar1lesion. Assessmenl pnx:edul'CS. in throwing movements. in hemiplegia in adhesive capsulitis.3tion in rotalOr curr pathology. 474 Axillary nerve 380r Arthroscopy injury or. 474 Athletes. training principles rO I� 368. perforated. See Evalua. strengthening exercise ror. 23. 322-323 case study on.31ion techniques in rcstora· 46Ir. 290 I I . 232 AI1criai pulses. muscle activity studies in. 26 1 . 443. 1 84. 81 r. detection or. 4-5. I 1 7 working posture and. 463. 282. 5 1 427-428. 344 �ul'gicaJ techniques ror shouldcr in stabilizalion of glenohumeral definition of. 422 tion or. 4f 1 9-55 1 1 7-1 1 8 role of steerer'S and depressors in. 7. 3. impact or myorascial mobili7. 32 1 r Biceps labral comple'\:. 445r 425r 221 . 2 1 po�topcr'3live management in. 258 indications ror. 439r. 185. 444. 374r a� diagnostic tool. 75r. 429 joint. 264 peripheral nerve entrnpments in. 397r in rOlation of shoulder. 82-83. 374r Ar1hropmhv. in throwing 443r. 2 1 430-431 injur)' or. 4 1 3 shonening and spa�ticily in. 1 9-55 . in rrozcn shoulder. 41. 23 preoperative steps in. 4 1 21. 20M in frozen shoulder. rdelTed pain rrom. 7 or. 422 of glenohumeral joint thmwing injuries or shoulder in. 423 injUlics or shoulder. 162 tenodesis or.houldcl·. 262r 4 1 1 -4 1 2 . A. 23. response to dysrunction. in nClIf'Omuscular train­ Appcndh:. 192 tendinitis or . 379r. 444. compared to open reconstructive ncumpraxia in. 424 physical c'\:amination in. palpation of . 473 impingement syndrome in. 371 -372 462-463 60 Bench PI'CSS exercise. in prorcssionals versus amateurs. 1 86. 4 vasoconstl"iction renex or. pneumoperi· 24 ing. 459. 231 Arthrokinematics 37 1-372 long head or. 467 short head or. 50r.319 Biceps curl exercise. 369 myorascial mobili7. 459-476 der in. 428r-430r Bacterial endocarditis. 273 muscles innen·atcd by. 461 -462. 8-9 Autonomic nervOllS system 396-397. 206.. 463. evaluation or shoulder' problems in. Arthritis in 10la1 shoulder rcplacemcni 322 4 1 1 -4 1 2 . 463 spec/lie sporl results or slI'CngLh training in. 29 1-292 from. 83. 335-336 Baseball. referred pain i n lotal shoulder replacement. 37 1 . 424-426..!>houldcr replaccmcnl in. 741. 466-467. 37 1 . 240-242 in impingement syndrome. 424. Biceps brachii muscle and tendon post-traumatic. 439 in scaption or shoulder. 424. 1 86 396-397 . 467-468. 85r. 293-294. 69t. 262r. 2 1 2-2 1 3 for �tcroid injections. 104 as diagnostic tool. 8U. 5 joint play techniques in assessment etiology or. 22. 385 arthroscopic debridement or. 439. 463. 378-380. 99 83r. 284 in throwing injuries or shoulder. 470 237. 193.181-182 rchabilitation in. 25 pathophysiology of. 188-189 gallbladder. 324 neous nerve palsy.202 palpation of nerve trunks and neu. tN0EX 479 Biomechanics of shouldcl' motor strength in.193.ation techniques involv­ in droopy shoulder syndrome. 185-186 in shoulder dysfunction .202 injuries. 184-185. 258.184 260-261.170.65. 182f. 196. 185. active range of motion in.184.180 special tests in. {lisa FI'Ol-en shoulder ud injuries.196. 22 evaluation of.196. 6. 192. &e also Fl'Olen 193 injury of..180.192. 238 mechanisms of. 213 196. medial cord.196 Cancer in type III aim. 189. 192-193 Capsula!' pattem. 196. 189-191. 191-192. uppenrunk. 202 rcfCITCd pain from in rotation. 347 emotional SUpp0l1 in.196. 183f.197 in type II ann. rovascular bundle of. symptoms of. 196-197. 67�8. 6 189. limitation of gleno- injury of. 286 divisions of.191. 238 latcral cord.205-214 195.181 &e. 192.188-189 ing protection from injuries. 67-68.198. 179. 264-265 in throwing movemelllS. 193 Bursitis.10f-13f.134 in impingement syndrome. 301.193. 188. causes of pain in.4f. 185. 7-8. 191. 183.172f.328 Brachialis muscles. 179.in throwing movements.200.201 ana. in br achial plexu� inj uries laboratory cvaluation of. 109 lower trunk. 189-195.179. 184t vocational assessment in. 213 passive range of motion in.99-100 196.304 relationship to spinc. in rnu�culocuta. 10 case study on. of sternoclavicular jOint. 192-193 of acromioclavicular joint.199 in frol-cn shoulder. ?r. 184. 157.202 Capsular lesions. 176 rehabilitation for.3 1 1-314 Brachial plexus.189 evaluation of.287-288 occupationallherapy in.190f vascular injuries in. 68. 159. 187-188 in brachial plexus injuries. 185.344 105 in segmental innelvation of shoul­ in range of motion lests.188 Breathing pattems in thoracic outlet fibrotic changes in. adhesive.68f electromyography in. 186. 196. 188 as risk factor.270. Nonprotective infraclavicular.180f.196.31 1 tUl'es. 197-198 of glcnohumeral joint chan on results of evaluation in. 324-325 anatomy of.185. 193. 259.192.187f myelography in.192-193 stress on. 189-191. mobili7. 187-188.10-14 194-195. 193 Capsular fibrosis. 157.241 daily living activities in.in clavicle fractures. in flexion. 211 pain in. 198. 181-182 radiography in.180 sensory loss in.196. 13 patholllechanics of. 193-195 injuries.12.237.185 treatmcnt of. 329 Body Blade. 9 201-202 161 Capsule-labrum complex. coordination in. 109 in glenohumeral stability.3 nClve conduction velocity tests in. 328 in relationship to other struc. 238.189. 258 .99.194f humeral movement� in.202 supraclavicular. 105. liver. 182-183 Tinel's sign in. dmmc.179 197-201 Capsular laxitv tests. 181f in stabili7.179-203 posterior cord. in neck. as complication of musculoskcle. 212 palpation in. 183f. 184-189 splinting in.180 scopic stabilization of shoul­ 196. 179. 5-9.172-173 use of telm.191 syndrome impingement syndromc in.radicular pain in. 264 injury of. physical e x amination in.196-197.case study on. 427-428. 195 8f. 3-5.116.omy of.422 194-195 tests in evaluation of. stages of. Bumcl' syndrome in bl-:lchial plexus in abduction. 109-110 Capsular mobility tests.. in anhro­ history of patient in. 188 pancreas. 187-188 neuralgia of. in thoracic outlet syndrome. 140 laxity of.201-202 lung. in hemiplegia. der. edema in. 66f. 182-183. cervical spine pathology in. in impingement �yn- in axilla.179-184 posture in. 192. 186 kidney. c1a))sification of. 192-193 Capsule from.ation of joint. 187f colon.448 peripheral nerve. 195-203 tdggerpoints in.192 glenohumeral joint in.183f ing. I 17-118 191-193. stomach. 193. 108 comparison to hemiplegia.200 c in type I ann.452 anatomic features in protection tests in.195. 286 conis of. 187. 428f hobby and leisun! activities in. 188 Brachial pulse. 191 Capsulitis.191 anatomy of. 237 components of. 199 roots of. 162-163 342-346 middle trunk. anatomic features provid­ 21 degrees of severity. 192 in cClvical ncrve root iiTitation. trunks of. 184. 325 Brace�. 187.201 in frol-en shoulder.191 shoulder. 201-202 of spine.202 der muscles. 133 pathology of impact of mvofasciallllobilil. 132 frozcn shouldcl' and. Cervical muscles relationship to shouldel' 13 cieclronlVographv of.119f in frozen shoulder.480 IN 0 E X Capsulolabral reconstruction. 320f. 143-150. splinting in. 118 138f tures of. 97-98 brachial plexus injulies in. 105. 107f lcnderpoint� in. 145f. 107.426f evaluation of. evaluation of. 98 compression test. 106-107.l�h injurics of. 110. 122. 59. 184 Cervical spondylosis ing injuries of shoulder. l lO-IIL I l l f convergence of afferent nerves in. IIS-124 facilitated segments in.327f posture in. 111-112.anatomy of. in brachial biomechanical. 97. rcfcn-cd pain from. 163. etiology of. 102f rehabilitation in. response to dv�function. active movement dysftlnc­ in. in brachial pll-xus in thoracic oULlet syndrome. 14Sf refcrTcd pain from. 141. 159. 448. 133-134 refen-cd pain in. 112 compared to nonnal �egments. 134-135 ca::.12lf-12Sf. 141 Cervical disc disease referred pain from. I 10 drome. drome. 100-101. 148 ing. 134-141. 60t need for pn. anatomy of. 448f plexus injuries. in throw­ palsy of. ccrvical disc disease and. of. onset of. 10M.105.or. 124f poslcdor. 105-108 self-treatment and managcmcnt in.317. 148f. 11 l f Cervical spinc. intrinsic shoulder pathol. 140-141 shouldel'-hand disordcrs of.'lse study on. 112. vasoconstriction of shoulder tissue in isokinetic exercise. IDS pain from. 121. See also Cervi­ shouldcr'-hand syndrome and. 109 See (Ilso Cervical radiculopathy anatomy of. 141. 132 cvaluation of. 195 musculoskeletal. posture in. 316-317. 193 dence of. 250 examination of. 121-124 typcs of. inci­ EMG rcsponscs lO nervc trunk stim­ injuries. 163f Cervical lateral glide technique.-itation occupatioll4ll. 10Sf in thoracic outlet syndromc. 110 cJ"Oss·�ectional vicws of. 59. 102-104. Cartilage of glenohumeral joint. 110. 96 pain in. 10. 113 tion of.161 Cervical radiculopathy. 10If mechanoreceptor' S in Chronic fatigue svndrome. 105f EMG responses to ncrve In.431-433 114f-115f rotation of. 97-99 191. hospitalization for. in neuromuscular train­ Celvical region evaluation of. 97f.147f Cervicobrachial pain syndrome. 108 t. 161. 24.mk stim- lion in. 321 f injury of.315-322 compression of.. IOIf. 193 . S7 local area pathology in. 112-113. 305-306. 1631".lcturc:o. tcslS in cvalua­ Cholccystitis. 330 treatment of. 146f-147f Causalgia. 167 ulation in. 121 inhibitory. 426. 424 Cervical ncrvc root it. 99 loss of inhibitory 11lcchanOreceplors Carpal tunncl syndrome Cervical quadrant tesL. I 12f case studies on. 132 Cardiovasculal'conditioning. 131. 132 rehabilitation in. 174. 106-107 150-151 118-120.69t. pressure gradient research on. 167 effect of sensitizcd neurai tissue in. 98 Circulation usc of pain chal1s in. 112f. 100-102. postural. ISO lests in evaluation of Cardiac disease. chronic.385 anatomy and function of.315-316 types of. diagnosis of. lOr. 109 Clavicle treatment of neural tissue. 108 range of motion tests in. 143-150. 185.136. 146f-147f lrealment of. frac­ shoulder' pain 311d. 147f Cerebellum. 105-106. 109 305f-306f. cobrachial pain syndrome 324 163. 26 Cervical plexus. 134 ulation in. 417 108 initiated by.c study on.in thoracic oUllet syn­ shoulder symptoms and.137 pain and paresthesia in.58t. Cervical db. 146f.148 ogy from. 97f palpation in. 60t.136.31 M. 427 Cervical nelves. 426-427 referred pain in. 10If treatmcnt regimen for. 121 58. 426.63 in shoulder pathologies. 140-141 l23f effects on nervous system. in in tendinitis. IS9 in thoracic outlct syndromt'. 161 110-116 in uppcr quurtcr. 6 myofascial neck and shoulder pain c. 265 in. 264-265 325-328. frozen shoulder and.318 initation of 174f Cardinal plane in reflex sympathetic dystrophy. in thoracic outlct syn­ 134. 99-100. 192. 146f.'cisc examination in. 95-125 incidcncc of. 318r. 73 ncurogenic. 136. Spurling's test. 157 pain in compl'es�ion testing in. 179.lIc Ccrvical faceljoint itTitation of. 100f fr. II If. fncc! joint blocks in.108 319-322. 112f.ution Cervical fascia rnyofascial neck and shouldcr 011.IDS whipl<. 122f.164f case study on. refcn-ed refcn'cd pain in.'catmenl of. 100-101.113-116. 118 involvemcnt in. 103f antcr. 154. 108 nerve compression in. 154. 316. 60t in acromioclavicular joint. 113f. Cervical transvcrsc processes. differential diagnosis physical sign� of ncural tis'. scm1'ing of.32M. 59. 143 distraction techniqucs in. 106-107 fluid dynamics in. 141-143. refcrTcd pain fTom. 113 surgery of. 309-3 1 0.380 104 afferent nelve3 from. 188 472f. 209. 258-259 in postoperative management of cutancous nerve palsy. fracture of.205-207. 463 pain from. 379 Cords of brachial plexus.250 Coracobrachialis musclc. 9.in i�oki­ Computed tomography (Cf) in strength training. 306-307. 1 99-200. Connective tissue. 462.202 122-123 improvement of.196.240.236.270 brachial plexus injLII'ics.8 in axillal) . in subacromiul space. 439 for. as indication for total tective injudes 2 1 6-223 shoulder replacement. Compression testing. 1 3 1 Impingement.in musculo­ shoulder in. 196. Cryotherapy. 2f strength and function of. See also Pro­ in hcmiplegia. 27 strengthening exercises for. 269 Coracoid process of scapula in stabilization of glenohumeral in impingement syndrome. 376 in throwing injlllies of shoulder. in subacromial space. 157 osteoarthritis of. palpation of. 1 22.anatomy of.407f. 285 272 joint. in cervical spine Crankshaft effect in rotation and cle­ 263 disorders. 230 force couple With.448 abrasion of.436f 164-166 movements of.83f in tendinitis. 230f in supraspinatu� tendon.422 239. 231-232 crankshaft effect i n .8 1 Coracohurneral ligament anatomy of. 366 Diagonal movement pattcm3. 1 16 for. evaluation of.13 Diagnostic bias ror upper qual1cr pain Compressive impingement. I I I .409 syndrome.ldiographv in.180 in throwing movements. 1 03f. for edema in anatomy of.310f suc� 140-141 symptoms of. See Cold applications 403-407. 1 1 3 . 267.283 following isokinetic exercise. 1 86 .2f Diabetcs mcllitus. 2 1 Collagen changes in immobilization. 259. See Myofascial tis­ Cutaneous tissue.cn shouldcl'.449f. 309.in cervical spine dbordcrs. limitations in. 258. thoracic outlct diagnosis of. 476 Colon and large intcstine. brnchial plexus injuries. 1 21 vation of clavicle.287f in fnnen shoulder. Diaphragm in strength training. 306f. 1 02-103 of.311 in thoracic outlct �yndl"Omc. frozen shoulder in. 417 116 Cumulative trauma disorders (CfO). 450f Coracoacromial arch predispositions to trauma and.307f. 1 3 decompression of.cn 246-247. in postopel11tive excrcbes for. 238 Codman exerci�es in fr07. 1 1 7 brachial plexu� injuries.306. lllf. in stabilization of glenohumeral manual muscle testing of. 423 See also Trauma 201 Concentric exercise ergonomic solutions to.79f. primary anaerobic capacity and. 451f joint.307f.372. 82-83. ders.25 etiology of.v. 193. 273 i n impingement syndrome. 1 3 f Clunk te�t.368.386 Costoclavicular syndromem. IN 0 E X 481 r. nerve. in cervical spine disorders. in rotator cuff rehabilitation.1 86 in injur'ed athletes.449. 309.in cervical spine disor­ in cervical �pine disorde�. 365. 153-177 3 1 0f Congenital abnomlalilies in gleno­ treatment failures in. 315-3 1 6 Conduction velocity tests. 267. 1 2 . in rotator cuff Decompression. 289 of.110. anatomy in abduction of shoulder.9 Coban elastic wrap.192. acromial. 435 range of motion tests for. frol. 1 0 Diathelmy in fnnen shoulder. 1 2 . 125f 199 Dislocation of shoulder. 1 01f. in in�tabilitie� of shoulder. 402. in impingemcnt in etiology of tcars. 198 in frozcn shouldel'.1 66 referred pain from. 475.329 Costovel1cbrai joint. rdelTed Costostcmal joint. in rolator cuff rehabilitation. 47 1 f. 435. II.306-3 1 0 . 1 4 . 9 in total shouldel' replaccment 346.310 humeral jOint. anatomy of. 1 6 1 .157 pneumoperitoneum and. 404f-405f. relationship of osseous structures in thoracic outlet syndrome. in frozen shoulder. 1 3 tears Deep venous thrombosis. in rotator cuff. 185. 24 injLII)'of. risk fac to� in stcl'11oclavicular joint. in brachial ple�us injuries. convergence in throwing injuries of shoulder. position of. 370. See Creatinc phosphokinase (CP) syndromes. 65 mobili/. 19.in rotator cufT tcm�. 461 axillary nen'e injury in. Costoclavicular ligament. Coordination 268 in brachial plexus injuries D Diet. 7. 287. 10. 437f Degenerative changes Closed-chain c:(crcise Coracoacromial ligamcnt. 306. 20. 1 0 f Coracoacromial joint. 58 rehabilitation in. 369f-371f. J 17-1 18 Deltoid muscle instability. exercises in brachial plexus injuries. 13f. 293. 359-360. position of.360f to. 200 Daily living activities Discography. I I I . 370 295 230f tests in evaluation of.8 rotator cuff muscles and Cold applications Coracohumcral space. nerve pab.195 in thoracic outlct. 2 1 in throwing injuries of shoulder.431 Coracoclavicular ligament. 462 dysfunction and. 365-366 netic exercise. 1 0 1 2 f.367.179.ation techniques involving.in pathophysiological issues in.235 in impingemcnt �yndromc. 310 Conoid ligament. 414.5. 104 examination of.136-137.198. 11-14 postoperativc.cvaluation drome. Elevated arm stress test.173f.tests patient interview. 57-91 in throwing injuries. 470f. 238.284-286. 197.267-268. 293. in poslopcmtive management of 173-174 337-341 instability.66f-68r. 367.242. l'efclTed pain from. 97-98.241.387 trcatment of. subscapularis muscle in.372 End-feel in protective injuries. 368. 284-286.280 on musculotendinous dvsfunction.105f sensory. Erbs' palsy. referred 192. sivc. See Po�tllre.201-202 Dblraclion techniques.377f.185.83. 466-467 in tendinitis. 339.472 obsclvational.365-366 p. 137-140. 378 Elastic resistive exercises. in thoracic outlet impact of training on. 231f palpation in.466-467 in frozen shoulder..8. 153.469[' 473 peripheral nerve.60 213. 123f 24 in frozen shoulder. 171-172 strength gains and.243-244. in brachial plexus injuries.268 in hemiplegia. 75f-85f.437f.60-6I physical examination requh-cments in functional arc. 363f shoulder. anatomy of. 372 387 syndrome.case study on.202 Elbow pain from.103f.157.337.471f in nonprotcctivc injuTies. entrapment in. 145f-147f. in brachial plexus injudes in passive range of motion tests.urcmcnt of. 369f. 191 phases of. 72-75.67-68. 103-104 total shoulder replacement in.350. 211. See also Abduc.edema in brachial myofascial pain in. 121) 122f.200 factors contl'ibuting to. 453-455.238f.cuff rehabilitation..59. 212.cuff pathology. in total neurovascular. shoulder replacement.268f 314-315 e:-cercise following. in impingement syndrome. Edgclow protocol.148 in impingement syndrome.268. .202 Endumnce aelive. 140 compressive forces in.posture and. 337.422-424.refen-cd pain from. 189-195. 342f. 223-224 Divcl1iculilis. 295 in brachial plexus injuries. 148 racic oUllet syndrome. exercises involving.98f outlet syndrome.strength difference and.100.154-155. 323 Entrapment tis. tmnscu­ for waJm-up. 466f. 330 special tcSls in. 198 Esophagus. Lion for.455[' 456f Electrical nerve stimulation. Double clUsh syndrome.116-118 285f. 471 in tensile overload.62"'.184. 231-232. compen� Ergometer brachial plexus injury in. 6 in brachial plexus injuries.361f. plcxus injuries.341 Edema. 376.99-100 joint play techniqucs. 185. 64f.57-58. 336 in throwing injuries of shoulder.76-86 flexion of. in humerus fractures. 166.437-438.59. 351f Electromagnetic therapy. 165 of E Empowelment of patients.196.191 on symmctlV. in hemiplegia.288 for endurance training. 60. 198 Epstein-Barr virus syndrome.238. 337f. 82-86 Drop armlest. 741. Dorsal nClvc rool.185. 63-65 82f-85f.360.267.76. 368. in instabilities of shoulder. 386 Domimtncc.101f.274 scapular. 97f.25 in frozen shouldel� 264. 22 in rotato'.285f in total shoulder replacement. 17I 286-287.266 palpation of.213f in total shoulder replacement.375 Dorsal scapular nerve Elevation of shoulder. 26 involving.232f patient tolenmce to.482 IN 0 E X Dislocation of shoulder (COIuhllled) in rotatOI. 99 cClvical spine in. 73(. 329 Electromyography history taking in. 252-253. 415 409 194-195 in impingemcnt syndromc.23I.242 .459 outlet syndrome.342.244 235-236.427 muscles innclvated by. in athletes. Droopy shoulder syndrome.167 effect of posture on.110-116 cervical facet.269 339.438f Elastic wrap.188. l00f 69f-70f. glenohumcml.in thoracic ouLiet syn­ on posture.66 on range of Illotion mcm.345 in frozen shoulder. 76 physical examination requiremems Ethafoam rollers. Doorbell test. 265 on neurallissuc. in throwing injuries of shoulder.in frozen 263-267. 463.184. 84f in frozen shoulder. 3371. 113 evaluation of.260.188 satory actions of.in bl'nchi:ll plexus injuries. 379 case study on. 379 196-197. 105. 192. on pmprioceptivc and kinesthetic Eccentric cxercise 171-172 abilities. Drug therapy hand-therapist positioning dur­ 343.379 chronic laneous (TENS) Ergonomics. 463f. 61.148 238f 468f. 75-76 in strength training. 387 for.373 in rotator cuff and bicipital tcndini­ Erforl thrombosis.2361. 337f. 435. 196. in thoracic pn .711-721.liLa· for. cClvical.116--117 tion of shoulder 252-253.postoperative rehab.65"'. 341 Emphysema.431 Evaluation procedures.in thoracic 239."opcrati\'e. 59 Duchenne-Erb paralysis. in treatment of tho­ rCClin-enl.134-141.362.153-154 in rotator cuff pathology. fOI. 237.272-273 ing. 57-59 in throwing injuries of shoulder. 211-212. 108-109. immobiliullion in celvical spine disorders. 243-250.58. 253 in isokinctic exercise age of onset. 183f in thoracic outlct s. 154. 403. soft tissues in. intensity.67-68 of clavicle. See Isometric exercise shoulder in. 367.182. with abductionlexternal rotation 257-261 380-381 movement. Body Blade. 261.201 in 10ta.yndrome. relationship etiology of. 368-369 stages in healing of . mobilization of. Fulcmm test. 3 subjective lindings in.470 dynamic stabilization. 29-51 in exercise program. injuries. 402. referred pain from.330 272 245-250 Fibmsis muscle guarding versus adhesions isokinetic. Exercise prescription of clavicle. 263 271-272 392r. 266-267 250 in isokinctic exercise pathology and delinition in. 424 for uppe'. 287 Gallbladdcr. drome. 367. 449 clinical features of. specificity.476 Foreann pronation in hemiplegia and Gapping of acromioclavicular joint. 272.163.454 F celVical spine in. 232 325-328. 447-456 Gastrointestinal tract. 263 proPlioceptive.452. 368 shoulder-hand syndrome and. 448 case studies on. in magnetic resonance in off season. course of condition. 369 case study on. 267-273.54 at glenohumeral joint. 472f lotal shoulder replacement in. 237.232 Gadolinium. in thoracic treatment of. postoperative. 29.245f-249r.475. 266. 447 372. 195. 262. 237 ing in. wann·up. 311 in \'isceral disea!)c. 406f treatment of. 32 palpation in. 76 in exc. 470. See Strengthening in carpal tunnel syndrome. 287-288 Gait. 447-448. 448 167-171 frequency and duration. 263 home. 52 233r.369.396f in diabetes mellitus. in frozen shoulder. 246-247.240. 453 23 maintenance. 26 definition of. 3lf. 237r. 407f arthrogram. 407 primary versus secondary. structure of.380r. 154. 172-174 161. at scapulothoracic joint.1 shoulder replacement. 448. 108-109 of scapula. 109 isometric.29-55 Force couples cardiovascular.£n shouldel� 267. 467f.164f Funiculi. 25. 25 movement. 249-250. 163f G 25-26. 253 brachial plexus injury in.328-329 . 99. 327f 472-474. rnnen in. See Isotonic exercise in impingement syndrome. with postviml fatigue syn· joint play motions in. 405f 262r. 463 type lJ arm.30r.261 muscle reeducation and strengthen- isotonic. 369-370 . 264 Impulse Incnial Exercise System. 259-260. for throwing injlllies. 121-122 472-473 affecting.joinl. anterior. Fascia.404f. Fractures of shoulder girdle. 448-449. 401. 449-455 in throwing injUlies of shoulder. 403-407. 143-150. 410 peak torque in. 29f-3M. 257-274 251 f.451. See Homc exercisc program Fibromyalgia syndrome.264 scapulnl' retraction.274 resistive. in lhoracic outlet syndrome. 262 strengthening.407.252r. 453 concentric and eccentric. 239 Fluid dynamics type of onset. 261-263 in fro:t.extremities.163f.-cise program for throwing 469. I 72f-174f. 324 199-200.163-164. 26.58t.164f in throwing injuries of shoulclcl� in upper qU3I1er. 264 repetition in.212f 355. with adduction/intcmal rotation compared to normal shoulder 250. 259-260 in postviral fatiguc syndrome.380 Extension of shoulder. 405f review of literature on. 368 Flexion of shoulder neural tiSS1'C involvement in. imaging. 237. 249 objective lindings in. 264 in lotal shoulder replacement imbalances in. preoperative.32M. See Resistivc exercise outlet syndrome. 373-374. 39f Froz.269-270. 25. 368 of humerus. 274 of humerus. 450. 37.35M for unstablc shouldcr. 271.252f movement.232-233. 299-301 periodization. 198. 406f. 272-273 in frdctures of shoulder girdle. 391. 22. 264-267 open and closed chain. 109.261 in impingement syndrome. 252r. in dislocalion of shoulder. 367-368 immobilization in. rercrred pain 251r.386-387 mulliplc� versus single. 136 muscle activit v elicited by. 249-250. 330 with adduction/extcrnal rotation reco\'ery of shoulder motion in. 404f. plyometric. 468. 262 equipmcnt lIsed in with abductionlintcnlal rotation anhrography in.395-396. 403-407. 27 in brachial plexus injudcs. 109.psule. 163. See Isokinetic exercise of glenohumeral joint C:1. 451f Exercise rest periods. 462f-473f. 162-163 trigger points in.259. 286 exercise 161. movement. 270.368 Flexion withdrawal reflex. 239. 406f. 369 of scapula. 261-262.262f isokinetic. 366. 257-263 373-374 osteokinematics in. IN 0 E X 483 in thoracic outlet syndrome.en shoulder. 237f."eferred pain and. 448 capsular pattern of. 188 from. 319 Hands 206-207..346-347. 206-207.422 shoulder girdlc. 209-214 tears in loss of muscle control in. load and shift test for. 5-6 alignment of shoulder girdle in dislocation of.68 in impingement syndrome. 6-7. .alion techniques involving.225 in lIexioo of shoulder. See also Stability of in mobili7.60-61.221 functional categories for. in shouldel'-hand syndrome.22 and body posture. 269 c�lpsular pattcm of restriction in. activities in. 216.23.423 trcatmenl of.80f. 447 restoration of. secondary overload on.6.22 neuromuscular deficits in. 385.in total in muscle. Glycogen.484 IN 0 £ X Gender differences.215.466f.houlder joint. 220. 209f. 421 protection of.. 6f in throwing movements. in humerus fTacturcs. peak torque of. 205 subluxation of. . 6 Heart disease.8. 5-6. 5-6. H 215f 284-285.6 Grasp pallems in hemiplegia.4[. 266 anatomy and function of.279.207f. 1.224.ll'diac disease r01310r's cuff [unction in.7[' Sf.261..370-371 Glycosaminoglycan levels secondary complication:'> in. shoulder pain in.13. 13 211-212. trophy of. of.285f sof1 tissue blocks 10 motion in.. 13f in throwing injuries. stabilitv or.421. shoulder replacement.hyper­ Headache. 2r in thoracic outlet syndrome.8-9.:\llil.6f.214-216.nion ' techniques. 452 detection of. 213 24. 9.205-207. Gliding motion open·ended (non-weight·bcaring) 347-354. in range of motion teslS.3-5.23.345 Glenohumcralligamenl.354[.64. 214.402-403. 371.lction of.284--285. See Dislocation of in stabili1.gliding place and hold activities in. See HUIl1<::rus.370 motion of posture in.266 in throwing movcments. 12f 224. shoulder or. 215. 217 in stabilization of joint. Heat applications 287-288 344 in frozen shoulder.213r. 223 209f-213r.422 drome. 220 PCI.8-9. anatomy or.472 209-214 anatomic.6-7.75 Goniometric measurement. 10. 215. 3. 214 extensibility 0[. 5-8. 215.slages of. 422 Hawkins sign leM. spasticity in.354-355. I.157 Head position 11-14. 354.282 226 in isokinctic exercise. 3 in hemiplegia. of gleno­ 8r.279. 12-13. 2-3 at joint surfaces.22.209 in scaption-abduction of shoulder. 226 in frozen shoulder. rebTcd pain 10.6-9.27. 370. mobilization techniques involving. SLAP lesions ""aunenl of. 288 anatomy of. of sternoclavicular joint.212 innervation of.11 r.trengthening exercises for. 205-214 lo�s of mobility.in thoracic outlet syn- syndrome.226 373.3tion of glenohumeral in trealment program.448 324 palpalion of.82-83. 21-22 in cumulative trauma disorder. Hematoma formation in fractlll'es of capsule. 226 15. 9 of humCius..211f. 223 220.lm and weight-bearing. Hands·up test. 241 221 join! play motion!'. 7f.218. 59 rOLator cuff pathology and. 346.223 in joint.207.&e Capsule.410.64[.11.1 joint Glenoid fossa Hemiplegia.structures of 285f rrom altered sensitivity. 6-8.207f. forces in.3.103 cictclminanls of. 100 in abduction of shoulder.426f etiology of.741.. 344.206. 205-226 canilage of. See Cl.268. 375.22 Glenohumeral joint. in hemiplegia anterior capsular rcconstl1.267. 3 Glenoid labl1.209 popping 01' clicking of.8 of injured athletes.63. 207.422 355f reeducating distal movements in. 214f. 19-21 10H 3rlhrokincmalic mOlion at. 6 anatomy of. 208f.4 Gravity eliminated motion. 83f stalic.422 473 in sublll'C3lion.100-102. 270 shoulder·hand syndrome and.23 in weight-bearing. position sublw(ation of shoulder ill. of. oslcokinematic motion at. in strength training.206.216. in range of motion tests.. 171 Gilcre�l sign lest.417 throwing injuries of.6.421 biomechanics of shouldel' in. 216--223. 212r.cles of 355f 222f-223f anatomy of.214. 206.348f-353f of acromioclavicular joint..s Healing of fractures. 373 in frozen shoulder. rcfclTed pain and.212. 217.215-216 anatomy of.81 209.447 hurner.224-226 and. 216-223 mobili/.213.10. 216 11f. 370. 207.79f. 209. 21Sr in stabilization of joint.grasp paltems of. in thoracic outlet dynamic.225f . 37M 67-68 in stabilization of shoulder.241 grasp pallems in.242 muscle ::otimulation techniques in. 23. Illu!.426. 387-388 a�iIlarv SUPPOl1 for. 12f. posture and.365-366 223 369f-374f.positioning undcrlying instability and.218.2-3 in immobilization.4f.:ula.219-223. range of motion in.. 223-226 svnchronous activity of. 166 287-288. 214f. i n frolcn shoulder i n . 302f-303f posterior. 447-448 in humerus fractures. M I-I"\'perabduction of a11m. 24 in nonproteclive injuries. 337 inferior. 4 1 4. in hemi· acth'e movemerll dysfunction in. dist raction of. 43 1 . 1 89-1 9 1 . 284 in rotutor cuff degeneration. 45 I f. i n mobili7. 330 i n paticllI interview. 2 1 2 f referred pain in. 272 and type I I aim. 452f-456f 1 96. 2361 . in frozen shoulder. 450. 2 1 4. 2 3 1 -232. 4-5. 85f. 5 type I ann i n . 20. 2 1 1 f. in abduction of in throwing injuries of shoulder. Ilome exercise programs in rOtator cuff disease. 2 1 2f i n rotator cuff rehabilitation. 239.. i n !teapula fractures. 258. 2 1 M. 455f. in hemiplegia periarticular tissue and muscles in. 4(. 452f in brachial plexus injuries. 5. in thoracic and shoulder pain. 450-45 I . 1 37 case stud. 409 in frol. 449 retroversion of. 2 1 1 -2 1 3 . 450. 240. 2 1 1 -2 1 2. 379 i n myofascial cvaluation. der. 25 rolling motion of. 201 impingement undcl' acromion. 4f. : collagen changes in. 167-168. 451 f.4 1 7 i n range of motion tc!o>ts. complications from.v on. 57-58 1 1. 209. 207.. 1 8 1 . 238 201 in hemiplegia. tvpe III �lIm i n . 346. 2 1 2f l-Iumel1Js Ilvaluronic acid levels i n frolen shoul. l lion. 198. 7f. 45 1 . 451-453. 1I)'pomobilitv of shoulder. 2 1 0f. 2 1 6. 1 8 5 . 468. 452 brachial plcxu� injudes. 2 7 1 . 450. in tendinitis. 338. 2 1 8. \· I m pingement-in�tabilitv complex. impact on myofascial tissue.. 453-455. 2 6 1 . 2 1 I f. 422 anterior. 270. tN 0EX 4&5 treatment of �houlder problems i n . 349f-350f. 4 5 1 f . 2 1 5. 258. 201 rehabilitation in. position of. 448 hvperextension of. refen-ed pain from. 64 classification scheme i n . 207f glycosaminoglycan levels in. 2 1 1r. 342 anterior/posterior. 2 5 1 252 gliding motion of 239. 8. 2 1 3-2 1 4 anatomy of. 293. 3 1 1-3 1 2 and scapulohumeral rhythm. 134. 35lr Immobilization i n protective injuries. I I . J 1 6 i n rotator' cuff pathology. 448. 5. 454 2 1 1-2 1 2 . 349-350 in fractures of shoulder girdle. predi�po!o>ition to rotation of protective i njuries trauma from.4 1 5 . fractul-cs of. 1 3 6 45M Hypermobility o f shoulder. 454-455 Icc applications 299-300. 385 428-430 230f passive mo\'cment following. radiography of. 324 in external rolation of shoulder. 236. 2 1 7-2 1 9 . 190. t�ts i n size of head i n relation 10 glenoid 2 1 6-226 evaluation of. 3 5 1 -352.1 7 1 2 1 5f plegia. 45 I f. 270 weight-bearing activities in 1 . 2 1 1 Humero�apular periar1hritis. 68. �elf-admin istered questionnaire in. 207. 451 f-456f plcgia and tvpe II arm. 269 in impingement syndrome. 353f. 4-5. dissociation from scapula i n hemi· outlet syndrome. 240. 447-448.3lion. i n rotator cuff rehabilitation. 344-345. 35 1 f in throwing injulies of shoulder. 235 i n Pancoast tumor. 209 Hvpere1asticity with impingement in treatment program. 2 1 4f. i n throwing injlllies of shoulder'. 472 Hvperextcnsion of humeru�. 2 1 8f-222r. 385 instabilitie� of shoulder. 2 2 1 f age relationships in in brachial plc'\:u� injur-les. 2 1 tvpe I I aml in. 207. 7f. 449-455. 376 information collected during. 347-349. 226 niques. See also Non­ proces!o>. 470 in impingement 'iyndrome. 2 1 3f. 350. 336. 193. periarticular structures i n stabiliz. 1 3 Impingement syndrome. i n hemiplegia. 22 I lcrpcs /. 209f. 57-58 lion. 324 in greater' tuberosity. 6f 242-243 in throwing injuries of shoulder. 348f-349f 339. 453 i n total shoulder replacement. I I also Stability of �houlder in rOiator cuff tear. i n mobilization tech· position in instability continuum. 433 lion of. See instability. 257 in throwing movements. 448 Hobby and leisure activities in grcater tuberositv of of humerus. 386 350-35 1 . 4 1 4.. 437 338-339 in clavicle fracture�.Oster positioning of. 1 36. 1 9 1 . i n evaluation fOI' visceral disease. 58 i n abduction of shoulder. 13 295 i n in�tabilitic� of �holiidcr. 4f. 72 lIi11·Sachs lesion. 1 7 5 i n rotation of shoulder. 6-7. 86 fossa. Ilornel'\ syndrome. 45 1 . 4 1 5 . 230f-232f. 448 in thoracic outlet syndrome. 8f 234f-235r. in subacrom ial space. in frolen shoulder. detection of. 6-7. 452f of scapula. 170. 292 in postoperative management of .e n �houlder. 3 5 1 f 243 Ilepatitis. 385 300. in abduction of shoulder. 72 shoulder-hand syndrome and. 2 1 5.. 235. 30lr-303f in shan. 6 8 . 22 Hooked (or tvpe I I I ) acromion shoulder. 459 353-354 of clavicle. 270 Holmium VAG laser cap�ulorraph". 4 1 6 . 454f following isokinetic c'\:crc isc. in mobilization. i n mobiliza­ Iceland di!>e3SC. 1 0 stages of pathology. fractures of. in glenohumeral joint. 2 6 1 . 449 195. tranwerse. 423 45lr History taking i n neck. rdclTCd pain from. 264 total shoulder replacement i n .. Humeral ligament. i n mobiliz . 207. 267.. acromion i n . 4. 64. 447 blocking of movements in. 1 1 3 neuromuscular retraining in. 4081 . anatomy of. 403. 286 pain from . 242-243 29f. 437f in stabili7. 422 in brachial plexus injuries. 237r. 2 5 1 f. 24. 80f. 374-378 in throwing injudes of shoulder. 2 1 408. 379 pain in. 4081. 238. 375 spasticity of muscles in. 237f. 240-253 tests in evaluation of. 236t. injulies. 236-237. 63. in impinge­ cles in. 4 1 7 primal"V versus secondal). 282-283 242-243 252-253. See a/�o Stabil· with underlying instabili ty. 239-240 252f advantages and disadvantage� of. 376f-377f ment syndrome. 29. 230 underlying instability in. 2 5 1 -253 predictive value of. 149-150. 30f general considerntions in. 243-250 strengthening cxercises for. 243-244. 7. 239. 235-239 I mpingement tests Irritable bowel syndrome. anatomy and 1 99-200. 1 99-200. 237. 236. 402 in throwing injuries of shoulder. tests in evaluation of. 1 80f. 237 in throwing injuries of shotlldel� 22 glenohumeral joint in stretching and strengthening exer­ Instability-related impingement. 4 1 0-41 1 . 237f. 8 1 r. 2 3 1 -234 treatment of. 253. 201 secondal)' 30r.ation of shoulder. 245f-249f. inside o r undcrsUiface tears in. 4 1 2 1 case study on. 25 1-253 in suprascapular nerve palsy. 243-244. force couple at. 329 precipitating factors in. 2 1 4 subcoracoid. 282 410 diagno�lic difficulties related to. and. in professionals versus amateurs. 280 Infraspinatus muscle nnd tendon compared to isotonic excrcise. 408. 29. 24 1 . 244-245. 4 1 2 1 . 1 4 concentric training in. See 3lt hrokincmatics. 236t Impulse Inertial Exercise System. 97. 435. tests in evaluation of. 2361. 57. 230f Intervertebral forumen. S1age III. 435 injury of. 81 f. 1 8 H size of subcoracoid space in. 1 49r. 239-240. in etiology of rotator cuff pathol­ InOammatory stage in healing of 401-403 ogy. 200 cryotherapy following. frequency of. 403-407. reproduction of. 1 2 . 233 in throwing injmies of shoulder. 402. 280-281 manual muscle testing of. 250. 242 Infrahyoid muscles. 239. i n fracture!lo of shoulder girdle. 2 1 Iontophoresis treatment. 1 6 1 posture and. 240. 234-235 2371. 404-405f. 236 252f. 59 slages of. Lnitability le\'els pathology of 461 -462 in passive range of motion lests. 29[. 237. 77. 97f. 370. 65-66 inldnsic factors. 370. 9 rehabiliLation of stabilizing mus· 3 7 1 f. 243 242-243. 8 1 -82. 4 1 4-4 1 7 S1age II. 233-234 Hawkins and Kennedy. 207. 243 in throwing movements. 243-250. secondal). 233f. 192. 4 1 7 evaluation of. 249-250. 1 1 . 372 case study on. 232. 4 1 1 . 234-235 Neer. 236. 1 85. 286-287 21 455 rehabilitation issues in.4 1 3. lnterclavicular ligament. Impingement. 232[. 1 79. 411 surgery in. painful arcs in. 286 Infraclavicular brachial plexus 409-4 1 0 position in instability continuum. 436f i n total shoulder replacement. 238f. 23 1 . 22 doorbell test of. 4 1 7 in etiology of rotator cuff pathol­ in injured athletes. 96 case studies on. 233 crossed illm adduction. cxtdnsic factors. 20. 288-293 subacromial space in.. Intel-rcrential stimulation. 22 4 1 1 . 236-237. S 368. 238. 2 8 1 . 401-417 predisposition to. 286-287. 232f. ogy.Iage I. 98. 372 treatment of.ebral foramina 236. 235-236. 369f-37 I f. 242 anatomy of. 22 1 2 f. 99. 242 extemaVinternal rotation ralio in. injmv of nClve in hemiplegia.es. 280 function of. 26-27 brachial plexus in. 236-237. 82. 375-378. 188 i n brachial plexus injUl.486 IN 0 E X Impingement syndrome (COIl/iuued) in tensile overload. 286-287 221 case study on. 435 shoulder ginilc fractures. 1 J 7 equipment used in. 240 tears in. 14. 402. 369f. 252-253 1 80. 280 in abduction of shoulder. in tensile overload. 2 1 normative data on. 237-238. 229. 1 60f. 239 treatment of. 1 1 . 280. undersurface rotator cuff tears classification scheme in. 239 183f muscle imbalances in. 47H eccentric tmining in. 245-248. Instability continuum.4 1 3. 40 I . 242. 183. 24 posture and. 238. 240. refcn-ed pol:llure in. 232-233. in brachial plexus injuries. 201 . 82. Innervation o f shoulder muscles. evaluation of. Im'el1. 283f surgical options in. 237. 235-239. 286 Isokinetic exercise. 2 3 1 -232. 197. 5. 241 -242 Lnhibition technique� in hemiplegia. 4081. 1 0 1 249-25 1 throwing movements in. 230 rOOI S aI. in athletes. 232-233. 28 1 ity of shoulder evaluation of. 453. 192. 236t. 229-230. 243-244 strengthening exercises for. 409 2371. and. 73. classification of. diagnosis of 22. 407f. 23 1-232. 40 1 . 285 diagonal movement pallel1lS in. diagnosis of. 286 abduction/adduction ratio in. anatomic description of. 184. 252-253. 237 243. upper surface rotator cuff teaf'S in scaption of shoulder. 238-239. 2 3 1 f cises in. pl'imary. 373f-374f. 6 1 . 287 8 1 f. 367. 1 35. 376. 286 dominantlnondominant side. 75-76 instability. 83f warm·up in. 367 M in rotator cuff rehabilitation. 377. 42 1 -422 body weight. 4 1 � l l Kidney. 372. 4 1 1 . 2 1 . referred pain from. 1 1 7 409-4 1 0.. 4 1 1 lion techniques. 43 1 . lllobiJi7. 8. 401-402 Kabat\ self ceryicle traction protocol. as indication for IotaI predictive value of.vndromc. in stabilization of shoulder..413 77. 402-403. 372 369[-37 1 [. 76 470[. 40 1 . 296 Leisure activitie� in brachial plexus 'p'->ed 0[. 75. i n profeSSionals versus amateurs. 403 L: lxitv of capsule. 422 'p'-'ed. 40 1 . 328 Lung. 1 2 1 .'e value of.. interpretation of. 1 pred icti. concentric and eccentric training in. 339. i n shoulder complex. 409 intcn-elationship with myofascial in brachial ple. 423 J. See also spe· time required for. 376. 20.xus injuries. 373[-374[. 83. plexus injuries. IN 0 E X 487 in impingement :-. 4 1 2t. in cervical spine disorders. 402 37 I f. 3 1 3 [ i n fraclUres of -"houlder girdle. 289.e sllId. 343 in rotator cufr rehabilitation. 324 age. as tc�ting procedure. 3 1 0-314. daily living activities in isons in. 4 1 0. 369f. 104 bilateral and unilateral compar· definition of. BO£. 3 1 3f in postoperat ive management of testing of. 176 Long thoracic nerve palsy. 75. 377[. 383 Lifestyle. 80£.houlder. 408. 4 1 3 in manipulalion technique. 61 eccentric. 2 4 1 eccentlic/concentric. 1-I8f maximal crrol1 in. 77[. 384f 199 413 in postoperati. 3 1 2f. 1 1 3. 379 LaboralOry evaluation of brachial defined. 29-5 1 21 italion in. 40 I. 403-407 122[. 379[. 8S£. 290. 401-402. 409 in frozen shoulder. 367. 368. 1 70[. in t1-eatmcnt 377. 70f-7 1 f. 424 1 16 . 4091. 43 1 . refelTed pain from . 4 1 3 Lippman test. Jobe subluxation relocation lcst. 3 7 1 [.xus injuries. 266 i n impingement syndrome. 408-409. 1 9 3 41 11. i n assessment of scapular posilion. 453 dc. 57-58 Isotonic exercise Lachman test. See also Mobili7. 1 70. 6-7. 380 of neural tissue. a n d stabilitv o f joint. 430. 4 1 0-4 1 1 .. 473 Labral integrity tests. 4 1 01. 409 i n rotalol' cuff rehabilitation. 402 combined with Ul1hroscopv. Lateral slide test. 95-96 in nonprotcctive injuries. propriocepti\'e neuromuscular faeil· 29[-36[. 3 1 2-3 1 4 . cine ligament torque ratios III in evaluation of shoulder problems.omctlic exercbe Kinesthesia 3 1 2[. 369f. 1 96. 25. Locking test.ation strengthening exercises for. 2 1 in�tabililv. 370 i n po�lopcrative managemenl of in tendinitis. 383. 22 290[. L 295 Macrotrauma in strength training.ation. 1 3 for nonnals. 1 4 negative respon!>C to. 432 shoulder replacement.c. 409. 4 1 0 378 Latissimu:. 4 1 1 Kibler scapular slide test. 7f. 4 1 1 . 3 7 1 . 6. 73. 428-430 i n celvical spine disorders. 377[ 367. injuries.yndmmc. 40 1 . 4 1 3 266 capsular mobility teslS for. 433 anatomy and function of. 57 i n lotal sllOuldcr l'Cplaccment. repetitions in. 408t. 8 1 history taking for. 34 1 ... 369£. 2 1 progression of. 4 1 7 grading system i n .. 40 1 . 286. I. 142. 401 Joint mobilization. 294. 86 torque relat ionship!oo i n Livel� refen'ed pain from. 465f. 40 I . on.'elopment of. 4 1 2-413 271 Links. 367. 232 mu�le loading in. 199 Laser capsuJol'raphy in inMabilities of in bmchial ple. 432-433 377[. bilitalion. shoulder. 370r. 373f-374f. 123[ Levator scapula s. 4 1 1 in impingement syndrome. 1 2. 3 rrequency o f training and. 193. Bf. 4 1 2 K Load and shift test.·c management of limitations in. 284 Ludington's lest. 4 1 7 in strength training. 402. 4 1 3 instability. 43 1 .. 1 0 . 373[. 368 in pobloperative management of in abduction of shoulder. anatomy of. dorsi muscle. in throwing movements. 1 9 3 compared 10 isokinetic exercise. 461 i n preM:reening.'ator scapula mUM:le in blrenglh training. in. 403 Joint play motion:. 79f. Lateral glide technique. 374[ 402. 4 1 1 t tests i n evalualion of. 250 ca<:.a­ anatomy and function of. 288 LigamcnlS of shoulder. Myofascial spasms i n . 380 mobili7. 402. 6 for alhletcs. I I I . 4 1 1 in throwing injuries of !. 4. 96 submaximal cffon in. 7M. 286 in rotalol' cuff reh� . 294. 82 in treatment prolocols. J in throwing movements. 4 1 0. 193-195 exercise following. 379-380 i n injured athletes. 432.4 1 2 .32 in protective injulies. 409 inblability. 295 strengthening exercises for. 370 po�itioning of glenohumeral joint 294. 270. 286 Magnetic resonance i maging (MRI) in brachial plexus injuries. 236 in lendinitis. 355 'pa. Icnglh-tension . e:(aggermed.l"Vical . 423-424 a� 'i essment of. referred in protectiH� injuries. 335-363.!opine diM)rdcn. 206. 242 172f-173f. contraindications for.m Mvofascial mobi­ in fracturc"i of shoulder girdle. 86-91 "icapuiothorncic mobilil. 237. 272-273 I"eCnrilmenl of. 2 . 2 1 8.okinelic c'(crci\C Metabolism.thetica. of glenohumeral joinl edema. 3 1 9 in rotator cuff tear. 1 9 1 192. 270-272. 288. of. 37�. direction of movcment in.. in fro/cn . 10.houlder. hVpel11'ophy of. 336 conlrol of in cClvica! . 272-273 in complications of immobilil.technique:. 294. 2 1 2. 293. 347 mvofascial. 206. 1 3 5 . Mobili71tion techniques. defined. in impingement :. 72 Ma!:>'. 1 2 1 of scapula. 97. 448 in thoradc outlel wndrome. 72-73 344-345.c in humcl1. 9 III c(. 1 3 9 237. 386. M i nor causal�ia. 103 in !otcnpula rractures. M icrotrallma 295. 336 in brachi'll plexus injuries.. 1 222f-221f.. 4 1 5. 167 in pmt('. 346 under anc"Ithesia. 439. pain in. 220.ticilY of. reeducalion of MilitalY' position.. 355-362 head JX)stllfC and.e therapy ( M ET).488 IN0EX Magnetic resonance Imaging (MRJ) Mixed spinal n('I"\-'e. 192. See al.. 66 237f. 20 I . 691.. 60 in rOialOl' cufr pathology. 691. 245 248 MCI-algia parae. 68. 198. 226 123 124 Muitiple cnrsh wndrome. 424 Mobilitv of shoulder. 448 fiber IYpes in. 344 3861 in primalY' tensile overload. 347 rcsiloli\'C lesl.. 385 in fro7en shouldec 267. 198 455 anatomy or.. 6·7. 1 96. 341 ·346 eccentriclconcentlic torque ratio"i 366 principlc!ot of.I S I .. 441f 366 caS(' slUdv on. 1 7 3. referred pain from. (:ontraindicalion:. coordination of. 273.-dationship in. radicular pain in neurnl ti"ilouc. 1 I l f. 6 1 -·72. 237 Medical c:(erci..'Ct iv'e injuriclo.. 4 1 4. 1 1 8 hand posilion in. 346.. 103 IVPC of force u!otcd in. 194-1 95. in overhead " . 336-341 loadmg of. 88-89 i n brachial plc:(us injuries in rotator cuff tcal"�. 336 ror mobilit\'.1 36. See 196.ation in. POI1. 236.. for. 365 palpation of. 454.vndrome. 1 37 in impingemenl syndrome. (:ti\C mjuric. 121 122 indication"i for. 98 i n abduction of shoulder. 1 2 1 .. 2·3. Mu�les. 346. 366 li1'<' 1 1 iol1 of claviclc. 346 in i-. 1 53. 2 1 2.. aerobic and anaerobic. 270-27 1 frequency of. 199-200. 232-233 provocation tC'it via. 33.ation of joint. 267. 4 1 6. 4 1 0 pain in. for. 95 histolv wldng for. 1 85 for glenohumel-al joint capsule. 1 4 1 143 . 6. 205-207. 4 1 3 Metacarpalphalangcal joint. 225. 335-363. 206.trenglhening c'(erciM's for. 344-345. 245f-249f. 449 morphological relationships of. complicationlo rmm immobili/ation Manipuhllion technique!. 4r in rro/en shou lder. poStlll-a1.. 452 226 injUN of. trigger poinls. 369-370 also Joint mobilization. 273. in cumulative trauma disorder. 344 i n hemiplegia �condarv effects of. 2 4 1 Motor nervc!ot. 1 40 237f. 206. 185 fOI' hypomobililies. 284-286.u"i . 1 2 3 f biomechrmical effcct of. 375 344-345.. in nonproll. 691. planes of. 3-4.alion. 438f !. for. gadol inium-enhanced..ation le\:hniquc. 192. 3W . enduran<':c and. 449 in stabili/. 272 throwing injurics. 346 for almpl1'\>'. 1 99--200 2 1 6-223. 237. �7 in impingclllt'nt syndromc. imbalanccs in.. pres. 346-347 in. 72 73 285f definition of.. 226 2 7 1 1 .agc. 202 Maintenance program� 1 2. injuries. 220. in hemiplegia. 2 2 1 Medial and lateral pectoral nen'e goals of.S.1s fractures. 346-347 spasticity or. mlllocJes i n nen'ated by. 202 definition of. 202 �lrc"glh training in. i n tho­ 1 1 4f I I Sf in brachial plc. 226 palsy. 72 slimulation or. 206f. t. 296. 2 2 1 most lengthent-d position or. M"'ofascial mobili7. 98 2 7 l f. 452-453. 8-9 i n (nuen . racic outlet wndrome. 73. improper lI.Ircnglh or.1 3f.m. 7 1 1 ·721. 220--2 23. 270-272. 45 1 .. Set' al.vpelo of. evalualion of Manual musdc tC'sting. motor nen'e inncl'vation"i of. 2 1 6. houlder. 346 manUal lC"i1S for. 2 1 5 Mcchanorcccplors in celvical spine. 347 1 96. 402..pinc dbordcrs. 236 in. Median ncn. 375 in impingement 'wndrome palsv of. 6 1 . 2 1 8. 346 bodv mechanics in. 209. ·US. I SO.(lIlo injurie"i. 378 . 386-387 Sec llho \pecific tcchnique duration and amplitude in.1 74 1 1 4f 1 1 51 repetltlvt' fOI. i n (''(crcise program for at joint surfaces. 379 phasic \'e. 336 under' anesthc"iia.'C hniquclo in. 387 Manual (herap. 36f ph\'''iiologic benefil of. 238 spa<.m VJeCI'/i(: ullI_\('le (Cot//iuued) 97f. 1 66. anatomy of. 1 59 in brachial plc)ttl!) injuries and of humerus. 1 50 in hemiplcgia. 170 Movement 199 200 Militar. 1 1 14 in in�t�lbililic� of �houldcr..Capulohumeral movement in. 346 in brachial plc'(u. 1 34 neurophysiologic effeu of.. 1 3 "renglh of. 58 in thoracic out lei svndmmc. 36.. 4 0 1 .. 8. 393. 462. 423 and cumulative trauma di'iorcier. pain from. 453 in impingement syndrome. 342.ation on. 356t syndromes related to.'CI. 9 in fractures of shoulder girdle..e study on. case study on. 1 22-123 Set' also Joint mobili. 383. 193. 60--6 1 h. patient-therapbt positioning dur­ NeeI' Slage!:> of impingement. 388f Ncurologic dbeases. 1 1 7· 1 1 8 histology of. mobi. 343-345 pectoral mu!oocle pia\". 1 4M. 8. 452f Mobi l i. 1 0 . lOS. activity of. in hemiplegia.-friclion . "ltion techniques Neck pain. 1 7 6 i n �aption of 'ihoulder. 395. tendon. 250. 82f-85f.)o Cervical nerves. 'is.1(iIlal). 345t dCI". 1 49f. nerve. 201 387-388 Nephritis. 209 tion. 2 1 6-223 of. 424-426. brachial impact of imlllobili7.':>M'SS­ pain in. 375 Peripheral nelves Occupational therapy in brachinl . 384-385 Neuromuscular deficits i n hemiplegia. 355-362. 169-1 70. 366 phases of. rdcn"t.houldcr.lOd treatment techniques in. 459. 104-105 Obstructive bowel disease. 1 40 2 1 9-223.1 1 0 pah\ in. 45 l f.. 96 bicep!<. 426. 329 liJ". 385 Neurovascular entrapment. 426f scapular mobilization. 1 3 1. 1 36.')irication of. 7 1 1-72t. 103 Nutrition. Neural tbsue evaluation and treat­ rc!oopon�e to nerve trunk stimulation. anatomy and func- cf"O!'>. Neuropathies.. 246-247. 2. 397f providing protection from Omohyoid wndrome. 237 evaluation of. 1 84. mion. 192. 450-4 5 1 . 396f to. 104 exten'iibilitv increa!<>e. Observational examinal ions. See al. 59. 60t Omohyoid mu!ooc lc.1 8 1 plexus injuries. of 'iupraspinalus and at intcr\"el1ebral foramen. 286 Occupation in nonprotective injul'ic'i. pain Open recon�tnlctive surgery !:>capular' fnlllling. 389f Nelvous system injuries. 105. 1 2 3 392f examination of.1 5 1 . fractul'cs of. referred pain from. 385 in brachial plexus. Neer impingement test. sources of. immobilization affect i ng. 81 f. . 187-188 lization and stretching of. 195 Omega-3 fattv acids. outlet syndr'Ome. 1 57 anterior capsular shift. 345 MU'iculotcndinous dysfunction. 24.xus injuries.1 1 0 'ikelelal. cobrachial pain syndrome in rotation of !. 250 355-362 1 83f Open-ended (non-weight-bearing) pectoral and antelior fOl'icial palpation of. 73 classification of. 355 1 0 2 . three-dimensionalil".. 1 1 f Mvofascial tissues function.. adaptations of. Nonsteroidal anti-innammatorv drugs Mvocardial b. 1 1 6 Mvopathies in shoulder dysfl. 342t. 1 3 upper thoracic region elongation. l'CfclTed intcrrclation'ihip with joint mobi. 147f thoracic laminar release.. 330 in workel'"!<. 383-385 Neuropraxia of a. equipment lI'ied in. 82. 387 Neer unconstrained shoulder prosthe. . anatomy components of. 355. 22. c1a. 236 Mvofascial dysfunction po!oo tviral fatigue syndrome (PFS) in brachial plcxu'i injuries.alion. 1 6 4 . 2S I f. 109. Ncuromu. 4 3 1 -433 395f ing. 102-104. in 200 anterior fa'>Cial elongation. 3 4 1 -346. in cClvical spine diM>rdel�. 372 447-448. 82 86. 384f 23 1-232. 1 05f. 69t..m CClvi­ 1 4 1 .. 3 1 6-317. 383 relationship to occup:ltion. 236t 1 0 1 f.chcmia. 252f 366. 1 53-154 pkxu� injuries as complication in impingement syndrome. in thoracic 12. 1 87-188 206-207. 386 examples of. 343. 1 03f ing. Neural adaptations in strength train­ rehabilitation in. 3 1 8f in impi ngement syndrome. compo­ goals of. 197 N and. 232f. 207f.. 1 89. 222f-223f. Open chain exerci�. 1 86 MlI'iculo�kelctOlI injulic'i. 150 subscapulalis techniques. 341 Nelves. injuries.1 66 to reduce Irigg('I' points. 6-7. in shoulder dysfunc- 1 85. a. 3841 treatment of. 425f . in pl"Otective injuries. 1 1 1 . Neck of humerus. 3 1 M. 339. 328 and thoracic outlet syndrome. stretche'i. 249-251 MU'iculocutaneous nen:e injUl"'l'. 392f Neurodynamic testing. brachial plexus injuries. 397-399 pain syndrome o in cervical !'opine disorders. 393. pain and. Myofascial mobili. 149-150. hvperalgesic responses activities in hemiplegia.v of.1 04 ncnb of. I SS. 388. pain 1 10 (NSAIDs) from.. 426... 1 83. 344. 1 2 1 mvofascial. i n shoulder dvs­ of 'icapulothoracic joint. 366. 336. 342t. 383 rehabilitation for 72-75. 391 ment. 395-396. Nonprotecti\"e injulics of. 39 1 .'> to motion. See also Cervicobrachial ca. 69f-70f. of �ternoclavicuJar joint. 372 Bankhal1 repair. 464 ple. 396--397. anaerobic capacity and.cular retraining in 'itrcngth training. 343f M\'elograph\ in cervical !'opine dbol'­ 365. technique'i in. 388-397 conduction velocity tests.3lion.lnction. 195. 89 Mvokinase. See al. 7f.. tN 0 E X 489 rene'\. 109. 1 80-. econdarv dfech of. and return to \vork i n brachial prolt'ction of hands and joinb in. 193. 1 05f definition of. 3 9 1 -393.3 388. 383. as block. 3 4 1 ment of. features tion of. 345 Neer' !oo ign test. 390f.. 393f-394f response to. 59 patienHherapist positioning in. 462f. behavior of. 53-55 l-eflex aClivity of muscles in. 284-286. 470. posterior instability rcpail� 426-427 parcd. 470 346.1 4 1 472 in brachial plexus injuries. causes of. 443 differentiation of local and referred 741. 76 in total shoulder replacement. 471 niques in athletes. 30 1 . 3 location of. 304 in fracl ul-e� of shoulder girdle. 386 Paralysis.teokincmatics 346 thoracic outlet syndrome in.·b. 27 1 .. abuses of. joint mobili/. 270.1 9 1 .. 1 1 3f. 731. 470 1 92 in frozen shoulder. 150 346 force couple imbalances in. 1 57. 134-135. 66 isokinetic exercise in. 240 Painful arc syndrome patterns of restriction� in. 304. 44 1 . 387 in po�Hrnumatic al1hritb. 1 7 2 . Duchenne·E.490 I N0EX Dlx:n reconstructive surgel)' area and nature of.1 9 1 in mobility asse��mcnt. deafferelllation. 209. in visceral disease 65-66 i n workcl'S. 439.2 1 6 . Osteonecrosis in neural injurics. t 86 Q:'lcoaI1hl"ilis. 462f. 342. 65-68. 474 pat ient descriptions of. 148 Palsy Oscil kHion techniques. 265 1 84 duration in. 1 50 in im pingement �yndl'ome. 7 1 t. 40 1 . 240. 27 2 in nonprolective injuries. definition of. 260. 1 9 6 . 104-105 of scapula. 104 39 1-393. See also Mobilil. 58-59 of cutaneous tissues. 336 evaluation of. 1 36. 140 indications for. 1 45f. 261 . 285[ refen·cd. Throwing movements sympathetically maintained. 1 34[. 288 in frozen ShOllldcl� 269 cnd-feel and. See (liso Throwing stages of. 170. 1 33[. 392[ 46 1 [. 1 3 3 324-325 1-3. in exercise program.tl. 347 in frozen shoulder. 44 i f-443f. 1 34f. 25-26. 89-90 results of. in neural tis�uc. 346 in. 338-339 Palpation. 290. descriptions of. 336. 439. 290f in passive range of motion tests. 335. 264. 1 89. 1 4 1 . lotal shoulder l"Cplacc­ in impingement syndrome. 240 visceral. 142-143 224-226 of serratus anterior muscle. 67f. 1 0 5 . 266-267 Ir. 304 of humerus. 387 instability in. 346 . 59 Pancreas. i n r-otalOr cuff dysfunction. 58. 239 Pancoast tumor ment in. See (llso Celvicobrachial pain in brachial plex us injuries. 387 compared 10 al1hroscopy. surgical techniques for shoulder 65-66 1 38-140. 63. sensory-molor deficits physiology 0[. 1 55. com· in thoracic ouLiet svndrome. 86. 22 initabili ty level and. I in isokinetic exercise. 202 evaluation of rolalor cuff pathology 1 36 restoration of. 1 55. 196. 2 1 syndromes related 10. See {l/SO Rcfel1"Cd pain and l"Csistance SCQuence in. 287-288 resislance and effectiveness of. 459. 4 1 0. 441 problems in. 387 (Cont. 58 Passive motion OSlcophytosis. 1 89 . 432 p tests for. in tensile overload. 83. 192. 196 463[ syndrome in cervic. of cClvical ncrve�. 424 constalll and musculoskeletal. 239 instability. 1 34. phases of. 65-66 in pitching. 4 5 1 . 140.IlIma • from. 449 i n pmfessionals versus amateurs. 265-266 21 in thoracic outlet syndrome. 463. 267 . 30 1 . 236. 343 233-234. 467 1 57 Paravenebral muscle. 236.. 1 3 3-134. 175 27 1 . 309. 424. 1 9 7 of myofascial structures. 46 1 . 191 etiology of. )44 in hemiplegia. 59 176 in rolalor cuff tcars. 3561 84[. 463.lIlled) management of. 257. fifth and �ixth. 242 in frozen shoulder. 454. 1 9 1 . 4 1 Ot 1 37 in nexion of shoulder. mapping of. 236. 66f. See RcfelTed pain in complications of immobilization. 220. 460[.-bs: 1 84. Pain. 10lal shoulder replacement in.. 464. 43 1 . 30 1 . 429 somatic. 448 Overhand throwing. 1 9 1 in mobi l izaL ion . 1 36. 269-270. pain and popping sensation during. 1 9 pain. 266 E. 1 85 in treatment of I1cuml lissllc. 149. 265 in poslOpcr"ative management of in impingement syndrome. "efel1-ed pain and. in omohyoid syndrome. 272 23 in throwi ng injuries of shoulder. 58. 150 rotatOl' cuff rehabili tation in. 263 of clavicle. 2 1 4. 68-7 1 . throwing injul"ies i n . 304 of upper qual1er stntcturcs. 269. 1 84. deep VCI'SUS supcrlici. 473 inhibition of. 1 48-149.alion tech­ Overuse problems of shoulder dUl'ing l"Chabilitation. 3 1 1 -3 1 4 O:. 455 lllu�c1e group� active during. evaluation of. 167. 66-68 in frozen shoulder. rcfclTcd pain from. 1 1 6 304 in brachial plexus i"jurie�. 185. 174. 430. 2[. 198 in. 1 85. 1 1 3. 304 of nerve trunk. exercise programs for. 424 in cancer. 240 treatment of. 339. 3[ myofascial. 467-468. 68f..1 43. in scaption-abduclion of shoulder. of median and ulnar nerves. Overhand athletes projection of. 283 as indication. 19-21 in total shoulder replacement in mobil ization It'Chniques. 1 05f.uion for. 448 injuries.'11 spine �crecning. 64 in protective injuries. by pcripheml ner'yes. mobilization of. 149. 72t. 268. 20 1 -202 mobili7. 1 9 1 . 87 in abduction of shoulder. 470. ' Nerves in open capsular shift surgery. 185. 58 Peripheral nerve entrapment in referred pain to shoulder. musculocutaneous. in cumulative trauma axilialY. 1 65. 1 92.. 96 in twe II aim. activities during. 459. 1 34f Post-traumatic anhropathy. in thoracic oUllet as risk factor.1 1 8 syndrome. 43 1 . 1 34-155.. 330 suprascapular. 2 1 2-2 1 3 structural features of. alignment of spine in. fOlWard. mobilization of. 185 mobili7. 389f dysfunction.1 47f. 37 1 f. 366 dynamic!'.1 1 7 during elevation of shoulder. in brachial plexus injuries.1 93. 1 9 1 . 1 02f in stabilization of . 448. 261 standing. 380-381 i n peripheral nerve entrapments.. 2 1 1-2 1 2 . 306f. 1 75. Throwing movements headache and. 136. See Overhand throwing.ation technique. 136 in brachial plcxus injuries. 100 37 1 .l uma disOI'dcl'.es for. 20. 1 1 6-1 1 7 i n profe�sionals versus amateurs. 443. 1 9 1 mcdial and lateral pectoral. 396f Pillow �uceze. I 1 7 in dislocation of shouldcr. 1 0 I f Pegboard test of coordination in 347. myofascial imbalances and. 105f in an hroscopy. 182f 196. See Baseball players in thoracic outlet syndrome. 330 PCripheral nCIVCS. 3 1 0 148 29 1 . 1 6 1 . 369f-37 I f. 474 purposes of.ation tcchniques in. 105..!. 439. I 38f. refen"Cd pain from. in hemiplegia. 395-396. 9. 3 sensory innervation of conncctive assessment of. 370 Personality. 1 0 1 f. 389f 461-463 1 96 stretching of. 1 36 shouldcr replacement. 145f Posture Pectoralis major muscle.1 04 mobili7. 1 38. 3 1 0f predisposition to lrauma and. 58-59 impact on mobility. 375 i n type I arm. 100. 358f in lotal shoulder replacement. 1 86 in lotal shouldcl' replacement. 1 57. in injUl"Cd athletes. 136. convergence with in dorsal scapular nerve palsv. 284 in �tabili7.1 4 1 . 1 6 1 166 myofa�cial neck and shouldcl' pain Postoperative peliod Postvin:d fatigue !'. 57 evaluation of. 409 Power. 1 0 I f strengthening exerci. 380[. 39M Peliscapular muscle. pneu� evaluation of. 348f i n hcmiplegia. 1 57. 369 creation of. in frozen shoulder. in speed and sll-cngth training. 386 humero�capular� 257 289-290. 167 1 0 i f. 373f. stretching tcchniqucs in. 60--6 1 . 1 1 8 Postfixcd plexus. 60--6 1 Pectoral ncrvc palsy. 454 in postoperative managemcnt of in type lIJ arm. 309-3 1 0 sustained. 337-341 relationship with fibromyalgia. 2 1 7 brachial plexu� injuries. 196-197. Preoperative evaluation i n 10lal fulcrum effect of humeral head on. 261 in strength training. 430-43 1 refcrred pain fTom. 373-374. 1 9 1 . 344. 103 dorsal scaplllal� 1 1 6. 1 0 I . 1 37. 444-445 shoulder rcplacement. 134. 369f. 2 1 Phrenic nerves. in total assessment of pain in.ation of glenohumeral Pitchers. 1 45f. 105. 103f in thl'Owing movements. 20 1-202 cvaluation of. See also isokinetic exercise in. 179. IN D E X 491 Patient contl'Ol. 294. 1 9 1 joint. 10If Pericarditis.!.. I 1 7 duling mobilization. 463. illVolving Peripheral neul"Opathy. 392f silting. 1 00f nClvc palsy in.I 02. 3 1 5-3 1 6 i n elevation of 3rm. 202 Platysma. 3 1 7. 1 7 1. 288. 100. 1 1 8 391-393. 2 1 3f in frozen �houlder� 272 instability. of. 1 59. 5 1 in rotator cuff pathology. 1 1 7. Pectoralis minor mu!>Cle in brachial plexu� injulics. 1 00f 21 Physical examination ergonomics and.!. 1 0 3 . anatomy and function of. 387 cvaluation of. 62f 357. 139-140. Phalen's sign. 1 1 8 for throwing injuries. 57-58 sensitized. 395-396. 388. 103f. 99-100. 2 1 3 . 1 38f in throwing injuries of shouldel� 24 461 -463 .1 72 dysesthetic and nerve lrunk pain 470-474. 296 nOlmal. 432 in impingement syndrome. personality in. 137 43 1 -433 Pregnancy. 386-387 nerve palsy in. 2 1 somatic nerves. in shoulder celvical spine in.yndrome in. 374f Plastic deformation head position in. drome. 62f. 102-104. strctching of. 47 1 . 306. in excrcise program myofascial. 319 Pneumoperitoneum 1 17 Periodization i n training. 388. 367. 2 1 1 f. 149-150 468. 295-296. 1 00. 295. 60--6 1 muscle play in. moperitoneum from.houlder. 1 1 8.'ltion tcchniqucs involving. 371 Pilching. 292. Pendulum exercise Plyometlic excrcise 2 1 2f in clavicle fractures. 264 strengthening exercises for. 100-102. muscle plav in. 1 4 tissues by. 1 34. in carpal tunnel syn­ i n cumulative tr. 99. 1 37. 50f. in rotalor cuff l"Chabililation. 1 69. 209. 472 in thoracic outlel syndrome long thoracic. history taking in. 1 1 7 Position of thcrnpist disorder. 206. in thoracic outlct syn­ injury of. 233 Perial11uitis in rotator cuff I'chabililation. 109 during elevation of ann. 370 drome. 60-6 1 . 475-476 Parient intelview from. in frozen shoulder. 209f 196.1 00. in sitting. 328 constrnined 01' fixed fulcnJm type.sh-up plus exerci. for scapular rotator muscles. 461 f.3 1 0 in isokinclic exercise.testing of. 133f.423 clinic�ll considerations in.459. 20M fOI-thmwing injuries. 220-223. 459. 463. 3 1 2-3 1 4 cady dc�igns of. 1 21 Proprioceptive neuromuscular facilita. 467 in instabilities of shoulder.201 Refen'cd pain Proprioception. 32M. 343. in strength training. 307-309. 26 1 hcmiplegia.sccral disea�c. 251f. 459 Radial pulse. in rheumatoid at1hritis. 307. 1 08. 46f Pulley exercises treatment of.206. 250 for throwing injul'ies. 1 33. 32. 462. 247f in brachial plexus injuries. Passive motion theories on. Psychological factors passive. 437 320-322.284-285.. 62-65. 1 34. 1 34f in Ihl'Owing injuries of shoulder. 226 Pdmar:v tensile overload. 249f neural tissue. 32.48.bOt.in brachial plexus from nerve trunk.133.se in disc disease.108 muhilevcl nervous system retrain­ Pu.58. 47 1 . 1 1 1 .373-374. 134f indications fOl'.75-76 Push-up exercise.237 refen-ed pain from.75. 464 joint. 132-133.65-68.323f in rotator cuff tears.1 32.336-337. 136. 58. 3 1 8f. 2 in vascular di. See also Active 327r examples of. in chronic dislocation. 247f. 222f-223f. 3 1 8f.133f 461 -463 in brachial plexus injUlies. 3 1 M. 324.3 1 5 Quadranl lest (Maitland).3 1 3f.3 1 4 .75. in osteonecrosis of glenohumeral evalu3lion of. 1 99-200 Primal''\' impingement syndrome.v tunnel syndrome. 343f 24M compared to local pain. 164f i n tOlal shoulder l'Cplaccmelll. in nervc root initation.3 1Of in impingement syndrome. 304-306 rehabilitation for in hemiplegia.1 1 2.3 1 3f contraindications to.1 35.in soft tissue Pulmonary disease.30n. Purdue pegboard test of coordination in hl!miplcgia.anatom. 245. 327r Questions.47 1 1 16 underlying medical conditions in.97f. equipment used in. evaluation of. 138-1 40. 3 1 4. 1 34. 325-328.44. in thoracic oUllet wndrome. 1 38 24-25 from galibladdcl. in carpal in frozen shoulder. Radial nerve from livel� 324 464 most lengthened position of. 105. 462f 312. radicular. 466--467. 71f. 48 from cervical region. 449[.322 ccdun:s in. 132. 252f fol' throwing injuries. 1 33-134.462.alion. 300-30 1 in fl'ozen shoulder. 58. 245. 473-474 in defining scaption. 336 motion. 59.464 somatic. in clavicle fnlclurcs. 326--328.459-475 fTom hearl.in assessment of pain.t:sc.454 from diaphragm.305 unconstrained design of. 221 Pressure glddienl research. 452-456f 1 35-1 36. 226 Refle'\( svmpalhetic dv:o. rcfelTcd pain Reeducation of muscles mobili:t. See Pulses.tl'Ophv case slUdy on.462. 423 comp�lJ'ed to sOl1l<ltic ptlin. 463.374f to arm and hand. from esoph<lgus. 3 1 5-322.2 7 1 Recun'cnl meningeal nl'l"ve. 163. palpation of. Radiographv from postviral fatigue syndl'Ollle. 47f. 1 34f postoperative management in. 460f. 311 in brachial plexus injuries. 337-341 in impingement syndrome. 262. in facet joinl inilation. 64f 247. in fro7.245.245. 462. 466.32 1 [ 466-467 R in instabilities of . 58t.shoulder. 461 vical radiculopathy physiology of. See also Cer­ patterns in. 1 39 case �tud:v on.se. 58t 464.492 IN 0 E X Pres��lIp exercise Provocation tests tests for in impingement syndrome. 132. 474 in humerlls fracture!).197 cognitive role in. abnormal. 58-59 Proslhc�i:. 3 1 0-314. 48f 1 34-. 475-476 in arthritis of glenohumeral joint. 113 tion (PNF). 1 1 0 ing in. 339. 466.337.322-324.98 Pressure techniques.3 2 1 r. 403 Q dysesthetic. 339. 463-470 injuric:" 1 92 fTom pancreas.72f. 459-463 from kidney.248f. 4S0f 58. 463f of.250 cru>c .340t pattcm of. pdmary in brachial plexus injul'ies. 1 45f goniomelric. aJ1erial. 380 24M.glenohumeral. 459. in frozen shouldel� 265 active. 1 4 8 in fractures o f humerus.en shouldel� 261. 249-250 in impingement syndrome.sleoarthrili�. 1 37 From lung. 328-329 revision of previous operalive pro­ in cervical spine disorders.capsular cervical spine in.6M-68f 247f in brachial plexus injuries. 134. 1 99 Recruitment of muscles. 1 93 from stomach. 308f. 459. 337t. 464. 225. 1 33 patient profile in.37 1 f in frozen shoulder. 1 1 3. I I I.262f.311 Proprioceptive exercise in impingement syndl'Ome. 330 470-474. 3371. 299-331 in trauma. 459. Protective injulies in rotator cuff leal'S. 2 1 6.324-325 in o. 1 3 1 . 240.285f for scapular rotatOl' muscles. 463. 3 1 6--317.341 Range of motion. 463 provocation teM via. 473 Radiculopathy.study on. 3 1 2f. 1 92. 320f. 250.247. 241 1 96. 247 1 12f.46 1 .267 in vi. 133f. 134f preoperative evaluation in.272 Impingement syndl·ome. 1 1 0 phases of. 306-310.3561 from.323-324 . 464.468.460f. 1 92. 206. 1 7 1 . 1 1 . 347. 373f. 285f 1 5 4 . 23 1 . 250. 7f. 95. 96. 467f in brachial plexus injUlics. 29. 292. 6. 83. 1 57 i n adhesive capsulitis. in frozen shoulder. 401 in brachial plexus injuries. 2381. 360-36 1 . 4081. Resistive tests.1 2 isometdc exercise in. 370f. 222. 292. 375.sulitis. 3. 197. 2 1 3 also specific muscle case study on. 245f case '>tudy on. 455 clinical forms of. 336-341 Rest periods. of. 437 pain in. 266 in strengthening exercises. 369f. 459. 374f in scaption. 7 1 t. 374 1 1. 2 1 8. 404f-407f i n rotator cuff tears. 239. 368. 377[' in fractures of humeru�.. 449 Rolling malion at joinl surfaces. 86 in cervical spine disorders. 337t. 24 1 2 . pain and 403-407. 243-250 rotator cuff tears in. rcfcrTcd pain from. menl of. 473-474 in isokinctic exercise. 4-5. 1 97-201 Resistive tubing. 372 430. 472 lears in.replacement. 3401 first. pro­ 408. for shoulder­ clinical evaluation of. 1 73 anatomy of. 1 99-200 specificity of training in. Rolyan hemi aml sling. 4[. 377f isokinetic exercise of. 468f 438. -lf ru1hroscopy. shoulder. 283f 65-66 362f surgery on. 353-354. I I . external/internal ratio in isokinetic in adhe!Sive cap. 372f. 235 in rolator cuff pat hology. 353f. phase� of. in hemiplegia and type muscles in. 341 . 43 1 -433 position of. 311hrokinemalics of. 238 Repet itions in cxercise. 4f. 437f. 367 cervical. 691. 284-285. 7 1 . 22. 343f Ribs in strengthening e. 49f. 368 in hemiplegia. 97f in isotonic excrcise. 36. neuromu�cular retraining. 466 in impingement syndrome.1 5 5 . subluxation in hemiplegia. 407 fibrosis and tendinitis of. 259 pha. 2 1 2f torque output dUling. 369 position of. 288-293. 8[' radiography. 44. 1 2 . 29 1 . eff0l1 thrombosis and. 249f. 376f fTom. 2 5 1 f in exercise pmgram for throwing in dislocation of shouldcl-."". 72t. 4 1 5 -4 1 7 Robot ic testing and training. 283. in hemiplegia and type Rotator cuff muscles and tendons. Rhcumatoid 3r1hritis in hemiplegia. 328 injudes. 1 72[. 454. 47 1 . in frozen �houlder: position of humerus in. 377f in open reconstructive surgery 265 testing of. 30r. 280 Resistance. 369 injudes. 224. 447 functional importance or. 4 1 4-4 1 5 Rhomboid major and minor muscles 403-407. 36-37. 342-346 290. 28 1 . 1 2 2 . 3 7 1 f. 72. 45f. 6-7. 244. 1 88 . in arthro. 5 1 hypovascu1ar zones in. 337-341 i n thoracic outlet syndmme in abduction of shoulder. 3. 447 in exercise program for throwing 1 3f. 287f Renal disease. 280 in cumulative trauma disorder. 369f. 69t. 448 retraining. 249f.lpture Repetit ive motion in impingement syndrome. strength gains in postoper::t tive period. 284-286. 260. i n stretching c.1 74. in frozen shouldcr. 2 5 1 f total shoulder replacement in. 280-2 8 1 Resistcd motion. 2 1 8 . 438f. 432 tesling of. 238. 189. nonnative data on. 24-26 Rotation of shouldel. 195. See in protcctivc injuries I I I arm. 1 3 posterior capsular shift. 473 internal. 367 in impingement syndrome. 366. 266 in nonprotective injuries 37 1 . 258-259 Reparative stage in healing of shoul­ 38f. in fr07cn maintenance programs in. 223f bone spurs and tendon I1. -BO-U I gression of. 443. 236. 29f. 1 7 1 isokinetic testing of. 222. 438 Remodeling stage in healing of shoul· i n adduction. 28 1-282 der girdle fractures. 404f-406f. 2 2 l f. 462(. 4 5 1 -453. 245f. 5 i n impingemelll syndrome. 295-296. 252f ultrasonography. 377f. 44. 285f anterior capsular shift. 245 lateral and medial. IN0EX 493 Rehabilitation in rotator cuff rehabilitation. 377f isometric exercise in.scopic stabiliz ation with in total shoulder replacement. 72. 193.'(crcises. 286 in abduction. 37[. 4 1 5-4 1 7 anatomy and function or. 162. 7[. 44f i n humems fractures. mobilization of. 437-438 i n throwing injuries of shouldel� Rotating motion at joint surfaces.s of. 470-474 extemal. 3 periodizalion principles in. 4 1 7 Iasel. 2 1 I f. 230 294. der girdle fractures. 341 -346. 3421. 4 1 21. evaluat-ion of 176-177 225f al1hrography. 280 in frozen shouldcr� 269 in mobilization techniques. 435. 444f in total shoulder. 3. 295 exercise. 438. 232. 287. 4 1 1 -4 1 3. 2 2 1 f. 443f. 466 223f in impingemcnt syndrome. 103 252[ edema and hemOiThage of. 323 i n isokinetic exercise. 336-337.cap�ulonnphy. 289. i n !locapula fractures. 8. 8. 438f Relocation lest. 345t examination of.:mge of motion tests. 464. 1 57 age-related degeneration of. 427 I I aml. 265.erciscs. 1 08 in thoracic outlet syndrome. 369-370 strengt hening exercises for. 5. 280. 7f. 1 7 1 . 294. 437f Resistive exercise 252f. 233f. 1 3 magnetic resonance imaging. 1 57. 2 1 1 . 8. 249f. 4-5. 8 force couple with deltoid muscle. 84f. 13 in cervical nerve root in-italion. 245f isokinetic exercise in 460f. for neuromuscular 1 23f in clavicle fractures. 348f. 6-7. inside or under sUifacc impinge­ in passive r. 444. etiology of. 288 29f. 229. 474 395. 286 i n hemiplegia. 282-283. 464. strength deficits of. 441 anatomy of. 75 in stabili/. 475-476 in range of motion tests. 70f-72f. 231-232. 422 474.. results of. 441 f-443[. from cervical spine pathology.1 02 (Contil/ued) superior surface.interstitial. 2 4 1 vascular predisposition to. 109 i n coracoid process. 439f joint. 282-283 exercises involving. 29. rclalion:ship of osseous structures ar1hropathy of. 464. 2 1 . 361 f. 325 :. 439. 240. 1 35. 22 open repair. 35f appropr-iateness of. 448-449. 37. 84f in rotator cuff pathology. 445f and scapulohumeral rhythm. 282 evaluation of manual mu:sc\e testing of.l ity in. 376. eliology of. 20. 2 1 i n impingement syndrome. 34f. 10 ar1hroscopic debddement. 438 in neck. 661 to tratlma from. 379f. 435 injuries of shoulder. 24M I"efen'ed pain to. 440� 444. in throwing injuries of shoulder. 293-296.. I 56f.to. 20. 369f. 73. 324 ef[ect of posturc on. intratendinous or. 439. 46 1 . 284-286. s 29 1 -292. 362f rehabilitation of. SAID (specific adaptations to imposed tests in evaluation of. 393f-394f in scaplion of shoulder. 466 dyskinesia of. 370. muscles acting at. 2 Iilnge o r motion tests in. 466 for w i nging. 245f. 1 1 r. 438 Scalene muscles in throwing movcments. 1-3. 393. 377f 2961. 376 . tests to identif)" 284 3 7 1 . 45 1 f case studies on. 46 1 . 368 73. 369f-371 f. dorsal.trcngthening exercises fOl� 289. 234-235 techniques. I . 279. 437 joint congn. 435 optimal muscle length�tension rcla� 47lf force couple imbalance and. 3f eccenll"ic overload and. 435. 439. 449. 2f. 4 1 5-4 1 7 tendinitis of.urgcry of Royal free disease. 466f. 436f in aCl'omion process. 1tion of glenohumeral i n slabili7. 33. 280 in exercise program for throwing Scapular plane . 243. 1 2 Scapular rotating muscles 292-293. Mf in impingement syndrome. 209. for scapular rotator muscles. 248f results or. 1 59 247. 345 289f. in abduction of shoulder. 239 nonoperative treatment of. 6 1 . 30f scapula muscle restorat ion of normal joint torque output of. 463f. 232f. 369f clinical Significance of. 283 external rotation of. i n rheumatoid illthdtis. 435. 324. rehabilitation in. 374f. 451 f immobilization during. 3 7 1 279-28 1 niqlles. 63. injur)' of. 281 torque production in. 62f joinl. 73. predisposition Rowing exercise 65. 1 57. . levator muscle of. 14 :surgery and. rdcrred pain from . 2 8 1 . 292. for slabil ity. 5 462 palpation of. 238. osteokinematics in. 284 439. 1 1 f. 1 0 in stabiliz. 63-65. 380f in body. 436f preoperative assessment of. 7 1 f-72f. 245. 451 f biomcchanical concepts in. 63-64. 3 muscle imbalance of. 239. 289-291 in injured athletes. 293-294. 448. 237. 73 muscle imbalances in. 1 3. 280 fraclul-es of. 438 anatomy of. 60. 466. 373f. 451 f 287-288 case sludy on. 284 teat'S in. 295. 451 f 444-445 chronic. 75 indications for. in thomcic outlet winging of. 393. in throwing injuries. framing prior.culo. 395f 10. 280. . 186 acromial architecture in. 283 Scapula 237f. 443 syndrome. 287 arthrokinematics in. 741. 3f in strength lmining. 239. 449 joint mobilization during. 435. calcific. 232 comcoacromial decompression.tion of glenohumeral pathologic classification of. 63. 24 1 . 435. abnonnalities of. 288. 3 elevation in. compcnsatOl)' actions of. 370. 2 1 3 292 in throwing movements. 2 9 1 -292 466 myofascial mobili/nion of. 44 1 . 287 tionship in. 439 demands) principle. 443. 292 tests for impingement of. 468. 306. 75. 284 285f total shoulder replacement in. distmction of. 464. 370. 58 in impingement syndrome. 2 diagnosis of. evaluation of. 8 1 f. 3 1 1 ."J.3tion of glenohumeral rehabililalion programs for. 3 2381. 1 4 22 40f. 37 1 f. 294-296. 1 2. 360. 284 287-288 undersutface. 360-36 1 . 63. 2 1 244-245 nonopcrative. 3 Scapular retraction exercise. 206-207. 288 330 ar1hro:scopically assisted repair. i n rnobili7. muscular lraining in. 363f strengthening exercises for.494 'NDEX Rotalor cufr muscles and tendons shoulder-hand syndrome and. 4 1 2 anatomic description of. 247f. 449. 2f.ation tech� joint. subluxation of. 288-293. 1 0 1 . 462. 1 3. 70f-72f. 288 in total shoulder replacement. tests in evaluation of. 4 1 i n rolalor cuff pathology ::. position of. 1 5 8 tests to identify. 6 1 . 378-380. 449. 362. 240. 369f. 83. See Levator reduction of overload in. 279-283. 292-293 strengthening exercises for. 279. 437r muscle activity during. 64f. 29 1 . 1 0 . 47 1 f exercises in. release techniques for. 82. in mobili7"alion in primary tensile overload. See also Protective injuries $caption of shoulder Scapular ncrve. 373f in rotation of sholllder� 10. 1-2. . IN0EX 495 Scapular stabilizing muscles in impingement syndrome. 192. I 1 4f-1 1 5f dysfunction. 423-424 265 in treatment of ncural tissue.:"'\ bility o f shoulder. for shoulder position of glenOid fossa affecting. surgery in instabilities Scientific therapeutic exercise progres­ 225[ al1hroscopic. 1 0 . 63. 285 in long thoracic nerve palsy. See Impingement syndrome. 32. Slings 76-78. 1 1 0 objective examination of. Scapulohumeral rhythm. 427-428. 202 examination of. brachial plexus injuries. 289. 1 3 shoulder replacement. 33f laser. 75f-79r. for Spasms in hemiplegia. 37M See also Glenohumeral joint. in rotator cuff reha. 63 2 1 5-2 1 6 Spinal cord refelTed pain to. See Evaluation Static progressive stretch (SPS). 6 techniques in.1 2 2 Shrugs. 4261 Secondary impingement syndrome. 1 76 drawal reflex of. 1 8 6 Sp0l1S. mobilization and stretching Sen'3tus antel'iol' muscle anal. 452 spine disorders. 1 4 mobili7. 237. as indicalion for lotal cial mobilization in abduction of shoulder. in rolal. in exercise program controver-sy over. in frozen shoulder. 22 Secondary tensile overload. 9f in thoracic outiet syndrome. 1 70. in hemiplegia. 424 Scoliosis. 461 Soft tissues. 359[ 1 89. 142-143 negative atmosphel'ic pn!ssure and. 1 0 in throwing movements. 2 1 0 in professionals versus amateurs. 1 36 Spine. refen-ed pain from. 193. Sensol). 369f. 164-166 Somatic nervous system. 1 0 2 SLAP lesions open reconSll1Jctive. See Myofascial tissues anatomy of. 1 1 2 f. 60t Steroid theraPY in fTozen shoulder. 464f palsy or. 97 stability of. Shoulder girdle oscillation tcchnique. 73 3 7 1 . 4 2 1 -422 stabilization test for. 323-324 periarticular structures affecting. 1 2 Spray and stretch techniques. 8 1 . in in rotation of shoulder. 286-287.ation of. postural relationship of for throwing injuries. in fTozen anhroscopy. 428-430 scapula 10 spine in. 1 3 . 59. 23 tests in evaluation of. misintel-prctalion of anatomy of. 305 convergence of afferent nerves in. 225f Stabilization exercises. 25 al1hrography and CT scans. flexion with­ in flcxion of shoulder. 359. 224. Speed training. 294. 422 in scapula fractures. 1 1 7 moperilOneum from. 6-8 Scar tissue after trauma. 3 Shaking of extremitics. motor nerve-muscle con'espon. bilitation. 1 83. pneu­ manual muscle testing of. 288. See also Cervical spine Stiffness. 226 gliding motion of. 160f for.3tion Shoulder saddle sling. 2 1 8. radiography. 1 2 . 240. 1 3 . 87 in rotator cuff pathology. 193. 2 1 stability of in abduction o f shoulder. 354f. 2r 21 imaging studies for analOmy of. 282 in hemiplegia. 424-427.. 69t. response to dysfunction. passive. 266 i n stabilization of shoulder. 422 ScapuJothoracicjoint. 196. 448 in throwing athlctes. 162 in frozen shoulder. 22 effects of rotator cuff tears on. 96 injulie . management of. 1 70f. 355f SenSitivity to pain in hemiplegia. innervation of connective tis­ Spinal nerve injuries. 427. 288 Shoulder-hand syndrome 42 1 in range of Illotion lesLS. See Athletes Scapulohumeral a1x!uction. in brachial plexus 305[-3061. 66 in abduction of shoulder. 373[. 347 199 Soft tissue mobilization. I . 1 22 Sclf-care. history taking in. procedures tic defomlation from. 45 1 . 224. 1 2 1 anatomy of. daily living activities in Soft tissue diagnosis.omyof. 60t. 59. 423 mobilization of. response to 287 dence in. Screening o f cervical region. S!. 328-329 force couple with trapezius muscle. 42 1 -434.nd function of. 422 assessment or. tunnels in. 1 1 2 . 2 1 6 pathomechanics in. 25. 206. 20. 232. 438 425r. 206. cxamination of. 1 . mobili7. anatomy Sensol). 1 73f. 272-273 sues.'icle traction. 449 in hemiplegia. 1 0 strengthening exercises for. 354. 428f-430f sions (STEP). 64 cervical spine in.or cuff reha­ mobilization techniques involving. 9 . 284 referred pain fTom. 1 98 Scapulohumcral muscles 371 Spurling's test. 63 injury of. 1 84 267. 1 2 1 . 73 . 438 force couple at. 2 1 2 265 neural tissue of upper quaneI'. 1 73-174 Stomach. 3 1 9 Sensory cortex. in cervical 24 1-242 in humenls fTactures. Self-treatment and management. 1 58r. 295 357. bilitation. 244. 220. SlOmmognathic muscles. 1 1 f. 2 1 . 3 Self cer. 27 1 magnetic resonance imaging. 1 2 . 245 Splenic infarct or rupture. examination of. 8 strengthening exercises for. evaluation. 423 i n flexion of shoulder. 287 shoulder.vicular joint. in mobilization 143 muscle pain in. 37 1 [. 309 strengthening or. in throwing athletes. I . See Myofas­ Sternocln. 2f limitations in. 305-306 n. Splinting in brachial plexus injuries. 9 pain in. 338-339 subluxation in hemiplegia. shoulder. 194[ in total shoulder replacement. 207. Stcrnocleidomastoid muscle. 366 in range of motion tests. 1 4 i n injured athletes. in frozen shouldel'. plas­ in brachial plexus injuries. 2 1 5 techniques. 422-423 secondat)' in clavicle fmctures. 2 1 clinical examination of. 1 96. 69t. 209 hcmolThagc or. 7f injury of. 280 Subscapular nerves. 1 9 1 Strength training in type I aml. 369f. Subluxation of shoulder 184 376. in bursitis. See Subacl'Omial in protective injUlies. 96 i n towl shoulder replacement. 422 82f-85f. 65. 288 in rotation of shouldel'. 1 1 7 biochemical changes arter. 373 shoulder. 2 1 201 cufr tears and. 285f in impingement syndrome. 234-235 200 anatomy of. 109 gram for throwing injuIies. 377f. 207. 78f. 8 calcific deposits in. in.okinctic. ing injuries. 2 1 2 . in impingement 369f-3 7 1 f. 436f scapular plane in. 1 1 . superio<. 2 7 1 f spasms in. 37<l-3 7 1 229-230. 223-224 injury of. 375. 377. 369f. 1 76 Subacromial bursa. 236 stretching plior to. refcm:d pain in poMoperativc management of exercise program in. 285. 378 refen'ed pain frol11. 1 2 . 71'. 366 109 hypovasculality of. 82-86. 2 7 1 f complications from immobilization manual muscle lesting of. 367. 208f. 250 ment syndrome. 367. 188. 207. 340. 14 compression of. 1 50. 376. 286. in frozen shoulder. 225f function of. 358[. 2f Supraclavicular brachial plexus injUl)" i. 367 Subdeltoid joint. 376. 2 3 1 in brachial plexus injUl.2 1 4 Suprascapular region. 245-248. in impinge­ 245f-247[. 2 1 3 Suprahyoid muscles. 209. anatomy of. 3 2 3 f Superior labrum anleroposler-ior h. 435 43f low-load. 367 Subscapu. inferior. 14. 1 9 2 423 377f. 224. anatomy of. 229 Supraclavicular region. 280 trigger points in. 391 Strength 344-345. evaluation of. 1 6 1 Sulcus sign tests. 356-357. 245. 401 in lhrowing injudes. 286.496 IN0EX Straight aim press. 3 7 1 [. 198. injUl'yof. 209. 2 9 1 i n injured nthlctcs. 1 99-200. 4 1 . 6-7. 99 237f.<:ltion of shoulder. 243 to. 82 lypes of exercise in. 375-376 reduction of. 259 370. 1 2 . 344-345 in siabilization of shoulder. long-duration. 1 86. 368. 68-75. 2 1 2 f palsy of. 6-7 endurance and. in impingement syndrome. 2 1 3f. 242 maximum. 342 i n mobilization. 2 1 2-2 1 3 space for scapular rolator muscles. 365-381 syndrome. 366. mobilization. mbuse of. Strctch-sh0l1ening exercise. 2 1 0. 365 in rotator cuff rehabilitation. 99 benefits of. assessment of. rcfen'cd pain impact on perfomlance. 377f in thoracic outlet syndromC'. 377. J 2r changes due to. 373f-374f.. 8 for hvpennobilities.ation of. 184. 26-27 in abduction or shoulder. 6 . 366 i n type I I I atOm . 22 Supraspinatlls muscle and tendon neuromuscular and mechanical case study on. 7 1 t-72t. i n adduclion o f shoulder. 368-370 anatomy of. 209-2 1 4 Suprahumcrnl space. mobilization techniques to mobilization of. 80f. 8 1 isomelIic. 378 diagnosis of. 422 . 322-323.es. 1 601'. in exercise pm­ indications and contraindications gual'ding of. in throw­ in stnbil i'l. 8 strengthening exercises for. 348f i n range of motion tests. in frozen shou ldcl� 258-259 speed of movement in. 7. 72 measurements or. 197. 243 in froLen shouldel� 270. 282. 12. 243 in frozen shoulder. 2 1 1 f. 6-7. 1 70. 199. 209[-2 1 3f. 397f 375-376. 66 in impingcmcnt syndromc. 2 1 3. 237 tCaI'S in. 207f. 2 1 1 muscles innervated by. 209. 2 1 in frozen shoulder. 20. 272 Subacromial space i n proressionals VCI"'l)US amateurs. 230f. 208f. 373f-374[. 37 I f. anntonw and in throwing injuries of shouldel� 25 shoulder supports in. 236 musculotendinous. misuse of. 390f. 79f. for. 343. 80f. 369f. 342. 422 in thoracic outlet syndrome. in frozen in secondary tensile overload. 2 Uf Suprascapular ncryc 462f-473f treatment of. 109. 370 Strengthening exercises. 347. 338. 366 for trapezius muscle. 306 bokinetic exercise in. 78.laris muscle and tcndon impingement of. 285 Slmin and counlcrslrain technique. J I . 68 definition of. 365. 209[' 2 1 0f. 375. 5 impact of resistive lraining on. 239 Siretching techniques I I . 25 8. 68. 370. 2 1 1-2 1 3 . 5. 65. 365. in soft tissue dynamic deficit of. Subacromial impingement. 223-224 Suprahumeral tissues. 376f manual muscle testing of. 3 inflammation of. 234-235. 69f-70f. rotator in throwing movement. 339. Subclavian artery and vein vated by. in impingement syndrome. 377. 372-373 Subscapular bursa in brachial plexlIs injlll'ics. 423 to. 7f. 1 6 1 (SLAP) lesion Lest. 282 in brachial plexus injuries. 8 1 f. 237. 89 Strumming techniques. 200 principles of. 396-397. 21 369f-3 7 1 [. 281 -282 types of contractions in. 8 1 . 37 I f. 373 in throwing injuries of shoulder. 432 in hemiplegia. rOl' glenohumeral muscles. 671'. 366. 357f. edema and 373f-374f pain in. muscles inner­ in impingement syndrome. 209. 371-372 relocation tests. 3 4 1 anteriOl". 3561 strengthening exercises for.otonic. 367 in :lbduction of shoulder. 245f-249f. 2 7 1 . 2 1 3. 37 1 . 365 in type n ann. 25 in scapt ion of shouldcl'.s. 3 1 1 instabil ity. 376f reverse.1 5 1 mobili7. 2 1 caution during. 429f. 82. 60. 180 in humerus fractures.1 4 1 impingement 21 in frozen shoulder. 180. 47 1 r. 1 4 early intelvenlion in. results of isokinetic slrength train� palsy in. 241 secondary. 279 injury of. 402.1 92. 1 72-174 tOlal shoulder replacement in. 109 passive range of motion. 284. der in.!. 197. 370. 83f. 192-193 working posture and. 323 rehabilitation after. 438 Teres minor muscle and tendon treatmenL of. arthroscopic. 1 1 7 242-243. 73. 3 1 0 Tennis players i n throwing injuries of shoulder. 176 439. See also specific lest mobilization in. 282 Sympathetic nerves strengthening exercises for. 428. 280-2 8 1 ing in. 1 75 in throwing injuries of shoulder. chronic. 84 T 202 in throwing movcmcnts. Suretac biodcgl'"3dabJe taco in arthro­ mobili7. 1 79.1 7 1 . 237 isokinetic exercise in. 1 96. 1 72. 292. 1 62-163 arthroscopic debridement. 1 I . 430f in rotator cuff tears duting. 4 ) I . 82. 427-428. abdominal or vaginal. 163-164. 370-3 7 1 . 1 72f-174f. 282 30r. 2 1 in :suprascapular nerve palsy. 286 :strengthening exercises for. in hemiplegia. 439f i n stabilization o f shoulder. 1 58f. 20. 23 in cervicobrachial pain syndrome. 436f in thoracic outlet syndrome. 1 59. 242 202 tests in L'valuation of. strengthening exercises for. 29. 176-177 439. 1 72-173 291-292. 167-168. 86 Neer. 87 21 anatomic description of. 75f-79f. 8 l f. 441 in impingement syndrome. l-efen-ed pain 10. 30f bicipital. 439.1 8 1 29f. Supra�pinous area. tN 0 E X 497 strengthening exercbes for. fTozen shoul­ anatomyof. pathology or. 83f-85r. 167. 60 laser. for. 8 1 r. 107-108 Tests. 186. 194-195. Tendinitis Hawkins and Kennedy. 293-294. bicipital. 397f Synovial membrane. 185. 155. i n brachial plexus injuries. in abduction of shoulder. tears in Symmetry. 244. 445f Teres major muscle and tendon as risk factor. 44 1 f-443f. 85f. 195 isokinetic torque !"atios for. 168. 1 4 treatment of. 24 1-242 brachial plexus in. 24 1 . 8. 29[. 438 1 69. 242 manual muscle testing or. 29r. 444. 435. 1 57-1 6 1 . 24 1 . 4 1 3 in throwing movements. 1 63r. 396-397. 291 undersurface rotator cuff tears and. fluid dynamics in. 1 1 7 muscle activity studies in. 242 473f 4 1 1-4 1 2. I 1 7 err0l1 thrombosis in. 2 3 1 -232. 240 analogy of lake in. 30f tendinitis of hyperactivity of. 154. 285 subjective. 286 :space cClvical spine pathology in. 286 Supraspinalu:s oUllet_ See Subacromial 82f. breathing pallems in artlu"Oscopically a:. isokinetic torque ratios for. 424 in etiology of rotator cuff pathology. 245 objective. 57-58 SurgelY calci. 1 9 1 in impingement :syndroml. 435. in tensile overload. 82-83. 157. 165f 425r. 4 1 3 Thoracic nerves. 1 76 open repail� 29 1 . 44 1 . 40 I . 4 1 21. 2 1 5 76-78. 103-104 del� 259 of cOOl-dination. 168.1 7 1 toneum from. ca!loe study on. 59. in abduction of shouldel� I I . 57-58 in injured athlt.3tion of shoulder. 60t injury of. 8. 23 in frozen shoulder. 370 case study on. 4 1 21. 396-397. 29. 82. 293-294 in brachial plexus. assessment of. 80f. 264-265 in professionals versus amateurs. in frozen shoul­ in brachial plexus injuries. 162-163 indication:. J 9 1 . 450 muscle activity in. 264. 1 72f.:siSied repair. strengthening exercises COI-. 1 70. 232f. 1 9. 439. 22. Swimmers tears i n . 162-163 controversy over. 200 evaluation of.1 7 1 results of. 440r. 174-177 coracoacromial decompression. 240. 372 Thoracic outlct i n instabilities o f shoulder Tenosynovilis. 24 in slabili7. 286-287.422-423 324 i n impingement syndrome. differential diagnosis of. 1 75-176 in temile overload. 196.!les. 8 1 . 1 4 exercises i n . 443 i n axillary nelve paby.3tion in. 472f 1 63-164. 424-427. pneumoperi. 369f-372r. of muscle strenglh. 1 6 1 approaches to. 267 crossed arm adduction. 164 in rotator cuff tears. 1 6 1 . 164f . tests in evaluation of. caution der. 22. 449. 20. 1 5M. 282-283 evaluation 0[. 140. in frozen shoulder. 166-167 439 369f-37 1 r. examination of. 2 1 Tender points in cClvical spine screening. 428-430 281 Thoracic outlet syndrome open reconstruct in" 24. in tensile overload. 83. 244-245 in professionals ver:sus amatclII"!>. 260. 291-292 i n brachial plexus injuries. 240. 1 2 . 258 1 60f 428f-430f Tensile overload dysfunctional reflexes in. 1 57.hc. 459-476 283f-285r. 29. 239. 273 4 1 2 . 472f dysfunctional reflexes in. 426f primary. 397r 403-407 scopic stabilization of shoul­ muscle guarding in. 109 in instability of shoulder. 2 4 1 analogy of orthodontist in. 294-296. 81 f. 1 57 o f supraspinatus muscle and ten� indications fOI� 463-470 evalualion of. 373f. Edgclow protocol fOI� 1 7 1 . 22 elTors during. 408. mobilization or. 22 471-472. 47 1 . joint during. 2 1 clas. 1 72. 24 and therapist in. 1 75 muscle activity in. in abduction of shoulder. 472. 322-32 3. t 57 cocking. 470-47 1 . 168. 53-55 critical points and techniques in. 1 57. 3 9 1 -393. 1 57 joint duting. transcutaneous methods to "ell-Olin swamp". See Electrical nerve goals in. 367 teMs in. 475 in shouldcr dvsfunction. 167. 236 Thrombophlebitis. deceleration.!ttenosis in. evaluation of. 1 6 1 . See Manipulation muscle. 20 371 Throwing injudes. 1 57. 1 55. anatomy of. 23 Trapezius muscle l 72f. 20 goals of. linel's sign 271. 4 1 2 strengthening c:'(crcises fOI� 369f. referred pain from. 245 Total shoulder replacement. dUling isokinetic exercise. 22-23 normative data on categori7. 408t.189.throscopy in. 408t.. 461 -463 during treatment. 1 9 1 Throwing movements 472-474 as risk factor. 1 59. 470 posture in throwing programs in. 1 54-. segmemaJ mobility or. 2-3 Trapezoid ligament. 388. rcfen-cd pain in. 459-476 multiple entrapment sites in. 24. 22 catcgories of. 58 tissue repair in. 476 fisk factors for. 155. 53-55 stimulation. 1 9-55 age and. 40Sf Trauma 22 measurement of deficits in. 22-23 of intel11allexternal rotators. 47 1 f biomechanics or. 1 4 patienl comrol in. 1 72.1 7 1 in injured throwers. 3 1 1 Thoracodol"'Sal nerve. a!. muscles inner· in carpal lllnnci syndrome. 367 dcconditioning renexes. dudng acceleration ph3se of pitch� in stabili7. 287 388f.o Strengt h training symptom control in. body in throwing movements. 23 physical examination in. 1 2. 392f techniques in frozen shoulder. 14. 1 6 9.1 6 1 . 9 401-402. See oL. 1 74f stabilization of glenohumeral 387. 1 65. 1 9-20 combination. 1 1 8 communication between surgeon 1 66-167 prevention of. 29-55 for normals. 1 6 7 in rotation of shoulder. 1 3 vated by. submaximal treatment of stabilization o f glenohumeral effol1 in. 4 1 3 Brachial plexus.. 40 1 .sl lumor in. 24. acceleration. 1 36. 240 clastic resistive exercises for. 174 surgery in.1 72 Windup. 1 75. Thrust techniques. 23 plyometl'ic. 459. 22 planes and.<. 1 9 force couple with sen-atus antel'ior Thoracic region. 1 6 1 in professional venous amateur rotator cuff and deltoid pro-­ scalene muscles in. 322 muscles active during. 1 76-177 joint during. 429 rehabilitation in Panco�. 24 glenohumeral joint in 1 53-177 of rotator cuff. 1 57. 20-2 1 Transverse muscle plav tcchnique. 4 1 3 hislOry o f patient i n . 2 1 . I I r.1 72 throwing injuries in. 2 1 -22 lation. 169. 1 53. 167. 25-26. 1 7 1 l11uscles active during.ification of. occupational and ADL issues in.'eight. in. 1 75 22 relationship t o body \". 57 exercise programs in. 4 1 2t cervical. predictive value of. 22 limited goals program. 2 1 . 4 1 2-4 1 3 mechanoreceptor"!. 2 1 . 368 1 76 repetitive microtrauma during. 22 relationship 1 0 speed.1 55. 1 6 6 instability continuum in. 2 1 -22. 4 1 0. 1 64 241 isokinetic exercise in. 409 strengthening or. for athletes.ation of shoulder. 1 54. 95 1 7 1 . 20-21 spt."'Cificily of. 470f pain in o f serratus nntel'ior muscle. 465f. 2 4 1 isometric cxerci�es for. 2 4 1 469f. 99 Torque spasms in. 4 1 1 case slUcly on. 1 59 pitchers. 4 1 7 gendel' iss-ues in. 1 75 don. 23. loss of inhibitory 29f-36f. 470 166 in injured throwers. 472 nCUI"Ovascular consequences of. 460 body's response lO. 22. 174. 1 7 1 exercise programs for. 20. trauma from. 25-26. 4 1 3 functional profile in. 1 3 7 lests in.498 IN 0 E X Thoracic outlet syndl"Ome (Continued) of infraspinatus muscle and tendon. 1 59. 389f method!> to "open tunnels". 241 anatomy and function or. 2 1 . 306. 162. stretching of.alion of. 106-107 . 192-193 "eferred pain to. 1 3 . rehabilitation goals in. Thoracic spine. of brachial plexus. 4 1 1 -4 1 2 . location or. 25-26. 37 1 r. 1 72-174 in professionals versus amateurs. 323f ing. 2 1 . 374f of biceps muscle and tendon. predisposition to r3lse�positive results of. 388. 2 1 grams. 466. 23 Training. 424. 271f 99 in brachial plexus injudes. 23 dominant side. 293-294 on dominant compared to non· 37 1 . 401 -402. 1 0 in decclemlion phase of pitching. 1 84-. 475-476 . 22. 167-1 68. 241 Transcutaneous electrical nerve stimu. See also dynamic stabilizers and. follO\v·through. 468. 473 164-166 pl'imary tensile overload i n .1 73f. 2 2 hislOry taking in. in musculocutaneous nerve palsy. 1 1 0 stabilization o f glenohumeral limelines in. injury of evaluation of. shouldcr··hand syndrome. 368-369 Triceps brachii muscle.2 1 9 . 192 264 cervicobrachial pain syndrome and Vasoconstdclion rcnex.1 50 injtllies. 192. 324 management of. in neurovascular entrapmenl. 97f brachial plexus injuries. Weight and torque in isokinctic exer­ v 43f. 4 1 7 Trigeminal neuralgia. 1 9 1 Women. 24 1 . 377f. sites of rden·cd pain to shoulder y 1 60f colon and large intestine. 322-324 Olacrotrauma. 1 32 outlet syndrome. 183f thoracic outlet syndrome and. 6 1 in impingement syndrome.. 306--3 1 0 Yergason's tcsl. 239 Vitamin and mineral supplements. 1 58f. Ventral nerve root. anatomy of. 247. 323f mobilization techniques for. 248f diagnostic tests for. 3 1 5-322 z Ulcer1>. 375. pneumoperitoneum in. 1 34 in hemiplegia. tendon. 2 7 1 outlet syndrome. 324-325 fractures of shoulder girdle in. 438 muscle. 82. 379 Whiplash injua-ies Vascular trauma in brachial plexus myofascial. 58 closed chain exer·dses for. 1 8U. 300-30 I hemiplegia. 1 32-133 Treatment plans. isokinetic torque ratios for. 240. 243. See Cumulative trauma palpation of. 97. use of. 336 Upper extremities 196 predisposition la. waming signs in. in frozen shoulder. for case study on. 8 cervical radiculopathy from. 322-323. 344 microlrauma. 300 230f Wrist flexors. 1 39 stomach. 166 for peripheral nerve entrapment�.. 299 impi ngement under acromion i n 164-165 palpation in. 226 atherosclerosis. 268-269 Volumetric measurement of edema in 102-103. 1 0 1 w niques in. 451 f. 324 joint irritation . 8 Warm-up Upper qual1er pain vascular. 1 4 3. 57-58.cn shouldel� 109. 197-198 Wheel exercises.'(ercise use of ergomeler in. 236.. 329 of thoracic outlet. 182-183. importance of. provocation test via. 97f Trunks of brachial ple'(us. palsy of. 149-150 Visceral disease 1 8 1 . 1 54 UncovcI1ebrai jOint. refen·ed pain fTom. 242 as therapy. 30 1 .-iggcr points in trealment program. aneurysms. diagnostic bias in. 3 1 0-3 1 4 disorden. 30 I in rOlalor cuff disease.. 309. 322 in brachial plexus injuries 2 1 M. mobilization tech­ effect of posture on. 328-329 intestinal wall. 1 59 in elderly population. 86-91 in rOLator cuff tears. 1 49f. 1 79. anatomy of. 28 I conditioning program for. 1 56f. in. 52 scar tissue after. 325-328 heart. compared. in frol. 379 program for throwing injulies. 2 1 7. in subacromial space. compensatory Wand exercises shoulder-hand !ooyndrome and. case study on. 450. 437 206. 2 1 4r. 452f for thoracic outlet syndrome. 140 lung.sive movement following. 2 1 6. in frozen shoulder. 185 pancreas. i n e. 2 1 4. 301 injury of. 330 Ulnar nerve kidney. 375 271 thrombophlebitis. 180. 300 position of. 462. 2 1 5. 184. 57. history laking in. IN 0 E X 499 cumulative. 20M. 25. 1 37 liver. 207.. 376. 57. rcfen"eCi pain from. 192 in impingement syndrome. 82f esophagus. 207f WrcsLlers. 2 1 8f-222r. 1 76 lligger points secondary to.Is. i n thoracic in subscapularis muscle. 9 1 1 methods in. 2 1 3 transmission of. in thoracic 463. 167 vascular. and collagen in overhand sports. 323-324 in impingement syndrome. 1 60f diaphragm. 448. 1 3 1 192 4 1 0-4 1 1 types or. 267. 408. 288 total shoulder replacement in. duration of. 379 i ntervertebral foramen injury in. in brachial plexus injuries.tion of. causes of. 454 Upper limb tension lests. 338-339 kineLie chain of. 324 actions in. 322 cxamin. 299-300. i n hCllliplegin. 246--247 of rotator cuff. 162-163 in lendinitis. 2 1 Sf 322-324 T. in isokinetic exercise. injuries. greater 1 17 302f-303f fractures of. 304 of spine and upper extremity. 3 1 0f orthopedic dysfunction fTom. 58. 76 U ltrasonography Viscoelasticity of connective tissue. See Cervical facet most lengthened po�ition of. pa!-. Tuberosity of humcn. 1 69-170. 97. in clavicle fractures. 3 1 4-3 1 5 u gallbladder. 2 1 5. 328 Zygapophyscal joint. 412 pain in. 30 I Tunnels types of. 187-1 88. 467 in frozen shoulder. 90. 304 T4 syndrome and thoracic outlet syn­ Worker risk groups orthopedic evaluation for drome. radicular pain Weight-bearing activities Vascular disease. 44 cise. 328-329 447-456 in thoracic outlet syndrome. 240.