Shoulder pain with Dr Jeremy Lewis

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• Based on Physio Edge podcast episode 021 with Dr Jeremy Lewis
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Shoulder Assessment
Historically shoulder assessments have consisted of orthopaedic tests.
Recent evidence has shown that these tests are good at reproducing pain
but are poor at providing a structural diagnosis. It is not possible to test
isolated structures as these tests compress and stretch multiple structures
such as bursae and the rotator cuff. There is also a limited link between
structural failure and symptoms, as 96% of asymptomatic people have
structural changes on ultrasound imaging (Girish et al., 2008).

Model of Impingement
In 1972 Neer presented a model of impingement that 95% of cuff pathology
is caused by irritation from the acromion on the cuff which lead to pockets
of micro trauma. Current evidence does not support the acromion as the
primary source of symptoms. The 2 potential other mechanisms are:

• The rotator cuff not functioning effectively as a humeral head depressor

therefore the humeral head moves upwards and causes symptoms. This
may develop from trauma, atrophy or pain inhibition. Strength and
endurance of the rotator cuff should be improved

• Reactive swelling from overload of the supraspinatus, infraspinatus and

teres minor complex. This swelling causes increased pressure under the
acromion. Treatment should focus on reducing the reactive swelling of the
tendon via relative rest.

Homeostasis of the rotator cuff should be restored before any subacromial

decompression is performed.

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Shoulder pain with Dr Jeremy Lewis

Shoulder Symptoms Modification Procedure (SSMP)
At the start of assessment pick a functional task patient wants to improve
eg. a cricketer throwing a ball from boundary.

The SSMP consists of mechanical corrections of the functional task

consisting of:
• Changes to kyphosis
• Position of Scapular – elevation/ depression, protraction/retraction,
tilting, or a combination of movements.
• Relationship of the humeral head and Glenoid Fossa
• Neuromodulatory procedures

Assess the percentage of change with these procedures and may require
a combination of the (SSMP) to resolve symptoms. If the patients
symptoms are not completely resolved with the procedure then there may
be another factor influencing the patients symptoms eg. a biceps tendon
problem requiring a different approach.

An exercise program can be designed to include the mechanical

corrections shown to improve function. For example if elevation of the
scapular resolves symptoms then exercises facilitating scapular elevation
may be included.

It may be appropriate to continue with conservative rehabilitation for 12

weeks or longer. If the patient is not improving as expected or wants a
surgical opinion then it may be appropriate to refer for a surgical opinion.
The clinician should give the patient an honest interpretation of the
evidence and outcomes so the patient can make a decision regarding future
management. The views of the patient should be respected.

24 hour pain response should be monitored and used to identify the

patients tolerance to the exercise programme.

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Shoulder pain with Dr Jeremy Lewis

Imaging
The use of imaging is complex due to the lack of relationship between
structural failure and symptoms. Clinical response of symptoms should be
more important than the results of imaging. Imaging is indicated if:

• Significant atrophy – MRI looking for nerve compression or fat infiltration

of the rotator cuff.
• History of trauma
• Suspicion of red flags
• Ruling in a diagnosis of frozen shoulder a 2 view x-ray is required to
rule out other potential causes that may masquerade as a frozen
shoulder e.g. avascular necrosis

Patient’s interpretation of structural failure may have a negative

psychological impact on treatment outcomes.

Rotator Cable
The Rotator Cable is a tendinous tissue which is located 1-2cm back from
the insertion of the rotator cuff. The cable runs perpendicular to the
direction of the tendon fibers and inserts into the anterior and posterior
aspect of the humerus. This mechanism may allow the shoulder to still
function despite structural failure of the cuff.

In massive rotator cuff tears where there is no tendon salvageable through

surgery and a surgeon suggests a reverse shoulder prosthesis, the
Ainsworth exercise programme may increase shoulder function and
reduce pain. The programme aims to use other structures such as the
latissimus dorsi/teres major complex to depress the humeral head and the
deltoid to move the shoulder.

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Shoulder pain with Dr Jeremy Lewis

Long head of Biceps Tendinopathy
Reactive long head of biceps tendinopathy (LHBT) may present similarly to
a frozen shoulder with high levels of pain and limitation of movement
specifically rotation. LHBT is relatively under diagnosed compared to
rotator cuff tendinopathy.

LHBT is linked to a history of increased loading of elbow flexion with

shoulder extension. E.g. 10 pin bowling with a 6kg ball in shoulder
extension 20 times. Pain is present over the bicipital groove, and pain is
often reproduced with loading of the biceps tendon, particularly into
shoulder extension. Palpation may be useful in confirming the diagnosis.

If patients present with a biceps tendon and rotator cuff tendon pain, initial
management should be aimed at the biceps tendon, as rotator cuff
exercises can irritate the biceps tendon. Management should start with
isometric elbow flexion in shoulder flexion gradually increasing the load
and degree of shoulder extension.

Treatment Modalities
• Manual therapy, taping and soft tissue techniques may be utilised.

• Relative rest for the shoulder is important to reduce the load on the
shoulder complex. For example a swimmer with shoulder pain may need
to temporarily change stroke to reduce shoulder loading or make technique
changes to avoid the catch phase

• Patients who have jobs that require prolonged use of shoulder in elevation
may require ergonomic changes to work to reduce time spent at end of
range shoulder elevation. eg. A builder using a stable platform to perform
activity in lower range of shoulder elevation.

• Discussion with medical professionals for medication management. eg.

Ibuprofen to reduce fibroblast activity.
• If the patient has night pain or is highly irritable injection into the
subacromial bursa in reactive rotator cuff pathology may be indicated.

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Shoulder pain with Dr Jeremy Lewis

Frozen Shoulder
A clinical diagnosis can be made when there is an equal restriction in active
and passive range of movement in the presence of a normal x-ray.

2 stages of frozen shoulder:

• More pain than stiff: ultrasound guided steroid and 2ml Lidocaine to
reduce pain. Physiotherapy then started 1 week later
• More stiff than pain: Hydrodistention injection (5ml Lidocaine and 30ml
Saline) and then physiotherapy.

Physiotherapy intervention consists of inferior and AP mobilisations of the

glenohumeral joint at end of range to patient tolerance. Patient can be
taught slow progressive home stretches. If injections are contraindicated,
20-25 minutes of heavy massage with mobilisation and passive movement
may be effective. If the patient has limited improvement, a surgical opinion
may be appropriate.

More information
Twitter – twitter.com/JeremyLewisPT
Website – http://www.londonshoulderclinic.com

Further Reading
Ainsworth, R., Lewis, J. 2007. Exercise therapy for the conservative
management of full thickness tears of the rotator cuff: a systematic review.
British Journal of Sports Medicine. 41: 200-210.
Lewis, J., 2015. Frozen shoulder contracture syndrome – Aetiology,
diagnosis and management. Manual Therapy. 20: 2-9.
Lewis, J. 2010. Rotator cuff tendinopathy: a model for the continuum of
pathology and related management. British Journal of Sports Medicine. 44:
918-923.
Lewis, J. 2008. Rotator cuff tendinopathy/subacromial impingement
syndrome: is it time for a new method of assessment? British Journal of
Sports Medicine. 43: 259-264.

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