Physical Therapy Protocols For Conditions of Shoulder Region PDF

Red Flags for Potential Serious Conditions in Patients with Neck and Shoulder Problems
Red Flags for the Neck and Shoulder Region

Red Flag Red Flag
Condition Data obtained during Data obtained during
Interview/History Physical Exam
Cervical Fractures Major trauma such as a motor vehicle Midline cervical spine tenderness
or Ligamentous accident or a fall from a height with Positive ligamentous integrity tests:
Instabilities1-6 associated immediate onset of neck Sharp-Purser test
pain Alar ligament integrity test
Rheumatoid arthritis or Downs Apprehension with or inability to actively rotate
syndrome head < 45o
Cervical Central Older age Gait disturbances due to hyperreflexic lower

Cord Lesion7-9 History of a trauma (esp. MVA or fall) extremities
Incontinence Upper extremity (especially hand) sensory and
motor deficits, and atrophy
Pancoast tumor10-12 Men over 50 with a history of cigarette Wheezing with auscultation when tumor obstructs
smoking. bronchus
Nagging type pain in the shoulder and May have Horners syndrome
along the vertebral border of the Ptosis (drooping eyelid)
Constricted pupil
scapula often progressing to Sweating disturbances
burning pain down the arm into the
ulnar nerve distribution.
Septic Arthritis Insidious onset of chest pain localized in Tender S-C joint
(A-C Joint)13 the S-C joint Limited shoulder movement
History of IV drug use, diabetes, trauma, Swelling over S-C joint
infection (especially of central Fever
venous access)
References:
1. Aspinall W. Clinical testing for the craniovertebral hypermobility syndrome. J Orthop Sports Phys Ther. 1990;12:47-54.
2. Panjabi M. (1992) in Swinkels R, Beeton K, Alltree J. Pathogenesis of upper cervical instability. Manual Therapy. 1996;
1:127-132.
3. Hoffman JR. Mower WR. Wolfson AB. Todd KH. Zucker MI. Validity of a set of clinical criteria to rule out injury to the
cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group.[erratum appears
in N Engl J Med 2001 Feb 8;344(6):464]. N Engl J Med. 2003;343:94-99.
4. Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, et al. The Canadian C-Spine Rule versus the Nexus
Low Risk Criteria in patients with trauma. N Engl J Med. 2003; 349:2510-2518.Niere KR, Torney SK. Clinicians
perception of minor cervical instability. Manual Therapy. 2004;9:144-150.Delfini R, Dorizzi A, Facchinetti G, et al.
Delayed post-traumatic cervical instability. Surg Neurol. 1999; 51:588-95.
7. Newey MI, Sen PK, Fraser RD. The long-term outcome after central cord syndrome: a study of the natural history. J Bone
Joint Surg Br. 2000;82:851-855.
8. Tow AM, Kong KH. Central cord syndrome: functional outcome after rehabilitation. Spinal Cord. 1998; 36:156-160.
9. Waters RL, Adkins RH, Sie IH, Yakura JS. Motor recovery following spinal cord injury associated with cervical
spondylosis: a collaborative study. Spinal Cord. 1996;34:711-715.
10. Spengler D, Kirsh M, Kaufer H. Orthopaedic aspects and early diagnosis of superior sulcus lung tumor. J Bone Joint Surg.
1973;55:1645-1650.
11. Jett J. Superior sulcus tumors and Pancoasts syndrome. Lung Cancer. 2000;42:S17-S21.
12. Robinson D, Halperin N, Agar G, et al. Shoulder girdle neoplasms mimicking frozen shoulder syndrome. J Shoulder Elbow
Surg. 2003; 12:451-5.
13. Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine. 2004;83:139-148.
Joe Godges, DPT, MA, OCS KP So Cal Ortho PT Residency

NECK AND SHOULDER SCREENING QUESTIONNAIRE
NAME: __________________________________________ DATE: _____________

Medical Record #: _________________________
Yes No
1. Have you recently experienced a blow to the head or a whiplash injury?
2. Do you have rheumatoid arthritis?
3. Are you currently taking steroids or have you been on prolonged
steroid therapy?
4. Have you noticed any recent weakness, tingling, or numbness in you
arms or legs?
5. Have you noticed a recent onset of difficulty with retaining your urine?
6. Do you now smoke or have you been a smoker in the past?
7. Do you administer medicine or drugs to yourself for which you need to

inject using a needle?
Joe Godges, DPT, MA, OCS KP So Cal Ortho PT Residency

Shoulder Mobility Deficits
ICD-9-CM codes: 726.0 Adhesive capsulitis of the shoulder
ICF codes: Activities and Participation Domain codes:

d4452 Reaching (Using the hands and arms to extend
outwards and touch and grasp something, such as when
reaching across a table or desk for a book.)
Body Structure code: s7201 Joints of shoulder region
Body Functions code: b7100 Mobility of a single joint
Common Historical Findings

Lateral shoulder pain - worsens with positions or activities which put stretch on the
glenohumeral joint
Progresses to stiffness
Gradual, usually insidious, onset of symptoms
Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions:
ROM limitations - external rotation and abduction are most limited, flexion and internal
rotation are least limited
Pain at end ranges--some motions are more painful than others (external rotation with
abduction is typically the most painful)
Limited glenohumeral accessory movements
Physical Examination Procedures:
Glenohumeral External Rotation ROM Measurement
Performance Cues:
Remember that glenohumeral ROM is different than shoulder ROM (shoulder ROM is
the sum of glenohumeral and scapular ROM)
Stand in patients axillary region
Stabilize scapula with forearm
Be precise with stabilization of humeral abduction (to 90 degrees if possible) and
horizontal abduction (maintain 0 degrees)
Joe Godges, DPT, MA, OCS 1 KP So Cal Ortho PT Residency

If glenohumeral external rotation ROM is greater at 90 degrees of abduction than at 45
degrees of abduction, suspect a muscle flexibility deficit of the subscapularis
Normal glenohumeral external rotation ROM is 90 degrees
Glenohumeral Internal Rotation ROM Measurement
Performance Cues:
Stand above the patient
Stabilize scapula in neutral - use forearm to prevent protraction
Be precise with humeral abduction (90 degrees if possible) and horizontal abduction
(maintain 0 degrees)
Normal is 60 degrees of isolated glenohumeral internal rotation ROM
Glenohumeral Flexion ROM Measurement
Performance Cues:
Stabilize scapula - maintain lateral scapular border in a position that is parallel to the
tabletop
Normal is 120 degrees of isolated glenohumeral flexion

Glenohumeral Abduction ROM Measurement
Performance Cues:
Glenohumumeral (GH) abduction is difficult to assess in patients with adhesive capsulitis
because GH abduction requires GH external rotation
Externally rotate humerus to the maximum of pain free motion - then abduct to
limitation. (Notate both: e.g., 70o of GH abduction with GH E/R at 30o)
Stabilize scapular to prevent compensatory scapular elevation
Normal is 120 degrees of isolated GH abduction (at 90 degrees of GH E/R)
Shoulder Mobility Deficits: Description, Etiology, Stages, and Intervention Strategies
The below description is consistent with descriptions of clinical patterns associated with shoulder
Adhesive Capsulitis the vernacular term Frozen Shoulder
Description: Insidious onset of progressive stiffness and pain of the shoulder
Etiology: The cause of this disorder is presumed to be due to repeated inflammatory reactions in
the glenohumeral capsule and synovium, which lead to a thickened, fibrotic and inextensible
glenohumeral joint capsule. The altered scapular and glenohumeral joint mechanics due to the
glenohumeral capsular restrictions often lead to abnormal stress and subsequent inflammation of
the rotator cuff tendons and subacromial bursa
Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions codes: b7100.3 SEVERE impairments of mobility of a single joint
Excessive scapular protraction

Excessive scapulothoracic joint motion a common characteristic is excessive
scapular elevation with the scapular upward rotation that normally accompanies
overhead activities
Restricted active ROM lateral rotation and abduction are commonly the most
limited if overhead reaching is the reported functional limitation. Medial rotation is
commonly limited if hand behind back movements are the reported functional
limitation.

Isolated glenohumeral motions are considerably limited typically about 50% of
normal (Normal glenohumeral PROM is 120o of flexion, 120o of abduction, 90o of
lateral rotation and 70o of medial rotation when measured at 90o of glenohumeral
abduction)
Glenohumeral accessory movements and joint play movements are also considerable
limited especially humeral inferior, posterior and anterior glides
Symptoms are worst with end-range positions that stretch the capsule
Rotator cuff muscles may weak and painful due to the tension transmitted to an
inflamed joint capsule by contracting musculotendinous units that attach to the
capsule
Pain around joint capsule (near axilla)
Sub Acute / Moderate Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions codes: b7100.2 MODERATE impairments of mobility of a single
joint
As above with the following differences:
Resisted Tests are strong and relatively painless when the glenohumeral joint
positioned in midrange (thus lessening tension on the capsule)
Now (when less acute) examine the patient for common coexisting upper quadrant impairments.
For example:
Segmental movement abnormalities cervical and upper thoracic spine

Limited glenohumeral physiologic and accessory movements
Muscle flexibility deficits especially subscapularis, infraspinatus, pectoralis minor,
pectoralis major, latissimus dorsi, and teres major myofascia
Nerve mobility deficits especially median, radial, and ulnar nerves in the common
thoracic outlet entrapment areas
Weak scapular upward rotator muscles commonly lower trapezius, middle
trapezius, and serratus anterior
Excessive scapular elevation, abduction, downward rotation or winging with
overhead reaching
Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions codes: b7100.1 MILD impairments of mobility of a single joint
Pain with repetitive activities of the shoulder especially at end range

Painful only with overpressures at end ranges

Intervention Approaches / Strategies
Acute Stage / Severe Condition
Goals: Prevent movement induced inflammatory reactions

Avoid muscle guarding
Painfree with daily activities that use shoulder within available range
Painfree sleep
Physical Agents:
Phonophoresis/iontophoresis or pulsed ultrasound to assist in reducing
inflammation
Ice and/or TENS for relief of acute pain as well as to reduce muscle guarding
External Devices (Taping/Splinting/Orthotics)

Fit patient with a sling if pain relief requires temporary use of an external device
Therapeutic Exercises
Painfree AROM or passive ROM exercises
Pendulum (Codmans) exercises
Re-injury Prevention Instruction

Temporarily limit end range motions or stretches, overhead or behind the back
activities that aggravate the patients condition
Sub Acute Stage / Moderate Condition
Goals: Improve glenohumeral ROM

Improve scapulohumeral rhythm
Prevent re-injury to the joint capsule
Restore strength of the muscles around shoulder and scapula
Physical Agents:
May use ultrasound to the joint capsule prior to active or passive stretching
procedures/exercises
Manual Therapy
Soft tissue mobilization to adaptive shortened myofascia
Joint mobilization to restricted accessory and joint play motions
Stretching exercises to enhance carryover of manual stretching procedures
Strengthening exercises to weak scapular depressors, scapular upward rotators,
and rotator cuff motions

Neuromuscular Reeducation
Facilitate neutral thoracic cage, scapular position, and shoulder proprioception
Ergonomic Instruction:
Promote efficient, painfree, motor control of the trunk, scapulae and arm with
overhead activities.
Modify activities to prevent overuse and re-injury
Settled Stage / Mild Condition
Goals: Normalize glenohumeral ROM

Normalize upper quarter posture, muscle flexibility and muscle strength
Progress activity tolerance
Approaches/ Strategies listed above
Manual Therapy
Increase intensity and duration of soft tissue mobilization and myofascial
stretching to the maximal tolerable level
Increase intensity and duration of joint mobilization procedures to the maximal
tolerable
Maximize muscle performance of the relevant trunk, scapulae, shoulder flexion
and shoulder girdle muscles required to perform the desired occupational or
recreational activities.
Ergonomic Instruction: as above

Add job or sport specific training
Intervention for High Performance / High Demand Functioning in Workers and Athletes
Goal: Return to desired occupational or sport activities
Progress exercises focusing on job/sport specific training program based on
individual needs of patient.

Selected References
Deyle GD, Bang MD. Examination and treatment of the shoulder. Orthopaedic Physical Therapy
Clinics of North America. 1999;8:83-115.
Gross J, Fetto J, Rosen E. Musculoskeletal Examination. Blackwell Science, 1996.
Hannifan JA, Chiaia TA. Adhesive capsulitis: a treatment approach. Clinical Orthop Rel Res.
2000; 372:95-109.
Loyd JA. Adhesive capsulitis of the shoulder, diagnosis and treatment. South Medical Journal.
1993;76:879-883.
Neviaser JS. Adhesive capsulitis and the stiff and painful shoulder. Orthop Clin of North Am.
1980;11:327-333.
Nicholson GG. The effects of passive joint mobilization on pain and hypomobility associated
with adhesive capsulitis of the shoulder. J Orthop Sports Phys Ther. 1985; 6(4): 238-246.
Placzek J, Roubal P, Freeman C, et al. Long term effectiveness of translational manipulation for
adhesive capsulitis. Clin Orthop and Rel Res. 1998;356:181-191.
Rizk TE, Christopher RP, Pinals RS, et al. Adhesive capsulitis (frozen shoulder): a new
approach to its management. Arch Phys Med Rehabil. 1983;64:29-33.
Roubal PJ, Dobitt D, Placzek JD. Glenohumeral gliding manipulation following interscalene
brachial plexus block in patients with adhesive capsulitis. J Orthop Sports Phys Ther.
1996;24:66-77.
Tomberlin J, Saunders D. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders,

3rd ed., Vol. 2, (Extremities). Educational Opportunities, 1994.
Vermeulen HM, Oberman WR, et. al. End-range mobilization techniques in adhesive capsulitis
of the shoulder joint: a multiple subject case report. Phys Ther. 2000;80:1204-1213.
Wadsworth T. Frozen shoulder. Phys Ther. 1986;66:1878-83.

SHOULDER MANUAL INTERVENTIONS
Patient Problem: LIMITED HUMERAL INTERNAL ROTATION
ST MOB: Infraspinatus/Teres Minor/Posterior Deltoid
JNT MOB: Posterior Glide (loose packed position)

Posterior Glide (combined movements)
Distraction
RE-ED: Extension/Adduction/Internal Rotation PNF pattern (emphasize traction +

rotation)
Contract/Relax to glenohumeral external rotators
MWM: Hand-Behind Back Maneuvers
Patient Problem: LIMITED HUMERAL EXTERNAL ROTATION
ST MOB: Pectoralis Minor

Subscapularis
JNT MOB: Inferior Glide

Posterior Glide
Anterior Glide
RE-ED: Contract/Relax of Extension/Adduction/Internal Rotation PNF pattern (emphasize

spiral/ diagonal)
Flexion/Abduction/External Rotation PNF pattern (facilitate movement/traction)
MWM: Arm Overhead Maneuvers

Infraspinatus
Soft Tissue Mobilization
Subscapularis
Soft Tissue Mobilization

Impairment: Limited Shoulder Hand Behind Back Motions
Limited Glenohumeral Internal Rotation
Limited Humeral Posterior Glide
Humeral Posterior Glide
Cues: Position the patient supine with a wedge under the spine of the scapula (not under the
glenohumeral joint)
A strap is handy to fixate the upper thorax and scapula - especially if you plan to add the
combined movement of humeral distraction
Hug the arm
Use a flat hand and padding (folded sheet) to prevent irritation of the anterior
humeral/bicipital groove area
Consider adding combined movements of humeral distraction, abduction, and internal
rotation as well as cervical sidebending prior to the posterior glide
The following reference provides additional information regarding this procedure:

Freddy Kaltenborn PT: Manual Mobilization of the Extremity Joints, p. 114, 1989

Impairment: Limited and Painful Shoulder Elevation
Shoulder Elevation MWM
Cues: Position patient seated at the end of a raised treatment table

Stand to the side of the uninvolved shoulder
Stabilize scapula with one hand
Glide the humeral head posteriorly - parallel to the glenoid treatment plane
Sustain the glide as the patient actively elevates his humerus
Alter the amplitude and direction of the glide to achieve painfree active elevation
Repeat several times (sets of 10)
Progress the re-education with 1) lifting a weight during the MWM, or 2) overpressure at
end of available active range one option is illustrated below

Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 88-91, 1995
Shoulder Elevation MWM

(with overpressure)

Impairment: Limited Shoulder Elevation
Limited Glenohumeral External Rotation
Limited Humeral Anterior Glide
Humeral Anterior Glide
Cues: Position the patient prone with the involved humerus off the side of the table place a
towel pad under the coracoid process and clavicle
A strap can be used to assist in stabilizing the scapula (especially when adding combined
movements)
Hug the distal humerus into your thigh with one hand
Apply an anterior glide to the proximal humerus with the other hand
Use a soft flat hand
Generate the anterior glide with a trunk lean or slight bend of the knees
Consider adding combined movements of humeral distraction, abduction, horizontal
abduction, or external rotation prior to the anterior glide (an adjustable, rolling stool
can be used to provide the external rotation)

Freddy Kaltenborn PT: Manual Mobilization of the Extremity Joints, p. 112, 1989

Ext/Add/IR Contract-Relax
FLEX/ABD/ER facilitation

Shoulder Muscle Power Deficits
ICD-9-CM codes: 840.6 Supraspinatus strain

726.12 Bicipital tenosynovitis

d4300 Lifting (Raising up an object in order to move it
from a lower to a higher level, such as when lifting a glass
from the table.)
Body Structure code: s7202 Muscles of shoulder region
Body Functions code: b7300 Power of isolated muscles and muscle groups
Shoulder abductors/external rotators musculotendinous involvement:

Pain in posterior-lateral shoulder
Pain with overhead activities
Midrange (about 90 degrees) catching sensation
Symptoms developed from, or worsen with, repetitive overhead activities or from an
acute strain such as a fall onto the shoulder
Shoulder flexors musculotendinous involvement:

Pain in anterior-lateral shoulder
Pain with shoulder flexion and lifting activities
Painful arc
Symptoms developed from, or worsen with, repetitive flexion and lifting activities
Shoulder abductors/external rotators musculotendinous involvement:

Painful arc with active elevation
Supraspinatus manual resistive test: weak and painful (moderately painful)
Infraspinatus manual resistive test: weak and painful (mildly painful)
Palpable posteriolateral rotator cuff tenderness
Shoulder girdle muscle flexibility, strength, and coordination deficits
Shoulder flexors musculotendinous involvement:

Painful arc with shoulder flexion
Biceps brachii manual resistive test: weak and painful
Palpable tenderness in bicipital groove
Shoulder girdle muscle flexibility, strength, and coordination deficits

Normal Arm Elevation Painful Arc and Associated

Motor Control Deficits
Performance Cues:
Common muscle flexibility deficits include short pectoralis minor, levator scapulae, teres
major, and latissimus dorsi
Common muscle strength deficits include weak supraspinatus, infraspinatus, lower
Common motor coordination deficits include excessive 1) thoracic spine flexion, 2)
contralateral weight shift of thorax, 3) scapular protraction and downward
rotation, 4) scapular abduction during overhead activities
Supraspinatus Manual Resistive Test
Performance Cues:
Elevate arm about 40 degrees in scapular plane
Thumb down to internally rotate humerus
Contact only dorsal surface of distal forearm
Stabilize thorax - contact contralateral shoulder
Remember - slow build-up of resistance, sustain peak, slow release of resistance
If there is a grade III (complete) tear of the rotator cuff the patient will be unable to hold
the arm in this position (positive Drop Arm Test)

Infraspinatus Manual Resistive Test
Performance Cues:
Contact only dorsal surface of distal wrist
Stabilize ipsilateral elbow
May test at differing degrees of humeral flexion and abduction
Biceps Manual Resistive Test
Supraspinatus and Infraspinatus Tendon

(Rotator Cuff) Palpation

Performance Cue:
Placing the humerus in a position of internal rotation, extension, and adduction assists in
gaining easier access to the tendons
Palpation of the Bicipital Groove
Shoulder Muscle Power Deficits: Description, Etiology, Stages, and Intervention Strategies
The below description is consistent with descriptions of clinical patterns associated with the vernacular term
Rotator Cuff Tendinitis
Description: Repetitive strain injury to the deep tendons of the shoulder most commonly the
tendons of the supraspinatus of infraspinatus muscles.
Etiology: The suspected cause of this disorder is the abnormal impingement of the tendons of
the rotator cuff between the humeral head and the acromial arch due to deficits in the ability of
the humeral head depressors (the rotator cuff muscles) or the scapular upward rotator muscles
to function in a coordinated manner during overhead activities.

ICF Body Functions codes: b7300.3 SEVERE impairments of muscle power
Accentuated thoracic kyphosis, scapular protraction, scapular abduction, and/or

scapular downward tilt
overhead reaching
Midrange arc of pain with overhead movements (e.g., pain during 130o to 160o of
shoulder flexion)
Weak and painful supraspinatus and/or infraspinatus during manual muscle tests
Palpation of involved rotator cuff tendons reproduce the patients reported pain
complaint

ICF Body Functions codes: b7300.2 MODERATE impairments of muscle power
As above, except:
Strong and painful supraspinatus and/or infraspinatus
Now (when less acute) assess thoracic and scapular malalignments, and muscle flexibility and
strength deficits for example:
Shortened pectoralis minor, levator scapulae, teres major, and latissimus dorsi
myofascia

ICF Body Functions codes: b7300.1 MILD impairments of muscle power
As above, except:
Strong and painful supraspinatus and/or infraspinatus muscles only with repeated
contractions
Midrange arc of pain only with repeated overhead movements
Overpressure, or passively forcing end range shoulder flexion (e.g., impingement
tests) reproduce the patients reported pain complaints
Goals: Alleviate pain with active arm elevation

Restore strength to supraspinatus and infraspinatus muscles
Physical Agents
Ultrasound, iontophoresis, and/or ice applied to the rotator cuff tendons
Manual Therapy
Soft tissue mobilization to shortened pectoralis minor, levator scapulae, teres
major, and latissimus dorsi myofascia
Facilitate neutral thoracic cage and scapular posture with overhead activities

Strengthening exercises for the supraspinatus and/or infraspinatus

Taping procedures to promote scapular alignment and to facilitate contraction of
the lower trapezius, middle trapezius, and/or serratus anterior
May consider a sling if necessary to temporarily limit painful active movements

Temporarily limit overhead activities
Goals: Prevent re-injury of the rotator cuff

Improve strength of supraspinatus and infraspinatus
Alleviate upper quarter malalignments and muscle flexibility and strength deficits
contributing to the mechanical impingement of the rotator cuff
Approaches / Strategies listed above
Manual Therapy
If a localized area of tendon thickening is palpable transverse friction massage
may be indicated
Normalize scapulohumeral and scapulothoracic rhythm using verbal, manual, or
biofeedback training
Stretching exercises for shortened pectoralis minor, levator scapulae, teres major,
and latissimus dorsi myofascia
Strengthening exercises for weak lower trapezius, middle trapezius, and serratus
anterior muscles
Ergonomic Instruction
Promote efficient, pain free, motor control of the trunk, scapulae and arm with
overhead activities
Goals: As above
Progress activity to improve tolerance with overhead arm use

Provide muscularendurance exercises to improve muscle performance of the
relevant trunk, scapulae, and glenohumeral muscles required to perform the
desired occupational or recreational activities
Add job/sport specific training
Intervention for High Performance / High Demand Functioning in Workers or Athletes
Goal: Return to desired occupational or leisure time activities
Provide exercises to maximize muscle performance of the relevant trunk,
scapulae, and glenohumeral muscles required to perform the desired occupational
or recreational activities
Progress job/sport specific training to increase more mechanically demanding
activities
Selected References
Bang MD, Deyle GD. A comparison of the effectiveness of two physical therapy treatment
approaches for impingement syndrome of the shoulder: supervised exercise versus supervised
exercise combined with manual physical therapy. J Orthop Sports Phys Ther. 2000;30:
Godges JJ, Matson-Bell M, Shah D, Thorpe D. The immediate effects of soft tissue mobilization
with PNF on shoulder external rotation and overhead reach. J Ortho Sports Phys Ther.
2003;33:713-718.
Host, HH. Scapular taping in the treatment of anterior shoulder impingement. Phys Ther.
1995;75:803-812.
Schmitt L, Snyder-Mackler L. Role of scapular stabilizers in etiology and treatment of

impingement syndrome. J Orthop Sports Phys Ther. 1999;29:31-38.

Shoulder Muscle Power Deficits: Description, Etiology, Stages, and Intervention Strategies
Bicipital Tendinitis
Description: An inflammatory process involving both the tendon and its sheath within the
intertubercular groove caused by repetitive strain injury to the long head of the biceps brachii
tendon typically producing anterior shoulder pain.
Etiology: The suspected cause of this disorder is abnormal friction or strain of biceps tendon
against the medial wall of the bicipital (intertubercular) groove. The structure of the anatomy
leaves the tendon relatively unprotected. It is very important to recall that the bicipital groove
acts as a trochlea, causing the tendon and its overlying sheath to be susceptible to wear and
injury in this region. Eventually, fraying and narrowing of the tendon may occur with dense
adhesions if the repetitive activities precipitating the condition are not ceased. It is important to
differentiate between primary and secondary bicipital tendonitis. With primary bicipital
tendonitis, the tendonitis is specific to the intertubercular groove without associated shoulder
pathology. When the condition occurs in association with other pathologic conditions, such as
impingement syndrome or rotator cuff disease, it is termed secondary bicipital tendonitis.

ICF Body Functions codes: b7300.3 SEVERE impairments of muscle power
Excessive scapular protraction

Pain with lifting objects
Pain with reaching and overhead activities
Pain with shoulder flexion, lateral rotation or extension
Weak and painful biceps brachii
Tenderness to palpation over bicipital groove

ICF Body Functions codes: b7300.2 MODERATE impairments of muscle power
Strong and painful biceps brachii contraction e.g., pain with resisted shoulder
flexion with the elbow fully extended
Pain with resisted shoulder horizontal adduction with the shoulder in 90o of
glenohumeral lateral rotation
In conjunction with the above findings, it is appropriate to examine the patient for common
coexisting upper quadrant impairments in this stage.
Posterior glenohumeral capsular tightness

Coexisting upper thoracic or cervical disorders

Upper limb nerve tension
Scapular malalignment
Muscle flexibility and strength deficits, e.g., shortened pectoralis major,
coracobrachialis, biceps brachii and weak middle and lower trapezius musculature

ICF Body Functions codes: b7300.1 MILD impairments of muscle power
Strong and painful biceps brachii only with repeated contractions

Pain with repetitive activities, such as lifting
It is important to rule out any rotator cuff disorders since these groups of muscles play a
critical role in anterior shoulder stability. One of the most vulnerable positions for the
shoulder complex is during extreme abduction and external rotation, as seen in the late
cocking phase of pitching or throwing. Studies have shown that the glenohumeral joint
(shoulder complex) can withstand higher and higher external rotational forces (torque) as
the long head of the biceps muscle force is increased. In other words, the shoulder
becomes torsionally stiffer with increasing biceps force. The greater the shoulders
torsional stiffness or rigidity, the more force that would be required to externally rotate it
to a state of dislocation. In one of the studies, it was discovered that while the shoulder
was being stressed in the vulnerable abducted and externally rotated position with 100%
predicted biceps force, the long head of the biceps muscle was able to increase the
torsional rigidity of the glenohumeral joint by 32%. Further studies have provided
evidence to support an additional significant stabilizing effect of the tendon of the long
head of the biceps brachii against superior translation of the humeral head during
abduction of the shoulder, contributing to a reduction in impingement.
Other reasons as to why it is important to rule out pathologies of the shoulder lie in the
possibility of pre-existing lesions or tears in the glenohumeral region, which may impair
stability. In the case of a superior labral lesion, this can lead to disruption of the superior
labrums firm attachment to the glenoid as well as a disruption of the origin of the long
head of the biceps tendon, impairing shoulder stability.
Goal: Alleviate pain with active arm flexion
Physical Agents
Ultrasound, phonophoresis, iontophoresis or ice applied to the biceps tendon for
pain relief and to decrease inflammation

Manual Therapy
Soft tissue mobilization and manual stretching to normalize the length of
pectoralis major and coracobrachialis
Friction Massage to the long head of the biceps brachii may be used to reduce
adhesions of the retinaculum and tenosynovitic tissues in the intertubercular
groove

Taping to reposition the scapula in order to promote normal scapulohumeral
rhythm when raising the arm.
Facilitate neutral thoracic cage, scapular posture, and shoulder proprioception
exercises
Taping may also be used to train the patient to use weak, elongated muscles (e.g.,
lower trapezius) to function in a normal position
Normalize the strength of the muscles commonly found to be weak, namely lower
trapezius, serratus anterior, and perhaps the biceps brachii and brachialis

Temporarily limit shoulder flexion, lateral rotation, and overhead activities
Goals: Prevent re-injury of the biceps tendon

Normal length and strength of the shoulder girdle musculature
Manual stretching procedures and home/gym stretching exercises to the trunk and
shoulder girdle muscles that have flexibility deficits
Progressive resistive exercises to trunk and shoulder girdle muscles that have
strength deficits. (Depending on the patients strength deficits, this may
include instructing the patient in isometric, isotonic (e.g., tubing or free
weights), and/or glenohumeral/scapular stabilization exercises (e.g., seated
press-ups, progressive push-ups, Swiss ball exercises)
Progression of strengthening exercises to regain normal coordination of rotator
cuff and shoulder girdle musculature during functional activities. (Depending on
the patients strength deficits, this may include instructing the patient in isometric,

isotonic exercises. For example, use of tubing or free weights for shoulder
elevation, rows, scaption, curls and/or glenohumeral/scapular stabilization
exercises such as seated press-ups, progressive push-ups, Swiss ball exercises)
Modification of jobsite or other environmental factors as well as ergonomic cuing
(movement training) to promote efficient, painfree, motor control of the trunk,
scapulae and arm with lifting, reaching and overhead activities
Goals: As above
Progress activities to tolerance
Maximize muscle performance of the relevant trunk, scapulae, shoulder flexion
and shoulder girdle muscles required to perform the desired occupational or
recreational activities
Approaches/ Strategies listed above
Progress job/sport specific training depending on the needs and desires and
(impairments) of the worker or athlete

Selected References
Bang MD, Deyle GD. A comparison of the effectiveness of two physical therapy treatment
approaches for impingement syndrome of the shoulder: supervised exercise versus supervised
exercise combined with manual physical therapy. J Orthop Sports Phys Ther. 2000; 30
Bonafede RP, Bennett RM. Shoulder Pain Guidelines to diagnosis and management.
Postgraduate Medicine. 1987 July; 82 (1): 185 193.
Bang MD. Deyle GD. Comparison of supervised exercise with and without manual physical
therapy for patients with shoulder impingement syndrome. J Orthop & Sports Phys Ther.
2000;30:126-137.
13a: Godges JJ, Matson-Bell M, Shah D, Thorpe D. The immediate effects of soft tissue
mobilization with PNF on shoulder external rotation and overhead reach. J Ortho Sports Phys
Ther. 2003;33:713-718.
Host, HH. Scapular taping in the treatment of anterior shoulder impingement. Physical Therapy.
1995; 75:803-812.
Post M, Benca P. Primary Tendonitis of the Long Head of the Biceps. Clinical Orthopedics and
Related Research. 1989 September; 246: 117 125.
Rodosky MW, Harner CD, Fu FH. The Role of the Long Head of the Biceps Muscle and
Superior Glenoid Labrum in Anterior Stability of the Shoulder. The American Journal of Sports
Medicine. 1994; 22 (1): 121 130.
Schmitt L, Snyder-Mackler L. Role of scapular stabilizers in etiology and treatment of

impingement syndrome. J Orthop Sports Phys Ther. 1999; 29:31-38.

3rd ed.,Vol. 2, (Extremities). Educational Opportunities, 1994.
Wadsworth C. Manual Examination and Treatment of the Spine and Extremities. Williams &
Wilkins, 1988.
Warner JP, McMahon PJ. The Role of the Long Head of the Biceps Brachii in Superior Stability
of the Glenohumeral Joint. The Journal of Bone and Joint Surgery. 1995 March; 77-A (3):
366 371.

Shoulder Movement Coordination Deficits
ICD-9-CM codes: 840.2 Shoulder ligament sprain

840.0 Acromioclavicular joint sprain

d4305 Putting down objects (Using hands, arms or other
parts of the body to place an object down on a surface or
place, such as when lowering a container of water to the
ground.)
d4451 Pushing (Using fingers, hands and arms to move
something from oneself, or to move it from place to place,
such as when pushing an animal away.)
d4300 Throwing (Using fingers, hands and arms to lift
something and propel it with some force through the air,
such as when tossing a ball.)
d4550 Crawling (Moving the whole body in a prone
position from one place to another on hands, or hands and
arms, and knees.)
d4551 Climbing (Moving the whole body upwards or
downwards, over surfaces of objects, such as climbing
steps, rocks, ladders of stairs, curbs or other objects.)
Body Structure code: s7203 Ligaments and fasciae of shoulder region
Body Functions code: b7601 Control of complex voluntary movements
Glenohumeral ligaments and fasciae involvement:

Shoulder pain during activity - aching afterwards
Recurrent subluxations or dislocations with certain movements, positions, and activities
Apprehension
Acromioclavicular ligaments and fasciae involvement:

Trauma--a fall on the tip of the shoulder or a fall onto an outstretched arm
Pain with reaching across body, with overhead activities and with weight bearing on
elbows or sleeping on the injured shoulder
Glenohumeral ligaments and fasciae involvement:

Excessive glenohumeral accessory motion
Apprehension at end range elevation, horizontal abduction, and external rotation (if
anterior instability)

Acromioclavicular ligaments and fasciae involvement:
If Grade II or III sprain - palpable and observable displacement between the clavicular
and acromial articular surfaces
Pain with accessory movement tests
Pain with palpation/provocation of acromioclavicular ligament
Glenohumeral Accessory Movement Test

Humeral Posterior Glide
Performance Cues:
Patient sits on end of table
Ensure loose packed position
Do not elevate scapula
Allow the patients wrist to rest on your elbow
Stabilize spine of scapula with palm
Glide humerus (and thus, humeral head) posteriolaterally - in a direction parallel to the
plane of the glenoid fossa
OK to use weight shift of thorax to produce glide
Glenohumeral Accessory Movement Test Glenohumeral Accessory Movement Test

Humeral Anterior Glide Humeral Anterior Glide

Performance Cues:
Glide humeral head anteriomedially - in line with the treatment plane
Stabilize the clavicle with fingers or palm
Normal is an excursion that is less than one half of the width of the humeral head
A/C Joint Accessory Movement Test A/C Joint Accessory Movement Test
Clavicular Anterior Glide Clavicular Posterior Glide
Performance Cues:
Stand behind patient
Stabilize posteriorly via the spine of the scapula with you thumb and anteriorly via the
glenoid fossa (hugging the humeral head into the fossa)
Grab the distal portion of the clavicle (it is OK to be somewhat medial to the A/C joint
line - which may be tender), glide the clavicle anteriorly and posteriorly
Determine the amount of accessory motion and the patients response to this movement
provocation
Shoulder Stability Deficits: Description, Etiology, Stages, and Intervention Strategies
Glenohumeral Instability
Description: This condition is the excessive mobility in the glenohumeral joint in one direction
or more, where the humeral head slips out of the glenoid cavity or the patient feels that it is about
to dislocate.
Etiology: The cause of glenohumeral instability could be due to traumatic or atraumatic (e.g.,
idiopathic glenohumeral ligament laxity or RA) causes that lead to dislocation of shoulder. The
coracohumeral ligament is the primary restraint to inferior translation in adduction. The middle
glenohumeral ligament is the primary restraint to anterior instability at 45o of abduction. The
inferior glenohumeral ligament is the primary restraint to anterior instability from 45-90 o of
abduction and secondary to posterior instability. The superior ligament prevents inferior
dislocation and stabilizes the shoulder during dependent positions. Instabilities are labeled
anterior, posterior, inferior, and superior depending on the direction of laxity. In addition,

dynamic stability is provided by the muscular action of the supraspinatus, infraspinatus,
subscapularis, and deltoid muscles along with the tendon of the longhead of the biceps.
Classification of Glenohumeral Instability is derived from four factors:
1. Frequency (acute, recurrent, chronic)
2. Causes (traumatic, atraumatic including voluntary, repeated micro trauma)
3. Direction (anterior, posterior, inferior, multidirectional)
4. Degree (subluxation, dislocation)

ICF Body Functions code: b7601.3 SEVERE impairment of motor control/coordination
of complex voluntary movements
Patients with a recent ligament injury typically try to support the arm with opposite
extremity and avoid using the injured arm
Active shoulder movements are restricted and painful
Passive and accessory movement testing reveals hypermobility of the glenohumeral
joint
Note: The direction of laxity typically corresponds to the label given to the instability
(e.g., excessive anterior glide corresponds with an anterior instability)
Positive apprehension (Crank) test
Supraspinatus and infraspinatus weakness is common
Palpatory abnormalities may be present (e.g., with an anterior instability the humeral
head may palpable anteriorly and shows a hallow beneath the acromion posteriorly.
Axillary nerve injury is most commonly associated with an anterior shoulder
dislocation leading to altered sensation in an area of the lateral shoulder
Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments)
ICF Body Functions code: b7601.2 MODERATE impairment of motor
control/coordination of complex voluntary movements

Weakness is common to the dynamic stabilizers such as scapular upward rotators
(trapezius, serratus anterior, rhomboids, and levator scapulae), and rotator cuff
musculature (supraspinatus, infraspinatus, teres minor, and subscapularis) with
contractions at end range of movement
Now (when less acute) examine patient for co-existing upper quadrant impairments,
such as upper thoracic and cervical pathologies, disorders of the acromioclavicular
and sternoclavicular joints, muscle flexibility deficits such as tight pectoralis minor,
pectoralis major, and/or serratus anterior and muscle strength deficits especially of the
rotator cuff muscles and scapular upward rotators

ICF Body Functions code: b7601.1 MILD impairment of motor control/coordination of
complex voluntary movements

Shoulder symptoms are reproduced with repeated movements at end range
Acute Stage / Severe Condition:
Goals: Prevent further tissue damage

Re-establish non-painful mid-range mobility and avoid unstable positions with the
involved shoulder
Retard muscle atrophy
Decrease pain and inflammation
Physical Agents
Ice pack or ice massage
Electrical stimulation

Application of a shoulder sling may reduce pain, protect the joint from futher
injury and prevent excessive muscle guarding following a glenohumeral ligament
injury
Pendulum and wand exercises in painfree, mid ranges
Isometric rotator cuff exercises in painfree, mid ranges
Re-injury Prevention Instruction:

Temporarily limit abduction, flexion, lateral rotation and overhead activities or
behind back activities that aggravate patient's symptoms.
Goals: As above
Regain and improve muscular strength and endurance
Regain and improve proprioception and neuromuscular control
Strengthening exercises for the dynamic stabilizers such as rotator cuff and
scapular muscles in order to increase stability with pain free active
movements at mid as well as end ranges
Upper body endurance can improved through use of mid range aerobic exercises
such as rowing machines or upper body ergometers

Taping procedures may be used to 1) assist stabilization, 2) aid proprioception,
and 3) promote scapular alignment
Neuromuscular reeducation
Proprioceptive neuromuscular facilitation (PNF) patterns be used to facilitate
neutral thoracic cage position, scapular posture, and shoulder proprioception
Closed chain shoulder stabilization exercises can be used to facilitate co-
ordination with rest of the shoulder girdle
Promote efficient, pain free, motor control of the trunk, scapulae and arm with
overhead activities
Modify activities to prevent repetitive strains or re-injury
Goals: As above
Increase power (Reaching 90% strength in the injured shoulder)
Progress activity tolerance and endurance
Increase neuromuscular control
Prepare individual for functional activities
Normalize upper quadrant posture, muscle flexibility, and muscle strength
Pain free AROM with increased stability with repeated active movements at end range
Stretching exercises for muscles that may have flexibility deficits, such pectoralis
major, pectoralis minor, and latissimus dorsi
Strengthening exercises as above with using increased resistance
Utilitize muscular endurance exercises to maximize muscle performance of the
relevant trunk, scapulae, shoulder girdle muscles required to perform the
desired occupational or recreational activities
Manual Therapy
Soft tissue mobilization for myofascia that may exhibit flexibility deficits, such
pectoralis major, pectoralis minor, and latissimus dorsi
PNF techniques to increase shoulder control and stability with repeated
movements at the end range

Selected References
Rockwood C., Masten III F., Fredrick A, The Shoulder 2nd ed. WBSaunders:Philadelphia, 1998.
Donatelli R., Physical Therapy of the Shoulder 3ed ed. Churchill Livingston, London. 1997.
Iannotti J, Williams G., Disorders of the Shoulder Diagnosis and Management, Lippincott:
Philadelphia, 1999.
Kessel L., Clinical Disorders of the Shoulder, Churchill Livingston, London. 1982.
Kibler WB, McMullen J, Uhl T: Shoulder rehabilitation strategies, guidelines, and practice.
Orthopedic Clinics of North America 2001;32:527-538.
Rubin BD, Kibler WB: Fundamental principles of shoulder rehabilitation: Conservative to

postoperative management. J Arthroscopic Related Surgery 2002:Suppl 2;18: 29-39.
Burkhead WZ, Rockwood CA: Treatment of instability of the shoulder with an exercise
program. J Bone Joint Surg. 1992; 74-A: 890-896.
Kibler WB: The role of the scapula in athletic shoulder function. Am J Sports Med 1998;26:325-37.
Jobe Fw, Bradley JP: The diagnosis and nonoperative treatment of shoulder injuries in athletes.
Clinics in Sports Medicine 1989 Jul; 8 (3): 419-437.
Dines DM, Levinson M: The conservative management of the unstable shoulder including
rehabilitation. Clinics in Sports Medicine 1995;14:797-814.
Moseley JB, Jobe FW, Pink M, Perry J: EMG analysis of the scapular muscles during a shoulder
rehabilitation program. Am J Sports Med 1992;20:128-134.
NevasierRJ, Nevasier TJ, Nevasier JS: Anterior dislocation of the shoulder and rotator cuff
rupture. Clinical Orthopaedic and Related Research 1993; 291:103-106.
Hovelius L et al.: Recurrences after initial dislocation of the shoulder. J Bone Joint Surg.
1983;65A: 343-348.
Gamulin A, Pizzolato G, Stern R: Anterior shoulder instability: histomorphometric study of the

subscapularis and deltoid muscles. Clinical Orthopaedics 2002;398:121-126.
Tibone JF, Lee TQ, Csintalan RP, Dettling J: Quantitative assessment of glenohumeral
translation. Clinical Orthopaedics 2002;400: 93-97.

Shoulder Stability Deficits: Description, Etiology, Stages, and Intervention Strategies
Acromioclavicular Instability
Description: Disruption of the ligamentous integrity of the acromioclavicular (also called A/C)
joint. The acromioclavicular ligament may be damaged with excessive posteriorly directed
translatory or rotatory force. The coracoclavicular ligaments (conoid and trapezoid) may be
damaged with excessive superiorly or anteriorly directed forces.
Etiology: The cause of this injury is generally a traumatic incident such as a fall directly on the
shoulder with the arm adducted or a fall on an outstretched hand.

ICF Body Functions codes: b7150.3 SEVERE impairments of stability of a single joint
Protective posturing (e.g., cradling the arm and stabilizing it against the body)
Variable elevation of the distal clavicle relative to the acromion
Pain limited active shoulder flexion
Pain with reaching across the body (horizontal abduction)
Weak and painful with resisted shoulder flexion and shoulder abducton
Tenderness to palpation over the acromioclavicular joint
Symptoms reproduced with palpation or provocation of the A/C ligament
Localized swelling around the joint
Positive A/C compression or shear tests

ICF Body Functions codes: b7150.3 MODERATE impairments of stability of a single
joint

Pain with overhead activities
Resisted shoulder flexion and abduction are now strong and painful

ICF Body Functions codes: b7150.3 MILD impairments of stability of a single joint

Resisted tests are now strong and painful only with repeated shoulder flexion and
abduction
Pain with repetitive activities of the shoulder especially at end range
Pain with sustained end ranges stresses to the A/C, such as with prone-on-elbows
positions

Goals: Avoid movements that increase inflammatory reactions

Decrease pain with daily activities
Physical Agents
Ice

Taping may be used to assist in stabilization and to reduce pain
A sling may be used especially if splint immobilization aids pain relief and
limits aggravation of the injury
Type II A/C sprains may benefit from a Kenny- Howard splint
Active or passive shoulder abduction to 90 degrees and external rotation to 30
degrees are initiated at 2 weeks if no internal fixation has been used
Sub-maximal isometric exercises to maintain scapular and glenohumeral strength

Temporarily limit end range ROM stretches, avoid vigorous work, avoid overhead
activities
Goals: Prevent re-injury of the AC joint

Restore full pain-free active and passive range of motion of the shoulder girdle
Restore strength of the muscles around scapula and glenohumeral joint
Progress mobility exercises to regain full pain free range of motion
Progress strengthening exercises (e.g., Rotator cuff strengthening, closed chain
exercises, progressive resistive exercises below 90 degree of flexion)
Manual Therapy
Joint mobilization of glenohumeral joint to prevent restrictions
Goals: As above

Progress activities to tolerance
Intervention for High Performance / High Demand Functioning in Workers and Athletes
Goal: Return to desired occupational or sport activities
Progress exercises focusing on job/sport specific training program based on
individual needs of patient.
Selected References
Fukuda K, Craig KE, Kai-nan AN, Cofield RH Chao EYS. Biomechanical study of the
ligamentous system of the acromioclavicular joint. J Bone Joint Surg. 1986; 68A:434-9.
Urist MR, Complete dislocation of the acromioclavicular joint: the nature of the traumatic lesion and
effective methods of treatment with an analysis of 41 cases. J Bone Joint Surg. 1946;28:813-37.
Donatelli R, Wooden MJ. Orthopedic Physical Therapy. 2nd ed. 1994. Churchill Livingston Inc.
Hulstyn MJ, Fadale PD. Shoulder Injuries in the athlete. Clinical Sports Medicine.
1997;16:663-679.
Dias JJ, Gregg PJ. Acromioclavicular joint injuries in sport. Sports Medicine. 1991;11: 125-32.
Bannister GC, Wallace WA, Stableforth PG, Hutson MA. The management of acute
acromioclavicular dislocation. J Bone Joint Surg. 1989;71B:848-50.
Larsen E, Bierg-Nielsen A, Christensen P. Conservative or surgical treatment of

acromioclavicular dislocation. J Bone Joint Surg. 1986;68(4):552-5.
Lemos MJ. The evaluation and treatment of the injured acromioclavicular joint in athletes. Am J
Sports Medicine. 1998;26:137-44.
Turnbull JR. Acromioclavicular joint disorders. Med Sci Sports Exercise. 1998;30(4
suppl.):526-32.
Shamus JL, Shamus EC. A taping technique for the treatment of acromioclavicular joint sprains:
a case study. J Orthop Sports Phys Ther. 1997;25:390-4.
Kisner C, Colby LA. Therapeutic Exercises Foundations and Techniques. Third Edition. 1996
F.A. Davis Company. Philadelphia, PA.

Shoulder Pain
ICD-9-CM code: 726.19 Subacromial bursitis

d4300 Lifting (Raising up an object in order to move it
from a lower to a higher level, such as when lifting a glass
from the table.)
d4305 Putting down objects (Using hands, arms or other
parts of the body to place an object down on a surface or
place, such as when lowering a container of water to the
ground.)
d4451 Pushing (Using fingers, hands and arms to move
something from oneself, or to move it from place to place,
such as when pushing an animal away.)
d4300 Throwing (Using fingers, hands and arms to lift
something and propel it with some force through the air,
such as when tossing a ball.)
d4550 Crawling (Moving the whole body in a prone
position from one place to another on hands, or hands and
arms, and knees.)
d4551 Climbing (Moving the whole body upwards or
downwards, over surfaces of objects, such as climbing
steps, rocks, ladders of stairs, curbs or other objects.)
Body Structure code: s7201 Joints of shoulder region
Body Functions code: b28016 Pain in joints
Common Historical Findings:

Diffuse shoulder pain
Pain at rest
Recent unaccustomed repetitive use of upper extremity
Pain with all shoulder movements
Symptoms are reproduced/increased with palpation of subacromial bursa
Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency

Subacromial Bursa Palpation/Provocation
Performance Cue:
Slightly extend and internally rotate the humerus to improve access to the bursa
Shoulder Pain: Description, Etiology, Stages, and Intervention Strategies
The below description is consistent with descriptions of clinical patterns associated with
Subacromial Bursitis.
Description: An inflammatory condition of the sub-deltoid bursa which develops due to recent
unaccustomed overuse causing diffuse shoulder pain. A discriminating characteristic of acute
subacromial bursitis is pain/aching at rest, which is aggravated by most all shoulder movements.
Etiology: The subacromial bursa is a synovial-lined sac separating the superior surface of the
supraspinatus tendon from coracoacromial arch and deep surface of deltoid muscle. The floor of
the bursa is the supraspinatus tendon and the roof is the acromium. Inflammation of this bursa is
most commonly the result of repetitive strain, or overuse, injury to other structures like the
rotator cuff. Subacromial bursitis rarely occurs alone and is usually associated with
supraspinatus tendonitis, or tenosynovitis of the rotator cuff, bicipital muscles, or glenohumeral
arthritis. A detailed history is important to distinguish the bursa from a supraspinatus strain or
involvement of other rotator cuff structures.

ICF Body Functions codes: b28016.3 SEVERE pain in joints
Protection of the shoulder and avoidance of use of the injured arm

Unable to flex or abduct the shoulder or reach during overhead activities secondary to
pain
Apprehension with all shoulder movements
Symptoms are reproduced or increased with palpation of the subacromial bursa

Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments)
ICF Body Functions codes: b28016.2 MODERATE pain in joints
Symptoms are provoked at end range of active abduction

Pain with resisted abduction/ flexion of the shoulder
Painful arc of ROM for subacromial bursitis is 70-110 of abduction
Resisted tests may be weak and painful due to the compression of an inflamed
subacromial bursa by a contracting deltoid muscle and involvement of rotator cuff
muscles
Impingement sign may help distinguish between bicipital tendonitis and bursitis.
Lateral subacromial tenderness suggests bursitis or supraspinatus tendonitis, anterior
subacromial tenderness suggests bicipital tendonitis
Arthritis may cause osteophyte/calcium projections into the bursa (calcific bursitis)
Limitations in functional activities include difficulty in sleeping, grooming, dressing,
work and sports activities
Now (when less acute) examine the patient for common coexisting upper quadrant
impairments. For example:
Cervical and upper thoracic segmental movement abnormalities

Limited glenohumeral physiologic and accessory movements
Muscle flexibility deficits especially subscapularis, infraspinatus, pectoralis minor,
pectoralis major, latissimus dorsi, and teres major myofascia
Nerve mobility deficits especially median, radial, and ulnar nerves in the common
thoracic outlet entrapment areas
overhead reaching
Chronic Stage radiographic findings show narrowing of acromiohumeral gap,
superior subluxation of the humeral head, erosive changes at the inferior aspect of the
acromium

ICF Body Functions codes: b28016.1 MILD pain in joints
Pain with repetitive activities of flexion/abduction such as overhead activities

Overpressure, or passively forcing end range shoulder flexion (e.g., impingement
tests) reproduces the patients reported pain complaint
Painfree resisted tests when performed in midrange shoulder positions
Pain only with repeated flexion and abduction contractions

Goal: Painfree at rest
Physical Agents
Phonophoresis/iontophoresis or pulsed ultrasound to assist in reducing
inflammation
(A random, controlled, double blind study suggests there is no evidence to support
ultrasound having an important therapeutic effect over treatment with just ROM
and non-steroidal anti-inflammatory drugs (NSAIDs)
Ice and/or TENS for relief of acute pain as well as to decrease muscle guarding

Pendulum (Codmans) exercises
Painfree passive ROM, active assisted AROM, or AROM exercises once or twice
a day

Temporarily limit flexion, abduction, and, overhead activities
Goal: Painfree with active movements
Progress AROM exercises to painfree tolerance
AROM exercises progress to weighted, supine and sitting shoulder flexion,
abduction and rotation strengthening program
Manual Therapy
Soft tissue mobilization to shortened subscapularis, infraspinatus, pectoralis
minor, pectoralis major, latissimus dorsi, and teres major myofascia
Joint mobilization in an attempt to normalize the accessory mobility or
physiologic motion deficits believed to be associated with the patients
complaints
Neuromuscular reeducation in an attempt to normalize the strength and
coordination deficits believed to be associated with the patients complaints

overhead activities
Modify functional activities to prevent overuse and re-injury
Patient education for prevention strategies
Goal: Painfree with repeated active movements
Attempt to normalize the strength and endurance deficits believed to be associated
with the patients complaints
Maximize muscle performance of the relevant trunk, scapulae, and shoulder girdle
muscles required to perform the desired occupational or recreational activities

Selected References
Bonafede PR, Bennett RM. Shoulder pain: guidelines to diagnosis and management. Postgrad
Med. 1987; 82:185-193
Downing DS, Weinstein A. Ultrasound therapy of subacromial bursitis: a double blind trial. Phys
Ther. 1986;66:194-199
Gorkiewicz R. Ultrasound for subacromial bursitis: a case report. Phys Ther. 1984;64:46-47
Reveille JD. Soft-tissue rheumatism: diagnosis and treatment. Am J Med. 1997;102 (suppl
1A):1A-25S
Salzman KL, Lilligard WA, Butcher JD. Upper extremity bursitis. American Family Physician.
1997;56(7) www.aafp.org
Steinfeld R MD, Rock M MD, Younge D MD, Cofield R MD. Massive subacromial bursitis with
rice bodies: report of three cases, one of which was bilateral. Clin Orthop. 1994;301:185-190

Vol. 2. 3rd ed. (Extremities). Minneapolis MN. Educational Opportunities, 1994.
Wadsworth C. Manual Examination and Treatment of the Spine and Extremities. Philadelphia.
Williams & Wilkins, 1988.

Shoulder and Related Upper Extremity Radiating Pain
ICD-9-CM codes: 723.3 Cervical brachial syndrome

d4301 Carrying in the hands (Taking or transporting an
object from one place to another using the hands, such as
when carrying a drinking glass or a suitcase.)
Body Structure code: s7208 Structure of shoulder region, other specified
s7308 Structure of upper extremity, other specified
Body Functions code: b28014 Pain in upper limb
b2804 Radiating pain in a segment or region

Paresthesias, pain, and numbness in upper extremity
Symptoms aggravated by postures or activities that put stretch on neurovascular bundle
(e.g., reaching tasks, sleeping with arms overhead)
Symptoms reproduced with nerve tension test
Symptoms reproduced with provocation of the peripheral entrapment site (e.g., scalenes,
clavipectoral fascia, pectoralis minor)
Nerve Tension Test

Median Nerve Stretch Test
Performance Cues:
Position patient with shoulder off edge of table and with the trunk and lower extremities
diagonally on the table

Establish baseline level of symptoms and determine the change in symptoms as the
following components are moved toward end range:
Scapular depression
Elbow extension
Humeral external rotation
Forearm supination
Wrist, fingers, thumb extension
Humeral abduction
Attempt to alter symptoms by moving a component two segments proximally or distally
(e.g., alter elbow pain with cervical side bending; alter shoulder pain with wrist
flexion and extension)
Nerve Tension Test

Radial Nerve Stretch Test
Performance Cues:
Components: Scapular depression
Elbow extension
Humeral internal rotation
Forearm pronation
Wrist, finger, thumb flexion
Humeral abduction
Nerve Tension Test

Ulnar Stretch Test

Performance Cues:
Components: Scapular depression
Elbow flexion (to 90 degrees)
Humeral external rotation
Forearm pronation
Wrist, finger extension
Elbow flexion (to available and range)
Humeral abduction
Shoulder and Related Upper Extremity Radiating Pain:

Description, Etiology, Stages, and Intervention Strategies
Thoracic Outlet Syndrome
Description: Thoracic outlet syndrome (TOS) is a complex of signs and symptoms caused by
compression or stretching of the nerves and vessels (portions of the brachial plexus, subclavian
artery, and subclavian vein) to the upper limb where they pass through the interval between the
scalene muscles, over the first rib, and down into the axilla. Patient complains of numbness,
tingling, weakness of hands and arms and pain in the upper chest, back and neck. The location
of paresthesias, pain, numbness, and muscle weakness in the shoulder, arm, and hand depend on
what nerve is vulnerable to compression. The patient with TOS may also report vascular
symptoms such as swelling of the fingers and hands, heaviness of the upper extremities,
clumsiness and coldness of hands, and tiredness, heaviness on elevation of arms. TOS
symptoms are worst with postures and ADLs that stress the neurovascular bundle, such as
combing hair, driving, or carrying bags with strap on sore shoulder. TOS symptoms are also
reproduced with activities such as lifting heavy objects, looking up (neck extension), arm
overstretched or reaching and overhead activities for extended periods of time.
Etiology: The cause of this disorder may be due to tight muscles, ligaments, fibrous bands or
bony abnormalities in the thoracic outlet area. The two common precipitating factors of TOS are
trauma (such as auto accidents that cause whiplash) and excessive strains from repetitive
activities. Other conditions that can lead to TOS are paradoxical breathing patterns, poor
posture, an extra cervical rib from the neck at birth, and tumors (such as upper lobe lung cancer).

ICF Body Functions codes: b28014 SEVERE pain in upper limb
Accentuated upper thoracic kyphosis and forward head posture leading to tightness
around shoulder and neck musculature
Excessive scapular abduction and medial rotation
Weak cervical flexors, upper thoracic extensors, and scapular depressors/retractors
Symptoms are reproduced with upper limb nerve tension testing

Symptoms are reproduced with palpatory provocation of peripheral entrapment site
(e.g., scalene muscles palpation will cause tingling down the arm)
Sensory and motor deficits may be present

ICF Body Functions codes: b28014 MODERATE pain in upper limb
As above, except:
Now (when less acute) examine patient for co-existing upper quadrant impairments such as
cervical pathologies (extra cervical rib), assess scapular, thoracic malalignments and muscle
flexibility and strength deficits For example:
Shortened anterior chest musculature such as pectoralis, serratus anterior

Shortened scalene muscles, and costoclavicular approximation
Tight muscles that are pressed against the nerves causing compression such as
subclavian artery or suprascapular nerve maybe affected.
Paradoxical breathing patterns in which the scalenes and pectorals are used as the
initiators of each breath, rather than assisting the diaphragm and lower intercostals
during a deep inspiration

ICF Body Functions codes: b28014 MILD pain in upper limb
As above, except:
Pain with repetitive activities such as arm elevation, hyperextension of neck or with
overhead activities
Goal: Reduce neurological and vascular symptoms

Limit any activity that aggravates the symptoms e.g., avoid sleeping on stomach
with arms overhead
Manual Therapy
Soft tissue mobilization to restricted myofascia or fascia adjacent to relevant
nerve and vascular entrapment sites e.g., scalene myofascia, clavipectoral
fascia, subclavius myofascia

Joint mobilization to restricted joints adjacent to relevant nerve and vascular
entrapment sites e.g., cervical articulations adjacent to lateral foramina, 1st
rib adjacent to C8 nerve root
Soft tissue mobilization and manual stretching to address shortened musculature
such as pectoralis minor, serratus anterior, scalene, levator scapulae
Painfree, and symptom-free nerve mobility exercises
Goals: As above
Improve strength of weak upper quarter musculature
Stretching exercises for shortened myofascia causing symptoms, such as
pectoralis minor, or anterior scalenes
Strengthening exercises for upper thoracic extensors, scapular adductors and
depressors, and neck flexors
Diaphragmatic and lateral costal breathing exercises to decrease paradoxical
breathing patterns
Facilitate neutral thoracic cage and neutral scapular posture.
overhead activities
Modify activities to prevent re-injury
Teach proper body mechanics and modify work-setting area as required to
prevent symptoms

Goals: As above
Progress activity tolerance
Lessen predisposition to symptoms during active repeated movements

Muscular endurance exercises to maximize muscle performance of the relevant
trunk, scapulae, shoulder girdle muscles required to perform the desired
occupational or recreational activities
Aerobic conditioning exercises such as progressive walking program with
emphasizing correct breathing techniques and posture
As above
Selected References
Colby L, Kisner C. Foundations and Techniques of Therapeutic Exercise, 2nd ed. F. A. Davis
Company, Philadelphia, PA 494-495, 1990
Daskalakis M. Thoracic outlet compression syndrome: current concepts and surgical experience.
Int Surg. 68:337-344, 1983
Donatelli R. Orthopedic Physical Therapy. Churchill Livingstone Inc., Georgia, 1994
Donatelli R. Physical Therapy of the Shoulder, 3rd edition, pp. 153-178. New York: Churchill
Livingstone, 1997
Kelly M, Clark W. Orthopedic Therapy of the Shoulder, pp. 144-148. Philadelphia: J.B.
Lippincott Company, 1995
Kenny R, Traynor G, Withington D, Keegan D. Thoracic outlet syndrome: a useful exercise

treatment option. Am J Surg. Feb 165:282-4, 1993
Lindgren K, Leino E, Hakola M, Hamberg J. Cervical spine rotation and lateral flexion
combined motion in examination of the thoracic outlet. Arch Phys Med Rehabil 71:343-344,
1989
Lindgren K, Leino E, Manninen H. Cervical rotation lateral flexion test in brachialgia. Arch Phys
Med Rehabil 73:735-7, 1992

Lindgren K. Conservative treatment of thoracic outlet syndrome: a 2-year follow up. Arch Phys
Med Rehabil Vol 78, April 1997
Magee D. Orthopedic Physical Assessment. W. B. Saunders Company, Philadelphia, PA. 90-

142, 1992
Novak CB, Mackinnon SE. Thoracic outlet syndrome. Orthopedic Clinics of North America
1996 Oct; 27(4): 747-762
Rockwood C, Matsen F. The Shoulder, 2nd edition, volume 2, pp. 984. Philadelphia: WB
Saunders Company, 1998
Saidoff D, McDonough A. Critical Pathways in Therapeutic Intervention: Extremities and

Spine, pp. 189-202. Mosby, Missouri, 1998

Cervical and Shoulder Examination
Algorithm #1
Suspect 1) Fracture or Loss of Connective Tissue

Integrity Due to Trauma or Disease, and/or 2) Yes Stabilization
Abnormal/Hypermobile Cervical Segmental Mobility Procedures
No
Consultation with Yes Screen for Potentially Serious If Negative Medical Clearance and
Appropriate Non-Musculoskeletal Negative Imaging
Healthcare Provider Pathology
If Negative
Cervical
Examination
Algorithm #2
Emmanuel Yung PT, MA, OCS Skulpan Asavasopon MPT, OCS Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency
Cervical Examination and Intervention
Algorithm #2
Cervical and Upper

Pain During Movement or Thoracic Single Plane Pain Does Not Limit Motion
Pain Limits Motion in Available Active Mobility in Available Ranges and/or
Ranges or Movement Produces Examination Pain at End of Range Does Not
Peripheral Symptoms Produce Peripheral Symptoms
If Positive for Upper

Motor Neuron Cervical Spine Side Produces
Consultation Bending, and/or Vertebrobasilar
Lesions Neurological Vertebro-
Insufficiency Exam
with Other Combined Side Basilar
Healthcare Status Bending/Rotation Insufficiency
Providers Examination Produces Peripheral Symptoms /Extension Signs
Over Pressures
Does Not Produce If Safe to Proceed

Peripheral Symptoms
Mobility Examination of
Upper Quarter Neural Elements If Segmental Instability
Mobility Examination of:
If Negative
Peripheral Nerve Entrapment Sites Upper Thoracic and Cervical Spine

Upper Quarter Neural Elements
If Symptoms
Unresolved If Positive If Negative
Pain Pain Resistance Resistance

Limited Limited Limited Limited
Nerve Cervical Nerve Cervical
Mobility Mobility Mobility Mobility
Nerve Entrapment Cervical Stabilization Mobilization of Upper Mobilization of

Reduction Procedures Procedures Quarter Neural Elements Cervical and Thoracic
Spinal Segments
If Symptoms Resolve to the Point Where Pain Does Not

Limit Motion in Available Range, Return to Single Plane To Algorithm #3
Active Mobility Examination Shoulder Examination
Shoulder Examination and Intervention Algorithm #3a
Active ROM Tests:

1) Elevation
2) 90/90 or Neutral External Rotation
3) Hand Behind Back
Passive ROM Tests:

1) Elevation with Over Pressure
2) Isolated Glenohumeral External Rotation\
3) Isolated Glenohumeral Internal Rotation
Passive Accessory Motion Tests:

1) Posterior Humeral Translation
2) Anterior Humeral Translation
3) Inferior Humeral Translation (sulcus sign)
4) Acromioclavicular Accessory Movements
Resisted Tests:
1) External Rotation
2) Abduction Active Compression
3) Flexion Test
Palpatory Examination of
Suspected Enthesopathy
To Algorithm #3b
First Time Traumatic Algorithm #3b Dislocation
Night Pain
Dislocation Over 40 Years of Age
Weak External Rotators
Age 25 Years Old Shoulder Elevation <90 or Over 65 Years of Age
degrees after 6 weeks
Medical/Surgical Suspect Medical/Surgical

Consultation in Glenohumeral Suspect Consultation in
Addition to PT Capsuloligamentous Addition to PT
Rotator
Intervention Labral Tear Intervention
Cuff Tear
Pain Limits Active and Normal or Excessive Active and Passive Pain with Active Motions Limited Active and Passive
Passive Movements in Range of Motion Pain with Passive Over Pressure Range of Motion
Mid Ranges Painful and/or Excessive Humeral Weak and/or Painful Resisted Tests Limited Humeral Accessory
Accessory Motions
Motions
Positive Active Compression Tests
Pain
continuum Resistance
Limited Impingement
Instability Limited
Shoulder
Shoulder
Mobility
Mobility
Physical Agents and Shoulder Strengthening Shoulder Shoulder Mobilization

Ergonomic Counseling Therapeutic Exercises Strengthening Procedures
If Symptoms Resolve, and Pain No Consultation

Longer Limits Active and Passive Associated Upper Quarter
Impairment Examination with Other
Movements in Mid Ranges, Return to Healthcare
Start of Algorithm #3 Algorithm #4
Providers
If Symptoms Unresolved
Associated Upper Quarter Impairment Examination
Algorithm #4
Shoulder
Physical Shoulder
Stabilization
Agents and Shoulder Mobilization
Procedures and
Ergonomic Strengthening Procedures
Therapeutic
Instructions Exercises Therapeutic
Exercises
Nerve Mobilization of
Entrapment Mobilization of Cervical and
Upper Quarter Cervical
Reduction Thoracic Spinal
Neural Elements Stabilization
Procedures Segments
Procedures
Strength/Motor Control/Endurance Deficits

Deep Neck Flexors Lower Trapezius Middle Trapezius Serratus Anterior
Flexibility Deficits
Levator Scapulae Pectoralis Major Pectoralis Minor
Upper Trapezius Latissimus Dorsi Subscapularis
Suboccipital Myofascia Teres Major Sternocleidomastoid
Postural Deficits
Excessive Capital Extension Protracted Scapulae Excessive Thoracic Kyphosis
Selected References
Aker PD, Gross AR, Goldsmith CH, Peloso P. Conservative management of mechanical neck pain: systematic overview and meta-analysis. BMJ.
1996;313:1291-6.
Antonaci F, Ghirmai S, Bono G, Sandrini G, Nappi G. Cervicogenic headache: evaluation of the original diagnostic criteria. Cephalalgia. 2001;21:573-
83.
Aprill C, Dwyer A, Bogduk N. Cervical zygapophyseal joint pain patterns. II: a clinical evaluation. Spine. 1990;15:458-61.
Aspinall W. Clinical testing for the craniovertebral hypermobility syndrome. J Orthop Sports Phys Ther. 1990;12:47-54.
Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J
Orthop Sports Phys Ther. 2000;30:126-37.
Bigliani LU, Kelkar R, Flatow EL, Pollock RG, Mow VC. Glenohumeral stability. biomechanical properties of passive and active stabilizers. Clin Orthop
Rel Res. 1996;330:13-30.
Bokor DJ, Hawkins RJ, Huckell GH, Angelo RL, Schickendantz MS. Results of nonoperative management of full-thickness tears of the rotator cuff. Clin
Orthop Rel Res. 1993;294:103-10.
Bronfort G, Evans R, Nelson B, Aker PD, Goldsmith CH, Vernon H. A randomized clinical trial of exercise and spinal manipulation for patients with
chronic neck pain. Spine. 2001;26:788-97.
Bulgen DY, Binder AI, Hazleman BL, Dutton J, Roberts S. Frozen shoulder: prospective clinical study with an evaluation of three treatment regimens.
Ann Rheum Dis. 1984;43:353-60.
Burkehead WZ, Rockwood CA. Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg. 1992;74A:890-6.
Calis M, Akgun K, Birtane M, Karacan I, Tuzun F. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis.
2000;59:44-7.
Chesworth BM, MacDermid JC, Roth JH. Movement diagram and "end-feel" reliability when measuring passive lateral rotation of the shoulder in patients
with shoulder pathology. Phys Ther. 1998;78:593-601.
Coderre TJ, Katz J, Vaccarino AL, Melzack R. Contribution of central neuroplasticity to pathological pain: review of clinical and experimental evidence.
Pain. 1993;52:259-85.
Conroy DE, Hayes KW. The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome. J
Orthop Sports Phys Ther. 1998;28:3-14.
Dall'Alba PT, Sterling MM, Treleaven JM, Edwards SL, Jull GA. Cervical range of motion discriminates between asymptomatic persons and those with
whiplash. Spine. 2001;26:2090-4.
Davidson RI, Dunn EJ, Metzmaker JN. The shoulder abduction test in the diagnosis of radicular pain in cervical extradural compressive
monoradiculopathies. Spine. 1981;6:441-6.
Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Therapy. 1999;79:50-65.
Donatelli R, Greenfield B. Rehabilitation of a stiff and painful shoulder: a biomechanical approach. J Orthop Sports Phys Ther. 1987;9:118-26.
Dreyfuss P, Michaelsen M, Fletcher D. Atlanto-occipital and lateral atlanto-axial joint pain patterns. Spine. 1994:1125-31.
Dreyfuss P, Tibiletti C, Dreyer SJ. Thoracic zygapophyseal joint pain patterns. a study in normal volunteers. Spine. 1994;19:807-11.
Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain patterns. I: a study in normal volunteers. Spine. 1990;15:453-7.
Farmer JC, Wisneski RJ. Cervical spine nerve root compression. an analysis of neuroforaminal pressures with varying head and arm positions. Spine.
1994;19:1850-5.
Feinstein B, Langton JNK, Jameson RM, Schiller F. Experiments on pain referred from deep structures. J Bone Joint Surg. 1954;36A:981-97.
Fukui S, Ohseto K, Shiotani M, Ohno K, Karasawa H, Naganuma Y, Yuda Y. Referred pain distribution of the cervical zygapophyseal joints and cervical
dorsal rami. Pain. 1996;68:79-83.
Fukui S, Ohseto K, Shiotani M. Patterns of pain induced by distending the thoracic zygapophyseal joints. Regional Anesthesia. 1997;22:332-6.
Gifford LS, Butler DS. The integration of pain sciences into clinical practice. J Hand Therapy. 1997;10:86-95.
Glousman RE. Instability versus impingement syndrome in the throwing athlete. Orthop Clin North Am. 1993;24:89-99.
Godges JJ, Matson-Bell M, Shah D, Thorpe D. The immediate effects of soft tissue mobilization with PNF on shoulder external rotation and overhead
reach. J Ortho Sports Phys Ther. 2003;33:713-718.
Grad A, Baloh RW. Vertigo of vascular origin. clinical and electronystagmographic features in 84 cases. Arch Neurology. 1989;46:281-4.
Green S, Buchbinder R, Glazier R, Forbes A. Systematic review of randomised controlled trials of interventions for painful shoulder:
selection criteria, outcome assessment, and efficacy. BMJ. 1998;316:354-60.
Haldeman S, Kohlbeck FJ, McGregor M. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma
and spinal manipulation. Spine. 1999;24:785-94.
Hanson JA, Blackmore CC, Mann FA, Wilson AJ. Cervical spine injury: a clinical decision rule to identify high-risk patients for helical CT screening.
AJR. 2000;174:713-7.
Hawkins RJ, Abrams JS. Impingement syndrome in the absence of rotator cuff tear (stages 1 and 2). Orthop Clin North Am. 1987;18:373-82.
Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med.1980;8:151-8.
Heald SL, Riddle DL, Lamb RL. The shoulder pain and disability index: the construct validity and responsiveness of a region-specific disability measure.
Phys Ther. 1997;77:1079-89.
Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with
blunt trauma. National Emergency X-Radiography Utilization Study Group. [erratum appears in N Engl J Med 2001;344:464]. N Engl J Medicine.
2000;343:94-9.
Hoving JL, Gross AR, Gasner D, Kay T, Kennedy C, Hondras MA, Haines T, Bouter LM. A critical appraisal of review articles on the effectiveness of
conservative treatment for neck pain. Spine. 2001;26:196-205.
Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG, Barr JS. Manipulation and mobilization of the cervical spine: a systematic review of the
literature. Spine. 1996;21:1746-60.
Ide M, Ide J, Yamaga M, Takagi K. Symptoms and signs of irritation of the brachial plexus in whiplash injuries. J Bone Joint Surg. 2001;83:226-9.
Johnson EG, Godges JJ, Lohman EB, Stephens JA, Zimmerman GJ. Disability self-assessment and upper quarter muscle balance between female dental
hygienists and non-dental hygienists. J Dent Hyg. 2003;77:217-23.
Jordan A, Bendix T, Nielsen H, Hansen FR, Host D, Winkel A. Intensive training, physiotherapy, or manipulation for patients with chronic neck pain. a
prospective, single-blinded, randomized clinical trial. Spine. 1998;23:311-8
Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A randomized controlled trial of exercise and manipulative
therapy for cervicogenic headache. Spine. 2002;27:1835-43.
Kasch H, Stengaard-Pedersen , Arendt-Nielsen L, Staehelin Jensen T. Headache, neck pain, and neck mobility after acute whiplash injury: a prospective
study. Spine. 2001;26:1246-51.
Katayama Y, Fukaya C, Yamamoto T. Poststroke pain control by chronic motor cortex stimulation: neurological characteristics predicting a favorable
response. J Neurosurgery. 1998;89:585-91.
Keating L, Lubke C, Powell V, Young T, Souvlis T, Jull G. Mid-thoracic tenderness: a comparison of pressure pain threshold between spinal regions, in
asymptomatic subjects. Manual Therapy. 2001;6:34-9.
Kellgren JH. Observation on referred pain arising from muscle. Clin Sci. 1938;3:175-190.
Kellgren JH. On the distribution of pain arising from deep somatic structures with charts of segmental pain areas. Clin Sci. 1939;4:35-46.
Kopell H, Thompson W. Peripheral Entrapment Neuropathies. Florida, Robert I. Krieger Pub. Co., 1976, pp. 146-153,156,167.
Larson E, Bjerg-Nielsen A, Christensen P. Conservative or surgical treatment of acromioclavicular dislocation. J Bone Joint Surg. 1986;68A:552-5.
Levy AS, Lintner S, Kenter K, Speer KP. Intra- and interobserver reproducibility of the shoulder laxity examination. Am J Sports Med. 1999;27:460-3.
Lorei M, Hershman E. Peripheral nerve injuries in athletes. Sports Medicine. 1993;16:130-147.
MacDonald PB, Clark P, Sutherland K. An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. J Shoulder
Elbow Surg. 2000;9:299-301.
Mahadevan S, Mower WR, Hoffman JR, Peeples N, Goldberg W, Sonner R. Interrater reliability of cervical spine injury criteria in patients with blunt
trauma. Ann Emerg Med. 1998;31:197-201.
McFarland EG, Campbell G, McDowell J. Posterior shoulder laxity in asymptomatic athletes. Am J Sports Med. 1996;24:468-71.
McFarland EG, Kim TK, Savino RM. Clinical assessment of three common tests for superior labral anterior-posterior lesions. Am J Sports Med.
2002;30:810-5.
Moseley JB, Jobe FW, Pink M, Perry J, Tibone J. EMG analysis of the scapular muscles during a shoulder rehabilitation program. Am J Sports Med.
1992;20:128-34.
Muhle C, Bischoff L, Weinert D, Lindner V, Falliner A, Maier C, Ahn JM, Heller M, Resnick D. Exacerbated pain in cervical radiculopathy at axial
rotation, flexion, extension, and coupled motions of the cervical spine: evaluation by kinematic magnetic resonance imaging. Investigative Radiology.
1998;33:279-88.
Muhle C, Resnick D, Ahn JM, Sudmeyer M, Heller M. In vivo changes in the neuroforaminal size at flexion-extension and axial rotation of the cervical
spine in healthy persons examined using kinematic magnetic resonance imaging. Spine. 2001;26:E287-93.
O'Brien SJ, Pagnani MJ, Fealy S, McGlynn SR, Wilson JB. The active compression test: a new and effective test for diagnosing labral tears and
acromioclavicular joint abnormality. Am J Sports Med. 1998;26:610-3.
Panjabi MM. The stabilizing system of the spine. Part I. function, dysfunction, adaptation, and enhancement. J Spinal Disorders. 1992;5:383-9.
Panjabi MM. The stabilizing system of the spine. Part II. neutral zone and instability hypothesis. J Spinal Disorders. 1992;5:390-7.
Panjabi MM, Lydon C, Vasavada A, Grob D, Crisco JJ, Dvorak J. On the understanding of clinical instability. Spine. 1994;19:2642-50.
Peeters GG, Verhagen AP, de Bie RA, Oostendorp RA. The efficacy of conservative treatment in patients with whiplash injury: a systematic review of
clinical trials. Spine. 2001;26:E64-73.
Petersen CM, Hayes KW. Construct validity of Cyriax's selective tension examination: association of end-feels with pain at the knee and shoulder. J
Orthop Sports Phys Ther. 2000;30:512-21; discussion 522-7.
Pevny T, Hunter RE, Freeman JR. Primary traumatic anterior shoulder dislocation in patients 40 years of age and older. Arthroscopy. 1998;14:289-94.
Philadelphia Panel. Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for neck pain. Phys Ther.
2001;81:1701-17.
Philadelphia Panel. Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for shoulder pain. Phys Ther.
2001;81:1719-30.
Pho C, Godges JJ. Management of whiplash-associated disorders addressing thoracic spine impairments: a case report. J Ortho Sports Phys Ther.
2004;34:511-523.
Pope DP, Croft PR, Pritchard CM, Macfarlane GJ, Silman AJ. The frequency of restricted range of movement in individuals with self-reported shoulder
pain: results from a population-based survey. British Journal of Rheumatology. 1996;35:1137-41.
Rheault W, Albright B, Byers C. Intertester reliability of the cervical range of motion device. J Orthop Sports Phys Ther. 1992;15:147-150.
Richards RR, An KN, Bigliani LU, Friedman RJ, Gartsman GM, Gristina, AG, Iannotti JP, Mow VC, Sidles JA, Zuckerman JD. A standardized method
for the assessment of shoulder function. J Shoulder and Elbow Surg, 1994;3:347-52.
Riddle DL, Stratford PW. Use of generic versus region-specific functional status measures on patients with cervical spine disorders. Phys Ther.
1998;78:951-63.
Robinson CM, Kelly M, Wakefield AE. Redislocation of the shoulder during the first six weeks after a primary anterior dislocation: risk factors and
results of treatment. J Bone Joint Surg. 2002;84-A:1552-9.
Rowe CR. Recurrent anterior transient subluxation of the shoulder. the "dead arm" syndrome. Orthop Clin North Am. 1988;19:767-72.
Sarhadi NS, Korday SN, Bainbridge LC. Radial tunnel syndrome: diagnosis and management. J Hand Surgery - British Volume.1998;23:617-9.
Schmitt L, Snyder-Mackler L, Role of scapular stabilizers in etiology and treatment of impingement syndrome. J Ortho Sports Phys Ther. 1999;29:31-8.
Schoensee SK. Jensen G. Nicholson G. Gossman M. Katholi C. The effect of mobilization on cervical headaches. J Ortho Sports Phys Ther. 1995;21:184-
96.
Sonnabend DH. Treatment of primary anterior shoulder dislocation in patients older than 40 years of age. conservative versus operative. Clin
Orthopaedics Rel Res. 1994;304:74-7.
Speer KP, Hannafin JA, Altchek D, Warren RF. An evaluation of the shoulder relocation test. Am J Sports Med. 1994;22:177-83.
Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, Zeiss E. Scientific monograph of the Quebec Task Force on Whiplash-
Associated Disorders: redefining "whiplash" and its management.[erratum appears in Spine 1995 Nov 1;20:2372]. Spine. 1995;20(8 Suppl):1S-73S.
Steiner WA, Ryser L, Huber E, Uebelhart D, Aeschlimann A, Stucki G. Use of the ICF model as a clinical problem-solving tool in physical therapy and
rehabilitation medicine. Phys Ther. 2002;82:1098-107.
Sterling M, Jull G, Vicenzino B, Kenardy J. Sensory hypersensitivity occurs soon after whiplash injury and is associated with poor recovery. Pain.
2003;104:509-17.
Sterling M, Jull G, Carlsson Y, Crommert L. Are cervical physical outcome measures influenced by the presence of symptomatology?. Physiotherapy
Research International. 2002;7:113-21.
Tanaka N, Fujimoto Y, An HS, Ikuta Y, Yasuda M. The anatomic relation among the nerve roots, intervertebral foramina, and intervertebral discs of the
cervical spine. Spine. 2000;25:286-91.
Taylor DC, Arciero RA. Pathologic changes associated with shoulder dislocations. arthroscopic and physical examination findings in first-time, traumatic
anterior dislocations. Am J Sports Med. 1997;25:306-11.
Thomas D, Williams RA, Smith DS. The frozen shoulder: a review of manipulative treatment. Rheumat Rehabil. 1980;19:173-9.
Tibone JE, Fechter J, Kao JT. Evaluation of a proprioception pathway in patients with stable and unstable shoulders with somatosensory cortical evoked
potentials. J Shoulder Elbow Surg.1997;6:440-3.
Uitvlugt G, Indenbaum S. Clinical assessment of atlantoaxial instability using the Sharp-Purser test. Arthritis Rheumatism. 1988;31:918-22.
Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet. 1973;2:359-62.
van der Heide B, Allison GT, Zusman M. Pain and muscular responses to a neural tissue provocation test in the upper limb. Manual Therapy. 2001;6:154-
62.
van der Heijden GJ, Van der Windt DA, De Winter AF. Physiotherapy for patients with soft tissue shoulder disorders: a systematic review of randomized
clinical trials. BMJ. 1997;31:25-30.
van der Windt DA, Koes BW, Boeke AJ, Deville W, De Jong BA, Bouter LM. Shoulder disorders in general practice: prognostic indicators of outcome.
British Journal of General Practice. 1996;46:519-23.
van der Windt DA, Koes BW, de Jong BA, Bouter LM. Shoulder disorders in general practice: incidence, patient characteristics, and management. Ann
Rheum Dis. 1995;54:959-64.
van der Windt DA, Koes BW, Deville W, et al. Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in
primary care: randomised trial. BMJ. 1998;317:1292-6.
Vermeulen HM, Oberman WR, Burger BJ, Kok GJ, Rozing PM. End-range mobilization techniques in adhesive capsulitis of the shoulder joint: a
multiple-subject case report. Phys Ther. 2000;80:1204-1213.
Vicenzino B, Neal R, Collins D, Wright A. The displacement, velocity and frequency profile of the frontal plane motion produced by the cervical lateral
glide treatment technique. Clinical Biomechanics. 1999;14:515-21.
Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-
report measures for cervical radiculopathy. Spine. 2003;28:52-62.
Warner JJ, Micheli LJ, Arslanian LE, Kennedy J, Kennedy R. Patterns of flexibility, laxity, and strength in normal shoulders and shoulders with
instability and impingement. Am J Sports Med. 1990;18:366-75.
Warner JJ, Micheli LJ, Arslanian LE, Kennedy J, Kennedy R. Scapulothoracic motion in normal shoulders and shoulders with glenohumeral instability
and impingement syndrome. a study using Moire topographic analysis. Clin Orthop Rel Res. 1992;285:191-9.
Williams JW, Holleman DR, Simel DL. Measuring shoulder function with the Shoulder Pain and Disability Index. J Rheumatology. 1995;22:727-32.
Wrisley DM, Sparto PJ, Whitney SL, Furman JM. Cervicogenic dizziness: a review of diagnosis and treatment. J Ortho Sports Phys Ther.
2000;30:755-66.
Yamaguchi K, Sher JS, Andersen WK, Garretson R, Uribe JW, Hechtman K, Neviaser RJ. Glenohumeral motion in patients with rotator cuff tears: a
comparison of asymptomatic and symptomatic shoulders. J Shoulder Elbow Surg. 2000;9:6-11.
Yoo JU, Zou D, Edwards WT, Bayley J,Yuan HA. Effect of cervical spine motion on the neuroforaminal dimensions of human cervical spine. Spine.
1992;17:1131-6.
Youdas JW, Carey JR, Garrett TR, Reliability of measurements of cervical spine range of motion-comparison of three methods. Phys Ther. 1991;71:98-
106.
SUMMARY OF SHOULDER DIAGNOSTIC CRITERIA AND PT MANAGEMENT STRATEGIES
DISORDER HISTORY PHYSICAL EXAM PT MANAGEMENT

Supraspinatus Tendinitis Post-Lat pain Painful arc Reduce aggravating activities
840.6 onov* = 4 or less Pain w/overhead ADL Weak and painful Supraspinitus MMT Physical agents
mnov** = 12
Midrange catch Post-Lat rotator cuff tenderness (Ice, US)
Sxs worse w/repetitive OH Shoulder girdle muscle flexibility, strength, and Address deficits in shoulder girdle strength,
ADL or strains coordination deficits flexibility, and coordination
Bicipital Tendinitis Ant-Lat pain Painful arc Reduce aggravating activities
726.12 onov = 4 or less Pain w/flexion and lifting Weak and painful Biceps Brachii MMT Physical agents
mnov = 12
ADL Bicipital groove tenderness (Ice, US)
Sxs worse w/repetitive Shoulder girdle muscle flexibility, strength, and Address deficits in shoulder girdle strength,
activities coordination deficits flexibility, and coordination
Subacromial Bursitis Diffuse pain SR w/palpation or provocation of the Rest (i.e. sling)
726.19 onov = 4 or less Pain at rest subacromial bursa Physical agents (Ice, E.Stim.)
mnov = 8
Recent unaccustomed use Patient ed. (Prevent recurrence)
Adhesive Capsulitis Lat pain Glenohumeral ROM deficits ER and ABD are Patient education
726.0 onov = 8 or less Sxs worse w/end range the most limited (Avoid aggravating positions/movements)
mnov = 16
stretch positions Pain at end of range Rx myofascial & joint ROM deficits (STM,
Gradual prog. of stiffness Limited accessory movements JM, MWM, C/R, Ther Ex)
Glenohumeral Instability Recurrent subluxations or Excessive GH accessory motion Patient education
840.2 onov = 4 or less dislocations Apprehension w/passive end range movements (Avoid unstable positions)
mnov = 12
Apprehension Shld girdle & GH strengthening
Acromioclavicular Joint Fall on tip of shld or onto Observable displacement of A/C joint Patient education
Sprain outstretched arm Pain w/accessory movements (Avoid positions of strain)
840.0 onov = 4 or less Pain w/reaching across SR w/palpation or provocation of A/C ligament Normalize ROM and strength deficits of
mnov = 8
body, overhead, or the scapulothoracic, GH and S/C
weight bearing on elbows articulations
Thoracic Outlet Syndrome UE paresthesias, pain, and SR: w/ULTT Reduce entrapment neuropathy with
723.3 onov = 8 or less numbness -- Sxs worse Provocation of peripheral applicable STM, Joint mob, Nerve mob,
mnov = 16
w/postures or ADLs entrapment site ergonomic cues, Ther Ex, Rx of Up
which stress NV bundle muscle flexibility and strength deficits
Myofascial Pain Syndrome Persistent neck & shld SR w/provocation of trigger points Rx trigger points
726.2 onov = 8 or less girdle aching Muscle flexibility and strength imbalances (Inhibit, elongate, prevent)
mnov = 12
Sxs worse w/repeated, Ergonomic deficiencies Rx muscle imbalances
inefficient muscle use Provide ergonomic cuing
onov = optimal number of visits
mnov = maximal number of visits
SR = Symptom reproduction

1
Acromioclavicular Joint Stabilization
Surgical Indications and Considerations:
Anatomical Considerations: The acromioclavicular (AC) joint is a diarthroidal joint formed by

the distal end of the clavicle and the medial facet of the acromion. A capsule consisting of
anterior, posterior, superior, and inferior AC ligaments supports the joint. The posterior and
superior ligaments are the strongest and are invested by the deltotrapezial fascia. The primary
functions of the AC joint are to transmit force from the appendicular skeleton to the axial
skeleton and to suspend the upper extremity. The coracoclavicular ligaments are extra-capsular
and consist of two components: the medial conoid ligament, and the lateral trapezoid ligament.
The AC joint is inherently unstable and relies heavily on these ligaments to maintain its
integrity. So strong are the ligaments of the AC joint and the sternoclavicular (SC) joint, that the
more frequent result of impact to the area is a fractured clavicle as opposed to rupturing of any
ligaments.
Pathogenesis: Injury to the AC joint is typically brought on by a force applied to the acromion
with the arm adducted. A moderate force will injure the AC ligaments, and a more severe force
will tear the coracoclavicular ligaments. A major trauma will involve all ligaments listed above
as well as injury to the deltotrapezial fascia.
Epidemiology: AC injuries are most common among athletes in contact sports, throwing sports,
or people whose occupation requires a lot of overhead activities. Other possible mechanisms
include falls and strength training. Males significantly outnumber females with this type of
injury.
Diagnosis:
Anterior and superior shoulder pain

Visible and palpable deformity at the AC joint
Limitations in strength and range of motion, especially in abduction and flexion
Radiographs to rule out fracture and classify the injury (see below for scale)
MRI may be helpful in distinguishing extent of soft tissue damage
Classification is typically done using the Rockwood classification scale for

acromioclavicular injuries, a scale with six levels of injury classification:
I. Mild injury of the AC ligaments
II. AC ligaments disrupted, coracoclavicular ligaments are intact.
III. AC and coracoclavicular ligaments disrupted.
IV. Ligaments disrupted, posterior displacement of clavicle through trapezius.
V. AC joint dislocation with extreme superior elevation of clavicle.
VI. Clavicle displaced inferior to the acromion and coracoid processes.
Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs Joe Godges DPT, MA, OCS
2
Nonoperative Versus Operative Management: Patients who sustained Grade I or II AC injuries

typically undergo conservative, nonoperative treatment. Most patients would rather deal with
the cosmetic issue of a deformed AC joint than go under general anesthesia and surgery to repair
their injury. Grades IV, V, and VI are all treated surgically for reduction and fixation of the
dislocated AC joint. Grade III injuries are highly controversial regarding course of treatment. In
the past, most Grade III injuries were treated surgically, but multiple recent studies have shown
no benefit to from nonoperative management focusing on immobilization for a period of time
followed by rehabilitation ro regain full strength, range of motion, and functional status. Several
studies concluded that using a good splint, such as the Kenny-Howard splint, to immobilize the
shoulder for several weeks was just as effective as surgical intervention at achieving
restabilization. The number of complications associated with surgery are well documented.
Infection and hardware malfunction were the primary concerns, and hardware has been known to
migrate to the great vessels, heart and lungs.
Surgical Procedure: Surgery typically occurs shortly after injury, one to two weeks at most.
However, for Grade III injuries, sometimes surgery is put off to try nonoperative rehabilitation
first. Several different surgical procedures have been described, including fixation across the
AC joint using Kirschner wire or hook plate, dynamic muscle transfer, coracoclavicular fixation
using Bosworth screw or synthetic augmentation, reconstruction of ligaments, and excision of
the distal clavicle. Lemos prefers to do reconstruction using synthetic loop augmentation. Holes
are drilled in the coracoid and clavicle, and synthetic fiber is used to tie the augmentation piece
between the two.
POSTOPERATIVE REHABILITATION
Note: The following rehabilitation progression is a summary of the guidelines provided by

Lemos. Refer to his publication for further information regarding criteria to progress
from one phase to the next.
Phase I: Weeks 1-6
Goals: Control pain and swelling

Protect the repair
Intervention:
Sling for 4-6 weeks in with the shoulder in adduction and internal rotation
Patient permitted to use arm for activities of daily living
Restrict active elevation or abduction, and pushing, pulling, or carrying over 5 lbs.
3
Phase II: Weeks 6-12
Goal: Regain full active range of motion and strength
Intervention:
Discontinue use of sling

Progressive range of motion exercises
Progressive strengthening regimen
Phase III: Weeks 12-24
Goal: Return to activities at prior level of function
Intervention:
Continue to progress strengthening, incorporating functional activities into treatment plan

Once patient has equal range of motion and strength bilaterally, he/she can return to pre-
injury activities, including contact sports at 24 weeks
Selected References:
Clarke H, McCann P. Acromioclavicular joint injuries. Orthop Clin North Am. 2000;31:177-187.
Deerhake R, Olix M. Stabilization in acromioclavicular disruption. J Sports Med. 1976;3:218-

227.
Lemos M. The evaluation and treatment of the injured acromioclavicular joint in athletes. Am J
Sports Med. 1998;26:137-144.
Neviaser R. Injuries to the clavicle and acromioclavicular joint. Orthop Clin North Am.
1987;18:433-438.
Taft T, Wilson F, Oglesby J. Dislocation of the acromioclavicular joint. J Bone Joint Surg.
1987;69-A:1045-1051.
1
Acromioplasty
Surgical Indications and Considerations
Anatomical Considerations: Any abnormality that disrupts the intricate relationship within the
subacromial space may lead to impingement. Both intrinsic (intratendinous) and extrinsic
(extratendinous) factors have been implicated as etiologies of the impingement process. The
unique anatomy of the shoulder joint sandwiches the soft tissue structures of the subacromial
space (rotator cuff tendons, coracoacromial ligament, long head of biceps, bursa) between the
overlying anterior acromion, acromioclavicular joint, coracoid process, underlying greater
tuberosity of the humeral head and the superior glenoid rim.
Pathogenesis: When subacromial impingement is suspected it is necessary to differentiate

primary from secondary impingement. This is essential for successful treatment. Primary
subacromial impingement is the result of an abnormal mechanical relationship between the
rotator cuff and the coracoacromial arch. Secondary impingement is a clinical phenomenon that
results in relative narrowing of the subacomial space. This often results from glenohumeral or
scapulothoracic joint instability. The loss of the stabilizing function of the rotator cuff also leads
to an abnormal superior translation of the humeral head (decreased depression of the humeral
head during overhead activity and less clearance) and mechanical impingement of the rotator
cuff on the coracoacromial arch. In patients who have scapular instability, impingement results
from improper positioning of the scapula with relation to the humerus. The instability leads to
the insufficient retraction of the scapula, which allows for earlier contact of the coracoacromial
arch on the underlying rotator cuff.
Epidemiology: Patients with primary impingement are usually older than 40 years, complain of
anterior shoulder and lateral upper arm pain, with an inability to sleep on the affected side. They
have complaints of shoulder weakness, and difficulty performing overhead activities. Patients
with secondary impingement are usually younger and often participate in overhead sporting
activities such as baseball, swimming, volleyball, or tennis. They complain of pain and
weakness with overhead motions and may even describe a feeling of the arm going dead.
Diagnosis
History and physical examination are crucial in diagnosing subacromial impingement

syndrome because findings may be subtle and symptoms may overlap with various
differential diagnoses
Physical examination focuses on shoulder and cervical spine. Cervical spine must be
cleared to rule out cervical radiculopathy, degenerative joint disease, and other disorders
of the neck contributing to referred pain in the shoulder.
Primary impingement:
o (+) Hawkins sign
o (+) Neer impingement sign
o Possible associated AC joint arthritis (tenderness to palpation and increased pain
with horizontal adduction)
2
Secondary impingement: look for associated pathology

o GH instability: (+) apprehension and relocation test, load and shift
o Abnormal scapular function: scapular winging, scapular dyskinesia
o Posterior capsule tightness: leads to an obligatory translation of the humeral head
and rotator cuff in an anterior and superior direction, which contributes to
impingement problem.
Radiographs are helpful in demonstrating acromial anatomy types, hypertrophic
coracoacromial ligament spurring, acromioclavicular joint osteoarthritis, and calcific
tendonitis.
MRI can be helpful in revealing relationships in impingement syndrome, especially if
rotator cuff tear and other internal derangement pathologies are suspected.
Nonoperative Versus Operative Management: Nonoperative treatment is very successful and the
comprehensive rehabilitative protocols for primary and secondary impingement syndrome are
similar and follow the postoperative rehabilitation plan for patients who have had a subacromial
decompression with a normal rotator cuff. Initial goals of the rehabilitation process are to obtain
pain relief and regain range of motion. Various modalities, oral medications and corticosteroid
subacromial injections are helpful in the early stages to decrease the inflammatory process
allowing for more successful advances in motion and strengthening. Strengthening exercises
begin by avoiding impingement positions while performing the exercises. The focus is on closed
kinetic chain exercises initially with open chain exercises to follow without aggravating shoulder
discomfort. These exercises help to restore the ability of the rotator cuff to dynamically depress
and stabilize the humeral head, resulting in a gradual relative increase in the subacromial space.
Nonoperative treatment should be considered unsuccessful if the patient shows no improvement
after 3 months of a comprehensive and coordinated medical and rehabilitative program. In
addition, after 6 months of appropriate treatment, most patients have achieved maximal
improvement from the nonoperative treatment program. The success of operative treatment is
determined by the choice of an appropriate operative procedure and the skills of the surgeon. It
is imperative to determine whether the patient has a primary or secondary impingement. For
primary impingement the procedure of choice presently is arthroscopic subacromial
decompression, although comparable long-term results can be obtained with a traditional open
acromioplasty. Arthroscopic subacromial decompression has many advantages including the
ability to evaluate the glenohumeral joint for associated labral, rotator cuff, and biceps
pathology, as well as assessment of the acromioclavicular joint. Second, this technique produces
less postoperative morbidity and is relatively noninvasive, minimizing deltoid muscle fiber
detachment. However, arthroscopic subacromial decompression is a technically demanding
procedure and the surgeon must be very skilled. When glenohumeral joint instability is the
reason for secondary impingement, surgical treatment is a stabilization procedure.
Surgical Procedure: Many different arthroscopic techniques have been described, but one that is
often recommended is the modified technique initially described by Caspari and Thaw. Using
standard posterior portal, the surgeon inserts the arthroscope into the glenohumeral joint and
evaluates for pathology including biceps tendon, labrum and rotator cuff. Any incidental
pathology can be addressed arthroscopically at this time prior to subacromial space arthroscopy
being performed. Starting from the posterior portal and using an aggressive synovial resector
with the inflow in the anterior portal, the surgeon uses the lateral portal to perform a bursectomy
3
and debride the soft tissues of the subacromial space. This is done in a sequential manner,
working from the lateral bursal area to the anterior and medial acromioclavicular regions. After
the subacromial bursectomy and denudement of the undersurface of the acromion, the superior
rotator cuff can be visualized along the acromioclavicular joint and anterior acromial anatomy is
more easily defined. The surgeon must be careful not to disturb the coracoacromial ligament
during the initial bursectomy procedure. Next the surgeon performs sequential acromioplasty
with an acromionizer instrument with the therapeutic goal of a flat type I acromion and removal
of the coracoacromial ligament from its bony attachment. In addition, the acromioclavicular
joint may be assessed at this point and minimal inferior osteophytes may be excised. Lastly,
dependent on preoperative evaluation the surgeon may choose to perform a distal clavicle
excision (usually 1.5-2.0 cm). Surgical outcomes for arthroscopic subacromial decompression,
partial acromioplasties, and distal clavical excisions have been favorable. Most surgical failures
are associated with incomplete bone resection and not addressing acromioclavicular joint
arthropathy.
Note: The following rehabilitation progression is a summary of the guidelines provided by

Phillips and Tippet. Refer to their publication to obtain further information regarding
criteria to progress from one phase to the next, anticipated impairments and functional
limitations, interventions, goals, and rationales.
Postoperative rehabilitation can be divided into three phases:

1. Phase one emphasizes a return of range of motion
2. Phase two stresses regaining muscle strength
3. Phase three stresses endurance and functional progression
Phase I: Return of range of motion: Weeks 0-3
Goals: Days: 1-10

Control normal postoperative inflammation and pain
Prevent infection
Protect healing soft tissues
Minimize effects of immobilization and activity restriction
Days: 11-14
Flexion PROM to 150
External/internal rotation PROM to functional levels
Supine AROM flexion to 120
4
Intervention:
Phase I a & b (first 10 days post op)

Cryotherapy
Grip strengthing exercises
Passive range of motion as indicated
Isometrics (Submaximal to maximal internal and external rotation)
Active range of motion (scapular retraction/protraction)
Joint mobilizations (sternoclavicular and acromioclavicular joints as indicated)
Phase I c (11-21 days post op)

Active range of motion:
o External rotation (at 60-90 abduction)
o Supine flexion, scapular protraction
o Sidelying external rotation
o Prone scapular retraction
Cardiovascular exercise, pool therapy
Return to limited work duties (depending on job tasks)
Phase II: Regaining muscle strength: Weeks 3-8
Goals: Control any residual symptoms of inflammation and pain

Full PROM in all ranges
Symmetric flexion AROM
AROM flexion in standing to shoulder height without substitution
Emphasis on muscle strengthening with continued work on rotator cuff musculature and
scapula stabilizer strengthening
Continue range of motion efforts if limited capsular extensibility detrimentally affects
physiologic motion
Restoration of normal arm strength ratios (involved/uninvolved)
Return to previous levels of activities/sport
Prevention of poor throwing mechanics
Intervention:
Progressive resistance exercises for rotator cuff musculature and scapular stabilizers
Joint mobilizations as indicated
Proprioceptive neuromuscular retraining
Towards end of phase 2 begin progressive throwing program and gentle plyometrics
5
Phase III: Endurance and Functional Progression: Weeks 9-12
Goals: Unrestricted overhead work and sporting activity

Focus on enhancing kinesthesia and joint position sense
Muscular endurance
Performing work-specific and sport-specific tasks
Intervention:
Exercises to improve both passive detection of shoulder movement and active joint
repositioning for enhanced kinethesia and joint positioning sense
Decreased weight with increased repetitions during strengthening exercises of rotator
cuff and scapular stabilizers.
Emphasis on timing of muscle contraction and movement without substitution
(proprioceptive neuromuscular facilitation)
Functional progression program involving a series of sport or work-specific basic
movement patterns graduated according to the difficulty of the skill and the patients
tolerance.
Caspari R: A technique for arthroscopic S.A.D., Arthroscopy. 1992;8:23.
Gartsman GM et al: Arthroscopic subacromial decompression. an anatomical study, Am J Sports

Med. 1988;16:48.
Jobe FW: Impingement problems in the athlete. In Nicholas JA, Hershamann EB, eds. The
Upper Extremity in Sports Medicine. St Louis, Mosby, 1990.
Jobe FW, Jobe CM: Painful athletic injuries of the shoulder. Clin orthop., 1989; 173:117-124.
Paulos LE, Franklin JC: Arthroscopic S.A.D. Development and application: a 5 year experience.
Am J Sports Med. 1990; 18:235.
Phillips P, Tippett S. Acromioplasty. In Maxey L, Magnusson J, eds, Rehabilitation for the

Postsurgical Orthopedic Patient. St. Louis, Mosby, 2001.
Wilk KE, Meister K, Andrews JR: Current concepts in the rehabilitation of the overhead
throwing athlete. Am J Sports Med. 2002; 30:136-151.
Wilk KE: The shoulder. In Malone TR, McPoil T, Nitz AJ, editors: Orthopaedic and sports
physical therapy, ed 3, St Louis, Mosby, 1997.
1
Arthroscopic Shoulder Stabilization and Rehabilitation
Anatomical Considerations: The concave surface of the glenoid is relatively less concave, and
only 1/3 the size of the articulating surface of the much larger, more convex humeral head.
However, the glenoid labrum accounts for the difference in concavity. In conjunction with the
static and dynamic stabilizers of the shoulder, the labrum enables proper articulation to be
possible in the non-pathologic shoulder, making up the difference between concavity/convexity
of the glenoid and humeral head. However, when the stabilizing mechanisms of the joint are not
sufficient, anatomic fit is compromised, causing excessive wear and tear on the joint, often
resulting in pain with activity.
Pathogenesis: While a certain amount of tissue laxity is required for proper articulation, a
breakdown at any level: labral, static and/or dynamic stabilization, can result in
excessive/pathologic laxity, termed instability. Breakdown at any level, static or dynamic, will
place undue stress on the other, and lend itself toward more global effects. Resultant instability
is often symptomatic by shoulder pain/discomfort with motions that cause excessive accessory
joint motion.
Epidemiology: While most common in overhead athletes and swimmers, glenohumeral capsular
instability is not widely common/problematic among the general public. Among those affected,
most are male. 86% male vs. 14% female.
Diagnosis/Indications for Surgery
Recurrent shoulder subluxation/dislocation

Acute traumatic dislocation
Pain or symptom associated with the above conditions.
Nonoperative Versus Operative Management: Conservative management of shoulder instability

consists of strengthening for the dynamic stabilizers of the shoulder in effort to compensate for
laxity in the static stabilizers. Dynamic stabilization of the rotator cuff and scapular stabilizers
can sufficiently achieve glenohumeral stability for everyday activities in most patients. In those
who participate in a high level of overhead activity, however (throwers, swimmers, etc.) surgical
intervention may be required for future return to sport. However, from the physical therapists
perspective, rehabilitation is quite similar for operative vs. nonoperative patients. Furthermore,
there is no urgent need for surgical intervention to be immediate. In fact, most patient cases are
those of chronic instability to begin with. Therefore, conservative management is often tried
first, before resorting to surgical intervention when the instability is not related to rotator cuff or
labral tears.
Surgical Procedure: Among the newest and increasingly more common ways to increase
shoulder stability is thermal-assisted capsular shrinkage. This is a process by which laser or
2
radio-frequency sound waves are used to heat collagen tissues to temperatures above 60C at
which the collagen helix begins to unwind and cause resultant tissue shrinkage. This is a simple,
yet very precise procedure in the sense that if the tissue is heated too rapidly, or too far, the
desired effect is lost and tissue necrosis results instead. Due to the repetitive nature of the
injuries that cause patients to require such a procedure, the majority of them (90%) have other
reparative surgical procedures simultaneously with capsullorhaphy. Most commonly these
include surgical repair and/or debridement of the labrum and/or rotator cuff as well as capsular
suture repair in addition to laser. Even with that being the case, 87% of overhead athletes who
undergo this procedure successfully return to competitive sport.
Preoperative Rehabilitation
None required
May include dynamic stabilization in attempt to manage nonoperatively.
The greatest factor in post-operative rehabilitation is whether the patients shoulder instability is
an acquired condition, or a congenital state of laxity, possibly worsened by lifestyle or activity.
Those born inherently loose are most prone to capsular creep and thus eventual failure of the
procedure, so their rehabilitation must be much more conservative so as to avoid any stretching
to the capsular structures, especially during the critical early stages after surgery when the
collagen is most susceptible to stretch. Patients whose laxity is an acquired condition may be
advanced more quickly. Acquired or congenital instability can be determined by examination of
the uninvolved shoulder.
Other considerations: Individuals prone to scar tissue deposition must be advanced through their
rehabilitation more aggressively to prevent development of excessive capsular scarring and
subsequent loss of range of motion (ie: frozen shoulder). For this reason, tissue end feel should
be re-assessed on a weekly basis for all individuals post-surgery. Stretchy end feels indicate
conservative treatment. Stiffer end feels indicate the need for more aggressive rehabilitation
with stretching to maintain/gain range of motion as required.
Note: The following rehabilitation progression is a synopsis of the guidelines provided by

Wilk, Reinold, Dugas, and Andrews. Refer to their publication for details regarding how
to apply the progression effectively to individual patients.
Phase I for individuals with Acquired Laxity: Weeks 1-6 (Protection Phase)
Goals: Tissue healing

Minimize pain and inflammation
Initiate protected motion
Retard muscular atrophy
3
Weeks 0-2:
Sling use for 14 days
Wrist, elbow, and cervical ROM exercises
Passive and active-assisted shoulder ROM (no aggressive stretching)
Shoulder isometrics and rhythmic stabilization (7 days)
Weeks 3-4:
Begin AROM at week 3, add 1 pound at week 4.
Emphasize strength of ER and scapular stabilization.
Weeks 5-6:
Progress ROM to:
o Elevation to 160o
o ER at 90o ABD (75-80o)
o IR at 90o ABD (60-65o)
Initiate Throwers Ten strengthening program
Phase II for individuals with Acquired Laxity: Weeks 7-12 (Intermediate Phase)
Goals: Restore full ROM (week 8)

Restore functional ROM (weeks 10-11)
Normalize arthrokinematics
Improve dynamic stability, muscular strength
Weeks 7-8:
Progress ROM
o Elevation 180o
o ER 90-100o
o IR 60-65o
May be more aggressive with ROM progression and stretching
May perform joint mobilization
Continue strengthening as above (Throwers Ten, dynamic stab, rhythmic stab)
Initiate plyometrics (2-handed drills)
Weeks 9-12:
Progress ROM to specific athletic demand
o ER 110-115o
Generalized stretching
Strengthening
o Continue as above, with progressive resistance
o Push-ups
o Bench press (do not allow arm below body)
o Single handed plyometric throwing
o Plyoball wall drills
4
Phase III for individuals with Acquired Laxity: Weeks 12-20 (Advanced Activity and
Strengthening Phase)
Goals: Improve strength, power, and endurance

Enhance neuromuscular control
Functional activities
Weeks 12-16:
Continue stretching/strengthening as above
Weeks 16-22
May resume normal training program
Phase IV for individuals with Acquired Laxity: Weeks 26 (Return to Activity Phase)
Goals: Gradual return to unrestricted activities

Maintain static and dynamic stability of shoulder joint
Criteria: Full functional ROM

No pain or tenderness
Satisfactory muscular strength
Satisfactory clinical exam
5
Phase I for individuals with Congenital Instability: Weeks 0-8 (Protection Phase)
Goals: Allow healing of tightened capsule

Begin early protected motion of elbow, wrist and hand
Decrease pain and inflammation
Gradual increase in ROM after week 3
Weeks 0-2
Active abduction after 10 days, but not to exceed 70o
Sleep in slign x 2 weeks
No overhead activity for 12 weeks
Weeks 2-4
Pulley exercises (to 90o)
Isometric strengthening
Rhythmic stabilization
Weeks 4-6
ROM exercises with cane
o Flexion to 125o
o ER to 25o
o IR to 45o
Continue strengthening as above
o Add theratubing at week 5
Gentle mobilization to reestablish normal arthrokinematics
Phase II for individuals with Congenital Instability: Weeks 6-12 (Intermediate Phase)
Goals: Full nonpainful ROM at weeks 10-12

Normalize arthrokinematics
Increase strength
Improve neuromuscular control
Weeks 6-12
Gradually progress to 80% of full ROM
Isotonic dumbbell/tubing program basic rotator cuff and scapular strengthening
program
Neuromuscular control exercises for scapulothoracic joint
Joint mobilization and self-capsular stretching after week 8
6
Phase III for individuals with Congenital Instability: Weeks 12-20 (Dynamic Strengthening
Phase)
Goals: Improve strength, power, and endurance

Improve neuromuscular control
Prepare the athlete to begin to throw
Exercises
Continue strengthening as above
Gradually return to recreational activity
Phase IV for individuals with Congenital Instability: Weeks 20-28 (Return to Activity Phase)
Goals: Progressively increase activities to prepare patient for full functional return
Criteria:
Full range of motion
No pain or tenderness
Isokinetic test that fulfills criteria
Satisfactory clinical exam
Exercises:
Continue strengthening
Emphasize closed kinetic chain
Initiate recreational sport (physician clearance required)
Cole BJ, Romeo AA. Arthroscopic shoulder stabilization with suture anchors: technique,
technology, and pitfalls. Clinical Ortho. 2001;390:17-30.
Hayashi K, Markel MD. Thermal capsulorrhaphy treatment of shoulder instability. Clinical
Ortho. 2001;390:59-72
Nebelung W, Jaeger A, Wiedemann E. Rationales of arthroscopic shoulder stabilization. Arch
Orthop Trauma Surg. 2002;122:472-487.
Reinold MM, Wilk KE, Hooks TR, Dugas JR, Andrews JR. Thermal-assisted capsular
shrinkage of theglenohumeral joint in overhead atheltes: a 15 to 47 month follow-up.
JOSPT. 2003;33:455-467.
Stein DA, Jazrawi L, Bartolozzi AR. Arthroscopic stabilization of anterior shoulder instability:
a review of the literature. Arthroscopy. 2002:912-924.
Wilk KE, Reinold MM, Dugas JF, Andrews JR. Rehabilitation Following Thermal-Assisted
Capsular Shrinkage of the Glenohumeral Joint: Current Concepts. JOSPT. 2002;32:268-
292.
1
Biceps Brachii Tendon Proximal Rupture
Anatomical Considerations: Biceps brachii, one of the dominant muscles of the arm, is involved
in functional activities of the upper limb, both as a result of its size and its orientation about both
the shoulder and elbow joints. At its proximal attachment, the biceps has two distinct tendinous
insertions on the scapula from its long and short heads. The short head arises from the coracoid
process with the coracobrachialis, while the long head originates from the supraglenoid tubercle
and passes over the humeral head within the capsule of the glenohumeral joint. The biceps
muscle then continues down the arm within the intertubercular groove covered by a synovial out
pouching of the joint capsule. The two muscle bellies unite near the midshaft of the humerus
and attach distally on the radial tuberosity. The distal tendon blends with the bicipital
aponeurosis, which affords protection to structures of the cubital fossa, allowing distribution of
forces across the elbow to lessen the pull on the radial tuberosity. The biceps receives
innervation via the musculocutaneous nerve (C5, C6) from the lateral cord of the brachial plexus.
Pathogenesis: The long head of the biceps is at risk of injury and degenerative changes because
of its mechanical function and proximity to the rotator cuff, bicipital groove, and acromion.
Most ruptures occur at the tendinous insertion to the bony anchor, both proximally and distally.
The conditions that are most frequently associated with, and probably contribute to, ruptures of
the long head of the biceps are rotator cuff pathology, spurs of the bicipital groove, and shoulder
instability. Histological studies associated with tendon rupture repeatedly have revealed similar
results. Nontraumatic tendon ruptures, including those of the biceps brachii, show evidence of
advanced degeneration. Changes include hypoxic tendinopathy, mucoid degeneration,
lipomatosis, and calcifying tendinopathy. In both symptomatic and asymptomatic patients with
rupture (not limited to biceps alone), a healthy tendon composition rarely, if ever, has been
encountered. In contrast, nonruptured (control) tendon samples have demonstrated much lower
incidence of degenerative change in large study populations. Although the etiology of
degenerative changes remains unclear, this group of subjects may be heterogeneous with
multiple factors at work. Younger individuals may rupture the biceps tendon following a
traumatic fall, during heavy weightlifting, or during sporting activities (e.g. snowboarding,
football).
Epidemiology: Biceps tendon ruptures are reported in the US with increasing frequency. A
majority of biceps ruptures occur in males aged 40-60 years with a history of shoulder problems.
The dominant arm is involved more commonly, probably related to its greater proportional use
compared with the nondominant side. Ruptures of the long head account for 96% of all biceps
brachii injuries, while distal tendon and short head ruptures account for 3% and 1% respectively.
2
Diagnosis
At the time of long head tendon rupture, patients often feel a pop. This is may be
accompanied by a sudden, sharp pain in the anterior shoulder. Pain may actually
diminish when a complete rupture occurs following chronic impingement and irritation.
Most patients present with unusual bulging of the biceps (Popeye arm) muscle on the
affected extremity.
The bicipital groove may show indentation or hollowing when the tendon is absent
following a rupture.
Positive Ludingtons test: The patient supports the weight of the upper limbs by clasping
both hands on top of the head and contracts and relaxes the biceps muscles of both arms.
A ruptured long head tendon is demonstrated in two ways, 1) the biceps muscle of the
injured extremity will show unusual bulging, and 2) the examiner will be unable to
palpate the tendon on the injured side.
Speeds test: Weakness can be a sign of tendonitis or of tendon rupture.
Radiographs and MRI: Diagnosis can usually be made on the basis of the history and
physical exam, but imaging may help rule out other conditions. The biceps groove may
demonstrate spurring of the groove, indicating chromic inflammation of the bicipital
tendon. A supraspinatus outlet view may show evidence of supraspinatus outlet
impingement syndrome.
Differential diagnosis: Other diagnoses to consider include brachialis tendon rupture,
biceps tendonitis, biceps tendon subluxation, and rotator cuff pathology.
Nonoperative Versus Operative Management: Treatment of biceps tendon ruptures is a topic of

debate. Several reviews of surgical repair versus conservative (nonoperative) management
report conflicting results; neither complete agreement nor general clinical consensus has been
reached. Although no concrete evidence provides unconditional support for one treatment
protocol, the results of these reviews ultimately may lend credence to the longstanding practice
of individualizing treatment to each patients circumstances.
Conservative management is considered appropriate for middle-aged or older patients and for
those who do not require a high degree of supination strength in daily activities. Most studies
have shown no significant deficits in forearm supination or elbow flexor strength in long-term
follow-up of nonoperative management. The number of patients managed conservatively
outweighs the number repaired surgically in most practice settings, and this therapy provides an
effective and highly tolerable means of treatment.
Generally accepted clinical guidelines advocate surgical repair consisting of tenodesis and
subacromial decompression proximally for young or athletic patients or those who require
maximum supination strength. Cosmetic concerns may prompt a surgical approach when
appearance is unacceptable the patient following rupture.
Surgical Procedure: Biceps tenodesis is a surgery to anchor the ruptured end of the biceps
tendon. The best surgical results are achieved when the repair is performed within 3 to 4 weeks
of the injury. A common method, called the keyhole technique, involves anchoring the ruptured
3
end to the upper end of the humerus. The keyhole describes the shape of a small hole made by
the surgeon in the humerus. The end of the tendon is slid into the top of the keyhole and pulled
down to anchor it in place. The surgeon tests the stability of the attachment by bending and
straightening the elbow. When the surgeon is satisfied with the repair, the skin incisions are
closed, and the shoulder is placed in a protective sling.
NONOPERATIVE REHABILITATION
Phase I for Immobilization and Rehabilitation: Weeks 1-4
Goals: Control edema and pain

Minimize deconditioning
Intervention:
Shoulder brace/immobilizer for 4 weeks.

Pendulums
Active-assisted ROM elbow 0-145 degrees with gentle ROM into extension.
Shoulder isometrics for 10-14 days.
Shoulder active-assisted ROM wand external and internal rotation in scapular plane.
Shoulder passive ROM: flexion, external and internal rotation.
Cryotherapy, other modalities as indicated to reduce edema or control pain
Phase II for Immobilization and Rehabilitation: Weeks 5-8
Goals: Control any residual symptoms of edema and pain

Intervention:
In addition to Phase I treatment, add light shoulder PREs.
Phase III for Immobilization and Rehabilitation: Weeks 9-16
Goals: Limit scar tissue adhesions

Full range of motion (ROM)
Improve strength of all shoulder girdle and elbow musculature
Intervention:
Progress to isotonic exercise program including bench press and shoulder press.
4
Phase I Immediate Postoperative phase-Restrictive Motion: Day 1 to Week 6
Goals: Protect the anatomic repair.

Prevent negative effects of immobilization
Promote dynamic stability.
Diminish pain and inflammation.
Intervention:
Week 0-2
Sling for 4 weeks
Sleep in immobilizer for 4 weeks
Elbow and hand ROM
Hand-gripping exercises
Passive and gentle active assisted ROM exercise
o Flexion to 60 degrees (week 2: flexion to 75 degrees).
o Elevation in scapular plane to 60 degrees.
o External and internal rotation with arm in scapular plane.
o External rotation to 10-15 degrees.
o Internal rotation to 45 degrees.
o Note: No active external rotation or extension or abduction.
Sub maximal isometrics for shoulder musculature.
NO isolated biceps contractions
Weeks 3-4
Discontinue use of sling at 4 weeks.
Sleep in immobilizer until week 4.
Continue gentle ROM exercises (passive ROM and active assisted ROM)
o Flexion to 90 degrees
o Abduction to 75-85 degrees
o External rotation in scapular plane to 25-30 degrees.
o Internal rotation in scapular plane to 55-60 degrees.
o Internal rotation in scapular plane to 55-60 degrees.
o Note: Rate of progression based on evaluation of the patient.
No active external rotation, extension, or elevation.
Initiate rhythmic stabilization drills.
Initiate proprioception training.
Tubing external and internal rotation at 0 degrees abduction.
Continue use of cryotherapy
5
Weeks 5-6
Gradually improve ROM.
o Flexion to 145 degrees.
o External rotation at 45 degrees abduction: 45-50 degrees.
o Internal rotation at 45 degrees abduction: 55-60 degrees.
May initiate stretching exercises.
May initiate light ROM at 90 degrees abduction
Continue tubing external and internal rotation (arm at side).
PNF manual resistance.
Initiate active shoulder abduction (without resistance).
Initiate full can exercise (weight of arm).
Initiate prone rowing, prone horizontal abduction.
NO biceps strengthening
Phase II Intermediate phase-Moderate Protection Phase: Weeks 7-9
Goals: Gradually restore full ROM (week 10)

Preserve the integrity of the surgical repair
Restore muscular strength and balance.
Intervention:
Gradually progress ROM

o Flexion to 180 degrees
o External rotation at 90 degrees abduction: 90-95 degrees.
o Internal rotation at 90 degrees abduction: 70-75 degrees.
Continue to progress isotonic strengthening program.
Continue PNF strengthening
Initiate Throwers Ten program.
Weeks 10-12
May initiate slightly more aggressive strengthening.
Progress external rotation to throwers motion
o External rotation at 90 degrees abduction: 110-115 in throwers (week 10-12)
Progress isotonic strengthening exercises.
Continue all stretching exercises. Progress ROM to functional demands (i.e., overhead
athlete).
Continue all strengthening exercises.
Phase III Minimal Protection Phase: Weeks 14-20
Criteria for Progression to Phase III:

Full nonpainful ROM.
6
Satisfactory stability.
Muscular strength (good grade or better).
No pain or tenderness.
Goals: Establish and maintain full ROM

Improve muscular strength, power, and endurance.
Gradually initiate functional activities.
Intervention:
Weeks 14-16
Continue all stretching exercises (capsular stretches).
Maintain throwers motion (especially external rotation).
Continue strengthening exercises.
o Throwers Ten program or fundamental exercises.
o PNF manual resistance.
o Endurance training.
o Initiate light plyometric program.
o Restricted sport activities (light swimming, half golf swings).
Weeks 16-20
Continue all exercises listed above.
Continue all stretching.
Continue Throwers Ten program.
Continue plyometric program.
Initiate interval sport program (e.g., throwing).
Phase IV Advanced Strengthening Phases: Weeks 20-26
Criteria for Progression to Phase IV:

Full nonpainful ROM.
Satisfactory static stability.
Muscular strength 75-80% of contralateral side.
Goals: Enhanced muscular strength, power, and endurance.

Progress functional activities.
Maintain shoulder mobility.
Weeks 20-26
Continue flexibility exercises.
Continue isotonic strengthening program.
PNF manual resistance patterns.
Plyometric strengthening.
7
Progress interval sport programs.
Phase V Return to Activity Phase: Months 6-9
Criteria for Progression to Phase V:
Full functional ROM.

Muscular performance isokinetic (fulfills criteria).
Satisfactory shoulder stability.
Goals: Enhanced muscular strength, power, and endurance.

Progress functional activities.
Maintain shoulder mobility.
Gradual return to sport activities
Maintain strength, mobility, and stability
Exercises
Gradually progress sport activities to unrestrictive participation.

Continue stretching and strengthening program.
Carter AM, Erickson SM. Proximal biceps tendon rupture, primarily an injury of middle age.
Phys Sportsmed. 1999;27:95-101.
Conrad MR, Nelms BA. Empty bicipital groove due to rupture and retraction of the biceps
tendon. J Ultrasound Med. 1990;9:231-233.
Curtis AS, Snyder SJ. Evaluation and treatment of biceps tendon pathology. Orthop Clin North
Am. 1993;24:33-43.
Jobe FW, Schwab DM, Wilk KE. Rehabilitation of the Shoulder. In Brotzman SB, Wilk, KE,
eds., Clinical Orthopaedic Rehabilitation. Philadelphia, Mosby, 2003.
Moorman CT, Silver SG, Potter HG, et al. Proximal rupture of the biceps brachii with slingshot
displacement into the forearm. J Bone Joint Surg Am. 1996;78:1749-1752.
Strauch RJ, Michelson H, Rosenwasser MP. Repair of rupture of the distal tendon of the biceps
brachii: review of the literature and report of three cases treated with a single anterior incision
and suture anchors. Am J Orthop. 1997;26:151-156.
1
Shoulder Capsulolabral Reconstruction
Anatomical Considerations: The function of the shoulder joint is described in terms of static and
dynamic terms. There are several joints that affect the stability and function of the shoulder
joint, such as the acromioclavicular (AC) joint, sternoclavicular (SC) joint, the glenohumeral
(GH) joint and the scapulothoracic (ST) articulation. In regards to the GH joint, the capsule and
labrum are intimately related to the stability of this joint. The labrum deepens the surface of the
glenoid. One-third of the humeral head contacts the glenoid fossa at any given time. There is
negative pressure in the GH joint that allows for optimal functioning. When the labrum is torn it
interrupts this negative pressure seal and diminishes the glenohumeral joint stability. The
capsule and the ligaments, which are thickenings of the capsule, provide static support of the GH
joint. The major ligaments and their functions are the:
Inferior glenohumeral ligament preventing anterior and inferior translations
Middle glenohumeral ligament (attached to the labrum superiorly) resists
external rotation and abduction
Superior glenohumeral ligament (attached to labrum and as well as the long head
of biceps) prevents superior translation
The dynamic support of the GH joint is provided by the rotator cuff muscles. There are nearly
20 muscles that act on the shoulder joint complex. The major dynamic muscles and their
function are as follows:
Supraspinatus and the deltoid assist in abduction
Subscapularis assists in decreasing displacement during external rotation and
abduction
Infraspinatus decreases the anterior translation (along with the long head of the
biceps)
Pathogenesis: The mobility of the shoulder complex occurs at the expense of stability. The
superior/anterior part of the labrum is meniscal in nature and is loosely attached to the glenoid.
If there is mobility of the inferior aspect of the labrum then there is a strong indicator of
pathology. High repetitive forces generate degenerative changes in the capsule, rotator cuff, and
labrum. This leads to abnormal humeral head translation, which leads to rotator cuff pathology.
Many individuals with shoulder instabilities eventually require surgery.
Epidemiology: Capsule and labral tears are frequent in the athletic population. Injuries that
occur to the capsulolabral complex are many times multidirectional. Dislocations and
subluxations are caused by falling on an outstretched arm, sliding into a base head/arm first, or
having the arm jerked or pulled by a dog or during an athletic game. Repetitive motions also
cause injury to the labrum and capsule, (e.g. in baseball and volleyball players). The labral
detachment can occur in any of the above scenarios requiring intervention such as surgery and
rehab. Therefore, capsulolabral reconstruction was developed to restore preinjury level of
function.
2
Diagnosis
Pain with throwing or during activities requiring use of the arm in the overhead throwing
position
Palpatory tenderness anterior over long head biceps, rotator cuff insertions and bony
landmarks of the AC, SC, ST and GH joints
Normal or hypermobile GH internal and external rotation ROM
Load and shift test clunk with axial loading with anterior and posterior shift
Apprehension test with combination of the relocation test
Positive sulcus sign
Rule out cervical spine and elbow conditions mimicking shoulder pathology
MRI can be helpful in demonstrating the presence, location, and severity of the tear(s)
with and without contrast
Nonoperative Versus Operative Management: Instability of the shoulder joint can be very
painful and may continue to cause further complications if surgery is not performed, such as
continued articular cartilage. Surgery can, ideally, repair and reconstruct the pathology. Even
though surgery is warranted the person may have stability but be limited in mobility that could
affect their career if they were a professional athlete, dancer, or muscian. Another challenge is
open versus closed procedures. Open procedures are usually recommended for individuals with
multiple dislocations and possible contact sports such as football and rugby. Arthroscopic
procedures are usually used for the overhead athlete since it traditionally provides stability
without compromising range of motion.
Surgical Procedure: There are over 100 open surgical techniques described in the literature.
They all have their goals of providing capsular tightening, bone block transfer or osteotomies.
The two most common procedures, stated by Donatelli and Jobe et al, are the open Bankhart
reconstruction and the anterior or posterior capsulolabral reconstruction. A Bankhart tear is
located in the front lower part of the labrum and a SLAP tear occurs on the top part of the labrum
Superior Labrum from Anterior to Posterior. The Bankhart lesion specifically refers to an
injury where part of the ligaments and capsule of the shoulder joint are pulled away from the
bone.
Donatelli states that the basic goal of the Bankhart procedure is repairing the capsular-periosteal
separation at the anterior glenoid neck. It attempts to correct the inferior GH ligamentous
complex. Jobe et al states that the goal of the capsulolabral reconstruction is to reduced the
capsular shift by providing a double-thickness affect for the anterior or posterior capsule thus,
providing reinforcement at the site of the previous instability. Sutures and tacs/anchors are done
according to the preference of the surgeon. During the capsular shift procedure in conjunction
with the Bankhart procedure, it is important that the surgeon considers the placement of the
sutures and the position of the flaps for reasons to protect the labrum as stated by Jobe et al.
Before closing the site, passive motion must be performed to ensure at least 90 of abduction and
45 of external rotation. This capsular tightness observed will determine the safe zone for
postoperative splinting and rehabilitation guidelines.
3
Preoperative Rehabilitation (for 6 months)
Rest (no throwing activities, etc.)

Nonsteroidal anti-inflammatory medications
Three steroid injections
Strengthening program for rotator cuff muscles and scapular muscles (trapezius,
rhomboids, and serratus anterior)
Note: The following rehabilitation progression is a summary of the guidelines provided Jobe,
Giangarra, Kvitne and Glousman. As with all protocols your surgeon may have one that
is specific to his or her surgical technique.
Phase I for Controlled Mobilization and Rehabilitation: Day one -2 weeks
Goals: Control edema and pain

Maintain range of motion
Protect repair (mainly by controlling excessive motion)
Intervention:
Postoperative orthosis in a position of 90 of abduction, 45 external rotation and 30 of

forward flexion.
NMES and ice
Strengthening exercises to include elbow flexion and extension, isometric abduction,
active-assisted horizontal adduction and abduction
Passive range of motion of abduction, flexion and external rotation
NOTE: perform abduction and external rotation in the scapular plane with no forced
motion (protect anterior capsule)
NOTE: If a posterior repair occurred then perform no posterior glides, internal rotation
and horizontal adductions will be limited initially
Phase II Rehabilitation: Weeks 2-6
Goals: Control any residual symptoms of edema and pain

Continue to protect repair
Improve strength
Improve range of motion
4
Intervention:
Discontinue orthosis instead use abduction brace/pillow at about 20 abduction as

needed
Actively abduct from neutral to beyond 90
Strengthening continued and progressed to add shoulder shrugs, and shoulder external
rotation
May use home over the door pulley or pool therapy for gentle range of motion
Phase III for Rehabilitation: 6 weeks - 5 months
Goals: Improve strength of GH and ST muscles

Full active range of motion
Begin synchronization of motor control
Intervention:
Strengthening of the rotator cuff muscles, shoulder flexion, horizontal adduction

beginning at 6-8 weeks post-op
By week 9 add strengthening regimen for scapular rotators, biceps, coracobrachialis,
pectoralis, and deltoid muscles (should be continued for minimum of 1 year)
Upper extremity ergometer low resistance
Progress to total body conditioning
Phase IV for Rehabilitation: 6-9 months
Goals: Return to sport activity

Improving endurance of the sport specific musculature
Re-established coordinated/synchrony of motion
Intervention:
Isokinetic testing okay, progression of total body conditioning program

Progress sport specific activities, such as throwing
By 9th month patients should be performing sport specific activity 30 minutes each day
5
Donatelli RA. Instabilities. In Physical Therapy of the Shoulder. New York, Churchill
Livingstone, 1997.
Ferretti A, De Carli A, Calderaro M, Conteduca F. Open capsulorrhaphy with suture anchors for
recurrent anterior dislocation of the shoulder. Am J Sports Med. 1998;26: 625-629
Jobe FW, Giangarra CE, Kvitne RS, Glousman RE. Anterior capsulolabral reconstruction of the
shoulder in athletes in overhand sports. Am J Sports Med. 1991;19:428-434.
Magarey ME, Jones MA, Grant ER. Biomedical considerations and clinical patterns related to
disorders of the glenoid labrum in the predominantly stable glenohumeral joint. Manual
Therapy. 1996;1:242-249
Ticker JB, Warner JJ. Selective capsular shift technique for anterior and anterior-inferior
glenohumeral instability. Clinics in Sports Medicine. 2000;19:1-17.
1
Proximal Humeral Fracture Repair and Rehabilitation
Anatomical Considerations: Numerous types of proximal humeral fractures can occur each of
which have separate surgical indications and considerations. Proximal humeral fractures
commonly occur along the physeal lines. Thus, fractures may involve the tubercles (greater
and/or lesser), surgical neck, or anatomical neck of the humerus. The surgical neck lies between
the tuberosities and the shaft while the anatomical neck is the junction between the humeral head
and the tuberosities. Fortunately, surgical neck fractures are more common. Anatomical neck
fractures typically have a less favorable prognosis due to their result in devascularization of the
humeral head. Between the two tuberosities of humerus lies a groove in which the biceps tendon
lies. It is through this groove that the terminal branches of the ascending division of the anterior
humeral circumflex artery enter the humeral head. Fractures that split the tuberosities from the
head disrupt this small arterial complex and can result in osteonecrosis of the humeral head.
The most recognized and used standard for assessing proximal fractures is the 4-part Neer
classification system. It is used for both treatment and prognosis.
The 4-part classification:
One-part fractures
Eight of ten proximal humeral fractures are of this type and include all fractures of the proximal
humerus, regardless of the level or number of fracture lines, in which no segment is displaced
more than 1cm or angulated more than 45.
Two-part fractures
The two-part fracture includes those proximal humeral fractures with a single displacement at
the anatomic neck, surgical neck, lesser tuberosity, or greater tuberosity. The fracture is named
by the structure that is displaced (Two-part surgical neck fracture).
Three-part fractures
The three-part fracture includes all proximal humeral fractures with a displaced surgical neck
and either a greater or lesser tuberosity displacement fracture.
Four-part fractures
Four-part fractures are proximal humeral fractures with three displaced, fractured segments
including both tuberosities and typically the surgical neck. Avascular necrosis is common in
these types of fractures.
The anatomical positioning of the neural and vascular structures of the arm can cause
complications in these types of fractures. Severe displacement of the structures of the shoulder
with these types of injury can cause damage to the brachial plexus (most commonly a traction
injury of the axillary nerve) or vascular structures (commonly effecting the axillary artery).
Avascular necrosis is also a complication causing bone cell death when the blood supply is cut
off from a fractured region of bone as mentioned above.
2
Pathogenesis: Bone fractures when the mechanical forces exceed the physiologic capacity of the
bone. Intrinsic weakening of bone increases the risk of such pathology. Weakening of proximal
humeral bone tissue may occur due to repetitive stress (as occurs in little leaguers shoulder and
stress fractures), endocrine functioning (as is the case in osteoporosis), pathology (such as sickle
cell anemia, tumors, or cancer), or nutritional deficits (as found in cases of Rickets and
osteomalacia). External forces commonly leading to proximal humerus fractures include a fall
on the outstretched arm, excessive rotation in the abducted position, a direct blow to the lateral
aspect of the shoulder, dislocation leading to subsequent avulsion fracture(s), electrical shock,
and muscular forces of seizures (subscapularis can avulse the lesser tuberosity).
Biomechanically with a fall on the outstretched arm, the most common cause of proximal
humeral fractures, the shoulder and limb remain medially rotated. Normally, to accomplish full
abduction, the humerus must externally rotate. If external rotation is blocked, as in a fall, the
proximal humerus becomes impinged against the acromion. The acromion acts as a fulcrum of a
lever and the depending on the quality of the tissues of the shoulder complex the humerus may
fracture, dislocate, or both dislocate and fracture.
Epidemiology: Proximal humeral fractures are relatively common. They represent about 4% of
all fractures seen in the average orthopedic clinic. These fractures occur in all ages but are most
common in relatively fit elderly. The injury is more common in females and the highest age-
specific incidence occurs in women between 80 and 89 years of age. Not surprisingly these
injuries are more commonly caused by sport and road traffic accidents in younger generations,
while over the age of 30 the chief cause of proximal humeral fractures is a standing height fall.
~49% of proximal humeral fractures are part-one, ~28% are part-two surgical neck fractures,
~9% are three-part greater tuberosity and surgical neck fractures. Four-part fractures and fracture
dislocations account for ~3% of proximal humeral fractures.
Diagnosis
Mechanism of injury is usually consistent with a fall on an out stretched arm or blow to
the shoulder during a traumatic or sports related event
Severe point tenderness over the fracture site can be found with palpation, caution should
be used to prevent further damage at the fracture site
Swelling usually appears immediately about the shoulder and upper arm while
ecchymosis generally appears 24-48 hrs later. Ecchymosis may spread to the chest wall,
flank, and forearm.
Confirmation of the fracture can be made with radiographic images.
CT scan is indicated in selected cases.
Non-operative Versus Operative Management: Treatment of proximal humeral fractures vary

depending on the type and severity of the fracture as well as the activity level, health, age,
quality of bone, and motivation of the patient. Generally, most unstable/displaced fractures or
fractures with accompanying vascular insult require surgical intervention. Various methods of
treatment include closed reduction, casts, splints, percutaneous pinning, external fixation, open
reduction and internal fixation, and humeral head replacement.
3
Non-operative:
Non-displaced or minimally displaced fractures as well as patients with medical illnesses that
preclude them from surgery should be treated conservatively. They can be managed non-
surgically, by immobilizing the arm in a sling for comfort and instituting early range of motion
exercises when pain permits. See protocol for treatment below.
Operative:
Isolated two-part fractures of the tuberosities are difficult to perform closed reduction on
secondary to the forces created by the attached rotator cuff muscles. The greater tuberosity
fracture is treated nonoperatively for fractures with less than .5 cm of superior displacement or
1cm of posterior displacement. If greater, these fractures are generally treated with open
reduction internal fixation to prevent subacromial impingement and malunions. The rare isolated
lesser trochanteric fracture is treated with open reduction internal fixation when the fragment is
large and blocks medical rotation.
Two-Part Surgical Neck Fractures are generally treated with open reduction internal fixation for
younger patients with good bone quality and ability to comply with postoperative therapy. Rigid
internal fixation devices often fail when applied to thin porous bone so hemiarthroplasty is often
a better treatment choice for elderly patients. Percutaneous internal fixation is often chosen for
displaced two-part fractures that can be reduced with closed manipulation. Intramedullary
fixation has been completed successfully by some but concern of torsional rigidity, risk of
displacement, and impingement by a prominent rod deters many from this technique.
Three part fractures also have multiple treatment choices including internal fixation options of
interfragmentary fixation with sutures or wire, percutaneous pinning, plate-and-screw fixation,
and intramedullary fixation with and without suture supplementation. Reduction can be
completed closed but are difficult to manage. Open reduction is the more common management.
Rarely, prosthetic hemi-arthroplasty is used.
Four-part fracture treatment options range from early mobilization to percutaneous reduction and
internal fixation, open reduction and internal fixation, and hemiarthroplasty. Nonoperative
treatment is typically reserved for those in which surgery is contraindicated secondary to the fact
that this treatment often results in malunion and pain. There is conflicting evidence recorded on
the most effective treatment for this injury.
4
NONOPERATIVE AND POSTOPERATIVE REHABILITATION
Note: The following rehabilitation progression is a summary of the guidelines provided by Basti,
Dionysian, Sherman, and Bigliani. Refer to their publication to obtain further information
regarding criteria to progress from one phase to the next, anticipated impairments and functional
limitations, interventions, goals, and rationales.
REHABILITATION FOR NON-OPERATIVE HUMERAL FRACTURES
Early Passive Motion: (7-10 days post fracture)
Goals: Control pain and edema

Protect fracture site
Maintain range in joints around the effected region (wrist, hand, and neck)
Prevent glenohumeral adhesive capsulitis and muscle flexibility deficits
Intervention:
Modalities, such as TENS and ice, for pain control

Splint/Sling as direct by MD
Monitor use and weight bearing instructions per MD
Cardiovascular conditioning
Gentle range of motion exercises of the neck, wrist, and hand
Pendulum exercises
Passive forward elevation of the shoulder
Passive external rotation of the shoulder
Early Passive Motion: (10 days to 3 weeks post fracture) When pain has diminished and the
patient is less apprehensive.
Goals: Same as above
Intervention: in addition to above

Active assistive forward elevation
Active assistive external rotation to 40
Phase I: (3-6 weeks post fracture)
Goals: Continue to control pain and edema as needed

Regain full range of motion
Prevent muscle atrophy
5
Intervention:
Pendulum
Active assistive forward elevation
Active assistive external rotation
Isometrics: Internal and external rotation, flexion, extension, and abduction in a neutral
position (at 4 weeks)
Active assistive hyper extension (at 6 weeks)
Gripping exercises
Phase II: (6-8 weeks post fracture)
Goals: Regain full Range of motion

Actively work within newly gained range of motion
Increase strength
Intervention:
Active forward elevation in supine

Active forward elevation with weights in supine
Forward elevation in standing with stick
Pulleys with eccentric lowering of involved arm
Phase III: (8 weeks post fracture)
Goals: Increase strength (especially at end range)

Gain adequate strength in the rotator cuff to allow for humeral head depression necessary
to avoid impingement
Strengthen scapular rotators to allow for proper scapulohumeral rhythm
Intervention:
Resistive exercises: standing forward press, theraband resisted (flexion, internal rotation,
external rotation and abduction) exercises, and rowing
Self stretching: flexion/abduction combined, internal rotation, flexion, abduction/external
rotation combined, bilateral hanging stretches
Advanced internal rotation, shoulder flexion, external rotation and horizontal abduction
stretching
6
REHABILITATION FOR OPEN REDUCTION/INTERNAL FIXATION

AND HUMERAL HEAD REPLACEMENT
Preoperative Rehabilitation
Injury is protected with immobilization through casting, splinting and/or placed in a sling
Patient is instructed of post-operative rehabilitation goals and plan
Early Passive Motion: (3-5 days post op)
Goals: Control pain and edema

Protect fracture site
Minimize cardiovascular deconditioning
Maintain range in joints around the effected region (wrist, hand, and neck)
Prevent glenohumeral adhesive capsulitis and muscle flexibility deficies
Intervention:
Modalities, such as TENS and ice, for pain control

Splint/Sling as direct by MD
Monitor use and weight bearing instructions per MD
Gentle range of motion exercises of the neck, wrist, and hand
Passive supine external rotation to 40
Passive supine forward elevation
Phase Ia: (7-10 days post op) and Phase Ib: (3 weeks post op)
Goals: Continue to control pain and edema as needed

Regain full range of motion
Prevent muscle atrophy
Intervention: Phase Ia
Pendulum
Passive external rotation with stick or pulleys
Passive forward elevation with assist from non involved arm or pulleys
Passive internal rotation and hyperextension with stick (not to be done with tuberosity
fracture)
7
Interventions: Phase Ib
Isometrics: Internal rotation, external rotation, flexion, extension, abduction in a neutral

position
Phase II: (4-6 weeks post op)
Goals: Regain full Range of motion

Actively work within newly gained range of motion
Increase strength
Intervention:
Active forward elevation in supine

Active forward elevation with weights in supine
Forward elevation in standing with stick
Pulleys with eccentric lowering of involved arm
Phase III: (12 weeks post op)
Goals: Increase strength (especially at end range)

Gain adequate strength in the rotator cuff to allow for humeral head depression necessary
to avoid impingement
Strengthen scapular rotators to allow for proper scapulohumeral rhythm
Intervention:
Resistive exercises: Standing forward press, theraband resisted (flexion, internal

rotation,
external rotation and abduction) exercises, and rowing
Self stretching: flexion/abduction combined, internal rotation, flexion, abduction/external
rotation
combined, bilateral hanging stretches
Advanced internal rotation, shoulder flexion, external rotation and horizontal abduction
stretching
8
Basti JJ, Dionysian E, Sherman PW, Bigliani LU. Management of proximal humeral fractures. J
Hand Ther. 1994;7:111-21.
Cornell N, Schneider K. Proximal Humerus. In Koval K, Zuckerman J, eds., Fractures in the

Elderly. Philadelphia, Lippincott-Raven 1998.
Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures.
Acta Orthop Scand. 2001;72:365-371.
Curwin S. Shoulder Injuries. In Zachazewski JE, Magee DJ, Quillen WS, eds. Athletic Injuries
and Rehabilitation. Philadelphia, 1996, WB Saunders.
Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD. Functional outcome after
humeral head replacement for acute three- and four-part proximal humeral fractures. J Shoulder
Elbow Surg. 1995;4:81-86.
Green A, Izzi J. Isolated fractures of the greater tuberosity of the proximal humerus. J Shoulder
Elbow Surg. 2003;12:641-649.
Iannotti JP, Ramsey ML, Williams GR, Warner JP. Nonprosthetic management of proximal
humeral fractures. J Bone Joint Surgery. 2003;8:1578-1593.
Neer CS. Four-segment classification of proximal humeral fractures: purpose and reliable use. J
Shoulder Elbow Surg. 2002;11:389-400.
Visser C, et al. Nerve lesions in proximal humeral fractures. J Shoulder Elbow Surg.
2001;10:421-427.
Zyto K, Wallace WA, Frostick SP, Preston BJ. Outcome after hemiarthroplasy for three-and
four-part fractures of the proximal humerus. J Shoulder Elbow Surg. 1998;7:85-89.
1
Repair of SLAP lesion
Anatomical Considerations: The rotator cuff is predisposed to tearing secondary to senescence

of the tendon with age, including apoptosis of fibroblasts, loss of cellular activity,
disorganization of the collagen, and decreased extracellular matrix synthesis. Furthermore the
tearing of the rotator cuff can occur because of decreased vascularity within the shoulder,
specifically, a centimeter of its insertion on the proximal humerus.
Pathogenesis: A SLAP lesion is a lesion of the Superior aspect of the glenoid Labrum that
extends Anteriorly and Posteriorly to the biceps insertion. There are four variations that include:
1) Type I, where the labrum is attached to the glenoid rim but fraying occurs at the leading edge
of the labrum. 2) Type II lesion, where the superior labrum or biceps insertion is detached from
the glenoid. 3) Type III, where the lesion is similar to Type II, but includes a bucket handle tear
of the labrum. 4) Type IV has a longitudinal split in the biceps tendon. SLAP lesions are also
common in patients with full-thickness rotator cuff tears or glenohumeral instability and
shoulder pain. A variety of mechanisms can cause a SLAP lesion, including a fall on an
outstretched arm, shoulder instability, and overhead work.
Epidemiology: The incidence and etiology of SLAP lesions is uncertain. Research has indicated
that pathologic shoulders that have been arthroscopically examined have revealed 6%-12% of
those had SLAP lesions. The most common causes of SLAP lesions include falling on an
outstretched arm, traction on the biceps tendon, and overhead athletic activity. Type I lesions
are common in older patients, greater than forty years old, and usually associated with rotator
cuff disease. Type II lesions are common in younger individuals, usually throwing athletes
secondary to biceps insertion twisting as the arm is brought into abduction and external rotation
causing a peeling back of the superior labrum. Approximately 81% of SLAP lesions in throwers
are Type II. Type III and IV lesions are fairly rare and are associated with traumatic instability.
Diagnosis:
Patient may complain of pain that is sharp, severe, and localized being deep within the joint
Symptoms may include intermittent catching or locking to the shoulder during overhead
sports or activities of daily living
Production of pain when the examiner applies compression to the abducted shoulder with
added rotation. Also pain with the internally rotated arm in adduction and having patient
resist a downward force.
Positive for these special tests: Speed test, apprehension test, active compression test,
Hawkins impingement test, OBrian test
MRI with contrast material
Common with full-thickness rotator cuff tears or glenohumeral instability.
Arthroscopic visualization is the standard for diagnosis
2
Nonoperative Versus Operative Management: Treatment for a patient with a suspected

symptomatic SLAP lesion is initially nonoperative. For example, athletes involved with
overhead sports with symptoms of a SLAP lesion often have symptoms of a rotator cuff
pathology. The treatment consists of rest, rehabilitation, pain relief, and graduated return to a
sport or activity. With throwing athletes being able to return to play, they must have full pre-
injury full range of motion and be able to perform pain free. Recurrent episodes of pain that
prevent full recovery may be an indication for surgery.
Surgical Procedure:
Type I lesions: The minor fraying at the free edge of the labrum is considered an
abnormality and do not perform any debridement.
Type II lesions: An anterosuperior portal is created. A spinal needle is inserted at the
anterolateral acromial corner and enter the joint lateral to the biceps tendon. Then a burr is
used to abrade the glenoid beneath the detached superior labrum to expose cancellous bone
anterior to posterior margins of the superior labrum detachment. Holes are drilled for suture
anchors. Then nylon sutures are used to suture the labrum.
Type III lesions: If the bucket handle is less than one third the width of the labrum, then it is
excised, and repair to the major portion to the superior labrum to the glenoid is performed as
that of type II. If the bucket handle is one third of more the width of the labrum, then the
detached portion is repaired with sutures.
Type IV lesions: If the longitudinal tear in the biceps tendon is less than one third the
diameter of the tendon, then the torn fragment is excised. If the fragment is one third or
more the diameter of the tendon, then the torn fragment is repaired to the major portion of the
bicep tendon. The superior labrum is repaired first as described in the Type II repair.
Usually one or two sutures are sufficient to repair the torn fragment to the major portion of
the biceps tendon.
Phase I for Immobilization and Rehabilitation: Weeks 1-3
Goals: Increasing passive shoulder range of motion

Control inflammation
Control pain/effusion
Intervention:
Shoulder immobilized immediately post-op in sling that is to be worn at all time except while
exercising or bathing for 4 weeks.
2 weeks after surgery, passive range of motion is allowed in all planes except external
rotation and abduction
No shoulder rotation above 60 of glenohumeral abduction until week 3
Modalities to reduce inflammation, pain, and edema
3
Phase II for Mobilization and Rehabilitation: Weeks 3-6
Goals: Progressive passive range of motion

Increase scapulothoracic motor control
Incorporate involved extremity with ADLs
Pain control
Intervention:
Week 4, sling is no longer needed

Progressive passive range of motion is started, with emphasis placed on posterior capsule
stretching and internal rotation.
Begin passive and manual scapulothoracic mobility program
Begin external rotation in abduction
Allow use of operative extremity for light activities of daily living
Modalities
Phase III for Immobilization and Rehabilitation: Weeks 6-12 to 7 months
Goals: Increase shoulder active and passive range of motion

Increase scapular stabilizers strength
Increase rotator cuff strength
Increase trunk stability
Intervention:
At 6 weeks after surgery, external rotation and abduction is allowed with continued
stretching
Progressive strengthening program for the deltoid, rotator cuff, scapular stabilizers, biceps,
triceps, and trunk stability
3 months after surgery - Patients engaged in sports that use upper extremities, such as
swimming and golf, are allowed
4 months after surgery, throwing athletes can return, beginning with low-velocity, short
distance, throwing on level ground with emphasis on proper throwing mechanics. Continue
stretching and strengthening regimen, with emphasis on posterior capsular stretching
Distance and velocity are gradually increased until 7 months with continuation of progressive
strengthening and posterior capsular stretching
4
Kim K, Queale W, Cosgariea A, McFarland E. Clinical features of the different types of SLAP
lesions. J Bone and Joint Surgery. 2003; 85:66-71.
Burkhart S, Morgan C. SLAP lesion in the overhead athlete. Orthopedic Clinics of North
America. 2001;32:1-10.
Conway J. Arthoscopid repair of partial-thickness rotator cuff tears and SLAP lesions in
professional baseball players. Orthopedic Clinics of North America. 2001;32(3).
Park H, Lin S, Yokota A, McFarland E. Return to play for rotator cuff injuries and superior
labrum anterior posterior (SLAP) lesions. Clinics in Sports Med. 2004; 23(3).
Garsman G., Hammerman S. Superior labrum, anterior and posterior lesions when and how to
treat them. Clinics in Sports Med. 2000;19(1).
1
Rotator Cuff Repair and Rehabilitation
Anatomical Considerations: The rotator cuff complex is comprised of four tendons from four
muscles: supraspinatus, infraspinatus, teres minor, and subscapularis, all originating from the
scapula and attaching to the tuberosities of the humerus. The supraspinatus tendon lies
superiorly along the scapula and under the coracoacromial arch of the scapula and has a
hypovascular zone near its insertion. The primary function of the rotator cuff is to rotate and
stabilize the humeral head in the glenoid socket against the upward pull of the deltoid with
overhead activities.
Pathogenesis: The supraspinatus tendon is the most commonly affected tendon in rotator cuff
tears. An acute tear may occur in the case of a traumatic event to the shoulder, but more
typically the tear occurs in progressive stages arising from glenohumeral instability and
scapulothoracic dysfunction. Also playing a role is the natural aging process of gradual
deterioration of tendon strength and flexibility, decreased use and vascularization, along with
postural changes. A combination of any of these factors leads to an impingement problem in
which the tendon is compressed between the acromion and the humeral head. These are
generally classified as chronic tears, referring to repetitive microtrauma to the tendon which
leads to inflammation, tendonitis, fibrosis, bone spurs, and eventually a partial thickness to
complete tear. Complete tears are classified based on their size in square centimeters: small (0 -
1 cm), medium (1 3 cm), large (3 5 cm), or massive (>5 cm).
Congenital bony abnormalities in which the acromion, coracoid, or greater tuberosity is
thicker or protrudes into the subacromial space will also predispose a person to an impingement
problem that eventually follows the same progressive course to a tear.
Epidemiology: Rotator cuff tears are more often seen in individuals who perform frequent
overhead lifting or reaching activities as well as athletes such as pitchers, swimmers, and tennis
players who perform repetitive overhead activities. These activities cause fatigue and
subsequent weakness in the rotator cuff muscles allowing superior and anterior migration of the
humeral head, and also weakness of the scapular stabilizers creating a secondary cause of an
impingement.
A spontaneous tear may occur after a sudden movement or impact, and is seen in 80% of
patients older than 60 years when a humeral head dislocation is involved.
Diagnosis:
Some evidence of atrophy may be seen in the supraspinatus fossa.
Possible atrophy in the infraspinatus fossa also, depending on size of tear
Passive motion usually maintained, but may be associated with subacromial crepitus.
However, if the injury is chronic, and the patient has been avoiding using the shoulder,
adhesive capsulitis may be present
Active motion is diminished, particularly abduction, and symptoms are reproduced when
the arm is lowered from an overhead position. Loss of active external rotation present in
2
massive tears
Muscle weakness is related to the size of the tear and muscles involved
Neer and Hawkins Impingement Signs may be positive, but are nonspecific because they
may be positive with other conditions as well (such as rotator cuff tendonitis or bursitis)
A subacromial injection of lidocaine would improve pain, but weakness would still be
present
It is important to rule out other potential etiologies such as patients with C5-6
radiculopathy as these patients may also have an insidious onset of shoulder pain, rotator
cuff weakness, and similar muscular atrophy
A trauma shoulder series of plain radiographs may show superior humeral migration
and degenerative conditions or bone collapse.
An MRI may help demonstrate the size and degree of retraction of a tear.
Non-operative versus Operative Management: Surgical repair is indicated for patients who do
not respond well to conservative treatment, active patients younger than 50 years with a full-
thickness tear, or who have an acute tearing of a chronic injury. Conservative management will
include nonsteroidal anti-inflammatory drugs (NSAIDs), cortisone injections, heat, ice, rest, and
rehabilitation programs. The goals are to first restore normal range of motion, then strengthen
the rotator cuff initially below shoulder level and gradually increase resistance to all functional
planes and range of motion without aggravating symptoms. Normalizing scapulothoracic and
glenohumeral rhythm may also be included. Approximately 50% of patients with rotator cuff
tears improve to their satisfaction within 4 to 6 months of this treatment, but these results can
deteriorate with time. Patients who do not progress, have pain even after regaining strength, or
have significant weakness or posterior cuff involvement may also benefit from earlier surgery
rather than waiting through the 4 to 6 month period of conservative treatment. This is
particularly the case with younger patients with higher functional demands.
Surgical Procedure: The primary goal of surgery is elimination or significant reduction of pain.
Other goals are to improve shoulder range of motion, strength, and function. Surgical repair can
be performed arthroscopically, partially open, or completely open. The type of procedure will
depend on the size, type, and pattern of the tear as well as the surgeons preference. Generally
the larger tears (3 to 5 cm) require more open techniques than the smaller tears (3 cm or less).
Along with repair of the rotator cuff operative procedures also typically include an anteroinferior
acromioplasty to decompress the subacromial space. The cuff tear is repaired using permanent
sutures to the greater tuberosity with the goal of having minimal tension with the arm positioned
at the side. A double layer fixation technique has been shown to provide greater initial fixation
strength than single layer fixation. This is critical as the occurrence of rotator cuff repair failure
is highest in the early postoperative phase before there has been time for sufficient tendon-to-
bone healing.
Clinical results for pain relief are satisfactory 85% to 95% of the time. This appears to
correlate with the sufficiency of the acromioplasty and subacromial decompression. The
integrity of the cuff repair, preoperative size of the tear, and quality of the tendon tissue
influence the functional outcome. Acute tears with early repair may have a slightly greater
susceptibility to develop stiffness, but it has also been noted that these patients progress with
rehabilitation more rapidly than those with late repair.
3
Preoperative Rehabilitation: The primary concerns preoperatively are to prevent loss of range
of motion and further damage to the glenohumeral joint and rotator cuff tendons. This can be
accomplished with passive range of motion and avoiding aggravating activities and positions. A
sling may be provided briefly for pain management if needed, but caution must be taken to avoid
adhesive capsulitis.
Please note: Exercise progression is dependent upon the size of the tear and achievement of
goals in previous phases of the rehabilitation protocol. Post-operative weeks indicated for each
phase are guidelines. Larger tears will require longer healing and protection time, and therefore,
delayed AROM and resistance exercises generally by 2 to 4 weeks. Small tears may be able to
progress more rapidly and follow an accelerated protocol if the surgeon agrees.
Precautions:
Keep incision clean and dry
For at least the first 6 to 8 weeks:
Avoid shoulder adduction behind the back, extension, and horizontal adduction
No lifting objects
No excessive stretching or sudden jerking movements
No supporting body weight by hands and arms
Phase I: Post-operative weeks 0 4
Goals: Decrease pain, including improved sleep patterns

Manage edema
Well-healed incision
Improve passive ROM and tolerance to movement
Maintain ROM of cervical spine, elbow, wrist and hand
Increase quality of muscle recruitment
Intervention:
Immobilization of shoulder in sling or airplane splint except during exercise

Cryotherapy - 4 to 8 times/day during the first 1 to 2 weeks as needed for pain control
Pendulum exercises
Passive range of motion (PROM)
Elbow, wrist, and cervical spine active range of motion (AROM)
Submaximal isometrics (pain free) at 1 to 3 weeks
Rhythmic stabilization drills in balanced position (100 to 110 of elevation and 10 of
horizontal abduction) at 10 days to 3 weeks
Hand gripping with putty
Joint mobilizations grades I and II to glenohumeral (GH) joint
4
Phase II: Post-operative weeks 5 8
Goals: Passive ROM shoulder flexion/abduction = 140 165, ext rot = 70, int rot = 55
Active-Assisted ROM (A/AROM) to reach above head height
Pain management
Re-establish dynamic shoulder stability (humeral head control)
Improve scar mobility
Improve fitness level
Intervention:
Continue phase 1 exercises and progress as indicated

May use heat prior to exercises
May use pool for light AROM exercises
Shoulder proprioceptive neuromuscular facilitation (PNF) D1 and D2 patterns
Initiate AROM shoulder flexion in scapular plane and shoulder abduction up to 90 as
able without scapular hiking
Pulleys and wand exercises
AROM external and internal rotation at 0 abduction progressing from gravity-
eliminated to gravity-resisted positions to resistance tubing
Prone rowing and horizontal abduction
Bicep curls
Soft tissue mobilization
GH joint mobilizations as needed Grades III- to III and IV
Cardiovascular conditioning (walking or stationary bicycle program)
Phase III: Post-operative weeks 8 12
Goals: Full AROM and PROM

Dynamic shoulder stability
Gradual return to shoulder strength and power
Gradual return to functional activities
Minimal pain associated with overhead activities
Increase exercises for performance at home (HEP)
5
Intervention:
Continue exercises and mobilizations from phases 1 and 2 as indicated

Progress AROM to full range, still avoiding scapular hiking with elevation movements
Progressive shoulder and elbow resistance exercises with tubing and light dumbbells
Manual resistance added to PNF patterns
Prone external rotation at 90 abduction
Modified military press
Body Blade exercises
Lower extremity and trunk strengthening if needed for preparation to return to strenuous
work or sport activities
Phase IV: Post-operative weeks 13 16
Goals: Independent/self-management of HEP

Self-management of pain associated with overhead activities
Able to reach in front and to the side with elbow extension for light-weight objects
Carry light weight objects for short periods (e.g., groceries)
Improve muscular strength and power
Maintain full AROM
Intervention:
Continue mobilizations and progress exercises from previous stages as indicated

Corner (anterior chest) and hand behind back stretches
Plyometrics if appropriate
Shoulder girdle depressions
Closed chain exercises
Self-capsular stretches
Joint mobilization to cervical and thoracic spine as appropriate
Phase V: Post-operative weeks 17 26
Goals: Pain-free with overhead activity

Gradual return to strenuous work activity or previous level of functioning
Gradual return to recreational sport activity
Intervention:
Continue mobilizations and progress Phase IV exercises as appropriate

Fundamental shoulder exercise program at least 4 times per week to include rotator cuff
and scapular stabilization exercises, bicep strengthening, and shoulder and chest stretches
Strengthen for sport-specific activities as appropriate
6
Initiate sport activity when appropriate
Cohen BS, Romeo AA, Bach BR. Shoulder Injuries. In Brotzman SB, Wilk KE, 2nd ed., Clinical
Orthopedic Rehabilitation. Philadelphia, Mosby, 2003.
Holtby R, Razmjou H: Validity of the supraspinatus test as a single clinical test in diagnosing
patients with rotator cuff pathology. J Orthop Sports Phys Ther. 2004;34:194-200.
Kibler WB, Livingston B, Chandler TJ: Current concepts in shoulder rehabilitation. Adv Oper
Orthop 3:249-301, 1996.
Mandelbaum B, Gruber J, Zachazewski J. Rotator Cuff Repair and Rehabilitation. In Maxey L,

Magnusson J, eds., Rehabilitation for the Postsurgical Orthopedic Patient. St. Louis, Mosby,
2001.
Romeo AA, Hang DW, Bach BR, Shott S: Repair of full thickness rotator cuff tears: gender, age,
and other factors affecting outcome. Clin Orthop 1999;367:243-255.
Waltrip RL, Zheng N, Dugas JR, Andrews JR: Rotator cuff repair: a biomechanical comparison
of three techniques. Am J Sports Med 31(4):493-497.
Wilk KE, Crockett HC, Andrews JR: Rehabilitation after rotator cuff surgery. Tech Shoulder
Elbow Surg. 2000;1(2):128-144, 2000.
1
Total Shoulder Arthroplasty
Surgical indications and contraindications
Anatomical Considerations: Total shoulder arthroplasty surgery involves the replacement of the
humeral head and the glenoid articulating surfaces with artificial components. This procedure
also involves precise placement and balancing or the muscles of the rotator cuff and the capsular
ligaments, in addition to other related shoulder muscles. The muscles considered to be part of
the shoulder include the Supraspinatus, Infraspinatus, Subscapularis, Teres Minor, Teres Major,
Latissimus Dorsi, Pectoralis Major, Serratus Anterior, Deltoids, and the Trapezius musculature.
Only the insertion of the subscapularis, at the lesser tubercle of the humerus, is affected during
this procedure. None of the other muscular attachments are disrupted by this particular surgery.
However, this procedure can alter the normal geometric mechanics of the shoulder, allowing
only limited range of motion upon complete recovery time.
Pathogenesis: Indication for a total shoulder arthroplasty involves a patient population with a
medical diagnosis of rheumatoid arthritis, osteoarthritis, severe comminuted fractures of the
humeral head, avascular necrosis, irradiation necrosis, ochronosis, and gout. The most common
indications for this particular procedure are patients with either osteoarthritis or rheumatoid
arthritis. With shoulder arthritis the joint surface is destroyed, by wear and tear, inflammation,
injury, or previous surgery. This type of injury to the joint makes the shoulder stiff and painful.
Total shoulder arthroplasty is indicated when the patient has a severe decreased ability to
perform activities of daily living due to decreased range of motion, and decreased strength, both
due to a rapid increase in pain.
Epidemiology: Even though the first TSA surgery took place in 1892, advanced techniques of
the total shoulder arthroplasty procedure began in the early 1970s. However this procedure did
not become a routine surgical procedure until years later. Beginning in the early 1990s
approximately 20,000 total shoulder arthroplastys are performed each year. It was difficult to
ascertain specific genders, age groups, work groups or races that are more likely to undergo this
procedure, however, within the last decade few patients have elected to have the procedure
outside the age range of 18 to 75 years of age. Of those patients over 90% are either pain free or
significantly improved after surgery. It is not uncommon for patients to plateau at a shoulder
range of motion less then that of their previous range of motion. In fact, achieving only two-
thirds of full mobility after a total shoulder arthroplasty procedure is not unheard of. This can be
attributed to, but not limited to, disruption of the normal geometric mechanics of the shoulder
during the surgical process.
Non-operative vs. operative management: Most often osteoarthritis of the shoulder is treated
with non-steroidal anti-inflammatory drugs, such as aspirin, ibuprofen, or cox-2 inhibitors.
Physical modalities and exercise can be used in conjunction with these medications to offer
greater pain relief and maintain function. Rheumatoid arthritis of the shoulder can also require
conservative measures such as medication to relieve the effects of RA, and it may require
2
exercise training to increase function and physical agents to offer limited pain relief. If and
when non-operative treatments for arthritis of the shoulder fail to relieve pain or improve
function, total shoulder arthroplasty may possibly yield more effective results. In general, this
surgery is elective, and can be performed whenever conditions are optimal. Occasionally pain
and stiffness from the shoulder osteoarthritis will plateau at a level that is acceptable to the
patient. In such cases the patient can delay surgery without compromising the potential for
future surgery. However, in cases of rheumatoid arthritis, excessive delay may result in loss of
tendon and bone, making surgery more difficult for the patient and the surgeon. Surgical repair
is typically recommended for patients who expect to eventually return to a relative prior level of
function. Risks can include, but are not limited to: infection, injury to the nerves and/or blood
vessels, fracture, stiffness or instability of the joint, loosening or wear of artificial components,
and increased pain and need for additional surgical procedures.
Surgical Procedure: There are several surgical techniques used in regard to the components
used in a total shoulder arthroplasty procedure. The constrained component used to be one of
the gold standards for this procedure used mainly in the 80s and 90s. It was designed for
patients who had severe deterioration without a reconstructible rotator cuff, but with a
functioning deltoid muscle. With technological advancements the semi-constrained or
monospherical component was produced. With this component the humeral head is smaller and
spherical with a head-neck angle of 60 degrees and reportedly permitted increased range of
motion. The glenoid component was matched to the humeral head prosthesis to allow for
constant surface contact. Today the most extensively used component is known as an
unconstrained component. This is used with a polyethylene glenoid component that conforms to
the radius of the glenoid articulating surface. The unconstrained components have replaced the
semi-constrained and constrained due to the problem of loosening of the latter two.
Due to the shoulders dependence on soft tissues, great care must be taken during total
shoulder arthroplasty to preserve and/or restore as much soft tissue integrity as possible. The
most common approach in use today is the anterior deltopectoral approach. The most notable
advantage of this approach is that it preserves the anterior deltoid, the primary flexor of the
shoulder, as well as the axillary and musculocutaneous nerves. The initial incision begins at the
superior aspect of the clavicle, traverses the coracoid process, and extends down the anterior
aspect of the arm. The cephalic vein is then identified and retracted laterally with the deltoid.
This is followed by release of the upper portion of the pectoralis major tendon as well as the
subscapularis tendon, which lies beneath. Subsequently, the joint capsule is reflected, and the
humeral head is dislocated anteriorly via external rotation and adduction of the arm. The rotator
cuff is inspected, and if any tears are found they can be repaired. Then the humeral head is
resected along the anatomic neck and the medullary canal is reamed. Prior to placement of the
humeral component, the glenoid fossa is debrided, reamed and fitted with a solid polyethylene
glenoid component that is cemented in place. Once the humerus has been reamed and sized, a
trial reduction is performed with various humeral head and neck sizes to obtain the best fit and
appropriate soft tissue tension to balance and stabilize the shoulder joint. Once the correct sizes
are determined, the humeral component can be press-fit or cemented into the humeral canal, and
the appropriate head and neck component impacted onto the humeral component. The newly-
replaced humeral component is then reduced back into the glenoid fossa and taken through a
final range of motion to assess stability. The subscapularis tendon is secured back into place,
and the wound closed.
3
Preoperative rehabilitation:
Maintain shoulder range of motion as able either actively or active assisted in supine to
eliminate gravity as a possible shoulder irritant
Sleeping in supine is encouraged. Do not sleep on the affected shoulder to avoid
increased pain and irritation to the shoulder
Continue use of anti-inflammatory and pain medication to offer maximal relief
Instructions/review post-operative rehabilitation plan
Phase I: Immediate Post Surgical (0-4 weeks)
Goals: Allow healing of soft tissue

Maintain integrity of replaced joint
Gradually increase PROM of shoulder; Restore AROM of elbow/wrist/hand
Diminish pain and inflammation
Prevent muscular inhibition
Independent with ADL with modification while maintaining integrity of the replaced
joint
Precautions: Sling should be worn for 3 weeks for comfort

Sling should be used for sleeping and removed gradually over course of 4 weeks
periodically throughout the day
While lying in supine place a small pillow behind elbow to avoid shoulder
hyperextension avoiding stretching the anterior capsule and subscapularis
tendon
Avoid shoulder AROM
No lifting of objects
No excessive shoulder motion behind back
No excessive stretching or sudden movements (especially ER)
No supporting of body weight by hand of involved side
Keep incision dry and clean (no soaking for 2 weeks)
No driving for 3 weeks
Criteria for progression to the next phase:

Tolerates PROM program
At least 90 PROM flexion
At least 90 PROM abduction
At least 45 PROM of ER in plane of scapula
At least 70 PROM of IR in plane of scapula
Be able to isometrically activate all shoulder, RC, and upper back musculature
4
Postoperative Day #1 Interventions (in hospital):
Passive forward flexion in supine to tolerance

ER in scapular plane to available gentle ROM (approx 30)
Passive IR to chest
Active distal extremity exercise (Elbow/wrist/hand)
Pendulum exercise to tolerance
Frequent cryotherapy for pain, swelling, and inflammation
Patient education regarding proper positioning and joint protection
Postoperative Days 2-10 Interventions (out of hospital):
Continue above exercises

Assisted flexion and abduction in scapular plane
Assisted external rotation
Begin submaximal, pain-free shoulder isometrics in neutral
Begin scapular musculature isometrics
Begin active assisted elbow ROM Pulleys (flexion and abduction) if patient can
achieve 90 of PROM
Continue cryotherapy to tolerance for pain, and inflammation management
Postoperative Days 10-21 Interventions:
Continue previous exercises

Continue to progress PROM as tolerated
Gradually progress to AAROM in pain free ROM
Progress active distal extremity exercise to strengthening as able
Restore active elbow ROM
Phase II: Early Strengthening (Weeks 3-6)
Goals: Continue PROM progression and gradually restore full PROM

Gradually restore AROM
Control pain and inflammation
Allow continued healing of soft tissue
Re-establish dynamic shoulder stability
Precautions: Sling should be used as needed for sleeping and removed gradually over the
course of
the next two weeks, periodically throughout the day
While lying in supine place a small pillow behind elbow to avoid shoulder
hyperextension avoiding stretching the anterior capsule and subscapularis
tendon
Begin shoulder AROM against gravity
5
No heavy lifting of objects (no heavier than coffee cup)

No supporting of body weight by hands and arms
No sudden jerking motions
Criteria for progression to next phase:

Tolerates P/AAROM isometric program
Has achieved 140 PROM flexion
Has achieved 120 PROM abduction
Has achieved 60 PROM ER in scapular plane
Has achieved 70 PROM IR in scapular plane
Able to actively elevate shoulder against gravity to 100
Week #3 Interventions:
Continue with PROM, AAROM, and isometric exercises

Scapular strengthening
Begin assisted horizontal adduction
Progress distal extremity exercise with light resistance as appropriate
Gentle joint mobilizations as able
Initiate rhythmic stabilization
Continue use of cryotherapy for pain and inflammation as needed
Begin active forward flexion, IR, ER, and Abd in supine (pain free ROM)
Progress scapular strengthening exercises
Wean from sling completely
Begin isometrics of rotator cuff and periscapular musculature
Phase III: Moderate strengthening (weeks 6-12)
Goals: Gradual restoration of shoulder strength, power and endurance

Optimize neuromuscular contro
Gradual return to functional activities with involved upper extremity
Precautions: No heavy lifting of objects (no heavier than 5lbs)

No sudden lifting or pushing activities
No sudden jerking motions
Criteria for progression to the next phase:

Tolerates AA/AROM
Has achieved 140 AROM flexion in supine
Has achieved 120 AROM abduction in supine
Has achieved 60 AROM ER in plane of scapula in supine
6
Has achieved 70 AROM IR in plane of scapula in supine

Able to actively elevate shoulder against gravity to 120
Increase antigravity forward flexion, abduction as appropriate
Active IR and ER in scapular plane
Advance PROM as tolerated, begin light stretching as appropriate
Continue PROM as needed to maintain ROM
Initiate assisted IR behind back
Begin light functional activities
Begin progressive supine active elevation (anterior deltoid strengthening) with light
weights (1-3 lbs) and variable degrees of elevation
Week #10 12 Interventions:

Begin resisted flexion, abduction, ER (using theraband / sport cords)
Continue progressing IR and ER strengthening
Progress IR behind back from AAROM to AROM as able
Phase IV: Advanced Strengthening (weeks 12 to 6 months)
Goals: Maintain full, non-painful AROM

Enhance functional use of involved UE
Improve muscular strength, power, and endurance
Gradual return to more advanced functional activities
Progress closed chain exercises as appropriate
Precautions: Avoid exercise and functional activities that place stress on anterior capsule and
surrounding structures (example: no combined ER and abduction above 80
abd)
Ensure gradual progression of strengthening
Criteria for discharge from skilled therapy:

Patient able to maintain full non-painful AROM
Maximized functional use of involved UE
Maximized muscular strength power, and endurance
Patient has returned to more advanced functional activities
7
Week #12+ Interventions:

Typically patient is on a HEP 3-4x/week
Gradually progress strengthening program
Gradual return to moderately challenging functional activities
Brems JJ. Rehabilitation following total shoulder arthroplasty. Clin Orthop. 1994;307: 70-85.
Brown D, Friedman RJ. Postoperative rehabilitation following total shoulder arthroplasty.

Orthop Clin North Am. 1998;29:535-547.
Fehringer E, Kopjar B, Boorman R. Characterizing the functional improvement after total

shoulder arthroplasty for osteoarthritis. J Bone Joint Surg. 2002; 1349-1353.
Iannotti J, Norris T. Influence of preoperative factors on outcomes of shoulder arthroplasty for

glenohumeral osteoarthritis. J Bone Joint Surg. 2003; 251-258
Karduna A, Gerald W, Williams J. Glenohumeral joint translations before and after total
shoulder arthroplasty. a study in cadavera. J Bone Joint Surg. 1997; 1166-1172.
Sanchez J, Sperling J, Rowland C. Instability after shoulder arthroplasty: results of a surgical

treatment. J Bone Joint Surg. 2003; 622-631.
Sperling J, Antuna S, Schleck C, Cofield R. Shoulder arthroplasty for arthritis after instability
surgery. J Bone Joint Surg. 2002; 1775-1781.
Wallace A, Phillips R, MacDougal G. Resurfacing of the glenoid in total shoulder arthroplasty. J

Bone Joint Surg. 1999; 510-518.

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Red Flags for Potential Serious Conditions in Patients with Neck and Shoulder Problems

Red Flags for the Neck and Shoulder Region

Cervical Central Older age Gait disturbances due to hyperreflexic lower

Joe Godges, DPT, MA, OCS KP So Cal Ortho PT Residency

NAME: __________________________________________ DATE: _____________

1. Have you recently experienced a blow to the head or a whiplash injury?

2. Do you have rheumatoid arthritis?

3. Are you currently taking steroids or have you been on prolonged

4. Have you noticed any recent weakness, tingling, or numbness in you

6. Do you now smoke or have you been a smoker in the past?

7. Do you administer medicine or drugs to yourself for which you need to

Joe Godges, DPT, MA, OCS KP So Cal Ortho PT Residency

ICD-9-CM codes: 726.0 Adhesive capsulitis of the shoulder

ICF codes: Activities and Participation Domain codes:

Common Historical Findings

Physical Examination Procedures:

Glenohumeral External Rotation ROM Measurement

Joe Godges, DPT, MA, OCS 1 KP So Cal Ortho PT Residency

Glenohumeral Internal Rotation ROM Measurement

Glenohumeral Flexion ROM Measurement

Joe Godges, DPT, MA, OCS 2 KP So Cal Ortho PT Residency

Shoulder Mobility Deficits: Description, Etiology, Stages, and Intervention Strategies

Description: Insidious onset of progressive stiffness and pain of the shoulder

Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)

Excessive scapular protraction

Joe Godges, DPT, MA, OCS 3 KP So Cal Ortho PT Residency

Sub Acute / Moderate Condition: Physical Examinations Findings (Key Impairments)

As above with the following differences:

Segmental movement abnormalities cervical and upper thoracic spine

Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments)

As above with the following differences:

Pain with repetitive activities of the shoulder especially at end range

Joe Godges, DPT, MA, OCS 4 KP So Cal Ortho PT Residency

Acute Stage / Severe Condition

Goals: Prevent movement induced inflammatory reactions

External Devices (Taping/Splinting/Orthotics)

Re-injury Prevention Instruction

Sub Acute Stage / Moderate Condition

Goals: Improve glenohumeral ROM

Joe Godges, DPT, MA, OCS 5 KP So Cal Ortho PT Residency

Settled Stage / Mild Condition

Goals: Normalize glenohumeral ROM

Approaches/ Strategies listed above

Ergonomic Instruction: as above

Goal: Return to desired occupational or sport activities

Joe Godges, DPT, MA, OCS 6 KP So Cal Ortho PT Residency

Gross J, Fetto J, Rosen E. Musculoskeletal Examination. Blackwell Science, 1996.

Tomberlin J, Saunders D. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders,

Wadsworth T. Frozen shoulder. Phys Ther. 1986;66:1878-83.

Joe Godges, DPT, MA, OCS 7 KP So Cal Ortho PT Residency

Patient Problem: LIMITED HUMERAL INTERNAL ROTATION

ST MOB: Infraspinatus/Teres Minor/Posterior Deltoid

JNT MOB: Posterior Glide (loose packed position)

RE-ED: Extension/Adduction/Internal Rotation PNF pattern (emphasize traction +

MWM: Hand-Behind Back Maneuvers

Patient Problem: LIMITED HUMERAL EXTERNAL ROTATION

ST MOB: Pectoralis Minor

JNT MOB: Inferior Glide

RE-ED: Contract/Relax of Extension/Adduction/Internal Rotation PNF pattern (emphasize

MWM: Arm Overhead Maneuvers

Joe Godges, DPT, MA, OCS 8 KP So Cal Ortho PT Residency

Joe Godges, DPT, MA, OCS 9 KP So Cal Ortho PT Residency

Humeral Posterior Glide

NAME: ______________________________ DATE: _