Physical Medicine and

Rehabilitation Management in
Shoulder Pain

RUDY HANDOYO
Program Studi/KSM Rehabilitasi Medik
FK Undip/RSUP Dr. Kariadi
Semarang
 Introduction
 Compromised shoulder movement due to pain, stiffness,
or weakness can cause substantial disability and affect a
person’s ability to carry out daily activities (eating,
dressing, personal hygiene) and work.
 Self reported prevalence of shoulder pain is estimated to
be between 16% and 26%;
 It is the third most common cause of musculoskeletal
consultation in primary care, and approximately 1% of
adults consult a general practitioner with new shoulder
pain annually.
Mitchell C.Shoulder pain: diagnosis and management in primary care.
BMJ 2005; 331: 1124-8.
Anatomy
Anatomy
 Causes of Shoulder Pain
 Pain arising from the shoulder:
 Rotator cuff disorders: rotator cuff tendinopathy,
impingement, subacromial bursitis, rotator cuff tears
 Glenohumeral disorders: capsulitis (“frozen
shoulder”), arthritis
 Acromioclavicular disease
 Infection (rare)
 Traumatic dislocation
 Causes of Shoulder Pain
 Pain arising from elsewhere
 Referred pain: neck pain, myocardial ischaemia,
referred diaphragmatic pain
 Polymyalgia rheumatica
 Malignancy: apical lung cancers, metastases
 Red Flag Indicators
 History of cancer; symptoms and signs of cancer;
unexplained deformity, mass, or swelling: tumour ?
 Red skin, fever, systemically unwell: infection ?
 Trauma, loss of rotation and normal shape: dislocation ?
 Trauma, acute disabling pain and significant weakness,
positive drop arm test: acute rotator cuff tear ?
 Unexplained significant sensory or motor deficit:
neurological lesion ?
 Diagnosis
 History
 Physical Examination:
 Inspection
 Palpation
 Range of Motion testing
 Evaluation of Rotator Cuff
 Provocative Testing
 Supporting diagnosis
 Laboratory
 Plain photo
 MRI
 USG musculoskeletal
 Problem
 Inflammation
 Pain
 ROM limitation, Stiffness, Frozen shoulder
 Muscle hypotrophy or atrophy
 Osteoporosis
 ADL disturbance
 Depression
 Problem
Pain

Loss Avoidance
of Motion Of
Motion
Increase
Muscle
Tightness
 Management
 Medication:
 Oral
 Local injection
 Physical Medicine and Rehabilitation
 Surgical intervension
 Goals of Rehabilitation
• Decrease symptoms
• Prevention of further complication
• Optimal strength, endurance
• Optimize daily function
• Minimize disability
• Return to normal functional activity
 Pain
 Acute/Inflammation:
 Rest
 Coldtherapy: Cryotherapy, Icing
 TENS
 Isometric exercise
Pain
• Cold therapy:
– Icing
– Cryo therapy
– Decrease pain in acute
condition
 Pain
• TENS:
– Non invasive, inexpensive, safe, easy to use
– Theories:
• Gate control theory
• Release of endogenous opioids
– Electrode placement:
• Local points, nerve trunk, trigger points,
dermatome, acupuncture points
 Pain
 Interferential therapy:
• The physiologic and therapeutic effects 
similar to TENS
• Effective stimulation of deep musculoskeletal
structures, whereas TENS is predominantly a
cutaneous or superficial stimulation
• The evidence base to determine the clinical
effectiveness is less adequate than TENS
 Pain

Trans Cutaneous Electrical Nerve Interferential Therapy

Stimulation (TENS)
 Pain
 Post acute:
 Heating:
 Superficial:
Infra Red, Hot pack
 Deep: Micro Wave Diathermy, Short Wave
Diathermy, Ultrasound Diathermy
 TENS
Pain
• Superficial heating:
– Infra red
– Hot pack
• Decrease pain
• Improve blood flow
• Reduce spasm
Pain
• Deep heating:
– Diathermy:
• Microwave
• Short wave
• Ultra sound
• Decrease pain
• Improve blood
circulation
• Reduce spasm
• Deeper
penetration
 Pain

Deep heating: Ultra sound

diathermy
 ROM Limitation, Stiffness,
Frozen Shoulder
 ROM exercise:
 passive
 passive with help
 active
ROM Limitation, Stiffness,
Frozen Shoulder
ROM Limitation, Stiffness,
Fozen Shoulder
ROM Limitation, Stiffness,
Frozen Shoulder
ROM Limitation, Stiffness,
Frozen Shoulder
 Muscle Hypotrophy or Atrophy
 Usually: disuse atrophy
 Strengthening exercise
 isometric: no movement of the joint
 isotonic: a gradual increase of the load
 isokinetic
Muscle Hypotrophy or Atrophy
 ADL Disturbance
 ADL training
 Use ADL aids/ adaptive equipments/
assistive device
ADL Disturbance
 Other Problem
 Osteoporosis
 Combine with disuse atrophy
 Gentle exercise

 Depression: psychological intervention