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Professional Papers _______________________________________________________ 
Conservative management of selected shoulder problems
Franklin Schoenoltz, DC, DABCO Arcadia, California
 ACA Journal of Chiropractic/October 1979
Copyright The Journal of the American Chiropractic AssociationCopyright Dr Franklin Schoenholtz 2009
Dr Franklin Schoenholtz is a diplomate of the American Board of Chiropractic Orthopedists. He maintains a private practice at 226-228East Foothill Blvd. In Arcadia, California. He has taught diversi
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edtechnique and undergraduate orthopedics at the Los Angeles Collegeof Chiropractic in Glendale, California, from 1964-1976. Presently,Dr Schoenholtz is the secretary-treasurer of the Board of Regentsat LACC. He has authored numerous articles on the manipulativemanagement of various musculosketela conditions. The most recent, “Conservative Management of Cervical Tension Cephalagia,” ap-peared in the June 1979 issue of the
 ACA Journal 
.
Shoulder problems associated with pain present a challenge in diagnosis andtreatment to all clinical practitioners because of the complexity of the etiologies.In this paper, an attempt will be made to discuss the differential diagnosis of themost common entities affecting the shoulder joint and its conservative therapeuticmanagement.
Introduction
The terms bursitis, tendinitis, pericapsulitis, ad-hesive capsulitis, frozen shoulder, etc have been used byclinicians for years to describe generalized shoulder pain.In many disorders of the shoulder, the lesion has not beende
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ned accurately. This paper will furnish the doctor of chiropractic with information on the most common shoul-der problems seen in everyday practice. Considerationof other conditions should not be overlooked and will bediscussed brie
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y, but extensive material would have to bepresented which is beyond the scope of this paper.
Pathophysiology
Tendinitis is a reaction to mechanical wear andtear plus degeneration. In the shoulder, degenerationbegins in the soft tissue. The rotator cuff bears the bruntof the mechanical stress, leading to premature aging.It should be noted that the tendon normally is awide ribbon made up of bundles of collagen
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bers. The
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bers widen slightly as they are anchored into the hu-meral tuberosity. Fibroblasts and a few blood vessels liebetween the bundles. Degeneration begins in the collagen
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bers and in the ground substance between the
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bers. As the tendon becomes roughened, its tensile strength isdecreased leading to
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brinoid degeneration and followedby
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brosis.The subacromial bursa is most likely to be affect-ed, losing its
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lamentous proportions and developing thick walls with redundant folds. Microscopic examination revealsthat the normally smooth synovial surface changes, replacedby
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brous tissue.Calci
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c tendinitis of the rotator cuff may occur ata later date. Microtraumatic injuries sustained by the cuff cause necrotic and degenerative changes in the tendon tis-sue. With necrotic and degenerative changes in the tendontissue. With necrosis, the localized tissue becomes alkalinewhich induces precipitation of calcium to the area The de-posits vary in consistency from a watery paste to powderygranules.The critical zone most often disturbed by thesedeposits is the supraspinatus insertion. The calcium oftenruptures into the bursa but rarely goes toward the oppositedirection of the joint.
Diagnosis
In degenerative tendinitis, the patient is usuallymiddle-aged and complaining of localized pain in the anteriorlateral aspect of the shoulder. The initial symptom is painwhich is proportionate to the swelling of the tendon andthe pain threshold of the patient. Discomfort is encountered
 
Figure 1. Anatomy of the shoulder girdle with illustrations of the normal range of motion of the shoulder.Figure 2. The “sit” muscles of the muscular cuff.Figure 3. Shoulder extension will move the rotatorcuff into a palpable position.
 
upon abduction starting at 70°, reaching its maximum inten-sity before 90°, and disappearing as the humeral head passesunder the overhanging arch.Characteristic of this condition is a nocturnal ach-ing pain. As the symptoms develop, and abnormal shouldergirdle rhythm occurs replacing
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uid, effortless scapulohumeralmotion. Abduction becomes limited at the glenohumeral jointand is substituted by a “hunching” (elevation) movement.The scapula and humerus move together as one unit and therange of motion may become severely limited.The continuous severe pain results from the con
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ne-ment of the insulted swollen tendon within the narrow con-tainer, causing a constant tension. Protective muscle spasmintensi
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es the restricted mobility.Degenerative tendinitis should be differentiated fromcervical root lesions or radiating patterns of neurovascularcompression syndromes.
Examination
The shoulder is one of the most interesting jointsof the body to examine. The shoulder moves within certainphysiological limits and the interpretation of 
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ndings is gener-ally a matter of functional anatomy. (Figure 1)Special maneuvers for differential diagnosis of primaryshoulder dysfunction may present symptoms which are ac-curately related to shoulder and arm motions.In order to establish a precise diagnosis, the examinermust reach the tissue at fault. The speci
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c maneuvers areherein presented along with their condition.
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Rotator cuff –
The cuff is composed of four muscles.Three of these muscles may be palpated as a unit wherethey insert into the greater tuberosity of the humerus. Thesemuscles have become known as the “sit” muscles becausetheir initials spell the word sit. (Figure 2)The sit muscles include the supraspinatus, the in-fraspinatus and the teres minor. The subscapularis is thefourth muscle of the cuff and is not palpable because of itsanterior position.When palpating the muscular cuff, the doctor shouldattempt to reproduce the pain caused by the defect. The tech-nique for this procedure is to passively extend the shoulder sothat the cuff rotates forward from underneath the acromion.The examiner should hold and lift the patient’s arm posteriorly(Figure 3). Palpation will reveal the roundness of the rotatorcuff slightly anterior and inferior to the anterior border of theacromion. Deep digital pressure may elicit diffuse pain, sug-gesting a lesion of the cuff. 
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Supraspinatus tendinitis –
Supraspinatus tendinitis isthe most common problem affecting the shoulder joint. Thiscondition may be tested with the examiner placing one handover the deltoid muscle to stabilize the shoulder girdle. Theexaminer then presses on the lateral aspect of the elbow whilethe patient abducts his arm against resistance. The pres-ence of pain on this maneuver incriminates the supraspinatusmuscle. (Figure 4)To rule out deltoid involvement, the examiner holdsthe patient’s arm passively at the horizontal plane. The patientis asked to move his arm forward and backward against resis-tance. If the pain is felt by the patient, involvement of the an-terior and posterior
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bers of the deltoid is indicated. However,if neither of these movements causes pain, the supraspinatusmuscle is suspected.
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Rotator cuff tears –
When a tear in the rotator cuff issuspected, the “drop arm test” may be performed. The patientis asked to fully abduct his arm. When a tear is present inthe cuff, the patient will be unable to slowly lower his arm. Itwill drop to his side from a position of 90° abduction. If thepatient is able to hold his arm in abduction, a mild tap on theforearm will cause the arm to fall. (Figure 5)
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Bursitis –
There is an informative diagnostic procedurewhich has been referred to as the “coracoid push button sign.” The examiner presses
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rmly into the deltopectoral triangle.The coracoid process may be felt at its tip and medial surface,and lies under the pectoralis major muscle. Deep palpationwill normally elicit tenderness (Figure 6). The examiner shouldslide his
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nger tip one-half inch laterally and superiorly untilhe reaches a portion of the subacormial bursa. The clinicianshould then press
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rmly with the same pressure as exertedon the coracoid process. If a subacromial bursitis is present,greater pain will occur, thus providing a differential sensationFigure 4. The examiner tests abduction by placing theupper hand over the deltoid to stabilize the shoulder. Thelower hand presses on the lateral aspect of the elbow asthe patient attempts to abduct his arm.
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